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Xu T, Jost E, Messer LH, Cook PF, Forlenza GP, Sankaranarayanan S, Fiesler C, Voida S. "Obviously, Nothing's Gonna Happen in Five Minutes": How Adolescents and Young Adults Infrastructure Resources to Learn Type 1 Diabetes Management. PROCEEDINGS OF THE SIGCHI CONFERENCE ON HUMAN FACTORS IN COMPUTING SYSTEMS. CHI CONFERENCE 2024; 2024:139. [PMID: 38846748 PMCID: PMC11153724 DOI: 10.1145/3613904.3642612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/09/2024]
Abstract
Learning personalized self-management routines is pivotal for people with type 1 diabetes (T1D), particularly early in diagnosis. Context-aware technologies, such as hybrid closed-loop (HCL) insulin pumps, are important tools for diabetes self-management. However, clinicians have observed that practices using these technologies involve significant individual differences. We conducted interviews with 20 adolescents and young adults who use HCL insulin pump systems for managing T1D, and we found that these individuals leverage both technological and non-technological means to maintain situational awareness about their condition. We discuss how these practices serve to infrastructure their self-management routines, including medical treatment, diet, and glucose measurement-monitoring routines. Our study provides insights into adolescents' and young adults' lived experiences of using HCL systems and related technology to manage diabetes, and contributes to a more nuanced understanding of how the HCI community can support the contextualized management of diabetes through technology design.
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Affiliation(s)
- Tian Xu
- Information Science, University of Colorado Boulder, Boulder, Colorado, USA
| | - Emily Jost
- University of Colorado Anschutz, Medical Campus, Aurora, Colorado, USA
| | - Laurel H Messer
- University of Colorado Anschutz, Medical Campus, Aurora, Colorado, USA
| | - Paul F Cook
- University of Colorado Anschutz, Medical Campus, Aurora, Colorado, USA
| | | | | | - Casey Fiesler
- Information Science, University of Colorado Boulder, Boulder, Colorado, USA
| | - Stephen Voida
- Information Science, University of Colorado Boulder, Boulder, Colorado, USA
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Godoi A, Reis Marques I, Padrão EMH, Mahesh A, Hespanhol LC, Riceto Loyola Júnior JE, de Souza IAF, Moreira VCS, Silva CH, Miyawaki IA, Oommen C, Gomes C, Silva AC, Advani K, de Sa JR. Glucose control and psychosocial outcomes with use of automated insulin delivery for 12 to 96 weeks in type 1 diabetes: a meta-analysis of randomised controlled trials. Diabetol Metab Syndr 2023; 15:190. [PMID: 37759290 PMCID: PMC10537468 DOI: 10.1186/s13098-023-01144-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 07/31/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Glycaemic control of Type 1 Diabetes Mellitus (T1DM) remains a challenge due to hypoglycaemic episodes and the burden of insulin self-management. Advancements have been made with the development of automated insulin delivery (AID) devices, yet, previous reviews have only assessed the use of AID over days or weeks, and potential benefits with longer time of AID use in this population remain unclear. METHODS We performed a systematic review and meta-analysis of randomised controlled trials comparing AID (hybrid and fully closed-loop systems) to usual care (sensor augmented pumps, multiple daily insulin injections, continuous glucose monitoring and predictive low-glucose suspend) for adults and children with T1DM with a minimum duration of 3 months. We searched PubMed, Embase, Cochrane Central, and Clinicaltrials.gov for studies published up until April 4, 2023. Main outcomes included time in range 70-180 mg/dL as the primary outcome, and change in HbA1c (%, mmol/mol), glucose variability, and psychosocial impact (diabetes distress, treatment satisfaction and fear of hypoglycaemia) as secondary outcomes. Adverse events included diabetic ketoacidosis (DKA) and severe hypoglycaemia. Statistical analyses were conducted using mean differences and odds ratios. Sensitivity analyses were performed according to age, study duration and type of AID device. The protocol was registered in PROSPERO, CRD42022366710. RESULTS We identified 25 comparisons from 22 studies (six crossover and 16 parallel designs) including a total of 2376 participants (721 in adult studies, 621 in paediatric studies, and 1034 in combined studies) which were eligible for analysis. Use of AID devices ranged from 12 to 96 weeks. Patients using AID had 10.87% higher time in range [95% CI 9.38 to 12.37; p < 0.0001, I2 = 87%) and 0.37% (4.77 mmol/mol) lower HbA1c (95% CI - 0.49% (- 6.39 mmol/mol) to - 0.26 (- 3.14 mmol/mol); p < 0·0001, I2 = 77%]. AID systems decreased night hypoglycaemia, time in hypoglycaemia and hyperglycaemia and improved patient distress, with no increase in the risk of DKA or severe hypoglycaemia. No difference was found regarding treatment satisfaction or fear of hypoglycaemia. Among children, there was no difference in glucose variability or time spent in hypoglycaemia between the use of AID systems or usual care. In sensitivity analyses, results remained consistent with the overall analysis favouring AID. CONCLUSION The use of AID systems over 12 weeks, regardless of technical or clinical differences, improved glycaemic outcomes and diabetes distress without increasing the risk of adverse events in adults and children with T1DM.
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Affiliation(s)
- Amanda Godoi
- Cardiff University School of Medicine, Neuadd Meirionnydd, Cardiff, CF144YS, UK.
| | | | | | | | | | | | | | | | | | | | | | - Cintia Gomes
- Federal University of Santa Maria, Santa Maria, Brazil
| | - Ariadne C Silva
- UniEvangelica University Centre of Anapolis, Anapolis, Brazil
| | | | - Joao Roberto de Sa
- Endocrinology Division, ABC School of Medicine and Federal University of Sao Paulo, Paulista School of Medicine, São Paulo, Brazil
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3
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Lakshman R, Boughton C, Hovorka R. The changing landscape of automated insulin delivery in the management of type 1 diabetes. Endocr Connect 2023; 12:e230132. [PMID: 37289734 PMCID: PMC10448576 DOI: 10.1530/ec-23-0132] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 06/08/2023] [Indexed: 06/10/2023]
Abstract
Automated insulin delivery systems, also known as closed-loop or 'artificial pancreas' systems, are transforming the management of type 1 diabetes. These systems consist of an algorithm which responds to real-time glucose sensor levels by automatically modulating insulin delivery through an insulin pump. We review the rapidly changing landscape of automated insulin-delivery systems over recent decades, from initial prototypes to the different hybrid closed-loop systems commercially available today. We discuss the growing body of clinical trials and real-world evidence demonstrating their glycaemic and psychosocial benefits. We also address future directions in automated insulin delivery such as dual-hormone systems and adjunct therapy as well as the challenges around ensuring equitable access to closed-loop technology.
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Affiliation(s)
- Rama Lakshman
- Wellcome-MRC Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge, UK
| | - Charlotte Boughton
- Wellcome-MRC Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge, UK
- Cambridge University Hospitals NHS Foundation Trust, Wolfson Diabetes and Endocrine Clinic, Cambridge, UK
| | - Roman Hovorka
- Wellcome-MRC Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge, UK
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Michou P, Gkiourtzis N, Christoforidis A, Kotanidou EP, Galli-Tsinopoulou A. The efficacy of automated insulin delivery systems in children and adolescents with Type 1 Diabetes Mellitus: a systematic review and meta-analysis of randomized controlled trials. Diabetes Res Clin Pract 2023; 199:110678. [PMID: 37094750 DOI: 10.1016/j.diabres.2023.110678] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 03/28/2023] [Accepted: 04/18/2023] [Indexed: 04/26/2023]
Abstract
AIMS Insulin administration is the treatment of choice for people with type 1 diabetes mellitus (T1D). Technological advances have led to the development of automated insulin delivery (AID) systems, aiming to optimize the quality of life of patients with T1D. We present a systematic review and meta-analysis of the current literature about the efficacy of AID systems in children and adolescents with T1D. METHODS We conducted a systematic literature search for randomized controlled trials (RCTs) until August 8th, 2022, investigating the efficacy of AID systems in the management of patients <21 years of age with T1D. A priori subgroup and sensitivity analyses based on different settings (free-living settings, type of AID system, parallel group or crossover design) were also conducted. RESULTS In total, 26 RCTs reporting a total of 915 children and adolescents with T1D were included in the meta-analysis. AID systems revealed statistically significant differences in the main outcomes, such as the proportion of time in the target glucose range (3.9-10 mmol/L) (p<0.00001), in hypoglycemia (<3.9 mmol/L) (p=0.003) and mean proportion of HbA1C (p=0.0007) compared to control group. CONCLUSIONS According to the present meta-analysis, AID systems are superior to insulin pump therapy, sensor-augmented pumps and multiple daily insulin injections. Most of the included studies have a high risk of bias because of allocation, blinding of patients and blinding of assessment. Our sensitivity analyses showed that patients <21 years of age with T1D can use AID systems, after proper education, following their daily activities. Further RCTs examining the effect of AID systems on nocturnal hypoglycemia, under free-living settings and studies examining the effect of dual-hormone AID systems are pending.
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Affiliation(s)
- Panagiota Michou
- Program of Postgraduate Studies Adolescent Medicine and Adolescent Health Care, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece, 54124; Department of Pediatrics, Gennimatas General Hospital of Thessaloniki, Thessaloniki, Greece, 54635.
| | - Nikolaos Gkiourtzis
- 4th Department of Pediatrics, Papageorgiou General Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece, 56429.
| | - Athanasios Christoforidis
- 1st Department of Pediatrics, Ippokrateio General Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece, 54643.
| | - Eleni P Kotanidou
- Program of Postgraduate Studies Adolescent Medicine and Adolescent Health Care, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece, 54124; 2nd Department of Pediatrics, AHEPA University General Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece, 54636.
| | - Asimina Galli-Tsinopoulou
- Program of Postgraduate Studies Adolescent Medicine and Adolescent Health Care, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece, 54124; 2nd Department of Pediatrics, AHEPA University General Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece, 54636.
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Bassi M, Franzone D, Dufour F, Strati MF, Scalas M, Tantari G, Aloi C, Salina A, d’Annunzio G, Maghnie M, Minuto N. Automated Insulin Delivery (AID) Systems: Use and Efficacy in Children and Adults with Type 1 Diabetes and Other Forms of Diabetes in Europe in Early 2023. Life (Basel) 2023; 13:783. [PMID: 36983941 PMCID: PMC10053516 DOI: 10.3390/life13030783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 03/07/2023] [Accepted: 03/10/2023] [Indexed: 03/17/2023] Open
Abstract
Type 1 diabetes (T1D) patients' lifestyle and prognosis has remarkably changed over the years, especially after the introduction of insulin pumps, in particular advanced hybrid closed loop systems (AHCL). Emerging data in literature continuously confirm the improvement of glycemic control thanks to the technological evolution taking place in this disease. As stated in previous literature, T1D patients are seen to be more satisfied thanks to the use of these devices that ameliorate not only their health but their daily life routine as well. Limited findings regarding the use of new devices in different age groups and types of patients is their major limit. This review aims to highlight the main characteristics of each Automated Insulin Delivery (AID) system available for patients affected by Type 1 Diabetes Mellitus. Our main goal was to particularly focus on these systems' efficacy and use in different age groups and populations (i.e., children, pregnant women). Recent studies are emerging that demonstrate their efficacy and safety in younger patients and other forms of diabetes.
