Technology for the Management of Type 1 Diabetes Mellitus in Saudi Arabia and MENA Region: A Systematic Review

BACKGROUND

Diabetes technology in the form of digital health or medical devices holds a promise for improving the quality of life and glycemic outcomes. A comprehensive insight into diabetes technology and its impact in Saudi Arabia and the MENA region may improve type 1 diabetes mellitus (T1DM) management.

OBJECTIVE

This study aimed to assess the impact of different DM-specific technologies: insulin pump therapy, continuous glucose monitoring (CGM), and automated insulin delivery system in terms of glycemic control and QoL among T1DM patients in Saudi Arabia and the MENA region.

METHOD

A systematic literature search was performed in PubMed and Scopus from 2005 until August 2023. The search was based on the PICO strategy, focusing on T1DM patients, diabetes technology, and QoL. The inclusion criteria were studies illustrating the effect of diabetes technologies on glycemic control or quality of life or both among T1DM patients. Systematic reviews, books, letters, or studies, including type 2 diabetes mellitus, were excluded.

RESULTS

From 101 articles, eighteen studies were duplicated, and thirty-three studies were excluded after reading the title and abstract. Of the 50 articles analyzed, twenty-five articles did not meet the inclusion criteria. Therefore, 25 articles involving a total of 3088 participants were enrolled in the study. It was shown that a continuous glucose monitoring system and continuous subcutaneous insulin infusion improved the glycemic control and the QoL of T1DM patients.

CONCLUSION

There was a positive impact of insulin pumps, continuous glucose monitoring (CGM) systems, and telemedicine in achieving optimal glucose control and better QoL. Further studies are recommended to clarify the significant role of advanced diabetes technologies.

Multiple basal infusion rates in open-loop insulin delivery systems: is there a metabolic benefit?

Objective

To evaluate glycemic control according to the number of daily basal rates (BRs) in type 1 diabetes patients using continuous subcutaneous insulin infusion (CSII).

Subjects and methods

Cross-sectional study of patients treated with an open-loop CSII for at least 6 months and using a flash glucose monitoring system. Patients were divided into 2 groups: group 1 (G1) and group 2 (G2), with ≤4 and >4 BRs/24h, respectively. The groups were compared regarding HbA1c, time in range (TIR), time above range (TAR), time below range (TBR), glucose management indicator (GMI), glucose variability and data related to hypoglycemia. Regression models were performed.

Results

The study included 99 patients (n = 55 in G1; n = 44 in G2). Median (Interquartile range) overall age was 30 (17) years, with 19.5 (48) and 51 (77) months of CSII use, respectively. The median number of different BRs was 3 (2) for G1 and 6 (2) for G2. There were no differences concerning age, sex, educational stage, weight, and insulin analog used. G2 had longer disease duration, longer CSII use, and higher total basal daily dose/kg. No significant differences regarding HbA1c, median glucose, GMI, TIR, TAR, and CV were found. G2 patients had more hypoglycemia, more asymptomatic hypoglycemia, and higher TBR. After adjusting for potential confounders, G1 maintained a lower risk of asymptomatic hypoglycemia.

Conclusion

Programming open-loop CSII devices with more than 4 BRs does not improve metabolic control. Additionally, it seems to be a risk factor for hypoglycemia and was an independent predictor for asymptomatic hypoglycemia.

A Nutritional Approach to Optimizing Pump Therapy in Type 1 Diabetes Mellitus

Achieving optimal glucose control in individuals with type 1 diabetes (T1DM) continues to pose a significant challenge. While continuous insulin infusion systems have shown promise as an alternative to conventional insulin therapy, there remains a crucial need for greater awareness regarding the necessary adaptations for various special circumstances. Nutritional choices play an essential role in the efficacy of diabetes management and overall health status for patients with T1DM. Factors such as effective carbohydrate counting, assessment of the macronutrient composition of meals, and comprehending the concept of the glycemic index of foods are paramount in making informed pre-meal adjustments when utilizing insulin pumps. Furthermore, the ability to handle such situations as physical exercise, illness, pregnancy, and lactation by making appropriate adjustments in nutrition and pump settings should be cultivated within the patient-practitioner relationship. This review aims to provide healthcare practitioners with practical guidance on optimizing care for individuals living with T1DM. It includes recommendations on carbohydrate counting, managing mixed meals and the glycemic index, addressing exercise-related challenges, coping with illness, and managing nutritional needs during pregnancy and lactation. Additionally, considerations relating to closed-loop systems with regard to nutrition are addressed. By implementing these strategies, healthcare providers can better equip themselves to support individuals with T1DM in achieving improved diabetes management and enhanced quality of life.

Evaluation of a New Clinical Tool to Enhance Clinical Care of Control-IQ Users

BACKGROUND

The purpose of this study was to develop and test a new Clinic Tool to assist health care professionals with clinical care of persons with diabetes using the Control-IQ system.

