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Zaharieva DP, Morrison D, Paldus B, Lal RA, Buckingham BA, O'Neal DN. Practical Aspects and Exercise Safety Benefits of Automated Insulin Delivery Systems in Type 1 Diabetes. Diabetes Spectr 2023; 36:127-136. [PMID: 37193203 PMCID: PMC10182962 DOI: 10.2337/dsi22-0018] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
Regular exercise is essential to overall cardiovascular health and well-being in people with type 1 diabetes, but exercise can also lead to increased glycemic disturbances. Automated insulin delivery (AID) technology has been shown to modestly improve glycemic time in range (TIR) in adults with type 1 diabetes and significantly improve TIR in youth with type 1 diabetes. Available AID systems still require some user-initiated changes to the settings and, in some cases, significant pre-planning for exercise. Many exercise recommendations for type 1 diabetes were developed initially for people using multiple daily insulin injections or insulin pump therapy. This article highlights recommendations and practical strategies for using AID around exercise in type 1 diabetes.
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Affiliation(s)
- Dessi P Zaharieva
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Dale Morrison
- Department of Medicine, The University of Melbourne, Melbourne, Australia
| | - Barbora Paldus
- Department of Medicine, The University of Melbourne, Melbourne, Australia
- Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Rayhan A Lal
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
- Stanford Diabetes Research Center, Stanford, CA
- Division of Endocrinology, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Bruce A Buckingham
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
- Stanford Diabetes Research Center, Stanford, CA
| | - David N O'Neal
- Department of Medicine, The University of Melbourne, Melbourne, Australia
- Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
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2
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Adolfsson P, Taplin CE, Zaharieva DP, Pemberton J, Davis EA, Riddell MC, McGavock J, Moser O, Szadkowska A, Lopez P, Santiprabhob J, Frattolin E, Griffiths G, DiMeglio LA. ISPAD Clinical Practice Consensus Guidelines 2022: Exercise in children and adolescents with diabetes. Pediatr Diabetes 2022; 23:1341-1372. [PMID: 36537529 PMCID: PMC10107219 DOI: 10.1111/pedi.13452] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/07/2022] [Indexed: 12/24/2022] Open
Affiliation(s)
- Peter Adolfsson
- Department of Pediatrics, Kungsbacka Hospital, Kungsbacka, Sweden.,Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Craig E Taplin
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Nedlands, Western Australia, Australia.,Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia.,Centre for Child Health Research, University of Western Australia, Perth, Western Australia, Australia
| | - Dessi P Zaharieva
- Division of Endocrinology, Department of Pediatrics, School of Medicine, Stanford University, Stanford, California, USA
| | - John Pemberton
- Department of Endocrinology and Diabetes, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Elizabeth A Davis
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Nedlands, Western Australia, Australia.,Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia.,Centre for Child Health Research, University of Western Australia, Perth, Western Australia, Australia
| | - Michael C Riddell
- Muscle Health Research Centre, York University, Toronto, Ontario, Canada
| | - Jonathan McGavock
- Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, Manitoba, Canada.,Diabetes Research Envisioned and Accomplished in Manitoba (DREAM) Theme, Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada.,Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada.,Diabetes Action Canada SPOR Network, Toronto, Ontario, Canada
| | - Othmar Moser
- Division Exercise Physiology and Metabolism, Department of Sport Science, University of Bayreuth, Bayreuth, Germany.,Interdisciplinary Metabolic Medicine Trials Unit, Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Agnieszka Szadkowska
- Department of Pediatrics, Diabetology, Endocrinology & Nephrology, Medical University of Lodz, Lodz, Poland
| | - Prudence Lopez
- Department of Paediatrics, John Hunter Children's Hospital, Newcastle, New South Wales, Australia.,University of Newcastle, Newcastle, New South Wales, Australia
| | - Jeerunda Santiprabhob
- Siriraj Diabetes Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.,Division of Endocrinology and Metabolism, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | | | - Linda A DiMeglio
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetology, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana, USA
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3
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Evin F, Ata A, Er E, Demir G, Çetin H, Altınok YA, Özen S, Darcan Ş, Gökşen D. Predictive low-glucose suspend system and glycemic variability. Int J Diabetes Dev Ctries 2022. [DOI: 10.1007/s13410-021-00957-1] [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: 10/21/2022] Open
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Rosales N, De Battista H, Garelli F. Hypoglycemia prevention: PID-type controller adaptation for glucose rate limiting in Artificial Pancreas System. Biomed Signal Process Control 2022. [DOI: 10.1016/j.bspc.2021.103106] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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5
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Verbeeten KC, Perez Trejo ME, Tang K, Chan J, Courtney JM, Bradley BJ, McAssey K, Clarson C, Kirsch S, Curtis JR, Mahmud FH, Richardson C, Cooper T, Lawson ML. Fear of hypoglycemia in children with type 1 diabetes and their parents: Effect of pump therapy and continuous glucose monitoring with option of low glucose suspend in the CGM TIME trial. Pediatr Diabetes 2021; 22:288-293. [PMID: 33179818 PMCID: PMC7983886 DOI: 10.1111/pedi.13150] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 10/27/2020] [Accepted: 10/29/2020] [Indexed: 01/01/2023] Open
Abstract
To determine if pump therapy with continuous glucose monitoring offering low glucose suspend (LGS) decreases fear of hypoglycemia among children with type 1 diabetes and their parents. The CGM TIME trial is a multicenter randomized controlled trial that enrolled 144 children with type 1 diabetes for at least 1 year (mean duration 3.4 ± 3.1 years) starting pump therapy (MiniMed™ Veo™, Medtronic Canada). CGM (MiniMed™ Enlite™ sensor) offering LGS was introduced simultaneously or delayed for 6 months. Hypoglycemia Fear Scale (HFS) was completed by children ≥10 years old and all parents, at study entry and 12 months later. Simultaneous and Delayed Group participants were combined for all analyses. Subscale scores were compared with paired t-tests, and individual items with paired Wilcoxon tests. Linear regression examined association with CGM adherence. 121/140 parents and 91/99 children ≥10 years had complete data. Mean Behavior subscale score decreased from 21.1 (SD 5.9) to 17.2 (SD 6.1) (p < .001) for children, and 20.7 (SD 7.5) to 17.4 (7.4) (p < .001) for parents. Mean Worry subscale score decreased from 17.9 (SD 11.9) to 11.9 (SD 11.4) (p < .001) for children, and 23.1 (SD 13.2) to 17.6 (SD 10.4) (p < .001) for parents. Median scores for 10/25 child items and 12/25 parent items were significantly lower at 12 months (p < .001). Linear regression found no association between HFS scores and CGM adherence. Insulin pump therapy with CGM offering LGS significantly reduced fear of hypoglycemia not related to CGM adherence in children with type 1 diabetes and their parents.
