1
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Polsky S, Valent AM, Isganaitis E, Castorino K, O'Malley G, Beck SE, Gao P, Laffel LM, Brown FM, Levy CJ. Performance of the Dexcom G7 Continuous Glucose Monitoring System in Pregnant Women with Diabetes. Diabetes Technol Ther 2024; 26:307-312. [PMID: 38315503 PMCID: PMC11058415 DOI: 10.1089/dia.2023.0516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
Background: We evaluated accuracy and safety of a seventh-generation real-time continuous glucose monitoring (CGM) system during pregnancy. Materials and Methods: Evaluable data for accuracy analysis were obtained from 96 G7 sensors (Dexcom, Inc.) worn by 96 of 105 enrolled pregnant women with type 1 (n = 59), type 2 (n = 21), or gestational diabetes (n = 25). CGM values were compared with arterialized venous glucose values from the YSI comparator instrument during 6-h clinic sessions at different time points throughout the sensors' 10-day wear period. The primary endpoint was the proportion of CGM values in the 70-180 mg/dL range within 15% of comparator glucose values. Secondary endpoints included the proportion of CGM values within 20% or 20 mg/dL of comparator values ≥ or <100 mg/dL, respectively (the %20/20 agreement rate). Results: Of the 1739 pairs with CGM in the 70-180 mg/dL range, 83.2% were within 15% of comparator values. The lower bound of the 95% confidence interval was 79.8%. Of the 2102 pairs with CGM values in the 40-400 mg/dL range, the %20/20 agreement rate was 92.5%. Of the 1659 pairs with comparator values in the 63-140 mg/dL range, the %20/20 agreement rate was 92.3%. The %20/20 agreement rates on days 1, 4 and 7, and 10 were 78.6%, 96.3%, and 97.3%, respectively. Consensus error grid analysis showed 99.8% of pairs in the clinically acceptable A and B zones. There were no serious adverse events. The sensors' 10-day survival rate was 90.3%. Conclusion: The G7 system is accurate and safe during pregnancies complicated by diabetes and does not require confirmatory fingerstick testing. Clinical Trial Registration: clinicaltrials.gov NCT04905628.
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Affiliation(s)
- Sarit Polsky
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Amy M. Valent
- Oregon Health and Science University, Portland, Oregon, USA
| | - Elvira Isganaitis
- Joslin Diabetes Center and Harvard Medical School, Boston, Massachusetts, USA
| | | | - Grenye O'Malley
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Stayce E. Beck
- Department of Clinical Affairs, Dexcom, Inc., San Diego, California, USA
| | - Peggy Gao
- Department of Clinical Affairs, Dexcom, Inc., San Diego, California, USA
| | - Lori M. Laffel
- Joslin Diabetes Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Florence M. Brown
- Joslin Diabetes Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Carol J. Levy
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
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2
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McGill JB, Hirsch IB, Parkin CG, Aleppo G, Levy CJ, Gavin JR. The Current and Future Role of Insulin Therapy in the Management of Type 2 Diabetes: A Narrative Review. Diabetes Ther 2024; 15:1085-1098. [PMID: 38573469 PMCID: PMC11043311 DOI: 10.1007/s13300-024-01569-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 03/14/2024] [Indexed: 04/05/2024] Open
Abstract
Early initiation of intensive insulin therapy has been demonstrated to be effective in controlling glycemia and possibly preserving beta-cell function. Innovations in insulin formulations and delivery systems continue. However, we have seen an acceleration in the development of new classes of diabetes medications for individuals with type 2 diabetes and obesity, such as, for example, glucagon-like peptide-1 receptor agonists (GLP-1 RAs). These formulations have been shown to confer significant benefits in achieving good glycemic control with reduced hypoglycemia risk, weight loss, and cardiorenal protection. Therefore, it is reasonable to question whether there is still a role for insulin therapy in the management of type 2 diabetes. However, there are clear limitations inherent to GLP-1 RA therapy, including high rates of suboptimal adherence and treatment discontinuation due to high cost and side effects, which diminish long-term efficacy, and supply issues. In addition, newer formulations have shown improvements in convenience and tolerability, and have been shown to be even more effective when used in conjunction with basal insulin. In this narrative review, we discuss current evidence that supports GLP-1 RA use in combination with insulin therapy and the potential pitfalls of reliance on GLP-1 RAs as a substitute for insulin therapy.
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Affiliation(s)
- Janet B McGill
- Division of Endocrinology, Metabolism and Lipid Research, School of Medicine, Washington University in St. Louis, 660 S. Euclid, Campus Box 8127, St. Louis, MO, 63110, USA
| | - Irl B Hirsch
- UW Medicine Diabetes Institute, University of Washington School of Medicine, 750 Republican Street, Building F, Seattle, WA, 98109, USA
| | - Christopher G Parkin
- CGParkin Communications, Inc., 2675 Windmill Pkwy, Ste. 2721, Henderson, NV, 89074, USA.
| | - Grazia Aleppo
- Division of Endocrinology, Metabolism and Molecular Medicine, Feinberg School of Medicine Northwestern University, 675 N St Clair St Galter Pavilion, Ste 14-100, Chicago, IL, 60611, USA
| | - Carol J Levy
- Division of Endocrinology, Diabetes, and Metabolism, Mount Sinai Diabetes Center and T1D Clinical Research, Icahn School of Medicine at Mount Sinai, 5 E 98th St, New York, NY, 10029, USA
| | - James R Gavin
- Emory University School of Medicine, 100 Woodruff Circle, Atlanta, GA, 30322, USA
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Tian T, Aaron RE, DuNova AY, Jendle JH, Kerr D, Cengiz E, Drincic A, Pickup JC, Chen KY, Schwartz N, Muchmore DB, Akturk HK, Levy CJ, Schmidt S, Bellazzi R, Wu AHB, Spanakis EK, Najafi B, Chase JG, Seley JJ, Klonoff DC. Diabetes Technology Meeting 2023. J Diabetes Sci Technol 2024:19322968241235205. [PMID: 38528741 DOI: 10.1177/19322968241235205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
Diabetes Technology Society hosted its annual Diabetes Technology Meeting from November 1 to November 4, 2023. Meeting topics included digital health; metrics of glycemia; the integration of glucose and insulin data into the electronic health record; technologies for insulin pumps, blood glucose monitors, and continuous glucose monitors; diabetes drugs and analytes; skin physiology; regulation of diabetes devices and drugs; and data science, artificial intelligence, and machine learning. A live demonstration of a personalized carbohydrate dispenser for people with diabetes was presented.
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Affiliation(s)
- Tiffany Tian
- Diabetes Technology Society, Burlingame, CA, USA
| | | | | | - Johan H Jendle
- School of Medicine and Health, Institute of Medical Sciences, Örebro University, Örebro, Sweden
| | | | - Eda Cengiz
- School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | | | - John C Pickup
- King's College London School of Medicine, London, UK
| | - Kong Y Chen
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, USA
| | | | | | - Halis K Akturk
- Barbara Davis Center for Diabetes, University of Colorado, Aurora, CO, USA
| | - Carol J Levy
- Division of Endocrinology, Diabetes, and Metabolism, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | | | | | - Alan H B Wu
- University of California, San Francisco, San Francisco, CA, USA
| | - Elias K Spanakis
- Baltimore VA Medical Center and School of Medicine, University of Maryland, Baltimore, MD, USA
| | | | | | - Jane Jeffrie Seley
- Division of Endocrinology, Diabetes & Metabolism, Weill Cornell Medicine, New York City, NY, USA
| | - David C Klonoff
- Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA, USA
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4
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Criego AB, Carlson AL, Brown SA, Forlenza GP, Bode BW, Levy CJ, Hansen DW, Hirsch IB, Bergenstal RM, Sherr JL, Mehta SN, Laffel LM, Shah VN, Bhargava A, Weinstock RS, MacLeish SA, DeSalvo DJ, Jones TC, Aleppo G, Buckingham BA, Ly TT. Two Years with a Tubeless Automated Insulin Delivery System: A Single-Arm Multicenter Trial in Children, Adolescents, and Adults with Type 1 Diabetes. Diabetes Technol Ther 2024; 26:11-23. [PMID: 37850941 PMCID: PMC10794844 DOI: 10.1089/dia.2023.0364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
Background: The Omnipod® 5 Automated Insulin Delivery (AID) System was shown to be safe and effective following 3 months of use in people with type 1 diabetes (T1D); however, data on the durability of these results are limited. This study evaluated the long-term safety and effectiveness of Omnipod 5 use in people with T1D during up to 2 years of use. Materials and Methods: After a 3-month single-arm, multicenter, pivotal trial in children (6-13.9 years) and adolescents/adults (14-70 years), participants could continue system use in an extension phase. HbA1c was measured every 3 months for up to 15 months; continuous glucose monitor metrics were collected for up to 2 years. Results: Participants (N = 224) completed median (interquartile range) 22.3 (21.7, 22.7) months of AID. HbA1c was reduced in the pivotal trial from 7.7% ± 0.9% in children and 7.2% ± 0.9% in adolescents/adults to 7.0% ± 0.6% and 6.8% ± 0.7%, respectively, (P < 0.0001), and was maintained at 7.2% ± 0.7% and 6.9% ± 0.6% after 15 months (P < 0.0001 from baseline). Time in target range (70-180 mg/dL) increased from 52.4% ± 15.6% in children and 63.6% ± 16.5% in adolescents/adults at baseline to 67.9% ± 8.0% and 73.8% ± 10.8%, respectively, during the pivotal trial (P < 0.0001) and was maintained at 65.9% ± 8.9% and 72.9% ± 11.3% during the extension (P < 0.0001 from baseline). One episode of diabetic ketoacidosis and seven episodes of severe hypoglycemia occurred during the extension. Children and adolescents/adults spent median 96.1% and 96.3% of time in Automated Mode, respectively. Conclusion: Our study supports that long-term use of the Omnipod 5 AID System can safely maintain improvements in glycemic outcomes for up to 2 years of use in people with T1D. Clinical Trials Registration Number: NCT04196140.
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Affiliation(s)
- Amy B. Criego
- Department of Pediatric Endocrinology, International Diabetes Center, Park Nicollet, Minneapolis, Minnesota, USA
| | - Anders L. Carlson
- International Diabetes Center, Park Nicollet, HealthPartners, Minneapolis, Minnesota, USA
| | - Sue A. Brown
- Division of Endocrinology, Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
| | - Gregory P. Forlenza
- Department of Pediatrics, Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | | | - Carol J. Levy
- Division of Endocrinology, Diabetes, and Metabolism, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - David W. Hansen
- Department of Pediatrics, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Irl B. Hirsch
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Richard M. Bergenstal
- International Diabetes Center, Park Nicollet, HealthPartners, Minneapolis, Minnesota, USA
| | - Jennifer L. Sherr
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut, USA
| | - Sanjeev N. Mehta
- Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Lori M. Laffel
- Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Viral N. Shah
- Department of Pediatrics, Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | | | - Ruth S. Weinstock
- Department of Medicine, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Sarah A. MacLeish
- Department of Pediatrics, University Hospitals Cleveland Medical Center, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Daniel J. DeSalvo
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Thomas C. Jones
- Department of Research, East Coast Institute for Research at The Jones Center, Macon, Georgia, USA
| | - Grazia Aleppo
- Division of Endocrinology, Metabolism, and Molecular Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Bruce A. Buckingham
- Division of Pediatric Endocrinology, Department of Pediatrics, Stanford University, Stanford, California, USA
| | - Trang T. Ly
- Insulet Corporation, Acton, Massachusetts, USA
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5
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Tian T, Aaron RE, Seley JJ, Longo R, Nayberg I, Umpierrez GE, Levy CJ, Klonoff DC. Use of Continuous Glucose Monitors Upon Hospital Discharge of People With Diabetes: Promise, Barriers, and Opportunity. J Diabetes Sci Technol 2024; 18:207-214. [PMID: 37784246 PMCID: PMC10899827 DOI: 10.1177/19322968231200847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
Continuous glucose monitors (CGMs) have increasingly been used in ambulatory and inpatient or hospital settings to improve glycemic outcomes for people with diabetes. Given their capacity to aid individuals in avoiding hypo- and hyperglycemia, they may also be useful when transitioning from hospital to home by reducing rates of hospital readmissions and emergency department visits. Several types of barriers presently exist that make the deployment of CGMs at the time of hospital discharge problematic, including (1) regulatory, (2) behavioral, (3) logistical, (4) technical, (5) staffing, and (6) systemic issues. In this commentary, we review the literature, discuss these barriers, and propose possible solutions to facilitate the use of CGMs in people with diabetes at the time of hospital discharge.
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Affiliation(s)
- Tiffany Tian
- Diabetes Technology Society, Burlingame, CA, USA
| | | | - Jane Jeffrie Seley
- Division of Endocrinology, Diabetes & Metabolism, Weill Cornell Medicine, New York, NY, USA
| | - Rebecca Longo
- Lahey Hospital & Medical Center, Beth Israel Lahey Health, Burlington, MA, USA
| | - Irina Nayberg
- Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA, USA
| | | | - Carol J. Levy
- Division of Endocrinology, Diabetes, and Metabolism, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - David C. Klonoff
- Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA, USA
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6
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Kondegowda NG, Filipowska J, Do JS, Leon-Rivera N, Li R, Hampton R, Ogyaadu S, Levister C, Penninger JM, Reijonen H, Levy CJ, Vasavada RC. RANKL/RANK is required for cytokine-induced beta cell death; osteoprotegerin, a RANKL inhibitor, reverses rodent type 1 diabetes. Sci Adv 2023; 9:eadf5238. [PMID: 37910614 PMCID: PMC10619938 DOI: 10.1126/sciadv.adf5238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 09/29/2023] [Indexed: 11/03/2023]
Abstract
Treatment for type 1 diabetes (T1D) requires stimulation of functional β cell regeneration and survival under stress. Previously, we showed that inhibition of the RANKL/RANK [receptor activator of nuclear factor kappa Β (NF-κB) ligand] pathway, by osteoprotegerin and the anti-osteoporotic drug denosumab, induces rodent and human β cell proliferation. We demonstrate that the RANK pathway mediates cytokine-induced rodent and human β cell death through RANK-TRAF6 interaction and induction of NF-κB activation. Osteoprotegerin and denosumab protected β cells against this cytotoxicity. In human immune cells, osteoprotegerin and denosumab reduce proinflammatory cytokines in activated T-cells by inhibiting RANKL-induced activation of monocytes. In vivo, osteoprotegerin reversed recent-onset T1D in nonobese diabetic/Ltj mice, reduced insulitis, improved glucose homeostasis, and increased plasma insulin, β cell proliferation, and mass in these mice. Serum from T1D subjects induced human β cell death and dysfunction, but not α cell death. Osteoprotegerin and denosumab reduced T1D serum-induced β cell cytotoxicity and dysfunction. Inhibiting RANKL/RANK could have therapeutic potential.
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Affiliation(s)
- Nagesha Guthalu Kondegowda
- Department of Translational Research and Cellular Therapeutics, Arthur Riggs Diabetes and Metabolism Research Institute, City of Hope, Duarte, CA 91010, USA
- Diabetes, Obesity, and Metabolism Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Joanna Filipowska
- Department of Translational Research and Cellular Therapeutics, Arthur Riggs Diabetes and Metabolism Research Institute, City of Hope, Duarte, CA 91010, USA
- Diabetes, Obesity, and Metabolism Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Jeong-su Do
- Department of Immunology and Theranostics, Arthur Riggs Diabetes and Metabolism Research Institute, City of Hope, Duarte, CA 91010, USA
| | - Nancy Leon-Rivera
- Department of Translational Research and Cellular Therapeutics, Arthur Riggs Diabetes and Metabolism Research Institute, City of Hope, Duarte, CA 91010, USA
| | - Rosemary Li
- Diabetes, Obesity, and Metabolism Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Rollie Hampton
- Diabetes, Obesity, and Metabolism Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Selassie Ogyaadu
- Diabetes, Obesity, and Metabolism Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Division of Endocrinology and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Camilla Levister
- Diabetes, Obesity, and Metabolism Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Division of Endocrinology and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Josef M. Penninger
- IMBA, Institute of Molecular Biotechnology of the Austrian Academy of Sciences, Vienna 1030, Austria
- Department of Medical Genetics, Life Sciences Institute, University of British Columbia, Vancouver, Canada
| | - Helena Reijonen
- Department of Immunology and Theranostics, Arthur Riggs Diabetes and Metabolism Research Institute, City of Hope, Duarte, CA 91010, USA
| | - Carol J. Levy
- Diabetes, Obesity, and Metabolism Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Division of Endocrinology and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Rupangi C. Vasavada
- Department of Translational Research and Cellular Therapeutics, Arthur Riggs Diabetes and Metabolism Research Institute, City of Hope, Duarte, CA 91010, USA
- Diabetes, Obesity, and Metabolism Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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7
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Aleppo G, Hirsch IB, Parkin CG, McGill J, Galindo R, Kruger DF, Levy CJ, Forlenza GP, Umpierrez GE, Grunberger G, Bergenstal RM. Coverage for Continuous Glucose Monitoring for Individuals with Type 2 Diabetes Treated with Nonintensive Therapies: An Evidence-Based Approach to Policymaking. Diabetes Technol Ther 2023; 25:741-751. [PMID: 37471068 PMCID: PMC10611973 DOI: 10.1089/dia.2023.0268] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
Numerous studies have demonstrated the clinical benefits of continuous glucose monitoring (CGM) in individuals with type 1 diabetes (T1D) and type 2 diabetes (T2D) who are treated with intensive insulin regimens. Based on this evidence, CGM is now a standard of care for individuals within these diabetes populations and widely covered by commercial and public insurers. Moreover, recent clinical guidelines from the American Diabetes Association and American Association of Clinical Endocrinology now endorse CGM use in individuals treated with nonintensive insulin regimens. However, despite increasing evidence supporting CGM use for individuals treated with less-intensive insulin therapy or noninsulin medications, insurance coverage is limited or nonexistent. This narrative review reports key findings from recent randomized, observational, and retrospective studies investigating use of CGM in T2D individuals treated with basal insulin only and/or noninsulin therapies and presents an evidence-based rationale for expanding access to CGM within this population.
