Association Between Diabetes Technology Use and Glycemic Outcomes in Adults With Type 1 Diabetes Over a Decade

Consensus Report on Glucagon-Like Peptide-1 Receptor Agonists as Adjunctive Treatment for Individuals With Type 1 Diabetes Using an Automated Insulin Delivery System

With increasing prevalence of obesity and cardiovascular diseases, there is a growing interest in the use of glucagon-like peptide-1 receptor agonists (GLP-1RAs) as an adjunct therapy in type 1 diabetes (T1D). The GLP-1RAs are currently not approved by the US Food and Drug Administration for the treatment of T1D in the absence of randomized controlled trials documenting efficacy and safety of these agents in this population. The Diabetes Technology Society convened a series of three consensus meetings of clinicians and researchers with expertise in diabetes technology, GLP-1RA therapy, and T1D management. The project was aimed at synthesizing current literature and providing conclusions on the use of GLP-1RA therapy as an adjunct to automated insulin delivery (AID) systems in adults with T1D. The expert panel members met virtually three times on January 17, 2024, and April 24, 2024, and August 14, 2024, to discuss topics ranging from physiology and outcomes of GLP-1RAs in T1D to limitations of current sensors, algorithms, and insulin for AID systems. The panelists also identified research gaps and future directions for research. The panelists voted to in favor of 31 recommendations. This report presents the consensus opinions of the participants that, in adults with T1D using AID systems, GLP-1RAs have the potential to (1) provide effective adjunct therapy and (2) improve glycemic and metabolic outcomes without increasing the risk of severe hypoglycemia or diabetic ketoacidosis.

7. Diabetes Technology: Standards of Care in Diabetes-2025

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Perioperative Care of Patients Using Wearable Diabetes Devices

The increasing prevalence of diabetes mellitus has been accompanied by a rapid expansion in wearable continuous glucose monitoring (CGM) devices and insulin pumps. Systems combining these components in a "closed loop," where interstitial glucose measurement guides automated insulin delivery (AID, or closed loop) based on sophisticated algorithms, are increasingly common. While these devices' efficacy in achieving near-normoglycemia is contributing to increasing usage among patients with diabetes, the management of these patients in operative and procedural environments remains understudied with limited published guidance available, particularly regarding AID systems. With their growing prevalence, practical management advice is needed for their utilization, or for the rational temporary substitution of alternative diabetes monitoring and treatments, during surgical care. CGM devices monitor interstitial glucose in real time; however, there are potential limitations to use and accuracy in the perioperative period, and, at the present time, their use should not replace regular point-of-care glucose monitoring. Avoiding perioperative removal of CGMs when possible is important, as removal of these prescribed devices can result in prolonged interruptions in CGM-informed treatments during and after procedures, particularly AID system use. Standalone insulin pumps provide continuous subcutaneous insulin delivery without automated adjustments for glucose concentrations and can be continued during some procedures. The safe intraoperative use of AID devices in their hybrid closed-loop mode (AID mode) requires the CGM component of the system to continue to communicate valid blood glucose data, and thus introduces the additional need to ensure this portion of the system is functioning appropriately to enable intraprocedural use. AID devices revert to non-AID insulin therapy modes when paired CGMs are disconnected or when the closed-loop mode is intentionally disabled. For patients using insulin pumps, we describe procedural factors that may compromise CGM, insulin pump, and AID use, necessitating a proactive transition to an alternative insulin regimen. Procedure duration and invasiveness is an important factor as longer procedures increase the risk of stress hyperglycemia, tissue malperfusion, and device malfunction. Whether insulin pumps should be continued through procedures, or substituted by alternative insulin delivery methods, is a complex decision that requires all parties to understand potential risks and contingency plans relating to patient and procedural factors. Currently available CGMs and insulin pumps are reviewed, and practical recommendations for safe glycemic management during the phases of perioperative care are provided.