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Affiliation(s)
- Kate C Verbeeten
- Division of Endocrinology and MetabolismChildren's Hospital of Eastern OntarioOttawaCanada
| | | | - Ken Tang
- CHEO Research InstituteOttawaCanada
| | | | | | | | | | - Cheril Clarson
- Department of PediatricsChildren's Hospital, London Health Sciences Centre, Lawson Health Research InstituteLondonCanada
| | - Susan Kirsch
- Department of PediatricsMarkham‐Stouffville HospitalMarkhamCanada
| | - Jacqueline R Curtis
- Division of Endocrinology and MetabolismHospital for Sick ChildrenTorontoCanada
| | - Farid H Mahmud
- Division of Endocrinology and MetabolismHospital for Sick ChildrenTorontoCanada
| | - Christine Richardson
- Division of Endocrinology and MetabolismChildren's Hospital of Eastern OntarioOttawaCanada
| | - Tammy Cooper
- Division of Endocrinology and MetabolismChildren's Hospital of Eastern OntarioOttawaCanada
| | - Margaret L Lawson
- Division of Endocrinology and MetabolismChildren's Hospital of Eastern OntarioOttawaCanada,CHEO Research InstituteOttawaCanada
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6
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Berget C, Lange S, Messer L, Forlenza GP. A clinical review of the t:slim X2 insulin pump. Expert Opin Drug Deliv 2020; 17:1675-1687. [PMID: 32842794 DOI: 10.1080/17425247.2020.1814734] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Insulin pumps are commonly used for intensive insulin therapy to treat type 1 diabetes in adults and youth. Insulin pump technologies have advanced dramatically in the last several years to integrate with continuous glucose monitors (CGM) and incorporate control algorithms. These control algorithms automate some insulin delivery in response to the glucose information received from the CGM to reduce the occurrence of hypoglycemia and hyperglycemia and improve overall glycemic control. The t:slim X2 insulin pump system became commercially available in 2016. It is an innovative insulin pump technology that can be updated remotely by the user to install new software onto the pump device as new technologies become available. Currently, the t:slim X2 pairs with the Dexcom G6 CGM and there are two advanced software options available: Basal-IQ, which is a predictive low glucose suspend (PLGS) technology, and Control-IQ, which is a Hybrid Closed Loop (HCL) technology. This paper will describe the different types of advanced insulin pump technologies, review how the t:slim X2 insulin pump works, and summarize the clinical studies leading to FDA approval and commercialization of the Basal-IQ and Control-IQ technologies.
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Affiliation(s)
- Cari Berget
- School of Medicine, Barbara Davis Center for Childhood Diabetes, University of Colorado Anschutz Campus , Aurora, CO, USA
| | - Samantha Lange
- School of Medicine, Barbara Davis Center for Childhood Diabetes, University of Colorado Anschutz Campus , Aurora, CO, USA
| | - Laurel Messer
- School of Medicine, Barbara Davis Center for Childhood Diabetes, University of Colorado Anschutz Campus , Aurora, CO, USA
| | - Gregory P Forlenza
- School of Medicine, Barbara Davis Center for Childhood Diabetes, University of Colorado Anschutz Campus , Aurora, CO, USA
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Gaweł WB, Deja G, Kamińska H, Tabor A, Skała-Zamorowska E, Jarosz-Chobot P. How does a predictive low glucose suspend (PLGS) system tackle pediatric lifespan challenges in diabetes treatment? Real world data analysis. Pediatr Diabetes 2020; 21:280-287. [PMID: 31715059 DOI: 10.1111/pedi.12944] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Revised: 09/17/2019] [Accepted: 10/28/2019] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES The aim of the study was to assess the benefits of a predictive low glucose suspend (PLGS) system in real-life in children and adolescents with type 1 diabetes of different age and age-related clinical challenges. METHODS Real life retrospective and descriptive analysis included 44 children (26 girls) with type 1 diabetes who were introduced to PLGS system. We divided them in three age groups: I (3-6 years old, n = 12), II (7-10 y/o, n = 16), III (11-19 y/o, n = 16). All children and their caregivers received unified training in self-management during PLGS therapy. Patients' data included: age, HbA1C levels, sex. While from the CGM metric, we obtained: time of sensor use (SENSuse), time in range (TiR): in, below and over target range and average blood glycemia (AVG), insulin suspension time (INSsusp). RESULTS SENSuse was 93% in total, with 92%, 94%, and 87% in age groups I, II, III, respectively. In total the reduction of mean HbA1C from 7.61% to 6.88% (P < .05), while for the I, II, and III it was 7.46% to 6.72%, 6.91% to 6.41%, and 8.46 to 7.44%, respectively (P < .05). Although we observed a significant reduction of HbA1C, the time below target range was minimal. Specific findings included: group I-longest INSsusp (17%), group II-lowest glycemic variability (CV) (36%), and group III-highest AVG (169 mg/dL). There was a reverse correlation between suspend before low and age (-0.32, P < .05). In group I CV reduced TiR in target range (TiRin) (-0.82, P < .05), in group II use of complex boluses increased TiRin (0.52, P < .05). In group III higher CV increased HbA1C (0.64, P < .05) while reducing TiRin (-0.72, P < .05). CONCLUSIONS PLGS is a suitable and safe therapeutic option for children with diabetes of all age and it is effective in addressing age-specific challenges. PLGS improves glycemic control in children of all age, positively affecting its different parameters.
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Affiliation(s)
- Władysław B Gaweł
- Students' Scientific Association at the Department of Children's Diabetology, Medical University of Silesia, Katowice, Poland
| | - Grażyna Deja
- Department of Children's Diabetology, Medical University of Silesia, Katowice, Poland
| | - Halla Kamińska
- Department of Children's Diabetology, Medical University of Silesia, Katowice, Poland
| | - Aleksandra Tabor
- Students' Scientific Association at the Department of Children's Diabetology, Medical University of Silesia, Katowice, Poland
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8
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Knoll MM, Vazifedan T, Gyuricsko E. Air occlusion in insulin pumps of children and adolescents with type 1 diabetes. J Pediatr Endocrinol Metab 2020; 33:179-184. [PMID: 31812947 DOI: 10.1515/jpem-2019-0358] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 10/13/2019] [Indexed: 11/15/2022]
Abstract
Background Insulin pumps are a frequently used technology among youth with type 1 diabetes. Air bubbles within insulin pump tubing are common, preventing insulin delivery and increasing the risk of large glycemic excursions and diabetic ketoacidosis (DKA). We sought to determine the prevalence of air bubbles in insulin pump tubing and identify factors associated with clinically significant air bubbles. Methods Fifty-three subjects were recruited over 65 office visits. The insulin pump tubing was visualized, and any air bubbles were measured by length. The length of air bubbles was then converted to time without insulin at the lowest basal rate. Generalized linear model (GLM) was used to determine the associations between air bubble size and other variables. Results Of the 65 encounters, 45 had air bubbles in the tubing. Five (5/65 = 7.7%) encounters had a time without insulin of more than 60 min. Air bubble size was inversely correlated with time since infusion set change (p < 0.001), and directly correlated with age of the subject (p = 0.049). Conclusions Significantly more air bubbles were found in the tubing of insulin pumps soon after infusion set change and with older subjects, suggesting a relationship with the technique of filling the insulin cartridge and priming the tubing.
