1
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Beolet T, Adenis A, Huneker E, Louis M. End-to-end offline reinforcement learning for glycemia control. Artif Intell Med 2024; 154:102920. [PMID: 38972092 DOI: 10.1016/j.artmed.2024.102920] [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: 10/13/2023] [Revised: 06/18/2024] [Accepted: 06/20/2024] [Indexed: 07/09/2024]
Abstract
The development of closed-loop systems for glycemia control in type I diabetes relies heavily on simulated patients. Improving the performances and adaptability of these close-loops raises the risk of over-fitting the simulator. This may have dire consequences, especially in unusual cases which were not faithfully - if at all - captured by the simulator. To address this, we propose to use model-free offline RL agents, trained on real patient data, to perform the glycemia control. To further improve the performances, we propose an end-to-end personalization pipeline, which leverages offline-policy evaluation methods to remove altogether the need of a simulator, while still enabling an estimation of clinically relevant metrics for diabetes.
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Affiliation(s)
- Tristan Beolet
- Diabeloop, 17 rue Félix Esclangon, Grenoble, 38000, France.
| | - Alice Adenis
- Diabeloop, 17 rue Félix Esclangon, Grenoble, 38000, France
| | - Erik Huneker
- Diabeloop, 17 rue Félix Esclangon, Grenoble, 38000, France
| | - Maxime Louis
- Diabeloop, 17 rue Félix Esclangon, Grenoble, 38000, France
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2
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Sebastian-Valles F, Arranz Martin JA, Martínez-Alfonso J, Jiménez-Díaz J, Hernando Alday I, Navas Moreno V, Armenta Joya T, Fandiño García MDM, Román Gómez GL, Garai Hierro J, Lander Lobariñas LE, Martinez de Icaya P, Sampedro-Nuñez MA, Martínez-Vizcaíno V, Marazuela M. Effect of Christmas Holidays on Type 1 Diabetes Mellitus in Users of Glucose Flash Systems. Endocr Pract 2024; 30:372-379. [PMID: 38307457 DOI: 10.1016/j.eprac.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 01/19/2024] [Accepted: 01/24/2024] [Indexed: 02/04/2024]
Abstract
OBJECTIVE Christmas holidays can impact weight and glycemic control in type 2 diabetes, but their effect on type 1 diabetes (T1D) remains understudied. This study assessed how Christmas holidays affect individuals with T1D who use flash continuous glucose monitoring systems. METHODS This retrospective study involved 812 adults diagnosed with T1D recruited from 3 hospitals. Clinical, anthropometric, and socioeconomic data were collected. Glucose metrics from 14 days before January 1st, and before December 1st and February 1st as control periods, were recorded. Analyses adjusted for multiple variables were conducted to assess the holiday season's impact on glycemic control. RESULTS The average time in range during the holidays (60.0 ± 17.2%) was lower compared to December (61.9 ± 17.2%, P < .001) and February (61.7 ± 17.7%, P < .001). Time above range (TAR > 180 mg/dL) was higher during Christmas (35.8 ± 18.2%) compared to December (34.1 ± 18.3%, P < .001) and February (34.2 ± 18.4%, P < .001). Differences were also observed in TAR >250 mg/dL, coefficient of variation, and average glucose (P < .05). No differences were found in time below range or other metrics. Linear regression models showed that the holidays reduced time in range by 1.9% (β = -1.92, P = .005) and increased TAR >180 mg/dL by 1.8% (β = 1.75, P = .016). CONCLUSION Christmas holidays are associated with a mild and reversible deterioration in glucose metrics among individuals with T1D using flash continuous glucose monitoring, irrespective of additional influencing factors. These discoveries can be useful to advise individuals with diabetes during the festive season and to recognize potential biases within studies conducted during this timeframe.
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Affiliation(s)
- Fernando Sebastian-Valles
- Department of Endocrinology and Nutrition, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria de La Princesa, Universidad Autónoma de Madrid, Madrid, Spain.
| | - Jose A Arranz Martin
- Department of Endocrinology and Nutrition, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria de La Princesa, Universidad Autónoma de Madrid, Madrid, Spain
| | - Julia Martínez-Alfonso
- Department of Family and Community Medicine, Hospital La Princesa/Centro de Salud Daroca, Madrid, Spain
| | - Jessica Jiménez-Díaz
- Department of Endocrinology and Nutrition, Hospital Universitario Severo Ochoa, Leganés, Madrid, Spain
| | - Iñigo Hernando Alday
- Department of Endocrinology and Nutrition, Hospital Universitario Basurto, Bilbao, Spain
| | - Victor Navas Moreno
- Department of Endocrinology and Nutrition, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria de La Princesa, Universidad Autónoma de Madrid, Madrid, Spain
| | - Teresa Armenta Joya
- Department of Endocrinology and Nutrition, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria de La Princesa, Universidad Autónoma de Madrid, Madrid, Spain
| | | | - Gisela L Román Gómez
- Department of Endocrinology and Nutrition, Hospital Universitario Severo Ochoa, Leganés, Madrid, Spain
| | - Jon Garai Hierro
- Department of Endocrinology and Nutrition, Hospital Universitario Basurto, Bilbao, Spain
| | - Luis E Lander Lobariñas
- Department of Endocrinology and Nutrition, Hospital Universitario Severo Ochoa, Leganés, Madrid, Spain
| | | | - Miguel A Sampedro-Nuñez
- Department of Endocrinology and Nutrition, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria de La Princesa, Universidad Autónoma de Madrid, Madrid, Spain
| | - Vicente Martínez-Vizcaíno
- Health and Social Care Research Center, Universidad de Castilla-La Mancha, Cuenca, Spain; Facultad de Ciencias de la Salud, Universidad Autónoma de Chile, Talca, Chile
| | - Mónica Marazuela
- Department of Endocrinology and Nutrition, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria de La Princesa, Universidad Autónoma de Madrid, Madrid, Spain
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3
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van Bon AC, Blauw H, Jansen TJP, Laverman GD, Urgert T, Geessink-Mennink J, Mulder AH, Out M, Groote Veldman R, Onvlee AJ, Schouwenberg BJJW, Vermeulen MAR, Diekman MJM, Gerding MN, van Wijk JPH, Klaassen M, Witkop M, DeVries JH. Bihormonal fully closed-loop system for the treatment of type 1 diabetes: a real-world multicentre, prospective, single-arm trial in the Netherlands. Lancet Digit Health 2024; 6:e272-e280. [PMID: 38443309 DOI: 10.1016/s2589-7500(24)00002-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 11/15/2023] [Accepted: 01/05/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND Management of insulin administration for intake of carbohydrates and physical activity can be burdensome for people with type 1 diabetes on hybrid closed-loop systems. Bihormonal fully closed-loop (FCL) systems could help reduce this burden. In this trial, we assessed the long-term performance and safety of a bihormonal FCL system. METHODS The FCL system (Inreda AP; Inreda Diabetic, Goor, Netherlands) that uses two hormones (insulin and glucagon) was assessed in a 1 year, multicentre, prospective, single-arm intervention trial in adults with type 1 diabetes. Participants were recruited in eight outpatient clinics in the Netherlands. We included adults with type 1 diabetes aged 18-75 years who had been using flash glucose monitoring or continuous glucose monitors for at least 3 months. Study visits were integrated into standard care, usually every three months, to evaluate glycaemic control, adverse events, and person-reported outcomes. The primary endpoint was time in range (TIR; glucose concentration 3·9-10·0 mmol/L) after 1 year. The study is registered in the Dutch Trial Register, NL9578. FINDINGS Between June 1, 2021, and March 2, 2022, we screened 90 individuals and enrolled 82 participants; 78 were included in the analyses. 79 started the intervention and 71 were included in the 12 month analysis. Mean age was 47.7 (SD 12·4) years and 38 (49%) were female participants. The mean preintervention TIR of participants was 55·5% (SD 17·2). After 1 year of FCL treatment, mean TIR was 80·3% (SD 5·4) and median time below range was 1·36% (IQR 0·80-2·11). Questionnaire scores improved on Problem Areas in Diabetes (PAID) from 30·0 (IQR 18·8-41·3) preintervention to 10·0 (IQR 3·8-21·3; p<0·0001) at 12 months and on World Health Organization-Five Well-Being Index (WHO-5) from 60·0 (IQR 44·0-72·0) preintervention to 76·0 (IQR 60·0-80·0; p<0·0001) at 12 months. Five serious adverse events were reported (one cerebellar stroke, two severe hypoglycaemic, and two hyperglycaemic events). INTERPRETATION Real-world data obtained in this trial demonstrate that use of the bihormonal FCL system was associated with good glycaemic control in patients who completed 1 year of treatment, and could help relieve these individuals with type 1 diabetes from making treatment decisions and the burden of carbohydrate counting. FUNDING Inreda Diabetic.
