Outcomes of using flash glucose monitoring technology by children and young people with type 1 diabetes in a single arm study

Importance of FDA-Integrated Continuous Glucose Monitors to Ensure Accuracy of Continuous Glucose Monitoring

Continuous glucose monitoring (CGM) has been shown to improve glycemic control and self-monitoring, as well as to reduce the risk of hypoglycemia. Integrated CGM (iCGM) FDA-cleared systems with published performance data are established nonadjunctive and accurate CGM tools that can directly inform decision-making in the treatment of diabetes (i.e., insulin dosing). Studies have assessed accuracy and safety data of CGMs that were eventually cleared for iCGM by the FDA and that informed the recommendation for their nonadjunctive use. Subsequent robust clinical trials and real-world studies demonstrated clinical effectiveness with improvements in a range of patient outcomes. In recent years, a number of non-iCGM-approved CGM devices have entered the market outside the United States worldwide. Some of these non-iCGM-approved CGM devices require additional user verification of blood glucose levels to be performed for making treatment decisions, termed adjunctive. Moreover, in many non-iCGM-approved CGM devices, accuracy studies published in peer-reviewed journals are scarce or have many limitations. Consequently, non-iCGM-approved CGM devices cannot be automatically perceived as having the same performance or quality standards than those approved for iCGM by the FDA. As a result, although these devices tend to cost less than iCGMs that carry FDA clearance and could therefore be attractive from the point of view of a health care payer, it must be emphasized that evaluation of costs should not be limited to the device (such as the usability preference that patients have for nonadjunctive sensors compared to adjunctive sensors) but to the wider value of the total benefit that the product provides to the patient.

Beyond HbA1c: Identifying Gaps in Glycemic Control Among Children and Young People with Type 1 Diabetes Using Continuous Glucose Monitoring

OBJECTIVES

To describe continuous glucose monitoring (CGM) derived glycemic variables, and study their association with HbA1c and socio-economic factors in young people with Type 1 diabetes mellitus (T1DM).

METHODS

Ninety-two participants [age 15.7 ± 5.0 y (mean ± SD), HbA1c 8.0 ± 1.5% (mean ± SD)] wore a professional CGM sensor for 14 d.

RESULTS

Median (IQR) time in range (TIR) was 41 (18)%. Participants spent 41 ± 20% of their day in hyperglycemia (>180 mg/dl), and 14 (13)% in hypoglycemia (<70 mg/dl). High glycemic variability (percent CV >36%) was seen in 92% participants. Older age at diagnosis was associated with higher TIR (β = 0.267, p = 0.01), lower time above range (TAR) (β = -0.352, p <0.001), but higher time below range (TBR) (β = 0.274, p = 0.006). The use of NPH vs. glargine basal insulin was associated with higher TBR (β = -0.262, p = 0.009) but lower TAR (β = 0.202, p = 0.041). HbA1c showed negative correlation with TIR (r = -0.449, p <0.001) and TBR (r = -0.466, p <0.001) and positive correlation with TAR (r = 0.580, p <0.001) and mean glucose (r = 0.589, p <0.001).

CONCLUSIONS

These data demonstrate wide gaps between the recommended vs. real world glycemic variables in patients with T1DM in this region on multiple daily insulin injections. CGM identifies glycemic variability and complements HbA1c in improving glycemic control.

Personalizing the Use of a Intermittently Scanned Continuous Glucose Monitoring Device in Individuals With Type 1 Diabetes: A Cost-Effectiveness Perspective in the Netherlands (FLARE-NL 9)

AIMS

Intermittently scanned continuous glucose monitoring (isCGM) is a method to monitor glucose concentrations without using a finger prick. Among persons with type 1 diabetes (T1D), isCGM results in improved glycemic control, less disease burden and improved health-related quality of life (HRQoL). However, it is not clear for which subgroups of patients isCGM is cost-effective. We aimed to provide a real-world cost-effectiveness perspective.

METHODS

We used clinical data from a 1-year nationwide Dutch prospective observational study (N = 381) and linked these to insurance records. Health-related quality of life was assessed with the EQ-5D-3L questionnaire. Individuals were categorized into 4 subgroups: (1) frequent hypoglycemic events (58%), (2) HbA1c > 70 mmol/mol (8.5%) (19%), (3) occupation that requires avoiding finger pricks and/or hypoglycemia (5%), and (4) multiple indications (18%). Comparing costs and outcomes 12 months before and after isCGM initiation, incremental cost-effectiveness ratios (ICERs) were calculated for the total cohort and each subgroup from a societal perspective (including healthcare and productivity loss costs) at the willingness to pay of €50,000 per quality-adjusted life year (QALY) gained.

RESULTS

From a societal perspective, isCGM was dominant in all subgroups (ie higher HRQoL gain with lower costs) except for subgroup 1. From a healthcare payer perspective, the probabilities of isCGM being cost-effective were 16%, 9%, 30%, 98%, and 65% for the total cohort and subgroup 1, 2, 3, and 4, respectively. Most sensitivity analyses confirmed these findings.

CONCLUSIONS

Comparing subgroups of isCGM users allows to prioritize them based on cost-effectiveness. The most cost-effective subgroup was occupation-related indications, followed by multiple indications, high HbA1c and the frequent hypoglycemic events subgroups. However, controlled studies with larger sample size are needed to draw definitive conclusions.

Use of wearables for monitoring cardiometabolic health: A systematic review

INTRODUCTION

Cardiometabolic disorders (CMD) such as hyperglycemia, obesity, hypertension, and dyslipidemia are the leading causes of mortality and significant public health concerns worldwide. With the advances in wireless technology, wearables have become popular for health promotion, but its impact on cardiometabolic health is not well understood.

PURPOSE

A systematic literature review aimed to describe the features of wearables used for monitoring cardiometabolic health and identify the impact of using wearables on those cardiometabolic health indicators.

METHODS

A systematic search of PubMed, CINAHL, Academic Search Complete, and Science and Technology Collection databases was performed using keywords related to CMD risk indicators and wearables. The wearables were limited to sensors for blood pressure (BP), heart rate (HR), electrocardiogram (ECG), glucose, and cholesterol.

INCLUDED STUDIES

1) were published from 2016 to March 2021 in English, 2) focused on wearables external to the body, and 3) examined wearable use by individuals in daily life (not by health care providers). Protocol, technical, and non-empirical studies were excluded.

RESULTS

Out of 53 studies, the types of wearables used were smartwatches (45.3%), patches (34.0%), chest straps (22.6%), wristbands (13.2%), and others (9.4%). HR (58.5%), glucose (28.3%), and ECG (26.4%) were the predominant indicators. No studies tracked BP or cholesterol. Additional features of wearables included physical activity, respiration, sleep, diet, and symptom monitoring. Twenty-two studies primarily focused on the use of wearables and reported direct impacts on cardiometabolic indicators; seven studies used wearables as part of a multi-modality approach and presented outcomes affected by a primary intervention but measured through CMD-sensor wearables; and 24 validated the precision and usability of CMD-sensor wearables.

CONCLUSION

The impact of wearables on cardiometabolic indicators varied across the studies, indicating the need for further research. However, this body of literature highlights the potential of wearables to promote cardiometabolic health.

Expert Recommendations for Using Time-in-Range and Other Continuous Glucose Monitoring Metrics to Achieve Patient-Centered Glycemic Control in People With Diabetes

New metrics for assessing glycemic control beyond HbA1c have recently emerged due to the increasing use of continuous glucose monitoring (CGM) in diabetes clinical practice. Among them, time in range (TIR) has appeared as a simple and intuitive metric that correlates inversely with HbA1c and has also been newly linked to the risk of long-term diabetes complications. The International Consensus on Time in Range established a series of target glucose ranges (TIR, time below range and time above range) and recommendations for time spent within these ranges for different diabetes populations. These parameters should be evaluated together with the ambulatory glucose profile (AGP). Using standardized visual reporting may help people with diabetes and healthcare professionals in the evaluation of glucose control in frequent clinical situations. The objective of the present review is to provide practical insights to quick interpretation of patient-centered metrics based on flash glucose monitoring data, as well as showing some visual examples of common clinical situations and giving practical recommendations for their management.

Implementation of flash glucose monitoring in four pediatric diabetes clinics: controlled before and after study to produce real-world evidence of patient benefit

AIMS

To assess the real-world evidence for flash glucose monitoring (Abbott FreeStyle Libre) for children with type 1 diabetes in terms of glucose control, secondary healthcare resources and costs.

RESEARCH DESIGN AND METHODS

We conducted a controlled before and after study (approximately 12 months before and after) using routinely collected health record data on children who start using flash monitors and a control population of children with self-monitoring of blood glucose (SMBG). Our population-based sample of eligible individuals using flash monitoring (n=114) and controls (n=80) aged between 4 and 18 years was drawn from four paediatric diabetes clinics (secondary care) in the South West England. Outcome measures included: glycated hemoglobin (HbA1c), frequency of BG tests; frequency of sensor scans; time in recommended glucose range; short-term complications (hypoglycemia, diabetic ketoacidosis and related illness resulting in investigation) and secondary care costs.

