Continuous subcutaneous insulin infusion versus multiple daily injection regimens in children and young people at diagnosis of type 1 diabetes: pragmatic randomised controlled trial and economic evaluation

Risk predictors of glycaemic control in children and adolescents with type 1 diabetes: A systematic review and meta-analysis

OBJECTIVES

To conduct systematic evaluation of the risk predictors of glycaemic control in children and adolescents with type 1 diabetes mellitus.

METHODS

Cohort studies on risk predictors of glycaemic control in children and adolescents with type 1 diabetes were retrieved from CNKI, PubMed, Web of Science, Embase databases, etc. from the construction of the repository to 3 February 2023. Literature screening was conducted according to inclusion and exclusion criteria, then data extraction of region, sample size, age, follow-up time, risk predictors, outcome indicators, etc., and quality evaluation of The Newcastle-Ottawa Scale were conducted by two researchers while the third researcher makes decisions if there are disagreements. Finally, Revman5.4 and StataMP17 were used for meta-analysis.

RESULTS

A total of 29 studies were included, and the results showed that insulin pump [Weighed mean difference (WMD) = -.48, 95% CI (-.73, -.24), p < .01], high-frequency sensor monitoring, early use of insulin pumps, prospective follow-up male, white race, large body mass index-standardised scoring, conscientiousness, agreeableness of mothers, eicosapentaenoic acid, leucine and protein (p < .05) were beneficial for reducing HbA1c levels in children and adolescents with diabetes. Ketoacidosis [WMD = .39, 95% CI (.28, .50), p < .01], selective admission, higher HbA1c level at one time (p < .01), higher glutamate decarboxylase antibody at 1 month after diagnosis, lower socio-economic status, non-living with biological parents, non-two-parent family, family disorder, family history of diabetes and high carbohydrate intake (p < .05) increased HbA1c levels in children and adolescents with diabetes.

CONCLUSION

For children and adolescents with type 1 diabetes mellitus, the use of insulin pump, high-frequency sensor monitoring, prospective follow-up, good family support and reasonable diet are conducive to blood glucose control, while selective admission and DKA are not. Disease characteristics and demographic characteristics of children are closely related to subsequent blood glucose control, and the relationship between diagnosis age and blood glucose control needs to be further explored.

MDI versus CSII in Chinese adults with type 1 diabetes in a real-world situation: based on propensity score matching method

BACKGROUND

Compared with multiple daily insulin injections (MDI), continuous subcutaneous insulin infusion (CSII) is significantly more expensive and has not been widely used in Chinese type 1 diabetes mellitus (T1DM) patients. So there are still significant knowledge gaps regarding clinical and patient-reported outcomes in China.

AIMS

This study aims to compare the glycated hemoglobin (HbA1C), insulin therapy related quality of life (ITR-QOL), fear of hypoglycemia (FOH) of adult T1DM patients treated with MDI and CSII based on propensity score matching in real-world conditions in China.

METHODS

Four hundred twenty adult T1DM patients who were treated with MDI or CSII continuously for more than 12 months in a national metabolic center from June 2021 to June 2023 were selected as the study subjects. Their QOL and FOH were evaluated with Insulin Therapy Related Quality of Life Measure Questionnaire-Chinese version (ITR-QOL-CV) and the Chinese Version Hypoglycemia Fear Survey-Worry Scale (CHFSII-WS), and their HbA1C were collected at the same time. Potential confounding variables between the two groups were matched using propensity score matching.

RESULTS

Of the 420 patients included in the study, 315 were in MDI group and 105 were in CSII group. 102 pairs were successfully matched. After matching, the total score of ITR-QOL-CV scale in CSII group was significantly higher than that in MDI group (87.08 ± 13.53 vs. 80.66 ± 19.25, P = 0.006). Among them, the dimensions of daily life, social life, and psychological state were all statistically different (P < 0.05). The scores of CHFSII-WS (8.33 ± 3.49 vs. 11.77 ± 5.27, P = 0.003) and HbA1C (7.19 ± 1.33% vs. 7.71 ± 1.93%, P = 0.045) in CSII group were lower than those in MDI group.

CONCLUSIONS

25.0% of T1DM adults are treated with CSII. Compared with adult T1DM patients treated with MDI, those treated with CSII have higher ITR-QOL, less FoH, and better control of HbA1C in real-world conditions in China. Therefore, regardless of economic factors, CSII is recommended for adult T1DM patients to optimize the therapeutic effect and outcomes.

RETINAL MICROVASCULOPATHY WITH DIFFERENT INSULIN INFUSION THERAPIES IN CHILDREN WITH TYPE 1 DIABETES MELLITUS WITHOUT CLINICAL DIABETIC RETINOPATHY

PURPOSE

To explore the characteristics and associated factors of retinal microvasculopathy and neurodegeneration with different insulin therapies in children with type 1 diabetes mellitus (T1DM) but without diabetic retinopathy.

METHODS

Forty-one children with T1DM with multiple daily insulin injections (MDI), 22 children with T1DM with continuous subcutaneous insulin infusion, and 62 age-matched normal control children were enrolled. SPECTRALIS Optical coherence tomography was used to scan 6×6 mm square area of posterior retina.

RESULTS

The vessel density of superficial vascular plexus, intermediate capillary plexus, and deep capillary plexus in T1DM-MDI group were all significantly lower than those in the T1DM-CSII and control groups (0.39 ± 0.05 vs. 0.44 ± 0.04 and 0.42 ± 0.06, P < 0.001; 0.26 ± 0.04 vs. 0.30 ± 0.02 and 0.28 ± 0.04, P = 0.003; 0.30 ± 0.04 vs. 0.33 ± 0.04 and 0.32 ± 0.04, P = 0.027). In T1DM-MDI group, lower vessel density of superficial vascular plexus was associated with higher hemoglobin A1c (r = -0.377, P = 0.015). Foveal avascular zone morphology index in T1DM-MDI and T1DM-CSII groups were smaller than that in the control group (0.63 ± 0.11 and 0.63 ± 0.12 vs. 0.69 ± 0.15, P = 0.040). There was no statistically significant difference in the thickness of the retina among the three groups ( P > 0.05).

CONCLUSION

The vessel density of posterior retina was lower in children with T1DM with MDI than in healthy control children and associated with higher hemoglobin A1c. There was a significant difference on vessel density betweenT1DM-MDI and T1DM-CSII, with the similar hemoglobin A1c. This study suggested that optical coherence tomography angiography could be beneficial for the detection of retinal abnormalities in children with early T1DM, and continuous subcutaneous insulin infusion may be a better choice than MDI for children with T1DM to prevent the retinal complication.

Approaches to Measuring Beta Cell Reserve and Defining Partial Clinical Remission in Paediatric Type 1 Diabetes

CONTEXT

Type 1 diabetes (T1D) results from the autoimmune T-cell mediated destruction of pancreatic beta cells leading to insufficient insulin secretion. At the time of diagnosis of T1D, there is residual beta cell function that declines over the subsequent months to years. Recent interventions have been approved to preserve beta cell function in evolving T1D.

OBJECTIVE

The aim of this review is to summarise the approaches used to assess residual beta cell function in evolving T1D, and to highlight potential future directions.

METHODS

Studies including subjects aged 0 to 18 years were included in this review. The following search terms were used; "(type 1 diabetes) and (partial remission)" and "(type 1 diabetes) and (honeymoon)". References of included studies were reviewed to determine if additional relevant studies were eligible.

RESULTS

There are numerous approaches to quantifying beta cell reserve in evolving T1D. These include c-peptide measurement after a mixed meal or glucagon stimuli, fasting c-peptide, the urinary c-peptide/creatinine ratio, insulin dose-adjusted haemoglobin A1c, and other clinical models to estimate beta cell function. Other biomarkers may have a role, including the proinsulin/c-peptide ratio, cytokines, and microRNA. Studies using thresholds to determine if residual beta cell function is present often differ in values used to define remission.

