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Wilkinson T, Tomic D, Boyle E, Burren D, Elghattis Y, Jenkins A, Keesing C, Middleton S, Nanayakkara N, Williman J, de Bock M, Cohen ND. Study protocol for a randomised open-label clinical trial examining the safety and efficacy of the Android Artificial Pancreas System (AAPS) with advanced bolus-free features in adults with type 1 diabetes: the 'CLOSE IT' (Closed Loop Open SourcE In Type 1 diabetes) trial. BMJ Open 2024; 14:e078171. [PMID: 38382954 PMCID: PMC10882371 DOI: 10.1136/bmjopen-2023-078171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 11/20/2023] [Indexed: 02/23/2024] Open
Abstract
INTRODUCTION Multiple automated insulin delivery (AID) systems have become commercially available following randomised controlled trials demonstrating benefits in people with type 1 diabetes (T1D). However, their real-world utility may be undermined by user-associated burdens, including the need to carbohydrate count and deliver manual insulin boluses. There is an important need for a 'fully automated closed loop' (FCL) AID system, without manual mealtime boluses. The (Closed Loop Open SourcE In Type 1 diabetes) trial is a randomised trial comparing an FCL AID system to the same system used as a hybrid closed loop (HCL) in people with T1D, in an outpatient setting over an extended time frame. METHODS AND ANALYSIS Randomised, open-label, parallel, non-inferiority trial comparing the Android Artificial Pancreas System (AAPS) AID algorithm used as FCL to the same algorithm used as HCL. Seventy-five participants aged 18-70 will be randomised (1:1) to one of two treatment arms for 12 weeks: (a) FCL-participants will be advised not to bolus for meals and (b) HCL-participants will use the AAPS AID algorithm as HCL with announced meals. The primary outcome is the percentage of time in target sensor glucose range (3.9-10.0 mmol/L). Secondary outcomes include other glycaemic metrics, safety, psychosocial factors, platform performance and user dietary factors. Twenty FCL arm participants will participate in a 4-week extension phase comparing glycaemic and dietary outcomes using NovoRapid (insulin aspart) to Fiasp (insulin aspart and niacinamide). ETHICS AND DISSEMINATION Approvals are by the Alfred Health Ethics Committee (615/22) (Australia) and Health and Disability Ethics Committees (2022 FULL 13832) (New Zealand). Each participant will provide written informed consent. Data protection and confidentiality will be ensured. Study results will be disseminated by publications, conferences and patient advocacy groups. TRIAL REGISTRATION NUMBERS ACTRN12622001400752 and ACTRN12622001401741.
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Affiliation(s)
- Tom Wilkinson
- University of Otago Christchurch, Christchurch, New Zealand
| | - Dunya Tomic
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Erin Boyle
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - David Burren
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Yasser Elghattis
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Alicia Jenkins
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | | | - Sonia Middleton
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | | | | | - Martin de Bock
- University of Otago Christchurch, Christchurch, New Zealand
| | - Neale D Cohen
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
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Elbarbary NS, Ismail EAR. Mitigating iftar-related glycemic excursions in adolescents and young adults with type 1 diabetes on MiniMed™ 780G advanced hybrid closed loop system: a randomized clinical trial for adjunctive oral vildagliptin therapy during Ramadan fasting. Diabetol Metab Syndr 2023; 15:257. [PMID: 38057844 DOI: 10.1186/s13098-023-01232-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 11/25/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND Ramadan Iftar meal typically causes glucose excursions. Dipeptidyl peptidase-4 inhibitors increase glucagon-like peptide-1 and thus, decrease blood glucose levels with low risk of hypoglycemia. AIM To investigate the efficacy and safety of vildagliptin as an add-on therapy on glucose excursions of Iftar Ramadan meals among adolescents and young adults with type 1 diabetes mellitus (T1DM) using advanced hybrid closed-loop (AHCL) treatment. METHODS Fifty T1DM patients on MiniMed™ 780G AHCL were randomly assigned either to receive vildagliptin (50 mg tablet) with iftar meal during Ramadan month or not. All participants received pre-meal insulin bolus based on insulin-to-carbohydrate ratio (ICR) for each meal constitution. RESULTS Vildagliptin offered blunting of post-meal glucose surges (mean difference - 30.3 mg/dL [- 1.7 mmol/L] versus - 2.9 mg/dL [- 0.2 mmol/L] in control group; p < 0.001) together with concomitant exceptional euglycemia with time in range (TIR) significantly increased at end of Ramadan in intervention group from 77.8 ± 9.6% to 84.7 ± 8.3% (p = 0.016) and time above range (180-250 mg/dL) decreased from 13.6 ± 5.1% to 9.7 ± 3.6% (p = 0.003) without increasing hypoglycemia. A significant reduction was observed in automated daily correction boluses and total bolus dose by 23.9% and 16.3% (p = 0.015 and p < 0.023, respectively) with less aggressive ICR settings within intervention group at end of Ramadan. Coefficient of variation was improved from 37.0 ± 9.4% to 31.8 ± 7.1%; p = 0.035). No severe hypoglycemia or diabetic ketoacidosis were reported. CONCLUSION Adjunctive vildagliptin treatment mitigated postprandial hyperglycemia compared with pre-meal bolus alone. Vildagliptin significantly increased TIR while reducing glycemic variability without compromising safety. Trial registration This trial was registered under ClinicalTrials.gov Identifier no. NCT06021119.
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Affiliation(s)
- Nancy Samir Elbarbary
- Department of Pediatrics, Faculty of Medicine, Ain Shams University, 25 Ahmed Fuad St. Saint Fatima, Heliopolis, Cairo, 11361, Egypt.
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Cardona-Hernandez R, Dôvc K, Biester T, Ekhlaspour L, Macedoni M, Tauschmann M, Mameli C. New therapies towards a better glycemic control in youths with type 1 diabetes. Pharmacol Res 2023; 195:106882. [PMID: 37543096 PMCID: PMC11073821 DOI: 10.1016/j.phrs.2023.106882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 07/10/2023] [Accepted: 08/02/2023] [Indexed: 08/07/2023]
Abstract
Type 1 diabetes (T1D) is the most frequent form of diabetes in pediatric age, affecting more than 1.5 million people younger than age 20 years worldwide. Early and intensive control of diabetes provides continued protection against both microvascular and macrovascular complications, enhances growth, and ensures normal pubertal development. In the absence of definitive reversal therapy for this disease, achieving and maintaining the recommended glycemic targets is crucial. In the last 30 years, enormous progress has been made using technology to better treat T1D. In spite of this progress, the majority of children, adolescents and young adults do not reach the recommended targets for glycemic control and assume a considerable burden each day. The development of promising new therapeutic advances, such as more physiologic insulin analogues, pioneering diabetes technology including continuous glucose monitoring and closed loop systems as well as new adjuvant drugs, anticipate a new paradigm in T1D management over the next few years. This review presents insights into current management of T1D in youths.
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Affiliation(s)
| | - Klemen Dôvc
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia; Department of Pediatric Endocrinology, Diabetes and Metabolic Diseases, University Children's Hospital, Ljubljana, Slovenia
| | - Torben Biester
- AUF DER BULT, Diabetes Center for Children and Adolescents, Hannover, Germany
| | - Laya Ekhlaspour
- Department of Pediatrics, Division of Endocrinology. University of California, San Francisco, CA, United States
| | | | - Martin Tauschmann
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Chiara Mameli
- Department of Pediatrics, V. Buzzi Children's Hospital, Milan, Italy; Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy.
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Nadendla K, Chintala S, Kover K, Friedman SH. In vivo variable and multi-day response from an insulin-releasing photoactivated depot. Bioorg Med Chem Lett 2023; 92:129388. [PMID: 37369330 PMCID: PMC10529906 DOI: 10.1016/j.bmcl.2023.129388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/08/2023] [Accepted: 06/22/2023] [Indexed: 06/29/2023]
Abstract
Previously we have demonstrated that light can be used to control the release of insulin in diabetic animals, followed by a reduction in blood glucose. This is accomplished using a photoactivated depot (PAD) of insulin injected into the skin, and irradiated by a small external LED light source. In this work for the first time we demonstrate dose-response, showing that we can vary insulin release and commensurate blood glucose reduction by varying the amount of light administered. In addition to demonstrating dose-response, we have shown multi-day depot response, with insulin being released on two different days from the same depot. The material used in these studies was CD-insulin, a form of insulin that has a highly non-polar cyclododecyl group attached, markedly reducing the solubility of the modified material, and allowing it to form a depot upon injection. Upon photolysis, the cyclododecyl group is removed, releasing fully native, soluble insulin. Variable response and multi-day response as demonstrated strongly support the potential utility of the PAD approach for the variable and extended release of therapeutic peptides.
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Affiliation(s)
- Karthik Nadendla
- Division of Pharmacology and Pharmaceutical Sciences, School of Pharmacy, University of Missouri-Kansas City, Kansas City, MO 64108, United States
| | - Swetha Chintala
- Division of Pharmacology and Pharmaceutical Sciences, School of Pharmacy, University of Missouri-Kansas City, Kansas City, MO 64108, United States
| | - Karen Kover
- Department of Endocrinology, Children's Mercy Hospital, Kansas City, MO 64108, United States; Department of Medicine, School of Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, United States
| | - Simon H Friedman
- Division of Pharmacology and Pharmaceutical Sciences, School of Pharmacy, University of Missouri-Kansas City, Kansas City, MO 64108, United States.
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Haidar A, Legault L, Raffray M, Gouchie-Provencher N, Jafar A, Devaux M, Ghanbari M, Rabasa-Lhoret R. A Randomized Crossover Trial to Compare Automated Insulin Delivery (the Artificial Pancreas) With Carbohydrate Counting or Simplified Qualitative Meal-Size Estimation in Type 1 Diabetes. Diabetes Care 2023; 46:1372-1378. [PMID: 37134305 PMCID: PMC10300520 DOI: 10.2337/dc22-2297] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 04/02/2023] [Indexed: 05/05/2023]
Abstract
OBJECTIVE Qualitative meal-size estimation has been proposed instead of quantitative carbohydrate (CHO) counting with automated insulin delivery. We aimed to assess the noninferiority of qualitative meal-size estimation strategy. RESEARCH DESIGN AND METHODS We conducted a two-center, randomized, crossover, noninferiority trial to compare 3 weeks of automated insulin delivery with 1) CHO counting and 2) qualitative meal-size estimation in adults with type 1 diabetes. Qualitative meal-size estimation categories were low, medium, high, or very high CHO and were defined as <30 g, 30-60 g, 60-90 g, and >90 g CHO, respectively. Prandial insulin boluses were calculated as the individualized insulin to CHO ratios multiplied by 15, 35, 65, and 95, respectively. Closed-loop algorithms were otherwise identical in the two arms. The primary outcome was time in range 3.9-10.0 mmol/L, with a predefined noninferiority margin of 4%. RESULTS A total of 30 participants completed the study (n = 20 women; age 44 (SD 17) years; A1C 7.4% [0.7%]). The mean time in the 3.9-10.0 mmol/L range was 74.1% (10.0%) with CHO counting and 70.5% (11.2%) with qualitative meal-size estimation; mean difference was -3.6% (8.3%; noninferiority P = 0.78). Frequencies of times at <3.9 mmol/L and <3.0 mmol/L were low (<1.6% and <0.2%) in both arms. Automated basal insulin delivery was higher in the qualitative meal-size estimation arm (34.6 vs. 32.6 units/day; P = 0.003). CONCLUSIONS Though the qualitative meal-size estimation method achieved a high time in range and low time in hypoglycemia, noninferiority was not confirmed.