Effectiveness of Semaglutide and Tirzepatide in Overweight and Obese Adults with Type 1 Diabetes

Objective: Adults with type 1 diabetes (T1D) are increasingly overweight or obese, in part due to intensive insulin therapy. Newer non-insulin medications targeting both hyperglycemia and weight loss are approved for people with type 2 diabetes. These drugs also reduce cardiovascular disease, the major cause of mortality in people with diabetes. We assessed the real-world use of semaglutide and tirzepatide, in adults with T1D followed in a specialty diabetes clinic. Materials and Methods: This retrospective chart review included 100 adults who were prescribed semaglutide or tirzepatide (50 each) and 50 controls frequency matched for age, sex, diabetes duration, body mass index, and glycosylated hemoglobin (HbA1c) and who did not receive any weight loss medications during the study period. Data were collected prior to initiation of weight loss medications (baseline) and then for up to 1 year for each patient. Results: Matching characteristics did not differ between cases and controls. There were declines in weight in both semaglutide (-19.2 ± standard error (SE) 2.9 lbs. [9.1% body weight lost]) and tirzepatide (-49.4 ± SE 3.0 lbs. [21.4% body weight lost]) groups, and HbA1c decreased in both semaglutide (-0.54 ± SE 0.14%, P = 0.0001) and tirzepatide users (-0.68 ± SE 0.16%, P < 0.0001) over 12 months. Weight and HbA1c didn't change in controls. Conclusions: We observed weight loss of 9.1% and 21.4% and improved glucose control in semaglutide and tirzepatide users, respectively, after 1 year of off-label use. As off-label use of these drugs is increasing in patients with T1D, larger, prospective safety and efficacy trials are needed.

Determinants of Liraglutide Treatment Discontinuation in Type 1 Diabetes: A Post Hoc Analysis of ADJUNCT ONE and ADJUNCT TWO Randomized Placebo-Controlled Clinical Studies

INTRODUCTION

Two phase 3 randomized controlled studies (ADJUNCT ONE (Clinicaltrials.gov: NCT01836523), ADJUNCT TWO (Clinicaltrials.gov: NCT02098395)) evaluated liraglutide (1.8, 1.2 or 0.6 mg) vs placebo in participants with type 1 diabetes (T1D) as an adjunct to insulin therapy. This paper aims to improve our understanding of the potential mechanisms leading to premature discontinuation of this treatment regimen.

METHODS

Post hoc comparisons were conducted on baseline characteristics and adverse event (AE) rates of participants completing and not completing the ADJUNCT studies due to AEs/lack of tolerance using summary tables and variance analysis.

RESULTS

Non-completers (liraglutide and placebo combined) had lower baseline body mass index (BMI) (ADJUNCT ONE: 27.8 kg/m2 vs 29.8 kg/m2, P < .0001; ADJUNCT TWO: 26.3 kg/m2 vs 29.2 kg/m2, P < .0001), longer duration of T1D (25.8 years vs 21.0 years, P < .0001; 24.1 years vs 21.0 years, P = .04), lower daily insulin doses by continuous infusion (46.4 U vs 57.3 U, P = .01; 40.9 U vs 57.4 U, P = .12) or multiple injections (58.4 U vs 68.5 U, P = .006; 56.0 U vs 65.8 U, P =.03) and a higher proportion of participants with undetectable C-peptide (91.5% vs 81.3%; 87.0% vs 84.9%) compared to completers. When analyzed by treatment group, only duration of T1D and C-peptide differed between completers and non-completers among liraglutide (and not placebo) participants. The AE rates were higher for non-completers.

CONCLUSION

Individuals with longer-standing T1D and low levels of C-peptide at baseline were more likely to discontinue adjunctive liraglutide treatment due to AEs/lack of tolerance than individuals with residual insulin production. Lower BMI predicted a greater likelihood of non-completion for the included participants, regardless of treatment. These new findings may be relevant for clinical practice.