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Affiliation(s)
- A C van Bon
- Department of Internal Medicine, Rijnstate Hospital, Arnhem, Netherlands.
| | - H Blauw
- Inreda Diabetic, Goor, Netherlands
| | | | - G D Laverman
- Department of Internal Medicine, ZGT Hospital, Hengelo, Netherlands
| | - T Urgert
- Department of Internal Medicine, ZGT Hospital, Hengelo, Netherlands
| | - J Geessink-Mennink
- Department of Internal Medicine, Slingeland Hospital, Doetinchem, Netherlands
| | - A H Mulder
- Department of Internal Medicine, Slingeland Hospital, Doetinchem, Netherlands
| | - M Out
- Department of Internal Medicine, MST, Enschede, Netherlands
| | | | - A J Onvlee
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - B J J W Schouwenberg
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - M J M Diekman
- Department of Internal Medicine, Deventer Hospital, Deventer, Netherlands
| | - M N Gerding
- Department of Internal Medicine, Deventer Hospital, Deventer, Netherlands
| | - J P H van Wijk
- Department of Internal Medicine, Hospital Gelderse Vallei, Ede, Netherlands
| | | | - M Witkop
- Inreda Diabetic, Goor, Netherlands
| | - J H DeVries
- Department of Internal Medicine, Amsterdam UMC, Amsterdam, Netherlands
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4
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Klonoff DC, Kohn MA, Rodbard D, Aaron RE, Tian T. Response to Sensitivity of the Glycemia Risk Index to Effects of Automated Insulin Delivery Initiation. J Diabetes Sci Technol 2024; 18:528-529. [PMID: 38142366 DOI: 10.1177/19322968231220064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2023]
Affiliation(s)
- David C Klonoff
- Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA, USA
| | - Michael A Kohn
- University of California, San Francisco, San Francisco, CA, USA
| | - David Rodbard
- Biomedical Informatics Consultants LLC, Potomac, MD, USA
| | | | - Tiffany Tian
- Diabetes Technology Society, Burlingame, CA, USA
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5
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Garg SK, McVean JJ. Development and Future of Automated Insulin Delivery (AID) Systems. Diabetes Technol Ther 2024; 26:1-6. [PMID: 38377322 DOI: 10.1089/dia.2023.0467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Affiliation(s)
- Satish K Garg
- Department of Medicine and Pediatrics, Barbara Davis Center for Diabetes, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado, USA
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6
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Benhalima K, Jendle J, Beunen K, Ringholm L. Automated Insulin Delivery for Pregnant Women With Type 1 Diabetes: Where do we stand? J Diabetes Sci Technol 2024:19322968231223934. [PMID: 38197363 DOI: 10.1177/19322968231223934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
Automated insulin delivery (AID) systems mimic an artificial pancreas via a predictive algorithm integrated with continuous glucose monitoring (CGM) and an insulin pump, thereby providing AID. Outside of pregnancy, AID has led to a paradigm shift in the management of people with type 1 diabetes (T1D), leading to improvements in glycemic control with lower risk for hypoglycemia and improved quality of life. As the use of AID in clinical practice is increasing, the number of women of reproductive age becoming pregnant while using AID is also expected to increase. The requirement for lower glucose targets than outside of pregnancy and for frequent adjustments of insulin doses during pregnancy may impact the effectiveness and safety of AID when using algorithms for non-pregnant populations with T1D. Currently, the CamAPS® FX is the only AID approved for use in pregnancy. A recent randomized controlled trial (RCT) with CamAPS® FX demonstrated a 10% increase in time in range in a pregnant population with T1D and a baseline glycated hemoglobin (HbA1c) ≥ 48 mmol/mol (6.5%). Off-label use of AID not approved for pregnancy are currently also being evaluated in ongoing RCTs. More evidence is needed on the impact of AID on maternal and neonatal outcomes. We review the current evidence on the use of AID in pregnancy and provide an overview of the completed and ongoing RCTs evaluating AID in pregnancy. In addition, we discuss the advantages and challenges of the use of current AID in pregnancy and future directions for research.
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Affiliation(s)
- Katrien Benhalima
- Department of Endocrinology, University Hospital Gasthuisberg, KU Leuven, Leuven, Belgium
| | - Johan Jendle
- Diabetes Endocrinology and Metabolism Research Centre, School of Medicine, Örebro University, Örebro, Sweden
| | - Kaat Beunen
- Department of Endocrinology, University Hospital Gasthuisberg, KU Leuven, Leuven, Belgium
| | - Lene Ringholm
- Center for Pregnant Women with Diabetes, Department of Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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7
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Zimmer RT, Auth A, Schierbauer J, Haupt S, Wachsmuth N, Zimmermann P, Voit T, Battelino T, Sourij H, Moser O. (Hybrid) Closed-Loop Systems: From Announced to Unannounced Exercise. Diabetes Technol Ther 2023. [PMID: 38133645 DOI: 10.1089/dia.2023.0293] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
Physical activity and exercise have many beneficial effects on general and type 1 diabetes (T1D) specific health and are recommended for individuals with T1D. Despite these health benefits, many people with T1D still avoid exercise since glycemic management during physical activity poses substantial glycemic and psychological challenges - which hold particularly true for unannounced exercise when using an AID system. Automated insulin delivery (AID) systems have demonstrated their efficacy in improving overall glycemia and in managing announced exercise in numerous studies. They are proven to increase time in range (70-180 mg/dL) and can especially counteract nocturnal hypoglycemia, even when evening exercise was performed. AID-systems consist of a pump administering insulin as well as a CGM sensor (plus transmitter), both communicating with a control algorithm integrated into a device (insulin pump, mobile phone/smart watch). Nevertheless, without manual pre-exercise adaptions, these systems still face a significant challenge around physical activity. Automatically adapting to the rapidly changing insulin requirements during unannounced exercise and physical activity is still the Achilles' heel of current AID systems. There is an urgent need for improving current AID-systems to safely and automatically maintain glucose management without causing derailments - so that going forward, exercise announcements will not be necessary in the future. Therefore, this narrative literature review aimed to discuss technological strategies to how current AID-systems can be improved in the future and become more proficient in overcoming the hurdle of unannounced exercise. For this purpose, the current state-of-the-art therapy recommendations for AID and exercise as well as novel research approaches are presented along with potential future solutions - in order to rectify their deficiencies in the endeavor to achieve fully automated AID-systems even around unannounced exercise.
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Affiliation(s)
- Rebecca Tanja Zimmer
- University of Bayreuth, 26523, Division Exercise Physiology and Metabolism Institute of Sport Science, Bayreuth, Bavaria, Germany;
| | - Alexander Auth
- University of Bayreuth, 26523, Division Exercise Physiology and Metabolism Institute of Sport Science, Bayreuth, Bavaria, Germany;
| | - Janis Schierbauer
- University of Bayreuth, 26523, Division Exercise Physiology and Metabolism Institute of Sport Science, Bayreuth, Bavaria, Germany;
| | - Sandra Haupt
- University of Bayreuth, 26523, Division Exercise Physiology and Metabolism Institute of Sport Science, Bayreuth, Bavaria, Germany;
| | - Nadine Wachsmuth
- University of Bayreuth, 26523, Division Exercise Physiology and Metabolism Institute of Sport Science, Bayreuth, Bavaria, Germany;
| | - Paul Zimmermann
- University of Bayreuth, 26523, Division Exercise Physiology and Metabolism Institute of Sport Science, Bayreuth, Bavaria, Germany;
| | - Thomas Voit
- University of Bayreuth, 26523, Division Exercise Physiology and Metabolism Institute of Sport Science, Bayreuth, Bavaria, Germany;
| | - Tadej Battelino
- University Children's Hospital, Ljubljana, Slovenia, Department of Endocrinology, Diabetes and Metabolism, Bohoriceva 20, Ljubljana, Slovenia, 1000
- Slovenia;
| | - Harald Sourij
- Medical University of Graz, 31475, Auenbruggerplatz 15, 8036 Graz, Graz, Austria, 8036;
| | - Othmar Moser
- University of Bayreuth, 26523, Division Exercise Physiology and Metabolism Institute of Sport Science, Universitätsstraße 30, Bayreuth, Bayern, Germany, 95440;
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8
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Diaz C JL, Villa-Tamayo MF, Moscoso-Vasquez M, Colmegna P. Simulation-driven optimization of insulin therapy profiles in a commercial hybrid closed-loop system. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2023; 242:107830. [PMID: 37806122 DOI: 10.1016/j.cmpb.2023.107830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 09/19/2023] [Accepted: 09/23/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Automated insulin delivery (AID) has represented a breakthrough in managing type 1 diabetes (T1D), showing safe and effective glucose control extensively across the board. However, metabolic variability still poses a challenge to commercial hybrid closed-loop (HCL) solutions, whose performance depends on customizable insulin therapy profiles. In this work, we propose an Identification-Replay-Optimization (IRO) approach to optimize gradually and safely such profiles for the Control-IQ AID algorithm. METHODS Closed-loop data are generated using the full adult cohort of the UVA/Padova T1D simulation platform in diverse glycemic scenarios. For each subject, daily records are processed and used to estimate a personalized model of the underlying insulin-glucose dynamics. Every two weeks, all identified models are integrated into an optimization procedure where daily basal and bolus profiles are adjusted so as to minimize the risks for hypo- and hyperglycemia. The proposed strategy is tested under different scenarios of metabolic and behavioral variability in order to evaluate the efficacy and convergence of the proposed strategy. Finally, glycemic metrics between cycles are compared using paired t-tests with p<0.05 as the significance threshold. RESULTS Simulations reveal that the proposed IRO approach was able to improve glucose control over time by safely mitigating the risks for both hypo- and hyperglycemia. Furthermore, smaller changes were recommended at each cycle, indicating convergence when simulation conditions were maintained. CONCLUSIONS The use of reliable simulation-driven tools capable of accurately reproducing field-collected data and predicting changes can substantially shorten the process of optimizing insulin therapy, adjusting it to metabolic changes and leading to improved glucose control.