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Affiliation(s)
- Grazia Aleppo
- Division of Endocrinology, Metabolism and Molecular Medicine, Feinberg School of Medicine Northwestern University, Chicago, Illinois, USA
| | | | | | - Janet McGill
- Division of Endocrinology, Metabolism and Lipid Research, Washington University in St. Louis, School of Medicine, St. Louis, Missouri, USA
| | - Rodolfo Galindo
- Lennar Medical Center, UMiami Health System, Jackson Memorial Health System, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Davida F. Kruger
- Division of Endocrinology, Diabetes, Bone & Mineral, Henry Ford Health System, Detroit, Michigan, USA
| | - Carol J. Levy
- Division of Endocrinology, Diabetes, and Metabolism, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Gregory P. Forlenza
- Division of Pediatric Endocrinology, Department of Pediatrics, Barbara Davis Center, University of Colorado Denver, Aurora, Colorado, USA
| | - Guillermo E. Umpierrez
- Division of Endocrinology, Metabolism Emory University School of Medicine, Grady Memorial Hospital, Atlanta, Georgia, USA
| | | | - Richard M. Bergenstal
- International Diabetes Center at Park Nicollet, HealthPartners Institute, Minneapolis, Minnesota, USA
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8
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Levy CJ, Raghinaru D, Kudva YC, Pandit K, Blevins T, Casaubon L, Desjardins D, Levister CM, O’Malley G, Reid C, Lum J, Kollman C, Beck RW. Beneficial Effects of Control-IQ Automated Insulin Delivery in Basal-Bolus and Basal-Only Insulin Users With Type 2 Diabetes. Clin Diabetes 2023; 42:116-124. [PMID: 38230336 PMCID: PMC10788662 DOI: 10.2337/cd23-0025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
The t:slim X2 insulin pump with Control-IQ technology (Control-IQ) advanced hybrid closed-loop automated insulin delivery system was evaluated in this prospective single-arm trial. Thirty adults with type 2 diabetes using the Control-IQ system showed substantial glycemic improvement with no increase in hypoglycemia. Mean time in range (70-180 mg/dL) improved 15%, representing an increase of 3.6 hours/day, and mean glucose decreased by 22 mg/dL.
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Affiliation(s)
- Carol J. Levy
- Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Yogish C. Kudva
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Keta Pandit
- Texas Diabetes and Endocrinology, Austin, TX
| | | | | | - Donna Desjardins
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Camilla M. Levister
- Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Grenye O’Malley
- Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Corey Reid
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - John Lum
- Jaeb Center for Health Research, Tampa, FL
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9
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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: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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10
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Levy CJ, Kudva YC, Ozaslan B, Castorino K, O'Malley G, Kaur RJ, Levister CM, Church MM, Desjardins D, McCrady-Spitzer S, Ogyaadu S, Trinidad MC, Reid C, Rizvi S, Deshpande S, Zaniletti I, Kremers WK, Pinsker JE, Doyle FJ, Dassau E. At-Home Use of a Pregnancy-Specific Zone-MPC Closed-Loop System for Pregnancies Complicated by Type 1 Diabetes: A Single-Arm, Observational Multicenter Study. Diabetes Care 2023:148936. [PMID: 37196353 DOI: 10.2337/dc23-0173] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 04/27/2023] [Indexed: 05/19/2023]
Abstract
OBJECTIVE There are no commercially available hybrid closed-loop insulin delivery systems customized to achieve pregnancy-specific glucose targets in the U.S. This study aimed to evaluate the feasibility and performance of at-home use of a zone model predictive controller-based closed-loop insulin delivery system customized for pregnancies complicated by type 1 diabetes (CLC-P). RESEARCH DESIGN AND METHODS Pregnant women with type 1 diabetes using insulin pumps were enrolled in the second or early third trimester. After study sensor wear collecting run-in data on personal pump therapy and 2 days of supervised training, participants used CLC-P targeting 80-110 mg/dL during the day and 80-100 mg/dL overnight running on an unlocked smartphone at home. Meals and activities were unrestricted throughout the trial. The primary outcome was the continuous glucose monitoring percentage of time in the target range 63-140 mg/dL versus run-in. RESULTS Ten participants (HbA1c 5.8 ± 0.6%) used the system from mean gestational age of 23.7 ± 3.5 weeks. Mean percentage time in range increased 14.1 percentage points, equivalent to 3.4 h per day, compared with run-in (run-in: 64.5 ± 16.3% versus CLC-P: 78.6 ± 9.2%; P = 0.002). During CLC-P use, there was significant decrease in both time over 140 mg/dL (P = 0.033) and the hypoglycemic ranges of less than 63 mg/dL and 54 mg/dL (P = 0.037 for both). Nine participants exceeded consensus goals of above 70% time in range during CLC-P use. CONCLUSIONS The results show that the extended use of CLC-P at home until delivery is feasible. Larger, randomized studies are needed to further evaluate system efficacy and pregnancy outcomes.
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Affiliation(s)
- Carol J Levy
- Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Basak Ozaslan
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Boston, MA
- Sansum Diabetes Research Institute, Santa Barbara, CA
| | | | | | | | | | | | | | | | | | | | | | | | - Sunil Deshpande
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Boston, MA
- Sansum Diabetes Research Institute, Santa Barbara, CA
| | | | | | | | - Francis J Doyle
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Boston, MA
| | - Eyal Dassau
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Boston, MA
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11
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Biskupiak JE, Ramos M, Levy CJ, Forlenza G, Hopley C, Boyd J, Swift D, Lamotte M, Brixner DI. Cost-effectiveness of the tubeless automated insulin delivery system vs standard of care in the management of type 1 diabetes in the United States. J Manag Care Spec Pharm 2023:1-11. [PMID: 37133431 PMCID: PMC10394185 DOI: 10.18553/jmcp.2023.22331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
BACKGROUND: A tubeless, on-body automated insulin delivery (AID) system (Omnipod 5 Automated Insulin Delivery System) demonstrated improved glycated hemoglobin A1c levels and increased time in range (70 mg/dL to 180 mg/dL) for both adults and children with type 1 diabetes in a 13-week multicenter, single-arm study. OBJECTIVE: To assess the cost-effectiveness of the tubeless AID system compared with standard of care (SoC) in the management of type 1 diabetes (T1D) in the United States. METHODS: Cost-effectiveness analyses were conducted from a US payer's perspective, using the IQVIA Core Diabetes Model (version 9.5), with a time horizon of 60 years and an annual discount of 3.0% on both costs and effects. Simulated patients received either tubeless AID or SoC, the latter being defined as either continuous subcutaneous insulin infusion (86% of patients) or multiple daily injections. Two cohorts (children: <18 years; adults: ≥18 years) of patients with T1D and 2 thresholds for nonsevere hypoglycemia (nonsevere hypoglycemia event [NSHE] <54 mg/dL and <70 mg/dL) were considered. Baseline cohort characteristics and treatment effects of different risk factors for tubeless AID were sourced from the clinical trial. Utilities and cost of diabetes-related complications were obtained from published sources. Treatment costs were derived from US national database sources. Scenario analyses and probabilistic sensitivity analyses were performed to test the robustness of the results. RESULTS: Treating children with T1D with tubeless AID, considering an NSHE threshold of less than 54 mg/dL, brings incremental life-years (1.375) and quality-adjusted life-years (QALYs) (1.521) at an incremental cost of $15,099 compared with SoC, resulting in an incremental cost-effectiveness ratio of $9,927 per QALY gained. Similar results were obtained for adults with T1D assuming an NSHE threshold of less than 54 mg/dL (incremental cost-effectiveness ratio = $10,310 per QALY gained). Furthermore, tubeless AID is a dominant treatment option for children and adults with T1D assuming an NSHE threshold of less than 70 mg/dL compared with SoC. The probabilistic sensitivity analyses results showed that compared with SoC, in both children and adults with T1D, tubeless AID was cost-effective in more than 90% of simulations, assuming a willingness-to-pay threshold of $100,000 per QALY gained. The key drivers of the model were the cost of ketoacidosis, duration of treatment effect, threshold of NSHE, and definition of severe hypoglycemia. CONCLUSIONS: The current analyses suggest that the tubeless AID system can be considered a cost-effective treatment compared with SoC in people with T1D from a US payer's perspective. DISCLOSURES: This research was funded by Insulet. Mr Hopley, Ms Boyd, and Mr Swift are full-time Insulet employees and own stock in Insulet Corporation. IQVIA, the employer of Ms Ramos and Dr Lamotte, received consulting fees for this work. Dr Biskupiak is receiving research support and consulting fees from Insulet. Dr Brixner has received consulting fees from Insulet. The University of Utah has received research funding from Insulet. Dr Levy is a consultant with Dexcom and Eli Lilly and has received grant/research support from Insulet, Tandem, Dexcom, and Abbott Diabetes. Dr Forlenza conducted research sponsored by Medtronic, Dexcom, Abbott, Tandem, Insulet, Beta Bionics, and Lilly. He has been speaker/consultant/advisory board member for Medtronic, Dexcom, Abbott, Tandem, Insulet, Beta Bionics, and Lilly.
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Affiliation(s)
| | | | - Carol J Levy
- Ichan School of Medicine at Mount Sinai, New York City, NY
| | - Greg Forlenza
- Children's Hospital, University of Colorado Denver, Aurora
| | | | | | | | | | - Diana I Brixner
- Department of Pharmacotherapy, University of Utah, Salt Lake City
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12
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Levy CJ, Galindo RJ, Parkin CG, Gillis J, Argento NB. All Children Deserve to Be Safe, Mothers Too: Evidence and Rationale Supporting CGM Use in Gestational Diabetes Within the Medicaid Population. J Diabetes Sci Technol 2023:19322968231161317. [PMID: 36919680 DOI: 10.1177/19322968231161317] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
Gestational diabetes mellitus (GDM) is a common metabolic disease of pregnancy that threatens the health of several million women and their offspring. The highest prevalence of GDM is seen in women of low socioeconomic status. Women with GDM are at increased risk of adverse maternal outcomes, including increased rates of Cesarean section delivery, preeclampsia, perineal tears, and postpartum hemorrhage. However, of even greater concern is the increased risk to the fetus and long-term health of the child due to elevated glycemia during pregnancy. Although the use of continuous glucose monitoring (CGM) has been shown to reduce the incidence of maternal and fetal complications in pregnant women with type 1 diabetes and type 2 diabetes, most state Medicaid programs do not cover CGM for women with GDM. This article reviews current statistics relevant to the incidence and costs of GDM among Medicaid beneficiaries, summarizes key findings from pregnancy studies using CGM, and presents a rationale for expanding and standardizing CGM coverage for GDM within state Medicaid populations.
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Affiliation(s)
- Carol J Levy
- Division of Endocrinology, Diabetes, and Metabolism, Mount Sinai Diabetes Center, and T1D Clinical Research, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rodolfo J Galindo
- Emory University School of Medicine, Atlanta, GA, USA
- Center for Diabetes Metabolism Research, Emory University Hospital Midtown, Atlanta, GA, USA
- Hospital Diabetes Taskforce, Emory Healthcare System, Atlanta, GA, USA
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13
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Karol AB, Viera N, Ogyaadu SJ, Brooks D, Shah NA, Linker AS, Lam DW, Levy CJ, O’Malley G. A Novel Algorithm for the Management of Inpatient COVID-19 Glucocorticoid-Induced Hyperglycemia. Clin Diabetes 2023; 41:378-385. [PMID: 37456090 PMCID: PMC10338271 DOI: 10.2337/cd22-0083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Hyperglycemia in hospitalized patients with coronavirus disease 2019 (COVID-19) is linked to increased morbidity and mortality. This article reports on a novel insulin titration protocol for the management of glucocorticoid-induced hyperglycemia in hospitalized patients with COVID-19. Sixty-five patients with COVID-19 and glucocorticoid-induced hyperglycemia admitted after the protocol implementation were matched 1:1 to patients admitted before the treatment protocol rollout for analysis. In a large, diverse health system, the protocol achieved reductions in hypoglycemic events without increasing hyperglycemia or insulin use.
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Affiliation(s)
| | - Natalia Viera
- Division of Endocrinology, Diabetes, and Bone Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Selassie J. Ogyaadu
- Division of Endocrinology, Diabetes, and Bone Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Danielle Brooks
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Nirali A. Shah
- Division of Endocrinology, Diabetes, and Bone Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Anne S. Linker
- Division of Hospital Medicine, Mount Sinai Hospital, New York, NY
| | - David W. Lam
- Division of Endocrinology, Diabetes, and Bone Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Carol J. Levy
- Division of Endocrinology, Diabetes, and Bone Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Grenye O’Malley
- Division of Endocrinology, Diabetes, and Bone Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
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14
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Karol AB, O'Malley G, Fallurin R, Levy CJ. Automated Insulin Delivery Systems as a Treatment for Type 2 Diabetes Mellitus: A Review. Endocr Pract 2023; 29:214-220. [PMID: 36241017 DOI: 10.1016/j.eprac.2022.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 09/29/2022] [Accepted: 10/03/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Approximately 6.3% of the worldwide population has type 2 diabetes mellitus (T2DM), and the number of people requiring insulin is increasing. Automated insulin delivery (AID) systems integrate continuous subcutaneous insulin infusion and continuous glucose monitoring with a predictive control algorithm to provide more physiologic glycemic control. Personalized glycemic targets are recommended in T2DM owing to the heterogeneity of the disease. Based on the success of hybrid closed-loop systems in improving glycemic control and safety in type 1 diabetes mellitus, there has been further interest in the use of these systems in people with T2DM. METHODS We performed a review of AID systems with a focus on the T2DM population. RESULTS In 5 randomized controlled trials, AID systems improve time in range and reduce glycemic variability, without increasing insulin requirements or the risk of hypoglycemia. CONCLUSION AID systems in T2DM are safe and effective in hospitalized and closely monitored settings. Home studies of longer duration are required to assess for long-term benefit and identify target populations of benefit.
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Affiliation(s)
- Alexander B Karol
- Division of Endocrinology, Diabetes, and Metabolism, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Grenye O'Malley
- Division of Endocrinology, Diabetes, and Metabolism, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Reshmitha Fallurin
- Division of Endocrinology, Diabetes, and Metabolism, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Carol J Levy
- Division of Endocrinology, Diabetes, and Metabolism, Icahn School of Medicine at Mount Sinai, New York, New York.
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15
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Szmuilowicz ED, Levy CJ, Buschur EO, Polsky S. Expert Guidance on Off-Label Use of Hybrid Closed-Loop Therapy in Pregnancies Complicated by Diabetes. Diabetes Technol Ther 2023; 25:363-373. [PMID: 36724300 DOI: 10.1089/dia.2022.0540] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Automated insulin delivery (AID) systems have established benefits in terms of glycemic control, health outcomes, and quality of life and are strongly recommended for people with type 1 diabetes outside of pregnancy. While evidence for use of investigational AID systems during pregnancy is promising, data and guidance are still needed regarding use of commercially available systems during pregnancy. Unfortunately, none of the hybrid closed-loop (HCL) systems that are currently available in the United States have glucose targets that are as aggressive as pregnancy glycemic targets, none have a pregnancy-specific algorithm, and none are approved for use during pregnancy. As such, any use of these systems during pregnancy is considered off-label in the United States and would be "assisted" by provider/user techniques. Despite these limitations, many women conceive while using clinically available HCL systems and may be hesitant to cease use during pregnancy. Achievement of strict pregnancy glycemic targets can be difficult, and it is conceivable that selective off-label use of clinically available HCL systems in some women could lead to improved glycemia. We herein offer expert guidance based on clinical experience and available case reports on how to identify appropriate candidates for HCL therapy in pregnancy, how to counsel pregnant women with diabetes on the potential risks and benefits of HCL therapy during pregnancy, and how to manage commercially available systems off-label throughout gestation in an assisted HCL approach.
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Affiliation(s)
- Emily D Szmuilowicz
- Division of Endocrinology, Metabolism and Molecular Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Carol J Levy
- Divisions of Endocrinology and Obstetrics, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Elizabeth O Buschur
- Division of Endocrinology, Metabolism and Diabetes, Department of Internal Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Sarit Polsky
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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16
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O’Malley G, Arumugam D, Ogyaadu S, Levister C, Nosova E, Vieira L, Levy CJ. Pilot Study for Use of Intermittently Scanned Continuous Glucose Monitoring in Women with Gestational Diabetes. J Diabetes Sci Technol 2023; 17:259-261. [PMID: 36321571 PMCID: PMC9846409 DOI: 10.1177/19322968221134544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Grenye O’Malley
- Division of Endocrinology, Diabetes and Bone
Disease, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Selassie Ogyaadu
- Division of Endocrinology, Diabetes and Bone
Disease, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Camilla Levister
- Division of Endocrinology, Diabetes and Bone
Disease, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Emily Nosova
- Division of Endocrinology, Diabetes and Bone
Disease, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Luciana Vieira
- Division of Maternal Fetal Medicine, Icahn
School of Medicine at Mount Sinai, New York, NY, USA
| | - Carol J. Levy
- Division of Endocrinology, Diabetes and Bone
Disease, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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17
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Polsky S, Foster NC, DuBose SN, Agarwal S, Lyons S, Peters AL, Uwaifo GI, DiMeglio LA, Sherr JL, Levy CJ. Incident diabetes complications among women with type 1 diabetes based on parity. J Matern Fetal Neonatal Med 2022; 35:4629-4634. [PMID: 33280471 DOI: 10.1080/14767058.2020.1858278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 11/18/2020] [Accepted: 11/27/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To assess risk factors and incidence of diabetes complications in women with type 1 diabetes (T1D) based on parity. RESEARCH DESIGN/METHODS Data were collected from women (16-40 years old) in the T1D Exchange completing pregnancy/childbirth questionnaires during 2011-2013 and 2016-2018. Incidence of risk factors and diabetes complications were compared between women with a first pregnancy at/within 1-year of enrollment (n = 28) and never pregnant women by year 5 (n = 469). RESULTS There was a trend for lower HbA1c (adjusted p = .14) and higher rates of overweight/obesity, triglyceride/HDL > 2, log (triglyercide/HDL), and hypertension among parous women compared with nulliparous women. There were no significant differences in rates of advanced nephropathy, albuminuria or cardiovascular disease. CONCLUSIONS Four-5 years after delivery, parous women with T1D tended to have lower HbA1c levels despite higher body mass indices and more frequent adverse lipid profiles and hypertension compared with nulliparous women. Further studies based on these trends are warranted.