RESULTS

After adjustment for age, time since diagnosis, deprivation and the test modality (point of care or laboratory), the mean HbA1c reading for controls was 61.2 (mmol/mol) for the period before and 63.9 after. For individuals using flash monitoring, the adjusted mean HbA1c reading was 64.6 for the period before implementation and 63.8 after. Rates of short-term complications were low across all groups in the study. Whereas the 'after' flash monitoring group had substantially higher incremental costs (+£703 vs the flash monitoring 'before' comparison and +£841 vs contemporaneous SMBG controls), these cost differences were driven by primary care prescribing (sensor costs).

CONCLUSIONS

There was some indication that flash monitoring might help young people improve the control of their diabetes but for our sample, the difference between finger-prick testing and flash monitoring was not clinically significant (HbA1c improvement <5 mmol/mol). Given the pace of technological change within diabetes, research efforts should now facilitate the real-time analysis of long-term routine data on flash and continuous glucose monitors.

Expanding the Role of Continuous Glucose Monitoring in Modern Diabetes Care Beyond Type 1 Disease

Application of continuous glucose monitoring (CGM) has moved diabetes care from a reactive to a proactive process, in which a person with diabetes can prevent episodes of hypoglycemia or hyperglycemia, rather than taking action only once low and high glucose are detected. Consequently, CGM devices are now seen as the standard of care for people with type 1 diabetes mellitus (T1DM). Evidence now supports the use of CGM in people with type 2 diabetes mellitus (T2DM) on any treatment regimen, not just for those on insulin therapy. Expanding the application of CGM to include all people with T1DM or T2DM can support effective intensification of therapies to reduce glucose exposure and lower the risk of complications and hospital admissions, which are associated with high healthcare costs. All of this can be achieved while minimizing the risk of hypoglycemia and improving quality of life for people with diabetes. Wider application of CGM can also bring considerable benefits for women with diabetes during pregnancy and their children, as well as providing support for acute care of hospital inpatients who experience the adverse effects of hyperglycemia following admission and surgical procedures, as a consequence of treatment-related insulin resistance or reduced insulin secretion. By tailoring the application of CGM for daily or intermittent use, depending on the patient profile and their needs, one can ensure the cost-effectiveness of CGM in each setting. In this article we discuss the evidence-based benefits of expanding the use of CGM technology to include all people with diabetes, along with a diverse population of people with non-diabetic glycemic dysregulation.

Emerging Diabetes Technologies: Continuous Glucose Monitors/Artificial Pancreases

Over the past decade there have been many advances in diabetes technologies, such as continuous glucose monitors (CGM s), insulin-delivery devices, and hybrid closed loop systems . Now most CGMs (Medtronic-Guardian, Dexcom-G6, and Abbott-Libre-2) have MARD values of < 10%, in contrast to two decades ago when the MARD used to be > 20%. In addition, the majority of the new CGMs do not require calibrations, and the latest CGMs last for 10-14 days. An implantable 6-months CGM by Eversense-3 is now approved in the USA and Europe. Recently, the FDA approved Libre 3 which provides real-time glucose values every minute. Even though it is approved as an iCGM it is not interoperable with automatic-insulin-delivery (AID) systems. The newer CGMs that are likely to be launched in the next few months in the USA include the 10-11 days Dexcom G7 (60% smaller than the existing G6), and the 7-days Medtronic Guardian 4. Most of the newer CGM have several features like automatic initialization, easy insertion, predictive alarms, and alerts. It has also been noticed that an arm insertion site might have better accuracy than abdomen or other sites, like the buttock for kids. Lag time between YSI and different sensors have been reported differently, sometimes it is down to 2-3 min; however, in many instances, it is still 15-20 min, especially when the rate of change of glucose is > 2 mg/min. We believe that in the next decade there will be a significant increase in the number of people who use CGM for their day-to-day diabetes care.

Safety and user experience with off-label use of a flash glucose monitor (FreeStyle Libre® 1) among very young children with type 1 diabetes mellitus

OBJECTIVES

FreeStyle Libre 1 (FGM) has been approved by the FDA for children older than 4 years. It enables noninvasive glucose monitoring without the need for finger pricking. Parents of very young children often use the device off-label. Thus, we aimed to evaluate the safety of and user experience with FreeStyle Libre^® 1 and determine its impact on sleep and glycemic control.

METHODS

This was an ambi-directional cohort study. We recruited parents of very young children with type 1 diabetes mellitus (T1DM) who were less than 5 years old when they started using FGM at the King Saud University Diabetes Center. The parents filled out a survey evaluating their experience with the system. In addition, the glucose metrics of the children were also obtained from the Libre View system.

RESULTS

We included 31 children with mean age of the children when they started using FGM was 3.88 ± 1.10 years (range, 1.46-5.4 years), and the mean sensor use was 2.3 ± 1.3 years. During the use of the device, the parents had increased sleep duration of 0.71 h (p-value=0.04), had earlier bedtime by 2.8 h (p-value=0.04), and were able to sleep in a separate room from their children. In addition, the time in range improved by 9.9%, the time above range decreased by 8.8%, and the HbA_1c level reduced by 1.56%.

CONCLUSIONS

The safety profile of FGM used for very young children with T1DM is the same for older children, which leads to improved metabolic control and sleep quality of both the parent and the child.

Expert Consensus Recommendations on Time in Range for Monitoring Glucose Levels in People with Diabetes: An Indian Perspective

Keeping up with the global scenario, diabetes prevalence is on rise in India. Inadequate glycemic control is a major cause of diabetes-related morbidity and mortality. The conventional standards of care (SOC) in diabetes, including self-monitoring of blood glucose and measurement of glycated hemoglobin, have supported achievement of glycemic control, yet there are a few limitations. With the use of current technologies and metrics, such as continuous glucose monitoring (CGM) and standardized CGM data reporting, the continuous real-time glucose levels can be measured, and importantly, the percentage of time above, below, and within the target glucose range can be calculated, which facilitates patient-centric care, a current goal in diabetes management. International consensus recommendations endorse the incorporation of CGM and CGM data reporting in SOC for diabetes management. The guidelines provide time in range (TIR) thresholds for different patient populations and different types of diabetes. However, extrapolation of these global guidelines does not aptly cover the Indian population, which has diverse diet, culture, and religious practices. In this context, a consensus meeting was held in India in 2021 with experts in the field of diabetes care. The purpose of the meeting was to develop consensus recommendations for TIR thresholds for different patient profiles in India. Those expert recommendations, together with an evidence-based review, are reported here. The aim of this agreement is to aid clinicians across India to routinely use CGM and CGM data reports for optimizing individualized diabetes care, by implementing clinical targets for TIR.

Continuous glucose monitoring and metrics for clinical trials: an international consensus statement

Randomised controlled trials and other prospective clinical studies for novel medical interventions in people with diabetes have traditionally reported HbA1c as the measure of average blood glucose levels for the 3 months preceding the HbA1c test date. The use of this measure highlights the long-established correlation between HbA1c and relative risk of diabetes complications; the change in the measure, before and after the therapeutic intervention, is used by regulators for the approval of medications for diabetes. However, with the increasing use of continuous glucose monitoring (CGM) in clinical practice, prospective clinical studies are also increasingly using CGM devices to collect data and evaluate glucose profiles among study participants, complementing HbA1c findings, and further assess the effects of therapeutic interventions on HbA1c. Data is collected by CGM devices at 1-5 min intervals, which obtains data on glycaemic excursions and periods of asymptomatic hypoglycaemia or hyperglycaemia (ie, details of glycaemic control that are not provided by HbA1c concentrations alone that are measured continuously and can be analysed in daily, weekly, or monthly timeframes). These CGM-derived metrics are the subject of standardised, internationally agreed reporting formats and should, therefore, be considered for use in all clinical studies in diabetes. The purpose of this consensus statement is to recommend the ways CGM data might be used in prospective clinical studies, either as a specified study endpoint or as supportive complementary glucose metrics, to provide clinical information that can be considered by investigators, regulators, companies, clinicians, and individuals with diabetes who are stakeholders in trial outcomes. In this consensus statement, we provide recommendations on how to optimise CGM-derived glucose data collection in clinical studies, including the specific glucose metrics and specific glucose metrics that should be evaluated. These recommendations have been endorsed by the American Association of Clinical Endocrinologists, the American Diabetes Association, the Association of Diabetes Care and Education Specialists, DiabetesIndia, the European Association for the Study of Diabetes, the International Society for Pediatric and Adolescent Diabetes, the Japanese Diabetes Society, and the Juvenile Diabetes Research Foundation. A standardised approach to CGM data collection and reporting in clinical trials will encourage the use of these metrics and enhance the interpretability of CGM data, which could provide useful information other than HbA1c for informing therapeutic and treatment decisions, particularly related to hypoglycaemia, postprandial hyperglycaemia, and glucose variability.

