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Trawley S, Stephens AN, McAuley SA, Speight J, Hendrieckx C, Vogrin S, Lee MH, Paldus B, Bach LA, Burt MG, Cohen ND, Colman PG, Davis EA, Holmes-Walker DJ, Jenkins AJ, Kaye J, Keech AC, Kumareswaran K, MacIsaac RJ, McCallum RW, Sims CM, Stranks SN, Sundararajan V, Ward GM, Jones TW, O'Neal DN. Driving with Type 1 Diabetes: Real-World Evidence to Support Starting Glucose Level and Frequency of Monitoring During Journeys. Diabetes Technol Ther 2022; 24:350-356. [PMID: 35156852 DOI: 10.1089/dia.2021.0460] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
There is limited evidence supporting the recommendation that drivers with insulin-treated diabetes need to start journeys with glucose >90 mg/dL. Glucose levels of drivers with type 1 diabetes were monitored for 3 weeks using masked continuous glucose monitoring (CGM). Eighteen drivers (median [IQR] age 40 [35, 51] years; 11 men) undertook 475 trips (duration 15 [13, 21] min). Hypoglycemia did not occur in any trip starting with glucose >90 mg/dL (92%; n = 436). Thirteen drivers recorded at least one trip (total n = 39) starting with glucose <90 mg/dL. Among these, driving glucose was <70 mg/dL in five drivers (38%) during 10 trips (26%). Among five drivers (28%), a ≥ 36 mg/dL drop was observed within 20 min of starting their journey. Journey duration was positively associated with maximum glucose change. These findings support current guidelines to start driving with glucose >90 mg/dL, and to be aware that glucose levels may change significantly within 20 min. A CGM-based, in-vehicle display could provide glucose information and alerts that are compatible with safe driving. Clinical Trial Registration number: ACTRN12617000520336.
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Affiliation(s)
- Steven Trawley
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Cairnmillar Institute, Melbourne, Australia
- Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Australia
| | | | - Sybil A McAuley
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Jane Speight
- Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Australia
- School of Psychology, Deakin University, Geelong, Australia
| | - Christel Hendrieckx
- Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Australia
- School of Psychology, Deakin University, Geelong, Australia
| | - Sara Vogrin
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Melissa H Lee
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Barbora Paldus
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Leon A Bach
- Department of Endocrinology and Diabetes, Alfred Hospital, Melbourne, Australia
- Department of Medicine (Alfred), Monash University, Melbourne, Australia
| | - Morton G Burt
- Southern Adelaide Diabetes and Endocrine Services, Flinders Medical Centre, Adelaide, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Neale D Cohen
- Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Peter G Colman
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, Australia
| | - Elizabeth A Davis
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Australia
- Telethon Kids Institute, University of Western Australia, Perth, Australia
- School of Paediatrics and Child Health, University of Western Australia, Perth, Australia
| | - D Jane Holmes-Walker
- Department of Diabetes and Endocrinology, Westmead Hospital, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
| | - Alicia J Jenkins
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Joey Kaye
- Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Perth, Australia
| | - Anthony C Keech
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Kavita Kumareswaran
- Department of Endocrinology and Diabetes, Alfred Hospital, Melbourne, Australia
- Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Richard J MacIsaac
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Roland W McCallum
- Department of Diabetes and Endocrinology, Royal Hobart Hospital, Hobart, Australia
| | - Catriona M Sims
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Stephen N Stranks
- Southern Adelaide Diabetes and Endocrine Services, Flinders Medical Centre, Adelaide, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | | | - Glenn M Ward
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Timothy W Jones
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Australia
- Telethon Kids Institute, University of Western Australia, Perth, Australia
- School of Paediatrics and Child Health, University of Western Australia, Perth, Australia
| | - David N O'Neal
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
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Lu JC, Vogrin S, McAuley SA, Lee MH, Paldus B, Bach LA, Burt MG, Clarke PM, Cohen ND, Colman PG, de Bock MI, Jane Holmes-Walker D, Jenkins AJ, Kaye J, Keech AC, Kumareswaran K, MacIsaac RJ, McCallum RW, Roem K, Sims C, Stranks SN, Trawley S, Ward GM, Sundararajan V, Jones TW, O'Neal DN. Meal-time glycaemia in adults with type 1 diabetes using multiple daily injections vs insulin pump therapy following carbohydrate-counting education and bolus calculator provision. Diabetes Res Clin Pract 2021; 179:109000. [PMID: 34455185 DOI: 10.1016/j.diabres.2021.109000] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 05/14/2021] [Accepted: 08/06/2021] [Indexed: 11/17/2022]
Abstract
AIMS To compare meal-time glycaemia in adults with type 1 diabetes mellitus (T1D) managed with multiple daily injections (MDI) vs. insulin pump therapy (IPT), using self-monitoring blood glucose (SMBG), following diabetes education. METHODS Adults with T1D received carbohydrate-counting education and a bolus calculator: MDI (Roche Aviva Expert) and IPT (pump bolus calculator). All then wore 3-weeks of masked-CGM (Enlite, Medtronic). Meal-times were assessed by two approaches: 1) Set time-blocks (breakfast 06:00-10:00hrs; lunch 11:00-15:00hrs; dinner 17:00-21:00hrs) and 2) Bolus-calculator carbohydrate entries signalling meal commencement. Post-meal masked-CGM time-in-range (TIR) 3.9-10.0 mmol/L was the primary outcome. RESULTS MDI(n = 61) and IPT (n = 59) participants were equivalent in age, sex, diabetes duration and HbA1c. Median (IQR) education time provided did not differ (MDI: 1.1 h (0.75, 1.5) vs. IPT: 1.1 h (1.0, 2.0); p = 0.86). Overall, daytime (06:00-24:00hrs), lunch and dinner TIR did not differ for MDI vs. IPT participants but was greater for breakfast with IPT in both analyses with a mean difference of 12.8%, (95 CI 4.8, 20.9); p = 0.002 (time-block analysis). CONCLUSION After diabetes education, MDI and IPT use were associated with similar day-time glycemia, though IPT users had significantly greater TIR during the breakfast period. With education, meal-time glucose levels are comparable with use of MDI vs. pumps.
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Affiliation(s)
- Jean C Lu
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia; Department of Medicine, University of Melbourne, Fitzroy, Victoria, Australia
| | - Sara Vogrin
- Department of Medicine, University of Melbourne, Fitzroy, Victoria, Australia
| | - Sybil A McAuley
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia; Department of Medicine, University of Melbourne, Fitzroy, Victoria, Australia
| | - Melissa H Lee
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia; Department of Medicine, University of Melbourne, Fitzroy, Victoria, Australia
| | - Barbora Paldus
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia; Department of Medicine, University of Melbourne, Fitzroy, Victoria, Australia
| | - Leon A Bach
- Department of Endocrinology and Diabetes, Alfred Hospital, Melbourne, Victoria, Australia; Department of Medicine (Alfred), Monash University, Melbourne, Victoria, Australia
| | - Morton G Burt
- Southern Adelaide Diabetes and Endocrine Services, Flinders Medical Centre, Adelaide, South Australia, Australia; School of Medicine, Flinders University, Adelaide, South Australia, Australia
| | - Philip M Clarke
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Neale D Cohen
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Peter G Colman
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Martin I de Bock
- Department of Paediatrics, University of Otago, Christchurch, New Zealand
| | - D Jane Holmes-Walker
- Department of Diabetes and Endocrinology, Westmead Hospital, Sydney, New South Wales, Australia; Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Alicia J Jenkins
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia; Department of Medicine, University of Melbourne, Fitzroy, Victoria, Australia; NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Joey Kaye
- Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Anthony C Keech
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Kavita Kumareswaran
- Department of Endocrinology and Diabetes, Alfred Hospital, Melbourne, Victoria, Australia; Department of Medicine (Alfred), Monash University, Melbourne, Victoria, Australia
| | - Richard J MacIsaac
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia; Department of Medicine, University of Melbourne, Fitzroy, Victoria, Australia
| | - Roland W McCallum
- Department of Diabetes and Endocrinology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Kerryn Roem
- Department of Medicine, University of Melbourne, Fitzroy, Victoria, Australia
| | - Catriona Sims
- Department of Medicine, University of Melbourne, Fitzroy, Victoria, Australia
| | - Stephen N Stranks
- Southern Adelaide Diabetes and Endocrine Services, Flinders Medical Centre, Adelaide, South Australia, Australia; School of Medicine, Flinders University, Adelaide, South Australia, Australia
| | | | - Glenn M Ward
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia; Department of Medicine, University of Melbourne, Fitzroy, Victoria, Australia; Department of Pathology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Vijaya Sundararajan
- Department of Medicine, University of Melbourne, Fitzroy, Victoria, Australia; Department of Public Health, La Trobe University, Australia
| | - Timothy W Jones
- Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children, Perth, Western Australia, Australia; Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia; School of Paediatrics and Child Health, University of Western Australia, Perth, Western Australia, Australia
| | - David N O'Neal
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia; Department of Medicine, University of Melbourne, Fitzroy, Victoria, Australia; NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia.
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McAuley SA, Vogrin S, Lee MH, Paldus B, Trawley S, de Bock MI, Abraham MB, Bach LA, Burt MG, Cohen ND, Colman PG, Davis EA, Hendrieckx C, Holmes-Walker DJ, Jenkins AJ, Kaye J, Keech AC, Kumareswaran K, MacIsaac RJ, McCallum RW, Sims CM, Speight J, Stranks SN, Sundararajan V, Ward GM, Jones TW, O'Neal DN. Less Nocturnal Hypoglycemia but Equivalent Time in Range Among Adults with Type 1 Diabetes Using Insulin Pumps Versus Multiple Daily Injections. Diabetes Technol Ther 2021; 23:460-466. [PMID: 33351699 DOI: 10.1089/dia.2020.0589] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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] [Indexed: 11/12/2022]
Abstract
Background: This prerandomization analysis from the Australian HCL-Adult trial (registration number: ACTRN12617000520336) compared masked continuous glucose monitoring (CGM) metrics among adults using insulin pumps versus multiple daily injections (MDIs), who were all self-monitoring blood glucose (SMBG). Methods: Adults with type 1 diabetes, using an insulin pump or MDIs without real-time CGM (and entering a trial of closed-loop technology), were eligible. MDI users were given an insulin dosage calculator. All participants received diabetes and carbohydrate-counting education, then wore masked CGM sensors for 3 weeks. Ethics Approval: HREC-D 088/16 Results: Adults using MDIs (n = 61) versus pump (n = 59) did not differ by age, sex, diabetes duration, insulin total daily dose, or HbA1c at baseline. After education, median (interquartile range) CGM time in range (TIR) 70-180 mg/dL (3.9-10.0 mmol/L) was 54% (47, 62) for those using MDIs and 56% (48, 66) for those using pump (P = 0.40). All CGM metrics were equivalent for 24 h/day for MDI and pump users. Overnight, those using MDIs (vs. pump) spent more time with glucose <54 mg/dL (<3.0 mmol/L): 1.4% (0.1, 5.1) versus 0.5% (0.0, 2.0), respectively (P = 0.012). They also had more CGM hypoglycemia episodes (121 vs. 54, respectively; incidence rate ratio [95% confidence interval] 2.48 [1.51, 4.06]; P < 0.001). Conclusions: Adults with type 1 diabetes using pumps versus MDIs in conjunction with SMBG experienced less nocturnal hypoglycemia, measured by masked CGM, after equivalent diabetes and dietary education in conjunction with insulin dosage calculator provision to all. However, both groups had equivalent TIR. This observation may reflect advantages afforded by flexibility in basal insulin delivery provided by pumps.
