Beneficial effect of real-time continuous glucose monitoring system on glycemic control in type 1 diabetic patients: systematic review and meta-analysis of randomized trials

Suplatast Tosilate and Eicosapentaenoic Acid as a Possible Strategy for Maintaining Remission in Minimal Change Nephrotic Syndrome: A Case Report

We report a case of a sudden onset of minimal change nephrotic syndrome (MCNS) in a 33-year-old woman with type 1 diabetes mellitus (T1DM), stable microalbuminuria, and chronic thyroiditis. She was successfully treated with intravenous corticosteroids to finally attain a complete remission. Four years later, she also experienced a relapse of MCNS in the same season as the first onset. The chronological levels of serum immunoglobulin E (IgE) showed that extremely high serum IgE levels preceded the onset or the relapse of MCNS, which may suggest an allergic mechanism of MCNS. Eicosapentaenoic acid (EPA) was reported to be beneficial in treating allergic diseases. Suplatast tosilate is an anti-allergic medication that suppresses serum IgE and was reported to be beneficial in reducing corticosteroid dose in nephrotic syndrome in a pilot study. Therefore, during the tapering of corticosteroids to the relapse of MCNS, suplatast tosilate and EPA were administered, and the IgE levels were considerably controlled. The patient was able to maintain remission even after the cessation of corticosteroids. In conclusion, suppressing IgE levels using suplatast tosilate and EPA may be beneficial in maintaining complete remission without corticosteroids in T1DM.

DiabetesWise: An innovative approach to promoting diabetes device awareness

BACKGROUND

DiabetesWise is an unbranded, data-driven online resource that tailors device recommendations based on preferences and priorities of people with insulin-requiring diabetes. The objective of this study is to examine whether DiabetesWise increases uptake of diabetes devices, which are empirically supported to improve glycemic and psychosocial outcomes.

METHODS

The sample included 458 participants (M_age  = 37.1, SD = 9.73; 66% female; 81% type 1 diabetes) with insulin-requiring diabetes and minimal diabetes device use at enrollment. Participants used DiabetesWise and completed online surveys. Chi-square and t tests evaluated requests for a device prescription, receiving a prescription, and starting a new device at 1 and 3 months post use. Baseline predictors of these variables and past use of continuous glucose monitors (CGMs) and changes in diabetes distress post use were also examined.

RESULTS

Within the first month of interacting with DiabetesWise 19% of participants asked for a prescription for a diabetes device. This rate rose to 31% in the first 3 months. These requests resulted in 16% of the sample starting a new device within the first 3 months. Whereas several factors were associated with prior CGM use, receiving a prescription, and starting a new device, more diabetes distress (t(343) = -3.13, p = .002) was the only factor associated with asking for a prescription. Diabetes distress decreased after interacting with DiabetesWise within 1 month (t(193) = 3.51, p < .001) and 3 months (t(180) = 5.23, p < .001).

CONCLUSIONS

Within 3 months of interacting with DiabetesWise, one in three participants had requested a prescription for a new diabetes device and average distress levels were reduced, indicating benefit from this low-intensity online platform.

Use of Continuous Glucose Monitoring System in Children with Type 1 Diabetes Mellitus in a Resource Limited Setting

Background

Regular self-monitoring of blood glucose (SMBG) remains the mainstay method for diabetes monitoring. The major limitation of SMBG is poor compliance and it only provides a snapshot of glucose values at that point of time. Continuous glucose monitors (CGMs) are non-invasive devices which measure subcutaneous interstitial glucose for every five minutes and provide glucose variability throughout the day.

Aim and Objective

To assess the effectiveness of intermittent continuous blood glucose monitoring in comparison with SMBG on the percentage reduction in HbA1c level in children with type 1 diabetes mellitus (DM).

Methods

Children diagnosed with type 1 DM of age group 3-18 years were enlisted into the study. Participants were randomised to the study arm (CGMs+SMBG) or the control arm (SMBG alone). Subjects in the study group were given CGM along with regular SMBG for 14 days. The control group was asked to perform SMBG. HbA1c levels were measured in both groups after three months of intervention.

Results

There were 62 children in each group. After three months, in the intervention group HbA1c level dropped from 11.23% ± 1.53% (Mean ± SD) to 10.14% ± 1.99%, in control group HbA1c level dropped from 11.62% ± 1.62% to 11.32% ± 1.57%. The fall in HbA1c level in intervention group is significant (p value -0.01).

Conclusion

In a resource-limited setting, intermittent use of CGMs atleast once every two to three months will help in understanding the factors influencing glucose variation throughout the day and, with appropriate therapeutic modifications, will aid in achieving optimal glycaemic control.

Statistical techniques used in analysing simultaneous continuous glucose monitoring and ambulatory electrocardiography in patients with diabetes: A systematic review

OBJECTIVES

There has been a steady increase in the number of studies of the complex relationship between glucose and electrical cardiac activity which use simultaneous continuous glucose monitors (CGM) and continuous electrocardiogram (ECG). However, data collected on the same individual tend to be similar (yielding correlated or dependent data) and require analyses that take into account that correlation. Many opt for simplified techniques such as calculating one measure from the data collected and analyse one observation per subject. These simplified methods may yield inconsistent and biased results in some instances. In this systematic review, we aim to examine the adequacy of the statistical analyses performed in such studies and make recommendations for future studies.

RESEARCH QUESTIONS

What are the objectives of studies collecting simultaneous CGM and ECG data? Do methods used in analysing CGM and continuous ECG data fully optimise the data collected?

DESIGN

Systematic review.

DATA SOURCES

PubMed and Web of Science.

METHODS

A comprehensive search of the PubMed and Web of Science databases to June 2022 was performed. Studies utilising CGM and continuous ECG simultaneously in people with diabetes were included. We extracted information about study objectives, technologies used to collect data and statistical analysis methods used for analysis. Reporting was done following PRISMA guidelines.

RESULTS

Out of 118 publications screened, a total of 31 studies met the inclusion criteria. There was a diverse array of study objectives, with only two studies exploring the same exposure-outcome relationship, allowing only qualitative analysis. Only seven studies (23%) incorporated methods which fully utilised the study data using methods that yield the correct power and minimize type I error rate. The rest (77%) used analyses that summarise the data first before analysis and/or totally ignored data dependency. Of those who applied more advanced methods, one study performed both simple and correct analyses and found that ignoring data structure resulted in no association whilst controlling for repeated measures yielded a significant relationship.

CONCLUSION

Most studies underutilised statistical methods suitable for analysis of dynamic continuous data, potentially attenuating their statistical power and overall conclusions. We recommend that aggregated data be used only as exploratory analysis, while primary analysis should use methods applied to the raw data such as mixed models or functional data analyses. These methods are widely available in many free, open source software applications.

Continuous glucose monitoring versus self-monitoring of blood glucose in the management of cystic fibrosis related diabetes: A systematic review and meta-analysis

BACKGROUND

Treatment of cystic fibrosis related diabetes (CFRD) can improve outcomes and use of continuous glucose monitoring (CGM) can positively impact glycemic control. We conducted a systematic review to assess current evidence on CGM compared to self-monitoring of blood glucose (SMBG) in the management of CFRD to determine its effect on glycemic, pulmonary, non-pulmonary and quality of life outcomes.

METHODS

Using pre-defined selection criteria, we searched MEDLINE, Embase, CENTRAL, Evidence-Based Medicine Reviews, grey literature and six relevant journals for studies using CGM and/or SMBG in CFRD with greater than 6 weeks of follow-up and reported change in HbA1c. The primary outcome was weighted mean difference (WMD) in plasma HbA1c between CGM and SMBG groups. Secondary outcomes included exploring interrelationships between CGM metrics and effects on disease-specific pulmonary, non-pulmonary and quality of life outcomes.

RESULTS

A total of 1671 references were retrieved, 862 studies screened and 124 full-texts assessed for eligibility. No studies directly compared CGM to SMBG. A meta-analysis of seventeen studies of 416 individuals (CGM = 138, SMBG = 278) found CGM group had 4.1 mmol/mol (95% CI -7.9 to -0.30, p = 0.034) lower HbA1c compared to SMBG group. Most studies demonstrated moderate-to-high risk of bias. Publication bias was also present. Heterogeneity was high and meta-regression identified duration of follow-up in SMBG group as main contributor.