METHODS

A Clinic Tool was iteratively developed with input from diabetes clinicians, which outlined a systematic process for assessing data, reviewing insulin settings, providing education, and documenting the encounter. Diabetes clinicians were recruited to trial the Clinical Tool in up to five clinical encounters (in-person, telehealth, or telephone). Quantitative surveys and free-text responses, including a knowledge quiz and the System Usability Scale (SUS), were administered to determine clinician satisfaction, confidence, knowledge, and implications for practice.

RESULTS

Twenty-nine clinicians (43% endocrinologists, mean 10.7 years in practice) enrolled in the study and completed 89 encounters using the Control-IQ Clinic Tool. Participants spent an average of 10 minutes using the Tool and reported excellent SUS scores within the 90%-95% percentile for usability. Knowledge quiz scores increased in 42% of participants. Both familiarity with Control-IQ and confidence providing clinical care to Control-IQ users significantly improved (P = .009 and P < .001 respectively). Ninety percent of participants agreed that the Tool will change their clinical care going forward.

CONCLUSION

The Control-IQ Clinical Tool is highly usable and impacted clinical care delivery to Control-IQ users. Tools that serve to improve clinician confidence in delivery of care to diabetes device users should be expanded, leveraged, and studied to assess the impact on adherence and glycemic control for persons with diabetes.

Developing the UVA/Padova Type 1 Diabetes Simulator: Modeling, Validation, Refinements, and Utility

Arguably, diabetes mellitus is one of the best quantified human conditions. In the past 50 years, the metabolic monitoring technologies progressed from occasional assessment of average glycemia via HbA1c, through episodic blood glucose readings, to continuous glucose monitoring (CGM) producing data points every few minutes. The high-temporal resolution of CGM data enabled increasingly intensive treatments, from decision support assisting insulin injection or oral medication, to automated closed-loop control, known as the "artificial pancreas." Throughout this progress, mathematical models and computer simulation of the human metabolic system became indispensable for the technological progress of diabetes treatment, enabling every step, from assessment of insulin sensitivity via the now classic Minimal Model of Glucose Kinetics, to in silico trials replacing animal experiments, to automated insulin delivery algorithms. In this review, we follow these developments, beginning with the Minimal Model, which evolved through the years to become large and comprehensive and trigger a paradigm change in the design of diabetes optimization strategies: in 2007, we introduced a sophisticated model of glucose-insulin dynamics and a computer simulator equipped with a "population" of N = 300 in silico "subjects" with type 1 diabetes. In January 2008, in an unprecedented decision, the Food and Drug Administration (FDA) accepted this simulator as a substitute to animal trials for the pre-clinical testing of insulin treatment strategies. This opened the field for rapid and cost-effective development and pre-clinical testing of new treatment approaches, which continues today. Meanwhile, animal experiments for the purpose of designing new insulin treatment algorithms have been abandoned.

Insulin Pump Alarms During Adverse Events: A Qualitative Descriptive Study

OBJECTIVE

Explore alarm signals cited in insulin pump-associated adverse events (AEs), describe the clinical consequences and other root cause informing remarks that cooccurred with the alarm signals, and identify opportunities for improvements to patient education, instructional materials, and alarm systems to prevent future AEs.

RESEARCH DESIGN AND METHODS

We explored the type, frequency, and associated clinical consequences of alarm signals cited in a pre-coded data set of 2294 insulin pump-associated AEs involving the MiniMed 670G, MiniMed 630G, and t:slim X2. We also explored the clinical consequences and other root cause informing remarks that cooccurred with the top 10 most frequently cited alarm signals.

RESULTS

Overall, 403 AEs narratives cited at least one alarm signal. Of the 40 unique alarm signals cited, 42.5% were "alarms," 25.0% were "alerts," and 32.5% were not referenced in the instructional materials packaged with the corresponding pump. The top 10 most frequently cited alarm signals included two obstruction of flow alarms, which accounted for 49.9% of all AEs citing at least one alarm, and two unreferenced alarms. The most frequent cooccurring root cause informing remark varied across the top 10 alarm signals and revealed valuable insight into why these alarms may have occurred.

CONCLUSIONS

Our findings demonstrate the value of analyzing alarm signals cited in insulin pump-associated AEs and reveal multiple opportunities for providers to educate patients on how to respond to alarm signals and manage their pumps to avoid AEs, and for insulin pump manufacturers to update instructional materials and improve alarm systems to support appropriate patient response.

Knowledge, Attitude, and Practice of Insulin Pump Among Non-Endocrinology Nurses in South China

Purpose

To investigate the knowledge, attitude, and practice (KAP) on insulin pump among non-endocrinology nurses in Southern China.

Methods

This multicenter cross-sectional study enrolled non-endocrinology nurses in Southern China between November 2020 and December 2020. A structured questionnaire about insulin pumps was designed and used to collect data.