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Affiliation(s)
- Marta Bassi
- IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, 16126 Genoa, Italy
| | - Daniele Franzone
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, 16126 Genoa, Italy
| | - Francesca Dufour
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, 16126 Genoa, Italy
| | - Marina Francesca Strati
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, 16126 Genoa, Italy
| | - Marta Scalas
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, 16126 Genoa, Italy
| | - Giacomo Tantari
- IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, 16126 Genoa, Italy
| | - Concetta Aloi
- LABSIEM (Laboratory for the Study of Inborn Errors of Metabolism), Pediatric Clinic, IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy
| | - Alessandro Salina
- LABSIEM (Laboratory for the Study of Inborn Errors of Metabolism), Pediatric Clinic, IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy
| | | | - Mohamad Maghnie
- IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, 16126 Genoa, Italy
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Liu Y, Yu Q, Ye L, Yang L, Cui Y. A wearable, minimally-invasive, fully electrochemically-controlled feedback minisystem for diabetes management. LAB ON A CHIP 2023; 23:421-436. [PMID: 36597970 DOI: 10.1039/d2lc00797e] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Diabetes is a chronic disease affecting 10% of the population globally, and can lead to serious damage in the heart, kidneys, eyes, blood vessels or nerves. Commercial artificial closed-loop feedback systems can significantly improve diabetes management and save lives. However, they are large and expensive for users. Here, we demonstrate for the first time a wearable, minimally-invasive, fully electrochemically-controlled feedback minisystem for diabetes management. Both the working principles of the sensor and pump in the feedback system are based on electrochemical reactions. The smart minisystem was constructed based on integrating the thermoplastic polyurethane hollow microneedles with an electrochemical biosensing device on its outer layer and an electrochemical micropump facing the inner layer of the microneedles. The sensing device was constructed based on sputtering thin metal films through a shadow mask and electroplating Prussian blue on the surface of the microneedles, followed by the immobilization of glucose oxidase on the working electrode. The electrochemical micropump was constructed by sputtering the interdigital electrodes, followed by sealing with a thin elastic film, which was further integrated with the inner channels of the microneedles. Both the sensor and the pump were electrically powered. Via being controlled by a printed circuit board, the biosensing device monitored the levels of interstitial glucose continuously to drive the electrochemical pump to deliver insulin intelligently, in order to control blood glucose within the normal range. The closed-loop feedback system was studied for its capability in maintaining the blood glucose levels of diabetic rats under various physiological conditions. The utility of the intelligent feedback system was successfully demonstrated on diabetic rats for controlling the blood glucose levels within the normal range. The minisystem is wearable, small, cost-effective, precise, stable and painless. It is anticipated that this approach opens a new paradigm for the development of closed-loop diabetes minisystems and may lead to a compelling future for diabetes management.
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Affiliation(s)
- Yiqun Liu
- School of Materials Science and Engineering, Peking University, First Hospital Interdisciplinary Research Center, Peking University, Beijing 100871, P.R. China.
| | - Qi Yu
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing 100034, P.R. China.
| | - Le Ye
- Institute of Microelectronics, Peking University, Beijing 100871, P.R. China
| | - Li Yang
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing 100034, P.R. China.
| | - Yue Cui
- School of Materials Science and Engineering, Peking University, First Hospital Interdisciplinary Research Center, Peking University, Beijing 100871, P.R. China.
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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: 18] [Impact Index Per Article: 18.0] [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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Kang SL, Hwang YN, Kwon JY, Kim SM. Effectiveness and safety of a model predictive control (MPC) algorithm for an artificial pancreas system in outpatients with type 1 diabetes (T1D): systematic review and meta-analysis. Diabetol Metab Syndr 2022; 14:187. [PMID: 36494830 PMCID: PMC9733359 DOI: 10.1186/s13098-022-00962-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 12/02/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The purpose of this study was to assess the effectiveness and safety of a model predictive control (MPC) algorithm for an artificial pancreas system in outpatients with type 1 diabetes. METHODS We searched PubMed, EMBASE, Cochrane Central, and the Web of Science to December 2021. The eligibility criteria for study selection were randomized controlled trials comparing artificial pancreas systems (MPC, PID, and fuzzy algorithms) with conventional insulin therapy in type 1 diabetes patients. The heterogeneity of the overall results was identified by subgroup analysis of two factors including the intervention duration (overnight and 24 h) and the follow-up periods (< 1 week, 1 week to 1 month, and > 1 month). RESULTS The meta-analysis included a total of 41 studies. Considering the effect on the percentage of time maintained in the target range between the MPC-based artificial pancreas and conventional insulin therapy, the results showed a statistically significantly higher percentage of time maintained in the target range in overnight use (10.03%, 95% CI [7.50, 12.56] p < 0.00001). When the follow-up period was considered, in overnight use, the MPC-based algorithm showed a statistically significantly lower percentage of time maintained in the hypoglycemic range (-1.34%, 95% CI [-1.87, -0.81] p < 0.00001) over a long period of use (> 1 month). CONCLUSIONS Overnight use of the MPC-based artificial pancreas system statistically significantly improved glucose control while increasing time maintained in the target range for outpatients with type 1 diabetes. Results of subgroup analysis revealed that MPC algorithm-based artificial pancreas system was safe while reducing the time maintained in the hypoglycemic range after an overnight intervention with a long follow-up period (more than 1 month).
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Affiliation(s)
- Su Lim Kang
- Department of Medical Device and Healthcare, Dongguk University-Seoul, 26, Pil-Dong 3-Ga, Seoul, Jung-Gu 04620 Republic of Korea
| | - Yoo Na Hwang
- Department of Medical Device and Healthcare, Dongguk University-Seoul, 26, Pil-Dong 3-Ga, Seoul, Jung-Gu 04620 Republic of Korea
| | - Ji Yean Kwon
- Department of Medical Device and Healthcare, Dongguk University-Seoul, 26, Pil-Dong 3-Ga, Seoul, Jung-Gu 04620 Republic of Korea
| | - Sung Min Kim
- Department of Medical Device and Healthcare, Dongguk University-Seoul, 26, Pil-Dong 3-Ga, Seoul, Jung-Gu 04620 Republic of Korea
- Department of Medical Device Regulatory Science, Dongguk University-Seoul, 26, Pil-dong 3-Ga, Seoul, Jung-Gu 04620 Republic of Korea
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9
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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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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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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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Abstract
First envisioned by early diabetes clinicians, a person-centred approach to care was an aspirational goal that aimed to match insulin therapy to each individual's unique requirements. In the 100 years since the discovery of insulin, this goal has evolved to include personalised approaches to type 1 diabetes diagnosis, treatment, prevention and prediction. These advances have been facilitated by the recognition of type 1 diabetes as an autoimmune disease and by advances in our understanding of diabetes pathophysiology, genetics and natural history, which have occurred in parallel with advancements in insulin delivery, glucose monitoring and tools for self-management. In this review, we discuss how these personalised approaches have improved diabetes care and how improved understanding of pathogenesis and human biology might inform precision medicine in the future.
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Affiliation(s)
- Alice L J Carr
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK.
| | - Carmella Evans-Molina
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, IN, USA
- Center for Diabetes and Metabolic Diseases, Indiana University School of Medicine, Indianapolis, IN, USA
- Herman B. Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN, USA
- Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Richard A Oram
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK.
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13
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Monzon AD, Patton SR, Koren D. Childhood diabetes and sleep. Pediatr Pulmonol 2022; 57:1835-1850. [PMID: 34506691 DOI: 10.1002/ppul.25651] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 07/18/2021] [Accepted: 08/26/2021] [Indexed: 12/18/2022]
Abstract
Sleep modulates glucose metabolism, both in healthy states and in disease. Alterations in sleep duration (insufficient and excessive) and obstructive sleep apnea may have reciprocal ties with obesity, insulin resistance and Type 2 diabetes, as demonstrated by emerging evidence in children and adolescents. Type 1 diabetes is also associated with sleep disturbances due to the influence of wide glycemic fluctuations upon sleep architecture, the need to treat nocturnal hypoglycemia, and the need for glucose monitoring and insulin delivery technologies. In this article, we provide an extensive and critical review on published pediatric literature regarding these topics, reviewing both epidemiologic and qualitative data, and provide an overview of the pathophysiology linking sleep with disorders of glucose homeostasis.
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Affiliation(s)
- Alexandra D Monzon
- Department of Psychology and Applied Behavioral Science, Clinical Child Psychology Program, University of Kansas, Lawrence, Kansas, USA
| | - Susana R Patton
- Department of Biomedical Research, Center for Healthcare Delivery Science, Nemours Children's Health System, Jacksonville, Florida, USA
| | - Dorit Koren
- Department of Pediatrics, Pediatric Endocrinology Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
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14
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Holder M, Kapellen T, Ziegler R, Bürger-Büsing J, Danne T, Dost A, Holl RW, Holterhus PM, Karges B, Kordonouri O, Lange K, Müller S, Raile K, Schweizer R, von Sengbusch S, Stachow R, Wagner V, Wiegand S, Neu A. Diagnosis, Therapy and Follow-Up of Diabetes Mellitus in Children and Adolescents. Exp Clin Endocrinol Diabetes 2022; 130:S49-S79. [PMID: 35913059 DOI: 10.1055/a-1624-3388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Martin Holder
- Klinikum Stuttgart, Olgahospital, Department of Pediatric Endocrinology and Diabetology, Germany
| | - Thomas Kapellen
- Department of Paediatrics and Adolescent Medicine, University Hospital, Leipzig, Germany
| | - Ralph Ziegler
- Practice for Paediatrics and Adolescent Medicine, Focus on Diabetology, Münster, Germany
| | - Jutta Bürger-Büsing
- Association of Diabetic Children and Adolescents, Diabetes Center, Kaiserslautern, Germany
| | - Thomas Danne
- Children's and Youth Hospital Auf der Bult, Hannover, Germany
| | - Axel Dost
- Department of Paediatrics and Adolescent Medicine, University Hospital Jena, Germany
| | - Reinhard W Holl
- Institute for Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Germany
| | - Paul-Martin Holterhus
- Department of General Paediatrics, University Hospital Schleswig-Holstein, Kiel Campus, Germany
| | - Beate Karges
- Endocrinology and Diabetology Section, University Hospital, RWTH Aachen University, Germany
| | - Olga Kordonouri
- Children's and Youth Hospital Auf der Bult, Hannover, Germany
| | - Karin Lange
- Department of Medical Psychology, Hannover Medical School, Hannover, Germany
| | | | - Klemens Raile
- Virchow Hospital, University Medicine, Berlin, Germany
| | - Roland Schweizer
- Department of Pediatrics and Adolescent Medicine, University Hospital Tübingen, Germany
| | - Simone von Sengbusch
- Department of Paediatrics and Adolescent Medicine, University Hospital Schleswig-Holstein, Campus Lübeck, Germany
| | - Rainer Stachow
- Sylt Specialist Hospital for Children and Adolescents, Westerland, Germany
| | - Verena Wagner
- Joint Practice for Paediatrics and Adolescent Medicine, Rostock, Germany
| | | | - Andreas Neu
- Department of Pediatrics and Adolescent Medicine, University Hospital Tübingen, Germany
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15
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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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16
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Rankin D, Kimbell B, Allen JM, Besser REJ, Boughton CK, Campbell F, Elleri D, Fuchs J, Ghatak A, Randell T, Thankamony A, Trevelyan N, Wilinska ME, Hovorka R, Lawton J. Adolescents' Experiences of Using a Smartphone Application Hosting a Closed-loop Algorithm to Manage Type 1 Diabetes in Everyday Life: Qualitative Study. J Diabetes Sci Technol 2021; 15:1042-1051. [PMID: 34261348 PMCID: PMC8411472 DOI: 10.1177/1932296821994201] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Closed-loop technology may help address health disparities experienced by adolescents, who are more likely to have suboptimal glycemic control than other age groups and, because of their age, find diabetes self-management particularly challenging. The CamAPS FX closed-loop has sought to address accessibility and usability issues reported by users of previous prototype systems. It comprises small components and a smartphone app used to: announce meal-time boluses, adjust ("boost" or "ease-off") closed-loop insulin delivery, customize alarms, and review/share data. We explored how using the CamAPS FX platform influences adolescents' self-management practices and everyday lives. METHODS Eighteen adolescents were interviewed after having ≥6 months experience using the closed-loop platform. Data were analyzed thematically. RESULTS Participants reported feeling less burdened and shackled by diabetes because closed-loop components were easier to carry/wear, finger-pricks were not required, the smartphone app provided a discreet and less stigmatizing way of managing diabetes in public, and they were able to customize alarms. Participants also reported checking and reviewing data more regularly, because they did so when using the smartphone for other reasons. Some reported challenges in school settings where use of personal phones was restricted. Participants highlighted how self-management practices were improved because they could easily review glucose data and adjust closed-loop insulin delivery using the "boost" and "ease-off" functions. Some described how using the system resulted in them forgetting about diabetes and neglecting certain tasks. CONCLUSIONS A closed-loop system with small components and control algorithm on a smartphone app can enhance usability and acceptability for adolescents and may help address the health-related disparities experienced by this age group. However, challenges can arise from using a medical app on a device which doubles as a smartphone. TRIAL REGISTRATION Closed Loop From Onset in Type 1 Diabetes (CLOuD); NCT02871089; https://clinicaltrials.gov/ct2/show/NCT02871089.