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Affiliation(s)
- Sybil A McAuley
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Sara Vogrin
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Melissa H Lee
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Barbora Paldus
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Steven Trawley
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Australian Centre for Behavioural Research in Diabetes, Melbourne, Australia
- The Cairnmillar Institute, Melbourne, Australia
| | - Martin I de Bock
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Australia
- Telethon Kids Institute, University of Western Australia, Perth, Australia
- School of Paediatrics and Child Health, University of Western Australia, Perth, Australia
- Department of Paediatrics and Child Health, University of Otago, Christchurch, New Zealand
| | - Mary B Abraham
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Australia
- Telethon Kids Institute, University of Western Australia, Perth, Australia
- School of Paediatrics and Child Health, University of Western Australia, Perth, Australia
| | - Leon A Bach
- Department of Endocrinology and Diabetes, The Alfred, Melbourne, Australia
- Department of Medicine (Alfred Medical Research and Education Precinct), Monash University, Melbourne, Australia
| | - Morton G Burt
- Southern Adelaide Diabetes and Endocrine Services, Flinders Medical Centre, Adelaide, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Neale D Cohen
- Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Peter G Colman
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, Australia
| | - Elizabeth A Davis
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Australia
- Telethon Kids Institute, University of Western Australia, Perth, Australia
- School of Paediatrics and Child Health, University of Western Australia, Perth, Australia
| | - Christel Hendrieckx
- Australian Centre for Behavioural Research in Diabetes, Melbourne, Australia
- School of Psychology, Deakin University, Geelong, Australia
| | - D Jane Holmes-Walker
- Department of Diabetes and Endocrinology, Westmead Hospital, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
| | - Alicia J Jenkins
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Joey Kaye
- Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Perth, Australia
| | - Anthony C Keech
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Kavita Kumareswaran
- Department of Endocrinology and Diabetes, The Alfred, Melbourne, Australia
- Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Richard J MacIsaac
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Roland W McCallum
- Department of Diabetes and Endocrinology, Royal Hobart Hospital, Hobart, Australia
| | - Catriona M Sims
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Jane Speight
- Australian Centre for Behavioural Research in Diabetes, Melbourne, Australia
- School of Psychology, Deakin University, Geelong, Australia
| | - Stephen N Stranks
- Southern Adelaide Diabetes and Endocrine Services, Flinders Medical Centre, Adelaide, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | | | - Glenn M Ward
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Timothy W Jones
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Australia
- Telethon Kids Institute, University of Western Australia, Perth, Australia
- School of Paediatrics and Child Health, University of Western Australia, Perth, Australia
| | - David N O'Neal
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
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McAuley SA, Lee MH, Paldus B, Vogrin S, de Bock MI, Abraham MB, Bach LA, Burt MG, Cohen ND, Colman PG, Davis EA, Hendrieckx C, Holmes-Walker DJ, Kaye J, Keech AC, Kumareswaran K, MacIsaac RJ, McCallum RW, Sims CM, Speight J, Stranks SN, Sundararajan V, Trawley S, Ward GM, Jenkins AJ, Jones TW, O'Neal DN. Six Months of Hybrid Closed-Loop Versus Manual Insulin Delivery With Fingerprick Blood Glucose Monitoring in Adults With Type 1 Diabetes: A Randomized, Controlled Trial. Diabetes Care 2020; 43:3024-3033. [PMID: 33055139 DOI: 10.2337/dc20-1447] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [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: 06/12/2020] [Accepted: 09/16/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To investigate glycemic and psychosocial outcomes with hybrid closed-loop (HCL) versus user-determined insulin dosing with multiple daily injections (MDI) or insulin pump (i.e., standard therapy for most adults with type 1 diabetes). RESEARCH DESIGN AND METHODS Adults with type 1 diabetes using MDI or insulin pump without continuous glucose monitoring (CGM) were randomized to 26 weeks of HCL (Medtronic 670G) or continuation of current therapy. The primary outcome was masked CGM time in range (TIR; 70-180 mg/dL) during the final 3 weeks. RESULTS Participants were randomized to HCL (n = 61) or control (n = 59). Baseline mean (SD) age was 44.2 (11.7) years, HbA1c was 7.4% (0.9%) (57 [10] mmol/mol), 53% were women, and 51% used MDI. HCL TIR increased from (baseline) 55% (13%) to (26 weeks) 70% (10%) with the control group unchanged: (baseline) 55% (12%) and (26 weeks) 55% (13%) (difference 15% [95% CI 11, 19]; P < 0.0001). For HCL, HbA1c was lower (median [95% CI] difference -0.4% [-0.6, -0.2]; -4 mmol/mol [-7, -2]; P < 0.0001) and diabetes-specific positive well-being was higher (difference 1.2 [95% CI 0.4, 1.9]; P < 0.0048) without a deterioration in diabetes distress, perceived sleep quality, or cognition. Seventeen (9 device-related) versus 13 serious adverse events occurred in the HCL and control groups, respectively. CONCLUSIONS In adults with type 1 diabetes, 26 weeks of HCL improved TIR, HbA1c, and their sense of satisfaction from managing their diabetes compared with those continuing with user-determined insulin dosing and self-monitoring of blood glucose. For most people living with type 1 diabetes globally, this trial demonstrates that HCL is feasible, acceptable, and advantageous.
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Affiliation(s)
- Sybil A McAuley
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Melissa H Lee
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Barbora Paldus
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Sara Vogrin
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Martin I de Bock
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Nedlands, Western Australia, Australia.,Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia.,School of Paediatrics and Child Health, University of Western Australia, Nedlands, Western Australia, Australia.,Department of Paediatrics and Child Health, University of Otago, Wellington, New Zealand
| | - Mary B Abraham
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Nedlands, Western Australia, Australia.,Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia.,School of Paediatrics and Child Health, University of Western Australia, Nedlands, Western Australia, Australia
| | - Leon A Bach
- Department of Endocrinology and Diabetes, The Alfred, Melbourne, Victoria, Australia.,Department of Medicine (Alfred Medical Research and Education Precinct), Monash University, Melbourne, Victoria, Australia
| | - Morton G Burt
- Southern Adelaide Diabetes and Endocrine Services, Flinders Medical Centre, Bedford Park, South Australia, Australia.,College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Neale D Cohen
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Peter G Colman
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Elizabeth A Davis
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Nedlands, Western Australia, Australia.,Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia.,School of Paediatrics and Child Health, University of Western Australia, Nedlands, Western Australia, Australia
| | - Christel Hendrieckx
- School of Psychology, Deakin University, Geelong, Victoria, Australia.,Australian Centre for Behavioural Research in Diabetes, North Melbourne, Victoria, Australia
| | - D Jane Holmes-Walker
- Department of Diabetes and Endocrinology, Westmead Hospital, Westmead, New South Wales, Australia.,Sydney Medical School, University of Sydney, Camperdown, New South Wales, Australia
| | - Joey Kaye
- Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Anthony C Keech
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
| | - Kavita Kumareswaran
- Department of Endocrinology and Diabetes, The Alfred, Melbourne, Victoria, Australia.,Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Richard J MacIsaac
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Roland W McCallum
- Department of Diabetes and Endocrinology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Catriona M Sims
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Jane Speight
- School of Psychology, Deakin University, Geelong, Victoria, Australia.,Australian Centre for Behavioural Research in Diabetes, North Melbourne, Victoria, Australia
| | - Stephen N Stranks
- Southern Adelaide Diabetes and Endocrine Services, Flinders Medical Centre, Bedford Park, South Australia, Australia.,College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Vijaya Sundararajan
- Department of Public Health, La Trobe University, Melbourne, Victoria, Australia
| | - Steven Trawley
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Australian Centre for Behavioural Research in Diabetes, North Melbourne, Victoria, Australia.,The Cairnmillar Institute, Hawthorn East, Victoria, Australia
| | - Glenn M Ward
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Alicia J Jenkins
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia.,Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Timothy W Jones
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Nedlands, Western Australia, Australia.,Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia.,School of Paediatrics and Child Health, University of Western Australia, Nedlands, Western Australia, Australia
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Jones AR, Kumareswaran K. The scourge of the C. Med J Aust 2018; 209:62-63. [PMID: 29996751 DOI: 10.5694/mja17.00876] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 10/18/2017] [Indexed: 11/17/2022]
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McAuley SA, de Bock MI, Sundararajan V, Lee MH, Paldus B, Ambler GR, Bach LA, Burt MG, Cameron FJ, Clarke PM, Cohen ND, Colman PG, Davis EA, Fairchild JM, Hendrieckx C, Holmes-Walker DJ, Horsburgh JC, Jenkins AJ, Kaye J, Keech AC, King BR, Kumareswaran K, MacIsaac RJ, McCallum RW, Nicholas JA, Sims C, Speight J, Stranks SN, Trawley S, Ward GM, Vogrin S, Jones TW, O'Neal DN. Effect of 6 months of hybrid closed-loop insulin delivery in adults with type 1 diabetes: a randomised controlled trial protocol. BMJ Open 2018; 8:e020274. [PMID: 29886443 PMCID: PMC6009467 DOI: 10.1136/bmjopen-2017-020274] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Manual determination of insulin dosing largely fails to optimise glucose control in type 1 diabetes. Automated insulin delivery via closed-loop systems has improved glucose control in short-term studies. The objective of the present study is to determine the effectiveness of 6 months' closed-loop compared with manually determined insulin dosing on time-in-target glucose range in adults with type 1 diabetes. METHODS AND ANALYSIS This open-label, seven-centre, randomised controlled parallel group clinical trial will compare home-based hybrid closed-loop versus standard diabetes therapy in Australia. Adults aged ≥25 years with type 1 diabetes using intensive insulin therapy (via multiple daily injections or insulin pump, total enrolment target n=120) will undertake a run-in period including diabetes and carbohydrate-counting education, clinical optimisation and baseline data collection. Participants will then be randomised 1:1 either to 26 weeks of MiniMed 670G hybrid closed-loop system therapy (Medtronic, Northridge, CA, USA) or continuation of their current diabetes therapy. The hybrid closed-loop system delivers insulin automatically to address basal requirements and correct to target glucose level, while bolus doses for meals require user initiation and carbohydrate estimation. Analysis will be intention to treat, with the primary outcome time in continuous glucose monitoring (CGM) target range (3.9-10.0 mmol/L) during the final 3 weeks of intervention. Secondary outcomes include: other CGM parameters, HbA1c, severe hypoglycaemia, psychosocial well-being, sleep, cognition, electrocardiography, costs, quality of life, biomarkers of vascular health and hybrid closed-loop system performance. Semistructured interviews will assess the expectations and experiences of a subgroup of hybrid closed-loop users. ETHICS AND DISSEMINATION The study has Human Research Ethics Committee approval. The study will be conducted in accordance with the principles of the Declaration of Helsinki and Good Clinical Practice. Results will be disseminated at scientific conferences and via peer-reviewed publications. TRIAL REGISTRATION NUMBER ACTRN12617000520336; Pre-results.
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Affiliation(s)
- Sybil A McAuley
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Martin I de Bock
- Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- School of Paediatrics and Child Health, University of Western Australia, Perth, Western Australia, Australia
| | - Vijaya Sundararajan
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Melissa H Lee
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Barbora Paldus
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Geoff R Ambler
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Leon A Bach
- Department of Endocrinology and Diabetes, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Medicine (Alfred), Monash University, Melbourne, Victoria, Australia
| | - Morton G Burt
- Southern Adelaide Diabetes and Endocrine Services, Flinders Medical Centre, Adelaide, South Australia, Australia
- School of Medicine, Flinders University, Adelaide, South Australia, Australia
| | - Fergus J Cameron
- Department ofEndocrinology and Diabetes and Centre for Hormone Research, Royal Children'sHospital, Melbourne, Victoria, Australia
- Murdoch Children'sResearch Institute, Melbourne, Victoria, Australia
- Department ofPaediatrics, University ofMelbourne, Melbourne, Victoria, Australia
| | - Philip M Clarke
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Neale D Cohen
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Peter G Colman
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Elizabeth A Davis
- Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- School of Paediatrics and Child Health, University of Western Australia, Perth, Western Australia, Australia
| | - Jan M Fairchild
- Endocrinology and Diabetes Centre, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Christel Hendrieckx
- School of Psychology, Deakin University, Geelong, Victoria, Australia
- Australian Centre for Behavioural Research in Diabetes, Melbourne, Victoria, Australia
| | - D Jane Holmes-Walker
- Department of Diabetes and Endocrinology, Westmead Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Jodie C Horsburgh
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Alicia J Jenkins
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Joey Kaye
- Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Anthony C Keech
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Bruce R King
- Department of Endocrinology and Diabetes, John Hunter Children's Hospital, Newcastle, New South Wales, Australia
| | - Kavita Kumareswaran
- Department of Endocrinology and Diabetes, Alfred Hospital, Melbourne, Victoria, Australia
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Richard J MacIsaac
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Roland W McCallum
- Department of Diabetes and Endocrinology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Jennifer A Nicholas
- Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | - Catriona Sims
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Jane Speight
- School of Psychology, Deakin University, Geelong, Victoria, Australia
- Australian Centre for Behavioural Research in Diabetes, Melbourne, Victoria, Australia
| | - Stephen N Stranks
- Southern Adelaide Diabetes and Endocrine Services, Flinders Medical Centre, Adelaide, South Australia, Australia
- School of Medicine, Flinders University, Adelaide, South Australia, Australia
| | - Steven Trawley
- Australian Centre for Behavioural Research in Diabetes, Melbourne, Victoria, Australia
- Cairnmillar Institute, Melbourne, Victoria, Australia
| | - Glenn M Ward
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
- Department of Pathology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Sara Vogrin
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Timothy W Jones
- Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | - David N O'Neal
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
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7
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Graf A, Ward GM, Vogrin S, Sundararajan V, Sharifi A, De Bock MI, Jayawardene D, Loh MM, Horsburgh JC, Berthold CL, Paramalingam N, Bach LA, Colman PG, Davis EA, Grosman B, Jenkins AJ, Kumareswaran K, Kurtz N, Kyoong A, MacIsaac RJ, Roy A, Jones TW, O'Neal DN. Overnight Counter-Regulatory Hormone Levels and Next Day Glycemia in Adults with Type 1 Diabetes During Closed-Loop Insulin Delivery Versus Sensor-Augmented Pump with Low-Glucose Suspend. Diabetes Technol Ther 2017; 19:438-439. [PMID: 28537427 DOI: 10.1089/dia.2017.0049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 11/12/2022]
Affiliation(s)
- Anneke Graf
- 1 Department of Endocrinology and Diabetes, St. Vincent's Hospital Melbourne , Melbourne, Australia
| | - Glenn M Ward
- 1 Department of Endocrinology and Diabetes, St. Vincent's Hospital Melbourne , Melbourne, Australia
| | - Sara Vogrin
- 2 University of Melbourne Department of Medicine, St. Vincent's Hospital Melbourne, Melbourne, Australia
| | - Vijaya Sundararajan
- 2 University of Melbourne Department of Medicine, St. Vincent's Hospital Melbourne, Melbourne, Australia
| | - Amin Sharifi
- 1 Department of Endocrinology and Diabetes, St. Vincent's Hospital Melbourne , Melbourne, Australia
| | - Martin I De Bock
- 3 Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children , Perth, Australia
| | - Dilshani Jayawardene
- 1 Department of Endocrinology and Diabetes, St. Vincent's Hospital Melbourne , Melbourne, Australia
| | - Margaret M Loh
- 1 Department of Endocrinology and Diabetes, St. Vincent's Hospital Melbourne , Melbourne, Australia
| | - Jodie C Horsburgh
- 1 Department of Endocrinology and Diabetes, St. Vincent's Hospital Melbourne , Melbourne, Australia
| | | | | | - Leon A Bach
- 5 Department of Endocrinology and Diabetes, Alfred Hospital , Melbourne, Australia
| | - Peter G Colman
- 6 Department of Diabetes and Endocrinology, Royal Melbourne Hospital , Melbourne, Australia
| | | | | | - Alicia J Jenkins
- 1 Department of Endocrinology and Diabetes, St. Vincent's Hospital Melbourne , Melbourne, Australia
- 2 University of Melbourne Department of Medicine, St. Vincent's Hospital Melbourne, Melbourne, Australia
- 7 NHMRC Clinical Trials Centre, University of Sydney , Sydney, Australia
| | - Kavita Kumareswaran
- 5 Department of Endocrinology and Diabetes, Alfred Hospital , Melbourne, Australia
| | | | - Andrew Kyoong
- 9 Department of Respiratory and Sleep Medicine, St. Vincent's Hospital Melbourne , Melbourne, Australia
| | - Richard J MacIsaac
- 1 Department of Endocrinology and Diabetes, St. Vincent's Hospital Melbourne , Melbourne, Australia
- 2 University of Melbourne Department of Medicine, St. Vincent's Hospital Melbourne, Melbourne, Australia
| | - Anirban Roy
- 8 Medtronic Diabetes , Northridge, California
| | - Timothy W Jones
- 3 Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children , Perth, Australia
- 4 Telethon Kids Institute , Perth, Australia
| | - David N O'Neal
- 1 Department of Endocrinology and Diabetes, St. Vincent's Hospital Melbourne , Melbourne, Australia
- 2 University of Melbourne Department of Medicine, St. Vincent's Hospital Melbourne, Melbourne, Australia
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Hendrieckx C, Poole LA, Sharifi A, Jayawardene D, Loh MM, Horsburgh JC, Bach LA, Colman PG, Kumareswaran K, Jenkins AJ, MacIsaac RJ, Ward GM, Grosman B, Roy A, O'Neal DN, Speight J. "It Is Definitely a Game Changer": A Qualitative Study of Experiences with In-home Overnight Closed-Loop Technology Among Adults with Type 1 Diabetes. Diabetes Technol Ther 2017; 19:410-416. [PMID: 28537437 DOI: 10.1089/dia.2017.0007] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [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] [Indexed: 12/18/2022]
Abstract
BACKGROUND This qualitative study explored trial participants' experiences of four nights of in-home closed loop. METHODS Sixteen adults with type 1 diabetes, who completed a randomized crossover trial, were interviewed after four consecutive nights of closed-loop. Interviews were audio recorded, transcribed, and analyzed with a coding framework developed to identify the main themes. RESULTS Participants had a mean age of 42 ± 10 years, nine were women; mean diabetes duration was 27 ± 7 years, and all were using insulin pumps. Overall, first impressions were positive. Participants found closed-loop easy to use and understand. Most experienced more stable overnight glucose levels, although for some these were similar to usual care or higher than they expected. Compared with their usual treatment, they noticed the proactive nature of the closed-loop, being able to predict trends and deliver micro amounts of insulin. Most reported technical glitches or inconveniences during one or more nights, such as transmission problems, problematic connectivity between devices, ongoing alarms despite addressing low glucose levels, and sensor inaccuracy. Remote monitoring by the trial team and their own hypoglycemic awareness contributed to feelings of trust and safety. Although rare, safety concerns were raised, related to feeling unsure whether the system would respond in time to falling glucose levels. CONCLUSIONS This study provides relevant insights for implementation of closed-loop in the real world. For people with diabetes who are less familiar with technology, remote monitoring for the first few days may provide reassurance, strengthen their trust/skills, and make closed-loop an acceptable option for more people with type 1 diabetes.