CONCLUSION

Our findings suggest use of CGM may be associated with improved glycemic control compared to SMBG in CFRD, however evidence of benefit on pulmonary, non-pulmonary and psychosocial outcomes are lacking.

Long-term glucose-lowering effect of intermittently scanned continuous glucose monitoring for type 1 diabetes patients in poor glycaemic control from Region North Denmark: An observational real-world cohort study

BACKGROUND

Lowering glucose levels is a complex task for patients with type 1 diabetes, and they often lack contact with health care professionals. Intermittently scanned continuous glucose monitoring (isCGM) has the potential to aid them with blood glucose management at home. The aim of this study was to investigate the long-term effect of isCGM on HbA1c in type 1 diabetes patients with poor glycaemic control in a region-wide real-world setting.

METHODS

All patients with type 1 diabetes receiving an isCGM due to poor glycaemic control (≥70 mmol/mol [≥8.6%]) in the period of 2020-21 in Region North Denmark ("T1D-CGM") were compared with all type 1 diabetes patients without isCGM ("T1D-NOCGM") in the same period. A multiple linear regression model adjusted for age, sex, diabetes duration and use of continuous subcutaneous insulin infusion was constructed to estimate the difference in change from baseline HbA1c between the two groups and within subgroups of T1D-CGM.

RESULTS

A total of 2,527 patients (T1D-CGM: 897; T1D-NOCGM: 1,630) were included in the study. The estimated adjusted difference in change from baseline HbA1c between T1D-CGM vs T1D-NOCGM was -5.68 mmol/mol (95% CI: (-6.69 to -4.67 mmol/mol; p<0.0001)). Older patients using isCGM dropped less in HbA1c.

CONCLUSIONS

Our results indicate that patients with type 1 diabetes in poor glycaemic control from Region North Denmark in general benefit from using isCGM with a sustained 24-month improvement in HbA1c, but the effect on HbA1c may be less pronounced for older patients.

Effect of Different Glucose Monitoring Methods on Bold Glucose Control: A Systematic Review and Meta-Analysis

Objective

To evaluate the effectiveness of different glucose monitoring methods on blood glucose control and the incidence of adverse events among patients with type 1 diabetes mellitus.

Methods

Using the method of literature review, the databases PubMed, Cochrane, and Embase were retrieved to obtain relevant research literature, and the selected studies were analyzed and evaluated. This study used Cochrane software RevMan5.4 to statistically analyze all the data.

Results

A total of 15 studies were included in this study, including 10 randomized controlled trials and 5 crossover design trials, with a total of 2071 patients. Meta-analysis results showed that continuous blood glucose monitoring (CGM) could significantly reduce the HbA1c level of patients, weighted mean difference (WMD) = −2.69, 95% confidence interval (CI) (-4.25, -1.14), and P < 0.001 compared with self-monitoring of blood glucose (SMBG). Meanwhile, the incidence of severe hypoglycemia in the CGM group was significantly decreased, risk ratio (RR) = 0.52, 95% CI 0.35-0.77, and P = 0.001. However, there was no statistical difference in the probability of diabetic ketoacidosis between CGM and SMBG groups, RR = 1.34, 95% CI 0.57-3.15, and P = 0.5.

Conclusion

Continuous blood glucose monitoring is associated with lower blood glucose levels than the traditional blood glucose self-test method.

Effectiveness of continuous glucose monitoring in maintaining glycaemic control among people with type 1 diabetes mellitus: a systematic review of randomised controlled trials and meta-analysis

AIMS/HYPOTHESIS

The aim of this work was to assess the effectiveness of continuous glucose monitoring (CGM) vs self-monitoring of blood glucose (SMBG) in maintaining glycaemic control among people with type 1 diabetes mellitus.

METHODS

Cochrane Library, PubMed, Embase, CINAHL, Scopus, trial registries and grey literature were searched from 9 June 2011 until 22 December 2020 for RCTs comparing CGM intervention against SMBG control among the non-pregnant individuals with type 1 diabetes mellitus of all ages and both sexes on multiple daily injections or continuous subcutaneous insulin infusion with HbA1c levels, severe hypoglycaemia and diabetic ketoacidosis (DKA) as outcomes. Studies also included any individual or caregiver-led CGM systems. Studies involving GlucoWatch were excluded. Risk of bias was appraised with Cochrane risk of bias tool. Meta-analysis and meta-regression were performed using Review Manager software and R software, respectively. Heterogeneity was evaluated using χ2 and I2 statistics. Overall effects and certainty of evidence were evaluated using Z statistic and GRADE (Grading of Recommendations, Assessment, Development and Evaluation) software.

RESULTS

Twenty-two studies, involving 2188 individuals with type 1 diabetes, were identified. Most studies had low risk of bias. Meta-analysis of 21 studies involving 2149 individuals revealed that CGM significantly decreased HbA1c levels compared with SMBG (mean difference -2.46 mmol/mol [-0.23%] [95% CI -3.83, -1.08], Z = 3.50, p=0.0005), with larger effects experienced among higher baseline HbA1c >64 mmol/mol (>8%) individuals (mean difference -4.67 mmol/mol [-0.43%] [95% CI -6.04, -3.30], Z = 6.69, p<0.00001). However, CGM had no influence on the number of severe hypoglycaemia (p=0.13) and DKA events (p=0.88). Certainty of evidence was moderate.

CONCLUSIONS/INTERPRETATION

CGM is superior to SMBG in improving glycaemic control among individuals with type 1 diabetes in the community, especially in those with uncontrolled glycaemia. Individuals with type 1 diabetes with HbA1c >64 mmol/mol (>8%) are most likely to benefit from CGM. Current findings could not confer a concrete conclusion on the effectiveness of CGM on DKA outcome as DKA incidences were rare. Current evidence is also limited to outpatient settings. Future research should evaluate the accuracy of CGM and the effectiveness of CGM across different age groups and insulin regimens as these remain unclear in this paper.

PROSPERO REGISTRATION

Registration no. CRD42020207042.

FUNDING

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Effects of continuous glucose monitoring on maternal and neonatal outcomes in perinatal women with diabetes: A systematic review and meta-analysis of randomized controlled trials

AIMS

This systematic review aims to assess the effects of continuous glucose monitoring (CGM) on maternal and neonatal outcomes in perinatal women with diabetes.

METHODS

A three-step comprehensive search was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guideline. Randomized controlled trials (RCTs) were retrieved from international databases of PubMed, Embase, Cochrane Library, CINAHL, PsycINFO and Scopus from their respective inception dates until 5th January 2021. Comprehensive Meta-Analysis Software Version 3 was used. The overall effect was determined using Hedges' g. Cochrane collaboration's tool version 1 and grading of recommendations, assessment, development and evaluation criteria were used for quality assessment.

RESULTS

A total of 1215 records were identified and 10 RCTs involving a total of 1358 perinatal women were selected. The meta-analysis revealed that CGM significantly improved HbA1c levels (g = -0.43, 95% CI: -0.63, -0.22), lowered cesarean section rate (g = -0.17, 95% CI: -0.33, -0.02) and neonatal birth weight (g = -0.16, 95% CI: -0.27, -0.04) when compared to the comparator. The majority (86.67%) has a low risk of biases and certainty of evidence ranged from very low to moderate.

CONCLUSION

CGM improves maternal and neonatal outcomes. Future studies should use well-designed large-scale trials.

Use of Personal Continuous Glucose Monitoring Device Is Associated With Reduced Risk of Hypoglycemia in a 16-Week Clinical Trial of People With Type 1 Diabetes Using Continuous Subcutaneous Insulin Infusion

AIMS

Continuous glucose monitoring (CGM) has the potential to promote diabetes self-management at home with a better glycemic control as outcome. Investigation of the effect of CGM has typically been carried out based on randomized controlled trials with prespecified CGM devices on CGM-naïve participants. The aim of this study was to investigate the effect on glycemic control in people using their personal CGM before and during the trial.

