Treatment with insulin glargine reduces asymptomatic hypoglycemia detected by continuous subcutaneous glucose monitoring in children and adolescents with type 1 diabetes

Technological Ecological Momentary Assessment Tools to Study Type 1 Diabetes in Youth: Viewpoint of Methodologies

Type 1 diabetes (T1D) is one of the most common chronic childhood diseases, and its prevalence is rapidly increasing. The management of glucose in T1D is challenging, as youth must consider a myriad of factors when making diabetes care decisions. This task often leads to significant hyperglycemia, hypoglycemia, and glucose variability throughout the day, which have been associated with short- and long-term medical complications. At present, most of what is known about each of these complications and the health behaviors that may lead to them have been uncovered in the clinical setting or in laboratory-based research. However, the tools often used in these settings are limited in their ability to capture the dynamic behaviors, feelings, and physiological changes associated with T1D that fluctuate from moment to moment throughout the day. A better understanding of T1D in daily life could potentially aid in the development of interventions to improve diabetes care and mitigate the negative medical consequences associated with it. Therefore, there is a need to measure repeated, real-time, and real-world features of this disease in youth. This approach is known as ecological momentary assessment (EMA), and it has considerable advantages to in-lab research. Thus, this viewpoint aims to describe EMA tools that have been used to collect data in the daily lives of youth with T1D and discuss studies that explored the nuances of T1D in daily life using these methods. This viewpoint focuses on the following EMA methods: continuous glucose monitoring, actigraphy, ambulatory blood pressure monitoring, personal digital assistants, smartphones, and phone-based systems. The viewpoint also discusses the benefits of using EMA methods to collect important data that might not otherwise be collected in the laboratory and the limitations of each tool, future directions of the field, and possible clinical implications for their use.

Comparison of glucose variability in patients with type 2 diabetes administrated glargine with needle-free jet injector and conventional insulin pen

Background: The effects of insulin delivered by needle-free jet injector on glycemic variations (GV) in patients with type 2 diabetes (T2D) which remains largely unknown.Research design and methods: We aimed to compare the glucose variability in Chinese T2D patients administrated glargine 100 U/mL (Gla-100) with a needle-free jet injector and conventional insulin pen. This was a self-comparative, observational study of 26 patients who were subjected to a flash glucose monitoring system (FGM) for 14 consecutive days. During the study period, all subjects received Gla-100 daily before breakfast using a conventional insulin pen, with the exception of day 3 and day 7, when insulin was delivered by needle-free jet injection. We analyzed FGM data of day 3, day 5, day 7, and day 9 at the endpoint.Results: There were no differences in the glycemic variability between the jet injector group and the conventional pen group. However, patients with needle-free jet injection had a lower 24 hr mean glucose (MG) and lower incremental area under the curve (AUC) of 1 hr, 12 hr, and 24 hr, compared to the conventional pen group (p = 0.001).Conclusions: Gla-100 delivered by needle-free jet injection potentially lowered MG in patients with T2D in the Chinese population.

A comparison of clinical efficacy and economic value in Basalin- and Lantus-treated patients with type 2 diabetes using continuous glucose monitoring system

AIM

To determine the clinical non-inferiority of recombinant glargine-Basalin vs glargine-Lantus, in treatment of type 2 diabetes mellitus (T2DM) using continuous glucose monitoring system (CGMS).

METHODS

One hundred patients with T2DM were recruited. They were either regularly taking Basalin (Basalin group) or Lantus (Lantus group) (n = 50 each). CGMS was employed to real-time monitor blood glucose profile for 4 days (from day 1 to day 5). To exclude the effect of patient background, the study design was to have a blinded crossover from glargine-Basalin to glargine-Lantus on day 3, and vice versa. 24-hour mean blood glucose (24hMBG), 24-hour standard deviation of blood glucose (24hSDBG), 24-hour mean amplitude of glycemic excursion (24hMAGE), and number of glycemic excursion (NGE) every 24 h (24hNGE) were calculated for each glargine from 100 patients.