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Affiliation(s)
- Christel Hendrieckx
- 1 School of Psychology, Deakin University , Geelong, Victoria, Australia
- 2 The Australian Center for Behavioral Research in Diabetes , Diabetes Victoria, Melbourne, Victoria, Australia
| | - Lucinda A Poole
- 1 School of Psychology, Deakin University , Geelong, Victoria, Australia
- 2 The Australian Center for Behavioral Research in Diabetes , Diabetes Victoria, Melbourne, Victoria, Australia
| | - Amin Sharifi
- 3 Department of Endocrinology and Diabetes, St. Vincent's Hospital , Melbourne, Victoria, Australia
| | - Dilshani Jayawardene
- 3 Department of Endocrinology and Diabetes, St. Vincent's Hospital , Melbourne, Victoria, Australia
| | - Margaret M Loh
- 3 Department of Endocrinology and Diabetes, St. Vincent's Hospital , Melbourne, Victoria, Australia
| | - Jodie C Horsburgh
- 3 Department of Endocrinology and Diabetes, St. Vincent's Hospital , Melbourne, Victoria, Australia
| | - Leon A Bach
- 4 Department of Endocrinology and Diabetes, Alfred Hospital , Melbourne, Victoria, Australia
- 5 Department of Medicine, Monash University , Melbourne, Victoria, Australia
| | - Peter G Colman
- 6 Department of Diabetes and Endocrinology, Royal Melbourne Hospital , Melbourne, Victoria, Australia
| | - Kavita Kumareswaran
- 4 Department of Endocrinology and Diabetes, Alfred Hospital , Melbourne, Victoria, Australia
| | - Alicia J Jenkins
- 3 Department of Endocrinology and Diabetes, St. Vincent's Hospital , Melbourne, Victoria, Australia
- 7 Department of Medicine, University of Melbourne , St. Vincent's Hospital, Melbourne, Victoria, Australia
- 8 NHMRC Clinical Trials Center, University of Sydney , Camperdown, New South Wales, Australia
| | - Richard J MacIsaac
- 3 Department of Endocrinology and Diabetes, St. Vincent's Hospital , Melbourne, Victoria, Australia
- 7 Department of Medicine, University of Melbourne , St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - Glenn M Ward
- 3 Department of Endocrinology and Diabetes, St. Vincent's Hospital , Melbourne, Victoria, Australia
- 7 Department of Medicine, University of Melbourne , St. Vincent's Hospital, Melbourne, Victoria, Australia
| | | | - Anirban Roy
- 9 Medtronic Diabetes, Northridge, California
| | - David N O'Neal
- 3 Department of Endocrinology and Diabetes, St. Vincent's Hospital , Melbourne, Victoria, Australia
- 7 Department of Medicine, University of Melbourne , St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - Jane Speight
- 1 School of Psychology, Deakin University , Geelong, Victoria, Australia
- 2 The Australian Center for Behavioral Research in Diabetes , Diabetes Victoria, Melbourne, Victoria, Australia
- 10 AHP Research , Hornchurch, Essex, United Kingdom
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9
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Sharifi A, De Bock MI, Jayawardene D, Loh MM, Horsburgh JC, Berthold CL, Paramalingam N, Bach LA, Colman PG, Davis EA, Grosman B, Hendrieckx C, Jenkins AJ, Kumareswaran K, Kurtz N, Kyoong A, MacIsaac RJ, Speight J, Trawley S, Ward GM, Roy A, Jones TW, O'Neal DN. Glycemia, Treatment Satisfaction, Cognition, and Sleep Quality in Adults and Adolescents with Type 1 Diabetes When Using a Closed-Loop System Overnight Versus Sensor-Augmented Pump with Low-Glucose Suspend Function: A Randomized Crossover Study. Diabetes Technol Ther 2016; 18:772-783. [PMID: 27835037 DOI: 10.1089/dia.2016.0288] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [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] [Indexed: 01/07/2023]
Abstract
BACKGROUND We compared glycemia, treatment satisfaction, sleep quality, and cognition using a nighttime Android-based hybrid closed-loop system (Android-HCLS) with sensor-augmented pump with low-glucose suspend function (SAP-LGS) in people with type 1 diabetes. MATERIALS AND METHODS An open-label, prospective, randomized crossover study of 16 adults (mean [SD] age 42.1 [9.6] years) and 12 adolescents (15.2 [1.6] years) was conducted. All participants completed four consecutive nights at home with Android-HCLS (proportional integral derivative with insulin feedback algorithm; Medtronic) and SAP-LGS. PRIMARY OUTCOME percent continuous glucose monitoring (CGM) time (00:00-08:00 h) within target range (72-144 mg/dL). Secondary endpoints: percent CGM time above target (>144 mg/dL); below target (<72 mg/dL); glycemic variability (SD); symptomatic hypoglycemia; adult treatment satisfaction; sleep quality; and cognitive function. RESULTS The primary outcome for all participants was not statistically different between Android-HCLS and SAP-LGS (mean [SD] 59.4 [17.9]% vs. 53.1 [18]%; p = 0.14). Adults had greater percent time within target range (57.7 [18.6]% vs. 44.5 [14.5]%; p < 0.006); less time above target (42.0 [18.7]% vs. 52.6 [16.5]%; p = 0.034); lower glycemic variability (35 [10.7] mg/dL vs. 46 [10.7] mg/dL; p = 0.003); and less (median [IQR]) time below target (0.0 [0.0-0.4]% vs. 0.80 [0.0-3.9]%; p = 0.025). In adolescents, time below target was lower with Android-HCLS vs. SAP-LGS (0.0 [0.0-0.0]% vs. 1.8 [0.1-7.9]%; p = 0.011). Nocturnal symptomatic hypoglycemia was less (1 vs. 10; p = 0.007) in adolescents, but not adults (5 vs. 13; p = 0.059). In adults, treatment satisfaction increased by 10 points (p < 0.02). Sleep quality and cognition did not differ. CONCLUSIONS Android-HCLS in both adults and adolescents reduced nocturnal hypoglycemia and, in adults, improved overnight time in target range and treatment satisfaction compared with SAP-LGS.
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Affiliation(s)
- Amin Sharifi
- 1 Department of Endocrinology and Diabetes, St. Vincent's Hospital Melbourne , Melbourne, Australia
| | - Martin I De Bock
- 2 Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children , Perth, Australia
| | - Dilshani Jayawardene
- 1 Department of Endocrinology and Diabetes, St. Vincent's Hospital Melbourne , Melbourne, Australia
| | - Margaret M Loh
- 1 Department of Endocrinology and Diabetes, St. Vincent's Hospital Melbourne , Melbourne, Australia
| | - Jodie C Horsburgh
- 1 Department of Endocrinology and Diabetes, St. Vincent's Hospital Melbourne , Melbourne, Australia
| | - Carolyn L Berthold
- 2 Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children , Perth, Australia
| | - Nirubasini Paramalingam
- 2 Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children , Perth, Australia
| | - Leon A Bach
- 3 Department of Endocrinology and Diabetes, Alfred Hospital , Melbourne, Australia
| | - Peter G Colman
- 4 Department of Diabetes and Endocrinology, Royal Melbourne Hospital , Melbourne, Australia
| | - Elizabeth A Davis
- 2 Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children , Perth, Australia
| | | | - Christel Hendrieckx
- 6 The Australian Centre for Behavioural Research in Diabetes , Diabetes Victoria, Australia
- 7 School of Psychology, Deakin University , Geelong, Australia
| | - Alicia J Jenkins
- 1 Department of Endocrinology and Diabetes, St. Vincent's Hospital Melbourne , Melbourne, Australia
- 8 Department of Medicine, University of Melbourne , St. Vincent's Hospital Melbourne, Melbourne, Australia
- 9 University of Sydney , NHMRC Clinical Trials Centre, Australia
| | - Kavita Kumareswaran
- 3 Department of Endocrinology and Diabetes, Alfred Hospital , Melbourne, Australia
| | | | - Andrew Kyoong
- 10 Department of Respiratory and Sleep Medicine, St. Vincent's Hospital Melbourne , Melbourne, Australia
| | - Richard J MacIsaac
- 1 Department of Endocrinology and Diabetes, St. Vincent's Hospital Melbourne , Melbourne, Australia
- 8 Department of Medicine, University of Melbourne , St. Vincent's Hospital Melbourne, Melbourne, Australia
| | - Jane Speight
- 6 The Australian Centre for Behavioural Research in Diabetes , Diabetes Victoria, Australia
- 7 School of Psychology, Deakin University , Geelong, Australia
- 11 AHP Research , Hornchurch, Essex, United Kingdom
| | - Steven Trawley
- 6 The Australian Centre for Behavioural Research in Diabetes , Diabetes Victoria, Australia
- 7 School of Psychology, Deakin University , Geelong, Australia
| | - Glenn M Ward
- 1 Department of Endocrinology and Diabetes, St. Vincent's Hospital Melbourne , Melbourne, Australia
- 8 Department of Medicine, University of Melbourne , St. Vincent's Hospital Melbourne, Melbourne, Australia
| | - Anirban Roy
- 5 Medtronic Diabetes , Northridge, California
| | - Timothy W Jones
- 2 Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children , Perth, Australia
| | - David N O'Neal
- 1 Department of Endocrinology and Diabetes, St. Vincent's Hospital Melbourne , Melbourne, Australia
- 8 Department of Medicine, University of Melbourne , St. Vincent's Hospital Melbourne, Melbourne, Australia
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Elleri D, Biagioni M, Allen JM, Kumareswaran K, Leelarathna L, Caldwell K, Nodale M, Wilinska ME, Haidar A, Calhoun P, Kollman C, Jackson NC, Umpleby AM, Acerini CL, Dunger DB, Hovorka R. Safety, efficacy and glucose turnover of reduced prandial boluses during closed-loop therapy in adolescents with type 1 diabetes: a randomized clinical trial. Diabetes Obes Metab 2015; 17:1173-9. [PMID: 26257323 PMCID: PMC4832358 DOI: 10.1111/dom.12549] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [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: 04/28/2015] [Revised: 07/20/2015] [Accepted: 07/31/2015] [Indexed: 01/27/2023]
Abstract
AIMS To evaluate safety, efficacy and glucose turnover during closed-loop with meal announcement using reduced prandial insulin boluses in adolescents with type 1 diabetes (T1D). METHODS We conducted a randomized crossover study comparing closed-loop therapy with standard prandial insulin boluses versus closed-loop therapy with prandial boluses reduced by 25%. Eight adolescents with T1D [3 males; mean (standard deviation) age 15.9 (1.5) years, glycated haemoglobin 74 (17) mmol/mol; median (interquartile range) total daily dose 0.9 (0.7, 1.1) IU/kg/day] were studied on two 36-h-long visits. In random order, subjects received closed-loop therapy with either standard or reduced insulin boluses administered with main meals (50-80 g carbohydrates) but not with snacks (15-30 g carbohydrates). Stable-label tracer dilution methodology measured total glucose appearance (Ra_total) and glucose disposal (Rd). RESULTS The median (interquartile range) time spent in target (3.9-10 mmol/l) was similar between the two interventions [74 (66, 84)% vs 80 (65, 96)%; p = 0.87] as was time spent above 10 mmol/l [21.8 (16.3, 33.5)% vs 18.0 (4.1, 34.2)%; p = 0.87] and below 3.9 mmol/l [0 (0, 1.5)% vs 0 (0, 1.8)%; p = 0.88]. Mean plasma glucose was identical during the two interventions [8.4 (0.9) mmol/l; p = 0.98]. Hypoglycaemia occurred once 1.5 h post-meal during closed-loop therapy with standard bolus. Overall insulin delivery was lower with reduced prandial boluses [61.9 (55.2, 75.0) vs 72.5 (63.6, 80.3) IU; p = 0.01] and resulted in lower mean plasma insulin concentration [186 (171, 260) vs 252 (198, 336) pmol/l; p = 0.002]. Lower plasma insulin was also documented overnight [160 (136, 192) vs 191 (133, 252) pmol/l; p = 0.01, pooled nights]. Ra_total was similar [26.3 (21.9, 28.0) vs 25.4 (21.0, 29.2) µmol/kg/min; p = 0.19] during the two interventions as was Rd [25.8 (21.0, 26.9) vs 25.2 (21.2, 28.8) µmol/kg/min; p = 0.46]. CONCLUSIONS A 25% reduction in prandial boluses during closed-loop therapy maintains similar glucose control in adolescents with T1D whilst lowering overall plasma insulin levels. It remains unclear whether closed-loop therapy with a 25% reduction in prandial boluses would prevent postprandial hypoglycaemia.