Flash glucose monitoring system in patients with type 1 diabetes in healthcare center in Brazil: real world data from a short-term prospective study

Objective

To evaluate the alternate use of flash glucose monitoring (FGM) with self-monitoring blood glucose (SMBG), in patients with type 1 diabetes (T1D).

Materials and methods

Two weeks of open FGM (P2), both preceded (P1) and followed by 2 weeks (P3) of SMBG with a blinded FGM system. Mean absolute relative difference (MARD) was calculated by (|FGMi - SMBGi|) / SMBGi, where it was a paired data sample.

Results

In total, 34 patients were evaluated. Time in range (TIR) did not change between P1 and P2. In 12 patients (35.3%), TIR increased from 40% at P1 to 52% at P2 (p = 0.002) and in 22 (64.7%), TIR decreased or did not change. FGM use resulted in decreased % time spent in hypoglycemia (<70 mg/dL) (6.5% vs. 5.0%; p = 0.005), increased % time spent in hyperglycemia (>180 mg/dL) (44.5% to 51%; p = 0.046) with no significant change in % TIR. The proportion of patients who reached sensor-estimated glycated hemoglobin (eA1c) < 7% decreased from 23.5% at P1 to 12.9% at P2, p = 0.028. For the whole sample, the MARD between the two methods was 15.5% (95% CI 14.5-16.6%). For normal glucose range, hyperglycemic levels and hypoglycemic levels MARD were 16.0% (95% CI 15.0-17.0%), 13.3% (95% CI 11.5-15.2%) and 23.4% [95% CI 20.5-26.3%)], respectively.

Conclusion

FGM after usual SMBG decreased the % time spent in hypoglycemia concomitant with an undesired increase in % time spent in hyperglycemia. Lower accuracy of FGM regarding hypoglycemia levels could result in overcorrection of hypoglycemia.

Effects of flash glucose monitoring on glycemic control in participants with diabetes mellitus: A meta-analysis of randomized controlled trials

BACKGROUND

With the introduction of flash glucose monitoring (FGM) into the international market in 2014, academics worldwide are exploring whether this device improves glycemic control in participants with diabetes mellitus.

OBJECTIVE

A study was conducted in which participants were evaluated to determine the effect of FGM on glycemic control.

METHODS

From inception to April 9, 2022, we searched the Cochrane Library, PubMed, SinoMed, Embase, Web of Science, MEDLINE, CNKI, Wan Fang Data, and VIP databases to collect randomized controlled trials (RCTs) related to the effect of FGM on glycemic control in participants with diabetes mellitus. Outcomes included glycated hemoglobin, the occurrence of hypoglycemic events, fasting plasma glucose (FPG), and 2-h postprandial glucose (2hPG) levels. The statistical analysis was performed using R 4.1.3 software.

RESULTS

We included 19 studies involving 2013 participants, all of which were RCTs. Meta-analysis results revealed that compared to self-monitoring of blood glucose (SMBG), FGM significantly reduced glycated hemoglobin levels in participants with type 2 diabetes mellitus [mean difference = -0.74 [95 % CI-1.16, -0.32], P < 0.01] and type 1 diabetes mellitus combined with type 2 diabetes mellitus [mean difference = -1.14 [95 % CI-3.14, 0.87], P < 0.01], with a greater effect in participants aged ≤65 years with type 2 diabetes mellitus (mean difference = -1.38 [95 % CI-2.05, -0.72], P < 0.01). However, there was no effect of FGM on the improvement of glycated hemoglobin levels in patients with type 1 diabetes mellitus [P = 0.45]. Furthermore, fasting plasma glucose levels and 2-h postprandial glucose levels were significantly lower in FGM than SMBG, and the number of hypoglycemic events was also significantly lower.

CONCLUSION

Comparing SMBG with FGM indicated that FGM improves fasting plasma glucose levels, 2-h postprandial glucose levels, and glycated hemoglobin levels, and it reduces the number of hypoglycemic events.

Reduced Rate of Acute Diabetes Events with Flash Glucose Monitoring Is Sustained for 2 Years After Initiation: Extended Outcomes from the RELIEF Study

Background: The RELIEF study has previously shown a fall in the rate of acute diabetes events (ADEs) in people living with type 1 diabetes (PwDT1) or people living with type 2 diabetes (PwDT2) in the 12 months after initiation of flash glucose monitoring (FLASH) in France. The 2-year follow-up has provided new insights on the frequency of ADEs, including severe hypoglycemia and diabetic ketoacidosis (DKA), during use of FLASH. Methods: The RELIEF study included 31,446 PwDT1 and 41,027 PwDT2 with a first delivery of FreeStyle Libre (FSL) between August 1 and December 31, 2017. Hospitalizations for DKA, severe hypoglycemia, diabetes-related coma, and hyperglycemia were recorded for the 12 months before and 24 months after FSL initiation. Persistence of the FSL system use was estimated through a Kaplan-Meier survival curve. Change in usual blood glucose monitoring was estimated through acquisition of blood glucose test strips. Results: In the 2 years after FSL initiation, hospitalizations for ADEs were reduced by 49% and by 48% in PwDT1 or PwDT2, respectively, driven by reductions in DKA. After 2 years, 88% of patients persisted with the system and estimated mean consumption of blood glucose test strips had fallen after 2 years by -82% and by -84% in type 1 diabetes mellitus and type 2 diabetes mellitus, respectively. Conclusion: Use of FSL consistently reduces the rates of hospitalization for ADEs, mainly DKA, 2 years after initiation, confirming this is not a transitory effect. Use of FSL also results in a clear and progressive drop in use of blood glucose test strips over the 2-year period.

Impact of intermittently scanned continuous glucose monitoring with alarms on sleep and metabolic outcomes in children and adolescents with type 1 diabetes

AIMS

Data about sleep quality and quantity are not available in patients with type 1 diabetes (T1D) using intermittently scanned continuous glucose monitoring (isCGM). We questioned whether the isCGM with alarms could fragment sleep in patients and parents, compared to isCGM without alarms.

METHODS

A prospective, observational study including 47 child-adolescents with T1D who had experience with isCGM without alarms (Freestyle Libre 1-FSL1). They were asked to wear the isCGM with alarms (Freestyle Libre 2-FSL2) for 14 days. Patients enrolled and their caregiver (s), during a 14 day period with FSL1 and the following 14 days with FSL2, completed psychosocial and sleep-related questionnaires. Furthermore they wore an actigraph that was downloaded to a web platform and processed by the validated and certified algorithm "Dormi^®."

RESULTS

By the switch to the alarmed FSL2 we found about a 5% increase in Time In Range (from 62.5 to 67.8%), a reduction in time spent in hypoglycemia, number of weekly hypoglycemic events, and coefficient of variation. We did not find significant differences in sleep parameters in patients and their parents; therefore, alarms did not worsen the duration and quality of sleep. A significant improvement in the Quality of Life was perceived by parents using FSL2.

CONCLUSIONS

Introduction of alarms in isCGM systems gives, in the short term, an improvement in metabolic control in terms of time in range and reduction in hypoglycemia, without worsening duration and quality of sleep, measured by actigraphy, in children-adolescent and their parents.

A role for the diabetes nurse educator to telemedically support children with type 1 diabetes on continuous glucose monitoring? The COVID-19 lockdown experience

The role of diabetes nurse educators during the COVID-19 lockdown to telematically provide routine reviews of glycaemic control in children with type 1 diabetes (T1D) using continuous glucose monitoring systems is evaluated. Implementing these routines in the day-to-day clinical practice could reduce in-person clinic visits and improve glucose control.

Reductions in HbA1c with Flash Glucose Monitoring Are Sustained for up to 24 Months: A Meta-Analysis of 75 Real-World Observational Studies

INTRODUCTION

Real-world evidence (RWE) confirms that reductions in HbA1c for children and adults with type 1 diabetes (T1DM) and adults with type 2 diabetes (T2DM) are associated with use of the FreeStyle Libre system. This current meta-analysis aims to investigate whether HbA1c benefits are sustained over 24 months and to identify patterns of change in HbA1c for users of the FreeStyle Libre system for people living with T1DM or T2DM.

METHODS

A bibliographic search up to December 2020 identified 75 studies reporting data on change in lab HbA1c in 30,478 participants with type 1 (n = 28,063; 62 trials) or type 2 diabetes (n = 2415; 13 trials) using the FreeStyle Libre system, including observations on children, adolescents and adults. Meta-analysis was performed using a random effects model.

RESULTS

Reductions in HbA1c at 3-4 months were similar for adults with T1DM (- 0.53%, 95% CI - 0.69 to - 0.38) or with T2DM (- 0.45%, 95% CI - 0.57 to - 0.33), continuing through 4.5-7.5 months in T1DM (- 0.42%, 95% CI - 0.58 to - 0.27) and in T2DM (- 0.59%, 95% CI - 0.80 to - 0.39). Meta-regression analysis shows that higher starting HbA1c is correlated with greater reductions in HbA1c in T1DM and in T2DM. These patterns of change in HbA1c were sustained for 24 months in T1DM and for at least 12 months in T2DM.