CONCLUSIONS

As interventions are approved to preserve beta cell function, it will become increasingly necessary to quantify residual beta cell function in research and clinical contexts. In this report, we have highlighted the strengths and limitations of the current approaches.

Teplizumab: promises and challenges of a recently approved monoclonal antibody for the prevention of type 1 diabetes or preservation of residual beta cell function

INTRODUCTION

Type 1 diabetes (T1D) is a chronic autoimmune endocrinopathy with increasing incidence that results in the depletion of pancreatic beta cells and exogenous insulin dependence. Despite technological advances in insulin delivery, disease control remains suboptimal, while previous immunotherapy options have failed to prevent T1D. Recently, teplizumab, an immunomodulating monoclonal antibody, was approved to delay or prevent T1D.

AREAS COVERED

Five randomized controlled trials have tested different regimens of administration, mostly 14-day schemes with dose escalation. In participants with new-onset T1D, teplizumab delayed C-peptide decline, improved glycemic control, and reduced insulin demand for a median of 1 or 2 years. Studies in at-risk relatives of patients showed a decrease in T1D incidence during 2 years of follow-up. Subgroups of responders with unique metabolic and immunological characteristics were identified. Mild to moderate adverse effects were reported, including transient rash, cytopenia, nausea, vomiting, and infections.

EXPERT OPINION

Teplizumab marks a turning point in T1D therapy. Areas of future research include the ideal population for screening, cost-effectiveness, and challenges in treatment accessibility. More studies are essential to evaluate the ideal duration of the regimen, the potential benefit of combinations with other drugs, and to identify endophenotypes with a high probability of response.

Close intervention sessions complement intensive insulin therapy in paediatric diabetes: a longitudinal study

OBJECTIVE

To examine the impact of multidisciplinary team input and intensive insulin therapy on glycaemic control in children and adolescents with diabetes over a 13-year period.

DESIGN

Two statistical approaches were used to interrogate the dataset. First a matched pair analysis to compare insulin treatment-type effect (pump vs multiple daily injections (MDIs)), followed by panel data regression to assess the impact of intensive re-education on glycated haemoglobin (HbA1c), in addition to treatment type.

SETTING

A large tertiary paediatric diabetes centre using a prospectively maintained database of clinical encounters from 2007 to 2020.

MAIN OUTCOME MEASURES

Difference in HbA1c between treatment types (matching methodology) and expected change in HbA1c with treatment type and re-education (panel data).

RESULTS

Compared with MDI, matched pump patients had a lower HbA1c 6 months after pump commencement (ΔHbA1c=-0.53%, CI -0.34% to -0.72%; n=106). This effect was robust in controlling for socioeconomic deprivation (ΔHbA1c=-0.74%, CI -0.40% to -1.08%; n=29). Panel data analysis demonstrated a -0.55% reduction in HbA1c with pump therapy compared with MDI therapy (CI -0.43% to -0.67%). Patients who had intensive re-education had recorded an HbA1c of 0.95% (CI 0.85% to 1.05%) greater than otherwise identical patients prior to re-education. Following these sessions, HbA1c dropped by a mean -0.81% (CI -0.68% to -0.95%) within 6 months. These were also robust in controlling for socioeconomic factors.

CONCLUSIONS

Compared with matched peers on MDI regimens, patients on pump therapy have lower expected HbA1c, an effect sustained for up to 8 years. Intensive re-education is associated with a significant drop in previously elevated HbA1c levels.

Association between sitagliptin plus vitamin D3 (VIDPP-4i) use and clinical remission in patients with new-onset type 1 diabetes: a retrospective case-control study

Objective

The occurrence of partial remission (honeymoon phase) in type 1 diabetes (T1D) has been associated with a reduced risk of chronic microvascular complications of diabetes. We have published case reports showing that a combination therapy with the DPP-4 inhibitor sitagliptin plus vitamin D3 (VIDPP-4i) can prolong the honeymoon phase in patients with new-onset T1D. In the present case-control study, we investigated the frequency of occurrence of clinical remission (CR) in patients with new-onset T1D after VIDPP-4i treatment.

Subjects and methods

In this case-control study, we collected data spanning 10 years from medical records of 46 patients (23 females) recently diagnosed with T1D. Overall, 27 participants with CR (insulin dose-adjusted glycated hemoglobin [IDAA1c] ≤ 9) at 12 or 24 months composed the case group, and 19 participants without CR served as the control group. Chi-square with Yates correction was used to analyze the association between VIDPP-4i use and CR, and odds ratio (OR) was used to determine the chance of CR due to VIDPP-4i treatment exposure.

Results

In all, 37 patients (80.4%) experienced CR at some time over 24 months. The mean CR duration was 13.15 ± 9.91 months. Treatment with VIDPP-4i was significantly associated with CR. At 24 months, the OR of CR after VIDPP-4i exposure was 9.0 (95% confidence interval [CI] 2.21-30.18, p = 0.0036). Additionally, 9 (33.6%) and 4 (14.8%) patients in the VIDPP-4i group experienced insulin-free CR at 12 and 24 months, respectively.

Conclusion

Therapy with VIDPP-4i was associated with a higher frequency and duration of the honeymoon phase. Randomized controlled trials are needed to confirm these findings.

Impact of Parental Food Choices on Nutritional and Metabolic Status of Children with Type 1 Diabetes

Parents play a key role in what their children eat. The Food Choice Questionnaire (FCQ) has been used elsewhere to assess the dietary motivations of parents of healthy children, but not for parents of children with chronic diseases such as type 1 diabetes (T1D). The aim of our research was to evaluate the associations between parental food choice motivations and the nutritional status and glycemic control of children with T1D. A cross-sectional observational study of children aged 5 to 16 years with T1D attending the Pediatric Endocrinology Unit of Puerta del Mar University Hospital in Cádiz (Spain) was performed. Demographic, anthropometric and clinical data, including glycated hemoglobin, were collected. The FCQ in Spanish was conducted to assess the eating behaviors of the main caregivers of children with T1D. Significance was established at the level of p-value < 0.05. In total, 85 children with T1D (female 56.5%, age 12.07 ± 2.93 years, HbA1c 7.29 ± 0.77%) were recruited. Of these children, 31.3% showed HbA1c levels of <7.0% and 44.9% had a TIR >70%. A significant positive correlation was found between Hb1Ac and "familiarity" (R: +0.233). Anthropometric measures (weight, BMI, skinfolds and body circumferences) showed significant positive correlations with "sensory appeal" and "price". Parents' eating behaviors influence the nutritional status of their children with T1D and their glycemic control of the disease.

Impact of Infusion Set Materials and Designs on the Subcutaneous Response in People With Diabetes: A Rapid Review of the Literature

Insulin infusion sets (IISs) are an integral and intricate part of continuous subcutaneous insulin infusion for subjects with type 1 diabetes, infusing insulin from pump to the subcutaneous space. Insulin infusion sets interface with the skin surface, the dermis, and the subcutaneous space and may be the cause of infusion failure due to biological events or mechanical problems. Novel IISs with extended wear time and anti-inflammatory properties to mitigate these issues are described in the literature although material-tissue interactions are poorly understood. This rapid review focuses on the impact of IIS materials and designs on the subcutaneous response in people with diabetes and includes literature identified in PubMed, Embase, and Cochrane databases. Twenty-one studies were identified for qualitative synthesis that encompassed a limited and heterogenic body of evidence including 10 clinical reports, six reviews, one case report, two abstracts, and two communications. Two clinical reports were randomized crossover studies. Reports on materials mostly compared steel versus polytetrafluoroethylene (Teflon) cannulas and suggested no substantial difference in tissue response to these materials. Reports on designs focused mostly on the angle of cannula insertion. To drive and improve research on extended wear and nonimmunogenic IISs, future studies should focus on material-tissue interaction as dedicated outcome measures, quantified with punch biopsy and imaging techniques such as ultrasound, optical coherence tomography, and confocal reflectance microscopy. Original studies are required to further a field too young for a systematic meta-analysis.