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Affiliation(s)
- Ahmad Haidar
- Department of Biomedical Engineering, McGill University, Montréal, Quebéc, Canada
- The Research Institute of McGill University Health Centre, Montréal, Québec, Canada
| | - Laurent Legault
- Montreal Children's Hospital, McGill University Health Centre, Montréal, Québec, Canada
| | - Marie Raffray
- Institut de Recherches Cliniques de Montréal, Montréal, Québec, Canada
| | | | - Adnan Jafar
- Department of Biomedical Engineering, McGill University, Montréal, Quebéc, Canada
| | - Marie Devaux
- Institut de Recherches Cliniques de Montréal, Montréal, Québec, Canada
| | - Milad Ghanbari
- Department of Biomedical Engineering, McGill University, Montréal, Quebéc, Canada
| | - Rémi Rabasa-Lhoret
- Institut de Recherches Cliniques de Montréal, Montréal, Québec, Canada
- Nutrition Department, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
- Montreal Diabetes Research Center and Endocrinology Division Centre Hospitalier de l’Université de Montréal, Saint-Denis Montréal, Québec, Canada
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6
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Renard E. Automated insulin delivery systems: from early research to routine care of type 1 diabetes. Acta Diabetol 2023; 60:151-161. [PMID: 35994106 DOI: 10.1007/s00592-022-01929-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 06/22/2022] [Indexed: 01/24/2023]
Abstract
Automated insulin delivery (AID) systems, so-called closed-loop systems or artificial pancreas, are based upon the concept of insulin supply driven by blood glucose levels and their variations according to body glucose needs, glucose intakes and insulin action. They include a continuous glucose monitoring device which provides a signal to a control algorithm tuning insulin delivery from an infusion pump. The control algorithm is the key of the system since it commands insulin administration in order to maintain blood glucose in a predefined target range and close to a near-normal glucose level. The last two decades have shown dramatic advances toward the use in free life of AID systems for routine care of type 1 diabetes through step-by-step demonstrations of feasibility, safety and efficacy in successive hospital, transitional and outpatient trials. Because of the constraints of pharmacokinetics and dynamics of subcutaneous insulin delivery, the currently available AID systems are all 'hybrid' or 'semi-automated' insulin delivery systems with a need of meal and exercise announcements in order to anticipate rapid glucose variations through pre-meal bolus or pre-exercise reduction of infusion rate. Nevertheless, these AID systems significantly improve time spent in a near-normal range with a reduction of the risk of hypoglycemia and the mental load of managing diabetes in everyday life, representing a milestone in insulin therapy. Expected progression toward fully automated, further miniaturized and integrated, possibly implantable on long-term and more physiological closed-loop systems paves the way for a functional cure of type 1 diabetes.
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Affiliation(s)
- Eric Renard
- Department of Endocrinology, Diabetes, Nutrition, Montpellier University Hospital, Montpellier, France.
- INSERM Clinical Investigation Centre CIC 1411, Montpellier, France.
- Department of Physiology, Institute of Functional Genomics, CNRS, INSERM, University of Montpellier, Montpellier, France.
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Sherr JL, Heinemann L, Fleming GA, Bergenstal RM, Bruttomesso D, Hanaire H, Holl RW, Petrie JR, Peters AL, Evans M. Automated insulin delivery: benefits, challenges, and recommendations. A Consensus Report of the Joint Diabetes Technology Working Group of the European Association for the Study of Diabetes and the American Diabetes Association. Diabetologia 2023; 66:3-22. [PMID: 36198829 PMCID: PMC9534591 DOI: 10.1007/s00125-022-05744-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/07/2022] [Indexed: 01/15/2023]
Abstract
A technological solution for the management of diabetes in people who require intensive insulin therapy has been sought for decades. The last 10 years have seen substantial growth in devices that can be integrated into clinical care. Driven by the availability of reliable systems for continuous glucose monitoring, we have entered an era in which insulin delivery through insulin pumps can be modulated based on sensor glucose data. Over the past few years, regulatory approval of the first automated insulin delivery (AID) systems has been granted, and these systems have been adopted into clinical care. Additionally, a community of people living with type 1 diabetes has created its own systems using a do-it-yourself approach by using products commercialised for independent use. With several AID systems in development, some of which are anticipated to be granted regulatory approval in the near future, the joint Diabetes Technology Working Group of the European Association for the Study of Diabetes and the American Diabetes Association has created this consensus report. We provide a review of the current landscape of AID systems, with a particular focus on their safety. We conclude with a series of recommended targeted actions. This is the fourth in a series of reports issued by this working group. The working group was jointly commissioned by the executives of both organisations to write the first statement on insulin pumps, which was published in 2015. The original authoring group was comprised by three nominated members of the American Diabetes Association and three nominated members of the European Association for the Study of Diabetes. Additional authors have been added to the group to increase diversity and range of expertise. Each organisation has provided a similar internal review process for each manuscript prior to submission for editorial review by the two journals. Harmonisation of editorial and substantial modifications has occurred at both levels. The members of the group have selected the subject of each statement and submitted the selection to both organisations for confirmation.
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Affiliation(s)
| | | | | | - Richard M Bergenstal
- International Diabetes Center and HealthPartners Institute, Minneapolis, MN, USA
| | - Daniela Bruttomesso
- Unit of Metabolic Diseases, Department of Medicine, University of Padova, Padova, Italy
| | - Hélène Hanaire
- Department of Diabetology, University Hospital of Toulouse, University of Toulouse, Toulouse, France
| | - Reinhard W Holl
- Institute of Epidemiology and Medical Biometry, Central Institute of Biomedical Engineering (ZIBMT), University of Ulm, Ulm, Germany
- German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
| | - John R Petrie
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Anne L Peters
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Mark Evans
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK.
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8
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Sherr JL, Heinemann L, Fleming GA, Bergenstal RM, Bruttomesso D, Hanaire H, Holl RW, Petrie JR, Peters AL, Evans M. Automated Insulin Delivery: Benefits, Challenges, and Recommendations. A Consensus Report of the Joint Diabetes Technology Working Group of the European Association for the Study of Diabetes and the American Diabetes Association. Diabetes Care 2022; 45:3058-3074. [PMID: 36202061 DOI: 10.2337/dci22-0018] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/07/2022] [Indexed: 02/03/2023]
Abstract
A technological solution for the management of diabetes in people who require intensive insulin therapy has been sought for decades. The last 10 years have seen substantial growth in devices that can be integrated into clinical care. Driven by the availability of reliable systems for continuous glucose monitoring, we have entered an era in which insulin delivery through insulin pumps can be modulated based on sensor glucose data. Over the past few years, regulatory approval of the first automated insulin delivery (AID) systems has been granted, and these systems have been adopted into clinical care. Additionally, a community of people living with type 1 diabetes has created its own systems using a do-it-yourself approach by using products commercialized for independent use. With several AID systems in development, some of which are anticipated to be granted regulatory approval in the near future, the joint Diabetes Technology Working Group of the European Association for the Study of Diabetes and the American Diabetes Association has created this consensus report. We provide a review of the current landscape of AID systems, with a particular focus on their safety. We conclude with a series of recommended targeted actions. This is the fourth in a series of reports issued by this working group. The working group was jointly commissioned by the executives of both organizations to write the first statement on insulin pumps, which was published in 2015. The original authoring group was comprised by three nominated members of the American Diabetes Association and three nominated members of the European Association for the Study of Diabetes. Additional authors have been added to the group to increase diversity and range of expertise. Each organization has provided a similar internal review process for each manuscript prior to submission for editorial review by the two journals. Harmonization of editorial and substantial modifications has occurred at both levels. The members of the group have selected the subject of each statement and submitted the selection to both organizations for confirmation.
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Affiliation(s)
| | | | | | | | - Daniela Bruttomesso
- Unit of Metabolic Diseases, Department of Medicine, University of Padova, Padova, Italy
| | - Hélène Hanaire
- Department of Diabetology, University Hospital of Toulouse, University of Toulouse, Toulouse, France
| | - Reinhard W Holl
- Institute of Epidemiology and Medical Biometry, Central Institute of Biomedical Engineering (ZIBMT), University of Ulm, Ulm, Germany.,German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
| | - John R Petrie
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, U.K
| | - Anne L Peters
- Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Mark Evans
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, U.K
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9
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Sanchez-Rangel E, Deajon-Jackson J, Hwang JJ. Pathophysiology and management of hypoglycemia in diabetes. Ann N Y Acad Sci 2022; 1518:25-46. [PMID: 36202764 DOI: 10.1111/nyas.14904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
In the century since the discovery of insulin, diabetes has changed from an early death sentence to a manageable chronic disease. This change in longevity and duration of diabetes coupled with significant advances in therapeutic options for patients has fundamentally changed the landscape of diabetes management, particularly in patients with type 1 diabetes mellitus. However, hypoglycemia remains a major barrier to achieving optimal glycemic control. Current understanding of the mechanisms of hypoglycemia has expanded to include not only counter-regulatory hormonal responses but also direct changes in brain glucose, fuel sensing, and utilization, as well as changes in neural networks that modulate behavior, mood, and cognition. Different strategies to prevent and treat hypoglycemia have been developed, including educational strategies, new insulin formulations, delivery devices, novel technologies, and pharmacologic targets. This review article will discuss current literature contributing to our understanding of the myriad of factors that lead to the development of clinically meaningful hypoglycemia and review established and novel therapies for the prevention and treatment of hypoglycemia.
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Affiliation(s)
- Elizabeth Sanchez-Rangel
- Department of Internal Medicine, Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jelani Deajon-Jackson
- Department of Internal Medicine, Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Janice Jin Hwang
- Department of Internal Medicine, Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut, USA.,Division of Endocrinology, Department of Internal Medicine, University of North Carolina - Chapel Hill, Chapel Hill, North Carolina, USA
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10
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Rodríguez-Sarmiento DL, León-Vargas F, García-Jaramillo M. Artificial pancreas systems: experiences from concept to commercialisation. Expert Rev Med Devices 2022; 19:877-894. [DOI: 10.1080/17434440.2022.2150546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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11
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Ware J, Hovorka R. Closed-loop insulin delivery: update on the state of the field and emerging technologies. Expert Rev Med Devices 2022; 19:859-875. [PMID: 36331211 PMCID: PMC9780196 DOI: 10.1080/17434440.2022.2142556] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 10/28/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Over the last five years, closed-loop insulin delivery systems have transitioned from research-only to real-life use. A number of systems have been commercialized and are increasingly used in clinical practice. Given the rapidity of new developments in the field, understanding the capabilities and key similarities and differences of current systems can be challenging. This review aims to provide an update on the state of the field of closed-loop insulin delivery systems, including emerging technologies. AREAS COVERED We summarize key clinical safety and efficacy evidence of commercial and emerging insulin-only hybrid closed-loop systems for type 1 diabetes. A literature search was conducted and clinical trials using closed-loop systems during free-living conditions were identified to report on safety and efficacy data. We comment on emerging technologies and adjuncts for closed-loop systems, as well as non-technological priorities in closed-loop insulin delivery. EXPERT OPINION Commercial hybrid closed-loop insulin delivery systems are efficacious, consistently improving glycemic control when compared to standard therapy. Challenges remain in widespread adoption due to clinical inertia and the lack of resources to embrace technological developments by health care professionals.
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Affiliation(s)
- Julia Ware
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
- Department of Pediatrics, University of Cambridge, Cambridge, United Kingdom
| | - Roman Hovorka
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
- Department of Pediatrics, University of Cambridge, Cambridge, United Kingdom
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12
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Weinzimer SA, Bailey RJ, Bergenstal RM, Nimri R, Beck RW, Schatz D, Ambler-Osborn L, Schweiger DS, von dem Berge T, Sibayan J, Johnson ML, Calhoun P, Phillip M. A Comparison of Postprandial Glucose Control in the Medtronic Advanced Hybrid Closed-Loop System Versus 670G. Diabetes Technol Ther 2022; 24:573-582. [PMID: 35363054 PMCID: PMC9353997 DOI: 10.1089/dia.2021.0568] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background: We recently reported that use of an "advanced" hybrid closed-loop system reduced hyperglycemia without increasing hypoglycemia compared to a first-generation system. The aim of this analysis was to evaluate whether this improved performance was specifically related to better mealtime glycemic control. Methods: We conducted a secondary analysis of postprandial glycemic control in an open-label, multinational, randomized crossover trial of 112 participants with type 1 diabetes, aged 14-29, of the Medtronic MiniMed™ 670G hybrid closed-loop system (670G) versus the Medtronic advanced hybrid closed-loop (AHCL) system, for 12 weeks each. We compared glycemic and insulin delivery metrics over a 3 h horizon across all meals to assess system performance and outcomes. Results: Overall meal size and premeal insulin on board were similar during run-in and between 670G and AHCL arms. Compared with 670G arm, premeal, peak, and mean glucose levels were numerically lower in the AHCL arm (167 ± 23, 231 ± 23, and 177 ± 20 mg/dL vs. 175 ± 23, 235 ± 23, and 180 ± 19 mg/dL, respectively), with a trend to lower hyperglycemia level 2 in AHCL arm. Adjusting for premeal glucose level, all postmeal outcomes between 670G and AHCL were statistically similar. Prandial insulin delivery also was similar in both treatment arms (21 ± 9 vs. 23 ± 10 U), with a shift in basal/bolus ratio from 28%/71% in 670G arm to 20%/80% in AHCL arm. Conclusions: Reduced hyperglycemia with AHCL compared to 670G was not related to early postprandial glycemic excursions after adjusting for premeal glucose level (<3 h after meal), but likely to later (>3 h) postprandial or overnight improvements. Further refinements to mealtime bolus algorithms and strategies may more optimally control prandial glycemic excursions.