CONCLUSIONS

Meta-analysis of RWE confirms that using the FreeStyle Libre system is associated with significant reductions in HbA1c for adults with T1DM or with T2DM. Reductions are greater for people with higher baseline HbA1c and are sustained for 24 and 12 months in T1DM and TD2M respectively.

Use of intermittently scanned continuous glucose monitoring in young people with high-risk type 1 diabetes-Extension phase outcomes following a 6-month randomized control trial

AIMS

To describe the impact of a 12-month intervention using intermittently scanned continuous glucose monitoring (isCGM) on glycaemic control and glucose test frequency in adolescents and young adults with type 1 diabetes (T1D) and high-risk glycaemic control (HbA_1c ≥75 mmol/mol [≥9.0%]).

METHODS

In total, 64 young people (aged 13-20 years, 16.6 ± 2.1 years; 48% female; 41% Māori or Pacific ethnicity; mean diabetes duration 7.5 ± 3.8 years) with T1D were enrolled in a 6-month, randomized, parallel-group study comparing glycaemic outcomes from the isCGM intervention (n = 33) to self monitoring blood glucose (SMBG) controls (n = 31). In this 6-month extension phase, both groups received isCGM; HbA_1c , glucose time-in-range (TIR), and combined glucose test frequency were assessed at 9 and 12 months.

RESULTS

At 12 months, the mean difference in HbA_1c from baseline was -4 mmol/mol [-0.4%] (95% confidence interval, CI: -8, 1 mmol/mol [-0.8, 0.1%]; p = 0.14) in the isCGM intervention group, and -7 mmol/mol [-0.7%] (95% CI: -16, 1 mmol/mol [-1.5, 0.1%]; p = 0.08) in the SMBG control group. No participants achieved ≥70% glucose TIR (3.9-10.0 mmol/L). The isCGM intervention group mean rate of daily glucose testing was highest at 9 months, 2.4 times baseline rates (p < 0.001), then returned to baseline by 12 months (incidence rate ratio = 1.4; 95% CI: 0.9, 2.1; p = 0.091).

CONCLUSIONS

The use of isCGM in young people with high-risk T1D resulted in transient improvements in HbA_1c and glucose monitoring over a 9-month time frame; however, benefits were not sustained to 12 months.

A guide for the use of LibreView digital diabetes platform in clinical practice: Expert paper of the Italian Working Group on Diabetes and Technology

Wider access to continuous glucose monitoring systems, including flash glucose monitoring, has enabled people with diabetes to achieve lower HbA1c levels and reduce the amount of time they spend in hypoglycaemia or hyperglycaemia, and has improved their quality of life. An International Consensus Panel proposed different target glucose ranges and recommendations according to different ages and situations (adults, young people and children with type 1 or type 2 diabetes, as well as elderly people who are at higher risk of hypoglycaemia, and women with diabetes during pregnancy). In this expert opinion, we interpret the international recommendations in the context of established clinical practice for diabetes care, and propose three different step-by-step algorithms to help the healthcare professionals use the most innovative glucose metrics, including time in glucose ranges, glucose management indicator, coefficient of variation, and ambulatory glucose profile. In detail, we focus on glucose metrics as measured by the FreeStyle Libre system and as visualized on the LibreView digital diabetes platform to support appropriate interpretation of flash glucose monitoring data. This is specifically structured for healthcare professionals and general practitioners who may have a low level of confidence with diabetes technology, with the aim of optimizing diabetes management, ensuring effective use of healthcare resources and to maximise outcomes for people with diabetes.

FreeStyle Libre Flash Glucose Monitoring system for people with type 1 diabetes in the UK: a budget impact analysis

INTRODUCTION

This study aims to estimate the budget impact of increased uptake of the FreeStyle Libre Flash Glucose Monitoring system in people with type 1 diabetes mellitus (T1DM) in the UK.

RESEARCH DESIGN AND METHODS

A budget impact model was developed, applying real-world data collected in the Association of British Clinical Diabetologists (ABCD) FreeStyle Libre Nationwide Audit. Costs of diabetes glucose monitoring in a T1DM population (n=1790) using self-monitoring of blood glucose (SMBG) or the FreeStyle Libre system were compared with a scenario with increased use of the FreeStyle Libre system.

RESULTS

The ABCD audit demonstrates FreeStyle Libre system use reduces diabetes-related resource utilization. The cost analysis found that higher acquisition costs are offset by healthcare costs avoided (difference £168 per patient per year (PPPY)). Total costs were £1116 PPPY with FreeStyle Libre system compared with £948 PPPY with SMBG. In an average-sized UK local health economy, increasing FreeStyle Libre system uptake from 30% to 50% increased costs by 3.4% (£1 787 345-£1 847 618) and when increased to 70% increased by a further 3.3%.

CONCLUSION

Increased uptake of the FreeStyle Libre system in the T1DM population marginally increases the cost to UK health economies and offers many system benefits.

[Evaluation of FreeStyle Libre in pediatric t1dm: improved glycemic control, reduction in diabetic ketoacidosis and severe hypoglycemia]

BACKGROUND

Self-monitoring of blood glucose (SMBG) with glucometers provides only a snapshot of the glycemic profile and is accompanied by significant psychological discomfort and pain, especially in children. Flash Glucose Monitoring System - FreeStyle Libre (FSL) overcomes many of the barriers associated with glucose measurement and improves metabolic control.

AIM

To evaluate the efficacy of FSL in children with type 1 diabetes mellitus (T1DM) in terms of glycemic control, episodes of severe hypoglycemia (SH) and diabetic ketoacidosis (DKA).

MATERIALS AND METHODS

A multicenter, prospective, observational study in real clinical practice was carried out. A total of 469 subjects (258 boys and 211 girls) aged 4-18 were included in the study. The median age was 11.3 (8.4-14.6) years, duration of T1DM - 4.2 (2.1-7.1) years. After FSL start, patient was followed up for 6 months.

RESULTS

After 3 and 6 months of FSL use, HbA1c significantly decreased from 7.4% to 7.1% and 7.2%, respectively (p&lt;0.001). The number of children with HbA1c &gt;&lt;7.5% increased from 51% to 60% and 58% at 3 and 6 months, respectively (p&gt;&lt;0.001). The incidence of DKA and SH, as well as the proportion of patients experiencing at least one episode of DKA and SH, were significantly reduced after 6 months of FSL use compared with baseline (p&gt;&lt;0.001).

CONCLUSION

The Study demonstrated a significant improvement in metabolic control in children with T1DM 6 months after FSL start: decrease in HbA1c, accompanied by reduction in incidence of DKA and SH.

A practical approach to continuous glucose monitoring (rtCGM) and FreeStyle Libre systems (isCGM) in children and young people with Type 1 diabetes

Real-time continuous glucose monitoring (rtCGM) and FreeStyle Libre glucose monitoring systems (isCGM) are new evolving technologies used in the management of Type 1 diabetes. They offer potential to improve diabetes control and reduce hypoglycaemia. rtCGM can be linked to insulin pump providing hybrid closed loop therapy. Families of children and young people are keen to have the benefit from these technologies. These are relatively expensive so it is important that health care professionals, families of children and young people (CYP) with diabetes are adequately trained in the use of these devices. Health care professionals need to be able to make patient selection based on individual needs and preferences to achieve maximum benefit. Association of Children's Diabetes Clinicians (ACDC) developed a comprehensive guideline in 2017 to help identify which patients may be most likely to benefit and how these technologies may be practically implemented. Since then new technologies have been introduced and the use of GCM has expanded in routine clinical practice. This article, aims to provide a practical approach and help identify which patients may be most likely to benefit and how the technology may be implemented in order to maximise the clinical benefits.

The influence of wearables on healthcare outcomes in chronic disease: a systematic review (Preprint)

Background

Chronic diseases contribute to high rates of disability and mortality. Patient engagement in chronic disease self-management is an essential component of chronic disease models of health care. Wearables provide patient-centered health data in real time, which can help inform self-management decision-making. Despite the perceived benefits of wearables in improving chronic disease self-management, their influence on health care outcomes remains poorly understood.

Objective

This review aimed to examine the influence of wearables on health care outcomes in individuals with chronic diseases through a systematic review of the literature.

Methods

A narrative systematic review was conducted by searching 6 databases for randomized and observational studies published between January 1, 2016, and July 1, 2021, that included the use of a wearable intervention in a chronic disease group to assess its impact on a predefined outcome measure. These outcomes were defined as any influence on the patient or clinician experience, cost-effectiveness, or health care outcomes as a result of the wearable intervention. Data from the included studies were extracted based on 6 key themes, which formed the basis for a narrative qualitative synthesis. All outcomes were mapped against each component of the Quadruple Aim of health care. The guidelines of the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement were followed in this study.

