1
|
Ferguson AM, Lin AC. Themes, Rates, and Risk of Adverse Events of the Artificial Pancreas in the United States Using MAUDE. Ann Biomed Eng 2024:10.1007/s10439-024-03529-6. [PMID: 38740730 DOI: 10.1007/s10439-024-03529-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 04/26/2024] [Indexed: 05/16/2024]
Abstract
Three manufacturers sell artificial pancreas systems in the United States for management of Type 1 Diabetes. Given the life-saving task required of an artificial pancreas there needs to be a high level of trust and safety in the devices. This evaluation sought to find the adjusted safety event reporting rate and themes along with device-associated risk in events reported utilizing the MAUDE database. We searched device names in the MAUDE database over the period from 2016 until August 2023 (the date of retrieval). Thematic analysis was performed using dual-reviewer examination with a 96% concurrence. Relative risk (RR) was calculated for injury, malfunction, and overall, for each manufacturer, as well as adjusted event rate per manufacturer. Most events reported related to defects in the manufacturing of the casing materials which resulted in non-delivery of therapy. Tandem Diabetes Care, Inc. had an adjusted event rate of 50 per 100,000 units and RR of 0.0225. Insulet had an adjusted event rate of 300 per 100,000 units and RR of 0.1684. Medtronic has an adjusted event rate of 2771.43 per 100,000 units and RR of 20.7857. The newer Medtronic devices show improvements in likely event rate. While the artificial pancreas is still in its infancy, these event rates are not at an acceptable level for a device which can precipitate death from malfunctions. Further exploration into safety events and much more research and development is needed for devices to reduce the event rates. Improved manufacturing practices, especially the casing materials, are highly recommended. The artificial pancreas holds promise for millions but must be improved before it becomes a true life-saving device that it has the potential to become.
Collapse
Affiliation(s)
- Andrew M Ferguson
- University of Cincinnati College of Medicine, Cincinnati, USA.
- University of Cincinnati College of Pharmacy, Cincinnati, USA.
| | - Alex C Lin
- University of Cincinnati College of Pharmacy, Cincinnati, USA
| |
Collapse
|
2
|
Haidar A, Legault L, Raffray M, Gouchie-Provencher N, Jafar A, Devaux M, Ghanbari M, Rabasa-Lhoret R. A Randomized Crossover Trial to Compare Automated Insulin Delivery (the Artificial Pancreas) With Carbohydrate Counting or Simplified Qualitative Meal-Size Estimation in Type 1 Diabetes. Diabetes Care 2023; 46:1372-1378. [PMID: 37134305 PMCID: PMC10300520 DOI: 10.2337/dc22-2297] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 04/02/2023] [Indexed: 05/05/2023]
Abstract
OBJECTIVE Qualitative meal-size estimation has been proposed instead of quantitative carbohydrate (CHO) counting with automated insulin delivery. We aimed to assess the noninferiority of qualitative meal-size estimation strategy. RESEARCH DESIGN AND METHODS We conducted a two-center, randomized, crossover, noninferiority trial to compare 3 weeks of automated insulin delivery with 1) CHO counting and 2) qualitative meal-size estimation in adults with type 1 diabetes. Qualitative meal-size estimation categories were low, medium, high, or very high CHO and were defined as <30 g, 30-60 g, 60-90 g, and >90 g CHO, respectively. Prandial insulin boluses were calculated as the individualized insulin to CHO ratios multiplied by 15, 35, 65, and 95, respectively. Closed-loop algorithms were otherwise identical in the two arms. The primary outcome was time in range 3.9-10.0 mmol/L, with a predefined noninferiority margin of 4%. RESULTS A total of 30 participants completed the study (n = 20 women; age 44 (SD 17) years; A1C 7.4% [0.7%]). The mean time in the 3.9-10.0 mmol/L range was 74.1% (10.0%) with CHO counting and 70.5% (11.2%) with qualitative meal-size estimation; mean difference was -3.6% (8.3%; noninferiority P = 0.78). Frequencies of times at <3.9 mmol/L and <3.0 mmol/L were low (<1.6% and <0.2%) in both arms. Automated basal insulin delivery was higher in the qualitative meal-size estimation arm (34.6 vs. 32.6 units/day; P = 0.003). CONCLUSIONS Though the qualitative meal-size estimation method achieved a high time in range and low time in hypoglycemia, noninferiority was not confirmed.
Collapse
Affiliation(s)
- Ahmad Haidar
- Department of Biomedical Engineering, McGill University, Montréal, Quebéc, Canada
- The Research Institute of McGill University Health Centre, Montréal, Québec, Canada
| | - Laurent Legault
- Montreal Children's Hospital, McGill University Health Centre, Montréal, Québec, Canada
| | - Marie Raffray
- Institut de Recherches Cliniques de Montréal, Montréal, Québec, Canada
| | | | - Adnan Jafar
- Department of Biomedical Engineering, McGill University, Montréal, Quebéc, Canada
| | - Marie Devaux
- Institut de Recherches Cliniques de Montréal, Montréal, Québec, Canada
| | - Milad Ghanbari
- Department of Biomedical Engineering, McGill University, Montréal, Quebéc, Canada
| | - Rémi Rabasa-Lhoret
- Institut de Recherches Cliniques de Montréal, Montréal, Québec, Canada
- Nutrition Department, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
- Montreal Diabetes Research Center and Endocrinology Division Centre Hospitalier de l’Université de Montréal, Saint-Denis Montréal, Québec, Canada
| |
Collapse
|
3
|
Zeng B, Jia H, Gao L, Yang Q, Yu K, Sun F. Dual-hormone artificial pancreas for glucose control in type 1 diabetes: A meta-analysis. Diabetes Obes Metab 2022; 24:1967-1975. [PMID: 35638377 PMCID: PMC9542047 DOI: 10.1111/dom.14781] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 05/17/2022] [Accepted: 05/26/2022] [Indexed: 12/14/2022]
Abstract
AIM To evaluate the efficacy and safety of a dual-hormone artificial pancreas (DH) in type 1 diabetes. MATERIAL AND METHODS PubMed, Embase, the Cochrane Library and ClinicalTrials.gov were searched for studies published up to February 16, 2022. We included randomized controlled trials that compared DH with single-hormone artificial pancreas (SH), continuous subcutaneous insulin infusion (CSII) or sensor-augmented pumps (SAP), and predictive low glucose suspend systems (PLGS) in type 1 diabetes. The primary outcome was percent time in target (3.9-10 mmol/L [70-180 mg/dL]). Data were summarized as mean differences (MDs) or risk differences (RDs). RESULTS A total of 17 randomized crossover trials (438 participants) were included. There were nine trials of DH versus SH, 13 trials of DH versus SAP/CSII, and two trials of DH versus PLGS. For time in target, DH showed no significant difference in time in target compared with SH (MD 2.69%, 95% confidence interval [CI] -0.38 to 5.76) but resulted in 16.05% (95% CI 12.06 to 20.05) and 6.89% (95% CI 2.63 to 11.14) more time in target range compared with SAP/CSII and PLGS, respectively. DH slightly reduced time in hypoglycaemia (MD -1.20%, 95% CI -1.85 to -0.56) but increased the risk of gastrointestinal symptoms (RD 0.18, 95% CI 0.08 to 0.27) compared with SH. CONCLUSIONS The results of this study suggest that DH has a comparable effect on time in target compared with SH, but is associated with a longer time in target range compared with SAP/CSII and PLGS. The DH slightly reduced time in hypoglycaemia but may increase the risk of gastrointestinal symptoms compared with the SH. PROSPERO registration number: CRD42022314015.
Collapse
Affiliation(s)
- Baoqi Zeng
- Department of Science and EducationPeking University Binhai HospitalTianjinChina
| | - Hao Jia
- Drug Clinical Trial InstitutionPeking University Binhai HospitalTianjinChina
| | - Le Gao
- Department of Pharmacology and PharmacyThe University of Hong KongHong KongChina
| | - Qingqing Yang
- Department of Epidemiology and Biostatistics, School of Public HealthPeking University Health Science CentreBeijingChina
| | - Kai Yu
- Department of Science and EducationPeking University Binhai HospitalTianjinChina
| | - Feng Sun
- Department of Epidemiology and Biostatistics, School of Public HealthPeking University Health Science CentreBeijingChina
| |
Collapse
|
4
|
Abstract
PURPOSE OF REVIEW Closed-loop insulin pump systems (artificial pancreas) represent the cutting edge of insulin delivery technology. There are only a few systems currently approved for use in the USA: the MiniMed 670G/770G (which share an algorithm), t:slim X2 Control IQ, and the Omnipod 5. We review these systems and look into the future of the technology. RECENT FINDINGS All of the approved closed-loop insulin pump systems have demonstrated in multicenter prospective trials improvements in time in range, hemoglobin A1c, and time spent in hypoglycemia. The newer systems have also improved time spent in automation. Comparisons between the systems with regard to glycemic control are difficult to make due to differences in clinical trial design, but there are notable differences in the user experience between systems. The past few years have been a time of exponential development in the field of closed-loop insulin pump systems. However, more research is needed to provide full automation of these systems without any need for information from the user.
Collapse
Affiliation(s)
- Keren Zhou
- Endocrinology and Metabolism Institute, Cleveland Clinic, 9500 Euclid Avenue, F20, Cleveland, OH, 44195, US.
| | - Diana Isaacs
- Endocrinology and Metabolism Institute, Cleveland Clinic, 9500 Euclid Avenue, F20, Cleveland, OH, 44195, US
| |
Collapse
|
5
|
Haidar A, Lovblom LE, Cardinez N, Gouchie-Provencher N, Orszag A, Tsoukas MA, Falappa CM, Jafar A, Ghanbari M, Eldelekli D, Rutkowski J, Yale JF, Perkins BA. Empagliflozin add-on therapy to closed-loop insulin delivery in type 1 diabetes: a 2 × 2 factorial randomized crossover trial. Nat Med 2022; 28:1269-1276. [PMID: 35551290 DOI: 10.1038/s41591-022-01805-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 03/28/2022] [Indexed: 11/09/2022]
Abstract
There is a need to optimize closed-loop automated insulin delivery in type 1 diabetes. We assessed the glycemic efficacy and safety of empagliflozin 25 mg d-1 as add-on therapy to insulin delivery with a closed-loop system. We performed a 2 × 2 factorial randomized, placebo-controlled, crossover two-center trial in adults, assessing 4 weeks of closed-loop delivery versus sensor-augmented pump (SAP) therapy and empagliflozin versus placebo. The primary outcome was time spent in the glucose target range (3.9-10.0 mmol l-1). Primary comparisons were empagliflozin versus placebo in each of closed-loop or SAP therapy; the remaining comparisons were conditional on its significance. Twenty-four of 27 randomized participants were included in the final analysis. Compared to placebo, empagliflozin improved time in target range with closed-loop therapy by 7.2% and in SAP therapy by 11.4%. Closed-loop therapy plus empagliflozin improved time in target range compared to SAP therapy plus empagliflozin by 6.1% but by 17.5% for the combination of closed-loop therapy and empagliflozin compared to SAP therapy plus placebo. While no diabetic ketoacidosis or severe hypoglycemia occurred during any intervention, uncomplicated ketosis events were more common on empagliflozin. Empagliflozin 25 mg d-1 added to automated insulin delivery improves glycemic control but increases ketone concentration and ketosis compared to placebo.