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Affiliation(s)
- Stuart A. Weinzimer
- Department of Pediatrics, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Ryan J. Bailey
- Jaeb Center for Health Research Foundation, Inc., Tampa, Florida, USA
| | - Richard M. Bergenstal
- International Diabetes Center, HealthPartners Institute, Minneapolis, Minnesota, USA
| | - Revital Nimri
- Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL
- Sacker Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Roy W. Beck
- Jaeb Center for Health Research Foundation, Inc., Tampa, Florida, USA
| | - Desmond Schatz
- University of Florida College of Medicine, Gainesville, Florida, USA
| | | | - Darja Smigoc Schweiger
- University Medical Center Ljubljana, University Children's Hospital, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | | | - Judy Sibayan
- Jaeb Center for Health Research Foundation, Inc., Tampa, Florida, USA
| | - Mary L. Johnson
- International Diabetes Center, HealthPartners Institute, Minneapolis, Minnesota, USA
| | - Peter Calhoun
- Jaeb Center for Health Research Foundation, Inc., Tampa, Florida, USA
| | - Moshe Phillip
- Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL
- Sacker Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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13
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Rodríguez-Sarmiento DL, León-Vargas F, Garelli F. Practical constraint definition in safety schemes for artificial pancreas systems. Int J Artif Organs 2022; 45:535-542. [DOI: 10.1177/03913988221095586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: Artificial pancreas systems usually define an insulin-on-board constraint ([Formula: see text]) for safety schemes to limit the insulin infusion and avoid hypoglycemia during the closed-loop performance. Several methods have been proposed with impractical considerations requiring information from the prandial events or complex procedures for ambulatory use. Methods: This paper presents a simple method that consists of two novel rules that allow finding an [Formula: see text] based only on common clinical parameters that do not require patient intervention. The method robustness was evaluated using a control system coupled to a safety layer under demanding scenarios implemented on the FDA-approved simulator for preclinical studies. Results: The method maintains a safe performance, even in the face of interpatient variability, hybrid and fully automatic implementations of an artificial pancreas system, and uncertain settings. Both proposed rules work as effectively or even better and without the patient intervention than other methods that have already been clinically validated. Conclusion: This method can be used to define a constant [Formula: see text] that ensures performance and safety of the control system, even under scenarios with incorrect clinical data. Unlike other methods, this method only requires reliable information that is easily obtained from the patient, such as their total daily dose of insulin or body mass.
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Affiliation(s)
- David L Rodríguez-Sarmiento
- Doctorate in Health Sciences, Universidad Antonio Nariño, Bogotá, Colombia
- Mechanical, Electronics and Biomedical Engineering Faculty, Universidad Antonio Nariño, Bogotá, Colombia
| | - Fabian León-Vargas
- Mechanical, Electronics and Biomedical Engineering Faculty, Universidad Antonio Nariño, Bogotá, Colombia
| | - Fabricio Garelli
- Engineering Faculty, Universidad Nacional de La Plata, Buenos Aires, Argentina
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14
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Tornese G, Carletti C, Giangreco M, Nisticò D, Faleschini E, Barbi E. Carbohydrate Tolerance Threshold for Unannounced Snacks in Children and Adolescents With Type 1 Diabetes Using an Advanced Hybrid Closed-Loop System. Diabetes Care 2022; 45:1486-1488. [PMID: 35522033 PMCID: PMC9210515 DOI: 10.2337/dc21-2643] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 03/28/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To find a carbohydrate (CHO) tolerance threshold for unannounced snacks to avoid the 2 h increase in glycemia (difference between pre- and postmeal blood glucose [ΔBG]) ≥50 mg/dL in advanced hybrid closed-loop (a-HCL) users. RESEARCH DESIGN AND METHODS Fourteen children and adolescents with type 1 diabetes (7 females; mean age [± SD] 14.5 ± 3.6 years), users of the Medtronic MiniMed 780G, participated in the study. For 12 days, they did not perform insulin bolus before breakfasts, with defined different quantities and types of CHO, with or without fats, performing blood glucose (BG) before and 2 h after the meal. RESULTS A cutoff of 19.8 g of total CHO was found to determine a ΔBG of 50 mg/dL. BG never exceeded 250 mg/dL. Mean time in range was ≥70% in the 2 h following each snack. CONCLUSIONS Unannounced snacks of up to 20 g of CHO can avoid ΔBG ≥50 mg/dL in MiniMed 780G users, although unannounced meals of up to 30 g of CHO are safe.
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Affiliation(s)
- Gianluca Tornese
- Institute for Maternal and Child Health - IRCCS "Burlo Garofolo," Trieste, Italy
| | - Claudia Carletti
- Institute for Maternal and Child Health - IRCCS "Burlo Garofolo," Trieste, Italy
| | - Manuela Giangreco
- Institute for Maternal and Child Health - IRCCS "Burlo Garofolo," Trieste, Italy
| | - Daniela Nisticò
- Department of Medical Sciences, University of Trieste, Trieste, Italy
| | - Elena Faleschini
- Institute for Maternal and Child Health - IRCCS "Burlo Garofolo," Trieste, Italy
| | - Egidio Barbi
- Institute for Maternal and Child Health - IRCCS "Burlo Garofolo," Trieste, Italy.,Department of Medical Sciences, University of Trieste, Trieste, Italy
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15
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Fang J, Huang S, Liu F, He G, Li X, Huang X, Chen HJ, Xie X. Semi-Implantable Bioelectronics. NANO-MICRO LETTERS 2022; 14:125. [PMID: 35633391 PMCID: PMC9148344 DOI: 10.1007/s40820-022-00818-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 02/09/2022] [Indexed: 06/15/2023]
Abstract
Developing techniques to effectively and real-time monitor and regulate the interior environment of biological objects is significantly important for many biomedical engineering and scientific applications, including drug delivery, electrophysiological recording and regulation of intracellular activities. Semi-implantable bioelectronics is currently a hot spot in biomedical engineering research area, because it not only meets the increasing technical demands for precise detection or regulation of biological activities, but also provides a desirable platform for externally incorporating complex functionalities and electronic integration. Although there is less definition and summary to distinguish it from the well-reviewed non-invasive bioelectronics and fully implantable bioelectronics, semi-implantable bioelectronics have emerged as highly unique technology to boost the development of biochips and smart wearable device. Here, we reviewed the recent progress in this field and raised the concept of "Semi-implantable bioelectronics", summarizing the principle and strategies of semi-implantable device for cell applications and in vivo applications, discussing the typical methodologies to access to intracellular environment or in vivo environment, biosafety aspects and typical applications. This review is meaningful for understanding in-depth the design principles, materials fabrication techniques, device integration processes, cell/tissue penetration methodologies, biosafety aspects, and applications strategies that are essential to the development of future minimally invasive bioelectronics.
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Affiliation(s)
- Jiaru Fang
- State Key Laboratory of Optoelectronic Materials and Technologies, Guangdong Province Key Laboratory of Display Material and Technology, School of Electronics and Information Technology, Sun Yat-Sen University, Guangzhou, 510006, People's Republic of China
| | - Shuang Huang
- State Key Laboratory of Optoelectronic Materials and Technologies, Guangdong Province Key Laboratory of Display Material and Technology, School of Electronics and Information Technology, Sun Yat-Sen University, Guangzhou, 510006, People's Republic of China
| | - Fanmao Liu
- State Key Laboratory of Optoelectronic Materials and Technologies, Guangdong Province Key Laboratory of Display Material and Technology, School of Electronics and Information Technology, Sun Yat-Sen University, Guangzhou, 510006, People's Republic of China
| | - Gen He
- State Key Laboratory of Optoelectronic Materials and Technologies, Guangdong Province Key Laboratory of Display Material and Technology, School of Electronics and Information Technology, Sun Yat-Sen University, Guangzhou, 510006, People's Republic of China
| | - Xiangling Li
- State Key Laboratory of Optoelectronic Materials and Technologies, Guangdong Province Key Laboratory of Display Material and Technology, School of Electronics and Information Technology, Sun Yat-Sen University, Guangzhou, 510006, People's Republic of China
| | - Xinshuo Huang
- State Key Laboratory of Optoelectronic Materials and Technologies, Guangdong Province Key Laboratory of Display Material and Technology, School of Electronics and Information Technology, Sun Yat-Sen University, Guangzhou, 510006, People's Republic of China
| | - Hui-Jiuan Chen
- State Key Laboratory of Optoelectronic Materials and Technologies, Guangdong Province Key Laboratory of Display Material and Technology, School of Electronics and Information Technology, Sun Yat-Sen University, Guangzhou, 510006, People's Republic of China
| | - Xi Xie
- State Key Laboratory of Optoelectronic Materials and Technologies, Guangdong Province Key Laboratory of Display Material and Technology, School of Electronics and Information Technology, Sun Yat-Sen University, Guangzhou, 510006, People's Republic of China.
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16
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León-Vargas F, Arango Oviedo JA, Luna Wandurraga HJ. Two Decades of Research in Artificial Pancreas: Insights from a Bibliometric Analysis. J Diabetes Sci Technol 2022; 16:434-445. [PMID: 33853377 PMCID: PMC8861788 DOI: 10.1177/19322968211005500] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Artificial pancreas is a well-known research topic devoted to achieving better glycemic outcomes that has been attracting increasing attention over the years. However, there is a lack of systematic, chronological, and synthesizing studies that show the background of the knowledge generation in this field. This study implements a bibliometric analysis to recognize the main documents, type of publications, research categories, countries, keywords, organizations, and authors related to this topic. METHODS Web of Science core collection database was accessed from 2000 to 2020 in order to select high-quality scientific documents based on a specific search query. Bibexcel, MS Excel, Power BI, R-Studio, VOSviewer, and CorText software were used for a descriptive and network analysis based on the local database obtained. Bibliometric parameters as the h-index, frequencies, co-authorship and co-ocurrences were computed. RESULTS A total of 756 documents were included that show a growing scientific production on this topic with an increasing contribution from engineering. Outstanding authors, organizations, and countries were identified. An analysis of trends in research was conducted according to the scientific categories of the Web of Science database to identify the main research interests of the last 2 decades and the emerging areas with greater prominence in the coming years. A keyword network analysis allowed to identify the main stages in the development of the AP research over time. CONCLUSIONS Results reveal a comprehensive background of the knowledge generation for the AP topic during the last 2 decades, which has been strengthened with international collaborations and a remarkable interdisciplinarity between endocrinology and engineering, giving rise to a growing number of research areas over time, where computer science and medical informatics stand out as the main emerging research areas.
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Affiliation(s)
- Fabian León-Vargas
- Universidad Antonio Nariño, Bogotá,
Colombia
- Fabian León-Vargas, PhD, Universidad
Antonio Nariño, Cll 22 Sur # 12D – 81, Bogotá, 111511, Colombia.