Results

A total of 30 articles were included; studies reported 2446 participants (mean age: range 10.1-74.4 years), and the influence of 14 types of wearables on 18 chronic diseases was presented. The most studied chronic diseases were type 2 diabetes (4/30, 13%), Parkinson disease (3/30, 10%), and chronic lower back pain (3/30, 10%). The results were mixed when assessing the impact on a predefined primary outcome, with 50% (15/30) of studies finding a positive influence on the studied outcome and 50% (15/30) demonstrating a nil effect. There was a positive effect of 3D virtual reality systems on chronic pain in 7% (2/30) of studies that evaluated 2 distinct chronic pain syndromes. Mixed results were observed in influencing exercise capacity; weight; and biomarkers of disease, such as hemoglobin A_1c, in diabetes. In total, 155 outcomes were studied. Most (139/155, 89.7%) addressed the health care outcomes component. This included pain (11/155, 7.5%), quality of life (7/155, 4.8%), and physical function (5/155, 3.4%). Approximately 7.7% (12/155) of outcome measures represented the patient experience component, with 1.3% (2/155) addressing the clinician experience and cost.

Conclusions

Given their popularity and capability, wearables may play an integral role in chronic disease management. However, further research is required to generate a strong evidence base for safe and effective implementation.

Trial Registration

PROSPERO International Prospective Register of Systematic Reviews CRD42021244562; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=244562

Metabolic Control of the FreeStyle Libre System in the Pediatric Population with Type 1 Diabetes Dependent on Sensor Adherence

Aims: To evaluate the relationship between daily sensor scan rates and changes in HbA1c and hypoglycemia in children. Methods: We enrolled 145 paediatric T1D patients into a prospective, interventional study of the impact of the FreeStyle Libre 1 system on measures of glycemic control. Results: HbA1c was higher at lower scan rates, and decreased as the scan rate increased to 15–20 scans, after which it rose at higher scan rates. An analysis of the change in hypoglycemia, based on the number of daily sensor scans, showed there was a significant correlation between daily scan rates and hypoglycemia. Subjects with higher daily scan rates reduced all levels of hypoglycaemia. Conclusions: HbA1c is higher at lower scan rates, and decreases as scan rate increases. Reductions in hypoglycemia were evident in subjects with higher daily scan rates.

Flash monitor initiation is associated with improvements in HbA1c levels and DKA rates among people with type 1 diabetes in Scotland: a retrospective nationwide observational study

AIMS/HYPOTHESIS

We assessed the real-world effect of flash monitor (FM) usage on HbA_1c levels and diabetic ketoacidosis (DKA) and severe hospitalised hypoglycaemia (SHH) rates among people with type 1 diabetes in Scotland and across sociodemographic strata within this population.

METHODS

This study was retrospective, observational and registry based. Using the national diabetes registry, 14,682 individuals using an FM at any point between 2014 and mid-2020 were identified. Within-person change from baseline in HbA_1c following FM initiation was modelled using linear mixed models accounting for within-person pre-exposure trajectory. DKA and SHH events were captured through linkage to hospital admission and mortality data. The difference in DKA and SHH rates between FM-exposed and -unexposed person-time was assessed among users, using generalised linear mixed models with a Poisson likelihood. In a sensitivity analysis, we tested whether changes in these outcomes were seen in an age-, sex- and baseline HbA_1c-matched sample of non-users over the same time period.

RESULTS

Prevalence of ever-FM use was 45.9% by mid-2020, with large variations by age and socioeconomic status: 64.3% among children aged <13 years vs 32.7% among those aged ≥65 years; and 54.4% vs 36.2% in the least-deprived vs most-deprived quintile. Overall, the median (IQR) within-person change in HbA_1c in the year following FM initiation was -2.5 (-9.0, 2.5) mmol/mol (-0.2 [-0.8, 0.2]%). The change varied widely by pre-usage HbA_1c: -15.5 (-31.0, -4.0) mmol/mol (-1.4 [-2.8, -0.4]%) in those with HbA_1c > 84 mmol/mol [9.8%] and 1.0 (-2.0, 5.5) mmol/mol (0.1 [-0.2, 0.5]%) in those with HbA_1c < 54 mmol/mol (7.1%); the corresponding estimated fold change (95% CI) was 0.77 (0.76, 0.78) and 1.08 (1.07, 1.09). Significant reductions in HbA_1c were found in all age bands, sexes and socioeconomic strata, and regardless of prior/current pump use, completion of a diabetes education programme or early FM adoption. Variation between the strata of these factors beyond that driven by differing HbA_1c at baseline was slight. No change in HbA_1c in matched non-users was observed in the same time period (median [IQR] within-person change = 0.5 [-5.0, 5.5] mmol/mol [0.0 (-0.5, 0.5)%]). DKA rates decreased after FM initiation overall and in all strata apart from the adolescents. Estimated overall reduction in DKA event rates (rate ratio) was 0.59 [95% credible interval (CrI) 0.53, 0.64]) after FM vs before FM initiation, accounting for pre-exposure trend. Finally, among those at higher risk for SHH, estimated reduction in event rates was rate ratio 0.25 (95%CrI 0.20, 0.32) after FM vs before FM initiation.

CONCLUSIONS/INTERPRETATION

FM initiation is associated with clinically important reductions in HbA_1c and striking reduction in DKA rate. Increasing uptake among the socioeconomically disadvantaged offers considerable potential for tightening the current socioeconomic disparities in glycaemia-related outcomes.

The automated pancreas: A review of technologies and clinical practice

Insulin pumps and glucose sensors are effective in improving diabetes therapy and reducing acute complications. The combination of both devices using an algorithm-driven interoperable controller makes automated insulin delivery (AID) systems possible. Many AID systems have been tested in clinical trials and have proven safety and effectiveness. However, currently, none of these systems are available for routine use in children younger than 6 years in Europe. For continued use, both users and prescribers must have sound knowledge of the features of the individual AID systems. Presently, all systems require various user interactions (e.g. meal announcements) because fully automated systems are not yet developed. Open-source systems are non-regulated variants to circumvent existing regulatory conditions. There are risks here for both users and prescribers. To evaluate AID therapy, the metric data of the glucose sensors, 'time in target range' and 'glucose management index', are novel recognized and suitable parameters allowing a consultation based on real glucose and insulin pump download data from the daily life of people with diabetes. Read out via cloud-based software or automatic download of such individual treatment data provides the ideal technical basis for shared decision-making through telemedicine, which must be further evaluated for general use.

Fear of hypoglycemia and quality of life in young people with type 1 diabetes and their parents in the era of sensor glucose monitoring

INTRODUCTION

It is crucial to understand psychosocial outcomes in children and adolescents with type 1 diabetes (T1D) and their families to provide optimal family-centered care. Hence, the aim of this study was to explore psychosocial outcomes in young people with T1D and their parents using currently available glucose monitoring devices in a real-life clinic setting.

METHODS

Children and adolescents aged 2-18 years with T1D for more than 6 months and their parents were recruited into a cross-sectional study to complete the Hypoglycemia Fear Survey (HFS) and the Pediatric Quality of Life Inventory (PedsQL) Generic Score Scales, Diabetes Module and Family Impact Module. Demographics and diabetes-specific parameters were obtained from medicals records.

RESULTS

Fifty-nine children and adolescents (mean age 15.1 ± 3.0 years) and 49 parents of children (mean age of children 12.5± 3.3 years) of which 44 were child-parent dyads completed the questionnaires. Parents had a higher mean (SD) FOH total and worry subscore than children, total score was 37.9 (14.6) vs. 32.2 (11.9), p = 0.047 and worry subscore was 17.8 (10.4) vs. 12.8 (9.0), p = 0.01. Furthermore, lower parental diabetes-specific QoL score was observed in parents, 78.8 (12.2) vs. 82.7 (10.3), p=0.02. No difference in FOH and QoL between real-time continuous glucose monitoring (rtCGM) and intermittently scanned glucose monitoring (isCGM) users and users of devices with and without alerts was observed. In isCGM users (n=36 completing the child questionnaires, n=33 completing parent questionnaires), higher parental FOH and lower parental diabetes-specific QoL correlated with higher scanning frequency, r = 0.399, p = 0.021, and r = -0.464, p = 0.007 respectively. No significant correlation was documented between scanning frequency and child questionnaire scores.

CONCLUSIONS

Parents are more likely to perceive higher levels of psychosocial burden related to their child's diabetes than children and adolescents with T1D, especially parents of younger children. This highlights the need for family-based education and treatment resources to support parents in diabetes management in addition to rapidly advancing diabetes technology. In isCGM users, higher parental FOH and lower parent-perceived QoL correlated with a higher scanning frequency, indicating the potential impact of glucose monitoring modality on psychosocial outcomes or vice versa.