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Affiliation(s)
- Sarit Polsky
- Barbara Davis Center for Diabetes, University of Colorado Denver, Aurora, CO, USA
| | | | | | | | - Sarah Lyons
- Baylor College of Medicine, Houston, TX, USA
| | - Anne L Peters
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | | | | | | | - Carol J Levy
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
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18
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Wang AW, O’Malley G, Levister C, Arasaratnam D, Rouviere M, Shah N, Lam DW, Levy CJ. LBSUN180 Preconception Counseling And Reproductive Education Program For People With Diabetes (PREPP'D) - An Educational Program For Underserved Women With Diabetes. J Endocr Soc 2022. [PMCID: PMC9624542 DOI: 10.1210/jendso/bvac150.584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Unintended pregnancy in women with diabetes is associated with high public cost, delay in initiating prenatal care, and maternal and fetal complications. One third of the women with diabetes in our underserved prenatal clinic present with an HbA1C >7.5%. Due to limited data regarding preconception counseling for women with diabetes, we developed PREPP'D, a quality improvement initiative and educational program aiming to improve women's and providers’ knowledge of diabetes and pregnancy, increase awareness of contraception options, and implement standard protocols in our diabetes clinic for underserved populations. Design: A questionnaire was developed to measure the rate of contraception use and assess women's knowledge regarding pregnancy planning. The questionnaire has two sections: general questions about the woman's reproductive health, contraception use, and current pregnancy plan and specific questions about the woman's current knowledge about pregnancy and diabetes including glycemic targets and glucose monitoring and medication safety during pregnancy. The latter part of the questionnaire was scored with 6 points indicating all questions answered correctly. Women aged 18-50 with pre-gestational diabetes were identified and given an English or Spanish questionnaire prior to seeing the provider. The providers were given a prewritten SmartPhrase to guide counseling and explaining the importance of pre-pregnancy planning, glucose targets during pregnancy, and medication optimization. After the visit, women were given an educational flyer. Results Thirty-six women aged 21-49 years with type 1 (n=16), type 2 (n=19), or steroid-induced (n=1) diabetes are included in this analysis. Women were from various backgrounds: Black/African American (n = 4), non-Hispanic White (n = 11), Hispanic (n =18), and other (n=3). Average diabetes duration was 10.2 (range 1-32) years. Mean HbA1C was 8.7% (range 5.3-14.7%). Only seven women met the HbA1C target goal for pregnancy (<6.5%). Complications of diabetes were reported in 23%, and one woman reported prior fetal cardiac anomalies. Of the three women planning pregnancies within the next year, only one had an HbA1c <6.5%. The mean questionnaire score was 1.6/6 points (±1.3, range 0-5) with nine women scoring 0 points. Documentation of pregnancy discussion was noted in 83% of records (compared to 38% prior to intervention). Conclusions Knowledge of pregnancy is limited for many women with diabetes. PREPP'D is a novel approach to standardize preconception counseling in the diabetes clinic. It also provides an opportunity to raise women's and providers’ awareness about diabetes and pregnancy. The next step of this project is to conduct follow-up surveys for both women and providers 3 to 6 months post initial survey to assess impact and improve future interventions including expansion to adolescents. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.
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Affiliation(s)
- Ally W Wang
- Division of Endocrinology, Diabetes and Bone Disease, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Grenye O’Malley
- Division of Endocrinology, Diabetes and Bone Disease, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Camilla Levister
- Division of Endocrinology, Diabetes and Bone Disease, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Dushyanthy Arasaratnam
- Division of Endocrinology, Diabetes and Bone Disease, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Madeleine Rouviere
- Registered Dietitian Nutritionist, Certified Diabetes Care and Education Specialist at The Mount Sinai Hospital, New York City, NY, USA
| | - Nirali Shah
- Division of Endocrinology, Diabetes and Bone Disease, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - David W Lam
- Division of Endocrinology, Diabetes and Bone Disease, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Carol J Levy
- Division of Endocrinology, Diabetes and Bone Disease, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
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19
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Wang AW, Emengo P, Taye A, Sharif Khawaja U, Levy CJ, Gallagher EJ. PSAT215 Hypercalcemic Crisis Complicating a First Trimester Pregnancy Caused by a Giant Parathyroid Adenoma Masquerading as a Thyroid Nodule. J Endocr Soc 2022. [PMCID: PMC9629358 DOI: 10.1210/jendso/bvac150.443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Background Primary hyperparathyroidism (PHP) during pregnancy is rare with a reported incidence of 1%, although the true incidence is unknown. It is associated with increased morbidity and mortality for both mother and fetus. Most reported cases of PHP during pregnancy are due to small adenomas causing mild hyperparathyroidism. Surgical management is recommended if the calcium level is >11mg/dL (2.75mmol/L) or the patient has symptomatic hypercalcemia. It is generally recommended that surgery be performed in the second trimester due to the risk of miscarriage in the first trimester, and preterm labor in the third trimester. Case A 29-year-old woman presented to our emergency department at 10 weeks’ gestation with nausea and vomiting. She also reported constipation and fatigue. On examination, she was euvolemic, awake and alert, with no neurological symptoms or signs. The suspected diagnosis was hyperemesis gravidarum until her laboratory evaluation revealed marked hypercalcemia [15.6mg/d (3.9mmol/L)]. Further labs revealed hypophosphatemia [1.2mg/dL (0.39mmol/L)], hypokalemia [3.3mEq/L], hypomagnesemia [1.4mEq/L], low 25-hydroxy vitamin D [16.2ng/mL (40.44pmol/L)], and elevated intact parathyroid hormone (iPTH) [573pg/mL], 1,25-dihydroxy vitamin D [251.1pg/mL (626.75pmol/L)], and 24 hour urinary calcium [448mg/24 hours (11.2mmol/24 hours]. On cardiac evaluation, her QTc was normal. The patient was given intravenous hydration with normal saline, which reduced the calcium to 13.6mg/dL (3.4mmol/L) after 48 hours. She remained symptomatic and severely hypercalcemic, so calcitonin 4 IU/kg every 12 hours was added, while a neck ultrasound was performed to localize the parathyroid adenoma. Her calcium level decreased to 10.7mg/dL (2.7mmol/L) after calcitonin, but rapidly rebounded to 13.3mg/dL (3.3mmol/L) along with hypophosphatemia and hypokalemia. Intravenous potassium phosphate was initiated and her calcium decreased to 11.8mg/dL (2.95mmol/L). The neck ultrasound did not identify a parathyroid adenoma, but identified a 2.5×1.5×3.3 cm right mixed cystic/ solid thyroid nodule. An MRI of the neck revealed two right thyroid nodules. The decision was made to perform a neck dissection given the persistent severe hypercalcemia after a multidisciplinary team evaluation, and extensive discussion with the patient. The surgical exploration of the right neck identified a giant parathyroid adenoma that weighed 11.3g. The intraoperative PTH levels reduced from 804pg/mL to 60.7pg/mL. Her calcium normalized immediately postoperatively and she was discharged home without complication. At the time of last follow up, she was 18 weeks’ gestation and a fetal ultrasound was normal. Discussion This case had three unusual features: PHP causing severe hypercalcemia during pregnancy; a giant parathyroid adenoma; and parathyroid adenoma masquerading as a thyroid nodule on imaging. This case highlights the importance of a multidisciplinary team approach in optimizing the care of such complicated patients, along with the need for definitive surgical intervention. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.
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20
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Forlenza GP, Carlson AL, Galindo RJ, Kruger DF, Levy CJ, McGill JB, Umpierrez G, Aleppo G. Real-World Evidence Supporting Tandem Control-IQ Hybrid Closed-Loop Success in the Medicare and Medicaid Type 1 and Type 2 Diabetes Populations. Diabetes Technol Ther 2022; 24:814-823. [PMID: 35763323 PMCID: PMC9618372 DOI: 10.1089/dia.2022.0206] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background: The Tandem Control-IQ (CIQ) system has demonstrated significant glycemic improvements in large randomized controlled and real-world trials. Use of this system is lower in people with type 1 diabetes (T1D) government-sponsored insurance and those with type 2 diabetes (T2D). This analysis aimed to evaluate the performance of CIQ in these groups. Methods and Materials: A retrospective analysis of CIQ users was performed. Users age ≥6 years with a t:slim X2 Pump and >30 days of continuous glucose monitoring (CGM) data pre-CIQ and >30 days post-CIQ technology initiation were included. Results: A total of 4243 Medicare and 1332 Medicaid CIQ users were analyzed among whom 5075 had T1D and 500 had T2D. After starting CIQ, the Medicare beneficiaries group saw significant improvement in time in target range 70-180 mg/dL (TIR; 64% vs. 74%; P < 0.0001), glucose management index (GMI; 7.3% vs. 7.0%; P < 0.0001), and the percentage of users meeting American Diabetes Association (ADA) CGM Glucometrics Guidelines (12.8% vs. 26.3%; P < 0.0001). The Medicaid group also saw significant improvement in TIR (46% vs. 60%; P < 0.0001), GMI (7.9% vs. 7.5%; P < 0.0001), and percentage meeting ADA guidelines (5.7% vs. 13.4%; P < 0.0001). Patients with T2D and either insurance saw significant glycemic improvements. Conclusions: The CIQ system was effective in the Medicare and Medicaid groups in improving glycemic control. The T2D subgroup also demonstrated improved glycemic control with CIQ use. Glucometrics achieved in this analysis are comparable with those seen in previous randomized controlled clinical trials with the CIQ system.
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Affiliation(s)
- Gregory P. Forlenza
- Barbara Davis Center, Division of Pediatric Endocrinology, Department of Pediatrics, University of Colorado Denver, Denver, Colorado, USA
| | - Anders L. Carlson
- International Diabetes Center, HealthPartners Institute, Minneapolis, Minnesota, USA
| | - Rodolfo J. Galindo
- Division of Endocrinology, Metabolism, and Lipids, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Davida F. Kruger
- Division of Endocrinology, Diabetes, Bone and Mineral, Henry Ford Health System, Detroit, Michigan, USA
| | - Carol J. Levy
- Division of Endocrinology, Diabetes, and Metabolism, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Janet B. McGill
- Division of Endocrinology, Metabolism and Lipid Research, Washington University in St. Louis, School of Medicine, St. Louis, Missouri, USA
| | - Guillermo Umpierrez
- Division of Endocrinology, Metabolism Emory University School of Medicine, Atlanta, Georgia, USA
| | - Grazia Aleppo
- Division of Endocrinology, Metabolism and Molecular Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Address correspondence to: Grazia Aleppo, MD, FACE, FACP, Division of Endocrinology, Metabolism and Molecular Medicine, Feinberg School of Medicine, Northwestern University, 645 N. Michigan Avenue, Suite 530, Chicago, IL 60611, USA
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21
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Karol AB, Viera N, Ogyaadu SJ, Brooks D, Shah NA, Linker AS, Lam D, Levy CJ, O’Malley G. LBSUN209 A Novel Algorithm For The Management Of Inpatient Covid-19 Steroid-induced Hyperglycemia. J Endocr Soc 2022. [PMCID: PMC9624954 DOI: 10.1210/jendso/bvac150.589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective/Background Hyperglycemia in hospitalized patients with COVID-19 is linked to increased morbidity and mortality. With increasing use of glucocorticoid (GC) therapy for COVID-19 hypoxemia, clinicians are challenged with an increased prevalence of hyperglycemia. Methods We developed an insulin protocol to aid front line providers in the management of GC-induced hyperglycemia for hospitalized adults with COVID-19. The protocol was based on expert opinion and was available from March 2021 onward. Glycemic and clinical outcomes were obtained for patients treated with GC and retrospectively compared to historical controls treated with GC admitted up to 6 months prior to protocol implementation. Glycemic parameters for finger stick glucose values (FSG) were defined as hypoglycemia <70 mg/dL, euglycemia 70-180 mg/dL, mild hyperglycemia 180-250 mg/dL and severe hyperglycemia >250 mg/dL. To account for differences in the quantity of total FSG between groups, we adjusted for length of stay and calculated the proportion of FSG per patient. Results 130 patients with COVID-19 and GC induced hyperglycemia from before (n=65) and after (n=65) protocol implementation were matched 1: 1 based on age, weight, and sex. There were no significant differences in other baseline patient characteristics. Significantly more patients in the protocol group had mean FSG in the euglycemic range (16.9% vs 38.5%, p=0. 006), and there was a decrease in patients with mean glucose in the mild hyperglycemia range that trended toward significance (50.8% vs 35.4%, p=0. 076). The protocol group had a significantly lower proportion of hypoglycemic FSG per patient (0. 003 vs 0. 008, p=0. 044). Patients in the protocol group had more euglycemic FSG per patient, but this did not reach significance (0.413 vs 0.350, p=0.239). Similarly, the proportion of mild hyperglycemic FSG per patient trended lower in the protocol group (0.315 vs 0.272, p=0.291). There were no significant differences in severe hyperglycemia per patient (0.311 vs 0.328, p=0.828). The protocol group had a significantly higher utilization of basal-bolus insulin regimen (n=43 vs n=63, p<0. 0001) with an increase percentage of bolus insulin utilization in peak total daily dose (70.2% vs. 62.4%, p=0. 08). Total peak day insulin dose trended lower in the protocol group (0.25 vs 0.32 U/kg, p=0.36). Conclusion A novel insulin protocol for the management of GC-induced hyperglycemia in hospitalized COVID-19 patients is an effective tool to achieve reductions in hypoglycemic events and higher utilization of standard of care basal-bolus insulin regimens without increased hyperglycemia or total daily dose of insulin. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.
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22
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Pinsker JE, Dassau E, Deshpande S, Raghinaru D, Buckingham BA, Kudva YC, Laffel LM, Levy CJ, Church MM, Desrochers H, Ekhlaspour L, Kaur RJ, Levister C, Shi D, Lum JW, Kollman C, Doyle FJ. Outpatient Randomized Crossover Comparison of Zone Model Predictive Control Automated Insulin Delivery with Weekly Data Driven Adaptation Versus Sensor-Augmented Pump: Results from the International Diabetes Closed-Loop Trial 4. Diabetes Technol Ther 2022; 24:635-642. [PMID: 35549708 PMCID: PMC9422791 DOI: 10.1089/dia.2022.0084] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Background: Automated insulin delivery (AID) systems have proven effective in increasing time-in-range during both clinical trials and real-world use. Further improvements in outcomes for single-hormone (insulin only) AID may be limited by suboptimal insulin delivery settings. Methods: Adults (≥18 years of age) with type 1 diabetes were randomized to either sensor-augmented pump (SAP) (inclusive of predictive low-glucose suspend) or adaptive zone model predictive control AID for 13 weeks, then crossed over to the other arm. Each week, the AID insulin delivery settings were sequentially and automatically updated by an adaptation system running on the study phone. Primary outcome was sensor glucose time-in-range 70-180 mg/dL, with noninferiority in percent time below 54 mg/dL as a hierarchical outcome. Results: Thirty-five participants completed the trial (mean age 39 ± 16 years, HbA1c at enrollment 6.9% ± 1.0%). Mean time-in-range 70-180 mg/dL was 66% with SAP versus 69% with AID (mean adjusted difference +2% [95% confidence interval: -1% to +6%], P = 0.22). Median time <70 mg/dL improved from 3.0% with SAP to 1.6% with AID (-1.5% [-2.4% to -0.5%], P = 0.002). The adaptation system decreased initial basal rates by a median of 4% (-8%, 16%) and increased initial carbohydrate ratios by a median of 45% (32%, 59%) after 13 weeks. Conclusions: Automated adaptation of insulin delivery settings with AID use did not significantly improve time-in-range in this very well-controlled population. Additional study and further refinement of the adaptation system are needed, especially in populations with differing degrees of baseline glycemic control, who may show larger benefits from adaptation.
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Affiliation(s)
| | - Eyal Dassau
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts, USA
| | - Sunil Deshpande
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts, USA
| | - Dan Raghinaru
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - Bruce A. Buckingham
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Yogish C. Kudva
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Lori M. Laffel
- Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Carol J. Levy
- Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mei Mei Church
- Sansum Diabetes Research Institute, Santa Barbara, California, USA
| | - Hannah Desrochers
- Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Laya Ekhlaspour
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Ravinder Jeet Kaur
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Camilla Levister
- Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Dawei Shi
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts, USA
| | - John W. Lum
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - Craig Kollman
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - Francis J. Doyle
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts, USA
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23
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Kaur RJ, Smith BH, Ozaslan B, Pinsker JE, Trinidad MC, O'Malley G, Desjardins D, Castorino KN, Levister C, Reid C, McCrady-Spitzer S, Ogyaadu SJ, Church MM, Piper M, Kremers WK, Rosenn B, Doyle FJ, Dassau E, Levy CJ, Kudva YC. Hypoglycemia in Prospective Multicenter Study of Pregnancies with Pre-Existing Type 1 Diabetes on Sensor-Augmented Pump Therapy: The LOIS-P Study. Diabetes Technol Ther 2022; 24:544-555. [PMID: 35349353 PMCID: PMC9353990 DOI: 10.1089/dia.2021.0479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background: Pregnancies in type 1 diabetes are high risk, and data in the United States are limited regarding continuous glucose monitoring (CGM)-based hypoglycemia throughout pregnancy while on sensor-augmented insulin pump therapy. Materials and Methods: Pregnant women with type 1 diabetes in the LOIS-P Study (Longitudinal Observation of Insulin use and glucose Sensor metrics in Pregnant women with type 1 diabetes using continuous glucose monitors and insulin pumps) were enrolled before 17 weeks gestation at three U.S. centers and we used their personal insulin pump and a study Dexcom G6 CGM. We analyzed data of 25 pregnant women for CGM hypoglycemia based on international consensus guidelines for percentage time <63 and 54 mg/dL, hypoglycemic events and prolonged hypoglycemia events for 24-h, daytime, and overnight periods, and severe hypoglycemia (SH) episodes. Results: For a 24-h period, biweekly median percentage of time <63 mg/dL ranged from 0.8% at biweek 4-5 to 3.7% at biweek 14-15 with high variability throughout pregnancy. Median percentage of time <63 and 54 mg/dL was higher overnight than daytime (P < 0.01). Hypoglycemic events occurred throughout the pregnancy, ranged 1-4 events per 2 weeks, significantly decreased after the 20th week, and occurred predominantly during daytime (P < 0.01). For overnight period, hypoglycemia and events were more concentrated from 12 to 3 am. Seven prolonged hypoglycemia events without any associated SH occurred in four participants (16%), primarily overnight. Three participants experienced a single episode of SH. Conclusions: Our results suggest a higher overall risk of hypoglycemia throughout pregnancy during the overnight period with continued daytime risk of hypoglycemic events in pregnancies complicated by type 1 diabetes.