MATERIALS AND METHODS

Data from the Onset 5 trial of 472 people with type 1 diabetes using either their personal CGM (n = 117) or no CGM (n = 355) and continuous subcutaneous insulin infusion in a 16-week treatment period were extracted. Change from baseline in glycated hemoglobin A1c (HbA_1c), number of hypoglycemic episodes, and CGM metrics at the end of treatment were analyzed with analysis of variance repeated-measures models.

RESULTS

Use of personal CGM compared with no CGM was associated with a reduction in risk of documented symptomatic hypoglycemia (event rate ratio: 0.82; 95% CI: 0.69-0.97) and asymptomatic hypoglycemia (event rate ratio: 0.72; 95% CI: 0.53-0.97), reduced time spent in hypoglycemia (P = .0070), and less glycemic variability (P = .0043) without a statistically significant increase in HbA_1c (P = .2028).

CONCLUSIONS

Results indicate that use of personal CGM compared with no CGM in a population of type 1 diabetes is associated with a safer glycemic control without a statistically significantly deteriorated effect on HbA_1c, which adds to the evidence about the real-world use of CGM, where device type is not prespecified, and users are not CGM naïve.

Correlation between short- and mid-term hemoglobin A1c and glycemic control determined by continuous glucose monitoring

BACKGROUND

Glucose monitoring is vital for glycemic control in patients with diabetes mellitus (DM). Continuous glucose monitoring (CGM) measures whole-day glucose levels. Hemoglobin A1c (HbA1c) is a vital outcome predictor in patients with DM.

METHODS

This study investigated the relationship between HbA1c and CGM, which remained unclear hitherto. Data of patients with DM (n = 91) who received CGM and HbA1c testing (1-3 months before and after CGM) were retrospectively analyzed. Diurnal and nocturnal glucose, highest CGM data (10%, 25%, and 50%), mean amplitude of glycemic excursions (MAGE), percent coefficient of variation (%CV), and continuous overlapping net glycemic action were compared with HbA1c values before and after CGM.

RESULTS

The CGM results were significantly correlated with HbA1c values measured 1 (r = 0.69) and 2 (r = 0.39) months after CGM and 1 month (r = 0.35) before CGM. However, glucose levels recorded in CGM did not correlate with the HbA1c values 3 months after and 2-3 months before CGM. MAGE and %CV were strongly correlated with HbA1c values 1 and 2 months after CGM, respectively. Diurnal blood glucose levels were significantly correlated with HbA1c values 1-2 months before and 1 month after CGM. The nocturnal blood glucose levels were significantly correlated with HbA1c values 1-3 months before and 1-2 months after CGM.

CONCLUSIONS

CGM can predict HbA1c values within 1 month after CGM in patients with DM.

Practical Approach to Using Trend Arrows on Real-Time Continuous Glucose Monitoring System in Type 1 Diabetes Adolescents Living Camp Setting Treated With Multiple Daily Injection or Continuous Subcutaneous Insulin Infusion Insulin Therapy

BACKGROUND

The aim of the study was to determine the effect of an educational intervention on the use of trend arrows of a real-time continuous glucose monitoring (rt-CGM) to manage daily therapy decisions in a group of adolescents with type 1 diabetes attending a camp. The secondary aim was to evaluate the variations in total daily dose (TDD) of insulin requirement.

METHODS

Twenty patients (15-17 years) on multiple insulin injections (n = 8) or continuous subcutaneous insulin infusion (n = 12) attended a training session at the beginning of the camp to learn our algorithm for the management of therapy depending on trend arrows. TDD, time in range (TIR), time above range (TAR), and time below range (TBR) (in the 24 hours and in the three hours after breakfast) before the training session (run-in) and at the end of the camp (T1) were analyzed.

RESULTS

Data showed a reduction of TAR (run-in 42.6%, T1 32.05%, P = .036) and an increase in TIR (run-in 52.9%, T1 62.4%, P = .013). Reduction of TBR (run-in 42.5%, T1 37.5%, P = .05) and improvement in TIR (run-in 49.0%, T1 57.0%, P = .02) were also observed in the post-breakfast period. Data showed a significant reduction in the TDD (run-in 52.02 ± 17.44 U/die, T1 46.49 ± 12.39 U/die, P = .024).

CONCLUSIONS

Statistically significant improvement of glycemic control and reduction of TTD were observed in all patients regardless of therapy type. The improvement between run-in and T1 demonstrates the importance of patients' education on the correct use of rt-CGM with simple algorithms for the management of therapy.

Type 1 Diabetes and Addison’s Disease: When the Diagnosis Is Suggested by the Continuous Glucose Monitoring System

Our objective is to emphasize the important role of continuous glucose monitoring (CGM) in suggesting adrenal insufficiency in patients affected by type 1 diabetes. We describe an adolescent girl with type 1 diabetes and subsequent latent Addison’s disease diagnosed based on a recurrent hypoglycemic trend detected by CGM. In patients with type 1 diabetes, persistent unexplained hypoglycemic episodes at dawn together with reduced insulin requirement arouse souspicionof adrenal insufficiency. Adrenal insufficiency secondary to autoimmune Addison’s disease, even if rarely encountered among young patients, may be initially symptomless and characterized by slow progression up to acute adrenal crisis, which represents a potentially life-threatening condition. Besides glycometabolic assessment and adequate insulin dosage adjustment, type 1 diabetes needs prompt recognition of potentially associated autoimmune conditions. Among these, Addison’s disease can be suspected, although latent or paucisymptomatic, through periodic and careful evaluation of CGM data.

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

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

Current treatment options and challenges in patients with Type 1 diabetes: Pharmacological, technical advances and future perspectives

Type 1 diabetes mellitus imposes a significant burden of complications and mortality, despite important advances in treatment: subjects affected by this disease have also a worse quality of life-related to disease management. To overcome these challenges, different new approaches have been proposed, such as new insulin formulations or innovative devices. The introduction of insulin pumps allows a more physiological insulin administration with a reduction of HbA1c level and hypoglycemic risk. New continuous glucose monitoring systems with better accuracy have allowed, not only better glucose control, but also the improvement of the quality of life. Integration of these devices with control algorithms brought to the creation of the first artificial pancreas, able to independently gain metabolic control without the risk of hypo- and hyperglycemic crisis. This approach has revolutionized the management of diabetes both in terms of quality of life and glucose control. However, complete independence from exogenous insulin will be obtained only by biological approaches that foresee the replacement of functional beta cells obtained from stem cells: this will be a major challenge but the biggest hope for the subjects with type 1 diabetes. In this review, we will outline the current scenario of innovative diabetes management both from a technological and biological point of view, and we will also forecast some cutting-edge approaches to reduce the challenges that hamper the definitive cure of diabetes.

Use of continuous glucose monitoring and its association with type 1 diabetes control in children over the first 3 years of reimbursement approval: Population data from the ČENDA registry

OBJECTIVE

Increased access to modern technologies is not always accompanied by a decrease in HbA1c. The aim of this study was to identify changes in the proportion of continuous glucose monitoring (CGM) users since 2017, when general reimbursement for CGM became effective in Czechia, and to test whether HbA1c is associated with the percentage of time spent on CGM.

RESEARCH DESIGN AND METHODS

All T1D children in the Czech national ČENDA registry (3197 children) were categorized according to their time spent on CGM and associations with age, sex, center size, and HbA1c were tested with calendar year as a stratification factor.

RESULTS

The proportion of children with any CGM use increased from 37.9% in 2017 to 50.3% in 2018 and 74.8% in 2019. Of the CGM users, 16%, 28%, and 41% of the children spent >70% of their time on CGM over the 3 years of the study period, with an overrepresentation of children in the <10 years age group versus the older age groups (p < 0.001). The proportion of CGM users differed among centers and was positively associated with a large center size (>100 patients) (p < 0.001). HbA1c was negatively associated with the time spent on CGM (p < 0.001).

CONCLUSIONS

A rapid increase in CGM use was reported over the 3 years after general reimbursement. HbA1c was associated with time spent on CGM, a continuing decrease was observed in the >70% category. Reimbursement for CGM likely contributes to the improvement of T1D control at the population level.