Results

A total of 1118 nurses from 29 hospitals participated in the study. The majority of them were female (98.48%), and 513 worked in the department of internal medicine (45.89%), followed by surgery (235, 21.00%), pediatrics (147, 13.14%), gynecology (127, 11.35%), and oncology (96, 8.71%). None of the nurses answered all questions correctly in the knowledge section. The score of knowledge was 50.12 ± 3.42 (total score range, 0 to 85). The attitude score of nurses in the department of gynecology was 47.76 ± 5.11 (total score range, 10 to 50), followed by nurses in the department of internal medicine (47.43 ± 4.65), pediatrics (46.71 ± 4.96), surgery (46.77 ± 5.78) and oncology (46.25 ± 5.87). The practice score of nurses in the internal medicine department was 79.16 ± 9.03 (total score range, 17 to 85), followed by nurses in the department of gynecology (78.76 ± 10.76), surgery (78.14 ± 10.09), oncology (76.89 ± 12.70) and pediatrics (73.35 ± 19.04).

Conclusion

There was limited knowledge regarding insulin pumps among nurses, although they had a positive attitude and attached importance to the management of insulin pumps. In clinical practice, their implementation of insulin pump management norms was acceptable.

Innovations in Diabetes Device Training: A Scoping Review

OBJECTIVE

The coronavirus disease 2019 pandemic highlighted a pre-existing need for alternatives to traditional in-person diabetes device trainings. Barriers to care, which include the heavy burden of training, pose a threat to optimal adoption and utilization of these devices. We searched the literature for alternative methods of training, evaluated user satisfaction, and compared short-term clinical outcomes with guideline-based glucometric targets and historical training results.

METHODS

A scoping review of Embase articles from 2019 to 2021 was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines using key words relevant to diabetes technologies. Original full-text articles investigating training of new users on devices were included. Titles and abstracts were screened for eligibility by 2 independent reviewers, and results were summarized.

RESULTS

Of 25 articles retrieved from the database, 11 met the criteria. Alternative training strategies included video conferencing, phone calls, mobile applications, and hybrids with traditional trainings. Overall, there was a high degree of user satisfaction with virtual visits, with a preference for hybrid approaches (6 articles). Although glucometrics varied between articles, short-term glucometrics were satisfactory overall (8 articles), including improved glycated hemoglobin measurements and time in range. Two articles compared time in range over various time points after traditional and remote training. One found equivalency, and the other identified a 5% improvement with remote training.

CONCLUSION

Alternative training approaches are a viable option to reduce the barriers to care and to alleviate training burden. Intentional implementation of alternatives should be considered a solution to address current barriers.

Experience with burdens of diabetes device use that affect uptake and optimal use in people with type 1 diabetes

Diabetes technology continues to advance, with more individuals with type 1 diabetes (T1D) adopting insulin pumps, continuous glucose monitoring (CGM), and automated insulin delivery (AID) systems that integrate real-time glucose data with an algorithm to assist with insulin dosing decisions. These technologies are linked with benefits to glycemic outcomes (e.g. increased time in target range), diabetes management behaviors, and quality of life. However, current devices and systems are not without barriers and hassles for the user. The intent of this review is to describe the personal challenges and reactions that users experience when interacting with current diabetes technologies, which can affect their acceptance and motivation to engage with their devices. This review will discuss user experiences and strategies to address three main areas: (i) the emotional burden of utilizing a wearable device; (ii) the perceived and experienced negative social consequences of device use; and (iii) the practical challenges of wearing devices.

Use of Telemedicine in Adults with Type 1 Diabetes: Do Age and Use of Diabetes-Related Technology Matter?

Objective: Older adults are generally less proficient in technology use compared with younger adults. Data on telemedicine use during the COVID-19 pandemic in older persons with type 1 diabetes (T1D) and the association of telemedicine with the use of diabetes-related technology are limited. We evaluated care delivery to older adults compared with younger adults with T1D in a prepandemic and pandemic period. Methods: Data from electronic health records were evaluated for visit types (in-person, phone, and video) from two sequential 12-month intervals: prepandemic (April 2019-March 2020) and pandemic (April 2020-March 2021). Results: Data from 2,832 unique adults with T1D were evaluated in two age cohorts: younger (40-64 years) and older (≥65 years). Half of each group used continuous glucose monitoring (CGM), whereas 54% of the younger and 37% of the older cohort used pump therapy (p < 0.001). During the pandemic compared with the prepandemic period, visit frequency increased in both the younger (0.65 vs. 0.76 visits/patient/quarter; p < 0.01) and older (0.72 vs. 0.80 visits/patient/quarter; p < 0.01) cohorts. During the pandemic, older adults used more phone visits compared with younger adults (48% vs. 32%; p = 0.001). Patients using either pump therapy or CGM were more likely to use video visits compared with phone visits in both younger (41% vs. 24%; p < 0.001) and older cohorts (53% vs. 42%; p < 0.001). Conclusions: Adults using diabetes-related technologies, independent of age, accessed more video visits than those not using devices. Telemedicine visits appeared to maintain continuity of care for younger and older adults with T1D, supporting the future of a hybrid-care model.

Effects of insulin therapy optimization with sensor augmented pumps on glycemic control and body composition in people with cystic fibrosis-related diabetes

Objective

Cystic fibrosis (CF)-related diabetes (CFRD) resulting from partial-to-complete insulin deficiency occurs in 40-50% of adults with CF. In people with CFRD, poor glycemic control leads to a catabolic state that may aggravate CF-induced nutritional impairment and loss of muscle mass. Sensor augmented pump (SAP) therapy may improve glycemic control as compared to multiple daily injection (MDI) therapy.