Factors influencing the effectiveness of using flash glucose monitoring on glycemic control for type 1 diabetes in Saudi Arabia

BACKGROUND

In 2017, 35000 Saudi children and adolescents were living with a type 1 diabetes (T1D) diagnosis. Diabetic complications are minimized upon strengthened glycemic regulation. The annual cost of treating diabetic patients with complications was four-fold higher than for patients without complications. The use of flash glucose monitoring (FGM) enables better diabetes treatment and thereby improves glycemic control. Understanding the factors that affect effectiveness of FGM will help enhance the device’s use and management of hospital resources, resulting in improved outcomes.

AIM

To investigate factors that affect effectiveness of the FGM system for glycated hemoglobin (HbA1c) levels/glycemic control among T1D patients.

METHODS

A retrospective empirical analysis of T1D patient records from King Abdul-Aziz University Hospital and Prince Sultan Military Medical City was performed. T1D patients who began FGM between 2017 and 2019 were included.

RESULTS

The data included 195 T1D patients (70 males and 125 females) with a mean age of 23.6 ± 8.1 years. Among them, 152 patients used multiple daily injection and 43 used an insulin pump. The difference in HbA1c level from baseline and after using FGM was -0.60 ± 2.10, with a maximum of 4.70 and a minimum of -6.30. There was a statistically significant negative correlation between the independent variables (age, duration of diabetes, level of engagement) and HbA1c. The group with the highest HbA1c mean (9.85) was 18-years-old, while the group with the lowest HbA1c mean (7.87) was 45-years-old. Patients with a low level of engagement (less than six scans per day) had the highest HbA1c mean (9.84), whereas those with a high level of engagement (more than eight scans per day) had the lowest HbA1c mean (8.33).

CONCLUSION

With proper education, FGM can help people with uncontrolled T1D over the age of 18 years to control their glucose level.

Basal Insulin Degludec and Glycemic Control Compared to Aspart Via Insulin Pump in Type 1 Diabetes (BIGLEAP): A Single-Center, Open-Label, Randomized, Crossover Trial

OBJECTIVE

We compared the efficacy of the second-generation basal insulin degludec (IDeg) to that of insulin aspart via pump using continuous glucose monitoring in patients with well-controlled type 1 diabetes.

METHODS

In this 40-week, single-center, randomized, crossover-controlled trial, adults with well-controlled type 1 diabetes (hemoglobin A1C of <7.5% [<58 mmol/mol]) (N = 52) who were using an insulin pump and continuous glucose monitoring were randomized to 1 of 2 treatments for a 20-week period: a single daily injection of IDeg with bolus aspart via pump or a continuous subcutaneous insulin infusion (CSII) with aspart, followed by crossover to the other treatment. The primary endpoint was time in range (70-180 mg/dL) during the final 2 weeks of each treatment period.

RESULTS

Fifty-two patients were randomized and completed both treatment periods. The time in range for IDeg and CSII was 71.5% and 70.9%, respectively (P = .553). The time in level 1 hypoglycemia for the 24-hour period with IDeg and CSII was 2.19% and 1.75%, respectively (P = .065). The time in level 2 hypoglycemia for the 24-hour period with IDeg and CSII was 0.355% and 0.271%, respectively (P = .212), and the nocturnal period was 0.330% and 0.381%, respectively (P = .639). The mean standard deviation of blood glucose levels for the 24-hour period for IDeg and CSII was 52.4 mg/dL and 51.0 mg/dL, respectively (P = .294). The final hemoglobin A1C level for each treatment was 7.04% (53 mmol/mol) with IDeg, and 6.95% (52 mmol/mol) with CSII (P = .288). Adverse events were similar between treatments.

CONCLUSION

We observed similar glycemic control between IDeg and insulin aspart via CSII for basal insulin coverage in patients with well-controlled type 1 diabetes.

Effect of Nutritional Habits on the Glycemic Response to Different Carbohydrate Diet in Children with Type 1 Diabetes Mellitus

Unhealthy eating habits are associated with obesity, metabolic syndrome, and increased insulin resistance in young patients with type 1 diabetes mellitus (T1DM), and may impact the possible benefit from dietary interventions on glycaemic control. This study determines how nutritional patterns influence the quality of dietary intervention with a 30% or 50% carbohydrate diet in terms of glycaemic control measured with continuous glucose monitoring (CGM). Eating habits were obtained with a frequency-of-consumption questionnaire (FFQ-6) before the diet assessment. Altogether, we collected CGM and FFQ-6 data from 30 children (16 boys and 14 girls aged 10-17 years) with T1DM subjected to two consecutive 3-day nutritional plans. From these, 23 patients met the CGM data quality criteria for further analysis. Furthermore, high accuracy achieved in training (95.65%) and V-fold cross-validation (81.67%) suggest a significant impact of food habits in response to introduced nutritional changes. Patients who consumed more vegetables or grains (>4 times per day), more wheat products (>once per day), fewer fats (<1.5 times per day), and ranked fruit juice as the most common selection in the drinks category achieved glycaemic control more often after the introduction of a 30% carbohydrate diet, as opposed to those with different dietary patterns, whose glycaemic control was negatively impacted after switching to this diet. Additionally, the 50% carbohydrate diet was safe for all patients in the context of glycaemic control.

Good Metabolic Control in Children with Type 1 Diabetes Mellitus: Does Glycated Hemoglobin Correlate with Interstitial Glucose Monitoring Using FreeStyle Libre?

BACKGROUND

Good metabolic control of Type 1 diabetes (T1D) leads to a reduction in complications. The only validated parameter for establishing the degree of control is glycated hemoglobin (HbA1c). We examined the relationship between HbA1c and a continuous glucose monitoring (CGM) system.

MATERIALS AND METHODS

A cohort prospective study with 191 pediatric patients with T1D was conducted. Time in range (TIR), time below range (TBR), coefficient of variation (CV), number of capillary blood glucose tests, and HbA1c before sensor insertion and at one year of use were collected.

RESULTS

Patients were classified into five groups according to HbA1c at one year of using CGM. They performed fewer capillary blood glucose test at one year using CGM (-6 +/- 2, p < 0.0001). We found statistically significant differences in TIR between categories. Although groups with HbA1c < 6.5% and HbA1c 6.5-7% had the highest TIR (62.214 and 50.462%), their values were highly below optimal control according to CGM consensus. Groups with TBR < 5% were those with HbA1c between 6.5% and 8%.

CONCLUSIONS

In our study, groups classified as well-controlled by guidelines were not consistent with good control according to the CGM consensus criteria. HbA1c should not be considered as the only parameter for metabolic control. CGM parameters allow individualized targets.

Impact of flash glucose monitoring on glycemic control varies with the age and residual β-cell function of patients with type 1 diabetes mellitus

Aims/Introduction

We aimed to explore the clinical factors associated with glycemic variability (GV) assessed with flash glucose monitoring (FGM), and investigate the impact of FGM on glycemic control among Chinese type 1 diabetes mellitus patients in a real‐life clinical setting.

Materials and Methods

A total of 171 patients were included. GV was assessed from FGM data. A total of 110 patients wore FGM continuously for 6 months (longitudinal cohort). Hemoglobin A1c (HbA1c), fasting and 2‐h postprandial C‐peptide, and glucose profiles were collected. Changes in HbA1c and glycemic parameters were assessed during a 6‐month FGM period.

Results

Individuals with high residual C‐peptide (HRCP; 2‐h postprandial C‐peptide >200 pmol/L) had less GV than patients with low residual C‐peptide ( 2‐h postprandial C‐peptide ≤200 pmol/L; P < 0.001). In the longitudinal cohort (n = 110), HbA1c and mean glucose decreased, time in range (TIR) increased during the follow‐up period (P < 0.05). The 110 patients were further divided into age and residual C‐peptide subgroups: (i) HbA1c and mean glucose were reduced significantly only in the subgroup aged ≤14 years during the follow‐up period, whereas time below range also increased in this subgroup at 3 months (P = 0.047); and (ii) HbA1c improved in the HRCP subgroup at 3 and 6 months (P < 0.05). The mean glucose decreased and TIR improved significantly in the low residual C‐peptide subgroup; however, TIR was still lower and time below range was higher than those of the HRCP subgroup at all time points (P < 0.05).

Conclusions

HRCP was associated with less GV. FGM wearing significantly reduced HbA1c, especially in pediatric patients and those with HRCP. Additionally, the mean glucose and TIR were also found to improve.

COVID-19 pandemic lockdown in young people with type 1 diabetes: Positive results of an unprecedented challenge for patients through telemedicine and change in use of continuous glucose monitoring

There has been little data published related to glucose control in adolescents and young adults with type 1 diabetes (T1D) during lockdown, but rarely focusing on telemedicine's role. During this unpreceded period, glucose control and self-monitoring improved in our young patients, with better results associated with telemedicine.