Diabetes education in pediatrics: How to survive diabetes

Diabetes mellitus is the most common abnormal carbohydrate metabolism disorder affecting millions of people worldwide. It is characterized by hyperglycemia as a result of ß-cell destruction or dysfunction by both genetic and environmental factors. Over time chronic hyperglycemia leads to microvascular (i.e., retinopathy, nephropathy and neuropathy) and macrovascular (i.e., ischemic heart disease, peripheral vascular disease, and cerebrovascular disease) complications of diabetes. Diabetes complication trials showed the importance of achieving near-normal glycemic control to prevent and/or reduce diabetes-related morbidity and mortality. There is a staggering rate of increased incidence of diabetes in youth, raising concerns for future generations' health, quality of life and its enormous economic burden. Despite advancements in the technology, diabetes management remains cumbersome. Training individuals with diabetes to gain life-long survival skills requires a comprehensive and ongoing diabetes education by a multidisciplinary team. Diabetes education and training start at the time of diagnosis of diabetes and should be continuous throughout the course of disease. The goal is to empower the individuals and families to gain diabetes self-management skills. Diabetes education must be individualized depending on the individual's age, education, family dynamics, and support. In this article, we review the history of diabetes, etiopathogenesis and clinical presentation of both type 1 and type 2 diabetes in children as well as adolescents. We then focus on diabetes management with education methods and materials.

The Effect of Lockdown and Physical Activity on Glycemic Control in Italian Children and Young Patients With Type 1 Diabetes

AIMS

The purpose of the study was to evaluate the impact of the lockdown established by the Italian government to limit the spread of Coronavirus disease (COVID-19) on glycemic control in a large sample of patients with type 1 diabetes (T1D) based on age, type of insulin therapy, number of telemedicine visits and physical activity.

MATERIAL AND METHODS

We retrospectively evaluated glycemic control in young T1D patients using the DexcomG6^® system before the Italian lockdown (February 10-23, 2020-Time 0) and during lockdown (April 17-30, 2020-Time 1). Data on age, type of insulin therapy, number of telemedicine visits and physical activity of 202 patients with T1D and a median age of 18.2 years (range: 6-39) were collected.

RESULTS

Data showed a significant improvement of TIR from 54.58% at T0 to 59.09% at T1 (p ≤0.0001). Glycemic control improved significantly in patients ≥14 years old, showing the best outcome in the "university students and young adults" group (55.40% at T0 and 61.37% at T1, p ≤0.001). All patients reduced physical activity during lockdown; in the 56 patients of "intense physical activity" group both at T0 and T1 TIR increased from ±56.91 to 64.11% (p ≤0.0001).

CONCLUSIONS

Overall, the lockdown led to an unexpected improvement in glycemic control of young patients with T1D. A healthier and stressless lifestyle changes in association with the maintenance of physical activity resulted in a significant age-proportional improvement in glycemic control.

Glycaemia and utilisation of technology across the lifespan of adults with type 1 diabetes: Results of the Australian National Diabetes Audit (ANDA)

AIMS

To evaluate the utilisation of technologies and associated glycaemia among adults with type 1 diabetes.

METHODS

De-identified data from adults with type 1 diabetes (≥18 years old) in the Australian National Diabetes Audit (ANDA)-2019 were analysed. Proportions using insulin pumps or injections with continuous glucose monitoring (CGM) or capillary-glucose testing were compared. Technology use among adults was compared to young people (<21 years old) with subsidised CGM. Glycaemia and complication-burden were assessed across management strategies.

RESULTS

1,693 adults were analysed. Mean(±SD) age, diabetes duration, and HbA1c were 43.3 ± 17.0 years, 20.3 ± 14.3 years and 8.4% ± 1.7 [68 ± 19 mmol/mol], respectively. Among adults, 40% used at least one device, 27% used insulin pumps, and 23% used CGM. CGM was used by 62% of young people with subsidised access. Mean HbA1c was consistently lower among adults using CGM, insulin pumps, or combined insulin pump and CGM compared to standard care (8.3% ± 1.6 [67 ± 18 mmol/mol], 8.2% ± 1.4 [66 ± 15 mmol/mol], and 7.8% ± 1.4 [62 ± 15 mmol/mol] respectively compared to 8.6% ± 1.8 [70 ± 20 mmol/mol], p < 0.001). Technology use was not associated with diabetic ketoacidosis but CGM was associated with more hypoglycaemia.

CONCLUSIONS

Government subsidy is an important consideration for utilisation of technologies among adults with type 1 diabetes. Technology use across the adult lifespan was associated with lower HbA1c than insulin injections and capillary-glucose testing.

A Systematic Review of Collective Evidences Investigating the Effect of Diabetes Monitoring Systems and Their Application in Health Care

INTRODUCTION

Diabetes monitoring systems (DMS) are a possible approach for regular control of glucose levels in patients with Type 1 or 2 diabetes in order to improve therapeutic outcomes or to identify and modify inappropriate patient behaviors in a timely manner. Despite the significant number of studies observing the DMS, no collective evidence is available about the effect of all devices.

GOAL

To review and consolidate evidences from multiple systematic reviews on the diabetes monitoring systems and the outcomes achieved.

MATERIALS AND METHODS

Internet-based search in PubMed, EMBASE, and Cochrane was performed to identify all studies relevant to the research question. The data regarding type of intervention, type of diabetes mellitus, type of study, change in clinical parameter(s), or another relevant outcome were extracted and summarized.

RESULTS

Thirty-three out of 1,495 initially identified studies, involving more than 44,100 patients with Type 1, Type 2, or gestational diabetes for real-time or retrospective Continuous Glucose Monitoring (CGMS), Sensor Augmented Pump Therapy (SAPT), Self-monitoring Blood Glucose (SMBG), Continuous subcutaneous insulin infusion (CSII), Flash Glucose Monitoring (FGM), Closed-loop systems and telemonitoring, were included. Most of the studies observed small nominal effectiveness of DMS. In total 11 systematic reviews and 15 meta-analyses, with most focusing on patients with Type 1 diabetes (10 and 6, respectively), reported a reduction in glycated hemoglobin (HbA1c) levels from 0.17 to 0.70% after use of DMS.

CONCLUSION

Current systematic review of already published systematic reviews and meta-analyses suggests that no statistically significant difference exists between the values of HbA1c as a result of application of any type of DMS. The changes in HbA1c values, number and frequency of hypoglycemic episodes, and time in glucose range are the most valuable for assessing the appropriateness and effectiveness of DMS. Future more comprehensive studies assessing the effectiveness, cost-effectiveness, and comparative effectiveness of DMS are needed to stratify them for the most suitable diabetes patients' subgroups.

The Efficacy of Technology in Type 1 Diabetes: A Systematic Review, Network Meta-analysis, and Narrative Synthesis

Background: Existing technologies for type 1 diabetes have not been compared against the full range of alternative devices. Multiple metrics of glycemia and patient-reported outcomes for evaluating technologies also require consideration. We thus conducted a systematic review, network meta-analysis, and narrative synthesis to compare the relative efficacy of available technologies for the management of type 1 diabetes. Methods: We searched MEDLINE, MEDLINE In-Process and other nonindexed citations, EMBASE, PubMed, All Evidence-Based Medicine Reviews, Web of Science, PsycINFO, CINAHL, and PROSPERO (inception-April 24, 2019). We included RCT ≥6 weeks duration comparing technologies for type 1 diabetes management among nonpregnant adults (>18 years of age). Data were extracted using a predefined tool. Primary outcomes were A1c (%), hypoglycemia rates, and quality of life (QoL). We estimated mean difference for A1c and nonsevere hypoglycemia, rate ratio for severe hypoglycemia, and standardized mean difference for QoL in network meta-analysis with random effects. Results: We identified 16,772 publications, of which 52 eligible studies compared 12 diabetes management technologies comprising 3,975 participants in network meta-analysis. Integrated insulin pump and continuous glucose monitoring (CGM) systems with low-glucose suspend or hybrid closed-loop algorithms resulted in A1c levels 0.96% (predictive interval [95% PrI] 0.04-1.89) and 0.87% (95% PrI 0.12-1.63) lower than multiple daily injections with either flash glucose monitoring or capillary glucose testing, respectively. In addition, integrated systems had the best ranking for A1c reduction utilizing the surface under the cumulative ranking curve (SUCRA-96.4). While treatment effects were nonsignificant for many technology comparisons regarding severe hypoglycemia and QoL, simultaneous evaluation of outcomes in cluster analyses as well as narrative synthesis appeared to favor integrated insulin pump and continuous glucose monitors. Overall risk of bias was moderate-high. Certainty of evidence was very low. Conclusions: Integrated insulin pump and CGM systems with low-glucose suspend or hybrid closed-loop capability appeared best for A1c reduction, composite ranking for A1c and severe hypoglycemia, and possibly QoL. Registration: PROSPERO, number CRD42017077221.