Research design and methods

This non-randomized clinical trial was aimed at evaluating the effects of insulin therapy optimization with SAP therapy, combined with a structured educational program, on glycemic control and body composition in individuals with insulin-requiring CFRD. Of 46 participants who were offered to switch from MDI to SAP therapy, 20 accepted and 26 continued the MDI therapy. Baseline demographic and clinical characteristics were balanced between groups using a propensity score-based overlap weighting procedure and weighted mixed-effects regression models were used to estimate changes in study outcomes.

Results

After 24 months changes in HbA1c were: -1.1% (-12.1 mmol/mol) (95% CI: -1.5; -0.8) and -0.1% (-1 mmol/mol) (95% CI: -0.5; 0.3) in the SAP and MDI therapy group, respectively, with a between-group difference of -1.0 (-10 mmol/mol) (-1.5; -0.5). SAP therapy was also associated with a decrease in mean glucose (between group difference: -32 mg/dL; 95% CI: -44; -20) and an increase in TIR (between group difference: 19.3%; 95% CI 13.9; 24.7) and in fat-free mass (between group difference: +5.5 Kg, 95% CI: 3.2; 7.8).

Conclusion

Therapy optimization with SAP led to a significant improvement in glycemic control, which was associated with an increase in fat-free mass.

Current Technologies for Managing Type 1 Diabetes Mellitus and Their Impact on Quality of Life-A Narrative Review

Type 1 diabetes mellitus is a chronic autoimmune disease that affects millions of people and generates high healthcare costs due to frequent complications when inappropriately managed. Our paper aimed to review the latest technologies used in T1DM management for better glycemic control and their impact on daily life for people with diabetes. Continuous glucose monitoring systems provide a better understanding of daily glycemic variations for children and adults and can be easily used. These systems diminish diabetes distress and improve diabetes control by decreasing hypoglycemia. Continuous subcutaneous insulin infusions have proven their benefits in selected patients. There is a tendency to use more complex systems, such as hybrid closed-loop systems that can modulate insulin infusion based on glycemic readings and artificial intelligence-based algorithms. It can help people manage the burdens associated with T1DM management, such as fear of hypoglycemia, exercising, and long-term complications. The future is promising and aims to develop more complex ways of automated control of glycemic levels to diminish the distress of individuals living with diabetes.

"Empowering Us": A Community-Led Survey of Real-World Perspectives of Adults with Type 1 Diabetes Using Insulin Pumps and Continuous Glucose Monitoring to Manage Their Glucose Levels

OBJECTIVE

To conduct an Australian community-led survey of adults with type 1 diabetes (T1D), identifying priorities for, and barriers to, optimal use of advanced glucose management technologies.

RESEARCH DESIGN AND METHODS

A 30-question online survey of current or past users of insulin pump therapy (IPT), real-time continuous glucose monitoring (RT-CGM), or intermittently scanned CGM (isCGM) explored perceptions regarding device design, access, education, outcomes, and support.

RESULTS

Between November 2021 and January 2022, surveys were completed by 3,380 participants (age [mean±SD] 45±16 years; 62% female; 20±14 years diabetes), with 55%, 82%, and 55% reporting experience with IPT, RT-CGM, and isCGM, respectively. Overall, most considered diabetes technology '(extremely) important' for maintaining target glucose levels (98%) and reducing hypoglycaemia severity and frequency (93%). For most, technology contributed positively to emotional well-being (IPT 89%; RT-CGM 91%; isCGM 87%), which was associated with device effectiveness in maintaining glucose in range, comfort, and convenience. Barriers included affordability (IPT 68%; RT-CGM 81%; isCGM 69%) and insufficient information for informed choices about device suitability (IPT 39%; RT-CGM 41%; isCGM 36%).

CONCLUSIONS

Technology is perceived by adults with T1D as important for managing glycaemia and emotional well-being. Modifiable barriers to use include affordability, and information regarding device suitability.

UK's Association of British Clinical Diabetologist's Diabetes Technology Network (ABCD-DTN): Best practice guide for hybrid closed-loop therapy

This best practice guide is written with the aim of providing an overview of current hybrid closed-loop (HCL) systems in use within the United Kingdom's (UK) National Health Service (NHS) and to provide education and advice for their management on both an individual and clinical service level. The environment of diabetes technology, and particularly HCL systems, is rapidly evolving. The past decade has seen unprecedented advances in the development of HCL systems. These systems improve glycaemic outcomes and reduce the burden of treatment for people with type 1 diabetes (pwT1D). It is anticipated that access to these systems will increase in England as a result of updates in National Institute of Health and Care Excellence (NICE) guidance providing broader support for the use of real-time continuous glucose monitoring (CGM) for pwT1D. NICE is currently undertaking multiple-technology appraisal into HCL systems. Based on experience from centres involved in supporting advanced technologies as well as from the recent NHS England HCL pilot, this guide is intended to provide healthcare professionals with UK expert consensus on the best practice for initiation, optimisation and ongoing management of HCL therapy.