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Affiliation(s)
- Ravinder Jeet Kaur
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Byron H. Smith
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Basak Ozaslan
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Minnesota, USA
| | | | - Mari Charisse Trinidad
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Grenye O'Malley
- Division of Endocrinology, Diabetes and Metabolism and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Donna Desjardins
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Camilla Levister
- Division of Endocrinology, Diabetes and Metabolism and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Corey Reid
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Shelly McCrady-Spitzer
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Selassie J. Ogyaadu
- Division of Endocrinology, Diabetes and Metabolism and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mei Mei Church
- Sansum Diabetes Research Institute, Santa Barbara, California, USA
| | - Molly Piper
- Sansum Diabetes Research Institute, Santa Barbara, California, USA
| | - Walter K. Kremers
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Barak Rosenn
- Division of Endocrinology, Diabetes and Metabolism and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Francis J. Doyle
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Minnesota, USA
| | - Eyal Dassau
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Minnesota, USA
| | - Carol J. Levy
- Division of Endocrinology, Diabetes and Metabolism and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Yogish C. Kudva
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
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24
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Polonsky WH, Hood KK, Levy CJ, MacLeish SA, Hirsch IB, Brown SA, Bode BW, Carlson AL, Shah VN, Weinstock RS, Bhargava A, Jones TC, Aleppo G, Mehta SN, Laffel LM, Forlenza GP, Sherr JL, Huyett LM, Vienneau TE, Ly TT. How introduction of automated insulin delivery systems may influence psychosocial outcomes in adults with type 1 diabetes: Findings from the first investigation with the Omnipod® 5 System. Diabetes Res Clin Pract 2022; 190:109998. [PMID: 35853530 PMCID: PMC10901155 DOI: 10.1016/j.diabres.2022.109998] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 06/28/2022] [Accepted: 07/14/2022] [Indexed: 11/28/2022]
Abstract
AIMS To evaluate psychosocial outcomes for adults with type 1 diabetes (T1D) using the tubeless Omnipod® 5 Automated Insulin Delivery (AID) System. METHODS A single-arm, multicenter (across the United States), prospective safety and efficacy study of the tubeless AID system included 115 adults with T1D. Participants aged 18-70 years completed questionnaires assessing psychosocial outcomes - diabetes distress (T1-DDS), hypoglycemic confidence (HCS), well-being (WHO-5), sleep quality (PSQI), insulin delivery satisfaction (IDSS), diabetes treatment satisfaction (DTSQ), and system usability (SUS) - before and after 3 months of AID use. Associations among participant characteristics, psychosocial measures and glycemic outcomes were evaluated using linear regression analyses. RESULTS Adults using the tubeless AID system demonstrated improvements in diabetes-specific psychosocial measures, including diabetes distress, hypoglycemic confidence, insulin delivery satisfaction, diabetes treatment satisfaction, and system usability after 3 months (all P < 0.001). No changes in general well-being or sleep quality were observed. The psychosocial outcomes assessed were not consistently associated with baseline participant characteristics (i.e., age, sex, diabetes duration, glycemic outcomes including percent time in range 70-180 mg/dL, percent time below range < 70 mg/dL, hemoglobin A1c, or insulin regimen). CONCLUSIONS Use of the Omnipod 5 AID system was associated with significant improvements in diabetes-related psychosocial outcomes for adults with T1D. CLINICAL TRIALS REGISTRATION NUMBER NCT04196140.
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Affiliation(s)
- William H Polonsky
- Behavioral Diabetes Institute, 5230 Carrol Canyon Road Ste 208, San Diego, CA 92121, United States; University of California San Diego, 9500 Gilman Dr, La Jolla, CA 92093, United States
| | - Korey K Hood
- Department of Pediatrics, Psychiatry & Behavioral Sciences, Stanford Diabetes Research Center, Stanford University School of Medicine, 279 Campus Drive, B300, Stanford, CA 94305, United States
| | - Carol J Levy
- Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY 10029, United States
| | - Sarah A MacLeish
- University Hospitals Cleveland Medical Center, Rainbow Babies and Children's Hospital, 11100 Euclid Ave, Cleveland, OH 44106, United States
| | - Irl B Hirsch
- Department of Medicine, University of Washington, 750 Republican Street, Building F, Floor 3, Seattle, WA 98109, United States
| | - Sue A Brown
- Division of Endocrinology, Center for Diabetes Technology, University of Virginia, 560 Ray C Hunt Dr, Charlottesville, VA 22903, United States
| | - Bruce W Bode
- Atlanta Diabetes Associates, 1800 Howell Mill Rd #450, Atlanta, GA 30318, United States
| | - Anders L Carlson
- International Diabetes Center, Park Nicollet, HealthPartners, 3800 Park Nicollet Blvd, Minneapolis, MN 55415, United States
| | - Viral N Shah
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, 1775 Aurora Ct #A140, Aurora, CO 80045, United States
| | - Ruth S Weinstock
- Department of Medicine, SUNY Upstate Medical University, 750 E Adams St, Syracuse, NY 13210, United States
| | - Anuj Bhargava
- Iowa Diabetes Research, 1031 Office Park Rd Suite #2, West Des Moines, IA 50265, United States
| | - Thomas C Jones
- Department of Research, East Coast Institute for Research at The Jones Center, 265 Sheraton Blvd, Macon, GA 31210, United States
| | - Grazia Aleppo
- Feinberg School of Medicine, Northwestern University, 645 N Michigan Ave Ste 530, Chicago, IL 60611, United States
| | - Sanjeev N Mehta
- Joslin Diabetes Center, Harvard Medical School, One Joslin Place, Boston, MA 02215, United States
| | - Lori M Laffel
- Joslin Diabetes Center, Harvard Medical School, One Joslin Place, Boston, MA 02215, United States
| | - Gregory P Forlenza
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, 1775 Aurora Ct #A140, Aurora, CO 80045, United States
| | - Jennifer L Sherr
- Department of Pediatrics, Yale School of Medicine, 333 Cedar St, New Haven, CT 06510, United States
| | - Lauren M Huyett
- Insulet Corporation, 100 Nagog Park, Acton, MA 01720, United States
| | - Todd E Vienneau
- Insulet Corporation, 100 Nagog Park, Acton, MA 01720, United States
| | - Trang T Ly
- Insulet Corporation, 100 Nagog Park, Acton, MA 01720, United States.
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25
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Ozaslan B, Levy CJ, Kudva YC, Pinsker JE, O'Malley G, Kaur RJ, Castorino K, Levister C, Trinidad MC, Desjardins D, Church MM, Plesser M, McCrady-Spitzer S, Ogyaadu S, Nelson K, Reid C, Deshpande S, Kremers WK, Doyle FJ, Rosenn B, Dassau E. Feasibility of Closed-Loop Insulin Delivery with a Pregnancy-Specific Zone Model Predictive Control Algorithm. Diabetes Technol Ther 2022; 24:471-480. [PMID: 35230138 PMCID: PMC9464083 DOI: 10.1089/dia.2021.0521] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Objective: Evaluating the feasibility of closed-loop insulin delivery with a zone model predictive control (zone-MPC) algorithm designed for pregnancy complicated by type 1 diabetes (T1D). Research Design and Methods: Pregnant women with T1D from 14 to 32 weeks gestation already using continuous glucose monitor (CGM) augmented pump therapy were enrolled in a 2-day multicenter supervised outpatient study evaluating pregnancy-specific zone-MPC based closed-loop control (CLC) with the interoperable artificial pancreas system (iAPS) running on an unlocked smartphone. Meals and activities were unrestricted. The primary outcome was the CGM percentage of time between 63 and 140 mg/dL compared with participants' 1-week run-in period. Early (2-h) postprandial glucose control was also evaluated. Results: Eleven participants completed the study (age: 30.6 ± 4.1 years; gestational age: 20.7 ± 3.5 weeks; weight: 76.5 ± 15.3 kg; hemoglobin A1c: 5.6% ± 0.5% at enrollment). No serious adverse events occurred. Compared with the 1-week run-in, there was an increased percentage of time in 63-140 mg/dL during supervised CLC (CLC: 81.5%, run-in: 64%, P = 0.007) with less time >140 mg/dL (CLC: 16.5%, run-in: 30.8%, P = 0.029) and time <63 mg/dL (CLC: 2.0%, run-in:5.2%, P = 0.039). There was also less time <54 mg/dL (CLC: 0.7%, run-in:1.6%, P = 0.030) and >180 mg/dL (CLC: 4.9%, run-in: 13.1%, P = 0.032). Overnight glucose control was comparable, except for less time >250 mg/dL (CLC: 0%, run-in:3.9%, P = 0.030) and lower glucose standard deviation (CLC: 23.8 mg/dL, run-in:42.8 mg/dL, P = 0.007) during CLC. Conclusion: In this pilot study, use of the pregnancy-specific zone-MPC was feasible in pregnant women with T1D. Although the duration of our study was short and the number of participants was small, our findings add to the limited data available on the use of CLC systems during pregnancy (NCT04492566).
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Affiliation(s)
- Basak Ozaslan
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Boston, Massachusetts, USA
- Sansum Diabetes Research Institute, Santa Barbara, California, USA
| | - Carol J. Levy
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | - Grenye O'Malley
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | - Camilla Levister
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | - Mei Mei Church
- Sansum Diabetes Research Institute, Santa Barbara, California, USA
| | - Mitchell Plesser
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Selassie Ogyaadu
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kristen Nelson
- Sansum Diabetes Research Institute, Santa Barbara, California, USA
| | | | - Sunil Deshpande
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Boston, Massachusetts, USA
- Sansum Diabetes Research Institute, Santa Barbara, California, USA
| | | | - Francis J. Doyle
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Boston, Massachusetts, USA
| | - Barak Rosenn
- Robert Wood Johnson Barnabas Health, New Brunswick, New Jersey, USA
| | - Eyal Dassau
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Boston, Massachusetts, USA
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26
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Miller KM, Kanapka LG, Rickels MR, Ahmann AJ, Aleppo G, Ang L, Bhargava A, Bode BW, Carlson A, Chaytor NS, Gannon G, Goland R, Hirsch IB, Kiblinger L, Kruger D, Kudva YC, Levy CJ, McGill JB, O'Malley G, Peters AL, Philipson LH, Philis-Tsimikas A, Pop-Busui R, Salam M, Shah VN, Thompson MJ, Vendrame F, Verdejo A, Weinstock RS, Young L, Pratley R. Benefit of Continuous Glucose Monitoring in Reducing Hypoglycemia Is Sustained Through 12 Months of Use Among Older Adults with Type 1 Diabetes. Diabetes Technol Ther 2022; 24:424-434. [PMID: 35294272 PMCID: PMC9208859 DOI: 10.1089/dia.2021.0503] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Objective: To evaluate glycemic outcomes in the Wireless Innovation for Seniors with Diabetes Mellitus (WISDM) randomized clinical trial (RCT) participants during an observational extension phase. Research Design and Methods: WISDM RCT was a 26-week RCT comparing continuous glucose monitoring (CGM) with blood glucose monitoring (BGM) in 203 adults aged ≥60 years with type 1 diabetes. Of the 198 participants who completed the RCT, 100 (98%) CGM group participants continued CGM (CGM-CGM cohort) and 94 (98%) BGM group participants initiated CGM (BGM-CGM cohort) for an additional 26 weeks. Results: CGM was used a median of >90% of the time at 52 weeks in both cohorts. In the CGM-CGM cohort, median time <70 mg/dL decreased from 5.0% at baseline to 2.6% at 26 weeks and remained stable with a median of 2.8% at 52 weeks (P < 0.001 baseline to 52 weeks). Participants spent more time in range 70-180 mg/dL (TIR) (mean 56% vs. 64%; P < 0.001) and had lower hemoglobin A1c (HbA1c) (mean 7.6% [59 mmol/mol] vs. 7.4% [57 mmol/mol]; P = 0.01) from baseline to 52 weeks. In BGM-CGM, from 26 to 52 weeks median time <70 mg/dL decreased from 3.9% to 1.9% (P < 0.001), TIR increased from 56% to 60% (P = 0.006) and HbA1c decreased from 7.5% (58 mmol/mol) to 7.3% (57 mmol/mol) (P = 0.025). In BGM-CGM, a severe hypoglycemic event was reported for nine participants while using BGM during the RCT and for two participants during the extension phase with CGM (P = 0.02). Conclusions: CGM use reduced hypoglycemia without increasing hyperglycemia in older adults with type 1 diabetes. These data provide further evidence for fully integrating CGM into clinical practice. Clinicaltrials.gov (NCT03240432).
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Affiliation(s)
| | - Lauren G. Kanapka
- Jaeb Center for Health Research, Tampa, Florida, USA
- Address correspondence to: Lauren G. Kanapka, MSc, Jaeb Center for Health Research, 15310 Amberly Drive, #350, Tampa, FL 33647, USA
| | - Michael R. Rickels
- Rodebaugh Diabetes Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Andrew J. Ahmann
- Division of Endocrinology, Diabetes, and Clinical Nutrition, Oregon Health and Science University, Portland, Oregon, USA
| | - Grazia Aleppo
- Division of Endocrinology, Metabolism, and Molecular Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Lynn Ang
- Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Anuj Bhargava
- Iowa Diabetes and Endocrinology Research Center, Des Moines, Iowa, USA
| | - Bruce W. Bode
- Formally Atlanta Diabetes Associates, Atlanta, Georgia, USA
| | - Anders Carlson
- Park Nicollet International Diabetes Center, Minneapolis, Minnesota, USA
| | - Naomi S. Chaytor
- Elson S. Floyd College of Medicine, Washington State University, Spokane, Washington, USA
| | - Gail Gannon
- Kovler Diabetes Center, University of Chicago, Chicago, Illinois, USA
| | - Robin Goland
- Naomi Berri Diabetes Center, Columbia University, New York, New York, USA
| | - Irl B. Hirsch
- Division of Metabolism, Endocrinology and Nutrition, University of Washington, Seattle, Washington, USA
| | - Lisa Kiblinger
- Formally Atlanta Diabetes Associates, Atlanta, Georgia, USA
| | | | | | - Carol J. Levy
- Division of Endocrinology, Diabetes and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Janet B. McGill
- Division of Endocrinology, Metabolism & Lipid Research, John T. Milliken Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Grenye O'Malley
- Division of Endocrinology, Diabetes and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Anne L. Peters
- Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | | | | | - Rodica Pop-Busui
- Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Maamoun Salam
- Division of Endocrinology, Metabolism & Lipid Research, John T. Milliken Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Viral N. Shah
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Michael J. Thompson
- Department of Endocrinology-Diabetes, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Francesco Vendrame
- Division of Endocrinology, Diabetes, and Metabolism at the University of Miami School of Medicine, University of Miami, Miami, Florida, USA
| | | | - Ruth S. Weinstock
- Department of Medicine, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Laura Young
- Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Richard Pratley
- AdventHealth Translation Research Institute, Orlando, Florida, USA
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Mizokami-Stout K, Bailey R, Ang L, Aleppo G, Levy CJ, Rickels MR, Shah VN, Polsky S, Nelson B, Carlson AL, Vendrame F, Pop-Busui R. Symptomatic diabetic autonomic neuropathy in type 1 diabetes (T1D): Findings from the T1D exchange. J Diabetes Complications 2022; 36:108148. [PMID: 35279403 DOI: 10.1016/j.jdiacomp.2022.108148] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 02/02/2022] [Accepted: 02/03/2022] [Indexed: 10/19/2022]
Abstract
AIMS We aimed to evaluate the contemporary prevalence of and risk factors for symptomatic diabetic autonomic neuropathy (DAN) in participants with type 1 diabetes (T1D) enrolled in the T1D Exchange Clinic Registry. METHODS DAN symptoms and severity were assessed with the Survey of Autonomic Symptoms (SAS) in adults with ≥5 years of T1D participating in the T1D Exchange from years 2010-2017. Associations of demographic, clinical, and laboratory factors with symptomatic DAN were assessed. RESULTS Of the 4919 eligible T1D participants, 965 (20%) individuals completed the SAS questionnaire [mean age 40 ± 17 years, median diabetes duration 20 years (IQR: 13,34), 64% female, 90% non-Hispanic White, and 82% with private insurance]. DAN symptoms were present in 166 (17%) of responders with 72% experiencing moderate severity symptoms or worse. Symptomatic DAN participants had higher hemoglobin A1c (p = 0.03), longer duration (p = 0.004), were more likely to be female (p = 0.03), and more likely to have lower income (p = 0.03) versus no DAN symptoms. Symptomatic DAN was associated with diabetic peripheral neuropathy (p < 0.0001), smoking (p = 0.002), cardiovascular disease (p = 0.02), depression (p < 0.001), and opioid use (p = 0.004). CONCLUSIONS DAN symptoms are common in T1D. Socioeconomic factors and psychological comorbidities may contribute to DAN symptoms and should be explored further.
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Affiliation(s)
| | - Ryan Bailey
- Jaeb Center for Health Research, Tampa, FL, United States of America
| | - Lynn Ang
- University of Michigan, Ann Arbor, MI, United States of America
| | - Grazia Aleppo
- Feinberg School of Medicine, Northwestern University, Chicago, IL, United States of America
| | - Carol J Levy
- Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Michael R Rickels
- Rodebaugh Diabetes Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States of America
| | - Viral N Shah
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO, United States of America
| | - Sarit Polsky
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO, United States of America
| | - Bryce Nelson
- Children's Hospital of Richmond, Virginia Commonwealth University, Richmond, VA, United States of America
| | - Anders L Carlson
- International Diabetes Center, Minneapolis, MN, United States of America
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28
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Levy CJ, O'Malley G, Raghinaru D, Kudva YC, Laffel LM, Pinsker JE, Lum JW, Brown SA. Insulin Delivery and Glucose Variability Throughout the Menstrual Cycle on Closed Loop Control for Women with Type 1 Diabetes. Diabetes Technol Ther 2022; 24:357-361. [PMID: 35099294 PMCID: PMC9127830 DOI: 10.1089/dia.2021.0431] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Objective: To analyze insulin delivery and glycemic metrics throughout the menstrual cycle for women with type 1 diabetes using closed loop control (CLC) insulin delivery. Methods: Menstruating women using a CLC system in a clinical trial were invited to record their menstrual cycles through a cycle-tracking application. Sixteen participants provided data for this secondary analysis over three or more complete cycles. Insulin delivery and continuous glucose monitoring (CGM) data were analyzed in relation to reported cycle phases. Results: Insulin delivery and CGM metrics remained consistent during cycle phases. Intraparticipant variability of CGM metrics and weight-based insulin delivery did not change through cycle phases. Conclusions: For this sample of menstruating women with type 1 diabetes using a CLC system, insulin delivery and glycemic metrics remained stable throughout menstrual cycle phases. Additional studies in this population are needed, particularly among women who report variable glycemic control during their cycles. Trial Registration: NCT03591354.