Continuous subcutaneous insulin infusions: Closing the loop

CONTEXT

Continuous subcutaneous insulin infusions (CSIIs) and continuous glucose monitors (CGMs) have revolutionized the management of diabetes mellitus (DM). Over the last two decades the development of advanced, small, and user-friendly technology has progressed substantially, essentially closing the loop in the fasting and post-absorptive state, nearing the promise of an artificial pancreas. The momentum was mostly driven by the diabetes community itself, to improve its health and quality of life.

EVIDENCE ACQUISITION

Literature regarding CSII and CGM was reviewed.

EVIDENCE SYNTHESIS

Management of DM aims to regulate blood glucose to prevent long term micro and macrovascular complications. CSIIs combined with CGMs provide an integrated system to maintain tight glycemic control in a safe and uninterrupted fashion, while minimizing hypoglycemic events. Recent advances have allowed to 'close the loop' by better mimicking endogenous insulin secretion and glucose level regulation. Evidence supports sustained improvement in glycemic control with reduced episodes of hypoglycemia using these systems, while improving quality of life. Ongoing work in delivery algorithms with or without counterregulatory hormones will allow for further layers of regulation of the artificial pancreas.

CONCLUSION

Ongoing efforts to develop an artificial pancreas have created effective tools to improve the management of DM. CSIIs and CGMs are useful in diverse populations ranging from children to the elderly, as well as in various clinical contexts. Individually and more so together, these have had a tremendous impact in the management of DM, while avoiding treatment fatigue. However, cost and accessibility are still a hindrance to its wider application.

Adolescent ambivalence about diabetes technology-The Janus faces of automated care

The Janus face metaphor approach highlights that a technology may simultaneously have two opposite faces or properties with unforeseen paradoxes within human-technology interaction. Suboptimal acceptance and clinical outcomes are sometimes seen in adolescents who use diabetes-related technologies. A traditional linear techno-determinist model of technology use would ascribe these unintended outcomes to suboptimal technology, suboptimal patient behavior, or suboptimal outcome measures. This paradigm has demonstratively not been successful at universally improving clinical outcomes over the last two decades. Alternatively, the Janus face metaphor moves away from a linear techno-determinist model and focuses on the dynamic interaction of the human condition and technology. Specifically, it can be used to understand variance in adoption or successful use of diabetes-related technology and to retrospectively understand suboptimal outcomes. The Janus face metaphor also allows for a prospective exploration of potential impacts of diabetes-related technology by patients, families, and their doctors so as to anticipate and minimize potential subsequent tensions.

The Effectiveness of Insulin Pump Therapy Versus Multiple Daily Injections in Children With Type 1 Diabetes Mellitus in a Specialized Center in Riyadh

Objectives

Comparison of continuous subcutaneous insulin infusion (CSII) with multiple daily injections (MDI) in achieving glycemic control in youths with type 1 diabetes mellitus (T1DM).

Methods

Retrospective cohort study including 2 matched groups of youths with T1DM treated by CSII or MDI in a tertiary specialized children's hospital in Saudi Arabia. Children and adolescents aged up to 18 years, diagnosed with T1DM and using CSII or MDI, from the period 2016 to 2018. Patients on MDI were newly-diagnosed patients with T1DM who had the disease for only 1 year duration; all CSII patients had at least 1 to 2 years of T1DM but who had just started on pumps in the past 3 months. We excluded patients with other autoimmune diseases, non-ambulatory patients and those admitted to hospital for non-diabetes reasons. Primary outcome was HbA1c at 1, 2, and 3 years, with weight gain as a secondary outcome. Ambulatory glycemic profile was analyzed from a subset of patients using intermittently scanned continuous glucose monitoring (isCGM).

Results

A total of 168 youths with T1DM (n = 129 in the MDI group, n = 39 in the CSII group) were included. The CSII group consistently had lower HbA1c levels compared to the MDI group throughout a 3-year follow up period: 8.1% versus 10.1, P-value < .001 at 1 year, 7.5% versus 10.1% at 2 years, P-value  < .001, 8.9% versus 10.3% at 3 years, P-value = .033. Body mass index significantly increased in both groups at 1 year, although greater in CSII group. In a subgroup using isCGM (n = 37 on MDI and n = 29 on CSII), the CSII group had a lower average blood glucose (194 mg/dL vs 228 mg/dL, P-value = .028) and a lower estimated HbA1c level (8.4% vs 9.6%, P-value = .022).

Conclusion

Treatment with CSII resulted in lower HbA1c compared to MDI in our cohort, which was sustained over a 3-year period.

Comparing the effectiveness of continuous subcutaneous insulin infusion with multiple daily insulin injection for patients with type 1 diabetes mellitus evaluated by retrospective continuous glucose monitoring: A real-world data analysis

Objective

Regarding the effects and practical application of insulin pumps on patients with type 1 diabetes mellitus (T1DM), the real-world evidence is limited especially concerning the incidence of hypoglycemia. This study aimed to compare the efficacy of continuous subcutaneous insulin infusion (CSII) therapy with multiple daily injection (MDI) therapy on glycemic metrics evaluated by retrospective continuous glucose monitoring (CGM) in Chinese patients with T1DM.

Methods

In total, 362 T1DM Chinese patients from the outpatient department of the Second Xiangya Hospital, Central South University, who underwent intensive insulin therapy and used a retrospective CGM system were included in this retrospective cross-sectional study. Comprehensive analysis of clinical and biological features and retrospective CGM derived-metrics was performed on the 362 enrolled T1DM patients who underwent CSII (n = 61) or MDI (n = 301) therapy (defined as 4 or more insulin injections per day).

Results

Our findings demonstrated that patients who underwent CSII therapy, compared with those who received MDI therapy, had lower levels of hemoglobin A1c (HbA1c) and fasting blood glucose; moreover, CSII therapy was associated with better glycemic outcomes in terms of increasing time in range (TIR), decreasing time above range (TAR), and achieving CGM-associated targets of TIR ≥70% and TAR <25%. However, patients who underwent CSII therapy did not experience decreasing time below range (TBR), achieving CGM-associated targets of TBR <4%, and reduction of the risk of hypoglycemia as evidenced by comparing TBR and low blood glucose index (LBGI) between the two treatment regimens. The parameters of glycemic variability, such as standard deviation of glucose (SD), mean amplitude glycemic excursion (MAGE), and large amplitude glycemic excursion (LAGE) in T1DM patients who underwent CSII therapy outperformed.

Conclusion

Our results provided further evidence that CSII therapy is safe and effective for management of Chinese T1DM patients, which was confirmed by a lower HbA1c level and better CGM-derived metrics but no demonstration of improvment in the risk of hypoglycemia. To achieve more satisfactory glycemic outcomes through the utilization of CSII therapy for Chinese T1DM patients, a strong physician-patient relationship is essential.

Pediatric Smart Insulin Pen Use: The Next Best Thing

In the pediatric population, insulin pump therapy, or CSII, is often considered the gold standard for intensive diabetes management. Insulin pump technology offers families and caregivers many beneficial features including a calculator for insulin dosing and the ability to review diabetes management data to provide data-driven diabetes management. However, for those who find CSII challenging or choose to use multiple daily injections (MDI) there is an option that offers similar features called the Smart Insulin Pen (SIP). Even though SIP technology provides a safe and data-driven diabetes self-management tool for the pediatric population using MDI, there is limited pediatric specific literature. This article will describe current options, data-driven diabetes management, benefits, challenges and clinical use of SIP technology in the pediatric population.