RESULTS

No significant difference of 24hMBG, 24hSDBG, 24hMAGE, and 24hNGE (p > 0.05 for all) was found between Basalin and Lantus treatments. The glucose area under the curve and time when blood glucose was below 3.9 mmol/L, between 3.9 and 10.0 mmol/L, or above 10.0 mmol/L were similar between Basalin and Lantus treatment. The frequency of hypoglycemic episodes was also similar. However, the mean cost of Basalin was only 72% of Lantus's in one treatment course.

CONCLUSION

Glargine-Basalin is non-inferior in clinical efficacy compared to glargine-Lantus. In view of the large difference in the cost of glargine-Basalin, it would be much more cost-effective for our patients.

[Use of insulin glargine in type 1 diabetes children with less than eight years old]

OBJECTIVES

To evaluate prospectively the efficacy and safety of insulin glargine use for the metabolic control of type 1 diabetes mellitus (T1DM) children younger than eight years old.

METHODS

Nineteen boys and 11 girls with T1DM were included. Before initiating insulin glargine, all children received intensive NPH and aspart insulins for three months. Afterwards, they were assisted for 12 more months for glargine treatment. All patients performed self blood glucose monitoring before and two hours after meals and in early morning (3:00 AM). Primary endpoints: metabolic control using A1C levels; frequency of mild hypoglycemia (capillary glycemia < 60 mg/dL); and frequency of severe hypoglycemia (loss or alteration of consciousness, seizures or need for medical intervention).

RESULTS

Mean A1C at the study entry was 8.68% and after 12 months of glargine, was 8.64% (p = 0.82). Frequency of mild hypoglycemia at 3.00 AM was 1.43/3 months during the NPH period and 0.28/3 months during the glargine period (p < 0.007). Frequency of severe hypoglycemia was 0.56/3 months during the NPH period and 0.008/3 months during the glargine period (p < 0.002).

CONCLUSIONS

The treatment of T1DM children with insulin glargine was considered as efficacious as with NPH. However, a better safety profile, disclosed by the lower incidence of nocturnal and severe hypoglycemia episodes, was observed for insulin glargine.

An overview and commentary on retrospective, continuous glucose monitoring for the optimisation of care for people with diabetes

INTRODUCTION

Normoglycaemia in people with diabetes results in improved outcome. Continuous glucose monitoring provides detailed diagnostic information used to optimise therapy with the goal of achieving normoglycaemia. The objective of this study was to review the published literature evaluating the single device available for blinded, professional clinical use of continuous glucose monitoring; in particular all randomised controlled trials (RCTs) and relevant observational studies.

METHODS

Published studies (to 31 March 2009) using the Medtronic MiniMed Continuous Glucose Monitoring System (CGMS System Gold, Medtronic MiniMed, Inc., Northridge, CA) were identified using appropriate search terms in a series of clinical databases including: Medline, Pubmed, Google Scholar and Scientific Web of Knowledge. Other measures were also taken such as reviewing the reference lists.

FINDINGS

In addition to an extensive range of non-randomised studies using the device, seven randomised controlled trials were identified, of which five were in children. Although HbA1c was explicitly stated as the primary endpoint in four studies, the studies were only adequately powered to detect large, between-group minimum differences (range 0.5 to 1.0% HbA1c). Only two studies included subjects with type 2 diabetes. Other endpoints included the frequency of hypoglycaemia and hyperglycaemia. Within-group HbA1c decreases were observed in all but one study. The crude, weighted mean improvement in HbA1c across the studies using the device was 0.6% (range 0% to 0.8%). When compared to a control measure the weighted, mean marginal benefit in HbA1c was 0.2%. No studies recorded how the information was utilised to modify treatment, such as changes in dose titration or treatment regimen.