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Affiliation(s)
- Michelle M Knoll
- Eastern Virginia Medical School/Children's Hospital of the King's Daughters, Department of Pediatrics, Norfolk, VA, USA.,Department of Pediatric Endocrinology, Children's Mercy Kansas City, 3101 Broadway Blvd, Kansas City, MO 64111, USA
| | - Turaj Vazifedan
- Children's Hospital of the King's Daughters, Department of Pediatrics, Norfolk, VA, USA
| | - Eric Gyuricsko
- Eastern Virginia Medical School/Children's Hospital of the King's Daughters, Department of Pediatrics, Division of Pediatric Endocrinology, Norfolk, VA, USA
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9
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Kovatchev B. A Century of Diabetes Technology: Signals, Models, and Artificial Pancreas Control. Trends Endocrinol Metab 2019; 30:432-444. [PMID: 31151733 DOI: 10.1016/j.tem.2019.04.008] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 04/14/2019] [Accepted: 04/25/2019] [Indexed: 12/24/2022]
Abstract
Arguably, diabetes mellitus is one of the best-quantified human conditions: elaborate in silico models describe the action of the human metabolic system; real-time signals such as continuous glucose monitoring are readily available; insulin delivery is being automated; and control algorithms are capable of optimizing blood glucose fluctuation in patients' natural environments. The transition of the artificial pancreas (AP) to everyday clinical use is happening now, and is contingent upon seamless concerted work of devices encompassing the patient in a digital treatment ecosystem. This review recounts briefly the story of diabetes technology, which began a century ago with the discovery of insulin, progressed through glucose monitoring and subcutaneous insulin delivery, and is now rapidly advancing towards fully automated clinically viable AP systems.
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Affiliation(s)
- Boris Kovatchev
- University of Virginia School of Medicine, UVA Center for Diabetes Technology, Ivy Translational Research Building, 560 Ray C. Hunt Drive, Charlottesville, VA 22903-2981, USA.
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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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11
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Vettoretti M, Facchinetti A. Combining continuous glucose monitoring and insulin pumps to automatically tune the basal insulin infusion in diabetes therapy: a review. Biomed Eng Online 2019; 18:37. [PMID: 30922295 PMCID: PMC6440103 DOI: 10.1186/s12938-019-0658-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 03/20/2019] [Indexed: 12/19/2022] Open
Abstract
For individuals affected by Type 1 diabetes (T1D), a chronic disease in which the pancreas does not produce any insulin, maintaining the blood glucose (BG) concentration as much as possible within the safety range (70–180 mg/dl) allows avoiding short- and long-term complications. The tuning of exogenous insulin infusion can be difficult, especially because of the inter- and intra-day variability of physiological and behavioral factors. Continuous glucose monitoring (CGM) sensors, which monitor glucose concentration in the subcutaneous tissue almost continuously, allowed improving the detection of critical hypo- and hyper-glycemic episodes. Moreover, their integration with insulin pumps for continuous subcutaneous insulin infusion allowed developing algorithms that automatically tune insulin dosing based on CGM measurements in order to mitigate the incidence of critical episodes. In this work, we aim at reviewing the literature on methods for CGM-based automatic attenuation or suspension of basal insulin with a focus on algorithms, their implementation in commercial devices and clinical evidence of their effectiveness and safety.
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Affiliation(s)
- Martina Vettoretti
- Department of Information Engineering, University of Padova, Via G. Gradenigo 6/B, 35131, Padova, Italy
| | - Andrea Facchinetti
- Department of Information Engineering, University of Padova, Via G. Gradenigo 6/B, 35131, Padova, Italy.
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12
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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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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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Forlenza GP, Li Z, Buckingham BA, Pinsker JE, Cengiz E, Wadwa RP, Ekhlaspour L, Church MM, Weinzimer SA, Jost E, Marcal T, Andre C, Carria L, Swanson V, Lum JW, Kollman C, Woodall W, Beck RW. Predictive Low-Glucose Suspend Reduces Hypoglycemia in Adults, Adolescents, and Children With Type 1 Diabetes in an At-Home Randomized Crossover Study: Results of the PROLOG Trial. Diabetes Care 2018; 41:2155-2161. [PMID: 30089663 DOI: 10.2337/dc18-0771] [Citation(s) in RCA: 154] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 06/28/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE This study evaluated a new insulin delivery system designed to reduce insulin delivery when trends in continuous glucose monitoring (CGM) glucose concentrations predict future hypoglycemia. RESEARCH DESIGN AND METHODS Individuals with type 1 diabetes (n = 103, age 6-72 years, mean HbA1c 7.3% [56 mmol/mol]) participated in a 6-week randomized crossover trial to evaluate the efficacy and safety of a Tandem Diabetes Care t:slim X2 pump with Basal-IQ integrated with a Dexcom G5 sensor and a predictive low-glucose suspend algorithm (PLGS) compared with sensor-augmented pump (SAP) therapy. The primary outcome was CGM-measured time <70 mg/dL. RESULTS Both study periods were completed by 99% of participants; median CGM usage exceeded 90% in both arms. Median time <70 mg/dL was reduced from 3.6% at baseline to 2.6% during the 3-week period in the PLGS arm compared with 3.2% in the SAP arm (difference [PLGS - SAP] = -0.8%, 95% CI -1.1 to -0.5, P < 0.001). The corresponding mean values were 4.4%, 3.1%, and 4.5%, respectively, represent-ing a 31% reduction in the time <70 mg/dL with PLGS. There was no increase in mean glucose concentration (159 vs. 159 mg/dL, P = 0.40) or percentage of time spent >180 mg/dL (32% vs. 33%, P = 0.12). One severe hypoglycemic event occurred in the SAP arm and none in the PLGS arm. Mean pump suspension time was 104 min/day. CONCLUSIONS The Tandem Diabetes Care Basal-IQ PLGS system significantly reduced hypoglycemia without rebound hyperglycemia, indicating that the system can benefit adults and youth with type 1 diabetes in improving glycemic control.