Psychosocial predictors of short-term glucose among people with diabetes: A narrative review

Type 1 and type 2 diabetes are metabolic disorders that require one to manage one's blood glucose levels on a daily basis through a series of behaviorally complex tasks. Research shows that psychosocial factors, including mood, stress, and social relationships, have a significant influence on one's ability to maintain these disease management routines and achieve healthy blood glucose levels. However, researchers have typically approached these questions from a between-person perspective. Here, we argue for greater consideration of short-term, within-person links of psychosocial factors-including mood, stress, and social interactions-to glucose outcomes. Drawing from existing social and health psychology theories, we put forth an organizing theoretical framework describing how psychosocial experiences may operate on glucose outcomes over subsequent hours. We then review the small but burgeoning literature of intensive longitudinal studies that have examined the short-term effects of negative affect, positive affect, stress, and social interactions on glucose outcomes. Findings showed somewhat stronger links for negative affect and stress compared to positive affect and social interactions, but studies varied greatly in their methodologies, making direct comparisons challenging. A number of findings, particularly in the social interaction literature, depended on dispositional or contextual factors, further complicating interpretation. There was little investigation of the mechanistic pathways that may connect psychosocial factors to glucose outcomes, and few studies conducted lagged analyses to probe the directionality of these links. We conclude by proposing best practices for future research that will address the key weaknesses in the extant literature.

Improvement in Newly Defined Continuous Glucose Monitor Metrics, Extended Hypoglycemia, and Extended Hyperglycemia With Automated Insulin Delivery Initiation in Adults With Type 1 Diabetes

OBJECTIVE

Extended hypoglycemia (Ehypo) and extended hyperglycemia (Ehyper) are recently defined continuous glucose monitoring (CGM) metrics by the International Consensus for clinical trials as secondary endpoints for continuous outcomes. This study aims to evaluate the changes in Ehypo and Ehyper before and after automated insulin delivery (AID) initiation in adults with type 1 diabetes (T1D).

RESEARCH METHODS

This is a retrospective single-center study that evaluated Ehypo and Ehyper in addition to other CGM metrics in 154 adults that initiated an AID system. Metrics were compared before and after AID initiation by Wilcoxon signed-rank test.

RESULTS

Median (interquartile range) Ehypo (<70 mg/dL) events/week decreased from 0.1 (0-0.4) to 0 (0-0.1) and Ehyper (>250 mg/dL) events/week decreased from 2.2 (0.9-4.5) to 0.8 (0.3-1.7) (both P < .001) after AID initiation compared with before AID initiation. All other CGM metrics improved after AID initiation. There was a strong positive correlation between Ehyper (>250 mg/dL) and mean glucose (before AID: r = 0.947, after AID: r = 0.894), glucose management indicator (before AID: r = 0.947, after AID: r = 0.887), and time above range (TAR; >180 mg/dL) (before AID: r = 0.957, after AID: r = 0.917) and a strong positive correlation between Ehypo (<70 mg/dL) and time below range (TBR; <70 mg/dL) (before AID: r = 0.823, after AID: r = 0.608) before and after AID initiation, respectively.

CONCLUSION

Automated insulin delivery initiation significantly improved Ehypo and Ehyper metrics. Ehypo and Ehyper had a strong positive correlation with TBR and TAR, respectively. Ehypo and Ehyper events can be used in addition to TBR and TAR metrics in clinical studies as secondary outcomes.

Technological advancements in glucose monitoring and artificial pancreas systems for shaping diabetes care