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17
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Ware J, Hovorka R. Recent advances in closed-loop insulin delivery. Metabolism 2022; 127:154953. [PMID: 34890648 PMCID: PMC8792215 DOI: 10.1016/j.metabol.2021.154953] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 11/05/2021] [Accepted: 11/24/2021] [Indexed: 02/03/2023]
Abstract
Since the discovery of insulin 100 years ago, we have seen considerable advances across diabetes therapies. The more recent advent of glucose-responsive automated insulin delivery has started to revolutionise the management of type 1 diabetes in children and adults. Evolution of closed-loop insulin delivery from research to clinical practice has been rapid, and multiple systems are now commercially available. In this review, we summarise key evidence on currently available closed-loop systems and those in development. We comment on dual-hormone and do-it-yourself systems, as well as reviewing clinical evidence in special populations such as very young children, older adults and in pregnancy. We identify future directions for research and barriers to closed-loop adoption, including how these might be addressed to ensure equitable access to this novel therapy.
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Affiliation(s)
- Julia Ware
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom; Department of Paediatrics, University of Cambridge, Cambridge, United Kingdom
| | - Roman Hovorka
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom; Department of Paediatrics, University of Cambridge, Cambridge, United Kingdom.
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18
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Templer S. Closed-Loop Insulin Delivery Systems: Past, Present, and Future Directions. Front Endocrinol (Lausanne) 2022; 13:919942. [PMID: 35733769 PMCID: PMC9207329 DOI: 10.3389/fendo.2022.919942] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 05/06/2022] [Indexed: 12/16/2022] Open
Abstract
Closed-loop (artificial pancreas) systems for automated insulin delivery have been likened to the holy grail of diabetes management. The first iterations of glucose-responsive insulin delivery were pioneered in the 1960s and 1970s, with the development of systems that used venous glucose measurements to dictate intravenous infusions of insulin and dextrose in order to maintain normoglycemia. Only recently have these bulky, bedside technologies progressed to miniaturized, wearable devices. These modern closed-loop systems use interstitial glucose sensing, subcutaneous insulin pumps, and increasingly sophisticated algorithms. As the number of commercially available hybrid closed-loop systems has grown, so too has the evidence supporting their efficacy. Future challenges in closed-loop technology include the development of fully closed-loop systems that do not require user input for meal announcements or carbohydrate counting. Another evolving avenue in research is the addition of glucagon to mitigate the risk of hypoglycemia and allow more aggressive insulin dosing.
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19
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Biester T, Tauschmann M, Chobot A, Kordonouri O, Danne T, Kapellen T, Dovc K. The automated pancreas: A review of technologies and clinical practice. Diabetes Obes Metab 2022; 24 Suppl 1:43-57. [PMID: 34658126 DOI: 10.1111/dom.14576] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 10/07/2021] [Accepted: 10/07/2021] [Indexed: 12/12/2022]
Abstract
Insulin pumps and glucose sensors are effective in improving diabetes therapy and reducing acute complications. The combination of both devices using an algorithm-driven interoperable controller makes automated insulin delivery (AID) systems possible. Many AID systems have been tested in clinical trials and have proven safety and effectiveness. However, currently, none of these systems are available for routine use in children younger than 6 years in Europe. For continued use, both users and prescribers must have sound knowledge of the features of the individual AID systems. Presently, all systems require various user interactions (e.g. meal announcements) because fully automated systems are not yet developed. Open-source systems are non-regulated variants to circumvent existing regulatory conditions. There are risks here for both users and prescribers. To evaluate AID therapy, the metric data of the glucose sensors, 'time in target range' and 'glucose management index', are novel recognized and suitable parameters allowing a consultation based on real glucose and insulin pump download data from the daily life of people with diabetes. Read out via cloud-based software or automatic download of such individual treatment data provides the ideal technical basis for shared decision-making through telemedicine, which must be further evaluated for general use.
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Affiliation(s)
- Torben Biester
- AUF DER BULT, Diabetes Center for Children and Adolescents, Hannover, Germany
| | - Martin Tauschmann
- Department of Pediatric and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Agata Chobot
- Department of Pediatrics, Institute of Medical Sciences, University of Opole, Opole, Poland
| | - Olga Kordonouri
- AUF DER BULT, Diabetes Center for Children and Adolescents, Hannover, Germany
| | - Thomas Danne
- AUF DER BULT, Diabetes Center for Children and Adolescents, Hannover, Germany
| | - Thomas Kapellen
- Department of Pediatrics, MEDIAN Clinic for Children 'Am Nicolausholz' Bad Kösen, Naumburg, Germany
| | - Klemen Dovc
- Department of Pediatric Endocrinology, Diabetes and Metabolic Diseases, UMC - University Children's Hospital, Ljubljana, Slovenia and Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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20
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Moon SJ, Jung I, Park CY. Current Advances of Artificial Pancreas Systems: A Comprehensive Review of the Clinical Evidence. Diabetes Metab J 2021; 45:813-839. [PMID: 34847641 PMCID: PMC8640161 DOI: 10.4093/dmj.2021.0177] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 10/24/2021] [Indexed: 12/19/2022] Open
Abstract
Since Banting and Best isolated insulin in the 1920s, dramatic progress has been made in the treatment of type 1 diabetes mellitus (T1DM). However, dose titration and timely injection to maintain optimal glycemic control are often challenging for T1DM patients and their families because they require frequent blood glucose checks. In recent years, technological advances in insulin pumps and continuous glucose monitoring systems have created paradigm shifts in T1DM care that are being extended to develop artificial pancreas systems (APSs). Numerous studies that demonstrate the superiority of glycemic control offered by APSs over those offered by conventional treatment are still being published, and rapid commercialization and use in actual practice have already begun. Given this rapid development, keeping up with the latest knowledge in an organized way is confusing for both patients and medical staff. Herein, we explore the history, clinical evidence, and current state of APSs, focusing on various development groups and the commercialization status. We also discuss APS development in groups outside the usual T1DM patients and the administration of adjunct agents, such as amylin analogues, in APSs.
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Affiliation(s)
- Sun Joon Moon
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Inha Jung
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Cheol-Young Park
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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21
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Daly A, Hartnell S, Boughton CK, Evans M. Hybrid Closed-loop to Manage Gastroparesis in People With Type 1 Diabetes: a Case Series. J Diabetes Sci Technol 2021; 15:1216-1223. [PMID: 34378426 PMCID: PMC8564229 DOI: 10.1177/19322968211035447] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Gastroparesis is associated with unpredictable gastric emptying and can lead to erratic glucose profiles and negative impacts on quality-of-life. Many people with gastroparesis are unable to meet glycemic targets and there is a need for new approaches for this population. Hybrid closed-loop systems improve glucose control and quality-of-life but evidence for their use in people with diabetic gastroparesis is limited. METHODS We present a narrative review of the challenges associated with type 1 diabetes management for people with gastroparesis and present a case series of 7 people with type 1 diabetes and gastroparesis. We compare glycemic control before and during the first 12 months of hybrid closed-loop therapy. Data were analyzed using electronic patient records and glucose management platforms. We also discuss future advancements for closed-loop systems that may benefit this population. RESULTS Five of 7 patients had data available for time in range before and during hybrid closed-loop therapy, and all had an improvement in percentage time in target glucose range, with the overall mean time in range increasing from 26.0% ± 15.7% to 58.4% ± 8.6% during HCL use, (P = .004). There were significant reductions in HbA1c (83 ± 9 mmol/mol to 71 ± 14 mmol/mol) and mean glucose from 13.0 ± 1.7 mmol/L (234 ± 31 mg/dL) to 10.0 ± 0.7 mmol/L (180 ± 13 mg/dL) with use of a hybrid closed-loop system. Importantly, this was achieved without an increase in time in hypoglycemia (P = .50). CONCLUSION Hybrid closed-loop systems may represent a valuable approach to improve glycemic control for people with type 1 diabetes and gastroparesis. Prospective studies are required to confirm these findings.
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Affiliation(s)
- Aideen Daly
- Wellcome Trust-MRC Institute of
Metabolic Science, University of Cambridge, Cambridge, UK
- Aideen Daly, MB BCh, Wellcome Trust-MRC
Institute of Metabolic Science, University of Cambridge, Level 4, Addenbrookes
Hospital, Cambridge, CB2 0QQ, UK.
| | - Sara Hartnell
- Wolfson Diabetes and Endocrine Clinic,
Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Charlotte K. Boughton
- Wellcome Trust-MRC Institute of
Metabolic Science, University of Cambridge, Cambridge, UK
- Wolfson Diabetes and Endocrine Clinic,
Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Mark Evans
- Wellcome Trust-MRC Institute of
Metabolic Science, University of Cambridge, Cambridge, UK
- Wolfson Diabetes and Endocrine Clinic,
Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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22
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Beneyto A, Bequette BW, Vehi J. Fault Tolerant Strategies for Automated Insulin Delivery Considering the Human Component: Current and Future Perspectives. J Diabetes Sci Technol 2021; 15:1224-1231. [PMID: 34286613 PMCID: PMC8655284 DOI: 10.1177/19322968211029297] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Automated Insulin Delivery (AID) are systems developed for daily use by people with type 1 diabetes (T1D). To ensure the safety of users, it is essential to consider how the human factor affects the performance and safety of these devices. While there are numerous publications on hardware-related failures of AID systems, there are few studies on the human component of the system. From a control point of view, people with T1D using AID systems are at the same time the plant to be controlled and the plant operator. Therefore, users may induce faults in the controller, sensors, actuators, and the plant itself. Strategies to cope with the human interaction in AID systems are needed for further development of the technology. In this paper, we present an analysis of potential faults introduced by AID users when the system is under normal operation. This is followed by a review of current fault tolerant control (FTC) approaches to identify missing areas of research. The paper concludes with a discussion on future directions for the new generation of FTC AID systems.
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Affiliation(s)
| | | | - Josep Vehi
- Universitat de Girona, Girona, Spain
- Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas, Madrid, Spain
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23
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The Closed-Loop System Improved the Control of a Pregnant Patient with Type 1 Diabetes Mellitus. Case Rep Endocrinol 2021; 2021:7310176. [PMID: 34594581 PMCID: PMC8478568 DOI: 10.1155/2021/7310176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 09/11/2021] [Indexed: 11/20/2022] Open
Abstract
Objective Closed-loop insulin systems represent a technological advance in diabetes management but have rarely been studied in pregnancy. We report a case of a patient with type 1 diabetes mellitus who was previously a user of the Paradigm VEO pump and then migrated to Medtronic 670G. Research Design and Methods. We reviewed the case of a G1P0 patient with type 1 diabetes, treated with the Medtronic 670G system during pregnancy; a comparison with current literature was done. Results The patient achieved improved glycemic control as measured by time spent in different ranges as follows: <70 mg/dL, 8–4% and 70–180 mg/dL, 83–94%. Secondary outcomes included reduction of stress, anxiety, fear of hypoglycemia, and the psychological burden related to the disease. There were no obstetric or neonatal complications. Conclusion The Medtronic 670G closed-loop system was used safely in a pregnant woman; nevertheless, further research is needed to validate this system in this patient population.