Collapse
Affiliation(s)
- Ahmad Haidar
- Department of Biomedical Engineering, McGill University, Montreal, Quebec, Canada.,The Research Institute of McGill University Health Centre, Montreal, Quebec, Canada.,Division of Endocrinology, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Leif Erik Lovblom
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Nancy Cardinez
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | | | - Andrej Orszag
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Michael A Tsoukas
- The Research Institute of McGill University Health Centre, Montreal, Quebec, Canada.,Division of Endocrinology, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - C Marcelo Falappa
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Adnan Jafar
- Department of Biomedical Engineering, McGill University, Montreal, Quebec, Canada
| | - Milad Ghanbari
- Department of Biomedical Engineering, McGill University, Montreal, Quebec, Canada
| | - Devrim Eldelekli
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Joanna Rutkowski
- Department of Biomedical Engineering, McGill University, Montreal, Quebec, Canada
| | - Jean-François Yale
- The Research Institute of McGill University Health Centre, Montreal, Quebec, Canada.,Division of Endocrinology, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Bruce A Perkins
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada. .,Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
| |
Collapse
|
6
|
Fang Z, Liu M, Tao J, Li C, Zou F, Zhang W. Efficacy and safety of closed-loop insulin delivery versus sensor-augmented pump in the treatment of adults with type 1 diabetes: a systematic review and meta-analysis of randomized-controlled trials. J Endocrinol Invest 2022; 45:471-481. [PMID: 34535888 DOI: 10.1007/s40618-021-01674-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 09/02/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Controversy remains regarding whether closed-loop (CL) insulin delivery or insulin sensor-augmented pump (SAP) delivery is more efficient for clinical treatment. Therefore, we aimed to compare the efficacy and safety of CL insulin delivery systems versus insulin SAP delivery for adults with type 1 diabetes (T1D). METHODS Embase, Ovid MEDLINE, PubMed, ScienceDirect, Scopus, the Cochrane Library, and other databases were searched for related articles, and we analyzed the average blood glucose (BG), time in range (TIR), and adverse effects (AEs) as primary endpoints to evaluate efficacy and safety. RESULTS Of 1616 articles, 12 randomized-controlled trials (RCTs) were included in the final analysis. Regarding BG control efficacy, CL insulin delivery resulted better outcomes than SAP therapy with regard to the average BG value, which was detected and recorded by continuous glucose monitoring (mean difference [MD][mmol/L]: - 0.25 95% confidence interval [CI] - 0.42 to - 0.08, p = 0.003); TIR 3.9-10 mmol/L (MD [%]: 7.91 95% CI 4.45-11.37, p < 0.00001). Similar results were observed for the secondary outcomes including low blood glucose index (LBGI) (MD: - 0.41 95% CI - 0.55 to - 0.26, p < 0.00001), high blood glucose index (HBGI) (MD: - 2.56 95% CI - 3.38 to - 1.74, p < 0.00001), and standard deviation (SD) of glucose variability (MD [mmol/L]: -0.25 95% CI - 0.44 to - 0.06, p = 0.01). Furthermore, SAP therapy was associated with more adverse effects (risk ratio: 0.20 95% CI 0.07-0.52, p = 0.001) than CL insulin delivery, and one of the most common adverse effects was hypoglycemia. CONCLUSIONS CL insulin delivery appears to be a better treatment method than SAP therapy for adults with T1D because of its increased BG control efficacy and decreased number of hypoglycemic events.
Collapse
Affiliation(s)
- Z Fang
- Department of Thoracic Surgery, The Second Affiliated Hospital of Nanchang University, 1 Minde Road, Nanchang, 330006, China
- Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
| | - M Liu
- Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
- Department of Endocrinology, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - J Tao
- Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
- Department of Endocrinology, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - C Li
- Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
- Department of Endocrinology, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - F Zou
- Department of Endocrinology, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - W Zhang
- Department of Thoracic Surgery, The Second Affiliated Hospital of Nanchang University, 1 Minde Road, Nanchang, 330006, China.
| |
Collapse
|
7
|
Rosales N, De Battista H, Garelli F. Hypoglycemia prevention: PID-type controller adaptation for glucose rate limiting in Artificial Pancreas System. Biomed Signal Process Control 2022. [DOI: 10.1016/j.bspc.2021.103106] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
8
|
Ma R, An X, Shao R, Zhang Q, Sun S. Recent advancement in noninvasive glucose monitoring and closed-loop management system for diabetes. J Mater Chem B 2022; 10:5537-5555. [DOI: 10.1039/d2tb00749e] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Diabetes can cause many complications, which has become one of the most common diseases that may lead to death. Currently, the number of diabetics continues increasing year by year. Thus,...
Collapse
|
9
|
Abstract
Closed-loop insulin delivery systems are fast becoming the standard of care in the management of type 1 diabetes and have led to significant improvements in diabetes management. Nevertheless, there is still room for improvement for the closed-loop systems to optimize treatment and meet target glycemic control. Adjunct treatments have been introduced as an alternative method to insulin-only treatment methods to overcome diabetes treatment challenges and improve clinical and patient reported outcomes during closed-loop treatment. The adjunct treatment agents mostly consist of medications that are already approved for type 2 diabetes treatment and aim to complete the missing physiologic factors, such as the entero-endocrine system, that regulate glycemia in addition to insulin. This paper will review many of these adjunct therapies, including the basic mechanisms of action, potential benefits, side effects, and the evidence supporting their use during closed-loop treatment.
Collapse
Affiliation(s)
- Shylaja Srinivasan
- Division of Pediatric Endocrinology and
Diabetes, University of San Francisco, CA, USA
| | - Laya Ekhlaspour
- Division of Pediatric Endocrinology and
Diabetes, Stanford University, Palo Alto, CA, USA
| | - Eda Cengiz
- Division of Pediatric Endocrinology and
Diabetes, Yale University, New Haven, NJ, USA
| |
Collapse
|
10
|
Abstract
Automated insulin delivery (AID) is the most recent advance in type 1 diabetes (T1D) management. It has the potential to achieve glycemic targets without disabling hypoglycemia, to improve quality of life and reduce diabetes distress and burden associated with self-management. Several AID systems are currently licensed for use by people with T1D in Europe, United States, and the rest of the world. Despite AID becoming a reality in routine clinical practice over the last few years, the commercially hybrid AID and other systems, are still far from a fully optimized automated diabetes management tool. Implementation of AID systems requires education and support of healthcare professionals taking care of people with T1D, as well as users and their families. There is much to do to increase usability, portability, convenience and to reduce the burden associated with the use of the systems. Co-design, involvement of people with lived experience of T1D and robust qualitative assessment is critical to improving the real-world use of AID systems, especially for those who may have greater need. In addition to this, information regarding the psychosocial impact of the use of AID systems in real life is needed. The first commercially available AID systems are not the end of the development journey but are the first step in learning how to optimally automate insulin delivery in a way that is equitably accessible and effective for people living with T1D.
Collapse
Affiliation(s)
- Marga Giménez
- Diabetes Unit, Endocrinology and
Nutrition Department, Hospital Clínic i Universitari, Barcelona, Spain
- CIBERDEM, Centro de Investigación
Biomédica en Red de Diabetes y Enfermedades Metabólicas, Madrid, Spain
- IDIBAPS, Institut
d’Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Ignacio Conget
- Diabetes Unit, Endocrinology and
Nutrition Department, Hospital Clínic i Universitari, Barcelona, Spain
- CIBERDEM, Centro de Investigación
Biomédica en Red de Diabetes y Enfermedades Metabólicas, Madrid, Spain
- IDIBAPS, Institut
d’Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Nick Oliver
- Department of Metabolism,
Digestion and Reproduction, Faculty of Medicine, Imperial College London,
London, UK
| |
Collapse
|
11
|
Moon SJ, Jung I, Park CY. Current Advances of Artificial Pancreas Systems: A Comprehensive Review of the Clinical Evidence. Diabetes Metab J 2021; 45:813-839. [PMID: 34847641 PMCID: PMC8640161 DOI: 10.4093/dmj.2021.0177] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 10/24/2021] [Indexed: 12/19/2022] Open
Abstract
Since Banting and Best isolated insulin in the 1920s, dramatic progress has been made in the treatment of type 1 diabetes mellitus (T1DM). However, dose titration and timely injection to maintain optimal glycemic control are often challenging for T1DM patients and their families because they require frequent blood glucose checks. In recent years, technological advances in insulin pumps and continuous glucose monitoring systems have created paradigm shifts in T1DM care that are being extended to develop artificial pancreas systems (APSs). Numerous studies that demonstrate the superiority of glycemic control offered by APSs over those offered by conventional treatment are still being published, and rapid commercialization and use in actual practice have already begun. Given this rapid development, keeping up with the latest knowledge in an organized way is confusing for both patients and medical staff. Herein, we explore the history, clinical evidence, and current state of APSs, focusing on various development groups and the commercialization status. We also discuss APS development in groups outside the usual T1DM patients and the administration of adjunct agents, such as amylin analogues, in APSs.
Collapse
Affiliation(s)
- Sun Joon Moon
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Inha Jung
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Cheol-Young Park
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| |
Collapse
|
12
|
Beneyto A, Bequette BW, Vehi J. Fault Tolerant Strategies for Automated Insulin Delivery Considering the Human Component: Current and Future Perspectives. J Diabetes Sci Technol 2021; 15:1224-1231. [PMID: 34286613 PMCID: PMC8655284 DOI: 10.1177/19322968211029297] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Automated Insulin Delivery (AID) are systems developed for daily use by people with type 1 diabetes (T1D). To ensure the safety of users, it is essential to consider how the human factor affects the performance and safety of these devices. While there are numerous publications on hardware-related failures of AID systems, there are few studies on the human component of the system. From a control point of view, people with T1D using AID systems are at the same time the plant to be controlled and the plant operator. Therefore, users may induce faults in the controller, sensors, actuators, and the plant itself. Strategies to cope with the human interaction in AID systems are needed for further development of the technology. In this paper, we present an analysis of potential faults introduced by AID users when the system is under normal operation. This is followed by a review of current fault tolerant control (FTC) approaches to identify missing areas of research. The paper concludes with a discussion on future directions for the new generation of FTC AID systems.
Collapse
Affiliation(s)
| | | | - Josep Vehi
- Universitat de Girona, Girona, Spain
- Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas, Madrid, Spain
| |
Collapse
|
13
|
Infante M, Baidal DA, Rickels MR, Fabbri A, Skyler JS, Alejandro R, Ricordi C. Dual-hormone artificial pancreas for management of type 1 diabetes: Recent progress and future directions. Artif Organs 2021; 45:968-986. [PMID: 34263961 DOI: 10.1111/aor.14023] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 06/09/2021] [Accepted: 06/14/2021] [Indexed: 02/06/2023]
Abstract
Over the last few years, technological advances have led to tremendous improvement in the management of type 1 diabetes (T1D). Artificial pancreas systems have been shown to improve glucose control compared with conventional insulin pump therapy. However, clinically significant hypoglycemic and hyperglycemic episodes still occur with the artificial pancreas. Postprandial glucose excursions and exercise-induced hypoglycemia represent major hurdles in improving glucose control and glucose variability in many patients with T1D. In this regard, dual-hormone artificial pancreas systems delivering other hormones in addition to insulin (glucagon or amylin) may better reproduce the physiology of the endocrine pancreas and have been suggested as an alternative tool to overcome these limitations in clinical practice. In addition, novel ultra-rapid-acting insulin analogs with a more physiological time-action profile are currently under investigation for use in artificial pancreas devices, aiming to address the unmet need for further improvements in postprandial glucose control. This review article aims to discuss the current progress and future outlook in the development of novel ultra-rapid insulin analogs and dual-hormone closed-loop systems, which offer the next steps to fully closing the loop in the artificial pancreas.