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Affiliation(s)
- David Rankin
- Usher Institute, Medical School,
University of Edinburgh, UK
- David Rankin, PhD, Usher Institute,
University of Edinburgh, Teviot Place, Edinburgh EH8 9AG, UK.
| | - Barbara Kimbell
- Usher Institute, Medical School,
University of Edinburgh, UK
| | - Janet M. Allen
- Wellcome Trust – Medical Research
Institute of Metabolic Science, University of Cambridge, UK
- Department of Paediatrics, University of
Cambridge, UK
| | - Rachel E. J. Besser
- NIHR Oxford Biomedical Research Centre,
Oxford University Hospitals NHS Foundation Trust, UK
- Department of Paediatrics, University of
Oxford, UK
| | - Charlotte K. Boughton
- Wellcome Trust – Medical Research
Institute of Metabolic Science, University of Cambridge, UK
| | | | | | - Julia Fuchs
- Wellcome Trust – Medical Research
Institute of Metabolic Science, University of Cambridge, UK
- Department of Paediatrics, University of
Cambridge, UK
| | - Atrayee Ghatak
- Alder Hey Children’s NHS Foundation
Trust, Liverpool, UK
| | | | - Ajay Thankamony
- Addenbrookes Hospital, Cambridge
University Hospitals NHS Foundation Trust, UK
| | | | - Malgorzata E. Wilinska
- Wellcome Trust – Medical Research
Institute of Metabolic Science, University of Cambridge, UK
- Department of Paediatrics, University of
Cambridge, UK
| | - Roman Hovorka
- Wellcome Trust – Medical Research
Institute of Metabolic Science, University of Cambridge, UK
- Department of Paediatrics, University of
Cambridge, UK
| | - Julia Lawton
- Usher Institute, Medical School,
University of Edinburgh, UK
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17
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Diagnostik, Therapie und Verlaufskontrolle des Diabetes mellitus im Kindes- und Jugendalter. DIABETOLOGE 2021. [DOI: 10.1007/s11428-021-00769-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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18
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Rilstone S, Reddy M, Oliver N. A Pilot Study of Flat and Circadian Insulin Infusion Rates in Continuous Subcutaneous Insulin Infusion (CSII) in Adults with Type 1 Diabetes (FIRST1D). J Diabetes Sci Technol 2021; 15:666-671. [PMID: 32081036 PMCID: PMC8120055 DOI: 10.1177/1932296820906195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Initiation of continuous subcutaneous insulin therapy (CSII) in type 1 diabetes requires conversion of a basal insulin dose into a continuous infusion regimen. There are limited data to guide the optimal insulin profile to rapidly achieve target glucose and minimize healthcare professional input. The aim of this pilot study was to compare circadian and flat insulin infusion rates in CSII naïve adults with type 1 diabetes. METHODS Adults with type 1 diabetes commencing CSII were recruited. Participants were randomized to circadian or flat basal profile calculated from the total daily dose. Basal rate testing was undertaken on days 7, 14 and 28 and basal rates were adjusted. The primary outcome was the between-group difference in absolute change in insulin basal rate over 24 hours following three rounds of basal testing. Secondary outcomes included the number of basal rate changes and the time blocks. RESULTS Seventeen participants (mean age 33.3 (SD 8.6) years) were recruited. There was no significant difference in absolute change in insulin basal rates between groups (P = .85). The circadian group experienced significant variation in the number of changes made with the most changes in the morning and evening (P = .005). The circadian group received a greater reduction in total insulin (-14.1 (interquartile range (IQR) -22.5-12.95) units) than the flat group (-7.48 (IQR -11.90-1.23) units) (P = .021). CONCLUSION The initial insulin profile does not impact on the magnitude of basal rate changes during optimization. The circadian profile requires changes at specific time points. Further development of the circadian profile may be the optimal strategy.
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Affiliation(s)
- Siân Rilstone
- Department of Nutrition and Dietetics,
Imperial College Healthcare NHS Trust, St Mary’s Hospital, London, UK
- Siân Rilstone, MSc, RD, Department of
Nutrition and Dietetics, Imperial College Healthcare NHS Trust, St Mary’s
Hospital, Praed Street, London W2 1NY, UK.
| | - Monika Reddy
- Diabetes and Endocrinology, Imperial
College Healthcare NHS Trust, St Mary’s Hospital, London, UK
| | - Nick Oliver
- Imperial College London, Hammersmith
Campus, London, UK
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19
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Ye M, Arnold MA. Selectivity and Sensitivity of Near-Infrared Spectroscopic Sensing of β-Hydroxybutyrate, Glucose, and Urea in Ternary Aqueous Solutions. Anal Chem 2021; 93:5586-5595. [PMID: 33760590 DOI: 10.1021/acs.analchem.1c00300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The next-generation artificial pancreas is under development with the goal to enhance tight glycemic control for people with type 1 diabetes. Such technology requires the integration of a chemical sensing unit combined with an insulin infusion device controlled by an algorithm capable of autonomous operation. The potential of near-infrared spectroscopic sensing to serve as the chemical sensing unit is explored by demonstrating the ability to quantify multiple metabolic biomarkers from a single near-infrared spectrum. Independent measurements of β-hydroxy-butyrate, glucose, and urea are presented based on analysis of near-infrared spectra collected over the combination spectral range of 5000-4000 cm-1 for a set of 50 ternary aqueous standard solutions. Spectra are characterized by a 1 μAU root-mean-square (RMS) noise for 100% lines with a resolution of 4 cm-1 and an optical path length of 1 mm. Calibration models created by the net analyte signal (NAS) and the partial least squares (PLS) methods provide selective measurements for each analyte with standard errors of prediction in the upper micromolar concentration range. The NAS method is used to determine both the selectivity and sensitivity for each analyte and their values are consistent with these standard errors of prediction. The NAS method is also used to characterize the background spectral variance associated with instrumental and environmental variations associated with buffer spectra collected over a multiday period.
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Affiliation(s)
- Maosong Ye
- Department of Chemistry, University of Iowa, Iowa City, Iowa 52242, United States
| | - Mark A Arnold
- Department of Chemistry, University of Iowa, Iowa City, Iowa 52242, United States
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20
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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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21
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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: 20] [Impact Index Per Article: 5.0] [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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22
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Boughton C, Allen JM, Tauschmann M, Hartnell S, Wilinska ME, Musolino G, Acerini CL, Dunger PD, Campbell F, Ghatak A, Randell T, Besser R, Trevelyan N, Elleri D, Northam E, Hood K, Scott E, Lawton J, Roze S, Sibayan J, Kollman C, Cohen N, Todd J, Hovorka R. Assessing the effect of closed-loop insulin delivery from onset of type 1 diabetes in youth on residual beta-cell function compared to standard insulin therapy (CLOuD study): a randomised parallel study protocol. BMJ Open 2020; 10:e033500. [PMID: 32169925 PMCID: PMC7069267 DOI: 10.1136/bmjopen-2019-033500] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Management of newly diagnosed type 1 diabetes (T1D) in children and adolescents is challenging for patients, families and healthcare professionals. The objective of this study is to determine whether continued intensive metabolic control using hybrid closed-loop (CL) insulin delivery following diagnosis of T1D can preserve C-peptide secretion, a marker of residual beta-cell function, compared with standard multiple daily injections (MDI) therapy. METHODS AND ANALYSIS The study adopts an open-label, multicentre, randomised, parallel design, and aims to randomise 96 participants aged 10-16.9 years, recruited within 21 days of diagnosis with T1D. Following a baseline mixed meal tolerance test (MMTT), participants will be randomised to receive 24 months treatment with conventional MDI therapy or with CL insulin delivery. A further 24-month optional extension phase will be offered to all participants to continue with the allocated treatment. The primary outcome is the between group difference in area under the stimulated C-peptide curve (AUC) of the MMTT at 12 months post diagnosis. Analyses will be conducted on an intention-to-treat basis. Key secondary outcomes are between group differences in time spent in target glucose range (3.9-10 mmol/L), glycated haemoglobin (HbA1c) and time spent in hypoglycaemia (<3.9 mmol/L) at 12 months. Secondary efficacy outcomes include between group differences in stimulated C-peptide AUC at 24 months, time spent in target glucose range, glucose variability, hypoglycaemia and hyperglycaemia as recorded by periodically applied masked continuous glucose monitoring devices, total, basal and bolus insulin dose, and change in body weight. Cognitive, emotional and behavioural characteristics of participants and parents will be evaluated, and a cost-utility analysis performed to support adoption of CL as a standard treatment modality following diagnosis of T1D. ETHICS AND DISSEMINATION Ethics approval has been obtained from Cambridge East Research Ethics Committee. The results will be disseminated by peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER NCT02871089; Pre-results.
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Affiliation(s)
- Charlotte Boughton
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Janet M Allen
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Martin Tauschmann
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Sara Hartnell
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Malgorzata E Wilinska
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Gianluca Musolino
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Carlo L Acerini
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | | | - Fiona Campbell
- Children's Diabetes Centre, Leeds Children's Hospital, Leeds, UK
| | - Atrayee Ghatak
- Department of Diabetes, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Tabitha Randell
- Department of Paediatric Diabetes and Endocrinology, Nottingham Children's Hospital, Nottingham, UK
| | - Rachel Besser
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Nicola Trevelyan
- Paediatric Diabetes, Southampton Children's Hospital, Southampton, UK
| | - Daniela Elleri
- Department of Diabetes, Royal Hospital for Sick Children, Edinburgh, UK
| | - Elizabeth Northam
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Korey Hood
- Endocrinology, Stanford University School of Medicine, Stanford, California, USA
| | - Eleanor Scott
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Julia Lawton
- The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | | | - Judy Sibayan
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - Craig Kollman
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - Nate Cohen
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - John Todd
- Wellcome Trust Centre for Human Genetics, Oxford, UK
| | - Roman Hovorka
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
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23
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Abstract
The advent of insulin pump therapy marked an important milestone in diabetes treatment in the past few decades and has become the tipping point for the development of automated insulin delivery systems (AID). Standalone insulin pump systems have evolved over the course of years and have been replaced by modern high-technology insulin pumps with continuous glucose monitor interface allowing real-time insulin dose adjustment to optimize treatment. This review summarizes evidence from AID studies conducted in children with type 1 diabetes and discusses the outlook for future generation AID systems from a pediatric treatment perspective.
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Affiliation(s)
- Eda Cengiz
- Yale School of Medicine, 333 Cedar Street, PO Box 208064, New Haven, CT 06520, USA; Bahçeşehir Üniversitesi, Istanbul, Turkey.
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24
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Dubey SK, Alexander A, Pradhyut KS, Agrawal M, Jain R, Saha RN, Singhvi G, Saraf S, Saraf S. Recent Avenues in Novel Patient-Friendly Techniques for the Treatment of Diabetes. Curr Drug Deliv 2020; 17:3-14. [DOI: 10.2174/1567201816666191106102020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 09/14/2019] [Accepted: 10/15/2019] [Indexed: 12/26/2022]
Abstract
Background:
Diabetes is one of the most common chronic metabolic disorders which affect
the quality of human life worldwide. As per the WHO report, between 1980 to 2014, the number of
diabetes patients increases from 108 million to 422 million, with a global prevalence rate of 8.5% per
year. Diabetes is the prime reason behind various other diseases like kidney failure, stroke, heart disorders,
glaucoma, etc. It is recognized as the seventh leading cause of death throughout the world. The
available therapies are painful (insulin injections) and inconvenient due to higher dosing frequency.
Thus, to find out a promising and convenient treatment, extensive investigations are carried out globally
by combining novel carrier system (like microparticle, microneedle, nanocarrier, microbeads etc.) and
delivery devices (insulin pump, stimuli-responsive device, inhalation system, bioadhesive patch, insulin
pen etc.) for more precise diagnosis and painless or less invasive treatment of disease.
Objective:
The review article is made with an objective to compile information about various upcoming
and existing modern technologies developed to provide greater patient compliance and reduce the undesirable
side effect of the drug. These devices evade the necessity of daily insulin injection and offer a
rapid onset of action, which sustained for a prolonged duration of time to achieve a better therapeutic
effect.
Conclusion:
Despite numerous advantages, various commercialized approaches, like Afrezza (inhalation
insulin) have been a failure in recent years. Such results call for more potential work to develop a
promising system. The novel approaches range from the delivery of non-insulin blood glucose lowering
agents to insulin-based therapy with minimal invasion are highly desirable.