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Affiliation(s)
- Jenny L Diaz C
- Center for Diabetes Technology, University of Virginia, Charlottesville, 22903, VA, USA.
| | - María F Villa-Tamayo
- Center for Diabetes Technology, University of Virginia, Charlottesville, 22903, VA, USA
| | | | - Patricio Colmegna
- Center for Diabetes Technology, University of Virginia, Charlottesville, 22903, VA, USA
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9
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Nørgaard K, Ranjan AG, Laugesen C, Tidemand KG, Green A, Selmer C, Svensson J, Andersen HU, Vistisen D, Carstensen B. Glucose Monitoring Metrics in Individuals With Type 1 Diabetes Using Different Treatment Modalities: A Real-World Observational Study. Diabetes Care 2023; 46:1958-1964. [PMID: 37610784 DOI: 10.2337/dc23-1137] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 08/04/2023] [Indexed: 08/24/2023]
Abstract
OBJECTIVE This study aimed to investigate the association between continuous glucose monitoring (CGM)-derived glycemic metrics and different insulin treatment modalities using real-world data. RESEARCH DESIGN AND METHODS A cross-sectional study at Steno Diabetes Center Copenhagen, Denmark, included individuals with type 1 diabetes using CGM. Data from September 2021 to August 2022 were analyzed if CGM was used for at least 20% of a 4-week period. Individuals were divided into four groups: multiple daily injection (MDI) therapy, insulin pumps with unintegrated CGM (SUP), sensor-augmented pumps with low glucose management (SAP), and automated insulin delivery (AID). The MDI and SUP groups were further subdivided based on CGM alarm features. The primary outcome was percentage of time in range (TIR: 3.9-10.0 mmol/L) for each treatment group. Secondary outcomes included other glucose metrics and HbA1c. RESULTS Out of 6,314 attendees, 3,184 CGM users were included in the analysis. Among them, 1,622 used MDI, 504 used SUP, 354 used SAP, and 561 used AID. Median TIR was 54.0% for MDI, 54.9% for SUP, 62,9% for SAP, and 72,1% for AID users. The proportion of individuals achieving all recommended glycemic targets (TIR >70%, time above range <25%, and time below range <4%) was significantly higher in SAP (odds ratio [OR] 2.4 [95% CI 1.6-3.5]) and AID (OR 9.4 [95% CI 6.7-13.0]) compared with MDI without alarm features. CONCLUSIONS AID appears superior to other insulin treatment modalities with CGM. Although bias may be present because of indications, AID should be considered the preferred choice for insulin pump therapy.
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Affiliation(s)
- Kirsten Nørgaard
- Copenhagen University Hospital, Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Ajenthen G Ranjan
- Copenhagen University Hospital, Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Christian Laugesen
- Copenhagen University Hospital, Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Katrine G Tidemand
- Copenhagen University Hospital, Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Allan Green
- Copenhagen University Hospital, Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Christian Selmer
- Copenhagen University Hospital, Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Jannet Svensson
- Copenhagen University Hospital, Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Henrik U Andersen
- Copenhagen University Hospital, Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Dorte Vistisen
- Copenhagen University Hospital, Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Bendix Carstensen
- Copenhagen University Hospital, Steno Diabetes Center Copenhagen, Herlev, Denmark
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10
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Benhamou PY, Adenis A, Lablanche S, Franc S, Amadou C, Penfornis A, Kariyawasam D, Beltrand J, Charpentier G. First Generation of a Modular Interoperable Closed-Loop System for Automated Insulin Delivery in Patients With Type 1 Diabetes: Lessons From Trials and Real-Life Data. J Diabetes Sci Technol 2023; 17:1433-1439. [PMID: 37449762 PMCID: PMC10658690 DOI: 10.1177/19322968231186976] [Citation(s) in RCA: 2] [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] [Indexed: 07/18/2023]
Abstract
BACKGROUND DBLG1 (Diabeloop Generation 1) stands as one of the five commercially available closed-loop solution worldwide for patients with type 1 diabetes as of 2023. Our aim was to provide an overview of all data obtained with this system regarding outcomes and populations, with an emphasis on interoperability. METHODS This report includes all available sources of data (three randomized control trials and five surveys on real-life data). Collection ran from March 3, 2017 to April 30, 2022. RESULTS We gathered data from 6859 adult patients treated with closed-loop from three to 12 months. Overall, all sources of data showed that time in range (TIR) 70 to 180 mg/dL, starting from 47.4% to 56.6%, improved from 12.2 to 17.3 percentage points. Time in hypoglycemia was reduced by 48% in average (range: 26%-70%) and reached a level of 1.3% in the largest and most recent cohort. In patients with excessive time in hypoglycemia at baseline (≥5%), closed-loop allowed a reduction in time below range (TBR) by 59%. The comparison of days with declared physical activity versus days without physical activity did not show differences in TBR. The improvement in TIR observed with three different pump systems (Vicentra Kaleido, n = 117; Sooil Dana-I, n = 84; and Roche Insight, n = 6684) ranged from 15.4 to 17.3 percentage points. DISCUSSION These data obtained in different European countries were consistent throughout all reports, showing that this closed-loop system is efficient (high improvement in TIR), safe (remarkably low level of TBR), and interoperable (three pump settings so far).
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Affiliation(s)
- Pierre-Yves Benhamou
- Department of Endocrinology, Grenoble
University Hospital, Grenoble Alpes University, INSERM U1055, Laboratory of
Fundamental and Applied Bioenergetics, Grenoble, France
- Endocrinology, Centre Hospitalier
Universitaire Grenoble Alpes, Grenoble Alpes University, Grenoble, France
| | | | - Sandrine Lablanche
- Department of Endocrinology, Grenoble
University Hospital, Grenoble Alpes University, INSERM U1055, Laboratory of
Fundamental and Applied Bioenergetics, Grenoble, France
| | - Sylvia Franc
- Center for Study and Research for
Improvement of the Treatment of Diabetes, Bioparc-Genopole Evry-Corbeil, Evry,
France
- Department of Diabetes and
Endocrinology, Sud-Francilien Hospital, Corbeil-Essonnes, France
- Department of Endocrinology,
Diabetology & Metabolic Diseases, Sud-Francilien Hospital, Paris-Saclay
University, Corbeil-Essonnes, France
| | - Coralie Amadou
- Department of Endocrinology,
Diabetology & Metabolic Diseases, Sud-Francilien Hospital, Paris-Saclay
University, Corbeil-Essonnes, France
| | - Alfred Penfornis
- Department of Endocrinology,
Diabetology & Metabolic Diseases, Sud-Francilien Hospital, Paris-Saclay
University, Corbeil-Essonnes, France
| | - Dulanjalee Kariyawasam
- Paediatric Endocrinology, Diabetology,
Gynaecology Department, Necker-Enfants Malades University Hospital, Assistance
Publique des Hôpitaux de Paris-Centre, Paris, France
- Paris Cite University, Paris,
France
| | - Jacques Beltrand
- Paediatric Endocrinology, Diabetology,
Gynaecology Department, Necker-Enfants Malades University Hospital, Assistance
Publique des Hôpitaux de Paris-Centre, Paris, France
- Paris Cite University, Paris,
France
| | - Guillaume Charpentier
- Center for Study and Research for
Improvement of the Treatment of Diabetes, Bioparc-Genopole Evry-Corbeil, Evry,
France
- Department of Diabetes and
Endocrinology, Sud-Francilien Hospital, Corbeil-Essonnes, France
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Navas Moreno V, Sebastian-Valles F, Sampedro-Nuñez M, Lahera Vargas M, Marazuela M, Arranz Martin JA. Patient satisfaction in three advanced hybrid closed-loop systems at 6 months of treatment in adults with type 1 diabetes mellitus: a follow-up study. ENDOCRINOL DIAB NUTR 2023; 70:548-555. [PMID: 37858412 DOI: 10.1016/j.endien.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 06/21/2023] [Accepted: 06/28/2023] [Indexed: 10/21/2023]
Abstract
INTRODUCTION Advanced hybrid closed-loop (AHCL) systems have demonstrated improved glycemic control in individuals with Type 1 Diabetes Mellitus. The aim of this study is to compare patient satisfaction among three available AHCL systems (Medtronic Minimed780 G, Roche Diabeloop DBLG1, and Tandem t:slim X2 Control IQ) after six months of treatment and to determine if it is related to glycemic control. METHODS The data of 75 individuals were analyzed, including 15 using the DBLG1 system, 9 using Control IQ, and 51 using MM780 G. Patient satisfaction was assessed using the Diabetes Treatment Satisfaction Questionnaire for Diabetes Mellitus (DTSQc), a validated instrument. RESULTS All systems demonstrated treatment satisfaction. The DBLG-1 system scored 14 (-15-21) points, while Control IQ scored 21 (9-24) and M780 G scored 19 (11-24) (p = 0.004). The multivariate analysis revealed that the DBLG-1 system is associated with a lower DTSQc score (OR 0.19, p = 0.019) independent of glycemic control, sex, age, duration of diabetes, duration as an insulin pump user, and daily insulin dose. CONCLUSION AHCL systems are satisfactory treatments for users, with potential variations observed between each system regardless of the achieved glycemic control.
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Affiliation(s)
- Victor Navas Moreno
- Servicio de Endocrinología y Nutrición, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria de La Princesa, Universidad Autónoma de Madrid, Madrid, Spain
| | - Fernando Sebastian-Valles
- Servicio de Endocrinología y Nutrición, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria de La Princesa, Universidad Autónoma de Madrid, Madrid, Spain.
| | - Miguel Sampedro-Nuñez
- Servicio de Endocrinología y Nutrición, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria de La Princesa, Universidad Autónoma de Madrid, Madrid, Spain
| | - Marcos Lahera Vargas
- Servicio de Endocrinología y Nutrición, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria de La Princesa, Universidad Autónoma de Madrid, Madrid, Spain
| | - Monica Marazuela
- Servicio de Endocrinología y Nutrición, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria de La Princesa, Universidad Autónoma de Madrid, Madrid, Spain
| | - José Alfonso Arranz Martin
- Servicio de Endocrinología y Nutrición, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria de La Princesa, Universidad Autónoma de Madrid, Madrid, Spain
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12
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Mangas N, Mateu-Salat M, Martínez MJ, López A, Pujol I, Martínez C, Corcoy R. Hybrid closed-loop systems can help patients with extreme fear of hypoglycemia or hyperglycemia. Hormones (Athens) 2023; 22:453-456. [PMID: 37198528 DOI: 10.1007/s42000-023-00451-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 04/26/2023] [Indexed: 05/19/2023]
Abstract
Fear of hypoglycemia and hyperglycemia can lead to inappropriate diabetes self-management and untoward health outcomes. We report two patients, representative of these opposite conditions, who benefited from hybrid closed-loop technology. In the patient with fear of hypoglycemia, time in range improved from 26 to 56% and the patient did not present with severe hypoglycemia. Meanwhile, the patient with hyperglycemia aversiveness had a drastic reduction in time below range, from 19 to 4%. We conclude that hybrid closed-loop technology was an effective tool for improvement of glucose values in two patients with fear of hypoglycemia and hyperglycemia aversiveness, respectively.