The management of diabetes mellitus has undergone remarkable progress with the introduction of cutting-edge technologies in glucose monitoring and artificial pancreas systems. These innovations have revolutionized diabetes care, offering patients more precise, convenient, and personalized management solutions that significantly improve their quality of life. This review aims to provide a comprehensive overview of recent technological advancements in glucose monitoring devices and artificial pancreas systems, focusing on their transformative impact on diabetes care. A detailed review of the literature was conducted to examine the evolution of glucose monitoring technologies, from traditional invasive methods to more advanced systems. The review explores minimally invasive techniques such as continuous glucose monitoring (CGM) systems and flash glucose monitoring (FGM) systems, which have already been proven to enhance glycemic control and reduce the risk of hypoglycemia. In addition, emerging non-invasive glucose monitoring technologies, including optical, electrochemical, and electro-mechanical methods, were evaluated. These techniques are paving the way for more patient-friendly options that eliminate the need for frequent finger-prick tests, thereby improving adherence and ease of use. Advancements in closed-loop artificial pancreas systems, which integrate CGM with automated insulin delivery, were also examined. These systems, often referred to as "hybrid closed-loop" or "automated insulin delivery" systems, represent a significant leap forward in diabetes care by automating the process of insulin dosing. Such advancements aim to mimic the natural function of the pancreas, allowing for better glucose regulation without the constant need for manual interventions by the patient. Technological breakthroughs in glucose monitoring and artificial pancreas systems have had a profound impact on diabetes management, providing patients with more accurate, reliable, and individualized treatment options. These innovations hold the potential to significantly improve glycemic control, reduce the incidence of diabetes-related complications, and ultimately enhance the quality of life for individuals living with diabetes. Researchers are continually exploring novel methods to measure glucose more effectively and with greater convenience, further refining the future of diabetes care. Researchers are also investigating the integration of artificial intelligence and machine learning algorithms to further enhance the precision and predictive capabilities of glucose monitoring and insulin delivery systems. With ongoing advancements in sensor technology, connectivity, and data analytics, the future of diabetes care promises to deliver even more seamless, real-time management, empowering patients with greater autonomy and improved health outcomes.

12-Month Time in Tight Range Improvement with Advanced Hybrid-Closed Loop System in Adults with Type 1 Diabetes

INTRODUCTION

Time in tight range (TITR) is an emerging and valuable metric for assessing normoglycemia. The latest advancement in automated insulin delivery (AID) systems, the advanced hybrid closed-loop (AHCL) systems, are particularly noteworthy for managing type 1 diabetes (T1D) and enhancing glycemic control.

METHODS

In a real-world clinical setting, we carried out a retrospective evaluation of TITR in 42 adult subjects with T1D using the AHCL Minimed™ 780G system over a 12-month period.

RESULTS

Within just 14 days of activating the automatic mode, the AHCL Minimed™ 780G system showed rapid improvement in TITR, and in the other continuous glucose monitoring (CGM) metrics. This improvement persisted over 12 months, achieving the proposed 45-50% range for effective glycemic control.

CONCLUSION

The AHCL Minimed™ 780G system significantly enhances TITR, demonstrating continuous improvement throughout a 12-month follow-up period.

Cost-Utility of Real-Time Continuous Glucose Monitoring versus Self-Monitoring of Blood Glucose in People with Insulin-Treated Type 2 Diabetes in Spain

Objective

Management of advanced type 2 diabetes (T2D) typically involves daily insulin therapy alongside frequent blood glucose monitoring, as treatments such as oral antidiabetic agents are therapeutically insufficient. Real-time continuous glucose monitoring (rt-CGM) has been shown to facilitate greater reductions in glycated hemoglobin (HbA1c) levels and improvements in patient satisfaction relative to self-monitoring of blood glucose (SMBG). This study aimed to investigate the cost-utility of rt-CGM versus SMBG in Spanish patients with insulin-treated T2D..

Methods

The analysis was conducted using the IQVIA Core Diabetes Model (CDM V9.5). Baseline characteristics of the simulated patient cohort and treatment efficacy data were sourced from a large-scale, United States-based retrospective cohort study. Costs were obtained from Spanish sources and inflated to 2022 Euros (EUR) where required. A remaining lifetime horizon (maximum 50 years) was used, alongside an annual discount rate of 3% for future costs and health effects. A willingness-to-pay (WTP) threshold of EUR 30,000 per quality-adjusted life year (QALY) was adopted, based on precedent across previous cost-effectiveness studies set in Spain. A Spanish payer perspective was adopted.