Five years of improving diabetes control in Czech children after the establishment of the population-based childhood diabetes register ČENDA

OBJECTIVES

The Czech National Childhood Diabetes Register (ČENDA) is a web-based nationwide database that collects treatment and outcome data in children and adolescents with diabetes. Here, we present data from the first 5 years of ČENDA (2013-2017).

METHODS

Data include characteristics of disease onset and annual summaries of key clinical care parameters from every patient treated by participating pediatric diabetes outpatient clinics.

RESULTS

The database contains data of 4361 children (aged 0-19 years) from 52 centers (85% of all Czech pediatric patients). Of these, 94% had type 1 diabetes (T1D), 4.5% had genetically proven monogenic or secondary, and 1.5% had type 2 diabetes. In children with T1D, median glycated hemoglobin (HbA1c) decreased throughout the observed period from 66.3 to 61.0 mmol/mol (P < .0001, 95% confidence interval [CI] for change -5.6 to -4 mmol/mol). Consequently, the proportion of children reaching the target therapeutic goal of 58.5 mmol/mol increased from 28% in 2013 to 40% in 2017. The proportion of children treated with insulin pumps (CSII) remained stable over the observed period (25%). In a subanalysis of 1602 patients (long-standing T1D diagnosed before 2011), the main predictors associated with lower HbA1c were treatment with CSII, male sex and care provided at a large diabetes center (>100 patients).

CONCLUSIONS

A significant continuous decrease in HbA1c was observed in Czech children over the past 5 years. As this improvement was not accompanied by appreciable changes in the mode of therapy, we assume that the establishment of our nationwide register has itself constituted a stimulus towards improvement in the care process.

Comparison of flash glucose monitoring with real time continuous glucose monitoring in children and adolescents with type 1 diabetes treated with continuous subcutaneous insulin infusion

AIMS

In 2016 intermittently scanned continuous glucose monitoring (isCGM) became the first reimbursed CGM system in Belgium. Many children with type 1 diabetes (T1D) treated with multiple daily injections as well as with continuous subcutaneous insulin infusion (CSII) switched from self-monitoring of blood glucose to isCGM to monitor their treatment. In 2017 the Enlite® real-time CGM (rtCGM) system was reimbursed enabling its use with the Minimed® 640G insulin pump with integrated SmartGuard technology. In this study we compared the metabolic control during CSII with isCGM with that during rtCGM. Patient's satisfaction and side effects of the rtCGM system were also evaluated.

METHODS

20 children with T1D, aged 5-16 years, were included. Metabolic control during the last month of isCGM use was compared to that during the 3rd and 6th month of rtCGM.

RESULTS

Three patients stopped early rtCGM mainly due to calibration burden. The HbA1c level and the mean glucose value in the other patients did not change after switching to the rtCGM system. Glucose variability was smaller (46.2% vs 38.4% and 36.4%, p = 0.000). Time in hypoglycemia (<70 mg/dl) was lower (7.4% vs 1.6% and 1.5%, p = 0.000). The main patient inconvenience was the sensor calibration.

CONCLUSIONS

Our data show that during Enlite® rtCGM with the Minimed® 640G pump system glucose variability was smaller and the patients spent less time in hypoglycemia than during isCGM. The need for timely calibrations is considered as the main drawback of the system.

Changes in Accuracy of Continuous Glucose Monitoring Using Dexcom G4 Platinum Over the Course of Moderate Intensity Aerobic Exercise in Type 1 Diabetes

Continuous glucose monitoring (CGM) systems help diabetes management in patients with type 1 diabetes (T1D) but could have lower accuracy during exercise. We aim to evaluate the dynamics of CGM accuracy during exercise in patients with T1D. Secondary analysis of data was carried out on 22 patients with T1D (glycated hemoglobin [HbA_1c]: 7.3% ± 1.0%, diabetes duration: 23 ± 13 years), who did three exercise sessions (45 min at 60% VO_2max on an ergocycle, 3 h postmeal) with paired Dexcom G4 Platinum, and capillary glucose values that were collected every 5 min. Dexcom accuracy was evaluated using sensor bias (SB) and absolute relative difference (ARD). For dynamics of SB analysis, data pairs following hypoglycemia correction were excluded. The analyzed data included 792 pairs (594 during 66 exercise sessions, 198 at rest before exercise). Median ARD was 8.44 (5.35-12.13)% at rest and increased to 16.77 (10.75-26.72)% during exercise (P < 0.001). During exercise, mean SB values evolved from T0 minutes = 5.95 ± 16.04 mg/dL (exercise start); T5 = 9.55 ± 16.40; T10 = 13.51 ± 18.02; T15 = 15.32 ± 20.36; T20 = 17.30 ± 18.92; T25 = 19.46 ± 17.48; T30 = 21.08 ± 19.64; T35 = 19.10 ± 20.36; T40 = 19.82 ± 20.18; and T45 = 18.02 ± 20.90 (exercise end). CGM overestimated capillary at a mean SB of 14.23 ± 16.76 mg/dL over the whole exercise session. CGM accuracy decreased during moderate aerobic exercise as previously described. However, the trend to overestimate capillary glucose was maintained at relatively stable values within 15 min of exercise initiation, which could help patients in their clinical decisions. Similar analyses would be needed for other types of exercise.

Utility of Real-Time and Retrospective Continuous Glucose Monitoring in Patients with Type 2 Diabetes Mellitus: A Meta-Analysis of Randomized Controlled Trials

In the present study, we aimed to investigate the effects of continuous glucose monitoring (CGM) on blood glucose levels, body weight, blood pressure, and hypoglycaemia in patients with type 2 diabetes mellitus using a meta-analysis of randomized controlled trials (RCTs). A literature search was performed using MEDLINE, Cochrane Controlled Trials Registry, and ClinicalTrials.gov. RCTs using CGM in patients with type 2 diabetes mellitus were then selected. Statistical analysis included calculation of the standardized mean difference (SMD) or risk ratio and 95% confidence intervals (CIs) using a random effects model. After literature search, seven RCTs (669 patients) satisfied the eligibility criteria established herein and were included into the meta-analysis. Compared with the self-monitoring blood glucose group, the CGM group exhibited significantly lower HbA1c levels (SMD, -0.35; 95% CI, -0.59--0.10; P = 0.006) and shorter time spent with hypoglycaemia (SMD, -0.42; 95% CI, -0.70--0.13; P = 0.004). Conversely, no differences in body weight and blood pressure were observed between the groups. CGM in patients with type 2 diabetes mellitus could reduce HbA1c levels and time spent with hypoglycaemia. However, because few RCTs were included in this present study and heterogeneity was also noted, care should be taken when interpreting the results.

Comparison between preprandial vs. postprandial insulin aspart in patients with type 1 diabetes on insulin pump and real-time continuous glucose monitoring

BACKGROUND

The objective was to compare glycemic control between preprandial and postprandial bolus administration (15 min before [PRE] or immediately after the meal [POST]) in patients with type 1 diabetes using insulin pump and real-time continuous glucose monitoring.