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Affiliation(s)
- Sunil Kumar Dubey
- Department of Pharmacy, Faculty of Pharmacy, Birla Institute of Technology and Science, Pilani (BITS-PILANI), Pilani Campus, Rajasthan, India
| | - Amit Alexander
- Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research (NIPER GUWAHATI), Ministry of Chemicals & Fertilizers, Govt. of India, NH 37, NITS Mirza, Kamrup- 781125, Guwahati (Assam), India
| | - K. Sai Pradhyut
- Department of Pharmacy, Faculty of Pharmacy, Birla Institute of Technology and Science, Pilani (BITS-PILANI), Pilani Campus, Rajasthan, India
| | - Mukta Agrawal
- Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research (NIPER GUWAHATI), Ministry of Chemicals & Fertilizers, Govt. of India, NH 37, NITS Mirza, Kamrup- 781125, Guwahati (Assam), India
| | - Rupesh Jain
- Department of Pharmacy, Faculty of Pharmacy, Birla Institute of Technology and Science, Pilani (BITS-PILANI), Pilani Campus, Rajasthan, India
| | - Ranendra Narayana Saha
- Department of Biotechnology, Faculty of Biotechnology, Birla Institute of Technology and Science, Pilani (BITS-PILANI), Dubai Campus, Dubai, United Arab Emirates
| | - Gautam Singhvi
- Department of Pharmacy, Faculty of Pharmacy, Birla Institute of Technology and Science, Pilani (BITS-PILANI), Pilani Campus, Rajasthan, India
| | - Swarnlata Saraf
- University Institute of Pharmacy, Pt. Ravishankar Shukla University, Raipur, Chhattisgarh 492 010, India
| | - Shailendra Saraf
- University Institute of Pharmacy, Pt. Ravishankar Shukla University, Raipur, Chhattisgarh 492 010, India
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25
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Lal RA, Ekhlaspour L, Hood K, Buckingham B. Realizing a Closed-Loop (Artificial Pancreas) System for the Treatment of Type 1 Diabetes. Endocr Rev 2019; 40:1521-1546. [PMID: 31276160 PMCID: PMC6821212 DOI: 10.1210/er.2018-00174] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 02/28/2019] [Indexed: 01/20/2023]
Abstract
Recent, rapid changes in the treatment of type 1 diabetes have allowed for commercialization of an "artificial pancreas" that is better described as a closed-loop controller of insulin delivery. This review presents the current state of closed-loop control systems and expected future developments with a discussion of the human factor issues in allowing automation of glucose control. The goal of these systems is to minimize or prevent both short-term and long-term complications from diabetes and to decrease the daily burden of managing diabetes. The closed-loop systems are generally very effective and safe at night, have allowed for improved sleep, and have decreased the burden of diabetes management overnight. However, there are still significant barriers to achieving excellent daytime glucose control while simultaneously decreasing the burden of daytime diabetes management. These systems use a subcutaneous continuous glucose sensor, an algorithm that accounts for the current glucose and rate of change of the glucose, and the amount of insulin that has already been delivered to safely deliver insulin to control hyperglycemia, while minimizing the risk of hypoglycemia. The future challenge will be to allow for full closed-loop control with minimal burden on the patient during the day, alleviating meal announcements, carbohydrate counting, alerts, and maintenance. The human factors involved with interfacing with a closed-loop system and allowing the system to take control of diabetes management are significant. It is important to find a balance between enthusiasm and realistic expectations and experiences with the closed-loop system.
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Affiliation(s)
- Rayhan A Lal
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California.,Division of Endocrinology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Laya Ekhlaspour
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Korey Hood
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California.,Department of Psychiatry, Stanford University School of Medicine, Stanford, California
| | - Bruce Buckingham
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
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26
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Lefkovits Y, Stewart Z, Murphy H. Using the Novel Approach of an Artificial Pancreas to Manage Type 1 Diabetes Mellitus in Pregnancy. EUROPEAN MEDICAL JOURNAL 2019. [DOI: 10.33590/emj/10312967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Recent National Institute for Health and Care Excellence (NICE) guidelines suggest that insulin pump therapy should be used in pregnant women with Type 1 diabetes mellitus (T1DM) who do not achieve optimal glycaemic control with multiple daily injection (MDI) therapy. Furthermore, a landmark trial has confirmed that prospective continuous glucose monitoring (CGM) may be beneficial for women using both MDI and insulin pumps during pregnancy, with positive effects on neonatal outcomes. More recently, overnight use of an artificial pancreas (AP) with a model-predictive control algorithm has been shown to improve the amount of time women spend within the overnight glucose target range (3.5–7.8 mmol/L) during pregnancy. However, preliminary studies where the AP is used day and night have shown a high degree of interindividual variability in response to the intervention, and further randomised trials are needed to understand which women are suitable candidates for CGM, insulin pump, and AP technology. It is understood that improvements in maternal glycaemic control can minimise the risk of adverse neonatal outcomes. Given the substantial improvements in glycaemic control with AP use outside of pregnancy, the recent advances in AP technology provide hope that AP systems will improve the effectiveness of continuous subcutaneous insulin infusion and CGM during pregnancy. Further research is needed to evaluate whether AP can optimise glucose control and neonatal outcomes in T1DM pregnancy. This paper will discuss emerging technologies available for the management of T1DM in pregnancy.
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Affiliation(s)
- Yael Lefkovits
- Monash University, Melbourne, Australia; University of Cambridge, Cambridge, UK
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27
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Musolino G, Allen JM, Hartnell S, Wilinska ME, Tauschmann M, Boughton C, Campbell F, Denvir L, Trevelyan N, Wadwa P, DiMeglio L, Buckingham BA, Weinzimer S, Acerini CL, Hood K, Fox S, Kollman C, Sibayan J, Borgman S, Cheng P, Hovorka R. Assessing the efficacy, safety and utility of 6-month day-and-night automated closed-loop insulin delivery under free-living conditions compared with insulin pump therapy in children and adolescents with type 1 diabetes: an open-label, multicentre, multinational, single-period, randomised, parallel group study protocol. BMJ Open 2019; 9:e027856. [PMID: 31164368 PMCID: PMC6561428 DOI: 10.1136/bmjopen-2018-027856] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 04/20/2019] [Accepted: 04/24/2019] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Closed-loop systems titrate insulin based on sensor glucose levels, providing novel means to reduce the risk of hypoglycaemia while improving glycaemic control. We will assess effectiveness of 6-month day-and-night closed-loop insulin delivery compared with usual care (conventional or sensor-augmented pump therapy) in children and adolescents with type 1 diabetes. METHODS AND ANALYSIS The trial adopts an open-label, multicentre, multinational (UK and USA), randomised, single-period, parallel design. Participants (n=130) are children and adolescents (aged ≥6 and <19 years) with type 1 diabetes for at least 1 year, and insulin pump use for at least 3 months with suboptimal glycaemic control (glycated haemoglobin ≥58 mmol/mol (7.5%) and ≤86 mmol/mol (10%)). After a 2-3 week run-in period, participants will be randomised to 6-month use of hybrid closed-loop insulin delivery, or to usual care. Analyses will be conducted on an intention-to-treat basis. The primary outcome is glycated haemoglobin at 6 months. Other key endpoints include time in the target glucose range (3.9-10 mmol/L, 70-180 mg/dL), mean sensor glucose and time spent above and below target. Secondary outcomes include SD and coefficient of variation of sensor glucose levels, time with sensor glucose levels <3.5 mmol/L (63 mg/dL) and <3.0 mmol/L (54 mg/dL), area under the curve of glucose <3.5 mmol/L (63 mg/dL), time with glucose levels >16.7 mmol/L (300 mg/dL), area under the curve of glucose >10.0 mmol/L (180 mg/dL), total, basal and bolus insulin dose, body mass index z-score and blood pressure. Cognitive, emotional and behavioural characteristics of participants and caregivers and their responses to the closed-loop and clinical trial will be assessed. An incremental cost-effectiveness ratio for closed-loop will be estimated. ETHICS AND DISSEMINATION Cambridge South Research Ethics Committee and Jaeb Center for Health Research Institutional Review Office approved the study. The findings will be disseminated by peer-review publications and conference presentations. TRIAL REGISTRATION NUMBER NCT02925299; Pre-results.
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Affiliation(s)
- Gianluca Musolino
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Janet M Allen
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Sara Hartnell
- Department of Diabetes and Endocrinology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Malgorzata E Wilinska
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Martin Tauschmann
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Charlotte Boughton
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Fiona Campbell
- Department of Paediatric Diabetes, Leeds Children’s Hospital, Leeds, UK
| | - Louise Denvir
- Department of Paediatric Diabetes and Endocrinology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Nicola Trevelyan
- Department of Paediatric Endocrinology and Diabetes, Southampton Children’s Hospital, Southampton General Hospital, Southampton, UK
| | - Paul Wadwa
- Barbara Davis Center for Childhood Diabetes, University of Colorado, Aurora, Colorado, USA
| | - Linda DiMeglio
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetology, Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Bruce A Buckingham
- Division of Pediatric Endocrinology, Stanford University, Stanford, California, USA
| | - Stuart Weinzimer
- Department of Pediatrics, Yale University, New Haven, Connecticut, USA
| | - Carlo L Acerini
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Korey Hood
- Division of Pediatric Endocrinology, Stanford University, Stanford, California, USA
| | - Steven Fox
- Department of Pharmaceutical and Health Economics, School of Pharmacy, University of Southern California, Los Angeles, California, USA
| | - Craig Kollman
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - Judy Sibayan
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - Sarah Borgman
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - Peiyao Cheng
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - Roman Hovorka
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Department of Paediatrics, University of Cambridge, Cambridge, UK
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Abstract
Over the past 50 years, the diabetes technology field progressed remarkably through self-monitoring of blood glucose (SMBG), continuous subcutaneous insulin infusion (CSII), risk and variability analysis, mathematical models and computer simulation of the human metabolic system, real-time continuous glucose monitoring (CGM), and control algorithms driving closed-loop control systems known as the "artificial pancreas" (AP). This review follows these developments, beginning with an overview of the functioning of the human metabolic system in health and in diabetes and of its detailed quantitative network modeling. The review continues with a brief account of the first AP studies that used intravenous glucose monitoring and insulin infusion, and with notes about CSII and CGM-the technologies that made possible the development of contemporary AP systems. In conclusion, engineering lessons learned from AP research, and the clinical need for AP systems to prove their safety and efficacy in large-scale clinical trials, are outlined.
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Affiliation(s)
- Boris Kovatchev
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia 22908
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Anderson SM, Dassau E, Raghinaru D, Lum J, Brown SA, Pinsker JE, Church MM, Levy C, Lam D, Kudva YC, Buckingham B, Forlenza GP, Wadwa RP, Laffel L, Doyle FJ, DeVries JH, Renard E, Cobelli C, Boscari F, Del Favero S, Kovatchev BP. The International Diabetes Closed-Loop Study: Testing Artificial Pancreas Component Interoperability. Diabetes Technol Ther 2019; 21:73-80. [PMID: 30649925 PMCID: PMC6354594 DOI: 10.1089/dia.2018.0308] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Use of artificial pancreas (AP) requires seamless interaction of device components, such as continuous glucose monitor (CGM), insulin pump, and control algorithm. Mobile AP configurations also include a smartphone as computational hub and gateway to cloud applications (e.g., remote monitoring and data review and analysis). This International Diabetes Closed-Loop study was designed to demonstrate and evaluate the operation of the inControl AP using different CGMs and pump modalities without changes to the user interface, user experience, and underlying controller. METHODS Forty-three patients with type 1 diabetes (T1D) were enrolled at 10 clinical centers (7 United States, 3 Europe) and 41 were included in the analyses (39% female, >95% non-Hispanic white, median T1D duration 16 years, median HbA1c 7.4%). Two CGMs and two insulin pumps were tested by different study participants/sites using the same system hub (a smartphone) during 2 weeks of in-home use. RESULTS The major difference between the system components was the stability of their wireless connections with the smartphone. The two sensors achieved similar rates of connectivity as measured by percentage time in closed loop (75% and 75%); however, the two pumps had markedly different closed-loop adherence (66% vs. 87%). When connected, all system configurations achieved similar glycemic outcomes on AP control (73% [mean] time in range: 70-180 mg/dL, and 1.7% [median] time <70 mg/dL). CONCLUSIONS CGMs and insulin pumps can be interchangeable in the same Mobile AP system, as long as these devices achieve certain levels of reliability and wireless connection stability.