Results

Over patient lifetimes, rt-CGM yielded 9.933 QALYs, versus 8.997 QALYs with SMBG, corresponding to a 0.937 QALY gain with rt-CGM. Total costs in the rt-CGM arm were EUR 2347 higher with rt-CGM versus SMBG (EUR 125,365 versus EUR 123,017). The base case incremental cost-utility ratio was therefore EUR 2506 per QALY gained, substantially lower than the WTP threshold of EUR 30,000 per QALY. The analysis also projected a reduction in cumulative incidence of ophthalmic, renal, neurological, and cardiovascular events in rt-CGM users, with reductions of 16.03%, 13.07%, 7.34%, and 9.09%, respectively.

Conclusion

Compared to SMBG, rt-CGM is highly likely to be a cost-effective intervention for patients living with insulin-treated T2D in Spain.

Safety and Feasibility Evaluation of Automated User Profile Settings Initialization and Adaptation With Control-IQ Technology

BACKGROUND

Optimization of automated insulin delivery (AID) settings is required to achieve desirable glycemic outcomes. We evaluated safety and efficacy of a computerized system to initialize and adjust insulin delivery settings for the t:slim X2 insulin pump with Control-IQ technology in adults with type 1 diabetes (T1D).

METHODS

After a 2-week continuous glucose monitoring (CGM) run-in period, adults with T1D using multiple daily injections (MDI) (N = 33, mean age 36.1 years, 57.6% female, diabetes duration 19.7 years) were transitioned to 13 weeks of Control-IQ technology usage. A computerized algorithm generated recommendations for initial pump settings (basal rate, insulin-to-carbohydrate ratio, and correction factor) and weekly follow-up settings to optimize glycemic outcomes. Physicians could override the automated settings changes for safety concerns.

RESULTS

Time in range 70 to 180 mg/dL improved from 45.7% during run-in to 69.1% during the last 30 days of Control-IQ use, a median improvement of 18.8% (95% confidence interval [CI]: 13.6-23.9, P < .001). This improvement was evident early in the study and was sustained over 13 weeks. Time <70 mg/dL showed a gradual decreasing trend over time. Percentage of participants achieving HbA1c <7% went from zero at baseline to 55% at study end (P < .001). Only six of the 318 automated settings adaptations (1.9%) were overridden by study investigators.

CONCLUSIONS

Computerized initiation and adaptation of Control-IQ technology settings from baseline MDI therapy was safe in adults with T1D. The use of this simplified system for onboarding and optimizing Control-IQ technology may be useful to increase uptake of AID and reduce staff and patient burden in clinical care.

Expert Panel Recommendations for a Standardized Ambulatory Glucose Profile Report for Connected Insulin Pens

Background: Connected insulin pens capture data on insulin dosing/timing and can integrate with continuous glucose monitoring (CGM) devices with essential insulin and glucose metrics combined into a single platform. Standardization of connected insulin pen reports is desirable to enhance clinical utility with a single report. Methods: An international expert panel was convened to develop a standardized connected insulin pen report incorporating insulin and glucose metrics into a single report containing clinically useful information. An extensive literature review and identification of examples of current connected insulin pen reports were performed serving as the basis for creation of a draft of a standardized connected insulin pen report. The expert panel participated in three virtual standardization meetings and online surveys. Results: The Ambulatory Glucose Profile (AGP) Report: Connected Insulin Pen brings all clinically relevant CGM-derived glucose and connected insulin pen metrics into a single simplified two-page report. The first page contains the time in ranges bar, summary of key insulin and glucose metrics, the AGP curve, and detailed basal (long-acting) insulin assessment. The second page contains the bolus (mealtime and correction) insulin assessment periods with information on meal timing, insulin-to-carbohydrate ratio, average bolus insulin dose, and number of days with bolus doses recorded. The report's second page contains daily glucose profiles with an overlay of the timing and amount of basal and bolus insulin administered. Conclusion: The AGP Report: Connected Insulin Pen is a standardized clinically useful report that should be considered by companies developing connected pen technology as part of their system reporting/output.

Cluster analysis of adult individuals with type 1 diabetes: Treatment pathways and complications over a five-year follow-up period

AIMS

To identify subgroups of adults with type 1 diabetes and analyse their treatment pathways and risk of diabetes-related complications over a 5-year follow-up.