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Affiliation(s)
- Natalia Mangas
- Department of Endocrinology and Nutrition, Hospital de la Santa Creu I Sant Pau, C/Sant Quintí 89, 08042, Barcelona, Spain
| | - Manel Mateu-Salat
- Department of Endocrinology and Nutrition, Hospital de la Santa Creu I Sant Pau, C/Sant Quintí 89, 08042, Barcelona, Spain
| | - María José Martínez
- Department of Endocrinology and Nutrition, Hospital de la Santa Creu I Sant Pau, C/Sant Quintí 89, 08042, Barcelona, Spain
| | - Alicia López
- Department of Endocrinology and Nutrition, Hospital de la Santa Creu I Sant Pau, C/Sant Quintí 89, 08042, Barcelona, Spain
| | - Isabel Pujol
- Department of Endocrinology and Nutrition, Hospital de la Santa Creu I Sant Pau, C/Sant Quintí 89, 08042, Barcelona, Spain
| | - Carmen Martínez
- Department of Endocrinology and Nutrition, Hospital de la Santa Creu I Sant Pau, C/Sant Quintí 89, 08042, Barcelona, Spain
| | - Rosa Corcoy
- Department of Endocrinology and Nutrition, Hospital de la Santa Creu I Sant Pau, C/Sant Quintí 89, 08042, Barcelona, Spain.
- CIBER-BBN, Instituto de Salud Carlos III, Madrid, Spain.
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.
- Sant Pau Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain.
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13
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Cordero TL, Dai Z, Arrieta A, Niu F, Vella M, Shin J, Rhinehart AS, McVean J, Lee SW, Slover RH, Forlenza GP, Shulman DI, Pop-Busui R, Thrasher JR, Kipnes MS, Christiansen MP, Buckingham BA, Pihoker C, Sherr JL, Kaiserman KB, Vigersky RA. Glycemic Outcomes During Early Use of the MiniMed™ 780G Advanced Hybrid Closed-Loop System with Guardian™ 4 Sensor. Diabetes Technol Ther 2023; 25:652-658. [PMID: 37252734 PMCID: PMC10460682 DOI: 10.1089/dia.2023.0123] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Background: Safety and significant improvement in overall glycated hemoglobin (A1C) and percentage of time spent in (TIR), below (TBR), and above (TAR) glucose range were demonstrated in the pivotal trial of adolescents and adults using the MiniMed™ advanced hybrid closed-loop (AHCL) system with the adjunctive, calibration-required Guardian™ Sensor 3. The present study evaluated early outcomes of continued access study (CAS) participants who transitioned from the pivotal trial investigational system to the approved MiniMed™ 780G system with the non-adjunctive, calibration-free Guardian™ 4 Sensor (MM780G+G4S). Study data were presented alongside those of real-world MM780G+G4S users from Europe, the Middle East, and Africa. Methods: The CAS participants (N = 109, aged 7-17 years and N = 67, aged >17 years) used the MM780G+G4S for 3 months and data of real-world MM780G+G4S system users (N = 10,204 aged ≤15 years and N = 26,099 aged >15 years) were uploaded from September 22, 2021 to December 02, 2022. At least 10 days of real-world continuous glucose monitoring (CGM) data were required for analyses. Glycemic metrics, delivered insulin and system use/interactions underwent descriptive analyses. Results: Time in AHCL and CGM use were >90% for all groups. AHCL exits averaged 0.1/day and there were few blood glucose measurements (BGMs) (0.8/day-1.0/day). Adults in both cohorts met most consensus recommendations for glycemic targets. Pediatric groups met recommendations for %TIR and %TBR, although not those for mean glucose variability and %TAR, possibly due to low use of recommended glucose target (100 mg/dL) and active insulin time (2 h) settings (28.4% in the CAS cohort and 9.4% in the real-world cohort). The CAS pediatric and adult A1C were 7.2% ± 0.7% and 6.8% ± 0.7%, respectively, and there were no serious adverse events. Conclusions: Early clinical use of the MM780G+G4S was safe and involved minimal BGMs and AHCL exits. Consistent with real-world pediatric and adult use, outcomes were associated with achievement of recommended glycemic targets. Clinical Trial Registration number: NCT03959423.
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Affiliation(s)
| | - Zheng Dai
- Medtronic, Northridge, California, USA
| | - Arcelia Arrieta
- Medtronic International Trading Sàrl, Tolochenaz, Switzerland
| | - Fang Niu
- Medtronic, Northridge, California, USA
| | | | - John Shin
- Medtronic, Northridge, California, USA
| | | | | | - Scott W. Lee
- Department of Endocrinology, Loma Linda University, Loma Linda, California, USA
| | - Robert H. Slover
- Department of Pediatrics, Barbara Davis Center of Childhood Diabetes, Aurora, Colorado, USA
| | - Gregory P. Forlenza
- Department of Pediatrics, Barbara Davis Center of Childhood Diabetes, Aurora, Colorado, USA
| | - Dorothy I. Shulman
- University of South Florida Diabetes and Endocrinology, Department of Pediatrics, Tampa, Florida, USA
| | - Rodica Pop-Busui
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, Michigan, USA
| | - James R. Thrasher
- Arkansas Diabetes and Endocrinology Center, Little Rock, Arkansas, USA
| | - Mark S. Kipnes
- Diabetes and Glandular Disease Clinic, San Antonio, Texas, USA
| | | | - Bruce A. Buckingham
- Stanford University School of Medicine, Department of Pediatric Endocrinology, Stanford, California, USA
| | - Catherine Pihoker
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Jennifer L. Sherr
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA
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14
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Amadou C, Melki V, Allain J, Clavel S, Gouet D, Chaillous L, Catargi B, Schaeplynck-Belicard P, Petit C, Thivolet C, Penfornis A. Performance and patients' satisfaction with the A7+TouchCare insulin patch pump system: A randomized controlled non-inferiority study. PLoS One 2023; 18:e0289684. [PMID: 37616289 PMCID: PMC10449223 DOI: 10.1371/journal.pone.0289684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 07/06/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND We assessed the performance and patient satisfaction of a new insulin patch pump, the A7+TouchCare (Medtrum), compared with the Omnipod system. METHODS This multicenter, randomized, open-label, controlled study enrolled 100 adult patients with type 1 or type 2 diabetes mellitus (A1C ≥ 6.5% and ≤ 9.5%, i.e., 48 to 80 mmol/mol) who were assigned with the Omnipod or with the A7+TouchCare pump for 3 months. The primary study outcome was the glucose management indicator (GMI) calculated with continuous glucose monitoring (CGM). RESULTS Premature withdrawals occurs respectively in 2 and 9 participants in the Omnipod and TouchCare groups. In the Per Protocol analysis, the difference in GMI between groups was 0.002% (95% confidence interval -0.251; 0.255). The non-inferiority was demonstrated since the difference between treatments did not overlap the pre-defined non-inferiority margin (0.4%). There was no significant difference in CGM parameters between groups. On average, patients in both groups were satisfied/very satisfied with the insulin pump system. Patients preferred Omnipod as an insulin management system and especially the patch delivery system but preferred the A7+TouchCare personal diabetes manager to control the system. CONCLUSIONS This study showed that the A7+TouchCare insulin pump was as efficient as the Omnipod pump in terms of performance and satisfaction. CLINICAL TRAIL REGISTRATION The study was registered in the ClinicalTrials.gov protocol register (NCT04223973).
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Affiliation(s)
- Coralie Amadou
- Service d’Endocrinologie, Diabétologie et Maladies Métaboliques, Centre Hospitalier Sud-Francilien de Corbeil-Essonnes, Corbeil-Essonnes, France
- Université Paris-Saclay, Gif-sur-Yvette, France
| | - Vincent Melki
- Service de Diabétologie–Maladies Métaboliques—Nutrition, CHU Hôpital Rangueil, Toulouse, France
| | - Jennifer Allain
- Service d’Endocrinologie-Diabétologie, Centre Hospitalier de Gonesse, Gonesse, France
| | | | - Didier Gouet
- Hôpitaux La Rochelle, Ré, Aunis, La Rochelle, France
| | - Lucy Chaillous
- Hôpital Nord Laennec, CHU Nantes, Saint-Herblain, France
| | | | | | - Catherine Petit
- Service d’Endocrinologie, Diabétologie et Maladies Métaboliques, Centre Hospitalier Sud-Francilien de Corbeil-Essonnes, Corbeil-Essonnes, France
- Université Paris-Saclay, Gif-sur-Yvette, France
| | - Charles Thivolet
- Centre du diabète Diab-e-Care—Hospices Civils de Lyon, Lyon, France
| | - Alfred Penfornis
- Service d’Endocrinologie, Diabétologie et Maladies Métaboliques, Centre Hospitalier Sud-Francilien de Corbeil-Essonnes, Corbeil-Essonnes, France
- Université Paris-Saclay, Gif-sur-Yvette, France
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15
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Benhalima K, Beunen K, Siegelaar SE, Painter R, Murphy HR, Feig DS, Donovan LE, Polsky S, Buschur E, Levy CJ, Kudva YC, Battelino T, Ringholm L, Mathiesen ER, Mathieu C. Management of type 1 diabetes in pregnancy: update on lifestyle, pharmacological treatment, and novel technologies for achieving glycaemic targets. Lancet Diabetes Endocrinol 2023; 11:490-508. [PMID: 37290466 DOI: 10.1016/s2213-8587(23)00116-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 04/04/2023] [Accepted: 04/06/2023] [Indexed: 06/10/2023]
Abstract
Glucose concentrations within target, appropriate gestational weight gain, adequate lifestyle, and, if necessary, antihypertensive treatment and low-dose aspirin reduces the risk of pre-eclampsia, preterm delivery, and other adverse pregnancy and neonatal outcomes in pregnancies complicated by type 1 diabetes. Despite the increasing use of diabetes technology (ie, continuous glucose monitoring and insulin pumps), the target of more than 70% time in range in pregnancy (TIRp 3·5-7·8 mmol/L) is often reached only in the final weeks of pregnancy, which is too late for beneficial effects on pregnancy outcomes. Hybrid closed-loop (HCL) insulin delivery systems are emerging as promising treatment options in pregnancy. In this Review, we discuss the latest evidence on pre-pregnancy care, management of diabetes-related complications, lifestyle recommendations, gestational weight gain, antihypertensive treatment, aspirin prophylaxis, and the use of novel technologies for achieving and maintaining glycaemic targets during pregnancy in women with type 1 diabetes. In addition, the importance of effective clinical and psychosocial support for pregnant women with type 1 diabetes is also highlighted. We also discuss the contemporary studies examining HCL systems in type 1 diabetes during pregnancies.