Safety and effectiveness of do-it-yourself artificial pancreas system compared with continuous subcutaneous insulin infusions in combination with free style libre in people with type 1 diabetes

AIMS

The use of do-it-yourself artificial pancreas systems (DIYAPS) among people with type 1 diabetes is increasing. At present, it is unclear how DIYAPS compares with other technologies such as FreeStyle Libre (FSL) and continuous subcutaneous insulin infusion (CSII). The aim of this analysis is to compare safety, effectiveness and quality-of-life outcomes of DIYAPS use with the addition of FSL to CSII.

METHOD

Data from two large UK hospitals were extracted from the Association of British Clinical Diabetologists (ABCD) DIYAPS and FSL audits. Outcomes included HbA_1c , glucose TBR (time-below-range), TIR (time-in-range), Diabetes Distress Score (DDS), and Gold hypoglycaemia score. Any adverse events were noted. Changes at follow-up were assessed using paired t-tests and ANOVA in Stata; TIR/TBR at follow-up assessed using unpaired t-tests; chi-square tests assessed the change in frequency of health utilisation (e.g. hospital admissions).

RESULTS

DIYAPS (n = 35) and FSL+CSII (n = 149) users, with median follow-up duration of 1.4 (IQR 0.8-2.1) and 1.3 (IQR 0.7-1.8) years, respectively, were included. HbA_1c with DIYAPS use changed by -10 mmol/mol [0.9%] (p < 0.001, 95% CI 5, 14 [0.5, 1.3%]) significantly lower (p < 0.001) than in the FSL+CSII group -3 mmol/mol [0.25%] (p < 0.001, 95% CI 1, 4 [0.1, 0.4%]). TIR was higher and TBR was lower in the DIYAPS group. Adverse events were rare in both groups and no significant differences were observed in the frequency of healthcare utilisation.

CONCLUSION

DIYAPS use was associated with a lower HbA_1c levels, higher TIR and lower TBR compared with FSL+CSII. There was no significant increase in adverse events, although this should be interpreted cautiously given the low numbers of users. Full results from the ABCD DIYAPS audit are awaited.

Factors associated with glycemic variability in children with type 1 diabetes mellitus based on flash glucose monitoring system

OBJECTIVES

Patients with classical type 1 diabetes mellitus (T1DM) require lifelong dependence on exogenous insulin therapy due to pancreatic beta-cell destruction and absolute insulin deficiency. T1DM accounts for about 90% of children with diabetes in China, with a rapid increase in incidence and a younger-age trend. Epidemiological studies have shown that the overall glycated haemoglobin (HbA1c) and compliance rate are low in Chinese children with T1DM. Optimal glucose control is the key for diabetes treatment, and maintaining blood glucose within the target range can prevent or delay chronic vascular complications in patients with T1DM. Therefore, this study aims to investigate the glycemic control of children with T1DM from Hunan and Henan Province with flash glucose monitoring system (FGMS), and to explore factors associated with glycemic variability.

METHODS

A total of 215 children with T1DM under 14 years old were enrolled continuously in 16 hospitals from August 2017 to August 2020. All subjects wore a FGMS device to collect glucose data. Correlation of HbA1c, duration of diabetes, or glucose scan rates with glycemic variability was analyzed. Glucose variability was compared according to the duration of diabetes, HbA1c, glucose scan rates and insulin schema.

RESULTS

HbA1c and duration of diabetes were positively correlated with mean blood glucose, standard deviation of glucose, mean amplitude of glucose excursions (MAGE), and coefficient of variation (CV) of glucose (all P<0.01). The glucose scan rates during FGMS wearing was significantly positively correlated with time in range (TIR) (P=0.001) and negatively correlated with MAGE and mean duration of hypoglycemia (all P<0.01). Children with duration ≤1 year had lower time below range (TBR) and MAGE when compared with those with duration >1 year (all P<0.05). TIR and TBR in patients with HbA1c ≤7.5% were higher (TIR: 65% vs 45%, TBR: 5% vs 4%, P<0.05), MAGE was lower (7.0 mmol/L vs 9.4 mmol/L, P<0.001) than those in HbA1c >7.5% group. Compared to the multiple daily insulin injections group, TIR was higher (60% vs 52%, P=0.006), MAGE was lower (P=0.006) in the continuous subcutaneous insulin infusion group. HbA1c was lower in the high scan rates (≥14 times/d) group (7.4% vs 8.0%, P=0.046), TIR was significantly higher (58% vs 47%, P<0.001), and MAGE was lower (P<0.001) than those in the low scan rate (<14 times/d) group.

CONCLUSIONS

The overall glycemic control of T1DM patients under 14 years old in Hunan and Henan Province is under a high risk of hypoglycemia and great glycemic variability. Shorter duration of diabetes, targeted HbA1c, higher glucose scan rates, and CSII are associated with less glycemic variability.

New idea to promote the clinical applications of stem cells or their extracellular vesicles in central nervous system disorders: combining with intranasal delivery

The clinical translation of stem cells and their extracellular vesicles (EVs)-based therapy for central nervous system (CNS) diseases is booming. Nevertheless, the insufficient CNS delivery and retention together with the invasiveness of current administration routes prevent stem cells or EVs from fully exerting their clinical therapeutic potential. Intranasal (IN) delivery is a possible strategy to solve problems as IN route could circumvent the brain‒blood barrier non-invasively and fit repeated dosage regimens. Herein, we gave an overview of studies and clinical trials involved with IN route and discussed the possibility of employing IN delivery to solve problems in stem cells or EVs-based therapy. We reviewed relevant researches that combining stem cells or EVs-based therapy with IN administration and analyzed benefits brought by IN route. Finally, we proposed possible suggestions to facilitate the development of IN delivery of stem cells or EVs.

RT‐CGM in conjunction with CSII vs MDI in optimizing glycaemic control in T1DM: Systemic review and meta‐analysis

Introduction

To determine the impact of real‐time continuous glucose monitoring (RT‐CGM) in conjunction with ‘Open loop’‐ continuous subcutaneous insulin infusion (CSII) as compared to conventional multiple daily injections (MDI) in type 1 diabetes.

Methods

We explored the COCHRANE database, MEDLINE, WEB OF SCIENCE, GOOGLE SCHOLARS, PUBMED, EMBASE, and cited literature in articles retrieved (2010–2021) for all randomized controlled trials and real‐world trials of more than 6 months duration in patients with type 1 diabetes that compared RT‐CGM+CSII vs RT‐ CGM+MDI. A total of 1645 publications have been identified; however, only 3 trials fulfilled our inclusion criteria with a total number of 150 patients (72 patients using RT‐CGM+CSII and 78 patients on RT‐CGM+MDI). A Systematic Review and Meta‐analysis were carried out.

Results

No statistically significant reduction in HbA1c was found on comparing RT‐CGM+CSII vs RT‐ CGM + MDI, with p‐value = .75. Likewise, impact on TIR, weight and insulin usage was found to be statistically insignificant with p‐value of 0.15, 0.75 and 0.20 respectively. There was an overall homogeneity between the 3 trials in respect to all previous variables with I² being 0%.

Conclusions

Real‐time continuous glucose monitors in conjunction with MDI open‐loop CSII had a similar impact on HbA1c, weight, insulin usage and TIR. In addition, RT‐CGM when combined with CSII was associated with higher costs and reduced quality of life, hence RT‐ CGM+MDI can be considered as a cheaper, safer yet equivalent substitute.