METHODS

We performed a k-means cluster analysis using the T1DExchange Registry (n = 6,302) to identify subgroups based on demographic and clinical characteristics. Annual reassessments linked treatment trajectories with these clusters, considering drug and technology use. Complication risks were analysed using Cox regression.

RESULTS

Five clusters were identified: 1) A favourable combination of all variables (31.67 %); 2) Longer diabetes duration (22.63 %); 3) Higher HbA1c levels (13.28 %); 4) Higher BMI (15.25 %); 5) Older age at diagnosis (17.17 %). Two-thirds of patients remained in their initial cluster annually. Technology adoption showed improved glycaemic control over time. Cox proportional hazards showed different risk patterns: Cluster 1 had low complication risk; Cluster 2 had the highest risk for retinopathy, coronary artery disease and autonomic neuropathy; Cluster 3 had the highest risk for albuminuria, depression and diabetic ketoacidosis; Cluster 4 had increased risk for multiple complications; Cluster 5 had the highest risk for hypertension and severe hypoglycaemia, with elevated coronary artery disease risk.

CONCLUSIONS

Clinical characteristics can identify subgroups of patients with T1DM showing differences in treatment and complications during follow-up.

Real-time continuous glucose monitoring-guided glucose management in inpatients with diabetes receiving short-term continuous subcutaneous insulin infusion: a randomized clinical trial

Background

The use of real-time continuous glucose monitoring (rtCGM) technology remains largely investigational in the hospital setting. The current study aimed to evaluate the effectiveness of rtCGM in inpatients with diabetes who were treated with short-term continuous subcutaneous insulin infusion (CSII).

Methods

In this randomized, parallel controlled trial conducted on the endocrinology wards in a tertiary hospital located in Shanghai, adults with type 1 and type 2 diabetes who required short-term CSII during hospitalization were randomly assigned (1:1) to receive either rtCGM-based glucose monitoring and management program or point-of-care (POC) standard of care (8 times/day) with blinded CGM. Primary outcome measure was the difference in the percentage of time within the target glucose range of 3.9-10 mmol/L (TIR, %). This study was registered at www.chictr.org.cn (ChiCTR2300068933).

Findings

Among the 475 randomized participants (237 in the rtCGM group and 238 in the POC group), the mean age of was 60 ± 13 years, and the mean baseline glycated hemoglobin level was 9.4 ± 1.8%. The CGM-recorded mean TIR was 71.1 ± 15.8% in the rtCGM group and 62.9 ± 18.9% in the POC group, with a mean difference of 8.2% (95% confidence interval [CI]: 5.1-11.4%, P < 0.001). The mean time above range >10 mmol/L was significantly lower in the rtCGM group than in the POC group (28.3 ± 15.8% vs. 36.6 ± 19.0%, P < 0.001), whereas there was no significant between-group difference in the time below range <3.9 mmol/L (P = 0.11). Moreover, the time to reach target glucose was significantly shorter in the rtCGM group than in the POC group (2.0 [1.0-4.0] days vs. 4.0 [2.0-5.0] days, P < 0.001). There were no serious adverse events in both groups.

Interpretation

In patients with diabetes who received short-term CSII during hospitalization, the rtCGM program resulted in better glucose control than the POC standard of care, without increasing the risk of hypoglycemia.

Funding

The Program of Shanghai Academic Research Leader (22XD1402300), Shanghai Oriental Talent Program (Youth Project) (No. NA), the Shanghai "Rising Stars of Medical Talent" Youth Development Program-Outstanding Youth Medical Talents (SHWSRS(2021)_099), and the Shanghai Research Center for Endocrine and Metabolic Diseases (2022ZZ01002).

Changes in Basal and Bolus Insulin Requirements with Tirzepatide as an Adjunctive Therapy in Adults with Type 1 Diabetes Using Tandem Control-IQ

INTRODUCTION

This study was aimed at investigating changes in insulin requirements and glycemic outcomes in adults with type 1 diabetes (T1D) using Control IQ (Tandem Diabetes) automated insulin delivery system (AID) over 8 months of tirzepatide treatment.