Contact Dermatitis to Diabetes Medical Devices

Skin adverse reactions to diabetes medical devices have been reported frequently over recent years. Adhesives attaching glucose sensors and continuous insulin infusion sets to the skin are proven to cause both allergic contact dermatitis and irritant contact dermatitis in patients with diabetes mellitus. Several allergens contained in adhesives and/or parts of medical devices are documented to cause allergic contact dermatitis, with acrylate chemicals being the most common culprit-especially isobornyl acrylate (IBOA), but also 2,2'-methylenebis(6-tert-butyl-4-methylphenol) monoacrylate or cyanoacrylates. Epoxy resin, colophonium and nickel were also identified as causative allergens. However, repetitive occlusion, maceration of the skin and resulting disruption of the skin barrier seem to have an impact on the development of skin lesions as well. The purpose of this study is to highlight the burden of contact dermatitis triggered by diabetes medical devices and to show possible mechanisms responsible for the development of contact dermatitis in a group of diabetic patients.

Automated Insulin Delivery (AID) Systems: Use and Efficacy in Children and Adults with Type 1 Diabetes and Other Forms of Diabetes in Europe in Early 2023

Type 1 diabetes (T1D) patients' lifestyle and prognosis has remarkably changed over the years, especially after the introduction of insulin pumps, in particular advanced hybrid closed loop systems (AHCL). Emerging data in literature continuously confirm the improvement of glycemic control thanks to the technological evolution taking place in this disease. As stated in previous literature, T1D patients are seen to be more satisfied thanks to the use of these devices that ameliorate not only their health but their daily life routine as well. Limited findings regarding the use of new devices in different age groups and types of patients is their major limit. This review aims to highlight the main characteristics of each Automated Insulin Delivery (AID) system available for patients affected by Type 1 Diabetes Mellitus. Our main goal was to particularly focus on these systems' efficacy and use in different age groups and populations (i.e., children, pregnant women). Recent studies are emerging that demonstrate their efficacy and safety in younger patients and other forms of diabetes.

Significant publications in diabetes pharmacotherapy and technology in 2020

INTRODUCTION

The most significant articles on diabetes pharmacotherapy and technology in the peer-reviewed literature from 2020, as determined by a panel of pharmacists with expertise in diabetes care and education, are summarized.

AREAS COVERED

Members of the Association of Diabetes Care and Education Specialists Pharmacy Community of Interest were selected to review articles published in prominent peer-reviewed journals in 2020 that most impacted diabetes pharmacotherapy and technology. A list of 37 nominated articles were compiled (22 in diabetes pharmacotherapy and 15 in diabetes technology). Based on discussion among the authors, the articles were ranked based on significant contribution, impact, and diversity to diabetes pharmacotherapy and technology. The top 10 highest ranked publications (n = 6 for diabetes pharmacotherapy and n = 4 in diabetes technology) are summarized in this article.

EXPERT OPINION

With the significant number of publications in diabetes care and education, it can be challenging and overwhelming to remain current with published literature. This review article may be helpful in identifying key articles in diabetes pharmacotherapy and technology from the year 2020.

Management of Individuals With Diabetes at High Risk for Hypoglycemia: An Endocrine Society Clinical Practice Guideline

CONTEXT

Hypoglycemia in people with diabetes is common, especially in those taking medications such as insulin and sulfonylureas (SU) that place them at higher risk. Hypoglycemia is associated with distress in those with diabetes and their families, medication nonadherence, and disruption of life and work, and it leads to costly emergency department visits and hospitalizations, morbidity, and mortality.

OBJECTIVE

To review and update the diabetes-specific parts of the 2009 Evaluation and Management of Adult Hypoglycemic Disorders: Endocrine Society Clinical Practice Guideline and to address developing issues surrounding hypoglycemia in both adults and children living with diabetes. The overriding objectives are to reduce and prevent hypoglycemia.

METHODS

A multidisciplinary panel of clinician experts, together with a patient representative, and methodologists with expertise in evidence synthesis and guideline development, identified and prioritized 10 clinical questions related to hypoglycemia in people living with diabetes. Systematic reviews were conducted to address all the questions. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess the certainty of evidence and make recommendations.

RESULTS

The panel agreed on 10 questions specific to hypoglycemia risk and prevention in people with diabetes for which 10 recommendations were made. The guideline includes conditional recommendations for use of real-time continuous glucose monitoring (CGM) and algorithm-driven insulin pumps in people with type 1 diabetes (T1D), use of CGM for outpatients with type 2 diabetes at high risk for hypoglycemia, use of long-acting and rapid-acting insulin analogs, and initiation of and continuation of CGM for select inpatient populations at high risk for hypoglycemia. Strong recommendations were made for structured diabetes education programs for those at high risk for hypoglycemia, use of glucagon preparations that do not require reconstitution vs those that do for managing severe outpatient hypoglycemia for adults and children, use of real-time CGM for individuals with T1D receiving multiple daily injections, and the use of inpatient glycemic management programs leveraging electronic health record data to reduce the risk of hypoglycemia.