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24
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Tsoukas MA, Majdpour D, Yale JF, Fathi AE, Garfield N, Rutkowski J, Rene J, Legault L, Haidar A. A fully artificial pancreas versus a hybrid artificial pancreas for type 1 diabetes: a single-centre, open-label, randomised controlled, crossover, non-inferiority trial. LANCET DIGITAL HEALTH 2021; 3:e723-e732. [PMID: 34580055 DOI: 10.1016/s2589-7500(21)00139-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 06/14/2021] [Accepted: 06/23/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND For people with type 1 diabetes, there is currently no automated insulin delivery system that does not require meal input. We aimed to assess the efficacy of a novel faster-acting insulin aspart (Fiasp) plus pramlintide fully closed-loop system that does not require meal input. METHODS In this open-label, randomised controlled, crossover, non-inferiority trial we compared the Fiasp (Novo Nordisk, Bagsværd, Denmark) plus pramlintide closed-loop system with no meal input (fully artificial pancreas) and the Fiasp-alone closed-loop system with precise carbohydrate counting (hybrid artificial pancreas). Adults (≥18 years) who had a clinical diagnosis of type 1 diabetes for at least 12 months, had glycated haemoglobin 12% or lower, and had been on insulin pump therapy for at least 6 months were enrolled at McGill University Health Centre, Montreal, QC, Canada. The Fiasp plus pramlintide fully closed-loop system delivered pramlintide in a basal-bolus manner with a fixed ratio of 10 μg:U relative to insulin. A research staff member counted the carbohydrate content of meals to input in the hybrid closed-loop system. Participants completed the two full-day crossover interventions in a random order allocated by a computer-generated code implementing a blocked randomisation (block size of four). The primary outcome was the percentage of time spent within the glucose target range (3·9-10·0 mmol/L), with a 6% non-inferiority margin, assessed in all participants who completed both interventions. This trial is registered with ClinicalTrials.gov, NCT03800875. FINDINGS Between Feb 8, 2019, and Sept 19, 2020, we enrolled 28 adults, of whom 24 completed both interventions and were included in analyses. The percentage of time spent in the target range was 74·3% (IQR 61·5-82·8) with the fully closed-loop system versus 78·1% (66·3-87·5) with the hybrid Fiasp-alone closed-loop system (paired difference 2·6%, 95% CI -2·4 to 12·2; non-inferiority p=0·28). Eight (33%) participants had at least one hypoglycaemia event (<3·3 mmol/L) with the fully closed-loop system compared with 14 (58%) participants with the hybrid closed-loop system (2200-2200 h). Non-mild nausea was reported by three (13%) participants and non-mild bloating by one (4%) participant with the fully closed-loop system compared with zero participants with the hybrid closed-loop system. INTERPRETATION The Fiasp plus pramlintide fully closed-loop system was not non-inferior to the Fiasp-alone hybrid closed-loop system for the overall percentage of time in the glucose target range. However, participants still spent a high percentage of time within the target range with the fully-closed loop system. Outpatient studies comparing the fully closed-loop hybrid systems with patient-estimated, rather than precise, carbohydrate counting are warranted. FUNDING Diabetes Canada.
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Affiliation(s)
- Michael A Tsoukas
- Division of Endocrinology and Metabolism, Royal Victoria Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Dorsa Majdpour
- Department of Biomedical Engineering, McGill University, Montreal, QC, Canada
| | - Jean-François Yale
- Division of Endocrinology and Metabolism, Royal Victoria Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Anas El Fathi
- Department of Biomedical Engineering, McGill University, Montreal, QC, Canada
| | - Natasha Garfield
- Division of Endocrinology and Metabolism, Royal Victoria Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Joanna Rutkowski
- Department of Biomedical Engineering, McGill University, Montreal, QC, Canada
| | - Jennifer Rene
- Department of Biomedical Engineering, McGill University, Montreal, QC, Canada
| | - Laurent Legault
- Division of Endocrinology and Metabolism, Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Ahmad Haidar
- Department of Biomedical Engineering, McGill University, Montreal, QC, Canada.
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25
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Tsoukas MA, Cohen E, Legault L, von Oettingen JE, Yale JF, Vallis M, Odabassian M, El Fathi A, Rutkowski J, Jafar A, Ghanbari M, Gouchie-Provencher N, René J, Palisaitis E, Haidar A. Alleviating carbohydrate counting with a FiASP-plus-pramlintide closed-loop delivery system (artificial pancreas): Feasibility and pilot studies. Diabetes Obes Metab 2021; 23:2090-2098. [PMID: 34047449 DOI: 10.1111/dom.14447] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 05/18/2021] [Accepted: 05/23/2021] [Indexed: 01/07/2023]
Abstract
AIM To assess whether a FiASP-and-pramlintide closed-loop system has the potential to replace carbohydrate counting with a simple meal announcement (SMA) strategy (meal priming bolus without carbohydrate counting) without degrading glycaemic control compared with a FiASP closed-loop system. MATERIALS AND METHODS We conducted a 24-hour feasibility study comparing a FiASP system with full carbohydrate counting (FCC) with a FiASP-and-pramlintide system with SMA. We conducted a subsequent 12-day outpatient pilot study comparing a FiASP-and-placebo system with FCC, a FiASP-and-pramlintide system with SMA, and a FiASP-and-placebo system with SMA. Basal-bolus FiASP-and-pramlintide were delivered at a fixed ratio (1 U:10 μg). Glycaemic outcomes were measured, surveys evaluated gastrointestinal symptoms and diabetes distress, and participant interviews helped establish a preliminary coding framework to assess user experience. RESULTS Seven participants were included in the feasibility analysis. Time spent in 3.9-10 mmol/L was similar between both interventions (81%-84%). Four participants were included in the pilot analysis. Time spent in 3.9-10 mmol/L was similar between the FiASP-and-placebo with FCC and FiASP-and-pramlintide with SMA interventions (70%), but was lower in the FiASP-and-placebo with SMA intervention (60%). Time less than 3.9 mmol/L and gastrointestinal symptoms were similar across all interventions. Emotional distress was moderate at baseline, after the FiASP-and-placebo with FCC and SMA interventions, and fell after the FiASP-and-pramlintide with SMA intervention. SMA reportedly afforded participants flexibility and reduced mealtime concerns. CONCLUSIONS The FiASP-and-pramlintide system has the potential to substitute carbohydrate counting with SMA without degrading glucose control.
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Affiliation(s)
- Michael A Tsoukas
- Division of Endocrinology, McGill University Health Centre, Montreal, Canada
- The Research Institute of McGill University Health Centre, Montreal, Canada
| | - Elisa Cohen
- Division of Experimental Medicine, McGill University, Montreal, Canada
| | - Laurent Legault
- The Research Institute of McGill University Health Centre, Montreal, Canada
- Department of Pediatrics, Division of Pediatric Endocrinology, McGill University Health Centre, Montreal, Canada
| | - Julia E von Oettingen
- The Research Institute of McGill University Health Centre, Montreal, Canada
- Department of Pediatrics, Division of Pediatric Endocrinology, McGill University Health Centre, Montreal, Canada
| | - Jean-François Yale
- Division of Endocrinology, McGill University Health Centre, Montreal, Canada
- The Research Institute of McGill University Health Centre, Montreal, Canada
| | - Michael Vallis
- Department of Family Medicine, Dalhousie University, Halifax, Canada
| | - Madison Odabassian
- Department of Biomedical Engineering, McGill University, Montreal, Canada
| | - Anas El Fathi
- Department of Biomedical Engineering, McGill University, Montreal, Canada
| | - Joanna Rutkowski
- Department of Biomedical Engineering, McGill University, Montreal, Canada
| | - Adnan Jafar
- Department of Biomedical Engineering, McGill University, Montreal, Canada
| | - Milad Ghanbari
- Department of Biomedical Engineering, McGill University, Montreal, Canada
| | | | - Jennifer René
- The Research Institute of McGill University Health Centre, Montreal, Canada
| | - Emilie Palisaitis
- Department of Biomedical Engineering, McGill University, Montreal, Canada
| | - Ahmad Haidar
- The Research Institute of McGill University Health Centre, Montreal, Canada
- Department of Biomedical Engineering, McGill University, Montreal, Canada
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Porcellati F, Di Mauro S, Mazzieri A, Scamporrino A, Filippello A, De Fano M, Fanelli CG, Purrello F, Malaguarnera R, Piro S. Glucagon as a Therapeutic Approach to Severe Hypoglycemia: After 100 Years, Is It Still the Antidote of Insulin? Biomolecules 2021; 11:biom11091281. [PMID: 34572493 PMCID: PMC8464883 DOI: 10.3390/biom11091281] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 08/23/2021] [Accepted: 08/26/2021] [Indexed: 12/11/2022] Open
Abstract
Hypoglycemia represents a dark and tormented side of diabetes mellitus therapy. Patients treated with insulin or drug inducing hypoglycemia, consider hypoglycemia as a harmful element, which leads to their resistance and lack of acceptance of the pathology and relative therapies. Severe hypoglycemia, in itself, is a risk for patients and relatives. The possibility to have novel strategies and scientific knowledge concerning hypoglycemia could represent an enormous benefit. Novel available glucagon formulations, even now, allow clinicians to deal with hypoglycemia differently with respect to past years. Novel scientific evidence leads to advances concerning physiopathological mechanisms that regulated glycemic homeostasis. In this review, we will try to show some of the important aspects of this field.
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Affiliation(s)
- Francesca Porcellati
- Department of Medicine and Surgery, Perugia University School of Medicine, Via Gambuli 1, 06126 Perugia, Italy; (F.P.); (A.M.); (M.D.F.); (C.G.F.)
| | - Stefania Di Mauro
- Department of Clinical and Experimental Medicine, Internal Medicine, Garibaldi-Nesima Hospital, University of Catania, 95122 Catania, Italy; (S.D.M.); (A.S.); (A.F.); (F.P.); (S.P.)
| | - Alessio Mazzieri
- Department of Medicine and Surgery, Perugia University School of Medicine, Via Gambuli 1, 06126 Perugia, Italy; (F.P.); (A.M.); (M.D.F.); (C.G.F.)
| | - Alessandra Scamporrino
- Department of Clinical and Experimental Medicine, Internal Medicine, Garibaldi-Nesima Hospital, University of Catania, 95122 Catania, Italy; (S.D.M.); (A.S.); (A.F.); (F.P.); (S.P.)
| | - Agnese Filippello
- Department of Clinical and Experimental Medicine, Internal Medicine, Garibaldi-Nesima Hospital, University of Catania, 95122 Catania, Italy; (S.D.M.); (A.S.); (A.F.); (F.P.); (S.P.)
| | - Michelantonio De Fano
- Department of Medicine and Surgery, Perugia University School of Medicine, Via Gambuli 1, 06126 Perugia, Italy; (F.P.); (A.M.); (M.D.F.); (C.G.F.)
| | - Carmine Giuseppe Fanelli
- Department of Medicine and Surgery, Perugia University School of Medicine, Via Gambuli 1, 06126 Perugia, Italy; (F.P.); (A.M.); (M.D.F.); (C.G.F.)
| | - Francesco Purrello
- Department of Clinical and Experimental Medicine, Internal Medicine, Garibaldi-Nesima Hospital, University of Catania, 95122 Catania, Italy; (S.D.M.); (A.S.); (A.F.); (F.P.); (S.P.)
| | - Roberta Malaguarnera
- Faculty of Medicine and Surgery, University of Enna “Kore”, 94100 Enna, Italy
- Correspondence: ; Tel.: +39-0935-536577
| | - Salvatore Piro
- Department of Clinical and Experimental Medicine, Internal Medicine, Garibaldi-Nesima Hospital, University of Catania, 95122 Catania, Italy; (S.D.M.); (A.S.); (A.F.); (F.P.); (S.P.)
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Garcia-Tirado J, Diaz JL, Esquivel-Zuniga R, Koravi CLK, Corbett JP, Dawson M, Wakeman C, Barnett CL, Oliveri MC, Myers H, Krauthause K, Breton MD, DeBoer MD. Advanced Closed-Loop Control System Improves Postprandial Glycemic Control Compared With a Hybrid Closed-Loop System Following Unannounced Meal. Diabetes Care 2021; 44:dc210932. [PMID: 34400480 DOI: 10.2337/dc21-0932] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 07/16/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Meals are a major hurdle to glycemic control in type 1 diabetes (T1D). Our objective was to test a fully automated closed-loop control (CLC) system in the absence of announcement of carbohydrate ingestion among adolescents with T1D, who are known to commonly omit meal announcement. RESEARCH DESIGN AND METHODS Eighteen adolescents with T1D (age 15.6 ± 1.7 years; HbA1c 7.4 ± 1.5%; 9 females/9 males) participated in a randomized crossover clinical trial comparing our legacy hybrid CLC system (Unified Safety System Virginia [USS]-Virginia) with a novel fully automated CLC system (RocketAP) during two 46-h supervised admissions (each with one announced and one unannounced dinner), following 2 weeks of data collection. Primary outcome was the percentage time-in-range 70-180 mg/dL (TIR) following the unannounced meal, with secondary outcomes related to additional continuous glucose monitoring-based metrics. RESULTS Both TIR and time-in-tight-range 70-140 mg/dL (TTR) were significantly higher using RocketAP than using USS-Virginia during the 6 h following the unannounced meal (83% [interquartile range 64-93] vs. 53% [40-71]; P = 0.004 and 49% [41-59] vs. 27% [22-36]; P = 0.002, respectively), primarily driven by reduced time-above-range (TAR >180 mg/dL: 17% [1.3-34] vs. 47% [28-60]), with no increase in time-below-range (TBR <70 mg/dL: 0% median for both). RocketAP also improved control following the announced meal (mean difference TBR: -0.7%, TIR: +7%, TTR: +6%), overall (TIR: +5%, TAR: -5%, TTR: +8%), and overnight (TIR: +7%, TTR: +19%, TAR: -5%). RocketAP delivered less insulin overall (78 ± 23 units vs. 85 ± 20 units, P = 0.01). CONCLUSIONS A new fully automated CLC system with automatic prandial dosing was proven to be safe and feasible and outperformed our legacy USS-Virginia in an adolescent population with and without meal announcement.