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Affiliation(s)
- Stacey M. Anderson
- Center for Diabetes Technology, Department of Medicine, University of Virginia
- Address correspondence to: Stacey M. Anderson, MD, Center for Diabetes Technology, Department of Medicine, University of Virginia, PO Box 400888, Charlottesville, VA 22903
| | - Eyal Dassau
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts
- Sansum Diabetes Research Institute, Santa Barbara, California
- Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts
| | | | - John Lum
- Jaeb Center for Health Research, Tampa, Florida
| | - Sue A. Brown
- Center for Diabetes Technology, Department of Medicine, University of Virginia
| | | | - Mei Mei Church
- Sansum Diabetes Research Institute, Santa Barbara, California
| | - Carol Levy
- Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - David Lam
- Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Yogish C. Kudva
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Bruce Buckingham
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Gregory P. Forlenza
- Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - R. Paul Wadwa
- Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Lori Laffel
- Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts
| | - Francis J. Doyle
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts
| | - J. Hans DeVries
- Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Eric Renard
- Department of Endocrinology, Diabetes, Nutrition, Montpellier University Hospital, Montpellier, France
- INSERM 1411 Clinical Investigation Center, Institute of Functional Genomics, UMR CNRS 5203/INSERM U1191, University of Montpellier, Montpellier, France
| | - Claudio Cobelli
- Department of Information Engineering, University of Padova, Padova, Italy
| | | | - Simone Del Favero
- Department of Information Engineering, University of Padova, Padova, Italy
| | - Boris P. Kovatchev
- Center for Diabetes Technology, Department of Medicine, University of Virginia
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30
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Karageorgiou V, Papaioannou TG, Bellos I, Alexandraki K, Tentolouris N, Stefanadis C, Chrousos GP, Tousoulis D. Effectiveness of artificial pancreas in the non-adult population: A systematic review and network meta-analysis. Metabolism 2019; 90:20-30. [PMID: 30321535 DOI: 10.1016/j.metabol.2018.10.002] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 09/20/2018] [Accepted: 10/09/2018] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Artificial pancreas is a technology that minimizes user input by bridging continuous glucose monitoring and insulin pump treatment, and has proven safety in the adult population. The purpose of this systematic review and meta-analysis is to evaluate the efficacy of closed-loop (CL) systems in the glycemic control of non-adult type 1 diabetes patients in both a pairwise and network meta-analysis (NMA) context and investigate various parameters potentially affecting the outcome. METHODS Literature was systematically searched using the MEDLINE (1966-2018), Scopus (2004-2018), Cochrane Central Register of Controlled Trials (CENTRAL) (1999-2018), Clinicaltrials.gov (2008-2018) and Google Scholar (2004-2018) databases. Studies comparing the glycemic control in CL (either single- or dual-hormone) with continuous subcutaneous insulin infusion (CSII) in people with diabetes (PWD) aged <18 years old were deemed eligible. The primary outcome analysis was conducted with regard to time spent in the target glycemic range. All outcomes were evaluated in NMA in order to investigate potential between-algorithm differences. Pairwise meta-analysis and meta-regression were performed using the RevMan 5.3 and Open Meta-Analyst software. For NMA, the package pcnetmetain R 3.5.1 was used. RESULTS The meta-analysis was based on 25 studies with a total of 504 PWD. The CL group was associated with significantly higher percentage of time spent in the target glycemic range (Mean (SD): 67.59% (SD: 8.07%) in the target range and OL PWD spending 55.77% (SD: 11.73%), MD: -11.97%, 95% CI [-18.40, -5.54%]) and with lower percentages of time in hyperglycemia (MD: 3.01%, 95% CI [1.68, 4.34%]) and hypoglycemia (MD: 0.67%, 95% CI [0.21, 1.13%]. Mean glucose was also decreased in the CL group (MD: 0.75 mmol/L, 95% CI [0.18-1.33]). The NMA arm of the study showed that the bihormonal modality was superior to other algorithms and standard treatment in lowering mean glucose and increasing time spent in the target range. The DiAs platform was superior to PID in controlling hypoglycemia and mean glucose. Time in target range and mean glucose were unaffected by the confounding factors tested. CONCLUSIONS The findings of this meta-analysis suggest that artificial pancreas systems are superior to the standard sensor-augmented pump treatment of type 1 diabetes mellitus in non-adult PWD. Between-algorithm differences are also addressed, implying a superiority of the bihormonal treatment modality. Future large-scale studies are needed in the field to verify these outcomes and to determine the optimal algorithm to be used in the clinical setting.
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Affiliation(s)
- Vasilios Karageorgiou
- First Department of Cardiology, Biomedical Engineering Unit, Hippokration Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Theodoros G Papaioannou
- First Department of Cardiology, Biomedical Engineering Unit, Hippokration Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece.
| | - Ioannis Bellos
- First Department of Cardiology, Biomedical Engineering Unit, Hippokration Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Krystallenia Alexandraki
- Clinic of Endocrine Oncology, Section of Endocrinology, Department of Pathophysiology, Laiko Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Tentolouris
- First Department of Propaedeutic Internal Medicine, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - George P Chrousos
- First Department of Pediatrics, Aghia Sophia Children's Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Tousoulis
- First Department of Cardiology, Biomedical Engineering Unit, Hippokration Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Renard E, Tubiana-Rufi N, Bonnemaison-Gilbert E, Coutant R, Dalla-Vale F, Farret A, Poidvin A, Bouhours-Nouet N, Abettan C, Storey-London C, Donzeau A, Place J, Breton MD. Closed-loop driven by control-to-range algorithm outperforms threshold-low-glucose-suspend insulin delivery on glucose control albeit not on nocturnal hypoglycaemia in prepubertal patients with type 1 diabetes in a supervised hotel setting. Diabetes Obes Metab 2019; 21:183-187. [PMID: 30047223 DOI: 10.1111/dom.13482] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Revised: 07/12/2018] [Accepted: 07/23/2018] [Indexed: 01/18/2023]
Abstract
This randomized control trial investigated glucose control with closed-loop (CL) versus threshold-low-glucose-suspend (TLGS) insulin pump delivery in pre-pubertal children with type 1 diabetes in supervised hotel conditions. The patients [n = 24, age range: 7-12, HbA1c: 7.5 ± 0.5% (58 ± 5 mmol/mol)] and their parents were admitted twice at a 3-week interval. CL control to range or TLGS set at 3.9 mmoL/L were assessed for 48 hour in randomized order. Admissions included three meals and one snack, and physical exercise. Meal boluses followed individual insulin/carb ratios. While overnight (22:00-08:00) per cent continuous glucose monitoring (CGM) time below 3.9 mmol/L (primary outcome) was similar, time in ranges 3.9 to 10.0 and 3.9 to 7.8 mmoL/L and mean CGM were all significantly improved with CL (P < 0.001). These results were confirmed over the whole 48 hour. Disconnections between devices and limited accuracy of glucose sensors in the hypoglycaemic range appeared as limiting factors for optimal control. CL mode was well accepted while fear of hypoglycaemia was unchanged. CL did not minimize nocturnal hypoglycaemia exposure but improved time in target range compared to TLGS. Although safe and well-accepted, CL systems would benefit from more integrated devices.
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Affiliation(s)
- Eric Renard
- Department of Endocrinology, Diabetes, Nutrition, Montpellier University Hospital, Montpellier, France
- INSERM Clinical Investigation Centre 1411, Montpellier, France
- Institute of Functional Genomics, University of Montpellier, Montpellier, France
| | - Nadia Tubiana-Rufi
- Department of Pediatric Endocrinology and Diabetology, Robert Debré University Hospital, Assistance Publique-Hôpitaux de Paris, University of Paris Diderot Sorbonne Paris Cité, Paris, France
| | | | - Régis Coutant
- Department of Endocrinology and Diabetology, Pediatrics Federation, Angers University Hospital, Angers, France
| | - Fabienne Dalla-Vale
- Department of Pediatrics, Montpellier University Hospital, University of Montpellier, Montpellier, France
| | - Anne Farret
- Department of Endocrinology, Diabetes, Nutrition, Montpellier University Hospital, Montpellier, France
- Institute of Functional Genomics, University of Montpellier, Montpellier, France
| | - Amélie Poidvin
- Department of Pediatric Endocrinology and Diabetology, Robert Debré University Hospital, Assistance Publique-Hôpitaux de Paris, University of Paris Diderot Sorbonne Paris Cité, Paris, France
| | - Natacha Bouhours-Nouet
- Department of Endocrinology and Diabetology, Pediatrics Federation, Angers University Hospital, Angers, France
| | - Charlotte Abettan
- Department of Endocrinology, Diabetes, Nutrition, Montpellier University Hospital, Montpellier, France
- Institute of Functional Genomics, University of Montpellier, Montpellier, France
| | - Caroline Storey-London
- Department of Pediatric Endocrinology and Diabetology, Robert Debré University Hospital, Assistance Publique-Hôpitaux de Paris, University of Paris Diderot Sorbonne Paris Cité, Paris, France
| | - Aurelie Donzeau
- Department of Endocrinology and Diabetology, Pediatrics Federation, Angers University Hospital, Angers, France
| | - Jerome Place
- Department of Endocrinology, Diabetes, Nutrition, Montpellier University Hospital, Montpellier, France
- Institute of Functional Genomics, University of Montpellier, Montpellier, France
| | - Marc D Breton
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia
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32
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Kovatchev B. Automated closed-loop control of diabetes: the artificial pancreas. Bioelectron Med 2018; 4:14. [PMID: 32232090 PMCID: PMC7098217 DOI: 10.1186/s42234-018-0015-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 10/08/2018] [Indexed: 12/28/2022] Open
Abstract
The incidence of Diabetes Mellitus is on the rise worldwide, which exerts enormous health toll on the population and enormous pressure on the healthcare systems. Now, almost hundred years after the discovery of insulin in 1921, the optimization problem of diabetes is well formulated as maintenance of strict glycemic control without increasing the risk for hypoglycemia. External insulin administration is mandatory for people with type 1 diabetes; various medications, as well as basal and prandial insulin, are included in the daily treatment of type 2 diabetes. This review follows the development of the Diabetes Technology field which, since the 1970s, progressed remarkably through continuous subcutaneous insulin infusion (CSII), mathematical models and computer simulation of the human metabolic system, real-time continuous glucose monitoring (CGM), and control algorithms driving closed-loop control systems known as the "artificial pancreas" (AP). All of these developments included significant engineering advances and substantial bioelectronics progress in the sensing of blood glucose levels, insulin delivery, and control design. The key technologies that enabled contemporary AP systems are CSII and CGM, both of which became available and sufficiently portable in the beginning of this century. This powered the quest for wearable home-use AP, which is now under way with prototypes tested in outpatient studies during the past 6 years. Pivotal trials of new AP technologies are ongoing, and the first hybrid closed-loop system has been approved by the FDA for clinical use. Thus, the closed-loop AP is well on its way to become the digital-age treatment of diabetes.