Collapse
Affiliation(s)
- Marco Infante
- Clinical Cell Transplant Program, Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA.,Division of Endocrinology, Metabolism and Diabetes, Department of Systems Medicine, CTO A. Alesini Hospital, Diabetes Research Institute Federation, University of Rome Tor Vergata, Rome, Italy.,UniCamillus, Saint Camillus International University of Health Sciences, Rome, Italy
| | - David A Baidal
- Clinical Cell Transplant Program, Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA.,Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Michael R Rickels
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Institute for Diabetes, Obesity and Metabolism, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Andrea Fabbri
- Division of Endocrinology, Metabolism and Diabetes, Department of Systems Medicine, CTO A. Alesini Hospital, Diabetes Research Institute Federation, University of Rome Tor Vergata, Rome, Italy
| | - Jay S Skyler
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Rodolfo Alejandro
- Clinical Cell Transplant Program, Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA.,Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Camillo Ricordi
- Clinical Cell Transplant Program, Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| |
Collapse
|
14
|
Colmegna P, Cengiz E, Garcia-Tirado J, Kraemer K, Breton MD. Impact of Accelerating Insulin on an Artificial Pancreas System Without Meal Announcement: An In Silico Examination. J Diabetes Sci Technol 2021; 15:833-841. [PMID: 32546001 PMCID: PMC8258534 DOI: 10.1177/1932296820928067] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Controlling postprandial blood glucose without the benefit of an appropriately sized premeal insulin bolus has been challenging given the delays in absorption and action of subcutaneously injected insulin during conventional and artificial pancreas (AP) system diabetes treatment. We aim to understand the impact of accelerating insulin and increasing aggressiveness of the AP controller as potential solutions to address the postprandial hyperglycemia challenge posed by unannounced meals through a simulation study. METHODS Accelerated rapid-acting insulin analogue is modeled within the UVA/Padova simulation platform by uniformly reducing its pharmacokinetic time constants (α multiplier) and used with a model predictive control, where the controller's aggressiveness depends on α. Two sets of single-meal simulations were performed: (1) where we only tune the controller's aggressiveness and (2) where we also accelerate insulin absorption and action to assess postprandial glycemic control during each intervention. RESULTS Mean percent of time spent within the 70 to 180 mg/dL postprandial glycemic range is significantly higher in set (2) than in set (1): 79.9, 95% confidence interval [77.0, 82.7] vs 88.8 [86.8, 90.9] ([Note to typesetter: Set all unnecessary math in text format and insert appropriate spaces between operators.] P < .05) for α = 2, and 81.4 [78.6, 84.3] vs 94.1 [92.6, 95.6] (P < .05) for α = 3. A decrease in percent of time below 70 mg/dL is also detected: 0.9 [0.4, 2.2] vs 0.6 [0.2, 1.4] (P = .23) for α = 2 and 1.4 [0.7, 2.8] vs 0.4 [0.1, 1.4] (P < .05) for α = 3. CONCLUSION These proof-of-concept simulations suggest that an AP without prandial insulin boluses combined with significantly faster insulin analogues could match the glycemic performance obtained with an optimal hybrid AP.
Collapse
Affiliation(s)
- Patricio Colmegna
- Center for Diabetes Technology, University of Virginia, Charlottesville, USA
- National Scientific and Technical Research Council, Buenos Aires, Argentina
- Patricio Colmegna, PhD, Center for Diabetes Technology, University of Virginia, 560 Ray C Hunt Dr, Charlottesville, VA 22903, USA.
| | - Eda Cengiz
- Division of Pediatric Endocrinology and Diabetes, Yale University School of Medicine, New Haven, CT, USA
- Bahcesehir University School of Medicine, Istanbul, Turkey
| | - Jose Garcia-Tirado
- Center for Diabetes Technology, University of Virginia, Charlottesville, USA
| | - Kristen Kraemer
- Division of Pediatric Endocrinology and Diabetes, Yale University School of Medicine, New Haven, CT, USA
| | - Marc D. Breton
- Center for Diabetes Technology, University of Virginia, Charlottesville, USA
| |
Collapse
|
15
|
Abstract
Advances in diabetes technologies have enabled the development of automated closed-loop insulin delivery systems. Several hybrid closed-loop systems have been commercialised, reflecting rapid transition of this evolving technology from research into clinical practice, where it is gradually transforming the management of type 1 diabetes in children and adults. In this review we consider the supporting evidence in terms of glucose control and quality of life for presently available closed-loop systems and those in development, including dual-hormone closed-loop systems. We also comment on alternative 'do-it-yourself' closed-loop systems. We remark on issues associated with clinical adoption of these approaches, including training provision, and consider limitations of presently available closed-loop systems and areas for future enhancements to further improve outcomes and reduce the burden of diabetes management.
Collapse
Affiliation(s)
- Charlotte K Boughton
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Roman Hovorka
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK.
| |
Collapse
|
16
|
Jafar A, Fathi AE, Haidar A. Long-term use of the hybrid artificial pancreas by adjusting carbohydrate ratios and programmed basal rate: A reinforcement learning approach. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2021; 200:105936. [PMID: 33515844 DOI: 10.1016/j.cmpb.2021.105936] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 01/06/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND AND OBJECTIVES The hybrid artificial pancreas regulates glucose levels in people with type 1 diabetes. It delivers (i) insulin boluses at meal times based on the meals' carbohydrate content and the carbohydrate ratios (CRs) and (ii) insulin basal, between meals and at night, continuously modulated around individual-specific programmed basal rate. The CRs and programmed basal rate significantly vary between individuals and within the same individual with type 1 diabetes, and using suboptimal values in the hybrid artificial pancreas may degrade glucose control. We propose a reinforcement learning algorithm to adaptively optimize CRs and programmed basal rate to improve the performance of the hybrid artificial pancreas. METHODS The proposed reinforcement learning algorithm was designed using the Q-learning approach. The algorithm learns the optimal actions (CRs and programmed basal rate) by applying them to the individual's state (previous day's glucose levels and insulin delivery) based on an exploration and exploitation trade-off. First, outcomes from our simulator were compared to those of a clinical study in 23 individuals with type 1 diabetes and have yielded similar results. Second, the learning algorithm was tested using the simulator with two scenarios. Scenario 1 has fixed meal sizes and ingestion times and scenario 2 has a more realistic eating behavior with random meal sizes, ingestion times, and carbohydrate counting errors. RESULTS After about five weeks, the reinforcement learning algorithm improved the percentage of time spent in target range from 67% to 86.7% in scenario 1 and 65.5% to 86% in scenario 2. The percentage of time spent below 4.0 mmol/L decreased from 9% to 0.9% in scenario 1 and 9.5% to 1.1% in scenario 2. CONCLUSIONS Results indicate that the proposed algorithm has the potential to improve glucose control in people with type 1 diabetes using the hybrid artificial pancreas. The proposed algorithm is a key in making the hybrid artificial pancreas adaptive for the long-term real life outpatient studies.
Collapse
Affiliation(s)
- Adnan Jafar
- Department of Biomedical Engineering, McGill University, Montreal, Canada.
| | - Anas El Fathi
- Department of Electrical and Computer Engineering, McGill University, Montreal, Canada.
| | - Ahmad Haidar
- Department of Biomedical Engineering, McGill University, Montreal, Canada.
| |
Collapse
|
17
|
Haidar A, Legault L, Raffray M, Gouchie-Provencher N, Jacobs PG, El-Fathi A, Rutkowski J, Messier V, Rabasa-Lhoret R. Comparison Between Closed-Loop Insulin Delivery System (the Artificial Pancreas) and Sensor-Augmented Pump Therapy: A Randomized-Controlled Crossover Trial. Diabetes Technol Ther 2021; 23:168-174. [PMID: 33050728 PMCID: PMC7906861 DOI: 10.1089/dia.2020.0365] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Objective: Several studies have shown that closed-loop automated insulin delivery (the artificial pancreas) improves glucose control compared with sensor-augmented pump therapy. We aimed to confirm these findings using our automated insulin delivery system based on the iPancreas platform. Research Design and Methods: We conducted a two-center, randomized crossover trial comparing automated insulin delivery with sensor-augmented pump therapy in 36 adults with type 1 diabetes. Each intervention lasted 12 days in outpatient free-living conditions with no remote monitoring. The automated insulin delivery system used a model predictive control algorithm that was a less aggressive version of our earlier dosing algorithm to emphasize safety. The primary outcome was time in the range 3.9-10.0 mmol/L. Results: The automated insulin delivery system was operational 90.2% of the time. Compared with the sensor-augmented pump therapy, automated insulin delivery increased time in range (3.9-10.0 mmol/L) from 61% (interquartile range 53-74) to 69% (60-73; P = 0.006) and increased time in tight target range (3.9-7.8 mmol/L) from 37% (30-49) to 45% (35-51; P = 0.011). Automated insulin delivery also reduced time spent below 3.9 and 3.3 mmol/L from 3.5% (0.8-5.4) to 1.6% (1.1-2.7; P = 0.0021) and from 0.9% (0.2-2.1) to 0.5% (0.2-1.1; P = 0.0122), respectively. Time spent below 2.8 mmol/L was 0.2% (0.0-0.6) with sensor-augmented pump therapy and 0.1% (0.0-0.4; P = 0.155) with automated insulin delivery. Conclusions: Our study confirms findings that automated insulin delivery improves glucose control compared with sensor-augmented pump therapy. ClinicalTrials.gov no. NCT02846831.
Collapse
Affiliation(s)
- Ahmad Haidar
- Department of Biomedical Engineering, McGill University, Montreal, Canada
- Centre for Translational Biology, Research Institute of McGill University Health Centre, Montréal, Canada
| | - Laurent Legault
- Department of Pediatrics, Division of Endocrinology and Metabolism, McGill University Health Centre, Montréal, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of McGill University Health Centre, Montréal, Canada
| | - Marie Raffray
- Metabolic Diseases Research Unit, Institut de recherches cliniques de Montréal, Montréal, Canada
| | - Nikita Gouchie-Provencher
- Centre for Translational Biology, Research Institute of McGill University Health Centre, Montréal, Canada
| | - Peter G. Jacobs
- Department of Biomedical Engineering, Oregon Health and Science University, Portland, Oregon, USA
| | - Anas El-Fathi
- Department of Biomedical Engineering, McGill University, Montreal, Canada
| | - Joanna Rutkowski
- Department of Biomedical Engineering, McGill University, Montreal, Canada
| | - Virginie Messier
- Metabolic Diseases Research Unit, Institut de recherches cliniques de Montréal, Montréal, Canada
| | - Rémi Rabasa-Lhoret
- Metabolic Diseases Research Unit, Institut de recherches cliniques de Montréal, Montréal, Canada
- Nutrition Department, Faculty of Medicine, Université de Montréal, Montréal, Canada
- Montreal Diabetes Research Center and Endocrinology Division, Montréal, Canada
- Address correspondence to: Rémi Rabasa-Lhoret, MD, PhD, Metabolic Diseases Research Unit, Institut de recherches cliniques de Montréal, 110, avenue des Pins Ouest, Montréal (Québec) Canada H2W 1R7
| |
Collapse
|
18
|
Wilson LM, Jacobs PG, Ramsey KL, Resalat N, Reddy R, Branigan D, Leitschuh J, Gabo V, Guillot F, Senf B, El Youssef J, Steineck IIK, Tyler NS, Castle JR. Dual-Hormone Closed-Loop System Using a Liquid Stable Glucagon Formulation Versus Insulin-Only Closed-Loop System Compared With a Predictive Low Glucose Suspend System: An Open-Label, Outpatient, Single-Center, Crossover, Randomized Controlled Trial. Diabetes Care 2020; 43:2721-2729. [PMID: 32907828 DOI: 10.2337/dc19-2267] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 08/16/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To assess the efficacy and feasibility of a dual-hormone (DH) closed-loop system with insulin and a novel liquid stable glucagon formulation compared with an insulin-only closed-loop system and a predictive low glucose suspend (PLGS) system. RESEARCH DESIGN AND METHODS In a 76-h, randomized, crossover, outpatient study, 23 participants with type 1 diabetes used three modes of the Oregon Artificial Pancreas system: 1) dual-hormone (DH) closed-loop control, 2) insulin-only single-hormone (SH) closed-loop control, and 3) PLGS system. The primary end point was percentage time in hypoglycemia (<70 mg/dL) from the start of in-clinic aerobic exercise (45 min at 60% VO2max) to 4 h after. RESULTS DH reduced hypoglycemia compared with SH during and after exercise (DH 0.0% [interquartile range 0.0-4.2], SH 8.3% [0.0-12.5], P = 0.025). There was an increased time in hyperglycemia (>180 mg/dL) during and after exercise for DH versus SH (20.8% DH vs. 6.3% SH, P = 0.038). Mean glucose during the entire study duration was DH, 159.2; SH, 151.6; and PLGS, 163.6 mg/dL. Across the entire study duration, DH resulted in 7.5% more time in target range (70-180 mg/dL) compared with the PLGS system (71.0% vs. 63.4%, P = 0.044). For the entire study duration, DH had 28.2% time in hyperglycemia vs. 25.1% for SH (P = 0.044) and 34.7% for PLGS (P = 0.140). Four participants experienced nausea related to glucagon, leading three to withdraw from the study. CONCLUSIONS The glucagon formulation demonstrated feasibility in a closed-loop system. The DH system reduced hypoglycemia during and after exercise, with some increase in hyperglycemia.