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Affiliation(s)
- Carol J. Levy
- Deparment of Medicine, Endocrinology, Diabetes and Bone Diseases, Mount Sinai Diabetes Center, New York, New York, USA
| | - Grenye O'Malley
- Deparment of Medicine, Endocrinology, Diabetes and Bone Diseases, Mount Sinai Diabetes Center, New York, New York, USA
| | - Dan Raghinaru
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - Yogish C. Kudva
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Lori M. Laffel
- Research Division, Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | | | - John W. Lum
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - Sue A. Brown
- Endocrinology and Metabolism Division, Department of Medicine, Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
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29
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Demeterco-Berggren C, Ebekozien O, Levy CJ, Maahs DM. Response to Letter to the Editor from Justin M. Gregory: "Age and Hospitalization Risk in People With Type 1 Diabetes and COVID-19: Data From the T1D Exchange Surveillance Study". J Clin Endocrinol Metab 2022; 107:e1769-e1770. [PMID: 34871436 PMCID: PMC8689707 DOI: 10.1210/clinem/dgab872] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Indexed: 12/05/2022]
Affiliation(s)
| | - Osagie Ebekozien
- T1D Exchange, Boston, MA 02111, USA
- University of Mississippi School Medical Center, Jackson, MS 39216, USA
| | - Carol J Levy
- Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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30
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Demeterco-Berggren C, Ebekozien O, Rompicherla S, Jacobsen L, Accacha S, Gallagher MP, Todd Alonso G, Seyoum B, Vendrame F, Haw JS, Basina M, Levy CJ, Maahs DM. Age and Hospitalization Risk in People With Type 1 Diabetes and COVID-19: Data From the T1D Exchange Surveillance Study. J Clin Endocrinol Metab 2022; 107:410-418. [PMID: 34581790 PMCID: PMC8500098 DOI: 10.1210/clinem/dgab668] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Indexed: 01/08/2023]
Abstract
CONTEXT COVID-19 morbidity and mortality are increased in type 1 diabetes (T1D), but few data focus on age-based outcomes. OBJECTIVE This work aimed to quantify the risk for COVID-19-related hospitalization and adverse outcomes by age in people with T1D. METHODS For this observational, multisite, cross-sectional study of patients with T1D and laboratory-confirmed COVID-19 from 56 clinical sites in the United States, data were collected from April 2020 to March 2021. The distribution of patient factors and outcomes across age groups (0-18, 19-40, and > 40 years) was examined. Descriptive statistics were used to describe the study population, and multivariate logistic regression models were used to analyze the relationship between age, adverse outcomes, and hospitalization. The main outcome measure was hospitalization for COVID-19. RESULTS A total of 767 patients were analyzed. Fifty-four percent (n = 415) were aged 0 to 18 years, 32% (n = 247) were aged 19 to 40 years, and 14% (n = 105) were older than 40 years. A total of 170 patients were hospitalized, and 5 patients died. Compared to the 0- to 18-years age group, those older than 40 years had an adjusted odds ratio of 4.2 (95% CI, 2.28-7.83) for hospitalization after adjustment for sex, glycated hemoglobin A1c, race, insurance type, and comorbidities. CONCLUSION Age older than 40 years is a risk factor for patients with T1D and COVID-19, with children and younger adults experiencing milder disease and better prognosis. This indicates a need for age-tailored treatments, immunization, and clinical management of individuals affected by T1D.
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Affiliation(s)
- Carla Demeterco-Berggren
- Rady Children’s Hospital, University of California, San Diego, San Diego, California 92123, USA
- Correspondence: Carla Demeterco-Berggren, MD, PhD, Rady Children’s Hospital, University of California, San Diego, 7960, Birmingham Dr, Ste 4111, San Diego CA, 92123, USA.
| | - Osagie Ebekozien
- T1D Exchange, Boston, Massachusetts 02111, USA
- University of Mississippi School Medical Center, Jackson, Mississippi 39216, USA
| | | | | | | | | | - G Todd Alonso
- Barbara Davis Center, University of Colorado, Aurora, Colorado 80045, USA
| | | | | | | | - Marina Basina
- Stanford University, Stanford, California 94305, USA
| | - Carol J Levy
- Icahn School of Medicine at Mount Sinai, New York, New York 10029, USA
| | - David M Maahs
- Stanford University, Stanford, California 94305, USA
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31
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O'Malley G, Ozaslan B, Levy CJ, Castorino K, Desjardins D, Levister C, McCrady-Spitzer S, Church MM, Kaur RJ, Reid C, Kremers WK, Doyle FJ, Trinidad MC, Rosenn B, Pinsker JE, Kudva YC, Dassau E. Longitudinal Observation of Insulin Use and Glucose Sensor Metrics in Pregnant Women with Type 1 Diabetes Using Continuous Glucose Monitors and Insulin Pumps: The LOIS-P Study. Diabetes Technol Ther 2021; 23:807-817. [PMID: 34270347 PMCID: PMC9057877 DOI: 10.1089/dia.2021.0112] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background: Suboptimal glycemic control is associated with maternal and neonatal morbidity and mortality in pregnancy complicated by type 1 diabetes (T1D). Prospective analysis of continuous glucose monitoring (CGM) metrics, insulin pump settings, and insulin delivery can better characterize the changes in glycemic levels and insulin use throughout pregnancy with T1D. Materials and Methods: Prescribed parameters, insulin delivery, carbohydrate intake, and CGM data for 25 pregnant women with T1D from three U.S. sites were collected. Participants enrolled before 17 weeks gestation and used personal insulin pumps and study CGM. Mean daily total, basal, and bolus insulin doses (units/kg), CGM time in range (TIR: 63-140 mg/dL), and pump-entered carbohydrates were analyzed for every 2-week gestational interval. Linear mixed-effects regression models were used to evaluate changes across gestational ages compared to 12-14 weeks. Results: Basal insulin was higher during weeks 6-12 and 24-40. Daily bolus and total insulin were higher during weeks 20-40. Pump parameters were adjusted to intensify insulin therapy from 22 weeks onward. Average TIR across pregnancy was 59% ± 14%. Between 18 and 30 weeks, TIR was significantly lower, and time above range was significantly higher compared to the reference biweek. Time below target was lower between 22 and 34 weeks. Seven participants achieved >70% recommended TIR for pregnancy. Participants with maternal complications or infant neonatal intensive care unit admissions had lower TIR. Conclusion: While insulin dosing changed significantly with advancing gestation, most participants did not achieve >70% TIR. Customized anticipatory pump setting adjustments and automated systems aimed toward the designated TIR are needed to improve outcomes for this population. NCT03761615.
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Affiliation(s)
- Grenye O'Malley
- Icahn School of Medicine at Mount Sinai, Division of Endocrinology, Diabetes and Bone Diseases, New York, New York, USA
| | - Basak Ozaslan
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts, USA
| | - Carol J. Levy
- Icahn School of Medicine at Mount Sinai, Division of Endocrinology, Diabetes and Bone Diseases, New York, New York, USA
| | | | - Donna Desjardins
- Mayo Clinic, Division of Endocrinology, Diabetes, Metabolism & Nutrition, Rochester, Minnesota, USA
| | - Camilla Levister
- Icahn School of Medicine at Mount Sinai, Division of Endocrinology, Diabetes and Bone Diseases, New York, New York, USA
| | - Shelly McCrady-Spitzer
- Mayo Clinic, Division of Endocrinology, Diabetes, Metabolism & Nutrition, Rochester, Minnesota, USA
| | - Mei Mei Church
- Sansum Diabetes Research Institute, Santa Barbara, California, USA
| | - Ravinder Jeet Kaur
- Mayo Clinic, Division of Endocrinology, Diabetes, Metabolism & Nutrition, Rochester, Minnesota, USA
| | - Corey Reid
- Mayo Clinic, Division of Endocrinology, Diabetes, Metabolism & Nutrition, Rochester, Minnesota, USA
| | - Walter K. Kremers
- Mayo Clinic, Division of Endocrinology, Diabetes, Metabolism & Nutrition, Rochester, Minnesota, USA
| | - Francis J. Doyle
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts, USA
| | | | - Barak Rosenn
- Icahn School of Medicine at Mount Sinai, Mount Sinai West Hospital, Division of Obstetrics and Maternal-Fetal Medicine, NY, NY, USA
| | | | - Yogish C. Kudva
- Mayo Clinic, Division of Endocrinology, Diabetes, Metabolism & Nutrition, Rochester, Minnesota, USA
| | - Eyal Dassau
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts, USA
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Abstract
PURPOSE OF REVIEW Diabetes during pregnancy increases the risk of maternal and fetal complications. This article reviews the types of CGM currently available, the glucose metrics which correlate with pregnancy outcomes, endocrine organization recommendations, clinical considerations for CGM implementation, and anticipated directions for future research. RECENT FINDINGS CGM use during pregnancy is increasing, and recommendations for use have been incorporated into many organizations' consensus guidelines. Increased time spent within a target range of 63-140 mg/dL and lower mean glucose are associated with lower risk of neonatal complications including large for gestational age infants. Use of CGM during pregnancy can detect postprandial and nocturnal hyperglycemia missed by self-monitoring of blood glucose (SMBG) which can be used for prognosis and to guide pharmacologic interventions. The use of continuous glucose monitoring (CGM) during pregnancies complicated by type 1, type 2, and gestational diabetes has been shown to improve outcomes.
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Affiliation(s)
- Grenye O'Malley
- Icahn School of Medicine At Mount Sinai, Division of Endocrinology, Diabetes and Bone Disease, New York, NY, USA.
| | - Ally Wang
- Icahn School of Medicine At Mount Sinai, Division of Endocrinology, Diabetes and Bone Disease, New York, NY, USA
| | - Selassie Ogyaadu
- Icahn School of Medicine At Mount Sinai, Division of Endocrinology, Diabetes and Bone Disease, New York, NY, USA
| | - Carol J Levy
- Icahn School of Medicine At Mount Sinai, Division of Endocrinology, Diabetes and Bone Disease, New York, NY, USA.
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33
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Levy CJ, Foster NC, DuBose SN, Agarwal S, Lyons SK, Peters AL, Uwaifo GI, DiMeglio LA, Sherr JL, Polsky S. Changes in Device Uptake and Glycemic Control Among Pregnant Women With Type 1 Diabetes: Data From the T1D Exchange. J Diabetes Sci Technol 2021; 15:1297-1302. [PMID: 33218278 PMCID: PMC8655289 DOI: 10.1177/1932296820972123] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVES To examine changes in device use and glycemic outcomes for pregnant women from the T1D Exchange Clinic Registry between the years 2010-2013 and 2016-2018. METHODS Participant-reported device use and glycemic outcomes were compared for women aged 16-40 years who were pregnant at the time of survey completion, comparing 2010-2013 (cohort 1) and 2016-2018 (cohort 2). Hemoglobin A1c results within 30 days prior to survey completion were obtained from medical records. RESULTS There were 208 pregnant women out of 5,236 eligible participants completing the questionnaire in cohort 1 and 47 pregnant women out of 2,818 eligible participants completing the questionaire in cohort 2. Continuous glucose monitor (CGM) use while pregnant trended upward among cohort 2 (70% vs 37%, P = .02), while reported continuous subcutaneous insulin infusion (CSII) use while pregnant declined (76% vs 64%, P = .04). HbA1c levels trended downward (6.8% cohort 1 vs 6.5% cohort 2, P = .07). CONCLUSIONS Self-reported CGM use while pregnant increased over the studied intervals whereas CSII use decreased. Additional evaluation of device use and the potential benefits for T1D pregnancies is needed.
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Affiliation(s)
| | - Nicole C. Foster
- Jaeb Center for Health Research, Tampa,
FL, USA
- Nicole C. Foster, MS, Jaeb Center for Health
Research, 15310 Amberly Drive, Suite 350, Tampa, FL 33647, USA.
| | | | - Shivani Agarwal
- Fleischer Institute of Diabetes and
Metabolism, Center for Diabetes Translational Research, Albert Einstein College of
Medicine, Bronx, NY, USA
| | - Sarah K. Lyons
- Baylor College of Medicine, Texas
Children’s Hospital, Houston, TX, USA
| | - Anne L. Peters
- Keck School of Medicine of the
University of Southern California, Los Angeles, CA, USA
| | | | | | | | - Sarit Polsky
- Barbara Davis Center for Diabetes,
Aurora, CO, USA
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34
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O’Malley G, Rosenn B, Nosova EV, Kudva YC, Scarpelli Shchur S, Levister C, Kaur R, Pinsker JE, Castorino K, Church MM, Dassau E, Levy CJ. Clinical Experience of Continuous Glucose Monitoring in Pregnancy. J Diabetes Sci Technol 2021; 15:1402-1403. [PMID: 34218719 PMCID: PMC8655302 DOI: 10.1177/19322968211024668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Grenye O’Malley
- Division of Endocrinology, Diabetes and Bone
Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Grenye O’Malley, MD, Division of Endocrinology,
Diabetes and Bone Diseases, Icahn School of Medicine at Mount Sinai, 1 Gustave Levy Place
Box 1055, New York, NY 10029, USA.
| | - Barak Rosenn
- Department of Obstetrics and Gynecology,
Jersey City Medical Center, Jersey City, NJ, USA
| | - Emily V. Nosova
- Division of Endocrinology, Diabetes and Bone
Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Yogish C. Kudva
- Division of Endocrinology, Diabetes,
Metabolism & Nutrition, Mayo Clinic, Rochester, MN, USA
| | | | - Camilla Levister
- Division of Endocrinology, Diabetes and Bone
Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ravinder Kaur
- Division of Endocrinology, Diabetes,
Metabolism & Nutrition, Mayo Clinic, Rochester, MN, USA
| | | | | | - Mei Mei Church
- Sansum Diabetes Research Institute, Santa
Barbara, CA, USA
| | - Eyal Dassau
- Harvard John A. Paulson School of Engineering
and Applied Sciences, Cambridge, MA, USA
| | - Carol J. Levy
- Division of Endocrinology, Diabetes and Bone
Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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35
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Kudva YC, Laffel LM, Brown SA, Raghinaru D, Pinsker JE, Ekhlaspour L, Levy CJ, Messer LH, Kovatchev BP, Lum JW, Beck RW, Gonder-Frederick L. Patient-Reported Outcomes in a Randomized Trial of Closed-Loop Control: The Pivotal International Diabetes Closed-Loop Trial. Diabetes Technol Ther 2021; 23:673-683. [PMID: 34115959 PMCID: PMC8573794 DOI: 10.1089/dia.2021.0089] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Background: Closed-loop control (CLC) has been shown to improve glucose time in range and other glucose metrics; however, randomized trials >3 months comparing CLC with sensor-augmented pump (SAP) therapy are limited. We recently reported glucose control outcomes from the 6-month international Diabetes Closed-Loop (iDCL) trial; we now report patient-reported outcomes (PROs) in this iDCL trial. Methods: Participants were randomized 2:1 to CLC (N = 112) versus SAP (N = 56) and completed questionnaires, including Hypoglycemia Fear Survey, Diabetes Distress Scale (DDS), Hypoglycemia Awareness, Hypoglycemia Confidence, Hyperglycemia Avoidance, and Positive Expectancies of CLC (INSPIRE) at baseline, 3, and 6 months. CLC participants also completed Diabetes Technology Expectations and Acceptance and System Usability Scale (SUS). Results: The Hypoglycemia Fear Survey Behavior subscale improved significantly after 6 months of CLC compared with SAP. DDS did not differ except for powerless subscale scores, which worsened at 3 months in SAP. Whereas Hypoglycemia Awareness and Hyperglycemia Avoidance did not differ between groups, CLC participants showed a tendency toward improved confidence in managing hypoglycemia. The INSPIRE questionnaire showed favorable scores in the CLC group for teens and parents, with a similar trend for adults. At baseline and 6 months, CLC participants had high positive expectations for the device with Diabetes Technology Acceptance and SUS showing high benefit and low burden scores. Conclusion: CLC improved some PROs compared with SAP. Participants reported high benefit and low burden with CLC. Clinical Trial Identifier: NCT03563313.
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Affiliation(s)
- Yogish C. Kudva
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Lori M. Laffel
- Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Sue A. Brown
- University of Virginia Center for Diabetes Technology, Charlottesville, Virginia, USA
- Division of Endocrinology, Department of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Dan Raghinaru
- Jaeb Center for Health Research, Tampa, Florida, USA
| | | | - Laya Ekhlaspour
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Carol J. Levy
- Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Laurel H. Messer
- Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Boris P. Kovatchev
- University of Virginia Center for Diabetes Technology, Charlottesville, Virginia, USA
| | - John W. Lum
- Jaeb Center for Health Research, Tampa, Florida, USA
- Address correspondence to: John W. Lum, MS, Jaeb Center for Health Research, 15310 Amberly Dr, Suite 350, Tampa, FL 33647, USA.
| | - Roy W. Beck
- Jaeb Center for Health Research, Tampa, Florida, USA
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36
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Aleppo G, Parkin CG, Carlson AL, Galindo RJ, Kruger DF, Levy CJ, Umpierrez GE, Forlenza GP, McGill JB. Lost in Translation: A Disconnect Between the Science and Medicare Coverage Criteria for Continuous Subcutaneous Insulin Infusion. Diabetes Technol Ther 2021; 23:715-725. [PMID: 34077674 PMCID: PMC8573795 DOI: 10.1089/dia.2021.0196] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Numerous studies have demonstrated the clinical value and safety of insulin pump therapy in type 1 diabetes and type 2 diabetes populations. However, the eligibility criteria for insulin pump coverage required by the Centers for Medicare & Medicaid Services (CMS) discount conclusive evidence that supports insulin pump use in diabetes populations that are currently deemed ineligible. This article discusses the limitations and inconsistencies of the insulin pump eligibility criteria relative to current scientific evidence and proposes workable solutions to address this issue and improve the safety and care of all individuals with diabetes.