Review Registration

This study was registered in PROSPERO (International prospective register of systematic reviews). Registration Name: RT‐CGM in conjunction with CSII vs MDI in optimizing glycaemic control in T1DM: a systematic review. Registration No: CRD42021255333. Accessible at: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021255333. Amendments: Few amendments to the above‐mentioned registration were made: (1) Title (Meta‐analysis was added). (2) Prof. Gleeson was added as an author. (3) Real‐world trials were included. (4) Outcomes required in studies as per our inclusion criteria amended to include at least 1 outcome. (5) Bias risk was assessed by the CASP tool.

Center differences in diabetes treatment outcomes among children with type 1 diabetes: A nationwide study of 3866 Danish children

OBJECTIVE

Mean differences in HbA_1c across centers are well established, but less well understood. The aim was to assess whether differences in patient case-mix can explain the variation in mean HbA_1c between pediatric diabetes centers in Denmark. The association between HbA_1c , frequency of blood glucose monitoring (BGM), treatment modality, and center visits was investigated.

RESEARCH DESIGN AND METHODS

This longitudinal nationwide study included 3866 Danish children with type 1 diabetes from 2013 to 2017 (n = 12,708 child-year observations) from 16 different pediatric diabetes centers. Mean HbA_1c , proportion of children reaching HbA_1c treatment target (HbA_1c  ≤ 58 mmol/mol [7.5%]) were compared across centers using linear regression models. This was done with and without adjustment for socioeconomic characteristics (patient case-mix).

RESULTS

The mean difference in HbA_1c during follow-up was 11.6 mmol/mol (95% CI 7.9, 15.3) (1.1% [95% CI 0.7, 1.4]) when comparing the centers with the lowest versus highest mean HbA_1c . The difference was attenuated and remained significant after adjustment for the patient case-mix (difference: 10.5 mmol/mol [95% CI 6.8, 14.2] (1.0% [95% CI 0.6, 1.3])). Overall, 6.8% of the differences in mean HbA_1c across centers were explained by differences in the patient case-mix. Across centers, more frequent BGM was associated with lower HbA_1c . The proportion of insulin pump users and number of visits was not associated with HbA_1c .

CONCLUSION

In a setting of universal health care, large differences in HbA_1c across centers were found, and could not be explained by patient background, number of visits or use of technology. Only BGM was associated with center HbA_1c .

Enhancing Choices Regarding the Administration of Insulin Among Patients With Diabetes Requiring Insulin Across Countries and Implications for Future Care

There are a number of ongoing developments to improve the care of patients with diabetes across countries given its growing burden. Recent developments include new oral medicines to reduce cardiovascular events and death. They also include new modes to improve insulin administration to enhance adherence and subsequent patient management thereby reducing hypoglycaemia and improving long-term outcomes. In the case of insulins, this includes long-acting insulin analogues as well as continuous glucose monitoring (CGM) systems and continuous subcutaneous insulin infusion systems, combined with sensor-augmented pump therapy and potentially hybrid closed-loops. The benefits of such systems have been endorsed by endocrine societies and governments in patients with Type 1 diabetes whose HbA1c levels are not currently being optimised. However, there are concerns with the low use of such systems across higher-income countries, exacerbated by their higher costs, despite studies suggesting their cost-effectiveness ratios are within accepted limits. This is inconsistent in higher-income countries when compared with reimbursement and funding decisions for new high-priced medicines for cancer and orphan diseases, with often limited benefits, given the burden of multiple daily insulin injections coupled with the need for constant monitoring. This situation is different among patients and governments in low- and low-middle income countries struggling to fund standard insulins and the routine monitoring of HbA1c levels. The first priority in these countries is to address these priority issues before funding more expensive forms of insulin and associated devices. Greater patient involvement in treatment decisions, transparency in decision making, and evidence-based investment decisions should help to address such concerns in the future.

Choice of basal insulin therapy is associated with weight and height development in type 1 diabetes: A multicenter analysis from the German/Austrian DPV registry in 10 338 children and adolescents

BACKGROUND

Available basal insulin regimes differ in pharmacokinetic profiles, which may be related to subsequent changes in anthropometry in patients with type 1 diabetes. This analysis elucidates the standardized height and body mass index development (height and BMI standard deviation score [height-SDS and BMI-SDS]) in pediatric type 1 diabetes patients depending on the choice of basal insulin.

METHODS

Longitudinal data of 10 338 German/Austrian patients from the Diabetes Prospective Follow-up (DPV, Diabetes Patienten Verlaufsdokumentation) database were analyzed. Patients aged 5.0 to 16.9 years were treated exclusively with neutral protamine Hagedorn (NPH), insulin detemir (IDet), insulin glargine (IGla), or continuous subcutaneous insulin infusion (CSII) for at least 3 years. Population-based German reference data were used to calculate height-SDS and BMI-SDS. Multiple linear regression was conducted.

RESULTS

BMI-SDS increased significantly in all regimes (NPH P = .0365; IDet P = .0003; IGla P < .0001; and CSII P < .0001). Direct comparison of the therapies revealed a favorable association only for NPH vs IGla. A rise in BMI-SDS was observed for all insulins in females, but only for IGla in males. BMI-SDS increment was not observed before 8 years of age. Initially and at the end of the observation period, mean height was above the 50th percentile of the reference population. Across the cohort, height-SDS declined during the observation period, except for CSII. Apart from the 5.0- to 7.9-year-old subgroup, long-acting insulin analogues were associated with a significant loss of height-SDS.

CONCLUSIONS

Choice of basal insulin regimen might influence height development. CSII appeared to have a favorable effect on growth trajectories. All therapies were associated with an increase of BMI-SDS, most evident in females.

Current Advances of Artificial Pancreas Systems: A Comprehensive Review of the Clinical Evidence

Since Banting and Best isolated insulin in the 1920s, dramatic progress has been made in the treatment of type 1 diabetes mellitus (T1DM). However, dose titration and timely injection to maintain optimal glycemic control are often challenging for T1DM patients and their families because they require frequent blood glucose checks. In recent years, technological advances in insulin pumps and continuous glucose monitoring systems have created paradigm shifts in T1DM care that are being extended to develop artificial pancreas systems (APSs). Numerous studies that demonstrate the superiority of glycemic control offered by APSs over those offered by conventional treatment are still being published, and rapid commercialization and use in actual practice have already begun. Given this rapid development, keeping up with the latest knowledge in an organized way is confusing for both patients and medical staff. Herein, we explore the history, clinical evidence, and current state of APSs, focusing on various development groups and the commercialization status. We also discuss APS development in groups outside the usual T1DM patients and the administration of adjunct agents, such as amylin analogues, in APSs.

Meal-time glycaemia in adults with type 1 diabetes using multiple daily injections vs insulin pump therapy following carbohydrate-counting education and bolus calculator provision

AIMS

To compare meal-time glycaemia in adults with type 1 diabetes mellitus (T1D) managed with multiple daily injections (MDI) vs. insulin pump therapy (IPT), using self-monitoring blood glucose (SMBG), following diabetes education.

METHODS

Adults with T1D received carbohydrate-counting education and a bolus calculator: MDI (Roche Aviva Expert) and IPT (pump bolus calculator). All then wore 3-weeks of masked-CGM (Enlite, Medtronic). Meal-times were assessed by two approaches: 1) Set time-blocks (breakfast 06:00-10:00hrs; lunch 11:00-15:00hrs; dinner 17:00-21:00hrs) and 2) Bolus-calculator carbohydrate entries signalling meal commencement. Post-meal masked-CGM time-in-range (TIR) 3.9-10.0 mmol/L was the primary outcome.

RESULTS

MDI(n = 61) and IPT (n = 59) participants were equivalent in age, sex, diabetes duration and HbA1c. Median (IQR) education time provided did not differ (MDI: 1.1 h (0.75, 1.5) vs. IPT: 1.1 h (1.0, 2.0); p = 0.86). Overall, daytime (06:00-24:00hrs), lunch and dinner TIR did not differ for MDI vs. IPT participants but was greater for breakfast with IPT in both analyses with a mean difference of 12.8%, (95 CI 4.8, 20.9); p = 0.002 (time-block analysis).