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Affiliation(s)
- Boris Kovatchev
- Center for Diabetes Technology, University of Virginia, P.O. Box 400888, Charlottesville, VA 22908 USA
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33
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Sherr JL, Tauschmann M, Battelino T, de Bock M, Forlenza G, Roman R, Hood KK, Maahs DM. ISPAD Clinical Practice Consensus Guidelines 2018: Diabetes technologies. Pediatr Diabetes 2018; 19 Suppl 27:302-325. [PMID: 30039513 DOI: 10.1111/pedi.12731] [Citation(s) in RCA: 128] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 07/10/2018] [Indexed: 12/12/2022] Open
Affiliation(s)
- Jennifer L Sherr
- Department of Pediatrics, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Martin Tauschmann
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK.,Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Tadej Battelino
- UMC-University Children's Hospital, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Martin de Bock
- Department of Paediatrics, University of Otago, Christchurch, New Zealand
| | - Gregory Forlenza
- University of Colorado Denver, Barbara Davis Center, Aurora, Colorado
| | - Rossana Roman
- Medical Sciences Department, University of Antofagasta and Antofagasta Regional Hospital, Antofagasta, Chile
| | - Korey K Hood
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California
| | - David M Maahs
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
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34
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Sánchez-Peña R, Colmegna P, Garelli F, De Battista H, García-Violini D, Moscoso-Vásquez M, Rosales N, Fushimi E, Campos-Náñez E, Breton M, Beruto V, Scibona P, Rodriguez C, Giunta J, Simonovich V, Belloso WH, Cherñavvsky D, Grosembacher L. Artificial Pancreas: Clinical Study in Latin America Without Premeal Insulin Boluses. J Diabetes Sci Technol 2018; 12:914-925. [PMID: 29998754 PMCID: PMC6134619 DOI: 10.1177/1932296818786488] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Emerging therapies such as closed-loop (CL) glucose control, also known as artificial pancreas (AP) systems, have shown significant improvement in type 1 diabetes mellitus (T1DM) management. However, demanding patient intervention is still required, particularly at meal times. To reduce treatment burden, the automatic regulation of glucose (ARG) algorithm mitigates postprandial glucose excursions without feedforward insulin boluses. This work assesses feasibility of this new strategy in a clinical trial. METHODS A 36-hour pilot study was performed on five T1DM subjects to validate the ARG algorithm. Subjects wore a subcutaneous continuous glucose monitor (CGM) and an insulin pump. Insulin delivery was solely commanded by the ARG algorithm, without premeal insulin boluses. This was the first clinical trial in Latin America to validate an AP controller. RESULTS For the total 36-hour period, results were as follows: average time of CGM readings in range 70-250 mg/dl: 88.6%, in range 70-180 mg/dl: 74.7%, <70 mg/dl: 5.8%, and <50 mg/dl: 0.8%. Results improved analyzing the final 15-hour period of this trial. In that case, the time spent in range was 70-250 mg/dl: 94.7%, in range 70-180 mg/dl: 82.6%, <70 mg/dl: 4.1%, and <50 mg/dl: 0.2%. During the last night the time spent in range was 70-250 mg/dl: 95%, in range 70-180 mg/dl: 87.7%, <70 mg/dl: 5.0%, and <50 mg/dl: 0.0%. No severe hypoglycemia occurred. No serious adverse events were reported. CONCLUSIONS The ARG algorithm was successfully validated in a pilot clinical trial, encouraging further tests with a larger number of patients and in outpatient settings.
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Affiliation(s)
- Ricardo Sánchez-Peña
- Instituto Tecnológico de Buenos Aires, Buenos Aires, Argentina
- National Scientific and Technical Research Council, Buenos Aires, Argentina
- Ricardo Sánchez-Peña, PhD, National Scientific and Technical Research Council (CONICET), Instituto Tecnológico de Buenos Aires (ITBA), Av Madero 399, Buenos Aires, C1106ACD, Argentina.
| | - Patricio Colmegna
- National Scientific and Technical Research Council, Buenos Aires, Argentina
- University of Virginia, Charlottesville, VA, USA
- Universidad Nacional de Quilmes, Bernal, Buenos Aires, Argentina
| | - Fabricio Garelli
- National Scientific and Technical Research Council, Buenos Aires, Argentina
- Universidad Nacional de La Plata, La Plata, Buenos Aires Argentina
| | - Hernán De Battista
- National Scientific and Technical Research Council, Buenos Aires, Argentina
- Universidad Nacional de La Plata, La Plata, Buenos Aires Argentina
| | - Demián García-Violini
- Instituto Tecnológico de Buenos Aires, Buenos Aires, Argentina
- National Scientific and Technical Research Council, Buenos Aires, Argentina
| | - Marcela Moscoso-Vásquez
- Instituto Tecnológico de Buenos Aires, Buenos Aires, Argentina
- National Scientific and Technical Research Council, Buenos Aires, Argentina
| | - Nicolás Rosales
- Universidad Nacional de La Plata, La Plata, Buenos Aires Argentina
| | - Emilia Fushimi
- National Scientific and Technical Research Council, Buenos Aires, Argentina
- Universidad Nacional de La Plata, La Plata, Buenos Aires Argentina
| | | | - Marc Breton
- University of Virginia, Charlottesville, VA, USA
| | - Valeria Beruto
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Paula Scibona
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - Javier Giunta
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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Artificial pancreas clinical trials: Moving towards closed-loop control using insulin-on-board constraints. Biomed Signal Process Control 2018. [DOI: 10.1016/j.bspc.2018.05.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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36
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Rollins DK, Mei Y. A new feedback predictive control approach for processes with time delay in the manipulated variable. Chem Eng Res Des 2018. [DOI: 10.1016/j.cherd.2018.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Esposito S, Santi E, Mancini G, Rogari F, Tascini G, Toni G, Argentiero A, Berioli MG. Efficacy and safety of the artificial pancreas in the paediatric population with type 1 diabetes. J Transl Med 2018; 16:176. [PMID: 29954380 PMCID: PMC6022450 DOI: 10.1186/s12967-018-1558-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 06/23/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Type 1 diabetes (DM1) is one of the most common chronic diseases in childhood and requires life-long insulin therapy and continuous health care support. An artificial pancreas (AP) or closed-loop system (CLS) have been developed with the aim of improving metabolic control without increasing the risk of hypoglycaemia in patients with DM1. As the impact of APs have been studied mainly in adults, the aim of this review is to evaluate the efficacy and safety of the AP in the paediatric population with DM1. MAIN BODY The real advantage of a CLS compared to last-generation sensor-augmented pumps is the gradual modulation of basal insulin infusion in response to glycaemic variations (towards both hyperglycaemia and hypoglycaemia), which has the aim of improving the proportion of time spent in the target glucose range and reducing the mean glucose level without increasing the risk of hypoglycaemia. Some recent studies demonstrated that also in children and adolescents an AP is able to reduce the frequency of hypoglycaemic events, an important limiting factor in reaching good metabolic control, particularly overnight. However, the advantages of the AP in reducing hyperglycaemia, increasing the time spent in the target glycaemic range and thus reducing glycated haemoglobin are less clear and require more clinical trials in the paediatric population, in particular in younger children. CONCLUSIONS Although the first results from bi-hormonal CLS are promising, long-term, head-to-head studies will have to prove their superiority over insulin-only approaches. More technological progress, the availability of more fast-acting insulin, further developments of algorithms that could improve glycaemic control after meals and physical activity are the most important challenges in reaching an optimal metabolic control with the use of the AP in children and adolescents.
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Affiliation(s)
- Susanna Esposito
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Piazza Menghini 1, 06129, Perugia, Italy.
| | - Elisa Santi
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Piazza Menghini 1, 06129, Perugia, Italy
| | - Giulia Mancini
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Piazza Menghini 1, 06129, Perugia, Italy
| | - Francesco Rogari
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Piazza Menghini 1, 06129, Perugia, Italy
| | - Giorgia Tascini
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Piazza Menghini 1, 06129, Perugia, Italy
| | - Giada Toni
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Piazza Menghini 1, 06129, Perugia, Italy
| | - Alberto Argentiero
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Piazza Menghini 1, 06129, Perugia, Italy
| | - Maria Giulia Berioli
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Piazza Menghini 1, 06129, Perugia, Italy
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Carrion J. Improving the Patient-Clinician Interface of Clinical Trials through Health Informatics Technologies. J Med Syst 2018; 42:120. [PMID: 29845581 DOI: 10.1007/s10916-018-0973-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 05/18/2018] [Indexed: 12/17/2022]
Abstract
The current state of clinical trials underscores a need for timely interventions to reduce the cost and length of the average trial. Newly developed health informatics technologies-including electronic health records, telemedicine systems, and mobile health applications-have recently been employed in a wide range of clinical trials in an effort to improve different aspects of the clinical trial process. The current review will focus on the observed benefits and drawbacks of using such technology to improve various patient-centered aspects of the clinical trial process, namely its potential to improve patient recruitment, patient retention, and data collection. Broad future challenges and opportunities in the field as a whole will also be covered.
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Affiliation(s)
- Jake Carrion
- Department of Biomedical Informatics, Columbia University, 622 W 168th St, New York, NY, 10032, USA.
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Forlenza GP, Raghinaru D, Cameron F, Bequette BW, Chase HP, Wadwa RP, Maahs DM, Jost E, Ly TT, Wilson DM, Norlander L, Ekhlaspour L, Min H, Clinton P, Njeru N, Lum JW, Kollman C, Beck RW, Buckingham BA. Predictive hyperglycemia and hypoglycemia minimization: In-home double-blind randomized controlled evaluation in children and young adolescents. Pediatr Diabetes 2018; 19:420-428. [PMID: 29159870 PMCID: PMC5951790 DOI: 10.1111/pedi.12603] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 08/28/2017] [Accepted: 10/04/2017] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE The primary objective of this trial was to evaluate the feasibility, safety, and efficacy of a predictive hyperglycemia and hypoglycemia minimization (PHHM) system vs predictive low glucose suspension (PLGS) alone in optimizing overnight glucose control in children 6 to 14 years old. RESEARCH DESIGN AND METHODS Twenty-eight participants 6 to 14 years old with T1D duration ≥1 year with daily insulin therapy ≥12 months and on insulin pump therapy for ≥6 months were randomized per night into PHHM mode or PLGS-only mode for 42 nights. The primary outcome was percentage of time in sensor-measured range 70 to 180 mg/dL in the overnight period. RESULTS The addition of automated insulin delivery with PHHM increased time in target range (70-180 mg/dL) from 66 ± 11% during PLGS nights to 76 ± 9% during PHHM nights (P<.001), without increasing hypoglycemia as measured by time below various thresholds. Average morning blood glucose improved from 176 ± 28 mg/dL following PLGS nights to 154 ± 19 mg/dL following PHHM nights (P<.001). CONCLUSIONS The PHHM system was effective in optimizing overnight glycemic control, significantly increasing time in range, lowering mean glucose, and decreasing glycemic variability compared to PLGS alone in children 6 to 14 years old.
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Affiliation(s)
- Gregory P Forlenza
- Department of Pediatric Endocrinology, Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Denver, Colorado
| | | | - Faye Cameron
- Rensselaer Polytechnic Institute, Troy, New York
| | | | - H Peter Chase
- Department of Pediatric Endocrinology, Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Denver, Colorado
| | - R Paul Wadwa
- Department of Pediatric Endocrinology, Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Denver, Colorado
| | - David M Maahs
- Department of Pediatric Endocrinology, Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Denver, Colorado,Department of Pediatric Endocrinology, Stanford University, Palo Alto, California
| | - Emily Jost
- Department of Pediatric Endocrinology, Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Denver, Colorado
| | - Trang T Ly
- Department of Pediatric Endocrinology, Stanford University, Palo Alto, California
| | - Darrell M Wilson
- Department of Pediatric Endocrinology, Stanford University, Palo Alto, California
| | - Lisa Norlander
- Department of Pediatric Endocrinology, Stanford University, Palo Alto, California
| | - Laya Ekhlaspour
- Department of Pediatric Endocrinology, Stanford University, Palo Alto, California
| | - Hyojin Min
- Department of Pediatric Endocrinology, Stanford University, Palo Alto, California
| | - Paula Clinton
- Department of Pediatric Endocrinology, Stanford University, Palo Alto, California
| | - Nelly Njeru
- Jaeb Center for Health Research, Tampa, Florida
| | - John W Lum
- Jaeb Center for Health Research, Tampa, Florida
| | | | - Roy W Beck
- Jaeb Center for Health Research, Tampa, Florida
| | - Bruce A Buckingham
- Department of Pediatric Endocrinology, Stanford University, Palo Alto, California
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Bekiari E, Kitsios K, Thabit H, Tauschmann M, Athanasiadou E, Karagiannis T, Haidich AB, Hovorka R, Tsapas A. Artificial pancreas treatment for outpatients with type 1 diabetes: systematic review and meta-analysis. BMJ 2018; 361:k1310. [PMID: 29669716 PMCID: PMC5902803 DOI: 10.1136/bmj.k1310] [Citation(s) in RCA: 246] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of artificial pancreas treatment in non-pregnant outpatients with type 1 diabetes. DESIGN Systematic review and meta-analysis of randomised controlled trials. DATA SOURCES Medline, Embase, Cochrane Library, and grey literature up to 2 February 2018. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Randomised controlled trials in non-pregnant outpatients with type 1 diabetes that compared the use of any artificial pancreas system with any type of insulin based treatment. Primary outcome was proportion (%) of time that sensor glucose level was within the near normoglycaemic range (3.9-10 mmol/L). Secondary outcomes included proportion (%) of time that sensor glucose level was above 10 mmol/L or below 3.9 mmol/L, low blood glucose index overnight, mean sensor glucose level, total daily insulin needs, and glycated haemoglobin. The Cochrane Collaboration risk of bias tool was used to assess study quality. RESULTS 40 studies (1027 participants with data for 44 comparisons) were included in the meta-analysis. 35 comparisons assessed a single hormone artificial pancreas system, whereas nine comparisons assessed a dual hormone system. Only nine studies were at low risk of bias. Proportion of time in the near normoglycaemic range (3.9-10.0 mmol/L) was significantly higher with artificial pancreas use, both overnight (weighted mean difference 15.15%, 95% confidence interval 12.21% to 18.09%) and over a 24 hour period (9.62%, 7.54% to 11.7%). Artificial pancreas systems had a favourable effect on the proportion of time with sensor glucose level above 10 mmol/L (-8.52%, -11.14% to -5.9%) or below 3.9 mmol/L (-1.49%, -1.86% to -1.11%) over 24 hours, compared with control treatment. Robustness of findings for the primary outcome was verified in sensitivity analyses, by including only trials at low risk of bias (11.64%, 9.1% to 14.18%) or trials under unsupervised, normal living conditions (10.42%, 8.63% to 12.2%). Results were consistent in a subgroup analysis both for single hormone and dual hormone artificial pancreas systems. CONCLUSIONS Artificial pancreas systems are an efficacious and safe approach for treating outpatients with type 1 diabetes. The main limitations of current research evidence on artificial pancreas systems are related to inconsistency in outcome reporting, small sample size, and short follow-up duration of individual trials.