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Affiliation(s)
- Grazia Aleppo
- Division of Endocrinology, Metabolism and Molecular Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Christopher G. Parkin
- Clinical Research, CGParkin Communications, Inc., Henderson, Nevada, USA
- Address correspondence to: Christopher G. Parkin, MS, Clinical Research, CGParkin Communications, Inc., 2352 Martinique Avenue, Henderson, NV 89044, USA.
| | - Anders L. Carlson
- International Diabetes Center, Endocrinologist, Regions Hospital & HealthPartners Clinics, Minneapolis, Minnesota, USA
- Diabetes Education Programs, HealthPartners and Stillwater Medical Group, Minneapolis, Minnesota, USA
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Rodolfo J. Galindo
- Emory University School of Medicine, Atlanta, Georgia, USA
- Center for Diabetes Metabolism Research Emory University Hospital Midtown, Atlanta, Georgia, USA
- Hospital Diabetes Taskforce, Emory Healthcare System, Atlanta, Georgia, USA
| | - Davida F. Kruger
- Division of Endocrinology, Diabetes, Bone & Mineral, Henry Ford Health System, Detroit, Michigan, USA
| | - Carol J. Levy
- Division of Endocrinology, Diabetes, and Metabolism, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
- Mount Sinai Diabetes Center and T1D Clinical Research, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Guillermo E. Umpierrez
- Division of Endocrinology, Metabolism Emory University School of Medicine, Atlanta, Georgia, USA
- Diabetes and Endocrinology, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Gregory P. Forlenza
- Barbara Davis Center, Division of Pediatric Endocrinology, Department of Pediatrics, University of Colorado Denver, Denver, Colorado, USA
| | - Janet B. McGill
- Division of Endocrinology, Metabolism and Lipid Research, Washington University in St. Louis, School of Medicine, St. Louis, Missouri, USA
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Abstract
Diabetes mellitus is a global health problem affecting 422 million people worldwide, of which 34.2 million live in the United States alone. Complications due to diabetes can lead to considerable morbidity and mortality related to both microvascular and macrovascular disease. While glycosylated hemoglobin testing is the standard test utilized to evaluate glycemic control, emerging targets like "time in range" and "glycemic variability" often provide more accurate assessments of glycemic fluctuations and have implications for diabetes complications and quality of life. Patients with diabetes face considerable burdens of self-care including frequent glucose monitoring, multiple insulin injections, dietary management, and the need to track daily activities, all of which lead to reduced adherence and psychological burnout. From the provider perspective, limited patient data and access to self-management tools lead to treatment inertia and a reduced ability to help patients achieve and maintain their glycemic goals. In the past few decades, there have been considerable advances in treatment-based technology and technological applications designed to help reduce patient burden and provide tools for better self-management. These advances make real-time clinical data available for clinicians to make necessary changes in treatment regimens. In this review, we discuss the latest emerging technologies available for the management of people with type 2 diabetes mellitus.
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Affiliation(s)
- Nirali A Shah
- Division of Endocrinology, Diabetes and Bone Metabolism, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Carol J Levy
- Division of Endocrinology, Diabetes and Bone Metabolism, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Galindo RJ, Parkin CG, Aleppo G, Carlson AL, Kruger DF, Levy CJ, Umpierrez GE, McGill JB. What's Wrong with This Picture? A Critical Review of Current Centers for Medicare & Medicaid Services Coverage Criteria for Continuous Glucose Monitoring. Diabetes Technol Ther 2021; 23:652-660. [PMID: 33844588 PMCID: PMC8501458 DOI: 10.1089/dia.2021.0107] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Numerous studies have demonstrated the clinical value of continuous glucose monitoring (CGM) in type 1 diabetes and type 2 diabetes populations. However, the eligibility criteria for CGM coverage required by the Centers for Medicare & Medicaid Services (CMS) ignore conclusive evidence that supports CGM use in various diabetes populations that are currently deemed ineligible. This article discusses the limitations and inconsistencies of the CMS eligibility criteria relative to current scientific evidence and proposes workable solutions to address this issue and improve the safety and care of all individuals with diabetes.
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Affiliation(s)
- Rodolfo J. Galindo
- Emory University School of Medicine, Atlanta, Georgia, USA
- Center for Diabetes Metabolism Research Emory University Hospital Midtown, Atlanta, Georgia, USA
- Hospital Diabetes Taskforce, Emory Healthcare System, Atlanta, Georgia, USA
| | - Christopher G. Parkin
- Clinical Research, CGParkin Communications, Inc., Henderson, Nevada, USA
- Address correspondence to: Christopher G. Parkin, MS, Clinical Research, CGParkin Communications, Inc., 2352 Martinique Avenue, Henderson, NV 89044, USA
| | - Grazia Aleppo
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University, Chicago, Illinois, USA
| | - Anders L. Carlson
- International Diabetes Center, Minneapolis, Minnesota, USA
- Regions Hospital & HealthPartners Clinics, St Paul, Minnesota, USA
- Diabetes Education Programs, HealthPartners and Stillwater Medical Group, Stillwater, Minnesota, USA
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Davida F. Kruger
- Division of Endocrinology, Diabetes, Bone & Mineral, Henry Ford Health System, Detroit, Michigan, USA
| | - Carol J. Levy
- Division of Endocrinology, Diabetes, and Metabolism, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
- Mount Sinai Diabetes Center and T1D Clinical Research, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Guillermo E. Umpierrez
- Division of Endocrinology, Metabolism, Emory University School of Medicine, Atlanta, Georgia, USA
- Diabetes and Endocrinology, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Janet B. McGill
- Division of Endocrinology, Metabolism and Lipid Research, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
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Brown SA, Forlenza GP, Bode BW, Pinsker JE, Levy CJ, Criego AB, Hansen DW, Hirsch IB, Carlson AL, Bergenstal RM, Sherr JL, Mehta SN, Laffel LM, Shah VN, Bhargava A, Weinstock RS, MacLeish SA, DeSalvo DJ, Jones TC, Aleppo G, Buckingham BA, Ly TT. Multicenter Trial of a Tubeless, On-Body Automated Insulin Delivery System With Customizable Glycemic Targets in Pediatric and Adult Participants With Type 1 Diabetes. Diabetes Care 2021; 44:1630-1640. [PMID: 34099518 PMCID: PMC8323171 DOI: 10.2337/dc21-0172] [Citation(s) in RCA: 120] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 04/14/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Advances in diabetes technology have transformed the treatment paradigm for type 1 diabetes, yet the burden of disease is significant. We report on a pivotal safety study of the first tubeless, on-body automated insulin delivery system with customizable glycemic targets. RESEARCH DESIGN AND METHODS This single-arm, multicenter, prospective study enrolled 112 children (age 6-13.9 years) and 129 adults (age 14-70 years). A 2-week standard therapy phase (usual insulin regimen) was followed by 3 months of automated insulin delivery. Primary safety outcomes were incidence of severe hypoglycemia and diabetic ketoacidosis. Primary effectiveness outcomes were change in HbA1c and percent time in sensor glucose range 70-180 mg/dL ("time in range"). RESULTS A total of 235 participants (98% of enrolled, including 111 children and 124 adults) completed the study. HbA1c was significantly reduced in children by 0.71% (7.8 mmol/mol) (mean ± SD: 7.67 ± 0.95% to 6.99 ± 0.63% [60 ± 10.4 mmol/mol to 53 ± 6.9 mmol/mol], P < 0.0001) and in adults by 0.38% (4.2 mmol/mol) (7.16 ± 0.86% to 6.78 ± 0.68% [55 ± 9.4 mmol/mol to 51 ± 7.4 mmol/mol], P < 0.0001). Time in range was improved from standard therapy by 15.6 ± 11.5% or 3.7 h/day in children and 9.3 ± 11.8% or 2.2 h/day in adults (both P < 0.0001). This was accomplished with a reduction in time in hypoglycemia <70 mg/dL among adults (median [interquartile range]: 2.00% [0.63, 4.06] to 1.09% [0.46, 1.75], P < 0.0001), while this parameter remained the same in children. There were three severe hypoglycemia events not attributable to automated insulin delivery malfunction and one diabetic ketoacidosis event from an infusion site failure. CONCLUSIONS This tubeless automated insulin delivery system was safe and allowed participants to significantly improve HbA1c levels and time in target glucose range with a very low occurrence of hypoglycemia.
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Affiliation(s)
- Sue A Brown
- Division of Endocrinology, Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | - Gregory P Forlenza
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO
| | | | | | - Carol J Levy
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - Amy B Criego
- International Diabetes Center, Park Nicollet Pediatric Endocrinology, Minneapolis, MN
| | - David W Hansen
- Department of Pediatrics, SUNY Upstate Medical University, Syracuse, NY
| | - Irl B Hirsch
- Department of Medicine, University of Washington, Seattle, WA
| | - Anders L Carlson
- International Diabetes Center, Park Nicollet, HealthPartners, Minneapolis, MN
| | | | - Jennifer L Sherr
- Department of Pediatrics, Yale School of Medicine, New Haven, CT
| | | | - Lori M Laffel
- Joslin Diabetes Center, Harvard Medical School, Boston, MA
| | - Viral N Shah
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Anuj Bhargava
- Department of Research, Iowa Diabetes Research, West Des Moines, IA
| | - Ruth S Weinstock
- Department of Medicine, SUNY Upstate Medical University, Syracuse, NY
| | - Sarah A MacLeish
- Department of Pediatrics, University Hospitals Cleveland Medical Center, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Daniel J DeSalvo
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Thomas C Jones
- Department of Research, East Coast Institute for Research at The Jones Center, Macon, GA
| | - Grazia Aleppo
- Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Bruce A Buckingham
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, CA
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40
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Forlenza GP, Buckingham BA, Brown SA, Bode BW, Levy CJ, Criego AB, Wadwa RP, Cobry EC, Slover RJ, Messer LH, Berget C, McCoy S, Ekhlaspour L, Kingman RS, Voelmle MK, Boyd J, O'Malley G, Grieme A, Kivilaid K, Kleve K, Dumais B, Vienneau T, Huyett LM, Lee JB, O'Connor J, Benjamin E, Ly TT. First Outpatient Evaluation of a Tubeless Automated Insulin Delivery System with Customizable Glucose Targets in Children and Adults with Type 1 Diabetes. Diabetes Technol Ther 2021; 23:410-424. [PMID: 33325779 PMCID: PMC8215410 DOI: 10.1089/dia.2020.0546] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background: The objective of this study was to assess the safety and effectiveness of the first commercial configuration of a tubeless automated insulin delivery system, Omnipod® 5, in children (6-13.9 years) and adults (14-70 years) with type 1 diabetes (T1D) in an outpatient setting. Materials and Methods: This was a single-arm, multicenter, prospective clinical study. Data were collected over a 14-day standard therapy (ST) phase followed by a 14-day hybrid closed-loop (HCL) phase, where participants (n = 36) spent 72 h at each of three prespecified glucose targets (130, 140, and 150 mg/dL, 9 days total) then 5 days with free choice of glucose targets (110-150 mg/dL) using the Omnipod 5. Remote safety monitoring alerts were enabled during the HCL phase. Primary endpoints were difference in time in range (TIR) (70-180 mg/dL) between ST and HCL phases and proportion of participants reporting serious device-related adverse events. Results: Mean TIR was significantly higher among children in the free-choice period overall (64.9% ± 12.2%, P < 0.01) and when using a 110 mg/dL target (71.2% ± 10.2%, P < 0.01), a 130 mg/dL target (61.5% ± 7.7%, P < 0.01), and a 140 mg/dL target (64.8% ± 11.6%, P < 0.01), and among adults using a 130 mg/dL target (75.1% ± 11.6%, P < 0.05), compared to the ST phase (children: 51.0% ± 13.3% and adults: 65.6% ± 15.7%). There were no serious device-related adverse events reported during the HCL phase, nor were there episodes of severe hypoglycemia or diabetic ketoacidosis. Conclusion: The Omnipod 5 System was safe and effective when used at glucose targets from 110 to 150 mg/dL for 14 days at home in children and adults with T1D.
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Affiliation(s)
- Gregory P. Forlenza
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Bruce A. Buckingham
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, California, USA
| | - Sue A. Brown
- Division of Endocrinology and Medicine, University of Virginia, Charlottesville, Virginia, USA
| | | | - Carol J. Levy
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Amy B. Criego
- Department of Pediatric Endocrinology, Park Nicollet Clinic, International Diabetes Center at Park Nicollet, Minneapolis, Minnesota, USA
| | - R. Paul Wadwa
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Erin C. Cobry
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Robert J. Slover
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Laurel H. Messer
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Cari Berget
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Susan McCoy
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Laya Ekhlaspour
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, California, USA
| | - Ryan S. Kingman
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, California, USA
| | - Mary K. Voelmle
- Division of Endocrinology and Medicine, University of Virginia, Charlottesville, Virginia, USA
| | | | - Grenye O'Malley
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Aimee Grieme
- Department of Pediatric Endocrinology, Park Nicollet Clinic, International Diabetes Center at Park Nicollet, Minneapolis, Minnesota, USA
| | | | | | | | | | | | | | | | | | - Trang T. Ly
- Insulet Corporation, Acton, Massachusetts, USA
- Address correspondence to: Trang T. Ly, MBBS, FRACP, PhD, Insulet Corporation, 100 Nagog Park, Acton, MA 01720, USA
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Brown SA, Levy CJ, Hirsch IB, Bode BW, Carlson AL, Shah VN, Pinsker JE, Weinstock RS, Bhargava A, Mehta SN, Laffel LM, Jones TC, Sherr JL, Aleppo G, Forlenza GP, Ly TT. Safety Evaluation of the Omnipod® 5 Automated Insulin Delivery System Over Three Months of Use in Adults and Adolescents With Type 1 Diabetes (T1D). J Endocr Soc 2021. [DOI: 10.1210/jendso/bvab048.1370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Advances in diabetes technology have transformed the treatment paradigm for type 1 diabetes (T1D), yet the burden of disease remains significant. The Omnipod 5 Automated Insulin Delivery System is a novel hybrid closed-loop (HCL) system with fully on-body operation. The system consists of a tubeless insulin pump (pod) containing a personalized Model Predictive Control algorithm which communicates directly with a Dexcom G6 continuous glucose monitor (CGM, or sensor) to automate insulin delivery. Therapy customization is enabled through glucose targets from 110-150 mg/dL, adjustable by time of day. The system adapts to changing insulin needs with each pod change. We report on the first, pivotal outpatient safety evaluation of the system in a large cohort of adults and adolescents with T1D.
Participants aged 14-70y with T1D≥6 months and A1C<10% used the HCL system for 3 months at home after a 14-day run-in phase of their standard therapy (ST). Prior therapy included both pump therapy and multiple daily injections. The primary safety and effectiveness endpoints, respectively, were occurrence of severe hypoglycemia (SH) and diabetic ketoacidosis (DKA), and change in A1C and sensor glucose percent time in target range (TIR) (70-180 mg/dL) during HCL compared with ST.
Participants (N=128) were aged (mean±SD) 37±14y with T1D duration 18±12y and baseline A1C 7.2±0.9% (range 5.2-9.8%). There was a significant increase in TIR from ST to HCL, from 64.7±16.6% to 73.9±11.0% (p<0.0001), corresponding to an additional 2.2 hours/day in target range. A1C at end of study was reduced by 0.4%, from 7.2±0.9% to 6.8±0.7% (p<0.0001). Glycemic outcomes for percent of time with CGM readings below and above target range were all reduced (p<0.0001): <54 mg/dL from 0.6±1.2% to 0.2±0.3% (a decrease of 6 minutes/day), <70 mg/dL from 2.9±3.1% to 1.3±1.1% (a decrease of 23 minutes/day), >180 mg/dL from 32.4±17.3% to 24.7±11.2% (a decrease of 1.8 hours/day), and ≥250 mg/dL from 10.1±10.5% to 5.8±5.5% (a decrease of 1.0 hours/day). The mean glucose also decreased from 161±28 to 154±17 mg/dL (p=0.0002). During the 3-month HCL phase there were 2 episodes of SH (both following user-initiated boluses) and no episodes of DKA reported. Most participants completing the pivotal study (92%) opted to continue using the system during an extension phase.
In this outpatient, multi-center pivotal study in a large cohort of adults and adolescents with T1D, the Omnipod 5 System was safe and effective when used for 3 months at home. There were significant improvements in both TIR and A1C with use of the system, while time in hypoglycemic ranges was also reduced. The current results and commitment to the extension phase highlight the safe and effective use of the HCL system, as well as the preference for the Omnipod 5 System over participants’ previous therapy.
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Affiliation(s)
- Sue A Brown
- University of Virginia, Charlottesville, VA, USA
| | - Carol J Levy
- Mount Sinai School of Medicine, New York, NY, USA
| | - Irl B Hirsch
- University of Washington School of Medicine, Seattle, WA, USA
| | | | | | | | | | | | | | | | | | - Thomas C Jones
- East Coast Institute for Research at The Jones Center, Macon, GA, USA
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Carlson AL, Kanapka LG, Miller KM, Ahmann AJ, Chaytor NS, Fox S, Kiblinger L, Kruger D, Levy CJ, Peters AL, Rickels MR, Salam M, Shah VN, Young LA, Kudva YC, Pratley R. Hypoglycemia and Glycemic Control in Older Adults With Type 1 Diabetes: Baseline Results From the WISDM Study. J Diabetes Sci Technol 2021; 15:582-592. [PMID: 31867988 PMCID: PMC8120041 DOI: 10.1177/1932296819894974] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Knowledge regarding the burden and predictors of hypoglycemia among older adults with type 1 diabetes (T1D) is limited. METHODS We analyzed baseline data from the Wireless Innovations for Seniors with Diabetes Mellitus (WISDM) study, which enrolled participants at 22 sites in the United States. Eligibility included clinical diagnosis of T1D, age ≥60 years, no real-time continuous glucose monitoring (CGM) use in prior three months, and HbA1c <10.0%. Blinded CGM data from 203 participants with at least 240 hours were included in the analyses. RESULTS Median age of the cohort was 68 years (52% female, 93% non-Hispanic white, and 53% used insulin pumps). Mean HbA1c was 7.5%. Median time spent in the glucose range <70 mg/dL was 5.0% (72 min/day) and <54 mg/dL was 1.6% (24 min/day). Among all factors analyzed, only reduced hypoglycemia awareness was associated with greater time spent <54 mg/dL (median time of 2.7% vs 1.3% [39 vs 19 minutes per day] for reduced awareness vs aware/uncertain, respectively, P = .03). Participants spent a mean 56% of total time in target glucose range of 70-180 mg/dL and 37% of time above 180 mg/dL. CONCLUSIONS Over half of older T1D participants spent at least an hour a day with glucose levels <70 mg/dL. Those with reduced hypoglycemia awareness spent over twice as much time than those without in a serious hypoglycemia range (glucose levels <54 mg/dL). Interventions to reduce exposure to clinically significant hypoglycemia and increase time in range are urgently needed in this age group.