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Affiliation(s)
- Gregory P Forlenza
- Barbara Davis Center for Diabetes, University of Colorado Denver, Aurora, CO
| | - Zoey Li
- Diabetes Study Group, Jaeb Center for Health Research, Tampa, FL
| | - Bruce A Buckingham
- Division of Pediatric Endocrinology and Diabetes, Stanford University, Stanford, CA
| | - Jordan E Pinsker
- Clinical Research, Sansum Diabetes Research Institute, Santa Barbara, CA
| | - Eda Cengiz
- Division of Pediatric Endocrinology and Diabetes, Yale University, New Haven, CT
| | - R Paul Wadwa
- Barbara Davis Center for Diabetes, University of Colorado Denver, Aurora, CO
| | - Laya Ekhlaspour
- Division of Pediatric Endocrinology and Diabetes, Stanford University, Stanford, CA
| | - Mei Mei Church
- Clinical Research, Sansum Diabetes Research Institute, Santa Barbara, CA
| | - Stuart A Weinzimer
- Division of Pediatric Endocrinology and Diabetes, Yale University, New Haven, CT
| | - Emily Jost
- Barbara Davis Center for Diabetes, University of Colorado Denver, Aurora, CO
| | - Tatiana Marcal
- Division of Pediatric Endocrinology and Diabetes, Stanford University, Stanford, CA
| | - Camille Andre
- Clinical Research, Sansum Diabetes Research Institute, Santa Barbara, CA
| | - Lori Carria
- Division of Pediatric Endocrinology and Diabetes, Yale University, New Haven, CT
| | - Vance Swanson
- Clinical Affairs, Tandem Diabetes Care, San Diego, CA
| | - John W Lum
- Diabetes Study Group, Jaeb Center for Health Research, Tampa, FL
| | - Craig Kollman
- Diabetes Study Group, Jaeb Center for Health Research, Tampa, FL
| | - William Woodall
- Diabetes Study Group, Jaeb Center for Health Research, Tampa, FL
| | - Roy W Beck
- Diabetes Study Group, Jaeb Center for Health Research, Tampa, FL
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Wadwa RP, Chase HP, Raghinaru D, Buckingham BA, Hramiak I, Maahs DM, Messer L, Ly T, Aye T, Clinton P, Kollman C, Beck RW, Lum J. Ketone production in children with type 1 diabetes, ages 4-14 years, with and without nocturnal insulin pump suspension. Pediatr Diabetes 2017; 18:422-427. [PMID: 27402452 PMCID: PMC5233607 DOI: 10.1111/pedi.12410] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 05/12/2016] [Accepted: 06/07/2016] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To compare the frequency of elevated morning blood ketone levels according to age in 4-14 year olds with type 1 diabetes following overnight use of an automated low glucose insulin suspension system, or following control nights when the system was not used. RESEARCH DESIGN AND METHODS For 28 children ages 4-9 years and 54 youth ages 10-14 years, elevation of morning blood ketone levels was assessed using the Precision Xtra Ketone meter following 1155 and 2345 nights, respectively. Repeated measures logistic regression models were used to compare age groups for blood ketone level elevation following control nights (system not activated) and following intervention nights with and without insulin suspension. RESULTS Elevated morning blood ketones (≥0.6 mmol/L) were present following 10% of 580 control nights in the 4-9 year olds compared with 2% of 1162 control nights in 10-14 year olds (P < 0.001). Likewise, the frequency was greater following intervention nights in the younger age group (13% of 575 nights vs 2% of 1183 nights, P < 0.001). A longer duration of pump suspension resulted in a higher percentage of mornings with elevated blood ketones in the younger age group (P = 0.002), but not in the older age group (P = 0.63). The presence of elevated morning ketone levels did not progress to ketoacidosis in any subject. CONCLUSIONS Elevated morning blood ketones are more common in younger children with type 1 diabetes with or without nocturnal insulin suspension. Care providers need to be aware of the differences in ketogenesis in younger age children relative to various clinical situations.
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Affiliation(s)
- R Paul Wadwa
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - H Peter Chase
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Dan Raghinaru
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - Bruce A Buckingham
- Division of Pediatric Endocrinology and Diabetes, Stanford University, Stanford, California, USA
| | - Irene Hramiak
- Division of Endocrinology & Metabolism, St. Joseph's Health Care, London, ON, Canada
| | - David M Maahs
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Laurel Messer
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Trang Ly
- Division of Pediatric Endocrinology and Diabetes, Stanford University, Stanford, California, USA
| | - Tandy Aye
- Division of Pediatric Endocrinology and Diabetes, Stanford University, Stanford, California, USA
| | - Paula Clinton
- Division of Pediatric Endocrinology and Diabetes, Stanford University, Stanford, California, USA
| | - Craig Kollman
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - Roy W Beck
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - John Lum
- Jaeb Center for Health Research, Tampa, Florida, USA
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16
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Abstract
PURPOSE OF REVIEW The review summarizes the current state of the artificial pancreas (AP) systems and introduces various new modules that should be included in future AP systems. RECENT FINDINGS A fully automated AP must be able to detect and mitigate the effects of meals, exercise, stress and sleep on blood glucose concentrations. This can only be achieved by using a multivariable approach that leverages information from wearable devices that provide real-time streaming data about various physiological variables that indicate imminent changes in blood glucose concentrations caused by meals, exercise, stress and sleep. The development of a fully automated AP will necessitate the design of multivariable and adaptive systems that use information from wearable devices in addition to glucose sensors and modify the models used in their model-predictive alarm and control systems to adapt to the changes in the metabolic state of the user. These AP systems will also integrate modules for controller performance assessment, fault detection and diagnosis, machine learning and classification to interpret various signals and achieve fault-tolerant control. Advances in wearable devices, computational power, and safe and secure communications are enabling the development of fully automated multivariable AP systems.
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Affiliation(s)
- Ali Cinar
- Department of Chemical and Biological Engineering and Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, IL, USA.
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17
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Battelino T, Nimri R, Dovc K, Phillip M, Bratina N. Prevention of Hypoglycemia With Predictive Low Glucose Insulin Suspension in Children With Type 1 Diabetes: A Randomized Controlled Trial. Diabetes Care 2017; 40:764-770. [PMID: 28351897 DOI: 10.2337/dc16-2584] [Citation(s) in RCA: 116] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Accepted: 03/07/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To investigate whether predictive low glucose management (PLGM) of the MiniMed 640G system significantly reduces the rate of hypoglycemia compared with the sensor-augmented insulin pump in children with type 1 diabetes. RESEARCH DESIGN AND METHODS This randomized, two-arm, parallel, controlled, two-center open-label study included 100 children and adolescents with type 1 diabetes and glycated hemoglobin A1c ≤10% (≤86 mmol/mol) and using continuous subcutaneous insulin infusion. Patients were randomly assigned to either an intervention group with PLGM features enabled (PLGM ON) or a control group (PLGM OFF), in a 1:1 ratio, all using the same type of sensor-augmented insulin pump. The primary end point was the number of hypoglycemic events below 65 mg/dL (3.6 mmol/L), based on sensor glucose readings, during a 14-day study treatment. The analysis was performed by intention to treat for all randomized patients. RESULTS The number of hypoglycemic events below 65 mg/dL (3.6 mmol/L) was significantly smaller in the PLGM ON compared with the PLGM OFF group (mean ± SD 4.4 ± 4.5 and 7.4 ± 6.3, respectively; P = 0.008). This was also true when calculated separately for night (P = 0.025) and day (P = 0.022). No severe hypoglycemic events occurred; however, there was a significant increase in time spent above 140 mg/dL (7.8 mmol/L) in the PLGM ON group (P = 0.0165). CONCLUSIONS The PLGM insulin suspension was associated with a significantly reduced number of hypoglycemic events. Although this was achieved at the expense of increased time in moderate hyperglycemia, there were no serious adverse effects in young patients with type 1 diabetes.