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Affiliation(s)
- Jose Garcia-Tirado
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | - Jenny L Diaz
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | | | | | - John P Corbett
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | - Martha Dawson
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | - Christian Wakeman
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | | | - Mary C Oliveri
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | - Helen Myers
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | | | - Marc D Breton
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | - Mark D DeBoer
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
- Department of Pediatrics, University of Virginia, Charlottesville, VA
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28
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Maahs DM, Ekhlaspour L, Shalitin S. Diabetes Technology and Therapy in the Pediatric Age Group. Diabetes Technol Ther 2021; 23:S113-S130. [PMID: 34061625 PMCID: PMC8881949 DOI: 10.1089/dia.2021.2508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- David M Maahs
- Department of Pediatrics, Division of Endocrinology and Diabetes, Stanford University, Stanford, CA
- Stanford Diabetes Research Center, Stanford University, Stanford, CA
- Department of Health Research and Policy (Epidemiology), Stanford University, Stanford, CA
| | - Laya Ekhlaspour
- Department of Pediatrics, Division of Endocrinology and Diabetes, Stanford University, Stanford, CA
- Stanford Diabetes Research Center, Stanford University, Stanford, CA
| | - Shlomit Shalitin
- Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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29
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Haidar A, Yale JF, Lovblom LE, Cardinez N, Orszag A, Falappa CM, Gouchie-Provencher N, Tsoukas MA, El Fathi A, Rene J, Eldelekli D, Lanctôt SO, Scarr D, Perkins BA. Reducing the need for carbohydrate counting in type 1 diabetes using closed-loop automated insulin delivery (artificial pancreas) and empagliflozin: A randomized, controlled, non-inferiority, crossover pilot trial. Diabetes Obes Metab 2021; 23:1272-1281. [PMID: 33528904 DOI: 10.1111/dom.14335] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 01/19/2021] [Accepted: 01/23/2021] [Indexed: 12/16/2022]
Abstract
AIM To assess whether adding empagliflozin to closed-loop automated insulin delivery could reduce the need for carbohydrate counting in type 1 diabetes (T1D) without worsening glucose control. MATERIALS AND METHODS In an open-label, crossover, non-inferiority trial, 30 adult participants with T1D underwent outpatient automated insulin delivery interventions with three random sequences of prandial insulin strategy days: carbohydrate counting, simple meal announcement (no carbohydrate counting) and no meal announcement. During each sequence of prandial insulin strategies, participants were randomly assigned empagliflozin (25 mg/day) or not, and crossed over to the comparator. Mean glucose for carbohydrate counting without empagliflozin (control) was compared with no meal announcement with empagliflozin (in the primary non-inferiority comparison) and simple meal announcement with empagliflozin (in the conditional primary non-inferiority comparison). RESULTS Participants were aged 40 ± 15 years, had 27 ± 15 years diabetes duration and HbA1c of 7.6% ± 0.7% (59 ± 8 mmol/mol). The system with no meal announcement and empagliflozin was not non-inferior (and thus reasonably considered inferior) to the control arm (mean glucose 10.0 ± 1.6 vs. 8.5 ± 1.5 mmol/L; non-inferiority p = .94), while simple meal announcement and empagliflozin was non-inferior (8.5 ± 1.4 mmol/L; non-inferiority p = .003). Use of empagliflozin on the background of automated insulin delivery with carbohydrate counting was associated with lower mean glucose, corresponding to a 14% greater time in the target range. While no ketoacidosis was observed, mean fasting ketones levels were higher on empagliflozin (0.22 ± 0.18 vs. 0.13 ± 0.11 mmol/L; p < .001). CONCLUSIONS Empagliflozin added to automated insulin delivery has the potential to eliminate the need for carbohydrate counting and improves glycaemic control in conjunction with carbohydrate counting, but does not allow for the elimination of meal announcement.
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Affiliation(s)
- Ahmad Haidar
- Department of Biomedical Engineering, McGill Universit, Montréal, Québec, Canada
- The Research Institute of McGill University Health Centre, Montréal, Québec, Canada
- Division of Endocrinology, Department of Medicine, McGill University, Montréal, Québec, Canada
| | - Jean-Francois Yale
- The Research Institute of McGill University Health Centre, Montréal, Québec, Canada
- Division of Endocrinology, Department of Medicine, McGill University, Montréal, Québec, Canada
| | - Leif Erik Lovblom
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Nancy Cardinez
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Andrej Orszag
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - C Marcelo Falappa
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | | | - Michael A Tsoukas
- The Research Institute of McGill University Health Centre, Montréal, Québec, Canada
- Division of Endocrinology, Department of Medicine, McGill University, Montréal, Québec, Canada
| | - Anas El Fathi
- Department of Biomedical Engineering, McGill Universit, Montréal, Québec, Canada
| | - Jennifer Rene
- Department of Biomedical Engineering, McGill Universit, Montréal, Québec, Canada
| | - Devrim Eldelekli
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Sebastien O Lanctôt
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Daniel Scarr
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Bruce A Perkins
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
- Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Diabetes Clinical Research Unit, Leadership Sinai Centre for Diabetes, Sinai Health System, Toronto, Ontario, Canada
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30
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Boscari F, Avogaro A. Current treatment options and challenges in patients with Type 1 diabetes: Pharmacological, technical advances and future perspectives. Rev Endocr Metab Disord 2021; 22:217-240. [PMID: 33755854 PMCID: PMC7985920 DOI: 10.1007/s11154-021-09635-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/09/2021] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Federico Boscari
- Department of Medicine, Unit of Metabolic Diseases, University of Padova, Padova, Italy.
| | - Angelo Avogaro
- Department of Medicine, Unit of Metabolic Diseases, University of Padova, Padova, Italy
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31
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Eckstein ML, Weilguni B, Tauschmann M, Zimmer RT, Aziz F, Sourij H, Moser O. Time in Range for Closed-Loop Systems versus Standard of Care during Physical Exercise in People with Type 1 Diabetes: A Systematic Review and Meta-Analysis. J Clin Med 2021; 10:jcm10112445. [PMID: 34072900 PMCID: PMC8198013 DOI: 10.3390/jcm10112445] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 05/26/2021] [Accepted: 05/27/2021] [Indexed: 11/16/2022] Open
Abstract
The aim of this systematic review and meta-analysis was to compare time in range (TIR) (70–180 mg/dL (3.9–10.0 mmol/L)) between fully closed-loop systems (CLS) and standard of care (including hybrid systems) during physical exercise in people with type 1 diabetes (T1D). A systematic literature search was conducted in EMBASE, PubMed, Cochrane Central Register of Controlled Trials, and ISI Web of Science from January 1950 until January 2020. Randomized controlled trials including studies with different CLS were compared against standard of care in people with T1D. The meta-analysis was performed using the random effects model and restricted maximum likelihood estimation method. Six randomized controlled trials involving 153 participants with T1D of all age groups were included. Due to crossover test designs, studies were included repeatedly (a–d) if CLS or physical exercise interventions were different. Applying this methodology increased the comparisons to a total number of 266 participants. TIR was higher with an absolute mean difference (AMD) of 6.18%, 95% CI: 1.99 to 10.38% in favor of CLS. In a subgroup analysis, the AMD was 9.46%, 95% CI: 2.48% to 16.45% in children and adolescents while the AMD for adults was 1.07% 95% CI: −0.81% to 2.96% in favor of CLS. In this systematic review and meta-analysis CLS moderately improved TIR in comparison to standard of care during physical exercise in people with T1D. This effect was particularly pronounced for children and adolescents showing that the use of CLS improved TIR significantly compared to standard of care.
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Affiliation(s)
- Max L. Eckstein
- Division of Exercise Physiology and Metabolism, Department of Sport Science, University of Bayreuth, 95440 Bayreuth, Germany; (M.L.E.); (R.T.Z.)
| | - Benjamin Weilguni
- Interdisciplinary Metabolic Medicine, Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (B.W.); (F.A.); (H.S.)
| | - Martin Tauschmann
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, 1090 Vienna, Austria;
| | - Rebecca T. Zimmer
- Division of Exercise Physiology and Metabolism, Department of Sport Science, University of Bayreuth, 95440 Bayreuth, Germany; (M.L.E.); (R.T.Z.)
| | - Faisal Aziz
- Interdisciplinary Metabolic Medicine, Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (B.W.); (F.A.); (H.S.)
| | - Harald Sourij
- Interdisciplinary Metabolic Medicine, Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (B.W.); (F.A.); (H.S.)
| | - Othmar Moser
- Division of Exercise Physiology and Metabolism, Department of Sport Science, University of Bayreuth, 95440 Bayreuth, Germany; (M.L.E.); (R.T.Z.)
- Interdisciplinary Metabolic Medicine, Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (B.W.); (F.A.); (H.S.)
- Correspondence: ; Tel.: +49-(0)921-55-3465
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Abstract
Advances in diabetes technologies have enabled the development of automated closed-loop insulin delivery systems. Several hybrid closed-loop systems have been commercialised, reflecting rapid transition of this evolving technology from research into clinical practice, where it is gradually transforming the management of type 1 diabetes in children and adults. In this review we consider the supporting evidence in terms of glucose control and quality of life for presently available closed-loop systems and those in development, including dual-hormone closed-loop systems. We also comment on alternative 'do-it-yourself' closed-loop systems. We remark on issues associated with clinical adoption of these approaches, including training provision, and consider limitations of presently available closed-loop systems and areas for future enhancements to further improve outcomes and reduce the burden of diabetes management.
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Affiliation(s)
- Charlotte K Boughton
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Roman Hovorka
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK.
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Abstract
Advances in diabetes technologies have enabled the development of automated closed-loop insulin delivery systems. Several hybrid closed-loop systems have been commercialised, reflecting rapid transition of this evolving technology from research into clinical practice, where it is gradually transforming the management of type 1 diabetes in children and adults. In this review we consider the supporting evidence in terms of glucose control and quality of life for presently available closed-loop systems and those in development, including dual-hormone closed-loop systems. We also comment on alternative 'do-it-yourself' closed-loop systems. We remark on issues associated with clinical adoption of these approaches, including training provision, and consider limitations of presently available closed-loop systems and areas for future enhancements to further improve outcomes and reduce the burden of diabetes management.
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Affiliation(s)
- Charlotte K Boughton
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Roman Hovorka
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK.
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Chintala S, Friedman SH. A Light Activated Glucagon Trimer with Resistance to Fibrillation. ACS Biomater Sci Eng 2021; 7:1506-1514. [PMID: 33703874 DOI: 10.1021/acsbiomaterials.1c00031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
In this work, we have brought the release of glucagon under the control of light. The aim of this approach is to allow minimally invasive, two-hormone control of blood glucose. Glucagon has two major challenges associated with its therapeutic application: (1) the required amount and timing of glucagon release is highly variable, and (2) glucagon rapidly fibrillates in solution, forming aggregates that are inactive. We have developed a light activated glucagon trimer, in which we have joined three glucagon molecules via light cleaved linkers. We demonstrated that this material can be stimulated by light to release glucagon in a predictable manner. In addition, we demonstrated that in the absence of light, the trimer does not form fibrils and thus releases normal unfibrillated glucagon upon irradiation. These qualities make this material ideal for incorporation into a two hormone light-activated artificial pancreas system.