Budget Impact of the Flash Continuous Glucose Monitoring System in Medicaid Diabetes Beneficiaries Treated with Intensive Insulin Therapy

Objective: We assessed the economic impact of using the newest flash continuous glucose monitoring (CGM) among Medicaid beneficiaries with diabetes treated with intensive insulin therapy (IIT). Research Design and Methods: A budget impact analysis was created to assess the impact of increasing the proportion of Medicaid beneficiaries with diabetes on IIT, who use flash CGM by 10%. The analysis included glucose monitoring device costs, cost savings due to reductions in glycated hemoglobin, severe hypoglycemia events, and hyperglycemic emergencies such as diabetic ketoacidosis. The net change in costs per person to adopt flash CGM for three populations treated with IIT (adults with type 1 diabetes [T1D] or type 2 diabetes [T2D], and children and adolescents with T1D or T2D) was calculated; these costs were used to estimate the impact of increasing flash CGM use by 10% to the U.S. Medicaid budget over 1-3 years. Results: The analysis found that flash CGM demonstrated cost savings in all populations on a per patient basis. Increasing use of flash CGM by 10% was associated with a $19.4 million overall decrease in costs over the year and continued to reduce costs by $25.3 million in years 2 and 3. Conclusions: Our results suggest that the new flash CGM system can offer cost savings compared to blood glucose monitoring in Medicaid beneficiaries treated with IIT, especially T1D adults, and children and adolescents. These findings support expanding access to CGM by Medicaid plans.

Benefits of the addition of continuous or flash glucose monitoring versus standard practice using self-monitored blood glucose and haemoglobin A1c in the primary care of diabetes mellitus: a systematic review protocol

INTRODUCTION

Studies demonstrate that optimal glycaemic control reduces morbidity from diabetes mellitus but remains elusive in a significant portion of patients. Although research shows that continuous glucose monitoring (CGM) and flash glucose monitoring (FGM) improves glycaemic control in selected subsets of patients with diabetes in specialty practices, we found no systematic reviews evaluating the use of CGM/FGM in primary care, where the majority of patients with diabetes are cared for.This systematic review aims to answer the questions: 'compared with usual care of self-monitoring blood glucose and haemoglobin A1c (HbA1c), does the addition of CGM/FGM use in the primary care of patients with diabetes improve glycaemic control, decrease rates of hypoglycaemia, and improve patient and physician satisfaction?' and if so, 'what subgroups of primary care patients with diabetes are most likely to benefit?'.

METHODS AND ANALYSIS

Aligning with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines, a search will be conducted in PubMed, EMBASE, Scopus, CINAHL, Cochrane Central Register of Controlled Trials and Web of Science. We will include studies investigating CGM/FGM use and reporting the primary outcome measure of HbA1c and secondary outcome measures of hypoglycaemia, time in range, time below range, time above range and patient/staff satisfaction. We will examine which patient populations appear to benefit from CGM/FGM. Three independent researchers will use the Covidence systematic review software for blinded screening and study selection. The National Heart, Lung, and Blood Institute quality assessment tool and Grading of Recommendations Assessment, Development and Evaluation will be used to assess the risk of bias and quality of evidence.

ETHICS AND DISSEMINATION

The systematic review methodology does not require ethics approval due to the nature of the study design. Study findings will be publicly available to a wide readership across disciplines and will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42021229416.

Assessment of metabolic control and use of flash glucose monitoring systems in a cohort of pediatric, adolescents, and adults patients with Type 1 diabetes

PURPOSE

Flash glucose monitoring (FGM) in patients with type 1 diabetes (DM1) provides glucometric data that allow assessing glycemic control beyond HbA1c. The objective of this study was to evaluate metabolic control and use of FGM in a cohort of the pediatric and adult population with DM1.

MATERIAL AND METHODS

A cross-sectional study of patients with DM1 and FGM. Data on the use of the system and metabolic control were evaluated, carrying out a comparative study between different age ranges, ≤12 years; 13-19 years, 20-25 years, and ≥26 years.

RESULTS

One hundred and ninety-five patients have included: 35.9% children and adolescents (≤19 years), 42.6% female, 26.2% in treatment with an insulin pump. Mean age was 28.5 ± 15.9 years, mean duration of diabetes 13.7 ± 11.0 years, and mean HbA1c 7.1 ± 0.9% (54 ± 6 mmol/l). Average daily FGM scans were 11.1 ± 6.7. Mean glucose was 162 ± 35 mg/dl, mean standard deviation (SD) 66.1 ± 20.4 mg/dl, mean coefficient of variation 41.4 ± 7.9%, mean time in range (TIR) 58.8 ± 17.0%, mean time above range 33.7 ± 17.6% and mean time below range 7.5 ± 5.8%. The pediatric group showed higher TIR, lower HbA1c, lower glycemic variability, lower mean glucose, and higher use of the device than the adult population. In the entire cohort, the device scans showed a negative quadratic correlation with HbA1c, mean glucose, SD, and age and a positive quadratic correlation with TIR.

CONCLUSIONS

Children under 12 years showed the best metabolic control and the most frequent use of the device. Metabolic control deteriorates with age. The greater number of device scans was in correlation with better metabolic control in all age groups.

Important Drop in Rate of Acute Diabetes Complications in People With Type 1 or Type 2 Diabetes After Initiation of Flash Glucose Monitoring in France: The RELIEF Study

OBJECTIVE

The RELIEF study assessed rates of hospitalization for acute diabetes complications in France before and after initiation of the FreeStyle Libre system.

RESEARCH DESIGN AND METHODS

A total of 74,011 patients with type 1 diabetes or type 2 diabetes who initiated the FreeStyle Libre system were identified from the French national claims database with use of ICD-10 codes, from hospitalizations with diabetes as a contributing diagnosis, or the prescription of insulin. Patients were subclassified based on self-monitoring of blood glucose (SMBG) strip acquisition prior to starting FreeStyle Libre. Hospitalizations for diabetic ketoacidosis (DKA), severe hypoglycemia, diabetes-related coma, and hyperglycemia were recorded for the 12 months before and after initiation.

RESULTS

Hospitalizations for acute diabetes complications fell in type 1 diabetes (-49.0%) and in type 2 diabetes (-39.4%) following FreeStyle Libre initiation. DKA fell in type 1 diabetes (-56.2%) and in type 2 diabetes (-52.1%), as did diabetes-related comas in type 1 diabetes (-39.6%) and in type 2 diabetes (-31.9%). Hospitalizations for hypoglycemia and hyperglycemia decreased in type 2 diabetes (-10.8% and -26.5%, respectively). Before initiation, hospitalizations were most marked for people noncompliant with SMBG and for those with highest acquisition of SMBG, which fell by 54.0% and 51.2%, respectively, following FreeStyle Libre initiation. Persistence with FreeStyle Libre at 12 months was at 98.1%.

CONCLUSIONS

This large retrospective study on hospitalizations for acute diabetes complications shows that a significantly lower incidence of admissions for DKA and for diabetes-related coma is associated with use of flash glucose monitoring. This study has significant implications for patient-centered diabetes care and potentially for long-term health economic outcomes.

Continuous glucose monitoring: A review of the evidence in type 1 and 2 diabetes mellitus

CONTEXT AND AIM

Continuous glucose monitoring (CGM) is becoming widely accepted as an adjunct to diabetes management. Compared to standard care, CGM can provide detailed information about glycaemic variability in an internationally standardised ambulatory glucose profile, enabling more informed user and clinician decision making. We aimed to review the evidence, user experience and cost-effectiveness of CGM.

METHODS

A literature search was conducted by combining subject headings 'CGM' and 'flash glucose monitoring', with key words 'type 1 diabetes' and 'type 2 diabetes', limited to '1999 to current'. Further evidence was obtained from relevant references of retrieved articles.

RESULTS

There is a strong evidence for CGM use in people with type 1 diabetes, with benefits of reduced glycated haemoglobin and hypoglycaemia, and increased time in range. While the evidence for CGM use in type 2 diabetes is less robust, similar benefits have been demonstrated. CGM can improve diabetes-related satisfaction in people with diabetes (PWD) and parents of children with diabetes, as well as the clinician experience. However, CGM does have limitations including cost, accuracy and perceived inconvenience. Cost-effectiveness analyses have indicated that CGM is a cost-effective adjunct to type 1 diabetes management that is associated with reduced diabetes-related complications and hospitalisation.

CONCLUSIONS

Continuous glucose monitoring is revolutionising diabetes management. It is a cost-effective adjunct to diabetes management that has the potential to improve glycaemic outcomes and quality of life in PWD, especially type 1 diabetes.

Flash glucose monitoring in gestational diabetes mellitus: study protocol for a randomised controlled trial

INTRODUCTION

Gestational diabetes mellitus (GDM) is a glucose intolerance occurring in 3%-10% of pregnant women and being a risk factor for multiple maternal and fetal complications. The risk of perinatal complications is proportional to the level of maternal hyperglycaemia. Proper glycaemic control is therefore one of the key elements of GDM therapy. Until recently, determination of blood glucose concentration was performed using glucose meters, which involved multiple fingerpricks. Nowadays, due to the flash glucose monitoring (FGM) availability, it is possible to collect measurements at any time without routine puncturing. The aim of the presented study is to assess the impact of FGM on the efficacy of treatment in population of patients diagnosed with GDM.