METHODS

In this single-center, observational study, we collected demographic, A1c, weight, sensor glucose, and insulin dose data for adults with T1D who were using AID and initiated tirzepatide adjunct therapy for clinical indications (n = 11, median age 37, 64% female and mean body mass index of 39.6 kg/m2). Data were compared from baseline and over 8 months.

RESULTS

Within 2 months of tirzepatide treatment, there were significant reductions in total daily insulin [median (IQR) 73.9 (47.6-95.8) to 51.7 (46.7-66.8) units/day, p < 0.001], basal insulin [47 (28.2-51.8) to 32.4 (25.5-46.3) units/day, p < 0.001], and bolus insulin [31.4 (19.9-38.3) to 17.9 (14.9-22.2) units/day, p < 0.001] requirements. Insulin dose reduction from 2 to 8 months was modest. The frequency of user-initiated boluses did not differ throughout the study. Despite reductions in total insulin requirement, time in range (70-180 mg/dl) increased by 7%, A1c reduced by 0.5%, weight reduced by 9%, without increase in time below 70 mg/dl.

CONCLUSIONS

This pilot study provides clinical guidance on insulin titration for adults with T1D who may initiate tirzepatide therapy. Based on the findings of this study, we recommend reducing 25% of total daily insulin dose at tirzepatide initiation in adults with T1D using AID with baseline A1c of less than 7.5%. Higher doses of tirzepatide were associated with greater weight loss, however, the reduction in insulin requirement was minimal.

[Position paper: Open-source technology in the treatment of people living with diabetes mellitus-an Austrian perspective : Technology Committee of the Austrian Diabetes Association]

People living with diabetes mellitus can be supported in the daily management by diabetes technology with automated insulin delivery (AID) systems to reduce the risk of hypoglycemia and improve glycemic control as well as the quality of life. Due to barriers in the availability of AID-systems, the use and development of open-source AID-systems have internationally increased. This technology provides a necessary alternative to commercially available products, especially when approved systems are inaccessible or insufficiently adapted to the specific needs of the users. Open-source technology is characterized by worldwide free availability of codes on the internet, is not officially approved and therefore the use is on the individual's own responsibility. In the clinical practice a lack of expertise with open-source AID technology and concerns about legal consequences, lead to conflict situations for health-care professionals (HCP), sometimes resulting in the refusal of care of people living with diabetes mellitus. This position paper provides an overview of the available evidence and practical guidance for HCP to minimize uncertainties and barriers. People living with diabetes mellitus must continue to be supported in education and diabetes management, independent of the chosen diabetes technology including open-source technology. Check-ups of the metabolic control, acute and chronic complications and screening for diabetes-related diseases are necessary and should be regularly carried out, regardless of the chosen AID-system and by a multidisciplinary team with appropriate expertise.

Diabetic peripheral neuropathy and glycemic variability assessed by continuous glucose monitoring: A systematic review and meta-analysis

Continuous glucose monitoring (CGM)-derived metrics have been used to accurately assess glycemic variability (GV) to facilitate management of diabetes mellitus, yet their relationship with diabetic peripheral neuropathy (DPN) is not fully understood. We performed a systematic review and meta-analysis to evaluate the association between GV metrics and the risk of developing DPN. Nine studies totaling 3,649 patients with type 1 and type 2 diabetes mellitus were included. A significant association was found between increased GV, as indicated by metrics including standard deviation (SD) with OR and 95% CI of 2.58 (1.45-4.57), mean amplitude of glycemic excursions (MAGE) with OR and 95% CI of 1.90 (1.01-3.58), mean of daily difference (MODD) with OR and 95% CI of 2.88 (2.17-3.81) and the incidence of DPN. Our findings support a link between higher GV and an increased risk of DPN in patients with diabetes. These findings highlight the potential of GV metrics as indicators for the development of DPN, advocating for their inclusion in diabetes management strategies to potentially mitigate neuropathy risk. Longitudinal studies with longer observation periods and larger sample sizes are necessary to validate these associations across diverse populations.