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Affiliation(s)
- Katrien Benhalima
- Endocrinology, University Hospital Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium.
| | - Kaat Beunen
- Endocrinology, University Hospital Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Sarah E Siegelaar
- Department of Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam, Netherlands
| | - Rebecca Painter
- Department of Gynaecology and Obstetrics, Amsterdam UMC, Vrije Universiteit, Netherlands; Amsterdam Reproduction and Development, Amsterdam, Netherlands
| | - Helen R Murphy
- Diabetes and Antenatal Care, University of East Anglia, Norwich, UK
| | - Denice S Feig
- Department of Medicine, Obstetrics, and Gynecology and Department of Health Policy, Management, and Evaluation, University of Toronto, Diabetes and Endocrinology in Pregnancy Program, Mt Sinai Hospital, Toronto, ON, Canada
| | - Lois E Donovan
- Division of Endocrinology and Metabolism, Department of Medicine, and Department of Obstetrics and Gynaecology, Cumming School Medicine, University of Calgary, Calgary, AB, Canada
| | - Sarit Polsky
- Medicine and Pediatrics, Barbara Davis Center for Diabetes, Adult Clinic, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Elizabeth Buschur
- Internal Medicine, Endocrinology, Diabetes, and Metabolism, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Carol J Levy
- Department of Medicine, Endocrinology and Obstetrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Yogish C Kudva
- Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Tadej Battelino
- Department of Endocrinology, Diabetes and Metabolism, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Lene Ringholm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
| | | | - Chantal Mathieu
- Endocrinology, University Hospital Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium
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16
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Diaz C. JL, Colmegna P, Breton MD. Maximizing Glycemic Benefits of Using Faster Insulin Formulations in Type 1 Diabetes: In Silico Analysis Under Open- and Closed-Loop Conditions. Diabetes Technol Ther 2023; 25:219-230. [PMID: 36595379 PMCID: PMC10066764 DOI: 10.1089/dia.2022.0468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background: Ultrarapid-acting insulin analogs that could improve or even prevent postprandial hyperglycemia are now available for both research and clinical care. However, clear glycemic benefits remain elusive, especially when combined with automated insulin delivery (AID) systems. In this work, we study two insulin formulations in silico and highlight adjustments of both open-loop and closed-loop insulin delivery therapies as a critical step to achieve clinically meaningful improvements. Methods: Subcutaneous insulin transport models for two faster analogs, Fiasp (Novo Nordisk, Bagsværd, Denmark) and AT247 (Arecor, Saffron Walden, United Kingdom), were identified using data collected from prior clamp experiments, and integrated into the UVA/Padova type 1 diabetes simulator (adult cohort, N = 100). Pump therapy parameters and the aggressiveness of our full closed-loop algorithm were adapted to the new insulin pharmacokinetic and pharmacodynamic profiles through a sequence of in silico studies. Finally, we assessed these analogs' glycemic impact with and without modified therapy parameters in simulated conditions designed to match clinical trial data. Results: Simply switching to faster insulin analogs shows limited improvements in glycemic outcomes. However, when insulin acceleration is accompanied by therapy adaptation, clinical significance is found comparing time-in-range (70-180 mg/dL) with Aspart versus AT247 in open-loop (+5.1%); and Aspart versus Fiasp (+5.4%) or AT247 (+10.6%) in full closed-loop with no clinically significant differences in the exposure to hypoglycemia. Conclusion: In silico results suggest that properly adjusting intensive insulin therapy profiles, or AID tuning, to faster insulin analogs is necessary to obtain clinically significant improvements in glucose control.
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Affiliation(s)
- Jenny L. Diaz C.
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
| | - Patricio Colmegna
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
| | - Marc D. Breton
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
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17
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Almurashi AM, Rodriguez E, Garg SK. Emerging Diabetes Technologies: Continuous Glucose Monitors/Artificial Pancreases. J Indian Inst Sci 2023; 103:1-26. [PMID: 37362851 PMCID: PMC10043869 DOI: 10.1007/s41745-022-00348-3] [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: 10/18/2022] [Accepted: 11/04/2022] [Indexed: 03/30/2023]
Abstract
Over the past decade there have been many advances in diabetes technologies, such as continuous glucose monitors (CGM s), insulin-delivery devices, and hybrid closed loop systems . Now most CGMs (Medtronic-Guardian, Dexcom-G6, and Abbott-Libre-2) have MARD values of < 10%, in contrast to two decades ago when the MARD used to be > 20%. In addition, the majority of the new CGMs do not require calibrations, and the latest CGMs last for 10-14 days. An implantable 6-months CGM by Eversense-3 is now approved in the USA and Europe. Recently, the FDA approved Libre 3 which provides real-time glucose values every minute. Even though it is approved as an iCGM it is not interoperable with automatic-insulin-delivery (AID) systems. The newer CGMs that are likely to be launched in the next few months in the USA include the 10-11 days Dexcom G7 (60% smaller than the existing G6), and the 7-days Medtronic Guardian 4. Most of the newer CGM have several features like automatic initialization, easy insertion, predictive alarms, and alerts. It has also been noticed that an arm insertion site might have better accuracy than abdomen or other sites, like the buttock for kids. Lag time between YSI and different sensors have been reported differently, sometimes it is down to 2-3 min; however, in many instances, it is still 15-20 min, especially when the rate of change of glucose is > 2 mg/min. We believe that in the next decade there will be a significant increase in the number of people who use CGM for their day-to-day diabetes care.
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Affiliation(s)
- Abdulhalim M. Almurashi
- Barbara Davis Center for Diabetes, University of Colorado Denver, 1775 Aurora Ct, Rm 1324, Aurora, CO 80045 USA
- Madinah Health Cluster, Madinah, Saudi Arabia
| | - Erika Rodriguez
- Barbara Davis Center for Diabetes, University of Colorado Denver, 1775 Aurora Ct, Rm 1324, Aurora, CO 80045 USA
| | - Satish K. Garg
- Barbara Davis Center for Diabetes, University of Colorado Denver, 1775 Aurora Ct, Rm 1324, Aurora, CO 80045 USA
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18
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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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19
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Benhamou PY, Adenis A, Lebbad H, Tourki Y, Heredia MB, Gehr B, Franc S, Charpentier G. One-year real-world performance of the DBLG1 closed-loop system: Data from 3706 adult users with type 1 diabetes in Germany. Diabetes Obes Metab 2023; 25:1607-1613. [PMID: 36751978 DOI: 10.1111/dom.15008] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/27/2023] [Accepted: 02/04/2023] [Indexed: 02/09/2023]
Abstract
AIM The Diabeloop Generation 1 (DBLG1) system is an interoperable hybrid closed-loop solution that was commercialized in Germany in March 2021. We report the longitudinal glycaemic outcomes among the first 3706 users in a real-world setting. METHODS We performed a retrospective data collection of all consenting adult patients with type 1 diabetes who were equipped in Germany with the DBLG1 system before 30 April 2022, and with a minimum 14 days of closed-loop usage. RESULTS In total, 3706 users (41% women, age 45.1 ± 14.5 years) met the inclusion criteria, reaching a mean follow-up of 131.0 ± 85.1 days, an overall 485 600 days of continuous glucose monitoring data, and a median time spent in closed-loop of 95.0% (IQR 89.1-97.4). The median percentage time in range (70-180 mg/dl) was 72.1% (IQR 65.0-78.9); the time below 70 mg/dl was 0.9% (0.5-1.7), the time below 54 mg/dl was 0.1% (0.1-0.3), and the median Glucose Management Index was 7.0% (6.8-7.3). Exploratory analysis of a subset of 2460 patients in whom baseline glycated haemoglobin (HbA1c) was available [7.4% (IQR 6.9-8.0)] showed that the achieved mean time in range was influenced by baseline HbA1c, ranging from 65.8 ± 9.9% (A1c ≥8.5%) to 81.3 ± 6.8% (A1c <6.5%). CONCLUSION This large real-world analysis confirms the relevance of the DBLG1 automated insulin delivery solution for the achievement of standards of care in adult patients with type 1 diabetes.