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Affiliation(s)
- Tadej Battelino
- Department of Pediatric Endocrinology, Diabetes and Metabolism, University Medical Centre-University Children's Hospital, Ljubljana, Slovenia .,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Revital Nimri
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center, Petah Tikva, Israel
| | - Klemen Dovc
- Department of Pediatric Endocrinology, Diabetes and Metabolism, University Medical Centre-University Children's Hospital, Ljubljana, Slovenia
| | - Moshe Phillip
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Natasa Bratina
- Department of Pediatric Endocrinology, Diabetes and Metabolism, University Medical Centre-University Children's Hospital, Ljubljana, Slovenia
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18
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Affiliation(s)
| | - Eyal Dassau
- 1 William Sansum Diabetes Center , Santa Barbara, California
- 2 Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University , Cambridge, Massachusetts
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19
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Efectividad del sistema MiniMed 640G con SmartGuard® para la prevención de hipoglucemia en pacientes pediátricos con diabetes mellitus tipo 1. ENDOCRINOL DIAB NUTR 2017; 64:198-203. [DOI: 10.1016/j.endinu.2017.02.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Revised: 02/08/2017] [Accepted: 02/20/2017] [Indexed: 12/20/2022]
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20
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Steineck I, Ranjan A, Nørgaard K, Schmidt S. Sensor-Augmented Insulin Pumps and Hypoglycemia Prevention in Type 1 Diabetes. J Diabetes Sci Technol 2017; 11:50-58. [PMID: 28264173 PMCID: PMC5375081 DOI: 10.1177/1932296816672689] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Hypoglycemia can lead to seizures, unconsciousness, or death. Insulin pump treatment reduces the frequency of severe hypoglycemia compared with multiple daily injections treatment. The addition of a continuous glucose monitor, so-called sensor-augmented pump (SAP) treatment, has the potential to further limit the duration and severity of hypoglycemia as the system can detect and in some systems act on impending and prevailing low blood glucose levels. In this narrative review we summarize the available knowledge on SAPs with and without automated insulin suspension, in relation to hypoglycemia prevention. We present evidence from randomized trials, observational studies, and meta-analyses including nonpregnant individuals with type 1 diabetes mellitus. We also outline concerns regarding SAPs with and without automated insulin suspension. There is evidence that SAP treatment reduces episodes of moderate and severe hypoglycemia compared with multiple daily injections plus self-monitoring of blood glucose. There is some evidence that SAPs both with and without automated suspension reduces the frequency of severe hypoglycemic events compared with insulin pumps without continuous glucose monitoring.
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Affiliation(s)
- Isabelle Steineck
- Department of Endocrinology, Hvidovre University Hospital, Hvidovre, Denmark
- Danish Diabetes Academy, Odense, Denmark
- Isabelle Steineck, MD, Department of Endocrinology, Hvidovre University Hospital, Kettegård Allé 30, 2650 Hvidovre, Denmark.
| | - Ajenthen Ranjan
- Department of Endocrinology, Hvidovre University Hospital, Hvidovre, Denmark
- Danish Diabetes Academy, Odense, Denmark
| | - Kirsten Nørgaard
- Department of Endocrinology, Hvidovre University Hospital, Hvidovre, Denmark
| | - Signe Schmidt
- Department of Endocrinology, Hvidovre University Hospital, Hvidovre, Denmark
- Danish Diabetes Academy, Odense, Denmark
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21
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Abraham MB, Davey R, O'Grady MJ, Ly TT, Paramalingam N, Fournier PA, Roy A, Grosman B, Kurtz N, Fairchild JM, King BR, Ambler GR, Cameron F, Jones TW, Davis EA. Effectiveness of a Predictive Algorithm in the Prevention of Exercise-Induced Hypoglycemia in Type 1 Diabetes. Diabetes Technol Ther 2016; 18:543-50. [PMID: 27505305 DOI: 10.1089/dia.2016.0141] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Sensor-augmented pump therapy (SAPT) with a predictive algorithm to suspend insulin delivery has the potential to reduce hypoglycemia, a known obstacle in improving physical activity in patients with type 1 diabetes. The predictive low glucose management (PLGM) system employs a predictive algorithm that suspends basal insulin when hypoglycemia is predicted. The aim of this study was to determine the efficacy of this algorithm in the prevention of exercise-induced hypoglycemia under in-clinic conditions. METHODS This was a randomized, controlled cross-over study in which 25 participants performed 2 consecutive sessions of 30 min of moderate-intensity exercise while on basal continuous subcutaneous insulin infusion on 2 study days: a control day with SAPT alone and an intervention day with SAPT and PLGM. The predictive algorithm suspended basal insulin when sensor glucose was predicted to be below the preset hypoglycemic threshold in 30 min. We tested preset hypoglycemic thresholds of 70 and 80 mg/dL. The primary outcome was the requirement for hypoglycemia treatment (symptomatic hypoglycemia with plasma glucose <63 mg/dL or plasma glucose <50 mg/dL) and was compared in both control and intervention arms. RESULTS Results were analyzed in 19 participants. In the intervention arm with both thresholds, only 6 participants (32%) required treatment for hypoglycemia compared with 17 participants (89%) in the control arm (P = 0.003). In participants with a 2-h pump suspension on intervention days, the plasma glucose was 84 ± 12 and 99 ± 24 mg/dL at thresholds of 70 and 80 mg/dL, respectively. CONCLUSIONS SAPT with PLGM reduced the need for hypoglycemia treatment after moderate-intensity exercise in an in-clinic setting.
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Affiliation(s)
- Mary B Abraham
- 1 Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children , Perth, Australia
- 2 School of Paediatrics and Child Health, The University of Western Australia , Perth, Australia
| | - Raymond Davey
- 2 School of Paediatrics and Child Health, The University of Western Australia , Perth, Australia
- 3 Telethon Kids Institute, The University of Western Australia , Perth, Australia
| | - Michael J O'Grady
- 1 Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children , Perth, Australia
- 3 Telethon Kids Institute, The University of Western Australia , Perth, Australia
| | - Trang T Ly
- 1 Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children , Perth, Australia
- 2 School of Paediatrics and Child Health, The University of Western Australia , Perth, Australia
- 3 Telethon Kids Institute, The University of Western Australia , Perth, Australia
| | - Nirubasini Paramalingam
- 1 Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children , Perth, Australia
- 3 Telethon Kids Institute, The University of Western Australia , Perth, Australia
| | - Paul A Fournier
- 4 School of Sport Science, Exercise and Health, The University of Western Australia , Perth, Australia
| | - Anirban Roy
- 5 Medtronic MiniMed , Northridge, California
| | | | | | - Janice M Fairchild
- 6 Department of Endocrinology and Diabetes, Women's and Children's Hospital , Adelaide, Australia
| | - Bruce R King
- 7 Department of Endocrinology and Diabetes, John Hunter Children's Hospital , Newcastle, Australia
| | - Geoffrey R Ambler
- 8 Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, The University of Sydney , Sydney, Australia
| | - Fergus Cameron
- 9 Department of Endocrinology and Diabetes, Royal Children's Hospital , Melbourne, Australia
| | - Timothy W Jones
- 1 Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children , Perth, Australia
- 2 School of Paediatrics and Child Health, The University of Western Australia , Perth, Australia
- 3 Telethon Kids Institute, The University of Western Australia , Perth, Australia
| | - Elizabeth A Davis
- 1 Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children , Perth, Australia