CONCLUSION

After diabetes education, MDI and IPT use were associated with similar day-time glycemia, though IPT users had significantly greater TIR during the breakfast period. With education, meal-time glucose levels are comparable with use of MDI vs. pumps.

Does Current Diabetes Technology Improve Metabolic Control? A Cross-Sectional Study on the Use of Insulin Pumps and Continuous Glucose Monitoring Devices in a Nationwide Pediatric Population

OBJECTIVE

To examine the use of multiple daily injections (MDI), insulin pumps, self-measured blood glucose (SMBG), and continuous glucose monitoring (CGM) systems, and their association with glycated hemoglobin (HbA1c), diabetic ketoacidosis (DKA), and severe hypoglycemia.

METHODS

In a pediatric population-based nationwide cross-sectional study, we analyzed data from 2623 participants up to 18 years of age with type 1 diabetes, using 2017 annual data from the Norwegian Childhood Diabetes Registry. HbA1c was adjusted for age, gender, and diabetes duration. Using a linear mixed-effects model, we assessed HbA1c and the incidence of DKA and severe hypoglycemia according to the use of MDI, insulin pumps, SMBG, and CGM.

RESULTS

We observed that 74.7% of participants were using an insulin pump and 52.6% were using a CGM system. Mean HbA1c was 7.8% (62 mmol/mol). The HbA1c of pump users was 0.14 percentage points (pp) higher than that of MDI users. Fewer pump users than MDI users achieved an HbA1c of < 7.5% (38.3 vs. 41.6%). CGM users had a 0.18 pp lower HbA1c than SMBG users, with 40.5 and 38.0%, respectively, achieving an HbA1c of < 7.5%. The incidence of severe hypoglycemia or hospitalization due to DKA was not different in pump and CGM users compared with nonusers. Compared with other insulin pumps, patch pump use was associated with a significantly lower odds ratio for DKA.

CONCLUSIONS

Despite the broad use of diabetes technology, as many as 61% of our pediatric cohort did not reach the HbA1c target recommended by the International Society for Pediatric and Adolescent Diabetes (ISPAD). Lower HbA1c was associated with CGM use but not with insulin pump use. Acute complications were not less frequent in the groups using insulin pumps or CGM compared with those using MDI and SMBG. Further research is required to explore the lower incidence of DKA among patch pump users.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT04201171.

Continuous subcutaneous insulin infusion alters microRNA expression and glycaemic variability in children with type 1 diabetes

To determine whether continuous subcutaneous insulin infusion (CSII) vs. multiple daily injections (MDI) therapy from near-diagnosis of type 1 diabetes is associated with reduced glycaemic variability (GV) and altered microRNA (miRNAs) expression. Adolescents (74% male) within 3-months of diabetes diagnosis (n = 27) were randomized to CSII (n = 12) or MDI. HbA1c, 1-5-Anhydroglucitol (1,5-AG), high sensitivity C-peptide and a custom TaqMan qPCR panel of 52 miRNAs were measured at baseline and follow-up (median (LQ-UQ); 535 (519–563) days). There were no significant differences between groups in baseline or follow-up HbA1c or C-peptide, nor baseline miRNAs. Mean ± SD 1,5-AG improved with CSII vs. MDI (3.1 ± 4.1 vs. − 2.2 ± − 7.0 mg/ml respectively, P = 0.029). On follow-up 11 miRNAs associated with diabetes vascular complications had altered expression in CSII-users. Early CSII vs. MDI use is associated with lower GV and less adverse vascular-related miRNAs. Relationships with future complications are of interest.

Comparing continuous subcutaneous insulin infusion and multiple daily injections in children with Type 1 diabetes in Sweden from 2011 to 2016-A longitudinal study from the Swedish National Quality Register (SWEDIABKIDS)

OBJECTIVE

This study aimed to compare metabolic control measured as hemoglobin A1c (HbA1c), the risk of severe hypoglycemia, and body composition measured as body mass index standard deviation scores (BMI-SDS) in a nationwide sample of children and adolescents with Type 1 diabetes with continuous subcutaneous insulin infusion (CSII) and multiple daily injections (MDI), respectively.

RESEARCH DESIGN AND METHODS

Longitudinal data from 2011 to 2016 were extracted from the Swedish National Quality Register (SWEDIABKIDS) with both cross-sectional (6 years) and longitudinal (4 years) comparisons. Main end points were changes in HbA1c, BMI-SDS, and incidence of severe hypoglycemia.

RESULTS

Data were available from 35,624 patient-years (54% boys). In general, HbA1c decreased approximately 0.5% (2-5 mmol/mol) from 2011 to 2016 (p_trend  < 0.001) and the use of CSII increased in both sexes and all age groups. Mean HbA1c was 0.1% (0.7-1.5 mmol/mol) lower in the CSII treated group. Teenagers, especially girls, using CSII tended to have higher BMI-SDS. There was no difference in the number of hypoglycemias between CSII and MDI over the years 2011-2016.

CONCLUSIONS

There was a small decrease in HbA1c with CSII treatment but of little clinical relevance. Overall, mean HbA1c decreased in both sexes and all age groups without increasing the episodes of severe hypoglycemia, indicating that other factors than insulin method contributed to a better metabolic control.

American Association of Clinical Endocrinology Clinical Practice Guideline: The Use of Advanced Technology in the Management of Persons With Diabetes Mellitus

OBJECTIVE

To provide evidence-based recommendations regarding the use of advanced technology in the management of persons with diabetes mellitus to clinicians, diabetes-care teams, health care professionals, and other stakeholders.

METHODS

The American Association of Clinical Endocrinology (AACE) conducted literature searches for relevant articles published from 2012 to 2021. A task force of medical experts developed evidence-based guideline recommendations based on a review of clinical evidence, expertise, and informal consensus, according to established AACE protocol for guideline development.

MAIN OUTCOME MEASURES

Primary outcomes of interest included hemoglobin A1C, rates and severity of hypoglycemia, time in range, time above range, and time below range.

RESULTS

This guideline includes 37 evidence-based clinical practice recommendations for advanced diabetes technology and contains 357 citations that inform the evidence base.

RECOMMENDATIONS

Evidence-based recommendations were developed regarding the efficacy and safety of devices for the management of persons with diabetes mellitus, metrics used to aide with the assessment of advanced diabetes technology, and standards for the implementation of this technology.

CONCLUSIONS

Advanced diabetes technology can assist persons with diabetes to safely and effectively achieve glycemic targets, improve quality of life, add greater convenience, potentially reduce burden of care, and offer a personalized approach to self-management. Furthermore, diabetes technology can improve the efficiency and effectiveness of clinical decision-making. Successful integration of these technologies into care requires knowledge about the functionality of devices in this rapidly changing field. This information will allow health care professionals to provide necessary education and training to persons accessing these treatments and have the required expertise to interpret data and make appropriate treatment adjustments.