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Affiliation(s)
| | | | - Kellee M. Miller
- Jaeb Center for Health Research, Tampa,
FL, USA
- Kellee M. Miller, PhD, Jaeb Center for
Health Research, 15310 Amberly Drive, Suite 350, Tampa, FL 33647, USA.
| | - Andrew J. Ahmann
- Harold Schnitzer Diabetes Health Center
at Oregon Health and Science University, Portland, OR, USA
| | - Naomi S. Chaytor
- Elson S. Floyd College of Medicine,
Washington State University, Spokane, WA, USA
| | - Steven Fox
- Keck School of Medicine of the
University of Southern California, Los Angeles, CA, USA
| | | | | | - Carol J. Levy
- Icahn School of Medicine at Mount Sinai,
New York, NY, USA
| | - Anne L. Peters
- Keck School of Medicine of the
University of Southern California, Los Angeles, CA, USA
| | - Michael R. Rickels
- Rodebaugh Diabetes Center, University of
Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Maamoun Salam
- Washington University School of
Medicine, St. Louis, MO, USA
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43
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Isganaitis E, Raghinaru D, Ambler-Osborn L, Pinsker JE, Buckingham BA, Wadwa RP, Ekhlaspour L, Kudva YC, Levy CJ, Forlenza GP, Beck RW, Kollman C, Lum JW, Brown SA, Laffel LM. Closed-Loop Insulin Therapy Improves Glycemic Control in Adolescents and Young Adults: Outcomes from the International Diabetes Closed-Loop Trial. Diabetes Technol Ther 2021; 23:342-349. [PMID: 33216667 PMCID: PMC8080922 DOI: 10.1089/dia.2020.0572] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Objective: To assess the efficacy and safety of closed-loop control (CLC) insulin delivery system in adolescents and young adults with type 1 diabetes. Research Design and Methods: Prespecified subanalysis of outcomes in adolescents and young adults aged 14-24 years old with type 1 diabetes in a previously published 6-month multicenter randomized trial. Participants were randomly assigned 2:1 to CLC (Tandem Control-IQ) or sensor augmented pump (SAP, various pumps+Dexcom G6 CGM) and followed for 6 months. Results: Mean age of the 63 participants was 17 years, median type 1 diabetes duration was 7 years, and mean baseline HbA1c was 8.1%. All 63 completed the trial. Time in range (TIR) increased by 13% with CLC versus decreasing by 1% with SAP (adjusted treatment group difference = +13% [+3.1 h/day]; 95% confidence interval [CI] 9-16, P < 0.001), which largely reflected a reduction in time >180 mg/dL (adjusted difference -12% [-2.9 h/day], P < 0.001). Time <70 mg/dL decreased by 1.6% with CLC versus 0.3% with SAP (adjusted difference -0.7% [-10 min/day], 95% CI -1.0% to -0.2%, P = 0.002). CLC use averaged 89% of the time for 6 months. The mean adjusted difference in HbA1c after 6 months was 0.30% in CLC versus SAP (95% CI -0.67 to +0.08, P = 0.13). There was one diabetic ketoacidosis episode in the CLC group. Conclusions: CLC use for 6 months was substantial and associated with improved TIR and reduced hypoglycemia in adolescents and young adults with type 1 diabetes. Thus, CLC has the potential to improve glycemic outcomes in this challenging age group. The clinical trial was registered with ClinicalTrials.gov (NCT03563313).
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Affiliation(s)
- Elvira Isganaitis
- Research Division, Department of Pediatrics, Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Dan Raghinaru
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - Louise Ambler-Osborn
- Research Division, Department of Pediatrics, Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Bruce A. Buckingham
- Pediatric Endocrinology and Diabetes, Stanford Children's Health, Stanford, California, USA
| | - R. Paul Wadwa
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Laya Ekhlaspour
- Pediatric Endocrinology and Diabetes, Stanford Children's Health, Stanford, California, USA
| | - Yogish C. Kudva
- Division of Endocrinology, Diabetes, Metabolism, Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Carol J. Levy
- Department of Medicine, Endocrinology, Diabetes and Bone Diseases, Mount Sinai Diabetes Center, New York, New York, USA
| | - Gregory P. Forlenza
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Roy W. Beck
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - Craig Kollman
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - John W. Lum
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - Sue A. Brown
- Endocrinology and Metabolism Division, Department of Medicine, Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
| | - Lori M. Laffel
- Research Division, Department of Pediatrics, Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts, USA
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O'Malley G, Messer LH, Levy CJ, Pinsker JE, Forlenza GP, Isganaitis E, Kudva YC, Ekhlaspour L, Raghinaru D, Lum J, Brown SA. Clinical Management and Pump Parameter Adjustment of the Control-IQ Closed-Loop Control System: Results from a 6-Month, Multicenter, Randomized Clinical Trial. Diabetes Technol Ther 2021; 23:245-252. [PMID: 33155824 PMCID: PMC8114941 DOI: 10.1089/dia.2020.0472] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background: Data are limited on the need for and benefits of pump setting optimization with automated insulin delivery. We examined clinical management of a closed-loop control (CLC) system and its relationship to glycemic outcomes. Materials and Methods: We analyzed personal parameter adjustments in 168 participants in a 6-month multicenter trial of CLC with Control-IQ versus sensor-augmented pump (SAP) therapy. Preset parameters (BR = basal rates, CF = correction factors, CR = carbohydrate ratios) were optimized at randomization, 2 and 13 weeks, for safety issues, participant concerns, or initiation by participants' usual diabetes care team. Time in range (TIR 70-180 mg/dL) was compared in the week before and after parameter changes. Results: In 607 encounters for parameter changes, there were fewer adjustments for CLC than SAP (3.4 vs. 4.1/participant). Adjustments involved BR (CLC 69%, SAP 80%), CR (CLC 68%, SAP 50%), CF (CLC 44%, SAP 41%), and overnight parameters (CLC 62%, SAP 75%). TIR before and after adjustments was 71.2% and 71.3% for CLC and 61.0% and 62.9% for SAP. The highest baseline HbA1c CLC subgroup had the largest TIR improvement (51.2% vs. 57.7%). When a CR was made more aggressive in the CLC group, postprandial time >180 mg/dL was 43.1% before the change and 36.0% after the change. The median postprandial time <70 mg/dL before making CR less aggressive was 1.8%, and after the change was 0.7%. Conclusions: No difference in TIR was detected with parameter changes overall, but they may have an effect in higher HbA1c subgroups or following user-directed boluses, suggesting that changes may matter more in suboptimal control or during discrete periods of the day. Clinical Trials Registration number: NCT03563313.
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Affiliation(s)
- Grenye O'Malley
- Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Laurel H. Messer
- Barbara Davis Center for Diabetes, University of Colorado, Aurora, Colorado, USA
| | - Carol J. Levy
- Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | | | - Gregory P. Forlenza
- Barbara Davis Center for Diabetes, University of Colorado, Aurora, Colorado, USA
| | - Elvira Isganaitis
- Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Yogish C. Kudva
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Laya Ekhlaspour
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Dan Raghinaru
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - John Lum
- Jaeb Center for Health Research, Tampa, Florida, USA
- Address correspondence to: John Lum, MS, Jaeb Center for Health Research, 15310 Amberly Drive, Suite 350, Tampa, FL 33647, USA
| | - Sue A. Brown
- Division of Endocrinology, Department of Medicine, Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
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O’Malley G, Ebekozien O, Desimone M, Pinnaro CT, Roberts A, Polsky S, Noor N, Aleppo G, Basina M, Tansey M, Steenkamp D, Vendrame F, Lorincz I, Mathias P, Agarwal S, Golden L, Hirsh IB, Levy CJ. COVID-19 Hospitalization in Adults with Type 1 Diabetes: Results from the T1D Exchange Multicenter Surveillance Study. J Clin Endocrinol Metab 2021; 106:e936-e942. [PMID: 33165563 PMCID: PMC7717244 DOI: 10.1210/clinem/dgaa825] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Indexed: 12/15/2022]
Abstract
CONTEXT Diabetes mellitus is associated with increased COVID-19 morbidity and mortality, but there are few data focusing on outcomes in people with type 1 diabetes. OBJECTIVE The objective of this study was to analyze characteristics of adults with type 1 diabetes for associations with COVID-19 hospitalization. DESIGN An observational multisite cross-sectional study was performed. Diabetes care providers answered a 33-item questionnaire regarding demographics, symptoms, and diabetes- and COVID-19-related care and outcomes. Descriptive statistics were used to describe the study population, and multivariate logistic regression models were used to analyze the relationship between glycated hemoglobin (HbA1c), age, and comorbidities and hospitalization. SETTING Cases were submitted from 52 US sites between March and August 2020. PATIENTS OR OTHER PARTICIPANTS Adults over the age of 19 with type 1 diabetes and confirmed COVID-19 infection were included. INTERVENTIONS None. MAIN OUTCOME MEASURES Hospitalization for COVID-19 infection. RESULTS A total of 113 cases were analyzed. Fifty-eight patients were hospitalized, and 5 patients died. Patients who were hospitalized were more likely to be older, to identify as non-Hispanic Black, to use public insurance, or to have hypertension, and less likely to use continuous glucose monitoring or insulin pumps. Median HbA1c was 8.6% (70 mmol/mol) and was positively associated with hospitalization (odds ratio 1.42, 95% confidence interval 1.18-1.76), which persisted after adjustment for age, sex, race, and obesity. CONCLUSIONS Baseline glycemic control and access to care are important modifiable risk factors which need to be addressed to optimize care of people with type 1 diabetes during the worldwide COVID-19 pandemic.
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Affiliation(s)
- Grenye O’Malley
- Department of Endocrinology, Diabetes and Bone Diseases, Icahn School of Medicine, New York, NY
| | - Osagie Ebekozien
- T1D Exchange
- Corresponding author: Osagie Ebekozien, MD, MPH, CPHQ, 11 Avenue de Lafayette, 5th Floor, Boston, MA 02111, 617-892-9940,
| | - Marisa Desimone
- Division of Endocrinology, Diabetes and Metabolism, SUNY Upstate Medical University, Syracuse, NY
| | | | - Alissa Roberts
- Department of Pediatrics, University of Washington, Seattle, WA
| | - Sarit Polsky
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO
| | | | - Grazia Aleppo
- Feinberg School of Medicine, Northwestern University, Chicago, IL
| | | | - Michael Tansey
- University of Iowa Boston University School of Medicine and Boston Medical Center
| | - Devin Steenkamp
- Division of Endocrinology, Diabetes, and Metabolism, University of Miami, Miami, FL
| | - Francesco Vendrame
- Department of Endocrinology, Diabetes, and Metabolism, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ilona Lorincz
- Division of Endocrinology, Diabetes, and Metabolism, University of Miami, Miami, FL
| | - Priyanka Mathias
- Department of Endocrinology, Diabetes, and Metabolism, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania
| | - Shivani Agarwal
- Department of Endocrinology, Diabetes, and Metabolism, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lauren Golden
- Fleischer Institute for Diabetes and Metabolism, NY-Regional Center for Diabetes and Translational Research, Albert Einstein College of Medicine, Bronx, NY
| | - Irl B Hirsh
- NYU Langone Medical Center University of Washington School of Medicine, Seattle, WA
| | - Carol J Levy
- Department of Endocrinology, Diabetes and Bone Diseases, Icahn School of Medicine, New York, NY
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Castorino K, Polsky S, O'Malley G, Levister C, Nelson K, Farfan C, Brackett S, Puhr S, Levy CJ. Performance of the Dexcom G6 Continuous Glucose Monitoring System in Pregnant Women with Diabetes. Diabetes Technol Ther 2020; 22:943-947. [PMID: 32324061 PMCID: PMC7757524 DOI: 10.1089/dia.2020.0085] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background: The aim of this study was to determine the performance of the Dexcom G6 continuous glucose monitoring (CGM) system across three sensor wear sites in pregnant women with diabetes in the second or third trimesters. Methods: Participants with type 1 (T1D), type 2 (T2D), or gestational (GDM) diabetes mellitus were enrolled at three sites. Each wore two G6 sensors on the abdomen, upper buttock, and/or posterior upper arm for 10 days and underwent a 6-h clinic session between days 3 and 7 of sensor wear, during which YSI reference blood glucose values were obtained every 30 min. No intentional glucose manipulations were performed. Accuracy metrics included the proportion of CGM values that were within ±20% of paired reference values >100 mg/dL or ±20 mg/dL of YSI values ≤100 mg/dL (hereafter referred to as %20/20), as well as the analogous %15/15, %30/30, and %40/40. The mean absolute relative difference (MARD) between CGM-YSI pairs was also calculated. Results: Thirty-two participants with T1D (n = 20), T2D (n = 3), or GDM (n = 9) were enrolled: 19 were in the second trimester and 13 were in the third trimester of pregnancy. Compared with the reference, 92.5% of CGM values were within ±20%/20 mg/dL. The overall MARD and that of sensors worn on the abdomen, upper buttock, and posterior upper arm was 10.3%, 11.5%, 11.2%, and 8.7%, respectively. There were no device-related adverse events. Skin reactions at the insertion sites were absent or minor. Conclusions: The Dexcom G6 CGM system is accurate and safe in pregnant women with diabetes.
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Affiliation(s)
- Kristin Castorino
- Sansum Diabetes Research Institute, Santa Barbara, California, USA
- Address correspondence to: Kristin Castorino, DO, Sansum Diabetes Research Institute, 2219 Bath Street, Santa Barbara, CA 93105, USA
| | - Sarit Polsky
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Grenye O'Malley
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Camilla Levister
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kristen Nelson
- Sansum Diabetes Research Institute, Santa Barbara, California, USA
| | - Christian Farfan
- Sansum Diabetes Research Institute, Santa Barbara, California, USA
| | - Scott Brackett
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Sarah Puhr
- Dexcom, Inc., San Diego, California, USA
| | - Carol J. Levy
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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47
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Nosova EV, O'Malley G, Dassau E, Levy CJ. Leveraging technology for the treatment of type 1 diabetes in pregnancy: A review of past, current, and future therapeutic tools. J Diabetes 2020; 12:714-732. [PMID: 32125763 DOI: 10.1111/1753-0407.13030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 03/01/2020] [Indexed: 12/16/2022] Open
Abstract
The significant risks associated with pregnancies complicated by type 1 diabetes (T1D) were first recognized in the medical literature in the mid-twentieth century. Stringent glycemic control with hemoglobin A1c (HbA1c) values ideally less than 6% has been shown to improve maternal and fetal outcomes. The management options for pregnant women with T1D in the modern era include a variety of technologies to support self-care. Although self-monitoring of blood glucose (SMBG) and multiple daily injections (MDI) are often the recommended management options during pregnancy, many people with T1D utilize a variety of different technologies, including continuous glucose monitoring (CGM), continuous subcutaneous insulin infusion (CSII), and CSII including automated delivery or suspension algorithms. These systems have yielded invaluable diagnostic and therapeutic capabilities and have the potential to benefit this understudied higher-risk group. A recent prospective, multicenter study evaluating pregnant patients with T1D revealed that CGM significantly improves maternal glycemic parameters, is associated with fewer adverse neonatal outcomes, and minimizes burden. Outcome data for CSII, which is approved for use in pregnancy and has been utilized for several decades, remain mixed. Current evidence, although limited, for commercially available and emerging technologies for the management of T1D in pregnancy holds promise for improving patient and fetal outcomes.
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Affiliation(s)
- Emily V Nosova
- Division of Endocrinology, Diabetes and Bone Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Grenye O'Malley
- Division of Endocrinology, Diabetes and Bone Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Eyal Dassau
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts, USA
| | - Carol J Levy
- Division of Endocrinology, Diabetes and Bone Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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48
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Brown SA, Beck RW, Raghinaru D, Buckingham BA, Laffel LM, Wadwa RP, Kudva YC, Levy CJ, Pinsker JE, Dassau E, Doyle FJ, Ambler-Osborn L, Anderson SM, Church MM, Ekhlaspour L, Forlenza GP, Levister C, Simha V, Breton MD, Kollman C, Lum JW, Kovatchev BP. Glycemic Outcomes of Use of CLC Versus PLGS in Type 1 Diabetes: A Randomized Controlled Trial. Diabetes Care 2020; 43:1822-1828. [PMID: 32471910 PMCID: PMC7372060 DOI: 10.2337/dc20-0124] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 04/29/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Limited information is available about glycemic outcomes with a closed-loop control (CLC) system compared with a predictive low-glucose suspend (PLGS) system. RESEARCH DESIGN AND METHODS After 6 months of use of a CLC system in a randomized trial, 109 participants with type 1 diabetes (age range, 14-72 years; mean HbA1c, 7.1% [54 mmol/mol]) were randomly assigned to CLC (N = 54, Control-IQ) or PLGS (N = 55, Basal-IQ) groups for 3 months. The primary outcome was continuous glucose monitor (CGM)-measured time in range (TIR) for 70-180 mg/dL. Baseline CGM metrics were computed from the last 3 months of the preceding study. RESULTS All 109 participants completed the study. Mean ± SD TIR was 71.1 ± 11.2% at baseline and 67.6 ± 12.6% using intention-to-treat analysis (69.1 ± 12.2% using per-protocol analysis excluding periods of study-wide suspension of device use) over 13 weeks on CLC vs. 70.0 ± 13.6% and 60.4 ± 17.1% on PLGS (difference = 5.9%; 95% CI 3.6%, 8.3%; P < 0.001). Time >180 mg/dL was lower in the CLC group than PLGS group (difference = -6.0%; 95% CI -8.4%, -3.7%; P < 0.001) while time <54 mg/dL was similar (0.04%; 95% CI -0.05%, 0.13%; P = 0.41). HbA1c after 13 weeks was lower on CLC than PLGS (7.2% [55 mmol/mol] vs. 7.5% [56 mmol/mol], difference -0.34% [-3.7 mmol/mol]; 95% CI -0.57% [-6.2 mmol/mol], -0.11% [1.2 mmol/mol]; P = 0.0035). CONCLUSIONS Following 6 months of CLC, switching to PLGS reduced TIR and increased HbA1c toward their pre-CLC values, while hypoglycemia remained similarly reduced with both CLC and PLGS.