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Affiliation(s)
- Pierre-Yves Benhamou
- Department of Endocrinology, Grenoble University Hospital, Grenoble Alpes University, INSERM U1055, LBFA, Grenoble, France
| | | | | | | | | | - Bernhard Gehr
- Zentrum für Diabetes und Stoffwechselerkrankungen, m&i Fachklinik Bad Heilbrunn, Bad Heilbrunn, Germany
| | - Sylvia Franc
- CERITD (Center for Study and Research for Improvement of the Treatment of Diabetes), Bioparc-Genopole Evry-Corbeil, Evry, France
- Department of Diabetes and Endocrinology, Sud-Francilien Hospital, Corbeil, France
| | - Guillaume Charpentier
- CERITD (Center for Study and Research for Improvement of the Treatment of Diabetes), Bioparc-Genopole Evry-Corbeil, Evry, France
- Department of Diabetes and Endocrinology, Sud-Francilien Hospital, Corbeil, France
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20
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Renard E. Automated insulin delivery systems: from early research to routine care of type 1 diabetes. Acta Diabetol 2023; 60:151-161. [PMID: 35994106 DOI: 10.1007/s00592-022-01929-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 06/22/2022] [Indexed: 01/24/2023]
Abstract
Automated insulin delivery (AID) systems, so-called closed-loop systems or artificial pancreas, are based upon the concept of insulin supply driven by blood glucose levels and their variations according to body glucose needs, glucose intakes and insulin action. They include a continuous glucose monitoring device which provides a signal to a control algorithm tuning insulin delivery from an infusion pump. The control algorithm is the key of the system since it commands insulin administration in order to maintain blood glucose in a predefined target range and close to a near-normal glucose level. The last two decades have shown dramatic advances toward the use in free life of AID systems for routine care of type 1 diabetes through step-by-step demonstrations of feasibility, safety and efficacy in successive hospital, transitional and outpatient trials. Because of the constraints of pharmacokinetics and dynamics of subcutaneous insulin delivery, the currently available AID systems are all 'hybrid' or 'semi-automated' insulin delivery systems with a need of meal and exercise announcements in order to anticipate rapid glucose variations through pre-meal bolus or pre-exercise reduction of infusion rate. Nevertheless, these AID systems significantly improve time spent in a near-normal range with a reduction of the risk of hypoglycemia and the mental load of managing diabetes in everyday life, representing a milestone in insulin therapy. Expected progression toward fully automated, further miniaturized and integrated, possibly implantable on long-term and more physiological closed-loop systems paves the way for a functional cure of type 1 diabetes.
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Affiliation(s)
- Eric Renard
- Department of Endocrinology, Diabetes, Nutrition, Montpellier University Hospital, Montpellier, France.
- INSERM Clinical Investigation Centre CIC 1411, Montpellier, France.
- Department of Physiology, Institute of Functional Genomics, CNRS, INSERM, University of Montpellier, Montpellier, France.
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21
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Lachal S, Tourki Y, Franc S, Huneker E, Charpentier G, Benhamou PY. Hybrid Closed-Loop Control with Ultrarapid Lispro Compared with Standard Insulin Aspart and Faster Insulin Aspart: An In Silico Study. J Diabetes Sci Technol 2023; 17:176-185. [PMID: 34658265 PMCID: PMC9846416 DOI: 10.1177/19322968211046021] [Citation(s) in RCA: 2] [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: 02/01/2023]
Abstract
OBJECTIVE There is room for improvement in the performance of closed-loop regulation algorithms during the prandial period. This in silico study evaluated the efficiency and safety of ultrarapid lispro insulin using the Diabeloop DBLG1® algorithm. METHODS We modeled the insulin profile of URLi according to literature data and integrated it to the model used within a simulation platform built from a 60 patients' virtual cohort. We then ran the DBLG1® algorithm in silico with various meal intakes using modeled URLi, Aspart and Faster Aspart. The primary endpoints were glucose metrics (time in 70-180 mg/dL range and time below range). RESULTS When insulin time constant values were tuned, time in 70-180 mg/dL range was 69.4 [61.1-75.6] (Aspart) vs 74.7 [65.5-81.5] (URLi). Glucose coefficient of variation was reduced from 34.1 [29.7-37.8] to 28.4 [25.7-34.6]. Time below 70 mg/dL and 54 mg/dL were significantly reduced with URLi, whether or not DBLG1 was specifically tuned to this insulin. Metrics with Faster Aspart were intermediate and did not significantly differ from URLi. CONCLUSIONS This simulation study performed on a virtual T1D population suggests that the use of URLi within an unmodified closed-loop DBLG1 regulation algorithm is safe and, with DBLG1 being tuned to this specific insulin type, improved the regulation performances as compared with Aspart. This fact supports the use of such an insulin in clinical investigations.
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Affiliation(s)
- Sylvain Lachal
- Diabeloop SA, HQ 155-157 cours Berriat,
Grenoble, France
| | - Yousra Tourki
- Diabeloop SA, HQ 155-157 cours Berriat,
Grenoble, France
| | - Sylvia Franc
- CERITD (Center for Study and Research
for Improvement of the Treatment of Diabetes), Bioparc-Genopole Evry-Corbeil, Evry,
France
| | - Erik Huneker
- Diabeloop SA, HQ 155-157 cours Berriat,
Grenoble, France
| | - Guillaume Charpentier
- CERITD (Center for Study and Research
for Improvement of the Treatment of Diabetes), Bioparc-Genopole Evry-Corbeil, Evry,
France
| | - Pierre Yves Benhamou
- Department of Endocrinology, Grenoble
Alpes University Hospital; Grenoble Alpes University, INSERM U1055, LBFA, Grenoble,
France
- Pr Pierre Yves Benhamou, MD, PhD,
Department of Endocrinology, CHU, CS 10217, Grenoble, Auvergne-Rhône-Alpes
38043, France.
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22
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Schütz-Fuhrmann I, Rami-Merhar B, Fröhlich-Reiterer E, Hofer SE, Tauschmann M, Mader JK, Resl M, Kautzky-Willer A, Winhofer-Stöckl Y, Laimer M, Zlamal-Fortunat S, Weitgasser R. [Insulin pump therapy and continuous glucose monitoring]. Wien Klin Wochenschr 2023; 135:53-61. [PMID: 37101025 PMCID: PMC10132921 DOI: 10.1007/s00508-023-02165-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2023] [Indexed: 04/28/2023]
Abstract
This Guideline represents the recommendations of the Austrian Diabetes Association (ÖDG) on the use of diabetes technology (insulin pump therapy; continuous glucose monitoring, CGM; hybrid closed-loop systems, HCL; diabetes apps) and access to these technological innovations for people with diabetes mellitus based on current scientific evidence.
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Affiliation(s)
- Ingrid Schütz-Fuhrmann
- 3. Medizinische Abteilung mit Stoffwechselerkrankungen und Nephrologie, Karl Landsteiner Institut für Endokrinologie und Stoffwechselerkrankungen, Klinik Hietzing, Wien, Österreich
| | - Birgit Rami-Merhar
- Universitätsklinik für Kinder- und Jugendheilkunde, Medizinische Universität Wien, Wien, Österreich.
| | - Elke Fröhlich-Reiterer
- Universitätsklinik für Kinder- und Jugendheilkunde, Medizinische Universität Graz, Graz, Österreich
| | - Sabine E Hofer
- Department für Pädiatrie 1, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Martin Tauschmann
- Universitätsklinik für Kinder- und Jugendheilkunde, Medizinische Universität Wien, Wien, Österreich
| | - Julia K Mader
- Klinische Abteilung für Endokrinologie und Diabetologie, Universitätsklinik für Innere Medizin, Medizinische Universität Graz, Graz, Österreich
| | - Michael Resl
- Abteilung für Innere Medizin I, Konventhospital der Barmherzigen Brüder Linz, Linz, Österreich
| | - Alexandra Kautzky-Willer
- Klinische Abteilung für Endokrinologie und Stoffwechsel, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Wien, Österreich
| | - Yvonne Winhofer-Stöckl
- Klinische Abteilung für Endokrinologie und Stoffwechsel, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Wien, Österreich
| | - Markus Laimer
- Universitätsklinik für Diabetologie, Endokrinologie, Ernährungsmedizin und Metabolismus (UDEM), Universitätsspital Bern, Inselspital, Bern, Schweiz
| | - Sandra Zlamal-Fortunat
- Abteilung für Innere Medizin und Gastroenterologie, Hepatologie, Endokrinologie, Rheumatologie und Nephrologie, Klinikum Klagenfurt am Wörthersee, Klagenfurt, Österreich
| | - Raimund Weitgasser
- Kompetenzzentrum Diabetes, Privatklinik Wehrle Diakonissen, Salzburg, Österreich
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23
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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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25
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Abstract
PURPOSE OF REVIEW Closed-loop insulin pump systems (artificial pancreas) represent the cutting edge of insulin delivery technology. There are only a few systems currently approved for use in the USA: the MiniMed 670G/770G (which share an algorithm), t:slim X2 Control IQ, and the Omnipod 5. We review these systems and look into the future of the technology. RECENT FINDINGS All of the approved closed-loop insulin pump systems have demonstrated in multicenter prospective trials improvements in time in range, hemoglobin A1c, and time spent in hypoglycemia. The newer systems have also improved time spent in automation. Comparisons between the systems with regard to glycemic control are difficult to make due to differences in clinical trial design, but there are notable differences in the user experience between systems. The past few years have been a time of exponential development in the field of closed-loop insulin pump systems. However, more research is needed to provide full automation of these systems without any need for information from the user.
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Affiliation(s)
- Keren Zhou
- Endocrinology and Metabolism Institute, Cleveland Clinic, 9500 Euclid Avenue, F20, Cleveland, OH, 44195, US.
| | - Diana Isaacs
- Endocrinology and Metabolism Institute, Cleveland Clinic, 9500 Euclid Avenue, F20, Cleveland, OH, 44195, US
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26
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Abstract
Combining technologies including rapid insulin analogs, insulin pumps, continuous glucose monitors, and control algorithms has allowed for the creation of automated insulin delivery (AID) systems. These systems have proven to be the most effective technology for optimizing metabolic control and could hold the key to broadly achieving goal-level glycemic control for people with type 1 diabetes. The use of AID has exploded in the past several years with several options available in the United States and even more in Europe. In this article, we review the largest studies involving these AID systems, and then examine future directions for AID with an emphasis on usability.