CONCLUSION

The recommendations are based on the consideration of critical outcomes as well as implementation factors such as feasibility and values and preferences of people with diabetes. These recommendations can be used to inform clinical practice and health care system improvement for this important complication for people living with diabetes.

Diabetes Technology: Many Steps From an Idea to a Product

The development of technology, for example in the field of information technology or biotechnology and genetic engineering, has been breathtaking in recent decades. Development has also been rapid in the field of diabetes technology. However, no "technical cure" for diabetes has yet been achieved. Patients and also diabetes experts ask themselves why the availability of modern technologies does not automatically become visible in medical technology. They feel a gap between high technology and diabetes technology. However, the development and marketing of any product is an ever-increasing challenge. This will be mastered the faster; the higher the general dissemination, the higher the amortization of investments will be. It is generally necessary to understand the multiple steps from the idea of a product to its application to people.

Continuous subcutaneous insulin infusions: Closing the loop

CONTEXT

Continuous subcutaneous insulin infusions (CSIIs) and continuous glucose monitors (CGMs) have revolutionized the management of diabetes mellitus (DM). Over the last two decades the development of advanced, small, and user-friendly technology has progressed substantially, essentially closing the loop in the fasting and post-absorptive state, nearing the promise of an artificial pancreas. The momentum was mostly driven by the diabetes community itself, to improve its health and quality of life.

EVIDENCE ACQUISITION

Literature regarding CSII and CGM was reviewed.

EVIDENCE SYNTHESIS

Management of DM aims to regulate blood glucose to prevent long term micro and macrovascular complications. CSIIs combined with CGMs provide an integrated system to maintain tight glycemic control in a safe and uninterrupted fashion, while minimizing hypoglycemic events. Recent advances have allowed to 'close the loop' by better mimicking endogenous insulin secretion and glucose level regulation. Evidence supports sustained improvement in glycemic control with reduced episodes of hypoglycemia using these systems, while improving quality of life. Ongoing work in delivery algorithms with or without counterregulatory hormones will allow for further layers of regulation of the artificial pancreas.

CONCLUSION

Ongoing efforts to develop an artificial pancreas have created effective tools to improve the management of DM. CSIIs and CGMs are useful in diverse populations ranging from children to the elderly, as well as in various clinical contexts. Individually and more so together, these have had a tremendous impact in the management of DM, while avoiding treatment fatigue. However, cost and accessibility are still a hindrance to its wider application.

Values and control in type 1 diabetes beyond glycemic outcomes: A qualitative interview study of everyday life with an insulin pump

OBJECTIVES

Diabetes technology provides people with diabetes with new opportunities, but the transformations allowed by new technology do not necessarily provide improvements in clinical metrics applied in diabetes care. This study seeks to understand how everyday life impacts on the way people use diabetes technology and how this influences diabetes care.

METHODS

Individual semi-structured qualitative interviews with 21 adults with type 1 diabetes treated with insulin pumps were recruited from two Danish diabetes outpatient clinics. Data were analyzed abductively and interpreted according to predetermined and emergent perspectives.

RESULTS

Transformations in care practices derived from new technological therapies were generally well-supported by healthcare providers, but adaptation to everyday life was often challenging. More advanced technology enabled people to better control diabetes, but the control they sought was defined by individual life experiences/factors. Work involved in controlling blood glucose could cause a sense of feeling controlled by diabetes in everyday life.

DISCUSSION

Everyday life with diabetes is often characterized by uncertainty and individual coping strategies are imbued with values that extend beyond purely clinical concerns and reflect the sociality of everyday life. The social values influencing individual decision-making regarding diabetes technology could be effectively expanded and enhanced with integrated peer-supported learning.

One-Year Real-World Study on Comparison among Different Continuous Subcutaneous Insulin Infusion Devices for the Management of Pediatric Patients with Type 1 Diabetes: The Supremacy of Hybrid Closed-Loop Systems

Since their advent in daily clinical practice, continuous subcutaneous insulin infusion (CSII) systems have been increasingly improved, leading to a high percentage of both adult and pediatric patients with diabetes now using insulin pumps. Different types of CSII systems are currently available, which are characterized by different settings and technical features. This longitudinal observational study aims to evaluate real-word glycemic outcomes in children and adolescents with type 1 diabetes using three different CSII devices: hybrid closed-loop (HCL) systems, predictive low glucose (PLGS) systems, and non-automated insulin pumps. The secondary objective was to identify clinical variables that may significantly influence the achievement of therapeutic goals in our study cohort. One-hundred-and-one patients on CSII therapy attending our pediatric diabetes center were enrolled. When compared with the non-automated group, patients using HCL systems showed higher levels of time in target glucose range (p = 0.003) and lower glucose variability (p = 0.008). Similarly, we found significantly better glucose metrics in HCL users in comparison to PLGS patients (time in range p = 0.008; coefficient of variation p = 0.009; time above 250 mg/dL p = 0.007). Multiple linear regression models showed that HCL systems (time in range p < 0.001) and high daily percentage of glycemic sensor use (time in range p = 0.031) are predictors for good glycemic control. The introduction and increasing availability of novel technologies for diabetes represent a promising strategy to improve glycemic control and quality of life in pediatric patients with type 1 diabetes. Our real-world data confirm the superiority of HCL systems in terms of improvement of time spent in the target glucose range, prevention of hypoglycemia, and reduction of glycemic variability.