CONCLUSIONS

Devices such as the professional CGMS provide detailed diagnostic information. However, any consequent changes in care and outcome can only result from the appropriate application of this information. Although there was a notable improvement in glucose control (HbA1c), existing studies were largely underpowered and did not capture the resulting treatment changes that could lead to improved outcome.

Continuous glucose monitoring in non-insulin-using individuals with type 2 diabetes: acceptability, feasibility, and teaching opportunities

BACKGROUND

Continuous glucose monitoring (CGM) has the potential to provide useful data for behavioral interventions targeting non-insulin-using, sedentary individuals with type 2 diabetes mellitus (T2DM). The aims of this study were to describe CGM in terms of (1) feasibility and acceptability and (2) dietary- and exercise-teaching events.

METHODS

Cross-sectional data were analyzed from 27 non-insulin-using adults with T2DM who wore CGM for 72 h as part of a larger study on using CGM for exercise counseling in this population. Feasibility data included accuracy of entering daily self-monitored blood glucose (SMBG) readings and events (e.g., meals, exercise), sensor failures, alarms, optimal accuracy of glucose data, and download failures. Acceptability data included CGM satisfaction and wearing difficulties. Dietary- and exercise-teaching events were identified from CGM and activity monitor data.

RESULTS

CGM graphs showed 141 dietary- and 71 exercise-teaching events. About half the participants (52%) reported difficulty remembering to enter events into CGM monitors, but most (82%) kept an accurate paper log of events. Insufficient SMBG entries resulted in 32 CGM graphs with "use clinical judgment" warnings. Eighty-three percent of missed SMBG entries were from 18 participants 55-77 years old. Missing correlation coefficients resulted from glucose concentrations varying <100 mg/dL. A majority of participants (n = 19) were willing to wear CGM again despite reporting minor discomfort at sensor site and with wearing the monitor.

CONCLUSIONS

CGM data provided several teaching opportunities in non-insulin-using adults with T2DM. Overall, CGM was acceptable and feasible. Some identified problems may be eliminated by newer technology.

Characterizing glucose exposure for individuals with normal glucose tolerance using continuous glucose monitoring and ambulatory glucose profile analysis

BACKGROUND

Efforts to mimic euglycemia depend upon targets from epidemiologic studies that rely on episodic measurements reduced to statistical summaries, leaving open the question, "What is normal glycemia?" We postulated that portrayal of euglycemia was possible through application of continuous glucose monitoring (CGM) and a novel analytical tool, the ambulatory glucose profile (AGP).

METHODS

Individuals with normal glucose tolerance (NGT) and with diabetes used CGM for 30 days. AGP analysis, which graphs CGM data by time without regard to date, was used to characterize glucose exposure, variability, and stability.

RESULTS

Sixty-two subjects completed the study, employing CGM for 28 +/- 4 days averaging 99 +/- 18 (range, 33-125) readings per day. NGT subjects (n = 32) had a mean CGM of 102 +/- 7 mg/dL, ranging between 94 and 117 mg/dL and averaging 105 +/- 8 mg/dL daytime and 97 +/- 6 mg/dL overnight. Glucose variability, as expressed by the interquartile range, was 21 +/- 4 mg/dL (range, 14-29 mg/dL). Stability in glycemic control (hourly change in the median) for NGT subjects averaged 3 +/- 1 mg/dL/h. Subjects with diabetes (n = 30) were significantly higher on all glycemic characteristics with the exception of the percentage of hypoglycemic (CGM <70 mg/dL) episodes for type 2 diabetes (2.9%), compared to 2.7% for subjects with NGT.

CONCLUSIONS

CGM technologies enabled collection of verified data under normal living conditions, providing an exceptional vantage point from which to obtain important clinical information. This will facilitate an understanding of the range of euglycemic patterns, provide a sensitive means of detecting impaired glucose tolerance, and help set realistic treatment goals for individuals with diabetes.