METHODS

Between September 2015 and February 2016, a single-centre, open randomized, 2-way crossover study of patients on bolus insulin aspart administration was conducted during two 14-day periods and according to 2 administration regimen schedules (PRE/POST or POST/PRE). Inclusion criteria were as follows: patients with type 1 diabetes, ≥18 and ≤ 65 years old, treated with insulin aspart using a Medtronic® insulin pump and trained on functional insulin therapy. Patients were randomly assigned to either regimen schedule. At the beginning of each period, each patient was provided with a standardized high fat meal. Primary outcome was the area under the curve for interstitial glucose above 140 mg/dL per minute (AUC > 140 mg/dL/min) during each period. Secondary outcomes were time spent in hypo/eu/hyperglycemia, glycemic variability indices, and AUC during 4 hours after high fat meal calculated with continuous glucose monitoring data.

RESULTS

Twenty-two patients were included. Mean AUC > 140 mg/dL/min was statistically higher in patients on POST (43.70 mg/dL/min; 95%CI: 34.08 to 53.31) versus PRE insulin aspart regimen (37.24 mg/dL/min 95%CI: 27.63 to 46.85) (P = 0.03). Mean interstitial glycemia and glycemic variability indices were also increased (P < 0.05) on POST regimen. The mean AUC 4 hours after the high fat meal was higher on POST regimen but not statistically different (P = 0.06).

CONCLUSIONS

In our study, postprandial administration of insulin aspart appears to mildly increase glycemic excursion and glycemic variability.

Technology in the management of type 1 diabetes mellitus - current status and future prospects

Type 1 diabetes mellitus (T1DM) represents 5-10% of diabetes cases worldwide. The incidence of T1DM is increasing, and there is no immediate prospect of a cure. As such, lifelong management is required, the burden of which is being eased by novel treatment modalities, particularly from the field of diabetes technologies. Continuous glucose monitoring has become the standard of care and includes factory-calibrated subcutaneous glucose monitoring and long-term implantable glucose sensing. In addition, considerable progress has been made in technology-enabled glucose-responsive insulin delivery. The first hybrid insulin-only closed-loop system has been commercialized, and other closed-loop systems are under development, including dual-hormone glucose control systems. This Review focuses on well-established diabetes technologies, including glucose sensing, pen-based insulin delivery, data management and data analytics. We also cover insulin pump therapy, threshold-based suspend, predictive low-glucose suspend and single-hormone and dual-hormone closed-loop systems. Clinical practice recommendations for insulin pump therapy and continuous glucose monitoring are presented, and ongoing research and future prospects are highlighted. We conclude that the management of T1DM is improved by diabetes technology for the benefit of the majority of people with T1DM, their caregivers and guardians and health-care professionals treating patients with T1DM.

Translating the HbA1c assay into estimated average glucose values in children and adolescents with type 1 diabetes mellitus

OBJECTIVE

The A1c assay, expressed as the percent of hemoglobin that is glycated, measures chronic glycemia and is widely used to judge the adequacy of diabetes treatment and adjust therapy. Day-to-day management is guided by self-monitoring of capillary glucose concentrations (milligrams per decilitre or millimoles per litter) as well as by using continuous glucose monitoring systems (CGMS). We found a mathematical relationship between A1c and average glucose (AG) levels measured by CGMS over 5 days and determined the correlation between the variable CGMS parameters and HbA1c in 50 children with type 1 diabetes mellitus (DM-1) on MDI therapy.

RESEARCH DESIGN AND METHODS

A total of 50 diabetic children randomly selected from a cohort of children with DM-1 were included in the analyses. A1c levels obtained at the end of 3 months and measured in a central laboratory were compared with the AG levels during the previous 5 days recorded by CGMS. AG was calculated by combining weighted results from 5 days of continuous glucose monitoring performed before measuring HbA1c, with 3-5 point daily self-monitoring of capillary (fingerstick) glucose.

RESULTS

Linear regression analysis between the A1c and AG values provided the tightest correlations HbA1c=0.0494 MG- 2E-14, R2=0.90, P<0.0001), allowing calculation of an estimated average glucose (eAG) for A1c values.

CONCLUSIONS

Our study showed a linear relationship between HbA1C and AG values measured by CGMS for 5 days before HbA1c measurement. The AG can be easily calculated using a formula derived from linear regression analysis of HbA1c data obtained in our diabetic children.

Performance of a new real-time continuous glucose monitoring system: A multicenter pilot study

AIMS/INTRODUCTION

The present study aimed to investigate the performance of a new real-time continuous glucose monitoring system.

MATERIALS AND METHODS

Interstitial glucose levels were monitored for 7 days in 63 patients with type 1 or type 2 diabetes using the Medtrum A6 TouchCare® CGM System. Venous blood was collected on a randomized day of the wear period. Plasma glucose levels were measured as reference values.

RESULTS

Among 1,678 paired sensor-reference values, 90.5% (95% confidence interval 89.1-91.9%) were within ±20%/20 mg/dL of the reference values, with a mean absolute relative difference of 9.1 ± 8.7% (95% CI: 8.9-9.2%). The percentages of paired sensor-reference values falling within zone A and B of the Clarke error grid analysis (EGA) and the type 1 diabetes consensus EGA were 99.1 and 99.8%. Continuous EGA showed that the percentages of accurate readings, benign errors, and erroneous readings were 89.9, 6.3 and 3.8%, respectively. Surveillance EGA showed that 90.6, 9.2, and 0.2% of sensor-reference values with no, slight and lower moderate risk, respectively. The mean absolute relative difference was 16.6, and 96.0% of the sensor values fell within zones A and B of the consensus EGA for hypoglycemia. More than 85% of sensor values were within ±20%/20 mg/dL of reference values, the mean absolute relative difference was <11, and >99.5% of the sensor values fell in zones A and B of the consensus EGA.

CONCLUSIONS

The Medtrum real-time continuous glucose monitoring system was numerically and clinically accurate over a large glucose range across 7 days of wear.

Real-time continuous glucose monitoring in type 1 diabetes: a systematic review and individual patient data meta-analysis

BACKGROUND

Real-time continuous glucose monitoring (RTCGM) may help in the management of individuals with type 1 diabetes mellitus (T1DM); however, the evidence supporting its use is unclear. The available meta-analyses on this topic use aggregate data which weaken inference.

OBJECTIVE

Individual patient data were obtained from randomized controlled trials (RCTs) to conduct a meta-analysis and synthesize evidence about the effect of RTCGM on glycosylated haemoglobin (HbA1c), hypoglycaemic events and time spent in hypoglycaemia in T1DM.

METHODS

We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and Database of Systematic Reviews, and Scopus through January 2015. We included RCTs that enrolled individuals with T1DM and compared RTCGM vs control group. A two-step regression model was used to pool individual patient data.

RESULTS

We included 11 RCTs at moderate risk of bias. Meta-analysis suggests that the use of RTCGM is associated with a statistically significant but modest reduction in HbA1c (-0·276; 95% confidence interval -0·465 to -0·087). The improvements in HbA1c were primarily seen in individuals over age 15 years. We were unable to identify a statistically significant difference in time spent in hypoglycaemia or the number of hypoglycaemic episodes although these analyses were imprecise and warrant lower confidence. There was no difference between males and females.

CONCLUSION

RTCGM in T1DM is associated with a reduction in HbA1c primarily in individuals over 15 years of age. We were unable to identify a statistically significant difference in the time spent in hypoglycaemia or the incidence of hypoglycaemic episodes.

Current and Emerging Technology for Continuous Glucose Monitoring

Diabetes has become a leading cause of death worldwide. Although there is no cure for diabetes, blood glucose monitoring combined with appropriate medication can enhance treatment efficiency, alleviate the symptoms, as well as diminish the complications. For point-of-care purposes, continuous glucose monitoring (CGM) devices are considered to be the best candidates for diabetes therapy. This review focuses on current growth areas of CGM technologies, specifically focusing on subcutaneous implantable electrochemical glucose sensors. The superiority of CGM systems is introduced firstly, and then the strategies for fabrication of minimally-invasive and non-invasive CGM biosensors are discussed, respectively. Finally, we briefly outline the current status and future perspective for CGM systems.