Insulin Titration Guidelines for Patients With Type 1 Diabetes: It Is About Time!

PURPOSE

A proposal that an Insulin Advisory Committee develop insulin titration guidelines 100 years after its discovery.

FINDINGS

Glucose control metrics remain poor despite significant advances in diabetes technology.

SUMMARY

A century after the introduction of insulin, health care providers and patients with type 1 diabetes have worldwide access to a variety of insulin delivery devices (IDDs), glucose monitors, bolus calculators (BCs), continuous glucose monitors (CGMs), and automated insulin delivery (AID) systems. However, these advances have not enabled most patients to achieve today's clear A1c and time-in-range goals. Much of this failure arises from the lack of clear insulin titration guidelines for determining appropriate insulin doses. The lack of dosing clarity results in local physicians, clinics, and individual patients managing insulin titrations as they see fit, creating significant inefficiencies for reaching recommended glycemic goals. This review (1) details the widespread problems generated by nonphysiological dose settings in today's BCs, insulin pumps, and AID systems; (2) presents a method to develop and implement optimized total daily doses of insulin to correct the most common problem of hyperglycemia; (3) discusses using large device databases to provide clear insulin titration guidelines that optimize BC settings from an optimized total daily dose (TDD) of insulin for patients with T1D; and (4) recommends the formation of an Insulin Advisory Committee to clarify the steps to take toward universal insulin titration guidelines, optimized BC settings, and a systematic logic for their use in insulin delivery devices.

External Physical and Technical Influences on Medical Devices for Diabetes Therapy

Home and work situations can expose diabetes medical devices to a number of environmental factors that may influence their function and safety. In accordance with regulatory requirements, manufacturing companies take great care in the construction and design of their products so that environmental factors encountered on a daily basis have as little influence as possible. However, more intense environmental conditions, such as undergoing magnetic resonance imaging (MRI), require patients to remove personal electronic medical devices beforehand. During product development, manufacturers thoroughly investigate how various environmental factors may impact a new medical device. Corresponding operational documents and manufacturer guarantees accompany each device. Similarly, manufacturers investigate any adverse interactions that may occur during communications between medical devices, such as those required with another product, smartphone, or another personal medical device, such as a pacemaker. Questions that arise from patients or medical professionals about a medical device's safety or quality, particularly because of environmental factors, are made to the manufacturer. Manufacturers then often refer to the operating instructions, even though these contain information, such as electromagnetic compatibility, that are difficult to understand for people lacking special technical or physical knowledge. This review highlights the effects of various physical and technical influences on medical devices used in diabetes therapy.

A Pharmacist-Driven Glycemic Control Protocol to Reduce the Rate of Severe Hypoglycemia in High-Risk Patients

Purpose: Hospital pharmacists contribute to patient safety and quality initiatives by overseeing the prescribing of antidiabetic medications. A pharmacist-driven glycemic control protocol was developed to reduce the rate of severe hypoglycemia events (SHE) in high-risk hospitalized patients. Methods: We retrospectively analyzed the rates of SHE (defined as blood glucose ≤40 mg/dL), before and after instituting a pharmacist-driven glycemic control protocol over a 4-year period. A hospital glucose management team that included a lead Certified Diabetes Educator Pharmacist (CDEP), 5 pharmacists trained in diabetes, a lead hospitalist, critical care and hospital providers established a process to first identify patients at risk for severe hypoglycemia and then implement our protocol. Criteria from the American Diabetes Association and the American Association of Clinical Endocrinologists was utilized to identify and treat patients at risk for SHE. We analyzed and compared the rate of SHE and physician acceptance rates before and after protocol initiation. Results: From January 2015 to March 2019, 18 297 patients met criteria for this study; 139 patients experienced a SHE and approximately 80% were considered high risk diabetes patients. Physician acceptance rates for the new protocol ranged from 77% to 81% from the year of initiation (2016) through 2018. The absolute risk reduction of SHE was 9 events per 1000 hospitalized diabetic patients and the relative risk reduction was 74% SHE from the start to the end of the protocol implementation. Linear regression analysis demonstrated that SHE decreased by 1.5 events per 1000 hospitalized diabetic patients (95% confidence interval, -1.54 to -1.48, P < .001) during the 2 years following the introduction of the protocol. This represents a 15% relative reduction of SHE per year. Conclusion: The pharmacist-driven glycemic control protocol was well accepted by our hospitalists and led to a significant reduction in SHE in high-risk diabetes patient groups at our hospital. It was cost effective and strengthened our physician-pharmacist relationship while improving diabetes care.