Reduced Efficacy of Glucagon-Like Peptide-1 Receptor Agonists Therapy in People With Type 1 Diabetes and Genetic Forms of Obesity

BACKGROUND

Once weekly Glucagon-Like Peptide-1 Receptor Agonists (GLP-1 RA) have been shown to improve glycemic outcomes and cause significant weight loss. However, 9% to 27% of individuals have little or no response to these drugs. In this article, we investigated the efficacy of GLP-1 RA therapy among adults with type 1 diabetes and obesity likely related to genetic mutations compared with obesity likely unrelated to genetic mutations.

METHODS

In this retrospective study, we compared body weight and glycated hemoglobin (HbA1c) change with the use of GLP-1 RA therapy (including a dual agonist, Tirzepatide) over six months among adults with type 1 diabetes and obesity likely (n = 11, median age 39.5 years with a median BMI of 43.0 kg/m2) versus unlikely related to genetic mutation(s) (n = 15, median age 45.8 years with a median BMI of 38.7 kg/m2).

RESULTS

Six months of GLP-1 RA treatment resulted in a numerically lower reduction of weight (-5.75 ± 9.46 kg vs -8.65 ± 9.36 kg, P = .44) and HbA1c (-0.28 ± 0.96% vs -0.43 ± 0.57%, P = .64) among individuals with obesity likely versus unlikely related to a genetic mutation(s), respectively. Fewer individuals with genetic obesity met goal weight loss ≥5% or HbA1c decrease ≥0.4% than did individuals with obesity unlikely related to a genetic cause (36.4% vs 80.0%, P = .04).

CONCLUSIONS

The weight loss and glycemic lowering effects of GLP-1 RA therapy may be decreased in people with type 1 diabetes and obesity likely related to genetic causes. Further research is needed to understand GLP-1 RA mechanisms via energy regulating genes.

Future of Time-in-Range Goals in the Era of Advanced Hybrid Closed-Loop Automated Insulin Delivery Systems

The concept of maintaining blood glucose levels within the 70-180 mg/dL range, known as time-in-range, has raised questions regarding its representation of true physiological euglycemia. Some have speculated that focusing on the time spent within the 70-140 mg/dL range, introduced as time in tight range (TITR) through the International Consensus statement, could serve as a more precise metric for assessing normoglycemia in individuals with type 1 diabetes. This article delves into the current status of TITR as an emerging marker and explores how advanced hybrid closed-loop systems may offer a promising avenue for achieving this higher level of glycemic control.

Real-time continuous glucose monitoring vs. self-monitoring of blood glucose: cost-utility in South Korean type 2 diabetes patients on intensive insulin

AIMS

This study investigated the cost-utility of real-time continuous glucose monitoring (rt-CGM) versus self-monitoring of blood glucose (SMBG) in people with type 2 diabetes (T2D) receiving intensive insulin therapy in South Korea.

METHODS

The IQVIA Core Diabetes Model (CDM v9.5) was used, with clinical effectiveness data obtained from a large-scale real world study. Costs were obtained from South Korean sources and inflated to 2022 South Korean Won (KRW). A South Korean payer perspective was adopted over a lifetime horizon, with future costs and effects discounted at 4.5% per annum. Baseline characteristics included a mean baseline HbA1c level of 8.6% (71 mmol/mol), and a mean age of 64.4 years. A willingness-to-pay (WTP) threshold of KRW 46.0 million was used.

RESULTS

Rt-CGM led to an increase of 0.683 quality-adjusted life years (QALYs) versus SMBG (7.526 QALYs for rt-CGM versus 6.843 QALYs for SMBG). An increase in costs of KRW 16.4 million (from KRW 90.4 million to KRW 106.8 million) was associated with rt-CGM. The incremental cost-utility ratio was KRW 24.0 million per QALY gained, significantly lower than the KRW 46 million threshold.

CONCLUSIONS

For individuals with T2D managed by intensive insulin therapy in South Korea, rt-CGM is cost-effective relative to SMBG.