Collapse
Affiliation(s)
- Leah M Wilson
- Harold Schnitzer Diabetes Health Center, Division of Endocrinology, Oregon Health & Science University, Portland, OR
| | - Peter G Jacobs
- Artificial Intelligence for Medical Systems (AIMS) Lab, Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR
| | - Katrina L Ramsey
- Oregon Clinical and Translational Research Institute Biostatistics and Design Program, Oregon Health & Science University & Portland State University School of Public Health, Portland, OR
| | - Navid Resalat
- Artificial Intelligence for Medical Systems (AIMS) Lab, Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR
| | - Ravi Reddy
- Artificial Intelligence for Medical Systems (AIMS) Lab, Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR
| | - Deborah Branigan
- Harold Schnitzer Diabetes Health Center, Division of Endocrinology, Oregon Health & Science University, Portland, OR
| | - Joseph Leitschuh
- Artificial Intelligence for Medical Systems (AIMS) Lab, Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR
| | - Virginia Gabo
- Harold Schnitzer Diabetes Health Center, Division of Endocrinology, Oregon Health & Science University, Portland, OR
| | - Florian Guillot
- Harold Schnitzer Diabetes Health Center, Division of Endocrinology, Oregon Health & Science University, Portland, OR
| | - Brian Senf
- Harold Schnitzer Diabetes Health Center, Division of Endocrinology, Oregon Health & Science University, Portland, OR
| | - Joseph El Youssef
- Harold Schnitzer Diabetes Health Center, Division of Endocrinology, Oregon Health & Science University, Portland, OR.,Artificial Intelligence for Medical Systems (AIMS) Lab, Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR
| | | | - Nichole S Tyler
- Artificial Intelligence for Medical Systems (AIMS) Lab, Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR
| | - Jessica R Castle
- Harold Schnitzer Diabetes Health Center, Division of Endocrinology, Oregon Health & Science University, Portland, OR
| |
Collapse
|
19
|
Ranjan AG, Schmidt S, Nørgaard K. Glucagon for hypoglycaemia treatment in type 1 diabetes. Diabetes Metab Res Rev 2020; 37:e3409. [PMID: 33090668 DOI: 10.1002/dmrr.3409] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 08/14/2020] [Accepted: 09/14/2020] [Indexed: 12/22/2022]
Abstract
To achieve strict glycaemic control and avoid chronic diabetes complications, individuals with type 1 diabetes (T1D) are recommended to follow an intensive insulin regimen. However, the risk and fear of hypoglycaemia often prevent individuals from achieving the treatment goals. Apart from early insulin suspension in insulin pump users, carbohydrate ingestion is the only option for preventing and treating non-severe hypoglycaemic events. These rescue treatments may give extra calories and cause overweight. As an alternative, the use of low-dose glucagon to counter hypoglycaemia has been proposed as a tool to raise glucose concentrations without adding extra calories. Previously, the commercially available glucagon formulations required reconstitution from powder to a solution before being injected subcutaneously or intramuscularly-making it practical only for treating severe hypoglycaemia. Several companies have developed more stable formulations that do not require the time-consuming reconstitution process before use. As well as treating severe hypoglycaemia, non-severe and impending hypoglycaemia can also be treated with lower doses of glucagon. Once available, low-dose glucagon can be either delivered manually, as an injection, or automatically, by an infusion pump. This review focuses on the role and perspectives of using glucagon to treat and prevent hypoglycaemia in T1D.
Collapse
Affiliation(s)
- Ajenthen G Ranjan
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
- Danish Diabetes Academy, Odense, Denmark
| | | | | |
Collapse
|
20
|
|
21
|
Haidar A, Tsoukas MA, Bernier-Twardy S, Yale JF, Rutkowski J, Bossy A, Pytka E, El Fathi A, Strauss N, Legault L. A Novel Dual-Hormone Insulin-and-Pramlintide Artificial Pancreas for Type 1 Diabetes: A Randomized Controlled Crossover Trial. Diabetes Care 2020; 43:597-606. [PMID: 31974099 DOI: 10.2337/dc19-1922] [Citation(s) in RCA: 78] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 11/22/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The rapid insulin-alone artificial pancreas improves glycemia in type 1 diabetes but daytime control remains suboptimal. We propose two novel dual-hormone artificial pancreas systems. RESEARCH DESIGN AND METHODS We conducted a randomized crossover trial comparing a rapid insulin-alone artificial pancreas with rapid insulin-and-pramlintide and with regular insulin-and-pramlintide artificial pancreas systems in adults with type 1 diabetes. Participants were assigned to the interventions in random order during three 24-h inpatient visits. Each visit was preceded by an outpatient hormonal open-loop run-in period of 10-14 days. The dual-hormone artificial pancreas delivered pramlintide in a basal-bolus manner, using a novel dosing algorithm, with a fixed ratio relative to insulin. The primary outcome was time in the range 3.9-10.0 mmol/L. RESULTS Compared with the rapid insulin-alone artificial pancreas system, the rapid insulin-and-pramlintide system increased the time in range from 74% (SD 18%) to 84% (13%) (P = 0.0014), whereas the regular insulin-and-pramlintide system did not change the time in range (69% [19%]; P = 0.22). The increased time in range with the rapid insulin-and-pramlintide system was due to improved daytime control (daytime time in range increased from 63% [23%] to 78% [16%], P = 0.0004). There were 11 (1 per 2.5 days) hypoglycemic events (<3.3 mmol/L with symptoms or <3.0 mmol/L irrespective of symptoms) with the rapid insulin-alone system, compared with 12 (1 per 2.3 days) and 18 (1 per 1.4 days) with the rapid and regular insulin-and-pramlintide systems, respectively. Gastrointestinal symptoms were reported after 0% (0 of 112) of meals with the rapid insulin-alone system, compared with 6% (6 of 108) and 11% (11 of 104) with the rapid and regular insulin-and-pramlintide systems, respectively; none of the symptoms were severe. CONCLUSIONS A novel rapid insulin-and-pramlintide artificial pancreas improves glucose control compared with a rapid insulin-alone artificial pancreas (ClinicalTrials.gov number NCT02814123).
Collapse
Affiliation(s)
- Ahmad Haidar
- Department of Biomedical Engineering, McGill University, Montréal, Québec, Canada .,The Research Institute of McGill University Health Centre, Montréal, Québec, Canada
| | - Michael A Tsoukas
- The Research Institute of McGill University Health Centre, Montréal, Québec, Canada.,Royal Victoria Hospital, McGill University Health Centre, Montréal, Québec, Canada
| | - Sarah Bernier-Twardy
- Department of Biomedical Engineering, McGill University, Montréal, Québec, Canada
| | - Jean-Francois Yale
- The Research Institute of McGill University Health Centre, Montréal, Québec, Canada.,Royal Victoria Hospital, McGill University Health Centre, Montréal, Québec, Canada
| | - Joanna Rutkowski
- Department of Biomedical Engineering, McGill University, Montréal, Québec, Canada
| | - Anne Bossy
- Department of Biomedical Engineering, McGill University, Montréal, Québec, Canada
| | - Evelyne Pytka
- Department of Biomedical Engineering, McGill University, Montréal, Québec, Canada
| | - Anas El Fathi
- Department of Biomedical Engineering, McGill University, Montréal, Québec, Canada
| | - Natalia Strauss
- Department of Biomedical Engineering, McGill University, Montréal, Québec, Canada
| | - Laurent Legault
- Montreal Children's Hospital, McGill University Health Centre, Montréal, Québec, Canada
| |
Collapse
|
22
|
Abstract
Treatment of type 1 diabetes with exogenous insulin often results in unpredictable daily glucose variability and hypoglycemia, which can be dangerous. Automated insulin delivery systems can improve glucose control while reducing burden for people with diabetes. One approach to improve treatment outcomes is to incorporate the counter-regulatory hormone glucagon into the automated delivery system to help prevent the hypoglycemia that can be induced by the slow pharmacodynamics of insulin action. This article explores the advantages and disadvantages of incorporating glucagon into dual-hormone automated hormone delivery systems.
Collapse
Affiliation(s)
- Leah M Wilson
- Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University, Harold Schnitzer Diabetes Health Center, 3181 Southwest Sam Jackson Park Road, L607, Portland, OR 97239-3098, USA.
| | - Peter G Jacobs
- Department of Biomedical Engineering, Oregon Health & Science University, Mail Code: CH13B, 3303 Southwest Bond Avenue, Portland, OR 97239, USA
| | - Jessica R Castle
- Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University, Harold Schnitzer Diabetes Health Center, 3181 Southwest Sam Jackson Park Road, L607, Portland, OR 97239-3098, USA
| |
Collapse
|
23
|
[What is the current state of the artificial pancreas in diabetes care?]. Internist (Berl) 2019; 61:102-109. [PMID: 31863132 DOI: 10.1007/s00108-019-00713-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The artificial pancreas (also referred to as closed-loop system) brings us one step closer to the decade-long dream of automated insulin delivery. The closed-loop system directs subcutaneous insulin delivery corresponding to the glucose concentration using a control algorithm. Evidence shows that closed-loop systems substantially improve glucose control and quality of life; however, fully automated closed-loop systems have not yet been accomplished. Active input from patients is required for mealtime insulin dosing and corrections. This article provides an overview on the current state of development of the artificial pancreas in the treatment of diabetes.