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Affiliation(s)
- Swetha Chintala
- Division of Pharmacology and Pharmaceutical Sciences, School of Pharmacy, University of Missouri-Kansas City, Kansas City, Missouri 64108, United States
| | - Simon H Friedman
- Division of Pharmacology and Pharmaceutical Sciences, School of Pharmacy, University of Missouri-Kansas City, Kansas City, Missouri 64108, United States
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Becker D, Eshmuminov D, Keller R, Mueller M, Bautista Borrego L, Hagedorn C, Duskabilova M, Tibbitt MW, Onder C, Clavien PA, Rudolf von Rohr P, Schuler MJ, Hefti M. Automated Insulin Delivery - Continuous Blood Glucose Control During Ex Situ Liver Perfusion. IEEE Trans Biomed Eng 2021; 68:1399-1408. [DOI: 10.1109/tbme.2020.3033663] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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36
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Majdpour D, Tsoukas MA, Yale JF, El Fathi A, Rutkowski J, Rene J, Garfield N, Legault L, Haidar A. Fully Automated Artificial Pancreas for Adults With Type 1 Diabetes Using Multiple Hormones: Exploratory Experiments. Can J Diabetes 2021; 45:734-742. [PMID: 33888413 DOI: 10.1016/j.jcjd.2021.02.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 02/11/2021] [Accepted: 02/14/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVES A fully automated insulin-pramlintide-glucagon artificial pancreas that alleviates the burden of carbohydrate counting without degrading glycemic control was iteratively enhanced until convergence through pilot experiments on adults with type 1 diabetes. METHODS Nine participants (age, 37±13 years; glycated hemoglobin, 7.7±0.7%) completed two 27-hour interventions: a fully automated multihormone artificial pancreas and a comparator insulin-alone artificial pancreas with carbohydrate counting. The baseline algorithm was a model-predictive controller that administered insulin and pramlintide in a fixed ratio, with boluses triggered by a glucose threshold, and administered glucagon in response to low glucose levels. RESULTS The baseline multihormone dosing algorithm resulted in noninferior time in target range (3.9 to 10.0 mmol/L) (71%) compared with the insulin-alone arm (70%) in 2 participants, with minimal glucagon delivery. The algorithm was modified to deliver insulin and pramlintide more aggressively to increase time in range and maximize the benefits of glucagon. The modified algorithm displayed a similar time in range for the multihormone arm (79%) compared with the insulin-alone arm (83%) in 2 participants, but with undesired glycemic fluctuations. Subsequently, we reduced the glucose threshold that triggers glucagon boluses. This resulted in inferior glycemic control for the multihormone arm (81% vs 91%) in 2 participants. Thereafter, a model-based meal-detection algorithm to deliver insulin and pramlintide boluses closer to mealtimes was added and glucagon was removed. The final dual-hormone system had comparable time in range (81% vs 83%) in the last 3 participants. CONCLUSION The final version of the fully automated system that delivered insulin and pramlintide warrants a randomized controlled trial.
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Affiliation(s)
- Dorsa Majdpour
- Department of Biomedical Engineering, McGill University, Montréal, Québec, Canada; The Research Institute of McGill University Health Centre, Montréal, Québec, Canada
| | - Michael A Tsoukas
- The Research Institute of McGill University Health Centre, Montréal, Québec, Canada; Royal Victoria Hospital, McGill University Health Centre, Montréal, Québec, Canada
| | - Jean-François Yale
- The Research Institute of McGill University Health Centre, Montréal, Québec, Canada; Royal Victoria Hospital, McGill University Health Centre, Montréal, Québec, Canada
| | - Anas El Fathi
- Department of Biomedical Engineering, McGill University, Montréal, Québec, Canada
| | - Joanna Rutkowski
- Department of Biomedical Engineering, McGill University, Montréal, Québec, Canada
| | - Jennifer Rene
- Royal Victoria Hospital, McGill University Health Centre, Montréal, Québec, Canada
| | - Natasha Garfield
- Royal Victoria Hospital, McGill University Health Centre, Montréal, Québec, Canada
| | - Laurent Legault
- The Research Institute of McGill University Health Centre, Montréal, Québec, Canada; Montreal Children's Hospital, McGill University Health Centre, Montréal, Québec, Canada
| | - Ahmad Haidar
- Department of Biomedical Engineering, McGill University, Montréal, Québec, Canada.
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Biester T, Muller I, von dem Berge T, Atlas E, Nimri R, Phillip M, Battelino T, Bratina N, Dovc K, Scheerer MF, Kordonouri O, Danne T. Add-on therapy with dapagliflozin under full closed loop control improves time in range in adolescents and young adults with type 1 diabetes: The DAPADream study. Diabetes Obes Metab 2021; 23:599-608. [PMID: 33217117 DOI: 10.1111/dom.14258] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 11/06/2020] [Accepted: 11/11/2020] [Indexed: 12/13/2022]
Abstract
AIM To investigate the effect of the sodium-glucose co-transporter-2 inhibitor dapagliflozin on glucose levels overnight and during the following day after two unannounced meals under full closed loop (FCL) conditions. MATERIALS AND METHODS For this single-centre, double-blind, randomized, placebo-controlled, cross-over trial, non-obese persons with type 1 diabetes (T1D) were studied twice (10 mg dapagliflozin bid vs. placebo) for 24 hours with two unannounced mixed meal tests 6 hours apart under FCL conditions. Primary outcome was sensor glucose time in range (TIR; 3.9-10 mmol/L). For safety evaluation, ß-hydroxybutyrate (BHB), glucagon, insulin and gastric inhibitory polypeptide were measured. RESULTS Fifteen adolescents (aged 15.4 ± 1.6 years, diabetes duration 10.0 ± 3.4 years, HbA1c 8.4% ± 0.9% [67.7 ± 10.1 mmol/mol]) and 15 young adults (aged 18.7 ± 0.8 years; diabetes duration 12.5 ± 3.6 years; HbA1c 8.3% ± 0.9% [68.5 ± 11.2 mmol/mol]) completed the trial. TIR was significantly higher in the intervention group compared with placebo (68% ± 6% vs. 50% ± 13%; P < .001); nocturnal glucose was significantly lower with dapagliflozin (6.2 ± 0.7 vs. 7.3 ± 1.7 mmol/L; P = .003) without an increase in time at less than 3.9 mmol/L (3.3% ± 6.0% vs 3.1% ± 5.2%; P = .75). Urinary glucose excretion was increased 3-fold using dapagliflozin (149 ± 42 vs. 49 ± 23 g/24 hours) with a total insulin reduction of 22% (39.7 ± 12.7 vs. 30.6 ± 10.4 U; P = .004). No abnormal elevated BHB values were observed. CONCLUSIONS In adolescents and adults with T1D, dapagliflozin significantly increased TIR on average by 259 minutes/day while reducing glycaemic variability during FCL control without any signs of hypoglycaemia or ketosis.
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Affiliation(s)
- Torben Biester
- Diabetes Centre for Children and Adolescents, Kinder und Jugendkrankenhaus, Auf der Bult, Hannover, Germany
| | - Ido Muller
- DreaMed Diabetes Ltd, Petah Tikva, Israel
| | - Thekla von dem Berge
- Diabetes Centre for Children and Adolescents, Kinder und Jugendkrankenhaus, Auf der Bult, Hannover, Germany
| | - Eran Atlas
- DreaMed Diabetes Ltd, Petah Tikva, Israel
| | - Revital Nimri
- The Jesse Z. and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Centre for Childhood Diabetes, Schneider Children's Medical Centre of Israel, Petah Tikva, Israel
| | - Moshe Phillip
- The Jesse Z. and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Centre for Childhood Diabetes, Schneider Children's Medical Centre of Israel, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tadej Battelino
- Department of Paediatric Endocrinology, Diabetes and Metabolic Diseases, UMC - University Children's Hospital, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Natasa Bratina
- Department of Paediatric Endocrinology, Diabetes and Metabolic Diseases, UMC - University Children's Hospital, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Klemen Dovc
- Department of Paediatric Endocrinology, Diabetes and Metabolic Diseases, UMC - University Children's Hospital, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | | | - Olga Kordonouri
- Diabetes Centre for Children and Adolescents, Kinder und Jugendkrankenhaus, Auf der Bult, Hannover, Germany
| | - Thomas Danne
- Diabetes Centre for Children and Adolescents, Kinder und Jugendkrankenhaus, Auf der Bult, Hannover, Germany
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Artificial Pancreas Technology Offers Hope for Childhood Diabetes. Curr Nutr Rep 2021; 10:47-57. [DOI: 10.1007/s13668-020-00347-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2020] [Indexed: 11/26/2022]
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Joseph JI. Review of the Long-Term Implantable Senseonics Continuous Glucose Monitoring System and Other Continuous Glucose Monitoring Systems. J Diabetes Sci Technol 2021; 15:167-173. [PMID: 32345047 PMCID: PMC7783000 DOI: 10.1177/1932296820911919] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The article published by Kevin Cowart in this issue of the Journal of Diabetes Science and Technology (JDST) is a detailed overview of the clinical trial data and analysis used to demonstrate the safety and effectiveness of the Eversense continuous glucose monitoring (CGM) System for regulatory approval and clinical acceptance. The article describes the published study results for safety, accuracy, reliability, ease of insertion/removal, adverse events, and ease of diabetes patient-use for controlling their glucose levels short and long term. The author nicely compares Eversense CGM System safety and performance with the short-term subcutaneous tissue CGM systems being commercialized by Dexcom, Medtronic Diabetes, and Abbott Diabetes. This comparison may help the clinician define which type of patient with diabetes might benefit the most from the long-term implantable CGM system. The majority of studied patients describe a positive experience managing their diabetes with the Eversense CGM System and request implantation of a new sensor 90 or 180 days later.
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Affiliation(s)
- Jeffrey I. Joseph
- Jeffrey I. Joseph, DO, Department of Anesthesiology, Sidney Kimmel Medical College, Jefferson Artificial Pancreas Center, Thomas Jefferson University, 1020 Locust Street, JAH # 565, Philadelphia, PA 19072, USA.
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Alam W, Khan Q, Riaz RA, Akmeliawati R. Arbitrary-order sliding mode-based robust control algorithm for the developing artificial pancreas mechanism. IET Syst Biol 2020; 14:307-313. [PMID: 33399094 PMCID: PMC8687268 DOI: 10.1049/iet-syb.2018.5075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 04/15/2020] [Accepted: 05/27/2020] [Indexed: 11/20/2022] Open
Abstract
In Diabetes Mellitus, the pancreas remains incapable of insulin administration that leads to hyperglycaemia, an escalated glycaemic concentration, which may stimulate many complications. To circumvent this situation, a closed-loop control strategy is much needed for the exogenous insulin infusion in diabetic patients. This closed-loop structure is often termed as an artificial pancreas that is generally established by the employment of different feedback control strategies. In this work, the authors have proposed an arbitrary-order sliding mode control approach for development of the said mechanism. The term, arbitrary, is exercised in the sense of its applicability to any n-order controllable canonical system. The proposed control algorithm affirms the finite-time effective stabilisation of the glucose-insulin regulatory system, at the desired level, with the alleviation of sharp fluctuations. The novelty of this work lies in the sliding manifold that incorporates indirect non-linear terms. In addition, the necessary discontinuous terms are filtered-out once before its employment to the plant, i.e. diabetic patient. The robustness, in the presence of external disturbances, i.e. meal intake is confirmed via rigorous mathematical stability analysis. In addition, the effectiveness of the proposed control strategy is ascertained by comparing the results with the standard literature.