- 2 School of Paediatrics and Child Health, The University of Western Australia , Perth, Australia
- 3 Telethon Kids Institute, The University of Western Australia , Perth, Australia
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22
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Kovatchev B, Tamborlane WV, Cefalu WT, Cobelli C. The Artificial Pancreas in 2016: A Digital Treatment Ecosystem for Diabetes. Diabetes Care 2016; 39:1123-6. [PMID: 27330124 PMCID: PMC4915552 DOI: 10.2337/dc16-0824] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Boris Kovatchev
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | - William V Tamborlane
- Division of Pediatric Endocrinology, Department of Pediatrics, Yale School of Medicine, New Haven, CT
| | - William T Cefalu
- Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, LA
| | - Claudio Cobelli
- Department of Information Engineering, University of Padova, Padova, Italy
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23
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Hering BJ, Clarke WR, Bridges ND, Eggerman TL, Alejandro R, Bellin MD, Chaloner K, Czarniecki CW, Goldstein JS, Hunsicker LG, Kaufman DB, Korsgren O, Larsen CP, Luo X, Markmann JF, Naji A, Oberholzer J, Posselt AM, Rickels MR, Ricordi C, Robien MA, Senior PA, Shapiro AMJ, Stock PG, Turgeon NA. Phase 3 Trial of Transplantation of Human Islets in Type 1 Diabetes Complicated by Severe Hypoglycemia. Diabetes Care 2016; 39:1230-40. [PMID: 27208344 PMCID: PMC5317236 DOI: 10.2337/dc15-1988] [Citation(s) in RCA: 407] [Impact Index Per Article: 50.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 02/21/2016] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Impaired awareness of hypoglycemia (IAH) and severe hypoglycemic events (SHEs) cause substantial morbidity and mortality in patients with type 1 diabetes (T1D). Current therapies are effective in preventing SHEs in 50-80% of patients with IAH and SHEs, leaving a substantial number of patients at risk. We evaluated the effectiveness and safety of a standardized human pancreatic islet product in subjects in whom IAH and SHEs persisted despite medical treatment. RESEARCH DESIGN AND METHODS This multicenter, single-arm, phase 3 study of the investigational product purified human pancreatic islets (PHPI) was conducted at eight centers in North America. Forty-eight adults with T1D for >5 years, absent stimulated C-peptide, and documented IAH and SHEs despite expert care were enrolled. Each received immunosuppression and one or more transplants of PHPI, manufactured on-site under good manufacturing practice conditions using a common batch record and standardized lot release criteria and test methods. The primary end point was the achievement of HbA1c <7.0% (53 mmol/mol) at day 365 and freedom from SHEs from day 28 to day 365 after the first transplant. RESULTS The primary end point was successfully met by 87.5% of subjects at 1 year and by 71% at 2 years. The median HbA1c level was 5.6% (38 mmol/mol) at both 1 and 2 years. Hypoglycemia awareness was restored, with highly significant improvements in Clarke and HYPO scores (P > 0.0001). No study-related deaths or disabilities occurred. Five of the enrollees (10.4%) experienced bleeds requiring transfusions (corresponding to 5 of 75 procedures), and two enrollees (4.1%) had infections attributed to immunosuppression. Glomerular filtration rate decreased significantly on immunosuppression, and donor-specific antibodies developed in two patients. CONCLUSIONS Transplanted PHPI provided glycemic control, restoration of hypoglycemia awareness, and protection from SHEs in subjects with intractable IAH and SHEs. Safety events occurred related to the infusion procedure and immunosuppression, including bleeding and decreased renal function. Islet transplantation should be considered for patients with T1D and IAH in whom other, less invasive current treatments have been ineffective in preventing SHEs.
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Affiliation(s)
- Bernhard J Hering
- Schulze Diabetes Institute and Department of Surgery, University of Minnesota, Minneapolis, MN
| | - William R Clarke
- Clinical Trials Statistical and Data Management Center, University of Iowa, Iowa City, IA
| | - Nancy D Bridges
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Thomas L Eggerman
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Rodolfo Alejandro
- Diabetes Research Institute, Miller School of Medicine, University of Miami, Miami, FL
| | - Melena D Bellin
- Schulze Diabetes Institute and Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | - Kathryn Chaloner
- Clinical Trials Statistical and Data Management Center, University of Iowa, Iowa City, IA
| | - Christine W Czarniecki
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Julia S Goldstein
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Lawrence G Hunsicker
- Clinical Trials Statistical and Data Management Center, University of Iowa, Iowa City, IA
| | - Dixon B Kaufman
- Division of Transplantation, Department of Surgery, University of Wisconsin, Madison, WI
| | - Olle Korsgren
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | | | - Xunrong Luo
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - James F Markmann
- Division of Transplant Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Ali Naji
- Institute for Diabetes, Obesity and Metabolism and Departments of Surgery and Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jose Oberholzer
- Division of Transplantation, University of Illinois Hospital and Health Sciences System, Chicago, IL
| | - Andrew M Posselt
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Michael R Rickels
- Institute for Diabetes, Obesity and Metabolism and Departments of Surgery and Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Camillo Ricordi
- Diabetes Research Institute, Miller School of Medicine, University of Miami, Miami, FL
| | - Mark A Robien
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Peter A Senior
- Clinical Islet Transplant Program and Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - A M James Shapiro
- Clinical Islet Transplant Program and Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Peter G Stock
- Department of Surgery, University of California, San Francisco, San Francisco, CA
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24
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Choudhary P, Olsen BS, Conget I, Welsh JB, Vorrink L, Shin JJ. Hypoglycemia Prevention and User Acceptance of an Insulin Pump System with Predictive Low Glucose Management. Diabetes Technol Ther 2016; 18:288-91. [PMID: 26907513 PMCID: PMC4870649 DOI: 10.1089/dia.2015.0324] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND The MiniMed 640G sensor-augmented insulin pump system (Medtronic, Inc., Northridge, CA) can automatically suspend insulin delivery in advance of predicted hypoglycemia and restart it upon recovery. The aims of this analysis were to determine the rate at which predicted hypoglycemia was avoided with this strategy, as well as to assess user acceptance of the system and its insulin management features. SUBJECTS AND METHODS Forty subjects with type 1 diabetes used the system for 4 weeks. We retrospectively evaluated performance of the system, using downloaded pump and sensor data, and evaluated user acceptance via questionnaires. RESULTS There were 2,322 suspend before low events (2.1 per subject-day). The mean (± SD) duration of pump suspension events was 56.4 ± 9.6 min, and the mean subsequent sensor glucose (SG) nadir was 71.8 ± 5.2 mg/dL. SG values following 1,930 (83.1%) of the predictive suspensions did not reach the preset low limit. Nadir SG values of ≤50 and ≤60 mg/dL were seen in 207 (8.9%) and 356 (15.3%) of the predictive suspensions, respectively. Blood glucose (BG) and SG values before and during the study were comparable (P > 0.05). The mean absolute relative difference between paired SG and BG values was 10.9 ± 13.8%. Subjects felt confident using the system, agreed that it helped protect them from hypoglycemia, and wished to continue using it. CONCLUSIONS Automatic insulin pump suspension as implemented in the MiniMed 640G system can help patients avoid hypoglycemia, without significantly increasing hyperglycemia.