METHODS AND ANALYSIS

This is a prospective, randomised study, that will recruit 100 women at 24-28 weeks of gestation at the 1st Department of Obstetrics and Gynecology, Medical University of Warsaw, Poland. Women diagnosed with GDM, who will meet the inclusion criteria, will be individually randomised to the FGM or self-monitoring of blood glucose groups. Further on, clinical and laboratory results of the mother and their newborns will be collected for analysis during the course of pregnancy. Primary outcome is mean glycaemia result in each group after 1 month analysis and percentage of results in the target glycaemic range. The secondary objectives will be to compare the two groups for maternal and neonatal outcomes in conjunction with long-term glycaemic control using blood glycated haemoglobin and fructosamine serum concentrations.

ETHICS AND DISSEMINATION

The study is exempt from regional ethics review due to its nature of quality improvement in patient care. The study has been approved by the Bioethics Committee at the Medical University of Warsaw and the patient privacy protection boards governing over the recruitment sites. Results of the study will be presented in peer-reviewed journals and at conferences.

TRIAL REGISTRATION NUMBER

NCT04422821.

Intermittently Scanned Glucose Values for Continuous Monitoring: Cross-Sectional Analysis of Glycemic Control and Hypoglycemia in 1809 Children and Adolescents with Type 1 Diabetes

Background and Objective: Intermittent scanning continuous glucose monitoring (iscCGM) is increasingly used for glycemic monitoring in diabetes care. In this cross-sectional real-world analysis, iscCGM data were compared to traditional parameters of glycemic control in young people with type 1 diabetes. Methods: Using the DPV registry, most recent data from children and adolescents aged <18 years with uploaded iscCGM sensor profiles with at least 14 days of data and a > 50% completeness were evaluated using recommended parameters of sensor metrics. Analysis was performed stratified by age group, glycemic control, and type of therapy; data were taken from DPV data pool in February 2020. Results: Glucose sensor profiles and clinical data from 1809 individuals (mean age 13.4 years, 53% male, and mean diabetes duration 5.02 years) were evaluated in this study. More than 50% of this population (n = 965) reached the current German treatment target of hemoglobin A1c (HbA1c) <7.5%. In this target, the mean scanning frequency was higher than in groups with HbA1c >7.5 or >8.0% (12.0 vs. 10.2 vs 7.6 times per day). The group of preschool children had the highest frequency of scanning (16.6 vs. 13.3 times per day in school kids and 7.9 in adolescents), the lowest HbA1c level, and the lowest risk for hypoglycemia (low blood glucose index 0.8 vs. 1.0 vs 1.2). Conclusion: Real-world data will help to determine the value of iscCGM to improve clinical and patient-related outcomes in pediatric diabetology. Not only the use of a device but also the intensity of use seems to have a high and direct impact on glycemic control.

Performance of three different continuous glucose monitoring systems in children with type 1 diabetes during a diabetes summer camp

The aim of this study was to assess accuracy of the three most commonly used continuous glucose monitoring (CGM) systems in almost real-life situation during a diabetes camp in children with type 1 diabetes (T1D) aged 9-14 years. Data was gathered during a 2-week summer camp under physicians' supervision. Out of 38 participating children with T1D (aged: 11.0 [9.9; 12.1] years; 57% girls, mean HbA1c 7.2 [6.9; 7.7] %,) 37 wore a CGM system (either Abbott FreeStyle Libre (FSL), Dexcom G6 (DEX) or Medtronic Enlite (ENL)) throughout the camp. All concomitantly available data pairs of capillary glucose measurements and sensor values were used for the analysis. Mean absolute relative difference (MARD) was calculated and Parkes Error Grid analyses were done for all three systems used. In total 2079 data pairs were available for analysis. The overall MARDs of CGM systems used at the camp was FSL: 13.3% (6.7;21.6). DEX: 10.3% (5.8; 16.7) and ENL 8.5% (3.6; 15.6). During eu-, hypo- and hyperglycemia MARDs were lowest in ENL. Highest MARDs were seen in hypoglycemia, where all three systems exhibited MARDs above 15%. Overnight MARDs of all systems was higher than during daytime. All sensors performed worst in hypoglycemia. Performance of the adequately calibrated Medtronic system outperformed the factory-calibrated sensors. For clinical practice, it is important to adequately train children with T1D and families in the correct procedures for sensors that require calibrations.

Technological innovation of Continuous Glucose Monitoring (CGM) as a tool for commercial aviation pilots with insulin-treated diabetes and stakeholders/regulators: A new chance to improve the directives?

Civil aviation pilots who develop insulin-treated diabetes and want to renew a Commercial Pilot License (CPL) represent a medical, social and regulatory problem. This depends on justified concerns about hypoglycemia, the most threatening event for people who carry out jobs requiring a high level of concentration and reliability. This negatively affects social and working aspects of pilots' lives, who have a high profile and a high-cost professional qualification. It could be possible now to revise this attitude thanks to the availability of Continuous Glucose Monitoring (CGM) devices. CGM clearly showed to prevent hypoglycemic events in insulin-treated diabetic patients by allowing strict monitoring and trend prediction of glucose levels. By systematizing available data on such devices and present regulations in CPL issuance worldwide, our review can be used as handy tool for a fruitful discussion among the scientific community, national and international civil aviation regulators, stakeholders and pilots, aimed at evaluating the evidence-based opportunity to revise CPL issuance criteria for insulin-treated diabetic pilots. For the above-mentioned reasons, there are, among the regulatory administrations of Civil Aviation around the globe, several different approaches and limitations set for the subjects with insulin-treated diabetes who want to obtain, or renew, a CPL.

Time in range: A best practice guide for UK diabetes healthcare professionals in the context of the COVID-19 global pandemic

The emergence of continuous glucose monitoring has driven improvements in glycaemic control and quality of life for people with diabetes. Recent changes in access to continuous glucose monitoring systems within UK health services have increased the number of people able to benefit from these technologies. The COVID-19 pandemic has created an opportunity for diabetes healthcare professionals to use continuous glucose monitoring technology to remotely deliver diabetes services to support people with diabetes. This opportunity can be maximized with improved application and interpretation of continuous glucose monitoring-generated data. Amongst the diverse measures of glycaemic control, time in range is considered to be of high value in routine clinical care because it is actionable and is visibly responsive to changes in diabetes management. Importantly, it is also been linked to the risk of developing complications associated with diabetes and can be understood by people with diabetes and healthcare professionals alike. The 2019 International Consensus on Time in Range has established a series of target glucose ranges and recommendations for time spent within these ranges that is consistent with optimal glycaemic control. The recommendations cover people with type 1 or type 2 diabetes, with separate targets indicated for elderly people or those at higher risk from hypoglycaemia, as well as for women with type 1 diabetes during pregnancy. The aim of this best practice guide was to clarify the intent and purpose of these international consensus recommendations and to provide practical insights into their implementation in UK diabetes care.

Improving HbA1c Control in Type 1 or Type 2 Diabetes Using Flash Glucose Monitoring: A Retrospective Observational Analysis in Two German Centres

INTRODUCTION

The aim of this study was to evaluate change in laboratory-measured HbA1c in patients with either type 1 diabetes (T1D) or type 2 diabetes (T2D) on insulin therapy following initiation of the FreeStyle Libre™ flash glucose monitoring system.

METHODS

This was a retrospective observational study on adults with T1D or T2D on insulin, who were started on the FreeStyle Libre system as part of standard care. HbA1c was recorded at initiation and at 3-month intervals thereafter.

RESULTS

The analysis included 131 patients with T1D and 176 patients with T2D on insulin. Mean HbA1c decreased significantly by 3 months following initiation of the FreeStyle Libre system, both in T1D (- 0.75%, p < 0.001) and in T2D (- 0.54%, p < 0.001). Reductions were maintained for 12 months. Change from 3 to 12 months was not significant either in T1D or T2D. Subgroup analysis showed significant reduction in patients with a baseline HbA1c > 7.5-10%, both in T1D (- 0.59%, p < 0.001) and in T2D on insulin (- 0.62%, p < 0.005) at 12 months. Reductions for subjects with HbA1c > 10% were - 4.66% in T1D and - 3.73% in T2D. No change was seen for subjects with a baseline HbA1c ≤ 7.5% (58 mmol/mol). Linear regression confirms that baseline HbA1c is strongly negatively correlated with subsequent change in HbA1c in T1D and in T2D.

CONCLUSIONS

Patients with T1D or T2D show a reduction in HbA1c by 3 months following initiation of the FreeStyle Libre system. The mean fall in HbA1c at 3 months is strongly negatively correlated with starting HbA1c. This reduction is maintained over 12 months. The significant benefit is seen in patients with a starting HbA1c > 7.5% (58 mmol/mol).