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Affiliation(s)
- Waqar Alam
- Department of Electrical and Computer Engineering, COMSATS University Islamabad, Islamabad, Pakistan
| | - Qudrat Khan
- Center for Advanced Studies in Telecommunications (CAST), COMSATS University Islamabad, Islamabad, Pakistan.
| | - Raja Ali Riaz
- Department of Electrical and Computer Engineering, COMSATS University Islamabad, Islamabad, Pakistan
| | - Rini Akmeliawati
- School of Mechanical Engineering, The University of Adelaide, Adelaide, South Australia 5005, Australia
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Glucose Control During Physical Activity and Exercise Using Closed Loop Technology in Adults and Adolescents with Type 1 Diabetes. Can J Diabetes 2020; 44:740-749. [DOI: 10.1016/j.jcjd.2020.06.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 05/28/2020] [Accepted: 06/01/2020] [Indexed: 12/13/2022]
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Dovc K, Battelino T. Closed-loop insulin delivery systems in children and adolescents with type 1 diabetes. Expert Opin Drug Deliv 2020; 17:157-166. [PMID: 32077342 DOI: 10.1080/17425247.2020.1713747] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Optimal glycemic control remains challenging in children and adolescents with type 1 diabetes due to highly variable day-to-day and night-to-night insulin requirements. This hurdle could be addressed by glucose-responsive insulin delivery based on real-time continuous glucose measurements.Areas covered: This review summaries recent advances of closed-loop systems in children and adolescents with type 1 diabetes, using both single- and dual-hormone closed-loop systems. The main outcomes, proportions of time spent in target range 70-180 mg/dl, and time spent in hypoglycemia below 70 mg/dl, are assessed particularly during unsupervised free-living randomized controlled trials.Expert opinion: Noteworthy and clinically meaningful translation of experimental investigations from controlled in-hospital settings to unrestricted home studies have been achieved over the past years, resulting in the regulatory approval of the first hybrid closed-loop system also in the pediatric population and with several other advanced devices in the pipeline. Large multinational and pivotal clinical trials including broad age populations are underway to facilitate the use of closed-loop systems in routine clinical practice.
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Affiliation(s)
- Klemen Dovc
- Department of Paediatric Endocrinology, Diabetes and Metabolic Diseases, UMC - University Children's Hospital, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Tadej Battelino
- Department of Paediatric Endocrinology, Diabetes and Metabolic Diseases, UMC - University Children's Hospital, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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Galderisi A, Cohen N, Calhoun P, Kraemer K, Breton M, Weinzimer S, Cengiz E. Effect of Afrezza on Glucose Dynamics During HCL Treatment. Diabetes Care 2020; 43:2146-2152. [PMID: 32661108 PMCID: PMC7440894 DOI: 10.2337/dc20-0091] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 06/15/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE A major obstacle in optimizing the performance of closed-loop automated insulin delivery systems has been the delay in insulin absorption and action that results from the subcutaneous (SC) route of insulin delivery leading to exaggerated postmeal hyperglycemic excursions. We aimed to investigate the effect of Afrezza inhaled insulin with ultrafast-in and -out action profile on improving postprandial blood glucose control during hybrid closed-loop (HCL) treatment in young adults with type 1 diabetes. RESEARCH DESIGN AND METHODS We conducted an inpatient, three-way, randomized crossover standardized meal study to assess the efficacy and safety of Afrezza at a low (AL) and a high (AH) dose as compared with a standard SC rapid-acting insulin (aspart) premeal bolus during Diabetes Assistant (DiAs) HCL treatment. Participants received two sequential meals on three study days, and premeal insulin bolus was determined based on home insulin-to-carbohydrate ratio for each meal (rounded up to the closest available Afrezza cartridge dose for AH and down for AL). The primary efficacy outcome was the peak postprandial plasma glucose (PPG) level calculated by pooling data for up to 4 h after the start of each meal. Secondary outcomes included hyperglycemic, hypoglycemic, and euglycemic venous glucose metrics. RESULTS The mean ± SD PPG for the rapid-acting insulin control arm and AH was similar (185 ± 50 mg/dL vs. 195 ± 46 mg/dL, respectively; P = 0.45), while it was higher for meals using AL (208 ± 54 mg/dL, P = 0.04). The AH achieved significantly lower early PPG level than the control arm (30 min; P < 0.001), and improvement in PPG waned at later time points (120 and 180 min; P = 0.02) coinciding with the end of Afrezza glucodynamic action. CONCLUSIONS Afrezza (AH) premeal bolus reduced the early glycemic excursion and improved PPG during HCL compared with aspart premeal bolus. The improvement in PPG was not sustained after the end of Afrezza glucodynamic action at 120 min.
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Affiliation(s)
- Alfonso Galderisi
- Department of Pediatrics, Yale School of Medicine, New Haven, CT .,Department of Women's and Children's Health, University of Padova, Padova, Italy
| | | | | | - Kristen Kraemer
- Department of Pediatrics, Yale School of Medicine, New Haven, CT
| | - Marc Breton
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | - Stuart Weinzimer
- Department of Pediatrics, Yale School of Medicine, New Haven, CT
| | - Eda Cengiz
- Department of Pediatrics, Yale School of Medicine, New Haven, CT.,Bahcesehir University School of Medicine, Istanbul, Turkey
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Dirr EW, Urdaneta ME, Patel Y, Johnson RD, Campbell-Thompson M, Otto KJ. Designing a bioelectronic treatment for Type 1 diabetes: targeted parasympathetic modulation of insulin secretion. BIOELECTRONICS IN MEDICINE 2020; 3:17-31. [PMID: 33169091 PMCID: PMC7604671 DOI: 10.2217/bem-2020-0006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 06/29/2020] [Indexed: 12/31/2022]
Abstract
The pancreas is a visceral organ with exocrine functions for digestion and endocrine functions for maintenance of blood glucose homeostasis. In pancreatic diseases such as Type 1 diabetes, islets of the endocrine pancreas become dysfunctional and normal regulation of blood glucose concentration ceases. In healthy individuals, parasympathetic signaling to islets via the vagus nerve, triggers release of insulin from pancreatic β-cells and glucagon from α-cells. Using electrical stimulation to augment parasympathetic signaling may provide a way to control pancreatic endocrine functions and ultimately control blood glucose. Historical data suggest that cervical vagus nerve stimulation recruits many visceral organ systems. Simultaneous modulation of liver and digestive function along with pancreatic function provides differential signals that work to both raise and lower blood glucose. Targeted pancreatic vagus nerve stimulation may provide a solution to minimizing off-target effects through careful electrode placement just prior to pancreatic insertion.
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Affiliation(s)
- Elliott W Dirr
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL 32611, USA
| | - Morgan E Urdaneta
- Department of Neuroscience, University of Florida, Gainesville, FL 32611, USA
| | - Yogi Patel
- Department of Biomedical Engineering, Georgia Institute of Technology University of Florida, Gainesville, FL 32611, USA
| | - Richard D Johnson
- Department of Neuroscience, University of Florida, Gainesville, FL 32611, USA
- Department of Physiological Sciences, University of Florida, Gainesville, FL 32611, USA
| | - Martha Campbell-Thompson
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL 32611, USA
- Department of Pathology, Immunology, & Laboratory Medicine University of Florida, Gainesville, FL 32611, USA
| | - Kevin J Otto
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL 32611, USA
- Department of Neuroscience, University of Florida, Gainesville, FL 32611, USA
- Department of Neurology, University of Florida, Gainesville, FL 32611, USA
- Department of Materials Science & Engineering, University of Florida, Gainesville, FL 32611, USA
- Department of Electrical & Computer Engineering, University of Florida, Gainesville, FL 32611, USA
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Fuchs J, Hovorka R. Closed-loop control in insulin pumps for type-1 diabetes mellitus: safety and efficacy. Expert Rev Med Devices 2020; 17:707-720. [PMID: 32569476 PMCID: PMC7441745 DOI: 10.1080/17434440.2020.1784724] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 06/16/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Type 1 diabetes is a lifelong disease with high management burden. The majority of people with type 1 diabetes fail to achieve glycemic targets. Algorithm-driven automated insulin delivery (closed-loop) systems aim to address these challenges. This review provides an overview of commercial and emerging closed-loop systems. AREAS COVERED We review safety and efficacy of commercial and emerging hybrid closed-loop systems. A literature search was conducted and clinical trials using day-and-night closed-loop systems during free-living conditions were used to report on safety data. We comment on efficacy where robust randomized controlled trial data for a particular system are available. We highlight similarities and differences between commercial systems. EXPERT OPINION Study data shows that hybrid closed-loop systems are safe and effective, consistently improving glycemic control when compared to standard therapy. While a fully closed-loop system with minimal burden remains the end-goal, these hybrid closed-loop systems have transformative potential in diabetes care.
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Affiliation(s)
- Julia Fuchs
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
| | - Roman Hovorka
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
- Department of Paediatrics, University of Cambridge, Cambridge, United Kingdom
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Abstract
Treatments for type 1 diabetes have advanced significantly over recent years. There are now multiple hybrid closed-loop systems commercially available and additional systems are in development. Challenges remain, however. This review outlines the recent advances in closed-loop systems and outlines the remaining challenges, including post-prandial hyperglycemia and exercise-related dysglycemia.
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Affiliation(s)
- Melanie Jackson
- Division of Endocrinology, Harold Schnitzer Diabetes Health Center, Oregon Health & Science University, Portland, Oregon
| | - Jessica R. Castle
- Division of Endocrinology, Harold Schnitzer Diabetes Health Center, Oregon Health & Science University, Portland, Oregon
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47
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Fabris C, Kovatchev B. The closed‐loop artificial pancreas in 2020. Artif Organs 2020; 44:671-679. [DOI: 10.1111/aor.13704] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 04/06/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Chiara Fabris
- Center for Diabetes Technology University of Virginia Charlottesville VA USA
| | - Boris Kovatchev
- Center for Diabetes Technology University of Virginia Charlottesville VA USA
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Gregory JM, Cherrington AD, Moore DJ. The Peripheral Peril: Injected Insulin Induces Insulin Insensitivity in Type 1 Diabetes. Diabetes 2020; 69:837-847. [PMID: 32312900 PMCID: PMC7171956 DOI: 10.2337/dbi19-0026] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 02/12/2020] [Indexed: 12/13/2022]
Abstract
Insulin resistance is an underappreciated facet of type 1 diabetes that occurs with remarkable consistency and considerable magnitude. Although therapeutic innovations are continuing to normalize dysglycemia, a sizable body of data suggests a second metabolic abnormality-iatrogenic hyperinsulinemia-principally drives insulin resistance and its consequences in this population and has not been addressed. We review this evidence to show that injecting insulin into the peripheral circulation bypasses first-pass hepatic insulin clearance, which leads to the unintended metabolic consequence of whole-body insulin resistance. We propose restructuring insulin therapy to restore the physiological insulin balance between the hepatic portal and peripheral circulations and thereby avoid the complications of life-long insulin resistance. As technology rapidly advances and our ability to ensure euglycemia improves, iatrogenic insulin resistance will become the final barrier to overcome to restore normal physiology, health, and life in type 1 diabetes.
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Affiliation(s)
- Justin M Gregory
- Ian Burr Division of Pediatric Endocrinology and Diabetes, Vanderbilt University School of Medicine, Nashville, TN
| | - Alan D Cherrington
- Department of Molecular Physiology and Biophysics, Vanderbilt University, Nashville, TN
| | - Daniel J Moore
- Ian Burr Division of Pediatric Endocrinology and Diabetes, Vanderbilt University School of Medicine, Nashville, TN
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50
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Abstract
Technological innovations have fundamentally changed diabetes care. Insulin pump use and continuous glucose monitoring are associated with improved glycemic control along with a better quality of life; automated insulin-dosing advisors facilitate and improve decision making. Glucose-responsive automated insulin delivery enables the highest targets for time in range, lowest rate and duration of hypoglycemia, and favorable quality of life. Clear targets for time in ranges and a standard visualization of the data will help the diabetes technology to be used more efficiently. Decision support systems within and integrated cloud environment will further simplify, unify, and improve modern routine diabetes care.
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Affiliation(s)
- Klemen Dovc
- Department of Paediatric Endocrinology, Diabetes and Metabolic Diseases, UMC - University Children's Hospital, University Medical Centre Ljubljana, Bohoriceva 20, Ljubljana SI-1000, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Tadej Battelino
- Department of Paediatric Endocrinology, Diabetes and Metabolic Diseases, UMC - University Children's Hospital, University Medical Centre Ljubljana, Bohoriceva 20, Ljubljana SI-1000, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.
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