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Affiliation(s)
- Gregory P. Forlenza
- School of Medicine, Barbara Davis Center, University of Colorado Anschutz Campus, Aurora, Colorado, USA
| | - Rayhan A. Lal
- Department of Medicine & Pediatrics, Divisions of Endocrinology Stanford Diabetes Research Center, Stanford University, Stanford, California, USA
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27
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Knoll C, Peacock S, Wäldchen M, Cooper D, Aulakh SK, Raile K, Hussain S, Braune K. Real-world evidence on clinical outcomes of people with type 1 diabetes using open-source and commercial automated insulin dosing systems: A systematic review. Diabet Med 2022; 39:e14741. [PMID: 34773301 DOI: 10.1111/dme.14741] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 10/17/2021] [Indexed: 12/12/2022]
Abstract
AIMS Several commercial and open-source automated insulin dosing (AID) systems have recently been developed and are now used by an increasing number of people with diabetes (PwD). This systematic review explored the current status of real-world evidence on the latest available AID systems in helping to understand their safety and effectiveness. METHODS A systematic review of real-world studies on the effect of commercial and open-source AID system use on clinical outcomes was conducted employing a devised protocol (PROSPERO ID 257354). RESULTS Of 441 initially identified studies, 21 published 2018-2021 were included: 12 for Medtronic 670G; one for Tandem Control-IQ; one for Diabeloop DBLG1; two for AndroidAPS; one for OpenAPS; one for Loop; three comparing various types of AID systems. These studies found that several types of AID systems improve Time-in-Range and haemoglobin A1c (HbA1c ) with minimal concerns around severe hypoglycaemia. These improvements were observed in open-source and commercially developed AID systems alike. CONCLUSIONS Commercially developed and open-source AID systems represent effective and safe treatment options for PwD of several age groups and genders. Alongside evidence from randomized clinical trials, real-world studies on AID systems and their effects on glycaemic outcomes are a helpful method for evaluating their safety and effectiveness.
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Affiliation(s)
- Christine Knoll
- Charité - Universitätsmedizin Berlin, Department of Paediatric Endocrinology and Diabetes, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
- School of Sociology, University College Dublin, Belfield, Ireland
| | - Sofia Peacock
- Department of Diabetes and Endocrinology, Guy's & St Thomas' NHS Foundation Trust, London, UK
- Department of Diabetes, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Mandy Wäldchen
- School of Sociology, University College Dublin, Belfield, Ireland
| | - Drew Cooper
- Charité - Universitätsmedizin Berlin, Department of Paediatric Endocrinology and Diabetes, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Simran Kaur Aulakh
- Molecular Biology of Metabolism Laboratory, The Francis Crick Institute, London, UK
| | - Klemens Raile
- Charité - Universitätsmedizin Berlin, Department of Paediatric Endocrinology and Diabetes, Berlin, Germany
| | - Sufyan Hussain
- Department of Diabetes and Endocrinology, Guy's & St Thomas' NHS Foundation Trust, London, UK
- Department of Diabetes, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Institute of Diabetes, Endocrinology and Obesity, King's Health Partners, London, UK
| | - Katarina Braune
- Charité - Universitätsmedizin Berlin, Department of Paediatric Endocrinology and Diabetes, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
- Charité - Universitätsmedizin Berlin, Institute of Medical Informatics, Berlin, Germany
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28
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Berget C, Sherr JL, DeSalvo DJ, Kingman RS, Stone SL, Brown SA, Nguyen A, Barrett L, Ly TT, Forlenza GP. Clinical Implementation of the Omnipod 5 Automated Insulin Delivery System: Key Considerations for Training and Onboarding People With Diabetes. Clin Diabetes 2022; 40:168-184. [PMID: 35669307 PMCID: PMC9160549 DOI: 10.2337/cd21-0083] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Automated insulin delivery (AID) systems, which connect an insulin pump, continuous glucose monitoring system, and software algorithm to automate insulin delivery based on real-time glycemic data, hold promise for improving outcomes and reducing therapeutic burden for people with diabetes. This article reviews the features of the Omnipod 5 Automated Insulin Delivery System and how it compares to other AID systems available on or currently under review for the U.S. market. It also provides practical guidance for clinicians on how to effectively train and onboard people with diabetes on the Omnipod 5 System, including how to personalize therapy and optimize glycemia. Many people with diabetes receive their diabetes care in primary care settings rather than in a diabetes specialty clinic. Therefore, it is important that primary care providers have access to resources to support the adoption of AID technologies such as the Omnipod 5 System.
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Affiliation(s)
- Cari Berget
- Barbara Davis Center for Childhood Diabetes, University of Colorado, Aurora, CO
| | - Jennifer L. Sherr
- Section of Pediatric Endocrinology, Yale School of Medicine, New Haven, CT
| | - Daniel J. DeSalvo
- Section of Pediatric Diabetes and Endocrinology, Baylor College of Medicine, Houston, TX
| | - Ryan S. Kingman
- Department of Pediatric Endocrinology, Stanford School of Medicine, Palo Alto, CA
| | | | - Sue A. Brown
- Division of Endocrinology, Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | | | | | | | - Gregory P. Forlenza
- Barbara Davis Center for Childhood Diabetes, University of Colorado, Aurora, CO
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29
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Kariyawasam D, Morin C, Casteels K, Le Tallec C, Sfez A, Godot C, Huneker E, Garrec N, Benhamou PY, Polak M, Charpentier G, Franc S, Beltrand J. Hybrid closed-loop insulin delivery versus sensor-augmented pump therapy in children aged 6–12 years: a randomised, controlled, cross-over, non-inferiority trial. Lancet Digit Health 2022; 4:e158-e168. [DOI: 10.1016/s2589-7500(21)00271-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 10/22/2021] [Accepted: 11/23/2021] [Indexed: 12/14/2022]
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30
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Ware J, Hovorka R. Recent advances in closed-loop insulin delivery. Metabolism 2022; 127:154953. [PMID: 34890648 PMCID: PMC8792215 DOI: 10.1016/j.metabol.2021.154953] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 11/05/2021] [Accepted: 11/24/2021] [Indexed: 02/03/2023]
Abstract
Since the discovery of insulin 100 years ago, we have seen considerable advances across diabetes therapies. The more recent advent of glucose-responsive automated insulin delivery has started to revolutionise the management of type 1 diabetes in children and adults. Evolution of closed-loop insulin delivery from research to clinical practice has been rapid, and multiple systems are now commercially available. In this review, we summarise key evidence on currently available closed-loop systems and those in development. We comment on dual-hormone and do-it-yourself systems, as well as reviewing clinical evidence in special populations such as very young children, older adults and in pregnancy. We identify future directions for research and barriers to closed-loop adoption, including how these might be addressed to ensure equitable access to this novel therapy.
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Affiliation(s)
- Julia Ware
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom; Department of Paediatrics, University of Cambridge, Cambridge, United Kingdom
| | - Roman Hovorka
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom; Department of Paediatrics, University of Cambridge, Cambridge, United Kingdom.
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31
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Pauley ME, Berget C, Messer LH, Forlenza GP. Barriers to Uptake of Insulin Technologies and Novel Solutions. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2021; 14:339-354. [PMID: 34803408 PMCID: PMC8594891 DOI: 10.2147/mder.s312858] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 10/29/2021] [Indexed: 12/15/2022] Open
Abstract
Diabetes-related technology has undergone great advancement in recent years. These technological devices are more commonly utilized in the type 1 diabetes population, which requires insulin as the primary treatment modality. Available devices include insulin pumps, continuous glucose monitors, and hybrid systems referred to as automated insulin delivery systems or hybrid closed-loop systems, which combine those two devices along with software algorithms to achieve advanced therapeutic capabilities, including automatic modulation of insulin delivery based on sensor-derived glucose levels to minimize abnormal glucose trends. Use of diabetes technology is associated with significant positive health and psychosocial outcomes, yet utilization rates are generally lacking across both adult and pediatric type 1 diabetes populations in the United States and other countries. There are consistent themes in existing barriers to technology uptake reported by individuals with type 1 diabetes or parents of children with type 1 diabetes, including physical burdens associated with wearing the devices, concerns in navigating the technology and the devices’ abilities to meet user expectations, high cost, inadequate resources within the healthcare team to support device use, disparities in technology access, and psychosocial barriers. It is important to understand the common barriers to uptake of not only the automated insulin delivery systems but also their component devices (insulin pumps and continuous glucose monitors) to fully support individuals in utilizing these devices and optimizing health benefits. The purpose of this article is to summarize the current automated insulin delivery devices that are available for use in management of type 1 diabetes, review common barriers to uptake of those systems and their component devices, and provide expert opinion on existing and future solutions to identified barriers.
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Affiliation(s)
- Meghan E Pauley
- Barbara Davis Center for Childhood Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Cari Berget
- Barbara Davis Center for Childhood Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Laurel H Messer
- Barbara Davis Center for Childhood Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Gregory P Forlenza
- Barbara Davis Center for Childhood Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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32
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Pinnaro CT, Tansey MJ. The Evolution of Insulin Administration in Type 1 Diabetes. JOURNAL OF DIABETES MELLITUS 2021; 11:249-277. [PMID: 37745178 PMCID: PMC10516284 DOI: 10.4236/jdm.2021.115021] [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: 09/26/2023]
Abstract
Insulin has been utilized in the treatment of type 1 diabetes (T1D) for 100 years. While there is still no cure for T1D, insulin administration has undergone a remarkable evolution which has contributed to improvements in quality of life and life expectancy in individuals with T1D. The advent of faster-acting and longer-acting insulins allowed for the implementation of insulin regimens more closely resembling normal insulin physiology. These improvements afforded better glycemic control, which is crucial for limiting microvascular complications and improving T1D outcomes. Suspension of insulin delivery in response to actual and forecasted hypoglycemia has improved quality of life and mitigated hypoglycemia without compromising glycemic control. Advances in continuous glucose monitoring (CGM) and insulin pumps, efforts to model glucose and insulin kinetics, and the application of control theory to T1D have made the automation of insulin delivery a reality. This review will summarize the past, present, and future of insulin administration in T1D.