Standardizing Reporting of Glucose and Insulin Data for Patients on Multiple Daily Injections Using Connected Insulin Pens and Continuous Glucose Monitoring

Background: Recent development and availability of several connected insulin pens with digital memory are likely to expand the availability of glucose and insulin metrics that previously had been available only for the much smaller number of people using insulin pumps. It would be highly desirable to standardize data presentations to avoid the chaotic emergence of multiple formats that might reduce the clinical utility of connected pens. Methods: We reviewed the literature and analyzed data displays from multiple blood glucose monitoring, continuous glucose monitoring (CGM), insulin pump, and automated insulin delivery systems, and methods for combination of glucose and insulin data. We examined multiple forms of presentation and now propose a prototype for a standardized method for data analysis and display, focusing on the content and format of a one-page dashboard summary for patients on multiple daily injection (MDI) insulin regimens. Results: We propose the following metrics to be included in the one-page report: (A) glucose metrics: simplified glucose distribution in the form of a stacked bar chart showing percentages of time below-, above-, or within-target ranges overall and (optionally) by date, by time of day, or day of the week; (B) insulin metrics: types and doses, and timing of basal and bolus insulin; (C) an enhanced ambulatory glucose profile or "AGP+" showing glucose data points and/or distributions (10th to 90th percentiles), dosages and timing of basal and bolus insulins and (optionally) graphical display of risk of hypoglycemia and hyperglycemia; and (D) user experience regarding technology usage, frequency of alerts for hypo- and hyperglycemia, and information regarding lifestyle, meals, exercise, and sleep, if available; and (E) clinical insights and interpretation. Conclusion: We propose a prototype for a dashboard summary report of glucose, insulin, meals, and activity data intended for providers and patients on MDI using connected pens and CGM. Our goal is to stimulate development of a standardized approach.

Increased Levels of Serum Glycosylated Hemoglobin are Associated with Depressive Symptoms in a Population with Cancer (≥49 Years): An Antidepressant-Stratified Analysis

Purpose

Patients with cancer tend to have a high prevalence of depressive symptoms. The direct relationship between serum glycosylated hemoglobin (GHb) levels and depressive symptoms in cancer patients is still uncertain. We aimed to evaluate the association with serum GHb levels with depressive symptoms in the population (aged ≥49 years) with cancer.

Patients and Methods

Longitudinal data in 204 participants with cancer obtained from The Irish LongituDinal Study on Ageing (TILDA) were used to investigate the association of serum GHb levels with depressive symptoms.

Results

Our results suggested a positive and significant association between serum GHb levels and depression score, independent of age, gender, body mass index (BMI), currently married, education, smoking status, drink alcohol, systolic and diastolic blood pressure (BP), physical activity, self-reported cardiovascular diseases and laboratory measurement in participants with cancer (coefficient =0.141, P<0.001; Model 2) at baseline (wave 1). Higher GHb levels did associate with higher prevalence of depressive symptoms in participants with cancer (OR=2.100, 95% CI 1.105–5.036, P=0.004; Model 2) after adjustment for these same confounding factors in wave 1 was made. Stratified analysis further showed that these significant associations were interfered by antidepressants. Sensitivity analysis showed that higher serum GHb levels in subjects with cancer were linked to higher prevalence of depression events during a follow-up of 4 years.

Conclusion

Our results found a significant association between elevated serum GHb levels and increased risk of depressive symptoms in the population aged ≥49 years with cancer after confounding factors were adjusted.

Use of insulin pump therapy is associated with reduced hospital-days in the long-term: a real-world study of 48,756 pediatric patients with type 1 diabetes

In pediatric diabetes, insulin pump therapy is associated with less acute complications but inpatient pump education may lead to more hospital days. We investigated the number of hospital days associated with pump vs. injection therapy between 2009 and 2018 in 48,756 patients with type 1 diabetes < 20 years of age from the German Diabetes Prospective Follow-up Registry (DPV). Analyses were performed separately for hospitalizations at diagnosis (hierarchical linear models adjusted for sex, age, and migration), and for hospitalizations in the subsequent course of the disease (hierarchical Poisson models stratified by sex, age, migration, and therapy switch). At diagnosis, the length of hospital stay was longer with pump therapy than with injection therapy (mean estimate with 95% CI: 13.6 [13.3-13.9] days vs. 12.8 [12.5-13.1] days, P < 0.0001), whereas during the whole follow-up beyond diagnosis, the number of hospital days per person-year (/PY) was higher with injection therapy than with pump therapy (4.4 [4.1-4.8] vs. 3.9 [3.6-4.2] days/PY), especially for children under 5 years of age (4.9 [4.4-5.6] vs. 3.5 [3.1-3.9] days/PY).Conclusions: Even in countries with hospitalizations at diabetes diagnosis of longer duration, the use of pump therapy is associated with a reduced number of hospital days in the long-term. What is known: • In pediatric diabetes, insulin pump therapy is associated with better glycemic control and less acute complications compared with injection therapy. • However, pump therapy implies more costs and resources for education and management. What is new: • Even in countries where pump education is predominantly given in an inpatient setting, the use of pump therapy is associated with a reduced number of hospital days in the long-term. • Lower rates of hospitalization due to acute complications during the course of the disease counterbalance longer hospitalizations due to initial pump education.

Obesity in Patients with Type 1 Diabetes: Links, Risks and Management Challenges

Obesity affects large numbers of patients with type 1 diabetes (T1D) across their lifetime, with rates ranging between 2.8% and 37.1%. Patients with T1D and obesity are characterized by the presence of insulin resistance, of high insulin requirements, have a greater cardiometabolic risk and an enhanced risk of developing chronic complications when compared to normal-weight persons with T1D. Dual treatment of obesity and T1D is challenging and no specific guidelines for improving outcomes of both glycemic control and weight management have been established for this population. Nevertheless, although evidence is scarce, a comprehensive approach based on a balanced hypocaloric diet, physical activity and cognitive behavioral therapy by a multidisciplinary team, expert in both obesity and diabetes, remains as the best clinical practice. However, weight loss responses with lifestyle changes alone are limited, so in the "roadmap" of the treatment of obesity in T1D, it will be helpful to include anti-obesity pharmacotherapy despite at present there is a lack of evidence since T1D patients have been excluded from anti-obesity drug clinical trials. In case of severe obesity, bariatric surgery has proven to be of benefit in obtaining a substantial and long-term weight loss and reduction in cardiovascular risk. The near future looks promising with the development of new and more effective anti-obesity treatments and strategies to improve insulin resistance and oxidative stress. Advances in precision medicine may help individualize and optimize the medical management and care of these patients. This review, by gathering current evidence, highlights the need of solid knowledge in all facets of the treatment of patients with obesity and T1D that can only be obtained through high quality well-designed studies.

Comparison of Insulin Glargine and Detemir Effects on Hormones of Appetite and Metabolic Control in Patients with Type 1 Diabetes: A Randomized Clinical Trial

The aim of this study was to compare the insulin glargine and detemir effects on hormons affecting appetite and metabolic control of patients with type 1 diabetes. This single-blind randomized clinical trial was conducted on patients aged 2 to 18 years with type 1 diabetes who were referred to the endocrinology department of Ali-Asghar Children Hospital in Tehran, from April to September 2019. Patients were randomly allocated to receive insulin Glargine or insulin Detemir. Before starting treatment, blood samples were obtained for routine biochemical tests and factors affecting appetite, including Leptin, Ghrelin, Aguti-Related Peptide (AGRP), and Peptide-YY3-36 (PYY 3-36). Patients were evaluated monthly and insulin dose was adjusted based on target glucose and carbohydrate counting. At the end of three months, the anthropometric values , HbA1C and factors that influence appetite were measured again in both groups, and the results were compared. A total of 40 children with a new onset of type 1 diabetes under 18 years who were hospitalized in Ali Asghar Children Hospital were randomly assigned into two groups as Glargine (n = 20) and Detemir (n = 20). The mean age of patients in the Glargine group was 11.07 ±4.18 years and in the Detemir group was 8.06 ± 3.56. In Glargine group HbA1C, Cholesterol, LDL, AGRP significantly decreased and leptin increased after treatment., while the change of BMI Z-score was not significant. There was a significant decrease of HbA1C in the Detemir group after treatment but there was no significant change of other variables. There was no significant difference for all the variables between two groups after treatment. There was no significant difference for BMI, metabolic control and appetite hormones between Glargine and Detemir groups. BMI-z score did not change in Glargine group while leptin increased and AGRP decreased after treatment. HbA1C decreased significantly after treatment in both groups.