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Affiliation(s)
- D Elleri
- Department of Paediatrics, University of Cambridge, Cambridge, UK
- Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
| | - M Biagioni
- Department of Paediatrics, University of Cambridge, Cambridge, UK
- Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
| | - J M Allen
- Department of Paediatrics, University of Cambridge, Cambridge, UK
- Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
| | - K Kumareswaran
- Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
| | - L Leelarathna
- Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
| | - K Caldwell
- Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
| | - M Nodale
- Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
| | - M E Wilinska
- Department of Paediatrics, University of Cambridge, Cambridge, UK
- Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
| | - A Haidar
- Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
| | - P Calhoun
- The Jaeb Center for Health Research, Tampa, FL, USA
| | - C Kollman
- The Jaeb Center for Health Research, Tampa, FL, USA
| | - N C Jackson
- Diabetes and Metabolic Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - A M Umpleby
- Diabetes and Metabolic Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - C L Acerini
- Department of Paediatrics, University of Cambridge, Cambridge, UK
- Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
| | - D B Dunger
- Department of Paediatrics, University of Cambridge, Cambridge, UK
- Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
| | - R Hovorka
- Department of Paediatrics, University of Cambridge, Cambridge, UK
- Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
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11
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Dick M, Catford SR, Kumareswaran K, Hamblin PS, Topliss DJ. Persistent syndrome of inappropriate antidiuretic hormone secretion following traumatic brain injury. Endocrinol Diabetes Metab Case Rep 2015; 2015:150070. [PMID: 26527077 PMCID: PMC4626642 DOI: 10.1530/edm-15-0070] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 08/27/2015] [Indexed: 11/08/2022] Open
Abstract
UNLABELLED The syndrome of inappropriate antidiuretic hormone secretion (SIADH) can occur following traumatic brain injury (TBI), but is usually transient. There are very few case reports describing chronic SIADH and all resolved within 12 months, except for one case complicated by meningo-encephalitis. Persistent symptomatic hyponatremia due to chronic SIADH was present for 4 years following a TBI in a previously well 32-year-old man. Hyponatremia consistent with SIADH initially occurred in the immediate period following a high-speed motorbike accident in 2010. There were associated complications of post-traumatic amnesia and mild cognitive deficits. Normalization of serum sodium was achieved initially with fluid restriction. However, this was not sustained and he subsequently required a permanent 1.2 l restriction to maintain near normal sodium levels. Multiple episodes of acute symptomatic hyponatremia requiring hospitalization occurred over the following years when he repeatedly stopped the fluid restriction. Given the ongoing nature of his hyponatremia and difficulties complying with strict fluid restriction, demeclocycline was commenced in 2014. Normal sodium levels without fluid restriction have been maintained for 6 months since starting demeclocycline. This case illustrates an important long-term effect of TBI, the challenges of complying with permanent fluid restrictions and the potential role of demeclocycline in patients with chronic hyponatremia due to SIADH. LEARNING POINTS Hyponatraemia due to SIADH commonly occurs after TBI, but is usually mild and transient.Chronic hyponatraemia due to SIADH following TBI is a rare but important complication.It likely results from damage to the pituitary stalk or posterior pituitary causing inappropriate non-osmotic hypersecretion of ADH.First line management of SIADH is generally fluid restriction, but hypertonic saline may be required in severe cases. Adherence to long-term fluid restriction is challenging. Other options include oral urea, vasopressin receptor antagonists and demeclocycline.While effective, oral urea is poorly tolerated and vasopressin receptor antagonists are currently not licensed for use in Australia or the USA beyond 30 days due to insufficient long-term safety data and specific concerns of hepatotoxicity.Demeclocycline is an effective, well-tolerated and safe option for management of chronic hyponatraemia due to SIADH.
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Affiliation(s)
- Michael Dick
- Faculty of Medical and Health Sciences, The University of Auckland , 85 Park Road, Grafton, Auckland , New Zealand
| | - Sarah R Catford
- Department of Endocrinology and Diabetes, The Alfred Hospital , Commercial Road, Melbourne, Victoria, 3004 , Australia
| | - Kavita Kumareswaran
- Department of Endocrinology and Diabetes, The Alfred Hospital , Commercial Road, Melbourne, Victoria, 3004 , Australia ; Department of Medicine, Faculty of Medicine, Nursing and Health Sciences, Alfred Hospital, Monash University , Clayton, Victoria, 3168 , Australia
| | - Peter Shane Hamblin
- Department of Endocrinology and Diabetes, The Alfred Hospital , Commercial Road, Melbourne, Victoria, 3004 , Australia ; Department of Medicine, Faculty of Medicine, Nursing and Health Sciences, Alfred Hospital, Monash University , Clayton, Victoria, 3168 , Australia
| | - Duncan J Topliss
- Department of Endocrinology and Diabetes, The Alfred Hospital , Commercial Road, Melbourne, Victoria, 3004 , Australia ; Department of Medicine, Faculty of Medicine, Nursing and Health Sciences, Alfred Hospital, Monash University , Clayton, Victoria, 3168 , Australia
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Elleri D, Maltoni G, Allen JM, Nodale M, Kumareswaran K, Leelarathna L, Thabit H, Caldwell K, Wilinska ME, Calhoun P, Kollman C, Dunger DB, Hovorka R. Safety of closed-loop therapy during reduction or omission of meal boluses in adolescents with type 1 diabetes: a randomized clinical trial. Diabetes Obes Metab 2014; 16:1174-8. [PMID: 24909206 PMCID: PMC4192111 DOI: 10.1111/dom.12324] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [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: 02/06/2014] [Revised: 04/22/2014] [Accepted: 06/02/2014] [Indexed: 11/27/2022]
Abstract
We evaluated the safety and efficacy of closed-loop therapy with meal announcement during reduction and omission of meal insulin boluses in adolescents with type 1 diabetes (T1D). Twelve adolescents with T1D [six male; mean (s.d.) age 15.9 (1.8) years; mean (s.d.) glycated haemoglobin (HbA1c) 77 (27) mmol/mol] were studied in a randomized crossover study comparing closed-loop therapy with meal announcement with conventional pump therapy over two 24-h stays at a clinical research facility. Identical meals were given on both occasions. The evening meal insulin bolus was calculated to cover half of the carbohydrate content of the meal and no bolus was delivered for lunch. Plasma glucose levels were in the target range of 3.9-10 mmol/l for a median [interquartile range (IQR)] of 74 (55,86)% of the time during closed-loop therapy with meal announcement and for 62 (49,75)% of the time during conventional therapy (p = 0.26). Median (IQR) time spent with plasma glucose levels > 10 mmol/l [23 (13,39) vs. 27 (10,50)%; p = 0.88] or < 3.9 mmol/l [1(0,4) vs. 5 (1,10)%; p = 0.24] and mean [standard deviation (SD)] glucose levels [8.0 (7.6,9.3) vs. 7.7 (6.6,10.1) mmol/l, p = 0.79] were also similar. In conclusion, these results assist home testing of closed-loop delivery with meal announcement in adolescents with poorly controlled T1D who miscalculate or miss meal insulin boluses.
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Affiliation(s)
- Daniela Elleri
- Department of Paediatrics, University of Cambridge, Cambridge, UK
- Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
| | - Giulio Maltoni
- Department of Paediatrics, University of Cambridge, Cambridge, UK
- Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
| | - Janet M Allen
- Department of Paediatrics, University of Cambridge, Cambridge, UK
- Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
| | - Marianna Nodale
- Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
| | | | | | - Hood Thabit
- Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
| | - Karen Caldwell
- Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
| | - Malgorzata E Wilinska
- Department of Paediatrics, University of Cambridge, Cambridge, UK
- Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
| | | | | | - David B Dunger
- Department of Paediatrics, University of Cambridge, Cambridge, UK
- Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
| | - Roman Hovorka
- Department of Paediatrics, University of Cambridge, Cambridge, UK
- Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
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13
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Ruan Y, Thabit H, Kumareswaran K, Hovorka R. Pharmacokinetics of insulin lispro in type 2 diabetes during closed-loop insulin delivery. Comput Methods Programs Biomed 2014; 117:298-307. [PMID: 25092225 DOI: 10.1016/j.cmpb.2014.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Revised: 07/09/2014] [Accepted: 07/14/2014] [Indexed: 06/03/2023]
Abstract
Insulin pharmacokinetics is not well understood during continuous subcutaneous insulin infusion in type 2 diabetes (T2D). We analyzed data collected in 11 subjects with T2D [6 male, 9 white European and two of Indian ethnicity; age 59.7(12.1) years, BMI 30.1(3.9) kg/m(2), fasting C-peptide 1002.2(365.8) pmol/l, fasting plasma glucose 9.6(2.2) mmol/l, diabetes duration 8.0(6.2) years and HbA1c 8.3(0.8)%; mean(SD)] who underwent a 24-h study investigating closed-loop insulin delivery at the Wellcome Trust Clinical Research Facility, Cambridge, UK. Subcutaneous delivery of insulin lispro was modulated every 15 min according to a model predictive control algorithm. Two complementary insulin assays facilitated discrimination between exogenous (lispro) and endogenous plasma insulin concentrations measured every 15-60 min. Lispro pharmacokinetics was represented by a linear two-compartment model whilst parameters were estimated using a Bayesian approach applying a closed-form model solution. The time-to-peak of lispro absorption (t(max)) was 109.6 (75.5-120.5) min [median (interquartile range)] and the metabolic clearance rate (MCR(I)) 1.26 (0.87-1.56)×10(-2) l/kg/min. MCR(I) was negatively correlated with fasting C-peptide (r(s)=-0.84; P=.001) and with fasting plasma insulin concentration (r(s)=-0.79; P=.004). In conclusion, compartmental modelling adequately represents lispro kinetics during continuous subcutaneous insulin infusion in T2D. Fasting plasma C-peptide or fasting insulin may be predictive of lispro metabolic clearance rate in T2D but further investigations are warranted.
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Affiliation(s)
- Yue Ruan
- University of Cambridge Metabolic Research Laboratories, Cambridge, UK; Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Hood Thabit
- University of Cambridge Metabolic Research Laboratories, Cambridge, UK
| | | | - Roman Hovorka
- University of Cambridge Metabolic Research Laboratories, Cambridge, UK; Department of Paediatrics, University of Cambridge, Cambridge, UK.
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14
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Thabit H, Lubina-Solomon A, Stadler M, Leelarathna L, Walkinshaw E, Pernet A, Allen JM, Iqbal A, Choudhary P, Kumareswaran K, Nodale M, Nisbet C, Wilinska ME, Barnard KD, Dunger DB, Heller SR, Amiel SA, Evans ML, Hovorka R. Home use of closed-loop insulin delivery for overnight glucose control in adults with type 1 diabetes: a 4-week, multicentre, randomised crossover study. Lancet Diabetes Endocrinol 2014; 2:701-9. [PMID: 24943065 PMCID: PMC4165604 DOI: 10.1016/s2213-8587(14)70114-7] [Citation(s) in RCA: 124] [Impact Index Per Article: 12.4] [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: 02/06/2023]
Abstract
BACKGROUND Closed-loop insulin delivery is a promising option to improve glycaemic control and reduce the risk of hypoglycaemia. We aimed to assess whether overnight home use of automated closed-loop insulin delivery would improve glucose control. METHODS We did this open-label, multicentre, randomised controlled, crossover study between Dec 1, 2012, and Dec 23, 2014, recruiting patients from three centres in the UK. Patients aged 18 years or older with type 1 diabetes were randomly assigned to receive 4 weeks of overnight closed-loop insulin delivery (using a model-predictive control algorithm to direct insulin delivery), then 4 weeks of insulin pump therapy (in which participants used real-time display of continuous glucose monitoring independent of their pumps as control), or vice versa. Allocation to initial treatment group was by computer-generated permuted block randomisation. Each treatment period was separated by a 3-4 week washout period. The primary outcome was time spent in the target glucose range of 3·9-8·0 mmol/L between 0000 h and 0700 h. Analyses were by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01440140. FINDINGS We randomly assigned 25 participants to initial treatment in either the closed-loop group or the control group, patients were later crossed over into the other group; one patient from the closed-loop group withdrew consent after randomisation, and data for 24 patients were analysed. Closed loop was used over a median of 8·3 h (IQR 6·0-9·6) on 555 (86%) of 644 nights. The proportion of time when overnight glucose was in target range was significantly higher during the closed-loop period compared to during the control period (mean difference between groups 13·5%, 95% CI 7·3-19·7; p=0·0002). We noted no severe hypoglycaemic episodes during the control period compared with two episodes during the closed-loop period; these episodes were not related to closed-loop algorithm instructions. INTERPRETATION Unsupervised overnight closed-loop insulin delivery at home is feasible and could improve glucose control in adults with type 1 diabetes. FUNDING Diabetes UK.