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Affiliation(s)
- Sue A Brown
- Division of Endocrinology and Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | - Roy W Beck
- Jaeb Center for Health Research, Tampa, FL
| | | | - Bruce A Buckingham
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Lori M Laffel
- Research Division, Joslin Diabetes Center, Harvard Medical School, Boston, MA
| | - R Paul Wadwa
- Barbara Davis Center for Diabetes, Anschutz Medical Campus, University of Colorado, Aurora, CO
| | - Yogish C Kudva
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Carol J Levy
- Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York City, NY
| | | | - Eyal Dassau
- Research Division, Joslin Diabetes Center, Harvard Medical School, Boston, MA.,Sansum Diabetes Research Institute, Santa Barbara, CA.,Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA
| | - Francis J Doyle
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA
| | | | - Stacey M Anderson
- Division of Endocrinology and Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | | | - Laya Ekhlaspour
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Gregory P Forlenza
- Barbara Davis Center for Diabetes, Anschutz Medical Campus, University of Colorado, Aurora, CO
| | - Camilla Levister
- Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York City, NY
| | - Vinaya Simha
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Marc D Breton
- Division of Endocrinology and Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | | | - John W Lum
- Jaeb Center for Health Research, Tampa, FL
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Levy CJ, Levister CM, Shah NA. New Paradigms in Diabetes Management From the Epicenter. J Diabetes Sci Technol 2020; 14:750-751. [PMID: 32486856 PMCID: PMC7673171 DOI: 10.1177/1932296820930040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Carol J. Levy
- Division of Endocrinology, Diabetes, and Metabolism, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Mount Sinai Diabetes Center and T1D Clinical Research, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Carol J. Levy, MD, CDE, Division of Endocrinology, Diabetes, and Metabolism, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1055, New York, NY 10029, USA.
| | - Camilla M. Levister
- Division of Endocrinology, Diabetes, and Metabolism, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nirali A. Shah
- Division of Endocrinology, Diabetes, and Metabolism, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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50
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Brown SA, Kovatchev BP, Raghinaru D, Lum JW, Buckingham BA, Kudva YC, Laffel LM, Levy CJ, Pinsker JE, Wadwa RP, Dassau E, Doyle FJ, Anderson SM, Church MM, Dadlani V, Ekhlaspour L, Forlenza GP, Isganaitis E, Lam DW, Kollman C, Beck RW. Six-Month Randomized, Multicenter Trial of Closed-Loop Control in Type 1 Diabetes. N Engl J Med 2019; 381:1707-1717. [PMID: 31618560 PMCID: PMC7076915 DOI: 10.1056/nejmoa1907863] [Citation(s) in RCA: 550] [Impact Index Per Article: 110.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Closed-loop systems that automate insulin delivery may improve glycemic outcomes in patients with type 1 diabetes. METHODS In this 6-month randomized, multicenter trial, patients with type 1 diabetes were assigned in a 2:1 ratio to receive treatment with a closed-loop system (closed-loop group) or a sensor-augmented pump (control group). The primary outcome was the percentage of time that the blood glucose level was within the target range of 70 to 180 mg per deciliter (3.9 to 10.0 mmol per liter), as measured by continuous glucose monitoring. RESULTS A total of 168 patients underwent randomization; 112 were assigned to the closed-loop group, and 56 were assigned to the control group. The age range of the patients was 14 to 71 years, and the glycated hemoglobin level ranged from 5.4 to 10.6%. All 168 patients completed the trial. The mean (±SD) percentage of time that the glucose level was within the target range increased in the closed-loop group from 61±17% at baseline to 71±12% during the 6 months and remained unchanged at 59±14% in the control group (mean adjusted difference, 11 percentage points; 95% confidence interval [CI], 9 to 14; P<0.001). The results with regard to the main secondary outcomes (percentage of time that the glucose level was >180 mg per deciliter, mean glucose level, glycated hemoglobin level, and percentage of time that the glucose level was <70 mg per deciliter or <54 mg per deciliter [3.0 mmol per liter]) all met the prespecified hierarchical criterion for significance, favoring the closed-loop system. The mean difference (closed loop minus control) in the percentage of time that the blood glucose level was lower than 70 mg per deciliter was -0.88 percentage points (95% CI, -1.19 to -0.57; P<0.001). The mean adjusted difference in glycated hemoglobin level after 6 months was -0.33 percentage points (95% CI, -0.53 to -0.13; P = 0.001). In the closed-loop group, the median percentage of time that the system was in closed-loop mode was 90% over 6 months. No serious hypoglycemic events occurred in either group; one episode of diabetic ketoacidosis occurred in the closed-loop group. CONCLUSIONS In this 6-month trial involving patients with type 1 diabetes, the use of a closed-loop system was associated with a greater percentage of time spent in a target glycemic range than the use of a sensor-augmented insulin pump. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases; iDCL ClinicalTrials.gov number, NCT03563313.).
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Affiliation(s)
- Sue A Brown
- From the University of Virginia Center for Diabetes Technology, Charlottesville (S.A.B., B.P.K., S.M.A.); the Jaeb Center for Health Research, Tampa, FL (D.R., J.W.L., C.K., R.W.B.); the Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford (B.A.B., L.E.), and the Sansum Diabetes Research Institute, Santa Barbara (J.E.P., M.C.) - both in California; the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN (Y.C.K., V.D.); the Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston (L.M.L., E.I.), and the Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge (E.D., F.J.D.) - both in Massachusetts; the Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York (C.J.L., D.W.L.); and the Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora (R.P.W., G.P.F.)
| | - Boris P Kovatchev
- From the University of Virginia Center for Diabetes Technology, Charlottesville (S.A.B., B.P.K., S.M.A.); the Jaeb Center for Health Research, Tampa, FL (D.R., J.W.L., C.K., R.W.B.); the Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford (B.A.B., L.E.), and the Sansum Diabetes Research Institute, Santa Barbara (J.E.P., M.C.) - both in California; the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN (Y.C.K., V.D.); the Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston (L.M.L., E.I.), and the Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge (E.D., F.J.D.) - both in Massachusetts; the Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York (C.J.L., D.W.L.); and the Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora (R.P.W., G.P.F.)
| | - Dan Raghinaru
- From the University of Virginia Center for Diabetes Technology, Charlottesville (S.A.B., B.P.K., S.M.A.); the Jaeb Center for Health Research, Tampa, FL (D.R., J.W.L., C.K., R.W.B.); the Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford (B.A.B., L.E.), and the Sansum Diabetes Research Institute, Santa Barbara (J.E.P., M.C.) - both in California; the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN (Y.C.K., V.D.); the Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston (L.M.L., E.I.), and the Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge (E.D., F.J.D.) - both in Massachusetts; the Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York (C.J.L., D.W.L.); and the Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora (R.P.W., G.P.F.)
| | - John W Lum
- From the University of Virginia Center for Diabetes Technology, Charlottesville (S.A.B., B.P.K., S.M.A.); the Jaeb Center for Health Research, Tampa, FL (D.R., J.W.L., C.K., R.W.B.); the Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford (B.A.B., L.E.), and the Sansum Diabetes Research Institute, Santa Barbara (J.E.P., M.C.) - both in California; the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN (Y.C.K., V.D.); the Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston (L.M.L., E.I.), and the Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge (E.D., F.J.D.) - both in Massachusetts; the Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York (C.J.L., D.W.L.); and the Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora (R.P.W., G.P.F.)
| | - Bruce A Buckingham
- From the University of Virginia Center for Diabetes Technology, Charlottesville (S.A.B., B.P.K., S.M.A.); the Jaeb Center for Health Research, Tampa, FL (D.R., J.W.L., C.K., R.W.B.); the Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford (B.A.B., L.E.), and the Sansum Diabetes Research Institute, Santa Barbara (J.E.P., M.C.) - both in California; the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN (Y.C.K., V.D.); the Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston (L.M.L., E.I.), and the Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge (E.D., F.J.D.) - both in Massachusetts; the Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York (C.J.L., D.W.L.); and the Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora (R.P.W., G.P.F.)
| | - Yogish C Kudva
- From the University of Virginia Center for Diabetes Technology, Charlottesville (S.A.B., B.P.K., S.M.A.); the Jaeb Center for Health Research, Tampa, FL (D.R., J.W.L., C.K., R.W.B.); the Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford (B.A.B., L.E.), and the Sansum Diabetes Research Institute, Santa Barbara (J.E.P., M.C.) - both in California; the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN (Y.C.K., V.D.); the Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston (L.M.L., E.I.), and the Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge (E.D., F.J.D.) - both in Massachusetts; the Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York (C.J.L., D.W.L.); and the Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora (R.P.W., G.P.F.)
| | - Lori M Laffel
- From the University of Virginia Center for Diabetes Technology, Charlottesville (S.A.B., B.P.K., S.M.A.); the Jaeb Center for Health Research, Tampa, FL (D.R., J.W.L., C.K., R.W.B.); the Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford (B.A.B., L.E.), and the Sansum Diabetes Research Institute, Santa Barbara (J.E.P., M.C.) - both in California; the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN (Y.C.K., V.D.); the Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston (L.M.L., E.I.), and the Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge (E.D., F.J.D.) - both in Massachusetts; the Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York (C.J.L., D.W.L.); and the Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora (R.P.W., G.P.F.)
| | - Carol J Levy
- From the University of Virginia Center for Diabetes Technology, Charlottesville (S.A.B., B.P.K., S.M.A.); the Jaeb Center for Health Research, Tampa, FL (D.R., J.W.L., C.K., R.W.B.); the Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford (B.A.B., L.E.), and the Sansum Diabetes Research Institute, Santa Barbara (J.E.P., M.C.) - both in California; the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN (Y.C.K., V.D.); the Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston (L.M.L., E.I.), and the Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge (E.D., F.J.D.) - both in Massachusetts; the Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York (C.J.L., D.W.L.); and the Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora (R.P.W., G.P.F.)
| | - Jordan E Pinsker
- From the University of Virginia Center for Diabetes Technology, Charlottesville (S.A.B., B.P.K., S.M.A.); the Jaeb Center for Health Research, Tampa, FL (D.R., J.W.L., C.K., R.W.B.); the Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford (B.A.B., L.E.), and the Sansum Diabetes Research Institute, Santa Barbara (J.E.P., M.C.) - both in California; the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN (Y.C.K., V.D.); the Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston (L.M.L., E.I.), and the Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge (E.D., F.J.D.) - both in Massachusetts; the Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York (C.J.L., D.W.L.); and the Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora (R.P.W., G.P.F.)
| | - R Paul Wadwa
- From the University of Virginia Center for Diabetes Technology, Charlottesville (S.A.B., B.P.K., S.M.A.); the Jaeb Center for Health Research, Tampa, FL (D.R., J.W.L., C.K., R.W.B.); the Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford (B.A.B., L.E.), and the Sansum Diabetes Research Institute, Santa Barbara (J.E.P., M.C.) - both in California; the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN (Y.C.K., V.D.); the Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston (L.M.L., E.I.), and the Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge (E.D., F.J.D.) - both in Massachusetts; the Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York (C.J.L., D.W.L.); and the Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora (R.P.W., G.P.F.)
| | - Eyal Dassau
- From the University of Virginia Center for Diabetes Technology, Charlottesville (S.A.B., B.P.K., S.M.A.); the Jaeb Center for Health Research, Tampa, FL (D.R., J.W.L., C.K., R.W.B.); the Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford (B.A.B., L.E.), and the Sansum Diabetes Research Institute, Santa Barbara (J.E.P., M.C.) - both in California; the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN (Y.C.K., V.D.); the Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston (L.M.L., E.I.), and the Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge (E.D., F.J.D.) - both in Massachusetts; the Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York (C.J.L., D.W.L.); and the Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora (R.P.W., G.P.F.)
| | - Francis J Doyle
- From the University of Virginia Center for Diabetes Technology, Charlottesville (S.A.B., B.P.K., S.M.A.); the Jaeb Center for Health Research, Tampa, FL (D.R., J.W.L., C.K., R.W.B.); the Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford (B.A.B., L.E.), and the Sansum Diabetes Research Institute, Santa Barbara (J.E.P., M.C.) - both in California; the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN (Y.C.K., V.D.); the Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston (L.M.L., E.I.), and the Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge (E.D., F.J.D.) - both in Massachusetts; the Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York (C.J.L., D.W.L.); and the Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora (R.P.W., G.P.F.)
| | - Stacey M Anderson
- From the University of Virginia Center for Diabetes Technology, Charlottesville (S.A.B., B.P.K., S.M.A.); the Jaeb Center for Health Research, Tampa, FL (D.R., J.W.L., C.K., R.W.B.); the Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford (B.A.B., L.E.), and the Sansum Diabetes Research Institute, Santa Barbara (J.E.P., M.C.) - both in California; the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN (Y.C.K., V.D.); the Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston (L.M.L., E.I.), and the Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge (E.D., F.J.D.) - both in Massachusetts; the Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York (C.J.L., D.W.L.); and the Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora (R.P.W., G.P.F.)
| | - Mei Mei Church
- From the University of Virginia Center for Diabetes Technology, Charlottesville (S.A.B., B.P.K., S.M.A.); the Jaeb Center for Health Research, Tampa, FL (D.R., J.W.L., C.K., R.W.B.); the Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford (B.A.B., L.E.), and the Sansum Diabetes Research Institute, Santa Barbara (J.E.P., M.C.) - both in California; the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN (Y.C.K., V.D.); the Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston (L.M.L., E.I.), and the Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge (E.D., F.J.D.) - both in Massachusetts; the Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York (C.J.L., D.W.L.); and the Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora (R.P.W., G.P.F.)
| | - Vikash Dadlani
- From the University of Virginia Center for Diabetes Technology, Charlottesville (S.A.B., B.P.K., S.M.A.); the Jaeb Center for Health Research, Tampa, FL (D.R., J.W.L., C.K., R.W.B.); the Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford (B.A.B., L.E.), and the Sansum Diabetes Research Institute, Santa Barbara (J.E.P., M.C.) - both in California; the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN (Y.C.K., V.D.); the Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston (L.M.L., E.I.), and the Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge (E.D., F.J.D.) - both in Massachusetts; the Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York (C.J.L., D.W.L.); and the Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora (R.P.W., G.P.F.)
| | - Laya Ekhlaspour
- From the University of Virginia Center for Diabetes Technology, Charlottesville (S.A.B., B.P.K., S.M.A.); the Jaeb Center for Health Research, Tampa, FL (D.R., J.W.L., C.K., R.W.B.); the Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford (B.A.B., L.E.), and the Sansum Diabetes Research Institute, Santa Barbara (J.E.P., M.C.) - both in California; the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN (Y.C.K., V.D.); the Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston (L.M.L., E.I.), and the Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge (E.D., F.J.D.) - both in Massachusetts; the Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York (C.J.L., D.W.L.); and the Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora (R.P.W., G.P.F.)
| | - Gregory P Forlenza
- From the University of Virginia Center for Diabetes Technology, Charlottesville (S.A.B., B.P.K., S.M.A.); the Jaeb Center for Health Research, Tampa, FL (D.R., J.W.L., C.K., R.W.B.); the Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford (B.A.B., L.E.), and the Sansum Diabetes Research Institute, Santa Barbara (J.E.P., M.C.) - both in California; the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN (Y.C.K., V.D.); the Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston (L.M.L., E.I.), and the Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge (E.D., F.J.D.) - both in Massachusetts; the Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York (C.J.L., D.W.L.); and the Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora (R.P.W., G.P.F.)
| | - Elvira Isganaitis
- From the University of Virginia Center for Diabetes Technology, Charlottesville (S.A.B., B.P.K., S.M.A.); the Jaeb Center for Health Research, Tampa, FL (D.R., J.W.L., C.K., R.W.B.); the Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford (B.A.B., L.E.), and the Sansum Diabetes Research Institute, Santa Barbara (J.E.P., M.C.) - both in California; the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN (Y.C.K., V.D.); the Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston (L.M.L., E.I.), and the Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge (E.D., F.J.D.) - both in Massachusetts; the Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York (C.J.L., D.W.L.); and the Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora (R.P.W., G.P.F.)
| | - David W Lam
- From the University of Virginia Center for Diabetes Technology, Charlottesville (S.A.B., B.P.K., S.M.A.); the Jaeb Center for Health Research, Tampa, FL (D.R., J.W.L., C.K., R.W.B.); the Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford (B.A.B., L.E.), and the Sansum Diabetes Research Institute, Santa Barbara (J.E.P., M.C.) - both in California; the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN (Y.C.K., V.D.); the Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston (L.M.L., E.I.), and the Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge (E.D., F.J.D.) - both in Massachusetts; the Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York (C.J.L., D.W.L.); and the Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora (R.P.W., G.P.F.)
| | - Craig Kollman
- From the University of Virginia Center for Diabetes Technology, Charlottesville (S.A.B., B.P.K., S.M.A.); the Jaeb Center for Health Research, Tampa, FL (D.R., J.W.L., C.K., R.W.B.); the Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford (B.A.B., L.E.), and the Sansum Diabetes Research Institute, Santa Barbara (J.E.P., M.C.) - both in California; the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN (Y.C.K., V.D.); the Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston (L.M.L., E.I.), and the Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge (E.D., F.J.D.) - both in Massachusetts; the Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York (C.J.L., D.W.L.); and the Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora (R.P.W., G.P.F.)
| | - Roy W Beck
- From the University of Virginia Center for Diabetes Technology, Charlottesville (S.A.B., B.P.K., S.M.A.); the Jaeb Center for Health Research, Tampa, FL (D.R., J.W.L., C.K., R.W.B.); the Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford (B.A.B., L.E.), and the Sansum Diabetes Research Institute, Santa Barbara (J.E.P., M.C.) - both in California; the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN (Y.C.K., V.D.); the Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston (L.M.L., E.I.), and the Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge (E.D., F.J.D.) - both in Massachusetts; the Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York (C.J.L., D.W.L.); and the Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora (R.P.W., G.P.F.)
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