Collapse
|
24
|
Moscardó V, Díez JL, Bondia J. Parallel Control of an Artificial Pancreas with Coordinated Insulin, Glucagon, and Rescue Carbohydrate Control Actions. J Diabetes Sci Technol 2019; 13:1026-1034. [PMID: 31631688 PMCID: PMC6835176 DOI: 10.1177/1932296819879093] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND An artificial pancreas with insulin and glucagon delivery has the potential to reduce the risk of hypo- and hyperglycemia in people with type 1 diabetes. However, a maximum dose of glucagon of 1 mg/d is recommended, potentially still requiring rescue carbohydrates in some situations. This work presents a parallel control structure with intrinsic insulin, glucagon, and rescue carbohydrates coordination to overcome glucagon limitations when needed. METHODS The coordinated controller that combines insulin, glucagon, and rescue carbohydrate suggestions (DH-CC-CHO) was compared with the insulin and glucagon delivery coordinated controller (DH-CC). The impact of carbohydrate quantization for practical delivery was also assessed. An in silico study using the UVA-Padova simulator, extended to include exercise and various sources of variability, was performed. RESULTS DH-CC and DH-CC-CHO performed similarly with regard to mean glucose (126.25 [123.43; 130.73] vs 127.92 [123.99; 132.97] mg/dL, P = .088), time in range (93.04 [90.00; 95.92] vs 92.91 [90.05; 95.75]%, P = .508), time above 180 mg/dL (4.94 [2.72; 7.53] vs 4.99 [2.93; 7.24]%, P = .966), time below 70 mg/dL (0.61 [0.09; 1.75] vs 0.96 [0.23; 2.17]%, P = .1364), insulin delivery (43.50 [38.68; 51.75] vs 42.86 [38.58; 51.36] U/d, P = .383), and glucagon delivery (0.75 [0.40; 1.83] vs 0.76 [0.43; 0.99] mg/d, P = .407). Time below 54 mg/dL was different (0.00 [0.00; 0.05] vs 0.00 [0.00; 0.16]%, P = .036), although non-clinically significant. This was due to the carbs quantization effect in a specific patient, as no statistical difference was found when carbs were not quantized (0.00 [0.00; 0.05] vs 0.00 [0.00; 0.00]%, P = .265). CONCLUSIONS The new strategy of automatic rescue carbohydrates suggestion in coordination with insulin and glucagon delivery to overcome constraints on daily glucagon delivery was successfully evaluated in an in silico proof of concept.
Collapse
Affiliation(s)
- Vanessa Moscardó
- Instituto Universitario de Automática e Informática Industrial, Universitat Politècnica de València, Valencia, Spain
| | - José Luis Díez
- Instituto Universitario de Automática e Informática Industrial, Universitat Politècnica de València, Valencia, Spain
- Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Av. Monforte de Lemos, Madrid, Spain
| | - Jorge Bondia
- Instituto Universitario de Automática e Informática Industrial, Universitat Politècnica de València, Valencia, Spain
- Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Av. Monforte de Lemos, Madrid, Spain
- Jorge Bondia, Instituto Universitario de Automática e Informática Industrial, Universitat Politècnica de València, C/Camino de Vera, s/n, 46022 Valencia, Spain.
| |
Collapse
|
25
|
Haidar A. Insulin-and-Glucagon Artificial Pancreas Versus Insulin-Alone Artificial Pancreas: A Short Review. Diabetes Spectr 2019; 32:215-221. [PMID: 31462876 PMCID: PMC6695257 DOI: 10.2337/ds18-0097] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IN BRIEF The advantage of the insulin-and-glucagon artificial pancreas is based on the rapid effect of subcutaneous glucagon delivery in preventing hypoglycemia compared to suspension of insulin delivery. In short-term studies, the dual-hormone artificial pancreas reduced daytime hypoglycemia, especially during exercise, compared to the insulin-alone artificial pancreas, but the insulin-alone system seemed sufficient in eliminating nocturnal hypoglycemia. The comparative benefits of the single- and dual-hormone systems for improving A1C and preventing severe hypoglycemia remain unknown.
Collapse
Affiliation(s)
- Ahmad Haidar
- Department of Biomedical Engineering, McGill University, Montreal, Quebec, Canada
- Division of Endocrinology and Metabolism, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
- The Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| |
Collapse
|
26
|
Beato-Víbora PI, Arroyo-Díez FJ. New uses and formulations of glucagon for hypoglycaemia. Drugs Context 2019; 8:212599. [PMID: 31402931 PMCID: PMC6675539 DOI: 10.7573/dic.212599] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 06/23/2019] [Accepted: 06/26/2019] [Indexed: 12/11/2022] Open
Abstract
Hypoglycaemia is the more frequent complication of insulin therapy and the main barrier to tight glycaemic control. Injectable glucagon and oral intake of carbohydrates are the recommended treatments for severe and non-severe hypoglycaemia episodes, respectively. Nasal glucagon is currently being developed as a ready-to-use device, to simplify severe hypoglycaemia rescue. Stable forms of liquid glucagon could open the field for different approaches for mild to moderate hypoglycaemia treatment, such as mini-doses of glucagon or continuous subcutaneous glucagon infusion as a part of dual-hormone closed-loop systems. Pharmaceutical companies are developing stable forms of native glucagon or glucagon analogues for that purpose.
Collapse
Affiliation(s)
- Pilar I Beato-Víbora
- Department of Endocrinology and Nutrition, Department of Paediatrics, Badajoz University Hospital, Badajoz, Spain
| | - Francisco J Arroyo-Díez
- Department of Endocrinology and Nutrition, Department of Paediatrics, Badajoz University Hospital, Badajoz, Spain
| |
Collapse
|
27
|
Artificial Pancreas: Current Progress and Future Outlook in the Treatment of Type 1 Diabetes. Drugs 2019; 79:1089-1101. [DOI: 10.1007/s40265-019-01149-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
28
|
Benhamou PY, Franc S, Reznik Y, Thivolet C, Schaepelynck P, Renard E, Guerci B, Chaillous L, Lukas-Croisier C, Jeandidier N, Hanaire H, Borot S, Doron M, Jallon P, Xhaard I, Melki V, Meyer L, Delemer B, Guillouche M, Schoumacker-Ley L, Farret A, Raccah D, Lablanche S, Joubert M, Penfornis A, Charpentier G. Closed-loop insulin delivery in adults with type 1 diabetes in real-life conditions: a 12-week multicentre, open-label randomised controlled crossover trial. LANCET DIGITAL HEALTH 2019; 1:e17-e25. [DOI: 10.1016/s2589-7500(19)30003-2] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 03/01/2019] [Accepted: 03/06/2019] [Indexed: 12/31/2022]
|
29
|
Navigating Two Roads to Glucose Normalization in Diabetes: Automated Insulin Delivery Devices and Cell Therapy. Cell Metab 2019; 29:545-563. [PMID: 30840911 DOI: 10.1016/j.cmet.2019.02.007] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 02/12/2019] [Accepted: 02/13/2019] [Indexed: 12/23/2022]
Abstract
Incredible strides have been made since the discovery of insulin almost 100 years ago. Insulin formulations have improved dramatically, glucose levels can be measured continuously, and recently first-generation biomechanical "artificial pancreas" systems have been approved by regulators around the globe. However, still only a small fraction of patients with diabetes achieve glycemic goals. Replacement of insulin-producing cells via transplantation shows significant promise, but is limited in application due to supply constraints (cadaver-based) and the need for chronic immunosuppression. Over the past decade, significant progress has been made to address these barriers to widespread implementation of a cell therapy. Can glucose levels in people with diabetes be normalized with artificial pancreas systems or via cell replacement approaches? Here we review the road ahead, including the challenges and opportunities of both approaches.
Collapse
|
30
|
Hövelmann U, Olsen MB, Mouritzen U, Lamers D, Kronshage B, Heise T. Low doses of dasiglucagon consistently increase plasma glucose levels from hypoglycaemia and euglycaemia in people with type 1 diabetes mellitus. Diabetes Obes Metab 2019; 21:601-610. [PMID: 30350477 PMCID: PMC6587565 DOI: 10.1111/dom.13562] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 10/07/2018] [Accepted: 10/16/2018] [Indexed: 02/06/2023]
Abstract
AIM To characterize the pharmacokinetic and pharmacodynamic properties of dasiglucagon, a novel, stable and liquid formulated glucagon analogue, during hypoglycaemic and euglycaemic conditions in adult patients with type 1 diabetes mellitus. RESEARCH DESIGN AND METHODS In this randomized double-blind trial, 17 patients received four single subcutaneous doses (0.03, 0.08, 0.2 and 0.6 mg) of dasiglucagon (4 mg/mL formulation) under euglycaemic (plasma glucose [PG] 5.6 mmol/L [100 mg/dL]) or hypoglycaemic (PG 3.1-3.7 mmol/L [56-66 mg/dL]) conditions. For comparison, three doses (0.03, 0.08 and 0.2 mg) of a commercial glucagon formulation (Eli Lilly) were investigated at euglycaemia. RESULTS Dasiglucagon led to a dose-dependent and rapid increase in PG levels across all doses tested (mean increases 30 minutes post-dosing of 2.2 to 4.4 mmol/L [39-80 mg/dL] from euglycaemia and 1.3 to 5.2 mmol/L [24-94 mg/dL] from hypoglycaemia), which was higher than the rises elicited by similar doses of commercial glucagon (1.7-3.9 mmol/L [30-71 mg/dL]). The median time (range) to an increase in PG of >1.1 mmol/L (20 mg/dL) was <20 (18-19.5) minutes with 0.03 mg dasiglucagon and, with higher doses, the median times ranged from 9 to 15 minutes (commercial glucagon 13-14 minutes). In hypoglycaemia, 0.03 and 0.08 mg dasiglucagon re-established normoglycaemia (PG ≥3.9 mmol/L [70 mg/dL]) within median times of 14 and 10 minutes, respectively. Nausea and vomiting occurred more frequently with dasiglucagon than with commercial glucagon at identical doses which might be attributable to dasiglucagon's higher potency. CONCLUSION Dasiglucagon rapidly increased PG at doses of 0.03 to 0.6 mg in a dose-dependent manner and, therefore, is a good candidate for use in dual-hormone artificial pancreas systems.
Collapse
|
31
|
Boughton CK, Hovorka R. Is an artificial pancreas (closed-loop system) for Type 1 diabetes effective? Diabet Med 2019; 36:279-286. [PMID: 30183096 DOI: 10.1111/dme.13816] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/03/2018] [Indexed: 12/12/2022]
Abstract
The artificial pancreas is now a viable treatment option for people with Type 1 diabetes and has demonstrated improved glycaemic outcomes while also reducing the onus of self-management of Type 1 diabetes. Closed-loop glucose-responsive insulin delivery guided by real-time sensor glucose readings can accommodate highly variable day-to-day insulin requirements and reduce the hypoglycaemia risk observed with tight glycaemic control in Type 1 diabetes. In 2011, the James Lind Alliance research priorities for Type 1 diabetes were produced and priority 3 was to establish whether an artificial pancreas (closed-loop system) for Type 1 diabetes is effective. This review focuses on the progress that has been made in the evolution of closed-loop systems as an effective treatment option for Type 1 diabetes. Development of closed-loop systems has advanced from feasibility evaluations in highly supervised settings over short periods, to clinical studies in free-living, unsupervised conditions lasting several months. The approval in the USA of the first hybrid closed-loop system (MiniMed® 670G pump, Medtronic, Northridge, CA, USA) in 2016 for use in Type 1 diabetes reflects these advancements. We discuss the evidence from clinical studies that closed-loop systems are effective with improved glycaemic outcomes, reduced hypoglycaemia and had positive end-user acceptance in children, adolescents, adults and pregnant women with Type 1 diabetes. We also present the outlook for future closed-loop systems in the treatment of Type 1 diabetes and identify the challenges facing the wide-spread clinical adoption of this technology.