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Affiliation(s)
- Hood Thabit
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Alexandra Lubina-Solomon
- Academic Unit of Diabetes, Endocrinology and Metabolism, Department of Human Metabolism, University of Sheffield, Sheffield, UK
| | | | - Lalantha Leelarathna
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Emma Walkinshaw
- Academic Unit of Diabetes, Endocrinology and Metabolism, Department of Human Metabolism, University of Sheffield, Sheffield, UK
| | - Andrew Pernet
- Diabetes Research Group, King's College London, London, UK
| | - Janet M Allen
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Ahmed Iqbal
- Academic Unit of Diabetes, Endocrinology and Metabolism, Department of Human Metabolism, University of Sheffield, Sheffield, UK
| | | | - Kavita Kumareswaran
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Marianna Nodale
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Chloe Nisbet
- Academic Unit of Diabetes, Endocrinology and Metabolism, Department of Human Metabolism, University of Sheffield, Sheffield, UK
| | - Malgorzata E Wilinska
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Katharine D Barnard
- Human Development and Health Academic Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - David B Dunger
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Simon R Heller
- Academic Unit of Diabetes, Endocrinology and Metabolism, Department of Human Metabolism, University of Sheffield, Sheffield, UK
| | | | - Mark L Evans
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Roman Hovorka
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK.
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Thabit H, Kumareswaran K, Haidar A, Leelarathna L, Caldwell K, Elleri D, Allen JM, Nodale M, Wilinska ME, Jackson NC, Umpleby AM, Evans ML, Hovorka R. Glucose turnover after replacement of usual therapy by insulin in insulin-naive type 2 diabetes subjects. J Clin Endocrinol Metab 2014; 99:2225-32. [PMID: 24606105 DOI: 10.1210/jc.2013-4519] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
CONTEXT Discontinuation of anti-hyperglycemic oral agents and initiation of insulin is recommended in certain clinical situations for inpatients with type 2 diabetes (T2D). The effects on glucose turnover when these agents are acutely withdrawn are poorly understood and may be of importance when insulin therapy is initiated. OBJECTIVE Our objective was to investigate alterations in glucose turnover after acute withdrawal of noninsulin therapy. DESIGN AND SETTING This was a randomized crossover study at a clinical research facility. PARTICIPANTS Participants included 12 insulin-naive subjects with T2D. METHODS Subjects attended two 24-hour visits. Standard therapy was discontinued and replaced by closed-loop insulin delivery during the intervention visit. Usual anti-hyperglycemic therapy was continued during the control visit. Systemic glucose appearance (Ra) and glucose disposal (Rd) were measured using a tracer dilution technique with iv [6,6-(2)H2]glucose. RESULTS Plasma glucose profiles during both visits were comparable (P = .48). Glucose Ra increased during the day (21.4 [19.5, 23.5] vs 18.6 [17.0, 21.6) μmol/kg/min, P = .019) and decreased overnight (9.7 [8.5, 11.4] vs 11.6 [10.3, 12.9] μmol/kg/min, P = .004) when the usual therapy was discontinued and replaced with insulin. Increased daytime glucose Rd (21.2 [19.4, 23.9] vs 18.8 [18.3, 21.7] μmol/kg/min, P = .002) and decreased overnight Rd (10.4 [9.1, 12.0] vs 11.8 [10.7, 13.7] μmol/kg/min, P = .005) were observed when the usual therapy was discontinued, whereas daytime peripheral insulin sensitivity was reduced (47.8 [24.8, 66.1] vs 62.5 [34.8, 75.8] nmol/kg/min per pmol/L, P = .034). CONCLUSION In T2D, acute discontinuation of anti-hyperglycemic therapy and replacement with insulin increases postprandial Ra and reduces peripheral insulin sensitivity. Insulin dose initiation may need to compensate for these alterations.
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Affiliation(s)
- H Thabit
- Metabolic Research Laboratories (H.T., K.K., L.L., K.C., D.E., J.M.A., M.N., M.E.W., M.L.E., R.H.), Wellcome Trust-Medical Research Council Institute of Metabolic Science, and Department of Paediatrics (D.E., J.M.A., M.E.W., R.H.), University of Cambridge, Cambridge CB2 0QQ, United Kingdom; Centre for Intelligent Machines (A.H.), McGill University, Montreal, Quebec H3A 0E9, Canada; and Postgraduate Medical School (N.C.J., A.M.U.), University of Surrey, Guildford GU2 7TE, United Kingdom
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Leelarathna L, English SW, Thabit H, Caldwell K, Allen JM, Kumareswaran K, Wilinska ME, Nodale M, Haidar A, Evans ML, Burnstein R, Hovorka R. Accuracy of subcutaneous continuous glucose monitoring in critically ill adults: improved sensor performance with enhanced calibrations. Diabetes Technol Ther 2014; 16:97-101. [PMID: 24180327 PMCID: PMC3894676 DOI: 10.1089/dia.2013.0221] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [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: 02/04/2023]
Abstract
OBJECTIVE Accurate real-time continuous glucose measurements may improve glucose control in the critical care unit. We evaluated the accuracy of the FreeStyle(®) Navigator(®) (Abbott Diabetes Care, Alameda, CA) subcutaneous continuous glucose monitoring (CGM) device in critically ill adults using two methods of calibration. SUBJECTS AND METHODS In a randomized trial, paired CGM and reference glucose (hourly arterial blood glucose [ABG]) were collected over a 48-h period from 24 adults with critical illness (mean±SD age, 60±14 years; mean±SD body mass index, 29.6±9.3 kg/m(2); mean±SD Acute Physiology and Chronic Health Evaluation score, 12±4 [range, 6-19]) and hyperglycemia. In 12 subjects, the CGM device was calibrated at variable intervals of 1-6 h using ABG. In the other 12 subjects, the sensor was calibrated according to the manufacturer's instructions (1, 2, 10, and 24 h) using arterial blood and the built-in point-of-care glucometer. RESULTS In total, 1,060 CGM-ABG pairs were analyzed over the glucose range from 4.3 to 18.8 mmol/L. Using enhanced calibration median (interquartile range) every 169 (122-213) min, the absolute relative deviation was lower (7.0% [3.5, 13.0] vs. 12.8% [6.3, 21.8], P<0.001), and the percentage of points in the Clarke error grid Zone A was higher (87.8% vs. 70.2%). CONCLUSIONS Accuracy of the Navigator CGM device during critical illness was comparable to that observed in non-critical care settings. Further significant improvements in accuracy may be obtained by frequent calibrations with ABG measurements.
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Affiliation(s)
- Lalantha Leelarathna
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
| | - Shane W. English
- Neurosciences Critical Care Unit, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Hood Thabit
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
| | - Karen Caldwell
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
| | - Janet M. Allen
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
| | - Kavita Kumareswaran
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
| | - Malgorzata E. Wilinska
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
| | - Marianna Nodale
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
| | - Ahmad Haidar
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
| | - Mark L. Evans
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
| | - Rowan Burnstein
- Neurosciences Critical Care Unit, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Roman Hovorka
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
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Kumareswaran K, Thabit H, Leelarathna L, Caldwell K, Elleri D, Allen JM, Nodale M, Wilinska ME, Evans ML, Hovorka R. Feasibility of closed-loop insulin delivery in type 2 diabetes: a randomized controlled study. Diabetes Care 2014; 37:1198-203. [PMID: 24026542 DOI: 10.2337/dc13-1030] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [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: 02/03/2023]
Abstract
OBJECTIVE Closed-loop insulin delivery offers a promising treatment option, but to date, it has only been evaluated in type 1 diabetes. Our aim was to evaluate the feasibility of fully closed-loop subcutaneous insulin delivery in insulin-naïve patients with type 2 diabetes. RESEARCH DESIGN AND METHODS Twelve subjects (seven males, age 57.2 years, BMI 30.5 kg/m2) with noninsulin-treated type 2 diabetes (HbA1c 8.4% [68 mmol/mol], diabetes duration 7.6 years) underwent two 24-h visits (closed-loop and control) in a randomized crossover design. During closed-loop visits, the subjects' routine diabetes therapy was replaced with model predictive control algorithm-driven subcutaneous insulin pump delivery based on real-time continuous glucose monitoring. Meals were unannounced, and no additional insulin was administered for carbohydrates consumed. During control visits, the usual diabetes regimen was continued (metformin 92%, sulfonylureas 58%, dipeptidyl peptidase-4 inhibitors 33%). On both visits, subjects consumed matched 50- to 80-g carbohydrate meals and optional 15-g carbohydrate snacks and remained largely sedentary. Plasma glucose measurements evaluated closed-loop performance. RESULTS Compared with conventional therapy, 24 h of closed-loop insulin delivery increased overall the median time in target plasma glucose (3.9-8.0 mmol/L) from 24 to 40% (P = 0.016), despite sensor under-reading by a median of 1.2 mmol/L. The benefit of the closed-loop system was more prominent overnight, with greater time in target glucose (median 78 vs. 35%; P = 0.041) and less time in hyperglycemia (22 vs. 65%; P = 0.041). There was no hypoglycemia during either intervention. CONCLUSIONS A closed-loop system without meal announcement and using subcutaneous insulin delivery in insulin-naïve patients with type 2 diabetes appears feasible and safe. Improvement in postprandial glucose control may require further optimization of system performance.
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Hovorka R, Elleri D, Thabit H, Allen JM, Leelarathna L, El-Khairi R, Kumareswaran K, Caldwell K, Calhoun P, Kollman C, Murphy HR, Acerini CL, Wilinska ME, Nodale M, Dunger DB. Overnight closed-loop insulin delivery in young people with type 1 diabetes: a free-living, randomized clinical trial. Diabetes Care 2014; 37:1204-11. [PMID: 24757227 PMCID: PMC3994941 DOI: 10.2337/dc13-2644] [Citation(s) in RCA: 167] [Impact Index Per Article: 16.7] [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] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To evaluate feasibility, safety, and efficacy of overnight closed-loop insulin delivery in free-living youth with type 1 diabetes. RESEARCH DESIGN AND METHODS Overnight closed loop was evaluated at home by 16 pump-treated adolescents with type 1 diabetes aged 12-18 years. Over a 3-week period, overnight insulin delivery was directed by a closed-loop system, and on another 3-week period sensor-augmented therapy was applied. The order of interventions was random. The primary end point was time when adjusted sensor glucose was between 3.9 and 8.0 mmol/L from 2300 to 0700 h. RESULTS Closed loop was constantly applied over at least 4 h on 269 nights (80%); sensor data were collected over at least 4 h on 282 control nights (84%). Closed loop increased time spent with glucose in target by a median 15% (interquartile range -9 to 43; P < 0.001). Mean overnight glucose was reduced by a mean 14 (SD 58) mg/dL (P < 0.001). Time when glucose was <70 mg/dL was low in both groups, but nights with glucose <63 mg/dL for at least 20 min were less frequent during closed loop (10 vs. 17%; P = 0.01). Despite lower total daily insulin doses by a median 2.3 (interquartile range -4.7 to 9.3) units (P = 0.009), overall 24-h glucose was reduced by a mean 9 (SD 41) mg/dL (P = 0.006) during closed loop. CONCLUSIONS Unsupervised home use of overnight closed loop in adolescents with type 1 diabetes is safe and feasible. Glucose control was improved during the day and night with fewer episodes of nocturnal hypoglycemia.
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Luijf YM, DeVries JH, Zwinderman K, Leelarathna L, Nodale M, Caldwell K, Kumareswaran K, Elleri D, Allen JM, Wilinska ME, Evans ML, Hovorka R, Doll W, Ellmerer M, Mader JK, Renard E, Place J, Farret A, Cobelli C, Del Favero S, Dalla Man C, Avogaro A, Bruttomesso D, Filippi A, Scotton R, Magni L, Lanzola G, Di Palma F, Soru P, Toffanin C, De Nicolao G, Arnolds S, Benesch C, Heinemann L. Day and night closed-loop control in adults with type 1 diabetes: a comparison of two closed-loop algorithms driving continuous subcutaneous insulin infusion versus patient self-management. Diabetes Care 2013; 36:3882-7. [PMID: 24170747 PMCID: PMC3836152 DOI: 10.2337/dc12-1956] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [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] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To compare two validated closed-loop (CL) algorithms versus patient self-control with CSII in terms of glycemic control. RESEARCH DESIGN AND METHODS This study was a multicenter, randomized, three-way crossover, open-label trial in 48 patients with type 1 diabetes mellitus for at least 6 months, treated with continuous subcutaneous insulin infusion. Blood glucose was controlled for 23 h by the algorithm of the Universities of Pavia and Padova with a Safety Supervision Module developed at the Universities of Virginia and California at Santa Barbara (international artificial pancreas [iAP]), by the algorithm of University of Cambridge (CAM), or by patients themselves in open loop (OL) during three hospital admissions including meals and exercise. The main analysis was on an intention-to-treat basis. Main outcome measures included time spent in target (glucose levels between 3.9 and 8.0 mmol/L or between 3.9 and 10.0 mmol/L after meals). RESULTS Time spent in the target range was similar in CL and OL: 62.6% for OL, 59.2% for iAP, and 58.3% for CAM. While mean glucose level was significantly lower in OL (7.19, 8.15, and 8.26 mmol/L, respectively) (overall P = 0.001), percentage of time spent in hypoglycemia (<3.9 mmol/L) was almost threefold reduced during CL (6.4%, 2.1%, and 2.0%) (overall P = 0.001) with less time ≤2.8 mmol/L (overall P = 0.038). There were no significant differences in outcomes between algorithms. CONCLUSIONS Both CAM and iAP algorithms provide safe glycemic control.