A new horizon for glucose monitoring

Regular self-monitoring of blood glucose is crucial for proper insulin dosing and gives a reliable foundation for reasonable glycaemic control. According to recent data, recommended values for glycated haemoglobin A1c as set by the professional associations remain out of the reach for a large proportion of the paediatric population. In the last decades, the treatment of type 1 diabetes has changed significantly as new devices gain a role in routine clinical care. Real-time glucose levels can be monitored with continuous glucose monitoring (CGM), which provides a broad spectrum of information on glucose trends on a moment-to-moment basis. This information can be useful for patients' decision making and clinicians' understanding of patients' conduct. However, several barriers, including the current price, impede a broader use of CGM in most regions of the world. This review summarizes data from randomized, controlled trials that included a paediatric population, and it provides some evidence-based visions for the possible broader utilization of CGM, also for incorporation into insulin delivery devices that enable a closed-loop insulin delivery.

Are Systematic Reviews and Meta-Analyses Appropriate Tools for Assessing Evolving Medical Device Technologies?

Systematic reviews and meta-analyses (SRMAs) provide unique insights into comparative effectiveness of diabetes treatments. However, use of these analyses may be inappropriate for assessing the value and utility of technologies that involve significant behavioral interventions and encompass rapidly evolving technologies such as real-time continuous glucose monitoring (RT-CGM). The rapid evolution of RT-CGM, compared with the time required for publication of clinical studies used in SRMAs, may preclude differentiation between past and current generations of devices. In addition, the effect of performance and usability differences between the various commercial devices on possible clinical outcomes associated with the devices are often not clearly discussed, and many of the RT-CGM studies assessed in SRMAs do not provide adequate information regarding whether and/or to what degree study subjects and clinicians were trained to use the RT-CGM and utilize the data to adjust therapy. Although numerous clinical studies have shown that the glycemic benefit of RT-CGM is related to the frequency and duration of use, a disproportionate number of RT-CGM studies included in recent SRMAs are based on the results of the intention-to-treat analyses and do not consider this fundamental behavioral component in their conclusions. Given these limitations, the generalizability of SRMA conclusions may be limited, and findings from these reports may significantly underestimate the potential glycemic benefit of current and future devices, posing challenges for coverage and reimbursement. We reviewed the potential limitations of the recent Cochrane Collaboration report on CGM, focusing on the 12 studies that assessed RT-CGM use in adults, children/adolescents or both.

Preclinical Evaluation of Poly(HEMA-co-acrylamide) Hydrogels Encapsulating Glucose Oxidase and Palladium Benzoporphyrin as Fully Implantable Glucose Sensors

BACKGROUND

Continuous glucose monitors (CGMs) require percutaneous wire probes to monitor glucose. Sensors based on luminescent hydrogels are being explored as fully implantable alternatives to traditional CGMs. Our previous work investigated hydrogel matrices functionalized with enzymes and oxygen-quenched phosphors, demonstrating sensitivity to glucose, range of response, and biofouling strongly depend on the matrix material. Here, we further investigate the effect of matrix composition on overall performance in vitro and in vivo.

METHODS

Sensors based on three hydrogels, a poly(2-hydroxyethyl methacrylate) (pHEMA) homopolymer and 2 poly(2-hydroxyethyl methacrylate-co-acrylamide) (pHEMA-co-AAm) copolymers, were compared. These were used to entrap glucose oxidase (GOx), catalase, and an oxygen-sensitive benzoporphyrin phosphor. All sensor formulations were evaluated for glucose response and stability at physiological temperatures. Selected sensors were then evaluated as implanted sensors in a porcine model challenged with glucose and insulin. The animal protocol used in this study was approved by an IACUC committee at Texas A&M University.

RESULTS

PHEMA-co-AAm copolymer hydrogels (75:25 HEMA:AAm) yielded the most even GOx and dye dispersion throughout the hydrogel matrix and best preserved GOx apparent activity. In response to in vitro glucose challenges, this formulation exhibited a dynamic range of 12-167 mg/dL, a sensitivity of 1.44 ± 0.46 µs/(mg/dL), and tracked closely with reference capillary blood glucose values in vivo.

CONCLUSIONS

The hydrogel-based sensors exhibited excellent sensitivity and sufficiently rapid response to the glucose levels achieved in vivo, proving feasibility of these materials for use in real-time glucose tracking. Extending the dynamic range and assessing long-term effects in vivo are ongoing efforts.

Evidence-informed clinical practice recommendations for treatment of type 1 diabetes complicated by problematic hypoglycemia

Problematic hypoglycemia, defined as two or more episodes per year of severe hypoglycemia or as one episode associated with impaired awareness of hypoglycemia, extreme glycemic lability, or major fear and maladaptive behavior, is a challenge, especially for patients with long-standing type 1 diabetes. Individualized therapy for such patients should include a composite target: optimal glucose control without problematic hypoglycemia. Therefore, we propose a tiered, four-stage algorithm based on evidence of efficacy given the limitations of educational, technological, and transplant interventions. All patients with problematic hypoglycemia should undergo structured or hypoglycemia-specific education programs (stage 1). Glycemic and hypoglycemia treatment targets should be individualized and reassessed every 3-6 months. If targets are not met, one diabetes technology-continuous subcutaneous insulin infusion or continuous glucose monitoring-should be added (stage 2). For patients with continued problematic hypoglycemia despite education (stage 1) and one diabetes technology (stage 2), sensor-augmented insulin pumps preferably with an automated low-glucose suspend feature and/or very frequent contact with a specialized hypoglycemia service can reduce hypoglycemia (stage 3). For patients whose problematic hypoglycemia persists, islet or pancreas transplant should be considered (stage 4). This algorithm provides an evidence-informed approach to resolving problematic hypoglycemia; it should be used as a guide, with individual patient circumstances directing suitability and acceptability to ensure the prudent use of technology and scarce transplant resources. Standardized reporting of hypoglycemia outcomes and inclusion of patients with problematic hypoglycemia in studies of new interventions may help to guide future therapeutic strategies.

The interrelationship of HbA1c and real-time continuous glucose monitoring in children with type 1 diabetes

AIMS

The aim of this observational study is to investigate the relationship between age, duration of diabetes, HbA1c and the parameters of glucose levels measured with real-time CGM in children with type 1 diabetes.

METHODS

Glucose level was characterized with the relative time spent in hyper- and hypoglycemia, central tendency, variability and MAGE during (real-time) CGM. These parameters were measured in 57 children with type 1 diabetes mellitus. The univariate association of the measured parameters was investigated with scatterplots as well as with linear and distance correlation coefficients.

RESULTS

Age and duration of diabetes were not clinically relevantly associated with any descriptor of glucose level. HbA1c had an overall positive association with variability and MAGE observed during CGM. Slight, but non-significant, positive association of HbA1c was observed with the time spent in hyperglycemia and the central tendency of glucose level. With the exception of MAGE, the associations of the descriptors with HbA1c are non-monotonic, with a temporary break in the positive correlation at 10%.

CONCLUSIONS

The results confirmed the well-known positive association of HbA1c with the central tendency of glucose level. The non-monotonic relationship between HbA1c and the indicators of the central tendency of glucose level might be caused by the changed adherence of the patients during the period of CGM. HbA1c's positive association with MAGE without non-monotonicity underlines MAGE's usefulness in the reliable assessment of the patients' glycemic state.