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Affiliation(s)
- Eleni Bekiari
- Clinical Research and Evidence Based Medicine Unit, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece
| | - Konstantinos Kitsios
- Diabetes Centre, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Hood Thabit
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Martin Tauschmann
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Eleni Athanasiadou
- Clinical Research and Evidence Based Medicine Unit, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece
| | - Thomas Karagiannis
- Clinical Research and Evidence Based Medicine Unit, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece
| | - Anna-Bettina Haidich
- Department of Hygiene and Epidemiology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Roman Hovorka
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Apostolos Tsapas
- Clinical Research and Evidence Based Medicine Unit, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece
- Harris Manchester College, University of Oxford, Oxford, UK
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Gingras V, Taleb N, Roy-Fleming A, Legault L, Rabasa-Lhoret R. The challenges of achieving postprandial glucose control using closed-loop systems in patients with type 1 diabetes. Diabetes Obes Metab 2018; 20:245-256. [PMID: 28675686 PMCID: PMC5810921 DOI: 10.1111/dom.13052] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 06/27/2017] [Accepted: 06/29/2017] [Indexed: 01/17/2023]
Abstract
For patients with type 1 diabetes, closed-loop delivery systems (CLS) combining an insulin pump, a glucose sensor and a dosing algorithm allowing a dynamic hormonal infusion have been shown to improve glucose control when compared with conventional therapy. Yet, reducing glucose excursion and simplification of prandial insulin doses remain a challenge. The objective of this literature review is to examine current meal-time strategies in the context of automated delivery systems in adults and children with type 1 diabetes. Current challenges and considerations for post-meal glucose control will also be discussed. Despite promising results with meal detection, the fully automated CLS has yet failed to provide comparable glucose control to CLS with carbohydrate-matched bolus in the post-meal period. The latter strategy has been efficient in controlling post-meal glucose using different algorithms and in various settings, but at the cost of a meal carbohydrate counting burden for patients. Further improvements in meal detection algorithms or simplified meal-priming boluses may represent interesting avenues. The greatest challenges remain in regards to the pharmacokinetic and dynamic profiles of available rapid insulins as well as sensor accuracy and lag-time. New and upcoming faster acting insulins could provide important benefits. Multi-hormone CLS (eg, dual-hormone combining insulin with glucagon or pramlintide) and adjunctive therapy (eg, GLP-1 and SGLT2 inhibitors) also represent promising options. Meal glucose control with the artificial pancreas remains an important challenge for which the optimal strategy is still to be determined.
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Affiliation(s)
- Véronique Gingras
- Institut de Recherches Cliniques de Montréal, Montreal, Quebec, Canada
- Department of nutrition, Université de Montréal, Montreal, Quebec, Canada
| | - Nadine Taleb
- Institut de Recherches Cliniques de Montréal, Montreal, Quebec, Canada
- Department of biomedical sciences, Université de Montréal, Montreal, Quebec, Canada
| | - Amélie Roy-Fleming
- Institut de Recherches Cliniques de Montréal, Montreal, Quebec, Canada
- Department of nutrition, Université de Montréal, Montreal, Quebec, Canada
| | - Laurent Legault
- Institut de Recherches Cliniques de Montréal, Montreal, Quebec, Canada
- Montreal Children’s Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Rémi Rabasa-Lhoret
- Institut de Recherches Cliniques de Montréal, Montreal, Quebec, Canada
- Department of nutrition, Université de Montréal, Montreal, Quebec, Canada
- Montreal Diabetes Research Center (MDRC), Montreal, Quebec, Canada
- Research Center of the Université de Montréal Hospital Center (CRCHUM), Montreal, Quebec, Canada
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42
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Boiroux D, Duun-Henriksen AK, Schmidt S, Nørgaard K, Madsbad S, Poulsen NK, Madsen H, Jørgensen JB. Overnight glucose control in people with type 1 diabetes. Biomed Signal Process Control 2018. [DOI: 10.1016/j.bspc.2017.08.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Bally L, Thabit H, Hovorka R. Glucose-responsive insulin delivery for type 1 diabetes: The artificial pancreas story. Int J Pharm 2017; 544:309-318. [PMID: 29258910 DOI: 10.1016/j.ijpharm.2017.12.022] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 12/04/2017] [Accepted: 12/10/2017] [Indexed: 12/20/2022]
Abstract
Insulin replacement therapy is integral to the management of type 1 diabetes, which is characterised by absolute insulin deficiency. Optimal glycaemic control, as assessed by glycated haemoglobin, and avoidance of hyper- and hypoglycaemic excursions have been shown to prevent diabetes-related complications. Insulin pump use has increased considerably over the past decade with beneficial effects on glycaemic control, quality of life and treatment satisfaction. The advent and progress of ambulatory glucose sensor technology has enabled continuous glucose monitoring based on real-time glucose levels to be integrated with insulin therapy. Low glucose and predictive low glucose suspend systems are currently used in clinical practice to mitigate against hypoglycaemia, and provide the first step towards feedback glucose control. The more advanced technology approach, an artificial pancreas or a closed-loop system, gradually increases and decreases insulin delivery in a glucose-responsive fashion to mitigate against hyper- and hypoglycaemia. Randomised outpatient clinical trials over the past 5 years have demonstrated the feasibility, safety and efficacy of the approach, and the recent FDA approval of the first single hormone closed-loop system establishes a new standard of care for people with type 1 diabetes.
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Affiliation(s)
- Lia Bally
- Department of Diabetes, Endocrinology Clinical Nutrition & Metabolism, Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland.
| | - Hood Thabit
- Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom; Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, University of Manchester, 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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Dassau E, Pinsker JE, Kudva YC, Brown SA, Gondhalekar R, Dalla Man C, Patek S, Schiavon M, Dadlani V, Dasanayake I, Church MM, Carter RE, Bevier WC, Huyett LM, Hughes J, Anderson S, Lv D, Schertz E, Emory E, McCrady-Spitzer SK, Jean T, Bradley PK, Hinshaw L, Laguna Sanz AJ, Basu A, Kovatchev B, Cobelli C, Doyle FJ. Twelve-Week 24/7 Ambulatory Artificial Pancreas With Weekly Adaptation of Insulin Delivery Settings: Effect on Hemoglobin A 1c and Hypoglycemia. Diabetes Care 2017; 40:1719-1726. [PMID: 29030383 PMCID: PMC5711334 DOI: 10.2337/dc17-1188] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 09/14/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Artificial pancreas (AP) systems are best positioned for optimal treatment of type 1 diabetes (T1D) and are currently being tested in outpatient clinical trials. Our consortium developed and tested a novel adaptive AP in an outpatient, single-arm, uncontrolled multicenter clinical trial lasting 12 weeks. RESEARCH DESIGN AND METHODS Thirty adults with T1D completed a continuous glucose monitor (CGM)-augmented 1-week sensor-augmented pump (SAP) period. After the AP was started, basal insulin delivery settings used by the AP for initialization were adapted weekly, and carbohydrate ratios were adapted every 4 weeks by an algorithm running on a cloud-based server, with automatic data upload from devices. Adaptations were reviewed by expert study clinicians and patients. The primary end point was change in hemoglobin A1c (HbA1c). Outcomes are reported adhering to consensus recommendations on reporting of AP trials. RESULTS Twenty-nine patients completed the trial. HbA1c, 7.0 ± 0.8% at the start of AP use, improved to 6.7 ± 0.6% after 12 weeks (-0.3, 95% CI -0.5 to -0.2, P < 0.001). Compared with the SAP run-in, CGM time spent in the hypoglycemic range improved during the day from 5.0 to 1.9% (-3.1, 95% CI -4.1 to -2.1, P < 0.001) and overnight from 4.1 to 1.1% (-3.1, 95% CI -4.2 to -1.9, P < 0.001). Whereas carbohydrate ratios were adapted to a larger extent initially with minimal changes thereafter, basal insulin was adapted throughout. Approximately 10% of adaptation recommendations were manually overridden. There were no protocol-related serious adverse events. CONCLUSIONS Use of our novel adaptive AP yielded significant reductions in HbA1c and hypoglycemia.
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Affiliation(s)
- Eyal Dassau
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA.,William Sansum Diabetes Center, Santa Barbara, CA
| | | | | | - Sue A Brown
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | - Ravi Gondhalekar
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA.,William Sansum Diabetes Center, Santa Barbara, CA
| | - Chiara Dalla Man
- Department of Information Engineering, University of Padova, Padova, Italy
| | - Steve Patek
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | - Michele Schiavon
- Department of Information Engineering, University of Padova, Padova, Italy
| | | | - Isuru Dasanayake
- William Sansum Diabetes Center, Santa Barbara, CA.,Department of Chemical Engineering, University of California, Santa Barbara, Santa Barbara, CA
| | | | - Rickey E Carter
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | | | - Lauren M Huyett
- William Sansum Diabetes Center, Santa Barbara, CA.,Department of Chemical Engineering, University of California, Santa Barbara, Santa Barbara, CA
| | - Jonathan Hughes
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | - Stacey Anderson
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | - Dayu Lv
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | - Elaine Schertz
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | - Emma Emory
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | | | - Tyler Jean
- William Sansum Diabetes Center, Santa Barbara, CA
| | | | - Ling Hinshaw
- Endocrine Research Unit, Mayo Clinic, Rochester, MN
| | - Alejandro J Laguna Sanz
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA.,William Sansum Diabetes Center, Santa Barbara, CA
| | - Ananda Basu
- Endocrine Research Unit, Mayo Clinic, Rochester, MN
| | - Boris Kovatchev
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | - Claudio Cobelli
- Department of Information Engineering, University of Padova, Padova, Italy
| | - Francis J Doyle
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA .,William Sansum Diabetes Center, Santa Barbara, CA
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Graveling AJ, Frier BM. The risks of nocturnal hypoglycaemia in insulin-treated diabetes. Diabetes Res Clin Pract 2017; 133:30-39. [PMID: 28888993 DOI: 10.1016/j.diabres.2017.08.012] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 08/17/2017] [Indexed: 12/29/2022]
Abstract
Over half of all episodes of severe hypoglycaemia (requiring external help) occur during sleep, but nocturnal hypoglycaemia is often asymptomatic and unrecognised. The precise incidence of nocturnal hypoglycaemia is difficult to determine with no agreed definition, but continuous glucose monitoring has shown that it occurs frequently in people taking insulin. Attenuation of the counter-regulatory responses to hypoglycaemia during sleep may explain why some episodes are undetected and more prolonged, and modifies cardiovascular responses. The morbidity and mortality associated with nocturnal hypoglycaemia is probably much greater than realised, causing seizures, coma and cardiovascular events and affecting quality of life, mood and work performance the following day. It may induce impaired awareness of hypoglycaemia. Cardiac arrhythmias that occur during nocturnal hypoglycaemia include bradycardia and ectopics that may provoke dangerous arrhythmias. Treatment strategies are discussed that may help to minimise the frequency of nocturnal hypoglycaemia.
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Affiliation(s)
- Alex J Graveling
- JJR Macleod Centre for Diabetes & Endocrinology, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZP, UK.
| | - Brian M Frier
- The Queen's Medical Research Institute, The University of Edinburgh, Edinburgh EH16 4TJ, UK.