Compatibility and Safety of Ultra Rapid Lispro with Continuous Subcutaneous Insulin Infusion in Patients with Type 1 Diabetes: PRONTO-Pump Study

Background: Ultra rapid lispro (URLi) is a new insulin lispro formulation that has accelerated absorption and improved postprandial glucose control compared with insulin lispro (Humalog^®). The compatibility and safety of URLi versus lispro were evaluated in patients with type 1 diabetes using continuous subcutaneous insulin infusion (insulin pump). Methods: In this phase 3, double-blind, crossover study, 49 patients were randomized to two 6-week treatment periods, after a 2-week lead-in period on lispro. The primary endpoint was the rate of infusion set failures due to a pump occlusion alarm, or unexplained hyperglycemia with blood glucose >13.9 mmol/L (250 mg/dL) that did not decrease within 1 h after a correction bolus. Results: There was no significant difference in the rate of infusion set failures between URLi and lispro (0.03 vs. 0.05 events/30 days, P = 0.375). A higher rate of premature infusion set changes was observed with URLi (1.13 vs. 0.78 events/30 days; P = 0.028), translating to one additional infusion set change approximately every 3 months. A trend toward improved glycemic control was observed with URLi treatment: Time in range 3.9-10.0 mmol/L (71-180 mg/dL) was 65.7% ± 1.3% versus 63.0% ± 1.3%. Treatment-emergent adverse events (TEAEs) were reported by 46.9% of patients on URLi treatment and 18.8% on lispro. This difference was driven by an increase in infusion site reactions-more than 90% were mild. Incidence of all other TEAEs and severe hypoglycemia was similar between treatments. Conclusions: URLi was compatible with insulin pump use with a safety profile similar to lispro.

Insulin Pump Therapy Issues Among Adults with Type 1 Diabetes Mellitus in Saudi Arabia: A Retrospective Study

INTRODUCTION

Type 1 diabetes mellitus (T1DM) is on the rise in Saudi Arabia. Management of T1DM is crucial in curbing the economic burden of this disease. Studies on insulin pump issues are scarce in the region. The present study aims to fill this gap.

METHODS

In this single-centre, retrospective study done in King Abdulaziz Medical City (KAMC) from March 2018 to March 2019, a total of 118 known Saudi T1DM adults (34 males and 84 females) were included. Data on demographics, glycated haemoglobin (HbA1c) and CSII use were collected.

RESULTS

The most common problem encountered by the patients on CSII was breaking down of the pump (30.0%), relocation of the cannula or tubing (22%) and air bubbles affecting delivery (16.1%). Eighty-one subjects (68.6%) claimed to have been admitted for DM management while on CSII. The use of CSII led to a significant reduction in HbA1c in all subjects (p < 0.001), but levels remain suboptimal. Only 53 subjects (44.9%) reported no significant problems in their CSII experience.

CONCLUSION

There is a high prevalence of T1DM adult patients experiencing device malfunctions and other issues while on CSII therapy. This may account for suboptimal improvement in the glycaemic control among T1DM Saudi patients. Issues on adherence and device malfunctions should be investigated further.

Therapeutic Advancements in the Management of Diabetes Mellitus with Special Reference to Nanotechnology

For improvisation of diabetic's quality of life, nanotechnology is facilitating the development of advanced glucose sensors as well as efficient insulin delivery systems. Our prime focus of the review is to highlight the advancement in diabetic research with special reference to nanotechnology at its interface. Recent studies are more focused on enhancing sensitivity, accuracy, and response by employing metal as well as nanoparticles based glucose sensors. Moreover, the review focuses on nanoscale based approaches i.e. closed-loop insulin delivery systems, which detect any fluctuation in blood glucose levels and allow controlled release of a drug, thus are also called self-regulating insulin release system. Additionally, this review summarizes the role of nanotechnology in the diagnosis and treatment of diabetic complications through little advancement in the existing techniques. To improve health, as well as the quality of life in diabetic's new sensing systems for blood glucose level evaluation and controlled administration of drugs through efficient drug delivery systems should be explored.

The Effects of Synbiotic Supplementation on Glycemic Status, Lipid Profile, and Biomarkers of Oxidative Stress in Type 1 Diabetic Patients. A Placebo-Controlled, Double-Blind, Randomized Clinical Trial

BACKGROUND AND OBJECTIVE

The aim of the present study was to evaluate the effects of synbiotic on glycemic status, lipid profile, and biomarkers of oxidative stress in type 1 diabetes mellitus (T1DM) patients.

MATERIALS AND METHODS

In this double-blind clinical trial, 50 T1DM patients were randomly allocated to intervention (n = 25) and control (n = 25) groups and received either synbiotic powder (Lactobacillus sporogenes GBI-30 (probiotic), maltodextrin and fructooligosaccharide (prebiotic)) or placebo 2 g per day for 8 weeks. Fasting blood samples were collected before and after the intervention to measure fasting blood glucose (FBG), insulin concentration, hemoglobin A1c (HbA1c), lipid profile, and biomarkers of oxidative stress such as total antioxidant capacity (TAC) and hs-C-reactive protein (hs-CRP).

RESULTS

Supplementation with synbiotic resulted in a significant decrease in the mean serum levels of HbA1c and hs-CRP (p = 0.01 and p = 0.004, respectively), and marginally significant decrease in FBG (p = 0.05) in the intervention group post- intervention. Also, the mean changes of FBG and hs-CRP were significantly lower in the intervention group compared with the control group (p = 0.03 and p = 0.005, respectively). There were no significant changes found in lipid profile in intervention group post-intervention (p≥ 0.05). The mean serum levels of insulin and TAC were significantly increased in the intervention group post-intervention (p = 0.001). There was a significant increase in the mean changes of TAC (p = 0.005) in the intervention group compared with the control group.

CONCLUSION

The 8-week synbiotic supplementation in T1DM patients may be effective in improvement of FBG, HbA1c, insulin, hs-CRP, and TAC.

Use of Diabetes Technology in Children: Role of Structured Education for Young People with Diabetes and Families

The current era has witnessed an explosion of advanced diabetes technologies. Young people with diabetes and their families require detailed, structured diabetes education in order to optimize use of such devices. There is need for youth and their families to participate in the selection of particular devices for personal use and comprehensive education regarding the safe and effective use of such technologies. The education process should ensure that youth and their families receive realistic expectations of what the advanced technologies can and cannot do to avoid disappointment and the premature discontinuation of such systems.

Clinical Use of Degludec in Children and Adolescents with T1D: A Narrative Review with Fictionalized Case Reports

The use of insulin in children and adolescents with type 1 diabetes (T1D) is a challenge because of the heterogeneity of these patients and their lifestyles, with consequent unpredictability in blood glucose levels. A new ultra-long-acting basal insulin, insulin degludec (degludec), has the potential to mitigate some of these challenges, notably variability in the glucose-lowering action of the basal insulin component of an insulin regimen, and consequent risks of hypo- and hyperglycemia. However, the protracted half-life and steady state pharmacokinetics of degludec potentially bring some new challenges. In particular, the adjustment of therapy in response to commonly encountered clinical situations might require a different approach when degludec is used in place of other currently used basal insulins in this challenging patient population. The purpose of this article is to guide clinicians through a series of case histories in the use of this insulin. These include, but are not limited to, how to initiate, titrate, switch from other basal insulin or pump therapy; how to alleviate difficulties arising as a result of unpredictable lifestyle/habits; and how to maintain treatment following diabetic ketoacidosis. The guidance presented in this review illustrates that degludec is a good option for a diverse range of children and adolescents with T1D, providing much needed flexibility in the treatment of this challenging patient population.Funding Novo Nordisk.