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Affiliation(s)
| | | | - Ignacio Conget
- Diabetes Unit, Clinic and University Hospital, Barcelona, Spain
| | - John B. Welsh
- Medtronic International Trading Sàrl, Tolochenaz, Switzerland
| | | | - John J. Shin
- Medtronic International Trading Sàrl, Tolochenaz, Switzerland
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25
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Abstract
Many patients with advanced type 2 diabetes mellitus (T2DM) and all patients with T1DM require insulin to keep blood glucose levels in the target range. The most common route of insulin administration is subcutaneous insulin injections. There are many ways to deliver insulin subcutaneously such as vials and syringes, insulin pens, and insulin pumps. Though subcutaneous insulin delivery is the standard route of insulin administration, it is associated with injection pain, needle phobia, lipodystrophy, noncompliance and peripheral hyperinsulinemia. Therefore, the need exists for delivering insulin in a minimally invasive or noninvasive and in most physiological way. Inhaled insulin was the first approved noninvasive and alternative way to deliver insulin, but it has been withdrawn from the market. Technologies are being explored to make the noninvasive delivery of insulin possible. Some of the routes of insulin administration that are under investigation are oral, buccal, nasal, peritoneal and transdermal. This review article focuses on the past, present and future of various insulin delivery techniques. This article has focused on different possible routes of insulin administration with its advantages and limitation and possible scope for the new drug development.
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Affiliation(s)
- Rima B Shah
- Department of Pharmacology, GMERS Medial College, Gandhinagar, Gujarat, India
| | - Manhar Patel
- Brain Research and Intervention Center, University of Illinois, Chicago, USA
| | - David M Maahs
- Barbara Davis Center for Diabetes, University of Colorado, Denver, USA
| | - Viral N Shah
- Barbara Davis Center for Diabetes, University of Colorado, Denver, USA
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26
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Hering BJ, Cozzi E, Spizzo T, Cowan PJ, Rayat GR, Cooper DKC, Denner J. First update of the International Xenotransplantation Association consensus statement on conditions for undertaking clinical trials of porcine islet products in type 1 diabetes--Executive summary. Xenotransplantation 2016; 23:3-13. [PMID: 26940725 DOI: 10.1111/xen.12231] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 02/16/2016] [Indexed: 01/17/2023]
Abstract
The International Xenotransplantation Association has updated its original "Consensus Statement on Conditions for Undertaking Clinical Trials of Porcine Islet Products in Type 1 Diabetes," which was published in Xenotransplantation in 2009. This update is timely and important in light of scientific progress and changes in the regulatory framework pertinent to islet xenotransplantation. Except for the chapter on "informed consent," which has remained relevant in its 2009 version, all other chapters included in the initial consensus statement have been revised for inclusion in this update. These chapters will not provide complete revisions of the original chapters; rather, they restate the key points made in 2009, emphasize new and under-appreciated topics not fully addressed in 2009, suggest relevant revisions, and communicate opinions that complement the consensus opinion. Chapter 1 provides an update on national regulatory frameworks addressing xenotransplantation. Chapter 2 a, previously Chapter 2, suggests several important revisions regarding the generation of suitable source pigs from the perspective of the prevention of xenozoonoses. The newly added Chapter 2b discusses conditions for the use of genetically modified source pigs in clinical islet xenotransplantation. Chapter 3 reviews porcine islet product manufacturing and release testing. Chapter 4 revisits the critically important topic of preclinical efficacy and safety data required to justify a clinical trial. The main achievements in the field of transmission of all porcine microorganisms, the rationale for more proportionate recipient monitoring, and response plans are reviewed in Chapter 5. Patient selection criteria and circumstances where trials of islet xenotransplantation would be both medically and ethically justified are examined in Chapter 6 in the context of recent advances in available and emerging alternative therapies for serious and potentially life-threatening complications of diabetes. It is hoped that this first update of the International Xenotransplantation Association porcine islet transplant consensus statement will assist the islet xenotransplant scientific community, sponsors, regulators, and other stakeholders actively involved in the clinical translation of islet xenotransplantation.
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Affiliation(s)
- Bernhard J Hering
- Schulze Diabetes Institute, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Emanuele Cozzi
- Transplant Immunology Unit, Department of Transfusion Medicine, Padua University Hospital, Padua, Italy.,CORIT (Consortium for Research in Organ Transplantation), Padua, Italy
| | | | - Peter J Cowan
- Immunology Research Centre, St Vincent's Hospital, Melbourne, Vic., Australia
| | - Gina R Rayat
- The Surgical-Medical Research Institute, Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada
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Levy BL, McCann TW, Finan DA. The Hypoglycaemia-Hyperglycaemia Minimizer System in the Management of Type 1 Diabetes. EUROPEAN ENDOCRINOLOGY 2016; 12:18-23. [PMID: 29632582 PMCID: PMC5813453 DOI: 10.17925/ee.2016.12.01.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 01/25/2016] [Indexed: 11/24/2022]
Abstract
Living with type 1 diabetes (T1D) presents many challenges in terms of daily living. Insulin users need to frequently monitor their blood glucose levels and take multiple injections per day and/or multiple boluses through an insulin infusion pump, with the consequences of failing to match the insulin dose to the body's needs resulting in hypoglycaemia and hyperglycaemia. The former can result in seizures, coma and even death; the latter can have both acute and long-term health implications. Many patients with T1D also fail to meet their treatment goals. In order to reduce the burdens of self-administering insulin, and improve efficacy and safety, there is a need to at least partially remove the patient from the loop via a closed-loop 'artificial pancreas’ system. The Hypoglycaemia-Hyperglycaemia Minimizer (HHM) System, comprising a continuous, subcutaneous insulin infusion pump, continuous glucose monitor (CGM) and closed-loop insulin dosing algorithm, is able to predict changes in blood glucose and adjust insulin delivery accordingly to help keep the patient at normal glucose levels. Early clinical data indicate that this system is feasible, effective and safe, and has the potential to dramatically improve the therapeutic outcomes and quality of life for people with T1D.
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Hering BJ, O'Connell PJ. First update of the International Xenotransplantation Association consensus statement on conditions for undertaking clinical trials of porcine islet products in type 1 diabetes--Chapter 6: patient selection for pilot clinical trials of islet xenotransplantation. Xenotransplantation 2016; 23:60-76. [PMID: 26918540 DOI: 10.1111/xen.12228] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 02/08/2016] [Indexed: 12/22/2022]
Abstract
Patients in whom type 1 diabetes is complicated by impaired awareness of hypoglycemia and recurrent episodes of severe hypoglycemia are candidates for islet or pancreas transplantation if severe hypoglycemia persists after completion of a structured stepped care approach or a formalized medical optimization run-in period that provides access to hypoglycemia-specific education including behavioral therapies, insulin analogs, and diabetes technologies under the close supervision of a specialist hypoglycemia service. Patients with type 1 diabetes and end-stage renal failure who cannot meet clinically appropriate glycemic goals or continue to experience severe hypoglycemia after completion of a formalized medical optimization program under the guidance of an expert diabetes care team are candidates for islet or pancreas transplantation either simultaneously with or after a previous kidney transplant. Similarly, patients with type 2 diabetes and problematic hypoglycemia or renal failure who meet these criteria are considered candidates for islet replacement. Likewise, patients with pancreatectomy-induced diabetes in whom an islet autograft was not available or deemed inappropriate are candidates for islet or pancreas transplantation if extreme glycemic lability persists despite best medical therapy. To justify participation of these transplant candidates in early-phase trials of porcine islet cell products, lack of timely access to islet or pancreas allotransplantation due to allosensitization, high islet dose requirements, or other factors, or alternatively, a more favorable benefit-risk determination associated with the xenoislet than the alloislet or allopancreas transplant must be demonstrated. Additionally, in non-uremic xenoislet recipients, the risks associated with diabetes must be perceived to be more serious than the risks associated with the xenoislet product and the rejection prophylaxis, and in xenoislet recipients with renal failure, the xenoislet product and immunosuppression must not impact negatively on renal transplant outcomes. The most appropriate patient group for islet xenotransplantation trials will be defined by the specific characteristics of each investigational xenoislet product and related technologies applied for preventing rejection. Selecting recipients who are more likely to experience prolonged benefits associated with the islet xenograft will help these patients comply with lifelong monitoring and other public health measures.