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Kahkoska AR, Mayer-Davis EJ, Hood KK, Maahs DM, Burger KS. Behavioural implications of traditional treatment and closed-loop automated insulin delivery systems in Type 1 diabetes: applying a cognitive restraint theory framework. Diabet Med 2017; 34. [PMID: 28626906 PMCID: PMC5647213 DOI: 10.1111/dme.13407] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
As the prevalence of obesity in Type 1 diabetes rises, the effects of emerging therapy options should be considered in the context of both weight and glycaemic control outcomes. Artificial pancreas device systems will 'close the loop' between blood glucose monitoring and automated insulin delivery and may transform day-to-day dietary management for people with Type 1 diabetes in multiple ways. In the present review, we draw directly from cognitive restraint theory to consider unintended impacts that closed-loop systems may have on ingestive behaviour and food intake. We provide a brief overview of dietary restraint theory and its relation to weight status in the general population, discuss the role of restraint in traditional Type 1 diabetes treatment, and lastly, use this restraint framework to discuss the possible behavioural implications and opportunities of closed-loop systems in the treatment of Type 1 diabetes. We hypothesize that adopting closed-loop systems will lift the diligence and restriction that characterizes Type 1 diabetes today, thus requiring a transition from a restrained eating behaviour to a non-restrained eating behaviour. Furthermore, we suggest this transition be leveraged as an opportunity to teach people lifelong eating behaviour to promote healthy weight status by incorporating education and cognitive reappraisal. Our aim was to use a transdisciplinary approach to highlight critical aspects of the emerging closed-loop technologies relating to eating behaviour and weight effects and to promote discussion of strategies to optimize long-term health in Type 1 diabetes via two key outcomes: glycaemic control and weight management.
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Affiliation(s)
- A R Kahkoska
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - E J Mayer-Davis
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - K K Hood
- Division of Pediatric Endocrinology, Stanford University, Stanford, CA, USA
| | - D M Maahs
- Division of Pediatric Endocrinology, Stanford University, Stanford, CA, USA
| | - K S Burger
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Brown SA, Breton MD, Anderson SM, Kollar L, Keith-Hynes P, Levy CJ, Lam DW, Levister C, Baysal N, Kudva YC, Basu A, Dadlani V, Hinshaw L, McCrady-Spitzer S, Bruttomesso D, Visentin R, Galasso S, Del Favero S, Leal Y, Boscari F, Avogaro A, Cobelli C, Kovatchev BP. Overnight Closed-Loop Control Improves Glycemic Control in a Multicenter Study of Adults With Type 1 Diabetes. J Clin Endocrinol Metab 2017; 102:3674-3682. [PMID: 28666360 PMCID: PMC5630248 DOI: 10.1210/jc.2017-00556] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 06/22/2017] [Indexed: 11/19/2022]
Abstract
CONTEXT Closed-loop control (CLC) for the management of type 1 diabetes (T1D) is a novel method for optimizing glucose control, and strategies for individualized implementation are being developed. OBJECTIVE To analyze glycemic control in an overnight CLC system designed to "reset" the patient to near-normal glycemic targets every morning. DESIGN Randomized, crossover, multicenter clinical trial. PARTICIPANTS Forty-four subjects with T1D requiring insulin pump therapy. INTERVENTION Sensor-augmented pump therapy (SAP) at home vs 5 nights of CLC (active from 23:00 to 07:00) in a supervised outpatient setting (research house or hotel), with a substudy of 5 nights of CLC subsequently at home. MAIN OUTCOME MEASURE The percentage of time spent in the target range (70 to 180 mg/dL measured using a continuous glucose monitor). RESULTS Forty subjects (age, 45.5 ± 9.5 years; hemoglobin A1c, 7.4% ± 0.8%) completed the study. The time in the target range (70 to 180 mg/dL) significantly improved in CLC vs SAP over 24 hours (78.3% vs 71.4%; P = 0.003) and overnight (85.7% vs 67.6%; P < 0.001). The time spent in a hypoglycemic range (<70 mg/dL) decreased significantly in the CLC vs SAP group over 24 hours (2.5% vs 4.3%; P = 0.002) and overnight (0.9% vs 3.2%; P < 0.001). The mean glucose level at 07:00 was lower with CLC than with SAP (123.7 vs 145.3 mg/dL; P < 0.001). The substudy at home, involving 10 T1D subjects, showed similar trends with an increased time in target (70 to 180 mg/dL) overnight (75.2% vs 62.2%; P = 0.07) and decreased time spent in the hypoglycemic range (<70 mg/dL) overnight in CLC vs SAP (0.6% vs 3.7%; P = 0.03). CONCLUSION Overnight-only CLC increased the time in the target range over 24 hours and decreased the time in hypoglycemic range over 24 hours in a supervised outpatient setting. A pilot extension study at home showed a similar nonsignificant trend.
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Affiliation(s)
- Sue A Brown
- Center for Diabetes Technology, Division of Endocrinology, University of Virginia, Charlottesville, Virginia 22903
| | - Marc D Breton
- Center for Diabetes Technology, Division of Endocrinology, University of Virginia, Charlottesville, Virginia 22903
| | - Stacey M Anderson
- Center for Diabetes Technology, Division of Endocrinology, University of Virginia, Charlottesville, Virginia 22903
| | - Laura Kollar
- Center for Diabetes Technology, Division of Endocrinology, University of Virginia, Charlottesville, Virginia 22903
| | | | - Carol J Levy
- Icahn School of Medicine at Mount Sinai, New York, New York 10029
| | - David W Lam
- Icahn School of Medicine at Mount Sinai, New York, New York 10029
| | - Camilla Levister
- Icahn School of Medicine at Mount Sinai, New York, New York 10029
| | - Nihat Baysal
- Rensselaer Polytechnic Institute, Troy, New York 12180
| | | | | | | | | | | | - Daniela Bruttomesso
- Unit of Metabolic Diseases, Department of Internal Medicine, University of Padua, Padua 35122, Italy
| | - Roberto Visentin
- Department of Information Engineering, University of Padua, Padua 35122, Italy
| | - Silvia Galasso
- Unit of Metabolic Diseases, Department of Internal Medicine, University of Padua, Padua 35122, Italy
| | - Simone Del Favero
- Department of Information Engineering, University of Padua, Padua 35122, Italy
| | - Yenny Leal
- Department of Information Engineering, University of Padua, Padua 35122, Italy
| | - Federico Boscari
- Unit of Metabolic Diseases, Department of Internal Medicine, University of Padua, Padua 35122, Italy
| | - Angelo Avogaro
- Unit of Metabolic Diseases, Department of Internal Medicine, University of Padua, Padua 35122, Italy
| | - Claudio Cobelli
- Department of Information Engineering, University of Padua, Padua 35122, Italy
| | - Boris P Kovatchev
- Center for Diabetes Technology, Division of Endocrinology, University of Virginia, Charlottesville, Virginia 22903
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Guilhem I, Penet M, Paillard A, Carpentier M, Esvant A, Lefebvre MA, Poirier JY. Manual Closed-Loop Insulin Delivery Using a Saddle Point Model Predictive Control Algorithm: Results of a Crossover Randomized Overnight Study. J Diabetes Sci Technol 2017; 11:1007-1014. [PMID: 28677416 PMCID: PMC5951001 DOI: 10.1177/1932296817717503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The purpose was to assess the efficacy of a new closed-loop algorithm (Saddle Point Model Predictive Control, SP-MPC) in achieving nocturnal normoglycemia while reducing the risk of hypoglycemia in patients with type 1 diabetes. METHOD In this randomized crossover study, 10 adult patients (mean hemoglobin A1c 7.35 ± 1.04%) were assigned to be treated overnight by open loop using sensor-augmented pump therapy (open-loop SAP) or manual closed-loop delivery. During closed loop, insulin doses were calculated using the SP-MPC algorithm and administered as manual boluses every 15 minutes from 9:00 pm to 8:00 am. Patients consumed a self-selected meal (65-125 g of carbohydrates) at 7:00 pm accompanied by their usual prandial bolus. Blood glucose was measured every 30 minutes. The primary endpoints were the time spent in target (70-145 mg/dl) and time spent below 70 mg/dl from 11:00 pm to 8:00 am. RESULTS Time spent in target did not differ between closed-loop and open-loop SAP. The number of hypoglycemic events (<70 mg/dl) was reduced 2.8-fold in closed loop (n = 5, median = 0/patient/hour; interquartile range: 0-0.11) as compared to open-loop SAP (n = 14, median = 0.22/patient/hour, 0.02-0.22) ( P = .02). The area under the curve for sensor glucose values >145 mg/dl was significantly lower during closed-loop than during open-loop SAP ( P = .03) as well as HBGI ( P = .02). CONCLUSIONS This pilot study suggests that the use of the SP-MPC algorithm may improve mean overnight glucose control and reduce the number of hypoglycemic events as compared to SAP therapy.
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Affiliation(s)
- Isabelle Guilhem
- CHU de Rennes, Department of Endocrinology, Diabetes and Nutrition, Rennes, France
- CHU de Rennes, CIC INSERM 1414, Rennes, France
- Isabelle Guilhem, MD, MSc, service d’Endocrinologie-Diabétologie-Nutrition, CHU de Rennes, hôpital sud, 16 boulevard de Bulgarie, 35203 Rennes cedex, France.
| | - Maxime Penet
- CentraleSupélec/I.E.T.R, Hybrid System Control Team, Cesson-Sévigné, France
| | - Anaïs Paillard
- CHU de Rennes, Department of Endocrinology, Diabetes and Nutrition, Rennes, France
- CHU de Rennes, CIC INSERM 1414, Rennes, France
| | - Marc Carpentier
- CHU de Rennes, Département d’Information Médicale, Rennes, France
| | - Annabelle Esvant
- CHU de Rennes, Department of Endocrinology, Diabetes and Nutrition, Rennes, France
- CHU de Rennes, CIC INSERM 1414, Rennes, France
| | | | - Jean-Yves Poirier
- CHU de Rennes, Department of Endocrinology, Diabetes and Nutrition, Rennes, France
- CHU de Rennes, CIC INSERM 1414, Rennes, France
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Tauschmann M, Hovorka R. Insulin delivery and nocturnal glucose control in children and adolescents with type 1 diabetes. Expert Opin Drug Deliv 2017; 14:1367-1377. [PMID: 28819992 PMCID: PMC5942151 DOI: 10.1080/17425247.2017.1360866] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Introduction: Nocturnal glucose control remains challenging in children and adolescents with type 1 diabetes due to highly variable overnight insulin requirements. The issue may be addressed by glucose responsive insulin delivery based on real-time continuous glucose measurements. Areas covered: This review outlines recent developments of glucose responsive insulin delivery systems from a paediatric perspective. We cover threshold-based suspend application, predictive low glucose suspend, and more advanced single hormone and dual-hormone closed-loop systems. Approaches are evaluated in relation to nocturnal glucose control particularly during outpatient randomised controlled trials. Expert opinion: Significant progress translating research from controlled clinical centre settings to free-living unsupervised home studies have been achieved over the past decade. Nocturnal glycaemic control can be improved whilst reducing the risk of hypoglycaemia with closed-loop systems. Following the US regulatory approval of the first hybrid closed-loop system in non-paediatric population, large multinational closed-loop clinical trials and pivotal studies including paediatric populations are underway or in preparation to facilitate the use of closed-loop systems in clinical practice.
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Affiliation(s)
- Martin Tauschmann
- a Wellcome Trust-MRC Institute of Metabolic Science , University of Cambridge , Cambridge , UK.,b Department of Paediatrics , University of Cambridge , Cambridge , UK
| | - Roman Hovorka
- a Wellcome Trust-MRC Institute of Metabolic Science , University of Cambridge , Cambridge , UK.,b Department of Paediatrics , University of Cambridge , Cambridge , UK
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50
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Ang KH, Sherr JL. Moving beyond subcutaneous insulin: the application of adjunctive therapies to the treatment of type 1 diabetes. Expert Opin Drug Deliv 2017; 14:1113-1131. [DOI: 10.1080/17425247.2017.1360862] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Kathleen H. Ang
- Yale Children’s Diabetes Program, Yale University School of Medicine, New Haven, CT, USA
| | - Jennifer L. Sherr
- Yale Children’s Diabetes Program, Yale University School of Medicine, New Haven, CT, USA
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