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Leelarathna L, Little SA, Walkinshaw E, Tan HK, Lubina-Solomon A, Kumareswaran K, Lane AP, Chadwick T, Marshall SM, Speight J, Flanagan D, Heller SR, Shaw JAM, Evans ML. Restoration of self-awareness of hypoglycemia in adults with long-standing type 1 diabetes: hyperinsulinemic-hypoglycemic clamp substudy results from the HypoCOMPaSS trial. Diabetes Care 2013; 36:4063-70. [PMID: 24130355 PMCID: PMC3836150 DOI: 10.2337/dc13-1004] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [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] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Impaired awareness of hypoglycemia (IAH) and defective counterregulation significantly increase severe hypoglycemia risk in type 1 diabetes (T1D). We evaluated restoration of IAH/defective counterregulation by a treatment strategy targeted at hypoglycemia avoidance in adults with T1D with IAH (Gold score ≥4) participating in the U.K.-based multicenter HypoCOMPaSS randomized controlled trial. RESEARCH DESIGN AND METHODS Eighteen subjects with T1D and IAH (mean ± SD age 50 ± 9 years, T1D duration 35 ± 10 years, HbA1c 8.1 ± 1.0% [65 ± 10.9 mmol/mol]) underwent stepped hyperinsulinemic-hypoglycemic clamp studies before and after a 6-month intervention. The intervention comprised the HypoCOMPaSS education tool in all and randomized allocation, in a 2 × 2 factorial study design, to multiple daily insulin analog injections or continuous subcutaneous insulin infusion therapy and conventional glucose monitoring or real-time continuous glucose monitoring. Symptoms, cognitive function, and counterregulatory hormones were measured at each glucose plateau (5.0, 3.8, 3.4, 2.8, and 2.4 mmol/L), with each step lasting 40 min with subjects kept blinded to their actual glucose value throughout clamp studies. RESULTS After intervention, glucose concentrations at which subjects first felt hypoglycemic increased (mean ± SE from 2.6 ± 0.1 to 3.1 ± 0.2 mmol/L, P = 0.02), and symptom and plasma metanephrine responses to hypoglycemia were higher (median area under curve for symptoms, 580 [interquartile range {IQR} 420-780] vs. 710 [460-1,260], P = 0.02; metanephrine, 2,412 [-3,026 to 7,279] vs. 5,180 [-771 to 11,513], P = 0.01). Glycemic threshold for deterioration of cognitive function measured by four-choice reaction time was unchanged, while the color-word Stroop test showed a degree of adaptation. CONCLUSIONS Even in long-standing T1D, IAH and defective counterregulation may be improved by a clinical strategy aimed at hypoglycemia avoidance.
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Haidar A, Elleri D, Kumareswaran K, Leelarathna L, Allen JM, Caldwell K, Murphy HR, Wilinska ME, Acerini CL, Evans ML, Dunger DB, Nodale M, Hovorka R. Pharmacokinetics of insulin aspart in pump-treated subjects with type 1 diabetes: reproducibility and effect of age, weight, and duration of diabetes. Diabetes Care 2013; 36:e173-4. [PMID: 24065849 PMCID: PMC3781562 DOI: 10.2337/dc13-0485] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Kumareswaran K, Elleri D, Allen JM, Caldwell K, Westgate K, Brage S, Raymond-Barker P, Nodale M, Wilinska ME, Amiel SA, Hovorka R, Murphy HR. Physical activity energy expenditure and glucose control in pregnant women with type 1 diabetes: is 30 minutes of daily exercise enough? Diabetes Care 2013; 36:1095-101. [PMID: 23404301 PMCID: PMC3631831 DOI: 10.2337/dc12-1567] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Accepted: 10/03/2012] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To describe activity patterns in pregnant women with type 1 diabetes and evaluate the impact of increased structured physical activity on glucose control. RESEARCH DESIGN AND METHODS Physical activity energy expenditure (PAEE) and glucose levels (continuous glucose monitoring) were measured in 10 pregnant women with type 1 diabetes (age 33.2 years, gestation 20 weeks, BMI 27.9 kg/m(2), diabetes duration 16.6 years, HbA1c 6.5% [48 mmol/mol], insulin pump duration 2.4 years) during a day at home (free-living) and during a 24-h visit incorporating controlled diet and structured physical activity with light intensity activity (three 20-min self-paced walks) and moderate intensity activity (two 50-min sessions of brisk treadmill walking). PAEE was evaluated through individually calibrated combined heart rate and movement sensing. RESULTS Free-living PAEE was comparable to that under controlled study conditions (3.8 and 5.1 kcal/kg/day, P = 0.241), with women achieving near to the recommended 30 min of moderate physical activity (median 27 min [interquartile range 14-68]). During the free-living period, more time was spent in light activity (10.3 vs. 7.2 h, P = 0.005), with less sedentary time (13.0 vs. 14.9 h, P = 0.047) and less moderate activity (27 vs. 121 min, P = 0.022). The free-living 24-h mean glucose levels by continuous glucose monitoring were significantly higher (7.7 vs. 6.0 mmol/L, P = 0.028). The effect of controlled diet and exercise persisted overnight, with significantly less time spent hyperglycemic (19 vs. 0%, P = 0.028) and less glucose variability (glucose SD 1.3 vs. 0.7 mmol/L, P = 0.022). CONCLUSIONS A controlled diet and structured physical activity program may assist women with type 1 diabetes in achieving optimal glucose control during pregnancy.
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Elleri D, Allen JM, Harris J, Kumareswaran K, Nodale M, Leelarathna L, Acerini CL, Haidar A, Wilinska ME, Jackson N, Umpleby AM, Evans ML, Dunger DB, Hovorka R. Absorption patterns of meals containing complex carbohydrates in type 1 diabetes. Diabetologia 2013; 56:1108-17. [PMID: 23435829 DOI: 10.1007/s00125-013-2852-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [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: 10/28/2012] [Accepted: 01/21/2013] [Indexed: 02/07/2023]
Abstract
AIMS/HYPOTHESIS Successful postprandial glycaemia management requires understanding of absorption patterns after meals containing variable complex carbohydrates. We studied eight young participants with type 1 diabetes to investigate a large low-glycaemic-load (LG) meal and another eight participants to investigate a high-glycaemic-load (HG) meal matched for carbohydrates (121 g). METHODS On Visit 1, participants consumed an evening meal. On follow-up Visit 2, a variable-target glucose clamp was performed to reproduce glucose and insulin levels from Visit 1. Adopting stable-label tracer dilution methodology, we measured endogenous glucose production on Visit 2 and subtracted it from total glucose appearance measured on Visit 1 to obtain meal-attributable glucose appearance. RESULTS After the LG meal, 25%, 50% and 75% of cumulative glucose appearance was at 88 ± 21, 175 ± 39 and 270 ± 54 min (mean ± SD), whereas glucose from the HG meal appeared significantly faster at 56 ± 12, 100 ± 25 and 153 ± 39 min (p < 0.001 to 0.003), and resulted in a 50% higher peak appearance (p < 0.001). Higher apparent bioavailability by 15% (p = 0.037) was observed after the LG meal. We documented a 20 min deceleration of dietary mixed carbohydrates compared with dietary glucose for the HG meal and a twofold deceleration for the LG meal. CONCLUSIONS/INTERPRETATION Absorption patterns may be influenced by glycaemic load and/or meal composition, affecting optimum prandial insulin dosing in type 1 diabetes.
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Affiliation(s)
- D Elleri
- University of Cambridge Metabolic Research Laboratories and NIHR Cambridge Biomedical Research Centre, Institute of Metabolic Science, Box 289, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
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Leelarathna L, English S, Thabit H, Caldwell K, Allen J, Kumareswaran K, Wilinska M, Nodale M, Mangat J, Evans M, Burnstein R, Hovorka R. Continuous glucose monitoring in critically ill adults: comparison of two different calibration protocols. Crit Care 2013. [PMCID: PMC3642847 DOI: 10.1186/cc12397] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Elleri D, Allen JM, Kumareswaran K, Leelarathna L, Nodale M, Caldwell K, Cheng P, Kollman C, Haidar A, Murphy HR, Wilinska ME, Acerini CL, Dunger DB, Hovorka R. Closed-loop basal insulin delivery over 36 hours in adolescents with type 1 diabetes: randomized clinical trial. Diabetes Care 2013; 36:838-44. [PMID: 23193217 PMCID: PMC3609499 DOI: 10.2337/dc12-0816] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2012] [Accepted: 09/22/2012] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We evaluated the safety and efficacy of closed-loop basal insulin delivery during sleep and after regular meals and unannounced periods of exercise. RESEARCH DESIGN AND METHODS Twelve adolescents with type 1 diabetes (five males; mean age 15.0 [SD 1.4] years; HbA1c 7.9 [0.7]%; BMI 21.4 [2.6] kg/m(2)) were studied at a clinical research facility on two occasions and received, in random order, either closed-loop basal insulin delivery or conventional pump therapy for 36 h. During closed-loop insulin delivery, pump basal rates were adjusted every 15 min according to a model predictive control algorithm informed by subcutaneous sensor glucose levels. During control visits, subjects' standard infusion rates were applied. Prandial insulin boluses were given before main meals (50-80 g carbohydrates) but not before snacks (15-30 g carbohydrates). Subjects undertook moderate-intensity exercise, not announced to the algorithm, on a stationary bicycle at a 140 bpm heart rate in the morning (40 min) and afternoon (20 min). Primary outcome was time when plasma glucose was in the target range (71-180 mg/dL). RESULTS Closed-loop basal insulin delivery increased percentage time when glucose was in the target range (median 84% [interquartile range 78-88%] vs. 49% [26-79%], P = 0.02) and reduced mean plasma glucose levels (128 [19] vs. 165 [55] mg/dL, P = 0.02). Plasma glucose levels were in the target range 100% of the time on 17 of 24 nights during closed-loop insulin delivery. Hypoglycemia occurred on 10 occasions during control visits and 9 occasions during closed-loop delivery (5 episodes were exercise related, and 4 occurred within 2.5 h of prandial bolus). CONCLUSIONS Day-and-night closed-loop basal insulin delivery can improve glucose control in adolescents. However, unannounced moderate-intensity exercise and excessive prandial boluses pose challenges to hypoglycemia-free closed-loop basal insulin delivery.
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Affiliation(s)
- Daniela Elleri
- Department of Paediatrics, University of Cambridge, Cambridge, U.K
- Metabolic Research Laboratories, Institute of Metabolic Science, Cambridge, U.K
| | - Janet M. Allen
- Department of Paediatrics, University of Cambridge, Cambridge, U.K
- Metabolic Research Laboratories, Institute of Metabolic Science, Cambridge, U.K
| | - Kavita Kumareswaran
- Metabolic Research Laboratories, Institute of Metabolic Science, Cambridge, U.K
| | | | - Marianna Nodale
- Metabolic Research Laboratories, Institute of Metabolic Science, Cambridge, U.K
| | - Karen Caldwell
- Metabolic Research Laboratories, Institute of Metabolic Science, Cambridge, U.K
| | | | | | - Ahmad Haidar
- Metabolic Research Laboratories, Institute of Metabolic Science, Cambridge, U.K
| | - Helen R. Murphy
- Metabolic Research Laboratories, Institute of Metabolic Science, Cambridge, U.K
| | - Malgorzata E. Wilinska
- Department of Paediatrics, University of Cambridge, Cambridge, U.K
- Metabolic Research Laboratories, Institute of Metabolic Science, Cambridge, U.K
| | - Carlo L. Acerini
- Department of Paediatrics, University of Cambridge, Cambridge, U.K
| | - David B. Dunger
- Department of Paediatrics, University of Cambridge, Cambridge, U.K
- Metabolic Research Laboratories, Institute of Metabolic Science, Cambridge, U.K
| | - Roman Hovorka
- Department of Paediatrics, University of Cambridge, Cambridge, U.K
- Metabolic Research Laboratories, Institute of Metabolic Science, Cambridge, U.K
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Kumareswaran K, Elleri D, Allen JM, Caldwell K, Nodale M, Wilinska ME, Amiel SA, Hovorka R, Murphy HR. Accuracy of continuous glucose monitoring during exercise in type 1 diabetes pregnancy. Diabetes Technol Ther 2013; 15:223-9. [PMID: 23445170 PMCID: PMC3598434 DOI: 10.1089/dia.2012.0292] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [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: 12/16/2022]
Abstract
BACKGROUND Performance of continuous glucose monitors (CGMs) may be lower when glucose levels are changing rapidly, such as occurs during physical activity. Our aim was to evaluate accuracy of a current-generation CGM during moderate-intensity exercise in type 1 diabetes (T1D) pregnancy. SUBJECTS AND METHODS As part of a study of 24-h closed-loop insulin delivery in 12 women with T1D (disease duration, 17.6 years; glycosylated hemoglobin, 6.4%) during pregnancy (gestation, 21 weeks), we evaluated the Freestyle Navigator(®) sensor (Abbott Diabetes Care, Alameda, CA) during afternoon (15:00-18:00 h) and morning (09:30-12:30 h) exercise (55 min of brisk walking on a treadmill followed by a 2-h recovery), compared with sedentary conditions (18:00-09:00 h). Plasma (reference) glucose, measured at regular 15-30-min intervals with the YSI Ltd. (Fleet, United Kingdom) model YSI 2300 analyzer, was used to assess CGM performance. RESULTS Sensor accuracy, as indicated by the larger relative absolute difference (RAD) between paired sensor and reference glucose values, was lower during exercise compared with rest (median RAD, 11.8% vs. 18.4%; P<0.001). These differences remained significant when correcting for plasma glucose relative rate of change (P<0.001). Analysis by glucose range showed lower accuracy during hypoglycemia for both sedentary (median RAD, 24.4%) and exercise (median RAD, 32.1%) conditions. Using Clarke error grid analysis, 96% of CGM values were clinically safe under resting conditions compared with only 87% during exercise. CONCLUSIONS Compared with sedentary conditions, accuracy of the Freestyle Navigator CGM was lower during moderate-intensity exercise in pregnant women with T1D. This difference was particularly marked in hypoglycemia and could not be solely explained by the glucose rate of change associated with physical activity.