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Affiliation(s)
- Catherina T Pinnaro
- University of Iowa Stead Family Department of Pediatrics
- Fraternal Order of Eagles Diabetes Research Center
| | - Michael J Tansey
- University of Iowa Stead Family Department of Pediatrics
- Fraternal Order of Eagles Diabetes Research Center
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33
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Abstract
Automated insulin delivery (AID) is the most recent advance in type 1 diabetes (T1D) management. It has the potential to achieve glycemic targets without disabling hypoglycemia, to improve quality of life and reduce diabetes distress and burden associated with self-management. Several AID systems are currently licensed for use by people with T1D in Europe, United States, and the rest of the world. Despite AID becoming a reality in routine clinical practice over the last few years, the commercially hybrid AID and other systems, are still far from a fully optimized automated diabetes management tool. Implementation of AID systems requires education and support of healthcare professionals taking care of people with T1D, as well as users and their families. There is much to do to increase usability, portability, convenience and to reduce the burden associated with the use of the systems. Co-design, involvement of people with lived experience of T1D and robust qualitative assessment is critical to improving the real-world use of AID systems, especially for those who may have greater need. In addition to this, information regarding the psychosocial impact of the use of AID systems in real life is needed. The first commercially available AID systems are not the end of the development journey but are the first step in learning how to optimally automate insulin delivery in a way that is equitably accessible and effective for people living with T1D.
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Affiliation(s)
- Marga Giménez
- Diabetes Unit, Endocrinology and
Nutrition Department, Hospital Clínic i Universitari, Barcelona, Spain
- CIBERDEM, Centro de Investigación
Biomédica en Red de Diabetes y Enfermedades Metabólicas, Madrid, Spain
- IDIBAPS, Institut
d’Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Ignacio Conget
- Diabetes Unit, Endocrinology and
Nutrition Department, Hospital Clínic i Universitari, Barcelona, Spain
- CIBERDEM, Centro de Investigación
Biomédica en Red de Diabetes y Enfermedades Metabólicas, Madrid, Spain
- IDIBAPS, Institut
d’Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Nick Oliver
- Department of Metabolism,
Digestion and Reproduction, Faculty of Medicine, Imperial College London,
London, UK
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34
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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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Amadou C, Franc S, Huneker E, Charpentier G, Penfornis A. Short course corticosteroid treatment and closed-loop insulin delivery system: the experience of the DBLG1 pre-launch. DIABETES & METABOLISM 2021; 48:101294. [PMID: 34666166 DOI: 10.1016/j.diabet.2021.101294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 10/11/2021] [Indexed: 11/19/2022]
Abstract
No abstract (brief report).
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Affiliation(s)
- Coralie Amadou
- Department of Diabetes and Endocrinologyt, Sud-Francilien Hospital, Paris-Saclay University, Corbeil-Essonnes, France; Paris-Saclay University, France.
| | - Sylvia Franc
- Department of Diabetes and Endocrinologyt, Sud-Francilien Hospital, Paris-Saclay University, Corbeil-Essonnes, France; CERITD (Center for Study and Research for the Intensification of Diabetes Treatment), Bioparc-Génopole, Évry, France; LBEPS, Univ Evry, IRBA, Université Paris Saclay, Evry 91025, France
| | | | - Guillaume Charpentier
- Department of Diabetes and Endocrinologyt, Sud-Francilien Hospital, Paris-Saclay University, Corbeil-Essonnes, France; CERITD (Center for Study and Research for the Intensification of Diabetes Treatment), Bioparc-Génopole, Évry, France
| | - Alfred Penfornis
- Department of Diabetes and Endocrinologyt, Sud-Francilien Hospital, Paris-Saclay University, Corbeil-Essonnes, France; Paris-Saclay University, France
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Garcia-Tirado J, Diaz JL, Esquivel-Zuniga R, Koravi CLK, Corbett JP, Dawson M, Wakeman C, Barnett CL, Oliveri MC, Myers H, Krauthause K, Breton MD, DeBoer MD. Advanced Closed-Loop Control System Improves Postprandial Glycemic Control Compared With a Hybrid Closed-Loop System Following Unannounced Meal. Diabetes Care 2021; 44:dc210932. [PMID: 34400480 DOI: 10.2337/dc21-0932] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 07/16/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Meals are a major hurdle to glycemic control in type 1 diabetes (T1D). Our objective was to test a fully automated closed-loop control (CLC) system in the absence of announcement of carbohydrate ingestion among adolescents with T1D, who are known to commonly omit meal announcement. RESEARCH DESIGN AND METHODS Eighteen adolescents with T1D (age 15.6 ± 1.7 years; HbA1c 7.4 ± 1.5%; 9 females/9 males) participated in a randomized crossover clinical trial comparing our legacy hybrid CLC system (Unified Safety System Virginia [USS]-Virginia) with a novel fully automated CLC system (RocketAP) during two 46-h supervised admissions (each with one announced and one unannounced dinner), following 2 weeks of data collection. Primary outcome was the percentage time-in-range 70-180 mg/dL (TIR) following the unannounced meal, with secondary outcomes related to additional continuous glucose monitoring-based metrics. RESULTS Both TIR and time-in-tight-range 70-140 mg/dL (TTR) were significantly higher using RocketAP than using USS-Virginia during the 6 h following the unannounced meal (83% [interquartile range 64-93] vs. 53% [40-71]; P = 0.004 and 49% [41-59] vs. 27% [22-36]; P = 0.002, respectively), primarily driven by reduced time-above-range (TAR >180 mg/dL: 17% [1.3-34] vs. 47% [28-60]), with no increase in time-below-range (TBR <70 mg/dL: 0% median for both). RocketAP also improved control following the announced meal (mean difference TBR: -0.7%, TIR: +7%, TTR: +6%), overall (TIR: +5%, TAR: -5%, TTR: +8%), and overnight (TIR: +7%, TTR: +19%, TAR: -5%). RocketAP delivered less insulin overall (78 ± 23 units vs. 85 ± 20 units, P = 0.01). CONCLUSIONS A new fully automated CLC system with automatic prandial dosing was proven to be safe and feasible and outperformed our legacy USS-Virginia in an adolescent population with and without meal announcement.
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Affiliation(s)
- Jose Garcia-Tirado
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | - Jenny L Diaz
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | | | | | - John P Corbett
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | - Martha Dawson
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | - Christian Wakeman
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | | | - Mary C Oliveri
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | - Helen Myers
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | | | - Marc D Breton
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | - Mark D DeBoer
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
- Department of Pediatrics, University of Virginia, Charlottesville, VA
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[Individualization of diabetes treatment by automated insulin delivery]. Monatsschr Kinderheilkd 2021; 169:902-911. [PMID: 34276070 PMCID: PMC8276231 DOI: 10.1007/s00112-021-01239-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2021] [Indexed: 12/02/2022]
Abstract
Insulinpumpen und Glucosesensoren haben sich in Registerdaten als effektiv in der Verbesserung der Diabetestherapie und Reduktion akuter Komplikationen gezeigt. In der pädiatrischen Diabetologie ist die Nutzung mindestens eines technischen Geräts Standard. Durch die Kombination beider Systeme ergibt sich Möglichkeit der automatischen Insulinabgabe („automated insulin delivery“, AID). Viele AID-Systeme sind in klinischen Studien getestet und haben sich als sicher und effektiv erwiesen. Die Versorgungsituation in Deutschland erlaubt es derzeit nur, Mitgliedern der gesetzlichen Krankenversicherungen ein bestimmtes System zu verordnen; dieses ist für Kinder, die jünger als 7 Jahre sind, nicht geeignet. Gründe liegen in gesetzlichen Hürden und mangelnder Zertifizierung durch die Hersteller. Die CE-Zertifikate können Probleme bei der Insulinverordnung mit sich bringen. „Open-source“-Systeme sind Varianten, mit denen bestehende Regularien umgangen werden können. Daraus ergeben sich sowohl für Nutzer wie auch für Verordner Risiken. Die dauerhafte Nutzung setzt sowohl auf Anwender- als auch auf Behandlerseite die fundierte Kenntnis der Eigenschaften der einzelnen AID-Systeme voraus. Eine vollständige Automatisierung funktioniert noch nicht. Zur Evaluation der AID-Therapie sind die metrischen Daten der Glucosesensoren, die „Zeit im Zielbereich“ und der „Glucose Management Indicator“ anerkannte und geeignete Parameter, da sie eine Beratung auf Basis der reellen Daten aus dem Alltag der Menschen mit Diabetes zulassen. Da alle Glucosesensoren über Cloud-basierte Software ausgelesen werden oder die Daten automatisch aus einem telefonverbundenen Empfangsgerät beziehen, ist die ideale technische Grundlage für eine telemedizinische Betreuung geschaffen, die noch der Ausgestaltung bedarf.
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Abstract
Insulinpumpen und Glukosesensoren können laut Registerdaten die Diabetestherapie verbessern sowie die Rate akuter Komplikationen reduzieren. In der pädiatrischen Diabetologie ist daher die Nutzung mindestens eines dieser technischen Geräte Standard. Deren Kombination macht Systeme zur automatischen Insulinabgabe („automated insulin delivery“ [AID]) möglich. Viele AID-Systeme wurden in klinischen Studien getestet und erwiesen sich als sicher und effektiv. Die Versorgungsituation in Deutschland jedoch lässt derzeit nur ein System als Verordnung bei Versicherten der gesetzlichen Krankenversicherungen zu, und Kinder unter 7 Jahren können damit derzeit nicht versorgt werden. Gründe hierfür sind gesetzliche Hürden und die mangelnde Zertifizierung durch die Hersteller. Die CE-Zertifikate können zudem zu Problemen bei der Insulinverordnung führen. Open-Source-Systeme sind nicht geprüfte Varianten, um bestehende regulatorische Verhältnisse zu umgehen. Deren Anwendung geht mit Risiken sowohl für Nutzer als auch Verordner einher. Für ihren dauerhaften Einsatz müssen sowohl Anwender als auch Behandler über fundierte Kenntnisse der Eigenschaften der einzelnen AID-Systeme verfügen. Zur Evaluation der AID-Therapie sind die metrischen Daten der Glukosesensoren, die „time in range“ und der Glukosemanagementindex die anerkannten und geeigneten Parameter, da sie eine Beratung auf Basis der reellen Werte aus dem Alltag der Menschen mit Diabetes zulassen. Da alle Glukosesensoren über Cloud-basierte Software ausgelesen werden oder die Daten direkt automatisch übermitteln, ist hiermit die ideale technische Grundlage für eine telemedizinische Betreuung geschaffen, die noch der Ausgestaltung bedarf.
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