Collapse
Affiliation(s)
- C K Boughton
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - R Hovorka
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| |
Collapse
|
32
|
Tauschmann M, Thabit H, Bally L, Allen JM, Hartnell S, Wilinska ME, Ruan Y, Sibayan J, Kollman C, Cheng P, Beck RW, Acerini CL, Evans ML, Dunger DB, Elleri D, Campbell F, Bergenstal RM, Criego A, Shah VN, Leelarathna L, Hovorka R. Closed-loop insulin delivery in suboptimally controlled type 1 diabetes: a multicentre, 12-week randomised trial. Lancet 2018; 392:1321-1329. [PMID: 30292578 PMCID: PMC6182127 DOI: 10.1016/s0140-6736(18)31947-0] [Citation(s) in RCA: 260] [Impact Index Per Article: 43.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 07/26/2018] [Accepted: 08/15/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND The achievement of glycaemic control remains challenging for patients with type 1 diabetes. We assessed the effectiveness of day-and-night hybrid closed-loop insulin delivery compared with sensor-augmented pump therapy in people with suboptimally controlled type 1 diabetes aged 6 years and older. METHODS In this open-label, multicentre, multinational, single-period, parallel randomised controlled trial, participants were recruited from diabetes outpatient clinics at four hospitals in the UK and two centres in the USA. We randomly assigned participants with type 1 diabetes aged 6 years and older treated with insulin pump and with suboptimal glycaemic control (glycated haemoglobin [HbA1c] 7·5-10·0%) to receive either hybrid closed-loop therapy or sensor-augmented pump therapy over 12 weeks of free living. Training on study insulin pump and continuous glucose monitoring took place over a 4-week run-in period. Eligible subjects were randomly assigned using central randomisation software. Allocation to the two study groups was unblinded, and randomisation was stratified within centre by low (<8·5%) or high (≥8·5%) HbA1c. The primary endpoint was the proportion of time that glucose concentration was within the target range of 3·9-10·0 mmol/L at 12 weeks post randomisation. Analyses of primary outcome and safety measures were done in all randomised patients. The trial is registered with ClinicalTrials.gov, number NCT02523131, and is closed to accrual. FINDINGS From May 12, 2016, to Nov 17, 2017, 114 individuals were screened, and 86 eligible patients were randomly assigned to receive hybrid closed-loop therapy (n=46) or sensor-augmented pump therapy (n=40; control group). The proportion of time that glucose concentration was within the target range was significantly higher in the closed-loop group (65%, SD 8) compared with the control group (54%, SD 9; mean difference in change 10·8 percentage points, 95% CI 8·2 to 13·5; p<0·0001). In the closed-loop group, HbA1c was reduced from a screening value of 8·3% (SD 0·6) to 8·0% (SD 0·6) after the 4-week run-in, and to 7·4% (SD 0·6) after the 12-week intervention period. In the control group, the HbA1c values were 8·2% (SD 0·5) at screening, 7·8% (SD 0·6) after run-in, and 7·7% (SD 0·5) after intervention; reductions in HbA1c percentages were significantly greater in the closed-loop group compared with the control group (mean difference in change 0·36%, 95% CI 0·19 to 0·53; p<0·0001). The time spent with glucose concentrations below 3·9 mmol/L (mean difference in change -0·83 percentage points, -1·40 to -0·16; p=0·0013) and above 10·0 mmol/L (mean difference in change -10·3 percentage points, -13·2 to -7·5; p<0·0001) was shorter in the closed-loop group than the control group. The coefficient of variation of sensor-measured glucose was not different between interventions (mean difference in change -0·4%, 95% CI -1·4% to 0·7%; p=0·50). Similarly, total daily insulin dose was not different (mean difference in change 0·031 U/kg per day, 95% CI -0·005 to 0·067; p=0·09) and bodyweight did not differ (mean difference in change 0·68 kg, 95% CI -0·34 to 1·69; p=0·19). No severe hypoglycaemia occurred. One diabetic ketoacidosis occurred in the closed-loop group due to infusion set failure. Two participants in each study group had significant hyperglycaemia, and there were 13 other adverse events in the closed-loop group and three in the control group. INTERPRETATION Hybrid closed-loop insulin delivery improves glucose control while reducing the risk of hypoglycaemia across a wide age range in patients with suboptimally controlled type 1 diabetes. FUNDING JDRF, NIHR, and Wellcome Trust.
Collapse
Affiliation(s)
- Martin Tauschmann
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK; Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Hood Thabit
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK; Department of Diabetes and Endocrinology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; Manchester University NHS Foundation Trust and University of Manchester, Manchester, UK
| | - Lia Bally
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK; Department of Diabetes and Endocrinology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Janet M Allen
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK; Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Sara Hartnell
- Department of Diabetes and Endocrinology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Malgorzata E Wilinska
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK; Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Yue Ruan
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | | | | | | | - Roy W Beck
- Jaeb Center for Health Research, Tampa, FL, USA
| | - Carlo L Acerini
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK; Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Mark L Evans
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK; Department of Diabetes and Endocrinology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - David B Dunger
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK; Department of Paediatrics, University of Cambridge, Cambridge, UK
| | | | | | | | - Amy Criego
- International Diabetes Center, Minneapolis, MN, USA
| | - Viral N Shah
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Lalantha Leelarathna
- Manchester University NHS Foundation Trust and University of Manchester, Manchester, UK
| | - Roman Hovorka
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK; Department of Paediatrics, University of Cambridge, Cambridge, UK.
| |
Collapse
|
33
|
Sánchez-Peña R, Colmegna P, Garelli F, De Battista H, García-Violini D, Moscoso-Vásquez M, Rosales N, Fushimi E, Campos-Náñez E, Breton M, Beruto V, Scibona P, Rodriguez C, Giunta J, Simonovich V, Belloso WH, Cherñavvsky D, Grosembacher L. Artificial Pancreas: Clinical Study in Latin America Without Premeal Insulin Boluses. J Diabetes Sci Technol 2018; 12:914-925. [PMID: 29998754 PMCID: PMC6134619 DOI: 10.1177/1932296818786488] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Emerging therapies such as closed-loop (CL) glucose control, also known as artificial pancreas (AP) systems, have shown significant improvement in type 1 diabetes mellitus (T1DM) management. However, demanding patient intervention is still required, particularly at meal times. To reduce treatment burden, the automatic regulation of glucose (ARG) algorithm mitigates postprandial glucose excursions without feedforward insulin boluses. This work assesses feasibility of this new strategy in a clinical trial. METHODS A 36-hour pilot study was performed on five T1DM subjects to validate the ARG algorithm. Subjects wore a subcutaneous continuous glucose monitor (CGM) and an insulin pump. Insulin delivery was solely commanded by the ARG algorithm, without premeal insulin boluses. This was the first clinical trial in Latin America to validate an AP controller. RESULTS For the total 36-hour period, results were as follows: average time of CGM readings in range 70-250 mg/dl: 88.6%, in range 70-180 mg/dl: 74.7%, <70 mg/dl: 5.8%, and <50 mg/dl: 0.8%. Results improved analyzing the final 15-hour period of this trial. In that case, the time spent in range was 70-250 mg/dl: 94.7%, in range 70-180 mg/dl: 82.6%, <70 mg/dl: 4.1%, and <50 mg/dl: 0.2%. During the last night the time spent in range was 70-250 mg/dl: 95%, in range 70-180 mg/dl: 87.7%, <70 mg/dl: 5.0%, and <50 mg/dl: 0.0%. No severe hypoglycemia occurred. No serious adverse events were reported. CONCLUSIONS The ARG algorithm was successfully validated in a pilot clinical trial, encouraging further tests with a larger number of patients and in outpatient settings.
Collapse
Affiliation(s)
- Ricardo Sánchez-Peña
- Instituto Tecnológico de Buenos Aires, Buenos Aires, Argentina
- National Scientific and Technical Research Council, Buenos Aires, Argentina
- Ricardo Sánchez-Peña, PhD, National Scientific and Technical Research Council (CONICET), Instituto Tecnológico de Buenos Aires (ITBA), Av Madero 399, Buenos Aires, C1106ACD, Argentina.
| | - Patricio Colmegna
- National Scientific and Technical Research Council, Buenos Aires, Argentina
- University of Virginia, Charlottesville, VA, USA
- Universidad Nacional de Quilmes, Bernal, Buenos Aires, Argentina
| | - Fabricio Garelli
- National Scientific and Technical Research Council, Buenos Aires, Argentina
- Universidad Nacional de La Plata, La Plata, Buenos Aires Argentina
| | - Hernán De Battista
- National Scientific and Technical Research Council, Buenos Aires, Argentina
- Universidad Nacional de La Plata, La Plata, Buenos Aires Argentina
| | - Demián García-Violini
- Instituto Tecnológico de Buenos Aires, Buenos Aires, Argentina
- National Scientific and Technical Research Council, Buenos Aires, Argentina
| | - Marcela Moscoso-Vásquez
- Instituto Tecnológico de Buenos Aires, Buenos Aires, Argentina
- National Scientific and Technical Research Council, Buenos Aires, Argentina
| | - Nicolás Rosales
- Universidad Nacional de La Plata, La Plata, Buenos Aires Argentina
| | - Emilia Fushimi
- National Scientific and Technical Research Council, Buenos Aires, Argentina
- Universidad Nacional de La Plata, La Plata, Buenos Aires Argentina
| | | | - Marc Breton
- University of Virginia, Charlottesville, VA, USA
| | - Valeria Beruto
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Paula Scibona
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - Javier Giunta
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | | | | | | |
Collapse
|
34
|
Majeed W, Thabit H. Closed-loop insulin delivery: current status of diabetes technologies and future prospects. Expert Rev Med Devices 2018; 15:579-590. [PMID: 30027775 DOI: 10.1080/17434440.2018.1503530] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Type 1 diabetes is characterised by destruction of pancreatic beta cells, leading to insulin deficiency and hyperglycaemia. The mainstay of treatment remains lifelong insulin therapy as a sustainable cure has as yet proven elusive. The burden of daily management of type 1 diabetes has contributed to suboptimal outcomes for people living with the condition. Innovative technological approaches have been shown to improve glycaemic and patient-related outcomes. AREAS COVERED We discuss recent advances in technologies in type 1 diabetes including closed-loop systems, also known as the 'artificial pancreas. Its various components, technical aspects and limitations are reviewed. We also discuss its advent into clinical practice, and other systems in development. Evidence from clinical studies are summarised. EXPERT COMMENTARY The recent approval of a hybrid closed-loop system for clinical use highlights the significant progress made in this field. Results from clinical studies have shown safety and glycaemic benefit, however challenges remain around improving performance and acceptability. More data is required to establish long-term clinical efficacy and cost-effectiveness, to fulfil the expectations of people with type 1 diabetes.
Collapse
Affiliation(s)
- Waseem Majeed
- a Manchester Academic Health Science Centre , Manchester University Hospitals NHS Foundation Trust , Manchester , UK
| | - Hood Thabit
- a Manchester Academic Health Science Centre , Manchester University Hospitals NHS Foundation Trust , Manchester , UK.,b Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health , University of Manchester , Manchester , UK
| |
Collapse
|
35
|
Benhamou PY, Huneker E, Franc S, Doron M, Charpentier G. Customization of home closed-loop insulin delivery in adult patients with type 1 diabetes, assisted with structured remote monitoring: the pilot WP7 Diabeloop study. Acta Diabetol 2018. [PMID: 29520615 DOI: 10.1007/s00592-018-1123-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
AIMS Improvement in closed-loop insulin delivery systems could result from customization of settings to individual needs and remote monitoring. This pilot home study evaluated the efficacy and relevance of this approach. METHODS A bicentric clinical trial was conducted for 3 weeks, using an MPC-based algorithm (Diabeloop Artificial Pancreas system) featuring five settings designed to modulate the reactivity of regulation. Remote monitoring was ensured by expert nurses with a web platform generating automatic Secured Information Messages (SIMs) and with a structured procedure. Endpoints were glucose metrics and description of impact of monitoring on regulation parameters. RESULTS Eight patients with type 1 diabetes (six men, age 41.8 ± 11.4 years, HbA1c 7.7 ± 1.0%) were included. Time spent in the 70-180 mg/dl range was 70.2% [67.5; 76.9]. Time in hypoglycemia < 70 mg/dl was 2.9% [2.1; 3.4]. Eleven SIMs led to phone intervention. Original default settings were modified in all patients by the intervention of the nurses. CONCLUSION This pilot trial suggests that the Diabeloop closed-loop system could be efficient regarding metabolic outcomes, whereas its telemedical monitoring feature could contribute to enhanced efficacy and safety. This study is registered at ClinicalTrials.gov with trial registration number NCT02987556.