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Affiliation(s)
- Kavita Kumareswaran
- University of Cambridge Metabolic Research Laboratories and National Institute for Health Research Cambridge Biomedical Research Centre, Cambridge, United Kingdom.
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Leelarathna L, Nodale M, Allen JM, Elleri D, Kumareswaran K, Haidar A, Caldwell K, Wilinska ME, Acerini CL, Evans ML, Murphy HR, Dunger DB, Hovorka R. Evaluating the accuracy and large inaccuracy of two continuous glucose monitoring systems. Diabetes Technol Ther 2013; 15:143-9. [PMID: 23256605 PMCID: PMC3558677 DOI: 10.1089/dia.2012.0245] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [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: 11/13/2022]
Abstract
OBJECTIVE This study evaluated the accuracy and large inaccuracy of the Freestyle Navigator (FSN) (Abbott Diabetes Care, Alameda, CA) and Dexcom SEVEN PLUS (DSP) (Dexcom, Inc., San Diego, CA) continuous glucose monitoring (CGM) systems during closed-loop studies. RESEARCH DESIGN AND METHODS Paired CGM and plasma glucose values (7,182 data pairs) were collected, every 15-60 min, from 32 adults (36.2±9.3 years) and 20 adolescents (15.3±1.5 years) with type 1 diabetes who participated in closed-loop studies. Levels 1, 2, and 3 of large sensor error with increasing severity were defined according to absolute relative deviation greater than or equal to ±40%, ±50%, and ±60% at a reference glucose level of ≥6 mmol/L or absolute deviation greater than or equal to ±2.4 mmol/L,±3.0 mmol/L, and ±3.6 mmol/L at a reference glucose level of <6 mmol/L. RESULTS Median absolute relative deviation was 9.9% for FSN and 12.6% for DSP. Proportions of data points in Zones A and B of Clarke error grid analysis were similar (96.4% for FSN vs. 97.8% for DSP). Large sensor over-reading, which increases risk of insulin over-delivery and hypoglycemia, occurred two- to threefold more frequently with DSP than FSN (once every 2.5, 4.6, and 10.7 days of FSN use vs. 1.2, 2.0, and 3.7 days of DSP use for Level 1-3 errors, respectively). At levels 2 and 3, large sensor errors lasting 1 h or longer were absent with FSN but persisted with DSP. CONCLUSIONS FSN and DSP differ substantially in the frequency and duration of large inaccuracy despite only modest differences in conventional measures of numerical and clinical accuracy. Further evaluations are required to confirm that FSN is more suitable for integration into closed-loop delivery systems.
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Affiliation(s)
- Lalantha Leelarathna
- Metabolic Research Laboratories, Institute of Metabolic Science, Cambridge, United Kingdom
| | - Marianna Nodale
- Metabolic Research Laboratories, Institute of Metabolic Science, Cambridge, United Kingdom
| | - Janet M. Allen
- Metabolic Research Laboratories, Institute of Metabolic Science, Cambridge, United Kingdom
| | - Daniela Elleri
- Metabolic Research Laboratories, Institute of Metabolic Science, Cambridge, United Kingdom
- Department of Paediatrics, University of Cambridge, Cambridge, United Kingdom
| | - Kavita Kumareswaran
- Metabolic Research Laboratories, Institute of Metabolic Science, Cambridge, United Kingdom
| | - Ahmad Haidar
- Metabolic Research Laboratories, Institute of Metabolic Science, Cambridge, United Kingdom
| | - Karen Caldwell
- Metabolic Research Laboratories, Institute of Metabolic Science, Cambridge, United Kingdom
| | - Malgorzata E. Wilinska
- Metabolic Research Laboratories, Institute of Metabolic Science, Cambridge, United Kingdom
- Department of Paediatrics, University of Cambridge, Cambridge, United Kingdom
| | - Carlo L. Acerini
- Metabolic Research Laboratories, Institute of Metabolic Science, Cambridge, United Kingdom
- Department of Paediatrics, University of Cambridge, Cambridge, United Kingdom
| | - Mark L. Evans
- Metabolic Research Laboratories, Institute of Metabolic Science, Cambridge, United Kingdom
| | - Helen R. Murphy
- Metabolic Research Laboratories, Institute of Metabolic Science, Cambridge, United Kingdom
| | - David B. Dunger
- Metabolic Research Laboratories, Institute of Metabolic Science, Cambridge, United Kingdom
- Department of Paediatrics, University of Cambridge, Cambridge, United Kingdom
| | - Roman Hovorka
- Metabolic Research Laboratories, Institute of Metabolic Science, Cambridge, United Kingdom
- Department of Paediatrics, University of Cambridge, Cambridge, United Kingdom
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Leelarathna L, English SW, Thabit H, Caldwell K, Allen JM, Kumareswaran K, Wilinska ME, Nodale M, Mangat J, Evans ML, Burnstein R, Hovorka R. Feasibility of fully automated closed-loop glucose control using continuous subcutaneous glucose measurements in critical illness: a randomized controlled trial. Crit Care 2013; 17:R159. [PMID: 23883613 PMCID: PMC4056260 DOI: 10.1186/cc12838] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Accepted: 07/24/2013] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Closed-loop (CL) systems modulate insulin delivery according to glucose levels without nurse input. In a prospective randomized controlled trial, we evaluated the feasibility of an automated closed-loop approach based on subcutaneous glucose measurements in comparison with a local sliding-scale insulin-therapy protocol. METHODS Twenty-four critically ill adults (predominantly trauma and neuroscience patients) with hyperglycemia (glucose, ≥10 mM) or already receiving insulin therapy, were randomized to receive either fully automated closed-loop therapy (model predictive control algorithm directing insulin and 20% dextrose infusion based on FreeStyle Navigator continuous subcutaneous glucose values, n = 12) or a local protocol (n = 12) with intravenous sliding-scale insulin, over a 48-hour period. The primary end point was percentage of time when arterial blood glucose was between 6.0 and 8.0 mM. RESULTS The time when glucose was in the target range was significantly increased during closed-loop therapy (54.3% (44.1 to 72.8) versus 18.5% (0.1 to 39.9), P = 0.001; median (interquartile range)), and so was time in wider targets, 5.6 to 10.0 mM and 4.0 to 10.0 mM (P ≤ 0.002), reflecting a reduced glucose exposure >8 and >10 mM (P ≤ 0.002). Mean glucose was significantly lower during CL (7.8 (7.4 to 8.2) versus 9.1 (8.3 to 13.0] mM; P = 0.001) without hypoglycemia (<4 mM) during either therapy. CONCLUSIONS Fully automated closed-loop control based on subcutaneous glucose measurements is feasible and may provide efficacious and hypoglycemia-free glucose control in critically ill adults. TRIAL REGISTRATION ClinicalTrials.gov Identifier, NCT01440842.
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Affiliation(s)
- Lalantha Leelarathna
- Wellcome Trust-MRC Institute of Metabolic Science, Metabolic Research Laboratories, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Shane W English
- Neurosciences Critical Care Unit, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Hood Thabit
- Wellcome Trust-MRC Institute of Metabolic Science, Metabolic Research Laboratories, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Karen Caldwell
- Wellcome Trust-MRC Institute of Metabolic Science, Metabolic Research Laboratories, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Janet M Allen
- Wellcome Trust-MRC Institute of Metabolic Science, Metabolic Research Laboratories, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Kavita Kumareswaran
- Wellcome Trust-MRC Institute of Metabolic Science, Metabolic Research Laboratories, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Malgorzata E Wilinska
- Wellcome Trust-MRC Institute of Metabolic Science, Metabolic Research Laboratories, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Marianna Nodale
- Wellcome Trust-MRC Institute of Metabolic Science, Metabolic Research Laboratories, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Jasdip Mangat
- Wellcome Trust-MRC Institute of Metabolic Science, Metabolic Research Laboratories, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Mark L Evans
- Wellcome Trust-MRC Institute of Metabolic Science, Metabolic Research Laboratories, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Rowan Burnstein
- Neurosciences Critical Care Unit, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Roman Hovorka
- Wellcome Trust-MRC Institute of Metabolic Science, Metabolic Research Laboratories, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
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Elleri D, Allen JM, Biagioni M, Kumareswaran K, Leelarathna L, Caldwell K, Nodale M, Wilinska ME, Acerini CL, Dunger DB, Hovorka R. Evaluation of a portable ambulatory prototype for automated overnight closed-loop insulin delivery in young people with type 1 diabetes. Pediatr Diabetes 2012; 13:449-53. [PMID: 22817340 DOI: 10.1111/j.1399-5448.2012.00903.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [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: 04/03/2012] [Revised: 06/13/2012] [Accepted: 06/19/2012] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To evaluate an ambulatory, portable prototype, overnight automated closed-loop (CL) system and to explore optimal time of CL initiation. METHODS We performed a randomized crossover study and compared automated overnight glucose control started at the time of an evening-meal or at bedtime. Eight young people with type 1 diabetes (T1D) on insulin pump therapy [M = 4; age = 14.3 (1.7) yr; HbA1c = 8.2 (1.3)%; mean (SD)] were studied on two occasions at clinical research facility. A standardized self-selected evening meal [70 (11)g CHO] and snack [22 (4)g CHO] accompanied by prandial insulin boluses were given at 18:00 and 21:00 hours, respectively. In random order, automated CL was started at 18:00 or 21:00 hours and ran until 8:00 hours the next day. Basal insulin delivery was automatically adjusted by a model predictive control algorithm based on real-time continuous glucose monitor readings. RESULTS Overnight plasma glucose levels (between 21:00 and 08:00 hours) were within the target range (71-145 mg/dL) for 82 (59, 98)% of time when CL started at 18:00 hours and 64 (48, 70)% when CL started at 21:00 hours [median (IQR), p = 0.036]. Time spent above 180 mg/dL [8 (0, 17) vs. 13 (3, 26)%, p = 0.310] or below 70 mg/dL [0 (0,7) vs. 0 (0, 8)%, p = 1.000] did not differ between the two occasions. Mean overnight glucose [121 (14) vs. 137 (13) mg/dL, p = 0.731) was also similar. Overnight insulin infusion rates were comparable [0.8 (0.5, 1.3) vs. 0.8 (0.6, 1.4) U/h, p = 0.263]. No interruptions to CL delivery were observed. CONCLUSION Automated CL delivery can be applied reliably and safely to control glucose levels overnight in young people with T1D. Tighter glucose levels may be achieved with an earlier time of CL initiation.
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Affiliation(s)
- Daniela Elleri
- Metabolic Research Laboratories, Institute of Metabolic Science, Cambridge, UK
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Haidar A, Elleri D, Allen JM, Harris J, Kumareswaran K, Nodale M, Acerini CL, Wilinska ME, Jackson N, Umpleby AM, Evans ML, Dunger DB, Hovorka R. Validity of triple- and dual-tracer techniques to estimate glucose appearance. Am J Physiol Endocrinol Metab 2012; 302:E1493-501. [PMID: 22454288 PMCID: PMC3378162 DOI: 10.1152/ajpendo.00581.2011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2011] [Accepted: 03/21/2012] [Indexed: 11/22/2022]
Abstract
The triple-tracer (TT) dilution technique has been proposed to be the gold standard method to measure postprandial glucose appearance. However, validation against an independent standard has been missing. We addressed this issue and also validated the simpler dual-tracer (DT) technique. Sixteen young subjects with type 1 diabetes (age 19.5 ± 3.8 yr, BMI 23.4 ± 1.5 kg/m(2), HbA(1c) 8.7 ± 1.7%, diabetes duration 9.0 ± 6.9 yr, total daily insulin 0.9 ± 0.2 U·kg(-1)·day(-1), mean ± SD) received a variable intravenous 20% dextrose infusion enriched with [U-(13)C]glucose over 8 h to achieve postprandial-resembling glucose excursions while intravenous insulin was administered to achieve postprandial-resembling levels of plasma insulin. Primed [6,6-(2)H(2)]glucose was infused in a manner that mimicked the expected endogenous glucose production and [U-(13)C; 1,2,3,4,5,6,6-(2)H(7)]glucose was infused in a manner that mimicked the expected glucose appearance from a standard meal. Plasma glucose enrichment was measured by gas chromatography-mass spectrometry. The intravenous dextrose infusion served as an independent standard and was reconstructed using the TT and DT techniques with the two-compartment Radziuk/Mari model and an advanced stochastic computational method. The difference between the infused and reconstructed dextrose profile was similar for the two methods (root mean square error 6.6 ± 1.9 vs. 8.0 ± 3.5 μmol·kg(-1)·min(-1), TT vs. DT, P = NS, paired t-test). The TT technique was more accurate in recovering the overall dextrose infusion (100 ± 9 and 92 ± 12%; P = 0.02). The root mean square error associated with the mean dextrose infusion profile was 2.5 and 3.3 μmol·kg(-1)·min(-1) for the TT and DT techniques, respectively. We conclude that the TT and DT techniques combined with the advanced computational method can measure accurately exogenous glucose appearance. The TT technique tends to outperform slightly the DT technique, but the latter benefits from reduced experimental and computational complexity.