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Affiliation(s)
- Bernhard J Hering
- Department of Surgery, Schulze Diabetes Institute, University of Minnesota, Minneapolis, MN, USA
| | - Philip J O'Connell
- The Centre for Transplant and Renal Research, Westmead Millennium Institute, University of Sydney at Westmead Hospital, Westmead, NSW, Australia
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Davis T, Salahi A, Welsh JB, Bailey TS. Automated insulin pump suspension for hypoglycaemia mitigation: development, implementation and implications. Diabetes Obes Metab 2015; 17:1126-32. [PMID: 26179879 DOI: 10.1111/dom.12542] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 02/05/2015] [Accepted: 07/10/2015] [Indexed: 12/14/2022]
Abstract
In type 1 diabetes (T1D), insulin replacement therapy should ideally replicate endogenous insulin secretion, but achieving this goal requires frequent adjustments to insulin delivery based on glucose levels and trends, carbohydrate intake and physical activity. An overriding concern for people taking insulin is hypoglycaemia, which remains the most feared consequence of insulin therapy and limits therapy intensification options. Although fully automated systems that achieve consistent euglycaemia in T1D remain an elusive goal, improvements in continuous glucose monitoring (CGM) sensors and control algorithms have enabled semi-automated systems that lower the risk of hypoglycaemia, especially nocturnal hypoglycaemia. The present review focuses on an important advance in insulin delivery systems: the use of CGM data to stop insulin delivery in the presence of hypoglycaemia. Although conceptually simple, this strategy represents a critical step in the journey toward a fully closed-loop artificial pancreas; the next steps in this journey are also discussed.
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Affiliation(s)
- T Davis
- AMCR Institute, Escondido, CA, USA
| | - A Salahi
- Medtronic, Inc., Northridge, CA, USA
| | - J B Welsh
- Medtronic, Inc., Northridge, CA, USA
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Vigersky RA. The benefits, limitations, and cost-effectiveness of advanced technologies in the management of patients with diabetes mellitus. J Diabetes Sci Technol 2015; 9:320-30. [PMID: 25555391 PMCID: PMC4604582 DOI: 10.1177/1932296814565661] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Hypoglycemia mitigation is critical for appropriately managing patients with diabetes. Advanced technologies are becoming more prevalent in diabetes management, but their benefits have been primarily judged on the basis of hemoglobin A1c. A critical appraisal of the effectiveness and limitations of advanced technologies in reducing both A1c and hypoglycemia rates has not been previously performed. The cost of hypoglycemia was estimated using literature rates of hypoglycemia events resulting in hospitalizations. A literature search was conducted on the effect on A1c and hypoglycemia of advanced technologies. The cost-effectiveness of continuous subcutaneous insulin infusion (CSII) and real-time continuous glucose monitors (RT-CGM) was reviewed. Severe hypoglycemia in insulin-using patients with diabetes costs $4.9-$12.7 billion. CSII reduces A1c in some but not all studies. CSII improves hypoglycemia in patients with high baseline rates. Bolus calculators improve A1c and improve the fear of hypoglycemia but not hypoglycemia rates. RT-CGM alone and when combined with CSII improve A1c with a neutral effect on hypoglycemia rates. Low-glucose threshold suspend systems reduce hypoglycemia with a neutral effect on A1c, and low-glucose predictive suspend systems reduce hypoglycemia with a small increase in plasma glucose levels. In short-term studies, artificial pancreas systems reduce both hypoglycemia rates and plasma glucose levels. CSII and RT-CGM are cost-effective technologies, but their wide adoption is limited by cost, psychosocial, and educational factors. Most currently available technologies improve A1c with a neutral or improved rate of hypoglycemia. Advanced technologies appear to be cost-effective in diabetes management, especially when including the underlying cost of hypoglycemia.
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Affiliation(s)
- Robert A. Vigersky
- Walter Reed National Military Medical Center, Bethesda, MD, USA
- Robert A. Vigersky, MD, Endocrinology and Diabetes Service, Department of Medicine, Walter Reed National Military Medical Center, 8901 Wisconsin Ave, Bethesda, MD 20889, USA.
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Shalitin S, Chase HP. Diabetes technology and therapy in the pediatric age group. Diabetes Technol Ther 2015; 17 Suppl 1:S96-S108. [PMID: 25679436 DOI: 10.1089/dia.2015.1512] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Shlomit Shalitin
- 1 Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel , Petah Tikva, Israel
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Cefalu WT, Boulton AJ, Tamborlane WV, Moses RG, LeRoith D, Greene EL, Hu FB, Bakris G, Wylie-Rosett J, Rosenstock J, Weinger K, Blonde L, de Groot M, Riddle MC, Henry RR, Golden SH, Rich S, Reynolds L. Status of Diabetes Care: "It just doesn't get any better . . . or does it?". Diabetes Care 2014; 37:1782-5. [PMID: 25093231 PMCID: PMC5131856 DOI: 10.2337/dc14-1073] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- William T. Cefalu
- Pennington Biomedical Research Center, Louisiana State University System, Baton Rouge, LA
| | | | | | | | - Derek LeRoith
- Division of Endocrinology, Diabetes and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Eddie L. Greene
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Frank B. Hu
- Departments of Nutrition and Epidemiology, Harvard School of Public Health, Boston, MA
| | - George Bakris
- ASH Comprehensive Hypertension Center, Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, The University of Chicago Medicine, Chicago, IL
| | - Judith Wylie-Rosett
- Department of Epidemiology and Social Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Julio Rosenstock
- Dallas Diabetes and Endocrine Center at Medical City, Dallas, TX
| | - Katie Weinger
- Joslin Diabetes Center, Harvard Medical School, Boston, MA
| | - Lawrence Blonde
- Ochsner Diabetes Clinical Research Unit, Department of Endocrinology, Diabetes and Metabolism, Ochsner Medical Center, New Orleans, LA
| | - Mary de Groot
- Indiana University School of Medicine, Indianapolis, IN
| | - Matthew C. Riddle
- Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University, Portland, OR
| | | | - Sherita Hill Golden
- Division of Endocrinology and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Stephen Rich
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA
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