Lessons learned from a pilot RCT of simultaneous versus delayed initiation of continuous glucose monitoring in children and adolescents with type 1 diabetes starting insulin pump therapy

Uncertainty remains about effectiveness of continuous glucose monitoring (CGM) in pediatric type 1 diabetes (T1D). Success with CGM is related to CGM adherence, which may relate to readiness to make the behavior changes required for effective use. We hypothesize that readiness for change will be greater at initiation of insulin pump therapy than in established pump users, and that this will predict CGM adherence. Our objective was to evaluate the feasibility of a randomized controlled trial (RCT) in children with established T1D comparing simultaneous pump and CGM initiation to standard pump therapy with delayed CGM initiation. We randomized participants to simultaneous pump and CGM initiation or to standard pump therapy with the option of adding CGM 4 months later. CGM adherence was tracked via web-based download and readiness for change assessed with the SOCRATES questionnaire. Of 41 eligible children, 20 agreed to participate; 15 subjects completed the study (7 males; baseline age 11.8 ± 4.0 years; T1D duration 2.7 ± 2.7 years; mean A1C 8.2 ± 0.8%). Six of 8 simultaneous group subjects used CGM > 60% of the time for 4 months compared to 1 of 7 delayed group subjects (P = .02). Using SOCRATES, we could assign 87-100% of subjects to a single motivation stage at baseline and 4 months. This pilot study demonstrates the feasibility of randomizing pump naïve children and adolescents with established T1D to simultaneous pump and CGM initiation versus standard pump therapy with delayed CGM initiation. Lessons from this pilot study were used to inform development of a full-scale multicenter RCT.

Management of type 1 diabetes in children and adolescents

Type 1 diabetes (T1D) is estimated to have a prevalence of approximately 1 in 5000 among Indian children. Living with T1D is a challenge for the child and the family because of the significant burden of treatment in terms of regular injections and monitoring of blood sugar, and risk of acute and long term complications that this condition imposes. Optimal glycemic control in T1D requires a meticulous balance of insulin therapy with diet and exercise. With the earlier insulin regimens this required lot of discipline in the eating and activity pattern, which led to significant curtailment of the lifestyle. Now, with availability of better insulins, delivery and monitoring devices, greater flexibility in lifestyle has become possible. The ultimate breakthrough in terms of therapy of T1D shall be easy availability of accurate and affordable closed loop systems, and 'cure' through islet or stem cell transplant. A review of the ambulatory management of T1D in children and adolescents and the upcoming therapeutic advances is being presented in this paper.

Relationship between HbA1c and continuous glucose monitoring in Chinese population: a multicenter study

Objective

Since there is a paucity of reference data in the literature to indicate the relationship between HbA1c, and 24 h mean blood glucose (MBG) from continuous glucose monitoring (CGM) in Chinese populations, we described the above relationship in adult Chinese subjects with different glucose tolerance status.

Methods

Seven-hundred-and-forty-two individuals without history of diabetes were included to the study at 11 hospitals in urban areas across China from 2007–2009 and data of 673 subjects were included into the final analysis. Oral glucose tolerance test (OGTT) classified the participants as nondiabetic subjects, including those with normal glucose regulation (NGR; n = 121) and impaired glucose regulation (IGR; n = 209), or newly diagnosed type 2 diabetes (n = 343). All participants completed testing for HbA1c levels and wore a CGM system for three consecutive days. The 24 h MBG levels were calculated. Spearman correlations and linear regression analyses were applied to quantify the relationship between glucose markers.

Results

The levels of HbA1c and 24 h MBG significantly increased with presence of glucose intolerance (NGR<IGR<type 2 diabetes; both, P<0.001). Analysis of the total population indicated that HbA1c was strongly correlated with 24 h MBG (r = 0.735). The correlation was also found to be significant for the subgroup of participants with newly diagnosed type 2 diabetes (r = 0.694, P<0.001). Linear regression analysis of the total study population yielded the following equation: 24 h MBG _mmol/L = 1.198×HbA1c–0.582 (24 h MBG _mg/dL = 21.564×HbA1c–10.476) (R² = 0.670, P<0.001). The model fit was not improved by application of exponential or quadratic modeling. When HbA1c was 6.5%, the calculated 24 h MBG was 7.2 (6.4–8.1) mmol/L (130 (115–146) mg/dL); and when HbA1c was 7.0%, the 24 h MBG was 7.8 (6.9–8.7) mmol/L (140 (124–157) mg/dL).

Conclusions

Our study provided the reference data of the relationship between HbA1c and CGM in Chinese subjects.

A randomized trial comparing the rate of hypoglycemia--assessed using continuous glucose monitoring--in 125 preschool children with type 1 diabetes treated with insulin glargine or NPH insulin (the PRESCHOOL study)

BACKGROUND

Avoidance of hypoglycemia is a key consideration in treating young children with type 1 diabetes (T1DM).

KEY OBJECTIVE

To evaluate hypoglycemia with insulin glargine vs. neutral protamine Hagedorn (NPH) insulin in young children, using continuous glucose monitoring (CGM).

SUBJECTS

Children of 1 to <6 yr treated with once-daily glargine vs. once- or twice-daily NPH, with bolus insulin lispro/regular human insulin provided to all.

METHODS

Twenty-four week, multicenter, randomized, open-label study. Primary endpoint was event rate of composite hypoglycemia [symptomatic hypoglycemia, low CGM excursions (<3.9 mmol/L) or low fingerstick blood glucose (FSBG; <3.9 mmol/L)]. Noninferiority of glargine vs. NPH was assessed for the primary endpoint.

RESULTS

One hundred and twenty-five patients (mean age, 4.2 yr) were randomized to treatment (glargine, n = 61; NPH, n = 64). At baseline, mean HbA1c was 8.0 and 8.2% with glargine and NPH, respectively. Composite hypoglycemia episodes/100 patient-yr was 1.93 for glargine and 1.69 for NPH; glargine noninferiority was not met. Events/100 patient-yr of symptomatic hypoglycemia were 0.26 for glargine vs. 0.33 for NPH; low CGM excursions 0.75 vs. 0.72; and low FSBG 1.93 vs.1.68. There was a slight difference in between-group severe/nocturnal/severe nocturnal hypoglycemia and glycemic control. All glargine-treated patients received once-daily injections; on most study days NPH-treated patients received twice-daily injections.

CONCLUSIONS

While glargine noninferiority was not achieved, in young children with T1DM, there was a slight difference in hypoglycemia outcomes and glycemic control between glargine and NPH. Once-daily glargine may therefore be a feasible alternative basal insulin in young populations, in whom administering injections can be problematic.

The evidence base for diabetes technology: appropriate and inappropriate meta-analysis

When we are interested in making decisions about best use, comparative therapeutic efficacy, or cost-effectiveness of diabetes technologies such as insulin pump therapy [continuous subcutaneous insulin infusion (CSII)] or continuous glucose monitoring, meta-analysis for the purpose of literature summary is inappropriate and may be misleading. Instead, "decision-making meta-analysis" is more appropriate and should involve either preselection of trials based on intended use [e.g., elevated baseline hemoglobin A1c or hypoglycemia rate for trials of multiple daily injections (MDI) versus CSII] or metaregression of summary effect sizes in different trials against potential effect-modifying covariates such as baseline risk, or models of the covariates that determine effect size using individual patient data. Appropriate meta-analysis should also only include trials that are of sufficient duration to accurately measure outcomes such as severe hypoglycemia, and they should not use obsolete technology that is of proven inferiority to current technology. The use of appropriate decision-making meta-analysis is illustrated by the change in the rate ratio for severe hypoglycemia in randomized controlled trials of MDI versus CSII in type 1 diabetes from 1.56 (95% confidence interval 0.96-2.55; p = .074) for literature-summary meta-analysis to 2.0 (1.08-3.69; p = .027) for decision-making meta-analysis of all patients and 3.91 (1.35-11.36; p = .01) for trials in children.

Role of continuous glucose monitoring in the management of diabetic pregnancy

Self-monitoring of blood glucose (SMBG) with intermittent capillary glucose fingerstick tests is currently the universally accepted method of glucose monitoring in pregnancy. During pregnancy SMBG tests are recommended before and after meals and before bed (typically 7 values/d). Continuous glucose monitoring systems consist of a disposable subcutaneous glucose-sensing device, electrochemically measuring glucose levels in subcutaneous tissues every 10 seconds, providing an average interstitial glucose value every 5 minutes (typically 288 values/d). From a research perspective this provides unprecedented insights into the pathophysiology of glucose metabolism, while from a clinical perspective it can facilitate enhanced patient-professional decision making, patient motivation, and improved glycaemic control. CGM has thus been described as a "roadmap for effective self-management" and as a "stepping stone in the journey towards a cure." This review will consider the lessons learned and evidence supporting current and potential future use of CGM in the management of diabetes in pregnancy.