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Affiliation(s)
- A. Haidar
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
- Centre for Intelligent Machines, McGill University, Montreal, Quebec, Canada
| | - D. Elleri
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
- Department of Paediatrics, University of Cambridge, Cambridge, United Kingdom; and
| | - J. M. Allen
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
- Department of Paediatrics, University of Cambridge, Cambridge, United Kingdom; and
| | - J. Harris
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
| | - K. Kumareswaran
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
| | - M. Nodale
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
| | - C. L. Acerini
- Department of Paediatrics, University of Cambridge, Cambridge, United Kingdom; and
| | - M. E. Wilinska
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
| | - N. Jackson
- Postgraduate Medical School, University of Surrey, Guilford, United Kingdom
| | - A. M. Umpleby
- Postgraduate Medical School, University of Surrey, Guilford, United Kingdom
| | - M. L. Evans
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
| | - D. B. Dunger
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
- Department of Paediatrics, University of Cambridge, Cambridge, United Kingdom; and
| | - R. Hovorka
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
- Department of Paediatrics, University of Cambridge, Cambridge, United Kingdom; and
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Kumareswaran K, Evans ML, Hovorka R. Closed-loop insulin delivery: towards improved diabetes care. Discov Med 2012; 13:159-70. [PMID: 22369975] [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] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
The prevalence of type 1 diabetes is escalating worldwide. Novel therapies and management strategies are needed to reduce associated morbidity. Aggressive blood glucose lowering using conventional insulin replacement regimens is limited by the risk of hypoglycemia. Even the most motivated patients may struggle to manage day-to-day variability in insulin requirements. The artificial pancreas or closed-loop insulin delivery may improve outcomes, building on recent technological progress and combining continuous glucose monitoring with insulin pump therapy. So far, closed-loop prototypes have been evaluated under controlled conditions suggesting improved glucose control and a reduced risk of hypoglycemia. Limitations include suboptimal accuracy and reliability of continuous glucose monitors and delays associated with subcutaneous insulin delivery. Outpatient evaluation is required as the next step, leading to deployment into clinical practice.
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Affiliation(s)
- Kavita Kumareswaran
- Metabolic Research Laboratories and NIHR Cambridge Biomedical Research Centre, Institute of Metabolic Science, University of Cambridge, Cambridge, CB2 0QQ, United Kingdom
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Murphy HR, Kumareswaran K, Elleri D, Allen JM, Caldwell K, Biagioni M, Simmons D, Dunger DB, Nodale M, Wilinska ME, Amiel SA, Hovorka R. Safety and efficacy of 24-h closed-loop insulin delivery in well-controlled pregnant women with type 1 diabetes: a randomized crossover case series. Diabetes Care 2011; 34:2527-9. [PMID: 22011408 PMCID: PMC3220861 DOI: 10.2337/dc11-1430] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Accepted: 09/21/2011] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To evaluate the safety and efficacy of closed-loop insulin delivery in well-controlled pregnant women with type 1 diabetes treated with continuous subcutaneous insulin infusion (CSII). RESEARCH DESIGN AND METHODS A total of 12 women with type 1 diabetes (aged 32.9 years, diabetes duration 17.6 years, BMI 27.1 kg/m(2), and HbA(1c) 6.4%) were randomly allocated to closed-loop or conventional CSII. They performed normal daily activities (standardized meals, snacks, and exercise) for 24 h on two occasions at 19 and 23 weeks' gestation. Plasma glucose time in target (63-140 mg/dL) and time spent hypoglycemic were calculated. RESULTS Plasma glucose time in target was comparable for closed-loop and conventional CSII (median [interquartile range]: 81 [59-87] vs. 81% [54-90]; P = 0.75). Less time was spent hypoglycemic (<45 mg/dL [0.0 vs. 0.3%]; P = 0.04), with a lower low blood glucose index (2.4 [0.9-3.5] vs. 3.3 [1.9-5.1]; P = 0.03), during closed-loop insulin delivery. CONCLUSIONS Closed-loop insulin delivery was as effective as conventional CSII, with less time spent in extreme hypoglycemia.
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Affiliation(s)
- Helen R Murphy
- Metabolic Research Laboratories and the National Institute for Health Research Cambridge Biomedical Research Center, University of Cambridge, Cambridge, UK.
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Kumareswaran K, Elleri D, Allen JM, Harris J, Xing D, Kollman C, Nodale M, Murphy HR, Amiel SA, Heller SR, Wilinska ME, Acerini CL, Evans ML, Dunger DB, Hovorka R. Meta-analysis of overnight closed-loop randomized studies in children and adults with type 1 diabetes: the Cambridge cohort. J Diabetes Sci Technol 2011; 5:1352-62. [PMID: 22226252 PMCID: PMC3262701 DOI: 10.1177/193229681100500606] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [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: 11/17/2022]
Abstract
AIM We reviewed the safety and efficacy of overnight closed-loop insulin delivery compared with conventional continuous subcutaneous insulin infusion (CSII) in two distinct age groups with type 1 diabetes mellitus (T1DM), young people aged 5 to 18 years and adults, combining data of previously published randomized studies. METHODS We evaluated four randomized crossover studies in 17 children and adolescents [13.4 ± 3.6 years; mean ± standard deviation (SD)] and 24 adults (37.5 ± 9.1 years) on 45 closed-loop (intervention) and 45 CSII (control) visits. Each subject attended for two overnight study visits, using either closed-loop or conventional pump therapy, in random order. In each age group, studies were designed to mimic realistic likely scenarios. In the children and adolescent studies, closed loop was used following a standard evening meal and following 40 min of moderate-intensity exercise. In the adult studies, closed loop was commenced following a 60 g carbohydrate meal or a 100 g carbohydrate meal accompanied by alcohol. The primary outcome measure was time for which plasma glucose was within target range (3.91-8.0 mmol/liter). RESULTS Overnight closed loop increased the time in target plasma glucose in both young (from 40% to 60%, p = .002) and adults (from 50% to 76%, p < .001) compared with conventional CSII. Combined analysis showed an increase from 43% to 71% with closed loop (p < .001). Additionally, closed loop reduced the time spent below 3.91 mmol/liter and above 8.0 mmol/liter, from 4.1% to 2.1% (p = .01) and 33% to 20% (p = .03), respectively. Glycemic variability, as measured by the SD of plasma glucose, was lower during closed loop compared with CSII (1.5 versus 2.1 mmol/liter, p = .007). CONCLUSIONS Overnight closed loop may improve glycemic control and reduce nocturnal hypoglycemia in both young people and adults with T1DM.
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Affiliation(s)
- Kavita Kumareswaran
- Institute of Metabolic Science, University of CambridgeCambridge, United Kingdom
- Department of Medicine, University of CambridgeCambridge, United Kingdom
| | - Daniela Elleri
- Institute of Metabolic Science, University of CambridgeCambridge, United Kingdom
- Department of Pediatrics, University of CambridgeCambridge, United Kingdom
| | - Janet M Allen
- Institute of Metabolic Science, University of CambridgeCambridge, United Kingdom
- Department of Pediatrics, University of CambridgeCambridge, United Kingdom
| | - Julie Harris
- Institute of Metabolic Science, University of CambridgeCambridge, United Kingdom
| | | | | | - Marianna Nodale
- Institute of Metabolic Science, University of CambridgeCambridge, United Kingdom
| | - Helen R Murphy
- Institute of Metabolic Science, University of CambridgeCambridge, United Kingdom
| | | | - Simon R Heller
- Diabetes Centre, Clinical Sciences Centre, Northern General HospitalSheffield, United Kingdom
| | - Malgorzata E Wilinska
- Institute of Metabolic Science, University of CambridgeCambridge, United Kingdom
- Department of Medicine, University of CambridgeCambridge, United Kingdom
| | - Carlo L Acerini
- Institute of Metabolic Science, University of CambridgeCambridge, United Kingdom
- Department of Pediatrics, University of CambridgeCambridge, United Kingdom
| | - Mark L Evans
- Institute of Metabolic Science, University of CambridgeCambridge, United Kingdom
- Department of Medicine, University of CambridgeCambridge, United Kingdom
| | - David B Dunger
- Institute of Metabolic Science, University of CambridgeCambridge, United Kingdom
- Department of Pediatrics, University of CambridgeCambridge, United Kingdom
| | - Roman Hovorka
- Institute of Metabolic Science, University of CambridgeCambridge, United Kingdom
- Department of Pediatrics, University of CambridgeCambridge, United Kingdom
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Hovorka R, Kumareswaran K, Harris J, Allen JM, Elleri D, Xing D, Kollman C, Nodale M, Murphy HR, Dunger DB, Amiel SA, Heller SR, Wilinska ME, Evans ML. Overnight closed loop insulin delivery (artificial pancreas) in adults with type 1 diabetes: crossover randomised controlled studies. BMJ 2011; 342:d1855. [PMID: 21493665 PMCID: PMC3077739 DOI: 10.1136/bmj.d1855] [Citation(s) in RCA: 193] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/04/2011] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To compare the safety and efficacy of overnight closed loop delivery of insulin (artificial pancreas) with conventional insulin pump therapy in adults with type 1 diabetes. DESIGN Two sequential, open label, randomised controlled crossover, single centre studies. SETTING Clinical research facility. PARTICIPANTS 24 adults (10 men, 14 women) with type 1 diabetes, aged 18-65, who had used insulin pump therapy for at least three months: 12 were tested after consuming a medium sized meal and the other 12 after consuming a larger meal accompanied by alcohol. INTERVENTION During overnight closed loop delivery, sensor measurements of glucose were fed into a computer algorithm, which advised on insulin pump infusion rates at 15 minute intervals. During control nights, conventional insulin pump settings were applied. One study compared closed loop delivery of insulin with conventional pump therapy after a medium sized evening meal (60 g of carbohydrates) at 1900, depicting the scenario of "eating in." The other study was carried out after a later large evening meal (100 g of carbohydrates) at 2030, accompanied by white wine (0.75 g/kg ethanol) and depicted the scenario of "eating out." MAIN OUTCOME MEASURES The primary outcome was the time plasma glucose levels were in target (3.91-8.0 mmol/L) during closed loop delivery and a comparable control period. Secondary outcomes included pooled data analysis and time plasma glucose levels were below target (≤ 3.9 mmol/L). RESULTS For the eating in scenario, overnight closed loop delivery of insulin increased the time plasma glucose levels were in target by a median 15% (interquartile range 3-35%), P = 0.002. For the eating out scenario, closed loop delivery increased the time plasma glucose levels were in target by a median 28% (2-39%), P = 0.01. Analysis of pooled data showed that the overall time plasma glucose was in target increased by a median 22% (3-37%) with closed loop delivery (P < 0.001). Closed loop delivery reduced overnight time spent hypoglycaemic (plasma glucose ≤ 3.9 mmol/L) by a median 3% (0-20%), P=0.04, and eliminated plasma glucose concentrations below 3.0 mmol/L after midnight. CONCLUSION These two small crossover trials suggest that closed loop delivery of insulin may improve overnight control of glucose levels and reduce the risk of nocturnal hypoglycaemia in adults with type 1 diabetes. Trial registration ClinicalTrials.gov NCT00910767 and NCT00944619.
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Affiliation(s)
- Roman Hovorka
- Institute of Metabolic Science, University of Cambridge, Cambridge, UK.
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Bibby S, Healy B, Steele R, Kumareswaran K, Nelson H, Beasley R. Association between leukotriene receptor antagonist therapy and Churg-Strauss syndrome: an analysis of the FDA AERS database. Thorax 2010; 65:132-8. [PMID: 20147592 DOI: 10.1136/thx.2009.120972] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND The possible role of leukotriene receptor antagonist (LTRA) therapy in the pathogenesis of Churg-Strauss syndrome (CSS) is uncertain. The aim was to examine the association between LTRA therapy and CSS in cases registered in the FDA Adverse Event Reporting System (AERS) database. METHODS All cases of suspected drug-induced CSS reported to the AERS database between November 1997 and April 2003 were reviewed. Subjects in whom LTRAs were the suspected medication and sufficient documentation existed to confirm the diagnosis of CSS were sequentially categorised into one of the following groups: (A) CSS before treatment initiation; (B) oral or inhaled corticosteroids reduced or stopped within 6 months of CSS onset; (C) possible prodromal phase of CSS at treatment initiation; (D) unstable asthma at treatment initiation; (E) stable asthma at treatment initiation. RESULTS There were 181 case reports of suspected drug-induced CSS with sufficient documentation to confirm a diagnosis of CSS; in 163 (90%) an LTRA was a suspect medication. In 140 of these 163 cases there was sufficient documentation to sequentially categorize the case into groups, with 13 (9%) in A, 27 (19%) in B, 11 (8%) in C, 28 (20%) in D and 61 (44%) in E. CONCLUSION LTRA therapy was a suspect medication in most confirmed cases of CSS reported in the AERS database. In the majority of cases treated with an LTRA, CSS could not be explained by either corticosteroid withdrawal or pre-existing CSS. These findings are informative in considering the potential associations between LTRA therapy and CSS.
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Affiliation(s)
- S Bibby
- Medical Research Institute of New Zealand, P O Box 10055, Wellington 6143, New Zealand
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Abstract
Intensive insulin therapy aimed at achieving normal glucose levels significantly reduces the complications that are associated with diabetes but is also associated with an increased risk of low glucose levels (hypoglycemia). The growing use of continuous glucose monitors has stimulated the development of the artificial pancreas, a closed-loop insulin-delivery system aimed at restoring near-normal glucose levels while reducing the risk of hypoglycemia. The artificial pancreas comprises three components: a continuous glucose monitor, an insulin infusion pump and a control algorithm delivering insulin according to real-time glucose readings. In this article, we review closed-loop glucose control, including its components, development, testing and clinical application.
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Affiliation(s)
- Kavita Kumareswaran
- Institute of Metabolic Science, University of Cambridge, Metabolic Research Laboratories, Box 289, Level 4, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK.
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