Collapse
Affiliation(s)
- Pierre Yves Benhamou
- Department of Endocrinology, Pôle DigiDune, Grenoble University Hospital, Grenoble Alpes University, CS 10217, 38043, Grenoble, France.
| | | | - Sylvia Franc
- CERITD (Centre d'Études et de Recherches pour l'Intensification du Traitement du Diabète), Bioparc-Génopole Évry-Corbeil, Évry, France
- Department of Diabetes, Sud-Francilien Hospital, 91106, Corbeil-Essonnes, France
| | - Maeva Doron
- Univ. Grenoble Alpes, 38000, Grenoble, France
- CEA LETI MlNATEC Campus, 38054, Grenoble, France
| | - Guillaume Charpentier
- CERITD (Centre d'Études et de Recherches pour l'Intensification du Traitement du Diabète), Bioparc-Génopole Évry-Corbeil, Évry, France
| |
Collapse
|
36
|
Bekiari E, Kitsios K, Thabit H, Tauschmann M, Athanasiadou E, Karagiannis T, Haidich AB, Hovorka R, Tsapas A. Artificial pancreas treatment for outpatients with type 1 diabetes: systematic review and meta-analysis. BMJ 2018; 361:k1310. [PMID: 29669716 PMCID: PMC5902803 DOI: 10.1136/bmj.k1310] [Citation(s) in RCA: 246] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of artificial pancreas treatment in non-pregnant outpatients with type 1 diabetes. DESIGN Systematic review and meta-analysis of randomised controlled trials. DATA SOURCES Medline, Embase, Cochrane Library, and grey literature up to 2 February 2018. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Randomised controlled trials in non-pregnant outpatients with type 1 diabetes that compared the use of any artificial pancreas system with any type of insulin based treatment. Primary outcome was proportion (%) of time that sensor glucose level was within the near normoglycaemic range (3.9-10 mmol/L). Secondary outcomes included proportion (%) of time that sensor glucose level was above 10 mmol/L or below 3.9 mmol/L, low blood glucose index overnight, mean sensor glucose level, total daily insulin needs, and glycated haemoglobin. The Cochrane Collaboration risk of bias tool was used to assess study quality. RESULTS 40 studies (1027 participants with data for 44 comparisons) were included in the meta-analysis. 35 comparisons assessed a single hormone artificial pancreas system, whereas nine comparisons assessed a dual hormone system. Only nine studies were at low risk of bias. Proportion of time in the near normoglycaemic range (3.9-10.0 mmol/L) was significantly higher with artificial pancreas use, both overnight (weighted mean difference 15.15%, 95% confidence interval 12.21% to 18.09%) and over a 24 hour period (9.62%, 7.54% to 11.7%). Artificial pancreas systems had a favourable effect on the proportion of time with sensor glucose level above 10 mmol/L (-8.52%, -11.14% to -5.9%) or below 3.9 mmol/L (-1.49%, -1.86% to -1.11%) over 24 hours, compared with control treatment. Robustness of findings for the primary outcome was verified in sensitivity analyses, by including only trials at low risk of bias (11.64%, 9.1% to 14.18%) or trials under unsupervised, normal living conditions (10.42%, 8.63% to 12.2%). Results were consistent in a subgroup analysis both for single hormone and dual hormone artificial pancreas systems. CONCLUSIONS Artificial pancreas systems are an efficacious and safe approach for treating outpatients with type 1 diabetes. The main limitations of current research evidence on artificial pancreas systems are related to inconsistency in outcome reporting, small sample size, and short follow-up duration of individual trials.
Collapse
Affiliation(s)
- Eleni Bekiari
- Clinical Research and Evidence Based Medicine Unit, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece
| | - Konstantinos Kitsios
- Diabetes Centre, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Hood Thabit
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Martin Tauschmann
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Eleni Athanasiadou
- Clinical Research and Evidence Based Medicine Unit, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece
| | - Thomas Karagiannis
- Clinical Research and Evidence Based Medicine Unit, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece
| | - Anna-Bettina Haidich
- Department of Hygiene and Epidemiology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Roman Hovorka
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Apostolos Tsapas
- Clinical Research and Evidence Based Medicine Unit, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece
- Harris Manchester College, University of Oxford, Oxford, UK
| |
Collapse
|
37
|
Peters TM, Haidar A. Dual-hormone artificial pancreas: benefits and limitations compared with single-hormone systems. Diabet Med 2018; 35:450-459. [PMID: 29337384 DOI: 10.1111/dme.13581] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/10/2018] [Indexed: 12/17/2022]
Abstract
Technological advances have made the artificial pancreas a reality. This has the potential to improve the lives of individuals with Type 1 diabetes by reducing the risk of hypoglycaemia, achieving better overall glucose control, and enhancing quality of life. Both single-hormone (insulin-only) and dual-hormone (insulin and glucagon) systems have been developed; however, a focused review of the relative benefits of each artificial pancreas system is needed. We reviewed studies that directly compared single- and dual-hormone systems to evaluate the efficacy of each system for preventing hypoglycaemia and maintaining glycaemic control, as well as their utility in specific situations including during exercise, overnight and during the prandial period. We observed additional benefits with the dual-hormone artificial pancreas for reducing the risk of hypoglycaemic events overall and during exercise over the study duration. The single-hormone artificial pancreas was sufficient for maintenance of euglycaemia in the overnight period and for preventing late-onset post-exercise hypoglycaemia. Future comparative studies of longer duration are required to determine whether one system is superior for improving mean glucose control, eliminating severe hypoglycaemia, or improving quality of life.
Collapse
Affiliation(s)
- T M Peters
- Division of Endocrinology and Metabolism, Faculty of Medicine
| | - A Haidar
- Division of Endocrinology and Metabolism, Faculty of Medicine
- Department of Biomedical Engineering, McGill University
- The Research Institute of the McGill University Health Centre, Montreal, Canada
| |
Collapse
|
38
|
Abitbol A, Rabasa-Lhoret R, Messier V, Legault L, Smaoui M, Cohen N, Haidar A. Overnight Glucose Control with Dual- and Single-Hormone Artificial Pancreas in Type 1 Diabetes with Hypoglycemia Unawareness: A Randomized Controlled Trial. Diabetes Technol Ther 2018; 20:189-196. [PMID: 29393675 DOI: 10.1089/dia.2017.0353] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND The dual-hormone (insulin and glucagon) artificial pancreas may be justifiable in some, but not all, patients. We sought to compare dual- and single-hormone artificial pancreas systems in patients with hypoglycemia unawareness and documented nocturnal hypoglycemia. METHODS We conducted a randomized crossover trial comparing the efficacy of dual- and single-hormone artificial pancreas systems in controlling plasma glucose levels over the course of one night's sleep. We recruited 18 adult participants with hypoglycemia unawareness and 17 participants with hypoglycemia awareness, all of whom had documented nocturnal hypoglycemia during 2 weeks of screening. Outcomes were calculated using plasma glucose. RESULTS In participants with hypoglycemia unawareness, the median (interquartile range [IQR]) percentage of time that plasma glucose was below 4.0 mmol/L was 0% (0-0) on dual-hormone artificial pancreas nights and 0% (0-10) on single-hormone artificial pancreas nights (P = 0.20). Additionally, participants with hypoglycemia unawareness experienced two hypoglycemic events (<3.0 mmol/L) on dual-hormone artificial pancreas nights and three hypoglycemic events on single-hormone artificial pancreas nights. In participants with hypoglycemia awareness, the median (IQR) percentage of time that plasma glucose was below 4.0 mmol/L was 0% (0-0) on both dual- and single-hormone artificial pancreas nights. Hypoglycemia awareness participants experienced zero hypoglycemic events on dual-hormone artificial pancreas nights and one event on single-hormone artificial pancreas nights. DISCUSSION In this study, dual-hormone and single-hormone systems performed equally well in preventing nocturnal hypoglycemia in participants with hypoglycemia unawareness. Longer studies over the course of multiple days and nights may be needed to explore possible specific benefits in this population. ClinicalTrials.gov No. NCT02282254.
Collapse
Affiliation(s)
- Alexander Abitbol
- 1 LMC Diabetes & Endocrinology , Toronto, Canada
- 2 Institut de Recherches Cliniques de Montréal , Montreal, Canada
- 3 Division of Endocrinology and Metabolism, Department of Medicine, McGill University Health Centre , Montreal, Canada
| | - Remi Rabasa-Lhoret
- 2 Institut de Recherches Cliniques de Montréal , Montreal, Canada
- 4 Montreal Diabetes Research Center , Montreal, Canada
- 5 Division of Endocrinology and Metabolism, Department of Medicine, Université de Montréal , Montreal, Canada
- 6 Nutrition Department, Faculty of Medicine, University of Montreal , Montreal, Canada
| | - Virginie Messier
- 2 Institut de Recherches Cliniques de Montréal , Montreal, Canada
| | - Laurent Legault
- 7 Division of Pediatric Endocrinology and Metabolism, Department of Medicine, Montreal Children's Hospital, McGill University Health Centre , Montreal, Canada
| | - Mohamad Smaoui
- 2 Institut de Recherches Cliniques de Montréal , Montreal, Canada
| | - Nathan Cohen
- 8 Jaeb Center for Health Research , Tampa, Florida
| | - Ahmad Haidar
- 3 Division of Endocrinology and Metabolism, Department of Medicine, McGill University Health Centre , Montreal, Canada
- 9 Department of Biomedical Engineering, Faculty of Medicine, McGill University , Montreal, Canada
| |
Collapse
|
39
|
|
40
|
Gingras V, Smaoui MR, Cameli C, Messier V, Ladouceur M, Legault L, Rabasa-Lhoret R. Impact of erroneous meal insulin bolus with dual-hormone artificial pancreas using a simplified bolus strategy - A randomized controlled trial. Sci Rep 2018; 8:2621. [PMID: 29422651 PMCID: PMC5805693 DOI: 10.1038/s41598-018-20785-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 01/22/2018] [Indexed: 01/12/2023] Open
Abstract
Postprandial glucose control remains challenging for patients with type 1 diabetes (T1D). A simplified meal bolus approach with a dual-hormone (insulin and glucagon) closed-loop system (DH-CLS) has been tested; yet, the impact of categorization errors with this strategy is unknown. The objective was to compare, in a randomized controlled inpatient trial, DH-CLS with the simplified meal bolus approach for two different meals properly categorized or overestimated. We tested, in patients with T1D, the simplified strategy with two standardized breakfasts (n = 10 per meal) adequately categorized or overestimated: (1) 75 g and (2) 45 g of carbohydrate. No difference was observed for percentage of time <4.0 mmol/L over a 4-hour post-meal period (primary outcome; median [IQR]: 0[0-0] vs. 0[0-0] for both comparisons, p = 0.47 and 0.31 for the 75 g and 45 g meals, respectively). Despite higher meal insulin boluses with overestimation for both meals (9.2 [8.2-9.6] vs. 8.1 [7.3-9.1] U and 8.4 [7.2-10.4] vs. 4.8 [3.7-5.6] U; p < 0.05), mean glycemia, percentage of time in target range and glucagon infusion did not differ. Additional scenarios were tested in silico with comparable results. These results suggest that the DH-CLS with a simplified meal bolus calculation is probably able to avoid hypoglycemia in the event of meal size misclassification.
Collapse
Affiliation(s)
- Véronique Gingras
- Institut de Recherches Cliniques de Montréal, Montreal, Quebec, Canada
- Department of nutrition, Université de Montréal, Montreal, Quebec, Canada
| | - Mohamed Raef Smaoui
- Institut de Recherches Cliniques de Montréal, Montreal, Quebec, Canada
- Department of nutrition, Université de Montréal, Montreal, Quebec, Canada
| | - Charlotte Cameli
- Institut de Recherches Cliniques de Montréal, Montreal, Quebec, Canada
- Université de Rennes 1, Rennes, France
| | - Virginie Messier
- Institut de Recherches Cliniques de Montréal, Montreal, Quebec, Canada
| | - Martin Ladouceur
- Research Center of the Université de Montréal Hospital Center (CRCHUM), Montreal, Quebec, Canada
| | - Laurent Legault
- Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Rémi Rabasa-Lhoret
- Institut de Recherches Cliniques de Montréal, Montreal, Quebec, Canada.
- Department of nutrition, Université de Montréal, Montreal, Quebec, Canada.
- Université de Rennes 1, Rennes, France.
- Montreal Diabetes Research Center (MDRC), Montreal, Quebec, Canada.
| |
Collapse
|
41
|
Yu X, Turksoy K, Rashid M, Feng J, Frantz N, Hajizadeh I, Samadi S, Sevil M, Lazaro C, Maloney Z, Littlejohn E, Quinn L, Cinar A. Model-Fusion-Based Online Glucose Concentration Predictions in People with Type 1 Diabetes. CONTROL ENGINEERING PRACTICE 2018; 71:129-141. [PMID: 29276347 PMCID: PMC5736323 DOI: 10.1016/j.conengprac.2017.10.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Accurate predictions of glucose concentrations are necessary to develop an artificial pancreas (AP) system for people with type 1 diabetes (T1D). In this work, a novel glucose forecasting paradigm based on a model fusion strategy is developed to accurately characterize the variability and transient dynamics of glycemic measurements. To this end, four different adaptive filters and a fusion mechanism are proposed for use in the online prediction of future glucose trajectories. The filter fusion mechanism is developed based on various prediction performance indexes to guide the overall output of the forecasting paradigm. The efficiency of the proposed model fusion based forecasting method is evaluated using simulated and clinical datasets, and the results demonstrate the capability and prediction accuracy of the data-based fusion filters, especially in the case of limited data availability. The model fusion framework may be used in the development of an AP system for glucose regulation in patients with T1D.
Collapse
Affiliation(s)
- Xia Yu
- School of Information Science and Engineering, Northeastern University, Shenyang 110819, PR China
| | - Kamuran Turksoy
- Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, IL 60616, USA
| | - Mudassir Rashid
- Department of Chemical and Biological Engineering, Illinois Institute of Technology, Chicago, IL 60616, USA
| | - Jianyuan Feng
- Department of Chemical and Biological Engineering, Illinois Institute of Technology, Chicago, IL 60616, USA
| | - Nicole Frantz
- Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, IL 60616, USA
| | - Iman Hajizadeh
- Department of Chemical and Biological Engineering, Illinois Institute of Technology, Chicago, IL 60616, USA
| | - Sediqeh Samadi
- Department of Chemical and Biological Engineering, Illinois Institute of Technology, Chicago, IL 60616, USA
| | - Mert Sevil
- Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, IL 60616, USA
| | - Caterina Lazaro
- Department of Electrical and Computer Engineering, Illinois Institute of Technology, Chicago, IL 60616, USA
| | - Zacharie Maloney
- Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, IL 60616, USA
| | - Elizabeth Littlejohn
- Department of Pediatrics and Medicine, Kovler Diabetes Center, University of Chicago, Chicago, IL 60637, USA
| | - Laurie Quinn
- Department of Biobehavioral Health Science, College of Nursing, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Ali Cinar
- Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, IL 60616, USA
- Department of Chemical and Biological Engineering, Illinois Institute of Technology, Chicago, IL 60616, USA
| |
Collapse
|
42
|
Dirnena-Fusini I, Åm MK, Fougner AL, Carlsen SM, Christiansen SC. Intraperitoneal, subcutaneous and intravenous glucagon delivery and subsequent glucose response in rats: a randomized controlled crossover trial. BMJ Open Diabetes Res Care 2018; 6:e000560. [PMID: 30487972 PMCID: PMC6235059 DOI: 10.1136/bmjdrc-2018-000560] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 08/31/2018] [Accepted: 10/06/2018] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE Hypoglycemia is a frequent and potentially dangerous event among patients with diabetes mellitus type 1. Subcutaneous glucagon is an emergency treatment to counteract severe hypoglycemia. The effect of intraperitoneal glucagon delivery is sparsely studied. We performed a direct comparison of the blood glucose response following intraperitoneally, subcutaneously and intravenously administered glucagon. RESEARCH DESIGN AND METHODS This is a prospective, randomized, controlled, open-label, crossover trial in 20 octreotide-treated rats. Three interventions, 1 week apart, in a randomized order, were done in each rat. All 20 rats were given intraperitoneal and subcutaneous glucagon injections, from which 5 rats were given intravenous glucagon injections and 15 rats received placebo (intraperitoneal isotonic saline) injection. The dose of glucagon was 5 µg/kg body weight for all routes of administration. Blood glucose levels were measured before and until 60 min after the glucagon/placebo injections. RESULTS Compared with placebo-treated rats, a significant increase in blood glucose was observed 4 min after intraperitoneal glucagon administration (p=0.009), whereas after subcutaneous and intravenous glucagon administration significant increases were seen after 8 min (p=0.002 and p<0.001, respectively). In intraperitoneally treated compared with subcutaneously treated rats, the increase in blood glucose was higher after 4 min (p=0.019) and lower after 40 min (p=0.005) and 50 min (p=0.011). The maximum glucose response occurred earlier after intraperitoneal compared with subcutaneous glucagon injection (25 min vs 35 min; p=0.003). CONCLUSIONS Glucagon administered intraperitoneally gives a faster glucose response compared with subcutaneously administered glucagon in rats. If repeatable in humans, the more rapid glucose response may be of importance in a dual-hormone artificial pancreas using the intraperitoneal route for administration of insulin and glucagon.
Collapse
Affiliation(s)
- Ilze Dirnena-Fusini
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
| | - Marte Kierulf Åm
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
- Department of Endocrinology, St Olavs Hospital, Trondheim, Norway
| | - Anders Lyngvi Fougner
- Department of Engineering Cybernetics, Faculty of Information Technology and Electrical Engineering, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
| | - Sven Magnus Carlsen
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
- Department of Endocrinology, St Olavs Hospital, Trondheim, Norway
| | - Sverre Christian Christiansen
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
- Department of Endocrinology, St Olavs Hospital, Trondheim, Norway
| |
Collapse
|
43
|
Bertachi A, Ramkissoon CM, Bondia J, Vehí J. Automated blood glucose control in type 1 diabetes: A review of progress and challenges. ACTA ACUST UNITED AC 2017; 65:172-181. [PMID: 29279252 DOI: 10.1016/j.endinu.2017.10.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 10/11/2017] [Accepted: 10/21/2017] [Indexed: 12/27/2022]
Abstract
Since the 2000s, research teams worldwide have been working to develop closed-loop (CL) systems able to automatically control blood glucose (BG) levels in patients with type 1 diabetes. This emerging technology is known as artificial pancreas (AP), and its first commercial version just arrived in the market. The main objective of this paper is to present an extensive review of the clinical trials conducted since 2011, which tested various implementations of the AP for different durations under varying conditions. A comprehensive table that contains key information from the selected publications is provided, and the main challenges in AP development and the mitigation strategies used are discussed. The development timelines for different AP systems are also included, highlighting the main evolutions over the clinical trials for each system.
Collapse
Affiliation(s)
- Arthur Bertachi
- Institute of Informatics and Applications, University of Girona, Campus de Montilivi, s/n, Edifici P4, 17071 Girona, Spain; Federal University of Technology - Paraná (UTFPR), Guarapuava, Avenida Professora Laura Pacheco Bastos 800, 85053-525 Guarapuava, Paraná, Brazil
| | - Charrise M Ramkissoon
- Institute of Informatics and Applications, University of Girona, Campus de Montilivi, s/n, Edifici P4, 17071 Girona, Spain
| | - Jorge Bondia
- Instituto Universitario de Automática e Informática Industrial, Universitat Politècnica de València, Camino de Vera, s/n, Edificio 8G, 46022 Valencia, Spain
| | - Josep Vehí
- Institute of Informatics and Applications, University of Girona, Campus de Montilivi, s/n, Edifici P4, 17071 Girona, Spain.
| |
Collapse
|
44
|
Bally L, Thabit H, Hovorka R. Glucose-responsive insulin delivery for type 1 diabetes: The artificial pancreas story. Int J Pharm 2017; 544:309-318. [PMID: 29258910 DOI: 10.1016/j.ijpharm.2017.12.022] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 12/04/2017] [Accepted: 12/10/2017] [Indexed: 12/20/2022]
Abstract
Insulin replacement therapy is integral to the management of type 1 diabetes, which is characterised by absolute insulin deficiency. Optimal glycaemic control, as assessed by glycated haemoglobin, and avoidance of hyper- and hypoglycaemic excursions have been shown to prevent diabetes-related complications. Insulin pump use has increased considerably over the past decade with beneficial effects on glycaemic control, quality of life and treatment satisfaction. The advent and progress of ambulatory glucose sensor technology has enabled continuous glucose monitoring based on real-time glucose levels to be integrated with insulin therapy. Low glucose and predictive low glucose suspend systems are currently used in clinical practice to mitigate against hypoglycaemia, and provide the first step towards feedback glucose control. The more advanced technology approach, an artificial pancreas or a closed-loop system, gradually increases and decreases insulin delivery in a glucose-responsive fashion to mitigate against hyper- and hypoglycaemia. Randomised outpatient clinical trials over the past 5 years have demonstrated the feasibility, safety and efficacy of the approach, and the recent FDA approval of the first single hormone closed-loop system establishes a new standard of care for people with type 1 diabetes.
Collapse
Affiliation(s)
- Lia Bally
- Department of Diabetes, Endocrinology Clinical Nutrition & Metabolism, Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland.
| | - Hood Thabit
- Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom; Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom
| | - Roman Hovorka
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom; Department of Paediatrics, University of Cambridge, Cambridge, United Kingdom
| |
Collapse
|
45
|
Review of a commercially available hybrid closed-loop insulin-delivery system in the treatment of Type 1 diabetes. Ther Deliv 2017; 9:77-87. [PMID: 29235423 DOI: 10.4155/tde-2017-0099] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Type 1 diabetes is an important medical condition causing significant burden and morbidity to those persons affected by it. Improvements in insulin products, insulin delivery and glucose monitoring technology have all contributed to reductions in long-term complications and hypoglycemia. This article reviews the Medtronic 670G device and summarizes the data supporting how this product reduces the burden and increases the safety of insulin dosing in Type 1 diabetes.
Collapse
|
46
|
Ang KH, Sherr JL. Moving beyond subcutaneous insulin: the application of adjunctive therapies to the treatment of type 1 diabetes. Expert Opin Drug Deliv 2017; 14:1113-1131. [DOI: 10.1080/17425247.2017.1360862] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Kathleen H. Ang
- Yale Children’s Diabetes Program, Yale University School of Medicine, New Haven, CT, USA
| | - Jennifer L. Sherr
- Yale Children’s Diabetes Program, Yale University School of Medicine, New Haven, CT, USA
| |
Collapse
|