Enhancing Choices Regarding the Administration of Insulin Among Patients With Diabetes Requiring Insulin Across Countries and Implications for Future Care

There are a number of ongoing developments to improve the care of patients with diabetes across countries given its growing burden. Recent developments include new oral medicines to reduce cardiovascular events and death. They also include new modes to improve insulin administration to enhance adherence and subsequent patient management thereby reducing hypoglycaemia and improving long-term outcomes. In the case of insulins, this includes long-acting insulin analogues as well as continuous glucose monitoring (CGM) systems and continuous subcutaneous insulin infusion systems, combined with sensor-augmented pump therapy and potentially hybrid closed-loops. The benefits of such systems have been endorsed by endocrine societies and governments in patients with Type 1 diabetes whose HbA1c levels are not currently being optimised. However, there are concerns with the low use of such systems across higher-income countries, exacerbated by their higher costs, despite studies suggesting their cost-effectiveness ratios are within accepted limits. This is inconsistent in higher-income countries when compared with reimbursement and funding decisions for new high-priced medicines for cancer and orphan diseases, with often limited benefits, given the burden of multiple daily insulin injections coupled with the need for constant monitoring. This situation is different among patients and governments in low- and low-middle income countries struggling to fund standard insulins and the routine monitoring of HbA1c levels. The first priority in these countries is to address these priority issues before funding more expensive forms of insulin and associated devices. Greater patient involvement in treatment decisions, transparency in decision making, and evidence-based investment decisions should help to address such concerns in the future.

The Impact of COVID-19 Lockdown on Glycemic Balance in Romanian Patients with Type 1 Diabetes Mellitus

INTRODUCTION

The COVID-19 pandemic has brought major changes not only at the economic and social level but especially in the medical system.

OBJECTIVE

To evaluate the impact of COVID-19 lockdown on the quality of glycemic control in Romanian patients with type 1 diabetes mellitus (T1DM).

MATERIAL AND METHOD

Our study group included 102 Romanian volunteers' patients with T1DM from both urban and rural areas. Data were collected during an interview, based on a structured questionnaire with multiple-choice questions about diabetes management during lockdown, how they interact with their diabetologist, how they accessed the treatment and what other factors influenced their diabetes management during the lockdown.

RESULTS

Blood glucose levels were significantly higher in the MDII group as a consequence of delayed administration of insulin corrections due to inadequate insulin dosing (60% vs 31.81%; χ ² = 5.51, p = 0.018). In addition, insulin pump users had improved response to stress and anxiety (ie, additional therapeutic safety being provided by use of insulin pump; in some devices, blood glucose being continuously monitored, leading to premature detection of important blood glucose excursions) compared to insulin pen users (χ ² = 5.09, p = 0.024). In the context of hypoglycemia, we observed that in the pen MDII group, more users have administered an excess of insulin, compared with the pump users (80% vs 45.45%; χ ² = 10.34; p = 0.001).

CONCLUSION

A lower impact of COVID-19 lockdown on glycemic control was observed in patients with T1DM treated using insulin pumps compared to patients with T1DM who administered their insulin using insulin pens. Telemedicine and online consultations have brought significant improvements in diseases management. Stress, emotions, and anxiety were among the main reasons that led to increases in blood sugar levels, suggesting that the psychological impact may have long-term complications.

Level of Digitalization in Germany: Results of the Diabetes Digitalization and Technology (D.U.T) Report 2020

BACKGROUND

New diagnostic and therapeutic technologies are increasingly changing the treatment of people with diabetes (PWD), along with increased usage of digital tools. To date, however, there is little data to which level and how diabetologists and PWD implement digitalization. Also, not much is known about the view of diabetologists on the current status and future developments in this respect.

METHOD

In an online survey, diabetologists working in clinics and practices across Germany provided responses regarding their view on digitalization and the adoption of new technologies in diabetology to 56 questions. These comments reflect the opinion of several experts about the current importance and use of specific digital/technological topics.

RESULTS

Overall, 326 diabetologists took part in the survey. They reported a positive attitude (75.8%) toward new technologies and digitalization, and they see more advantages rather than disadvantages. Younger age of the diabetologists was significantly associated with a more positive attitude (r = -0.176; P < .01), and there was no gender effect (P = .738). On average, in each practice, 5.5% of PWD are using an insulin pump for therapy, 4.8% a real-time continuous glucose monitoring system, 16.9% an intermittent scanning continuous glucose monitoring system, and 0.3% an automated insulin delivery (AID) system. With respect to digitalization, the three most important current topics are software for glucose data analysis (average rank on a scale from one to six, with one being the most important: 2.4), compatibility with other systems (2.9), and AID systems (3.8)).

CONCLUSIONS

This survey, which is going to be repeated annually, showed that the diabetologists who participated predominantly have a positive attitude toward new technologies and digital applications and were aware of the associated advantages. However, perceived disadvantages need to be addressed to enable wider adoption of new technologies and digital solutions.

Education programmes for persons with type 1 diabetes using an insulin pump: A systematic review

Education is essential in insulin pump therapy, but literature in the field is limited. We systematically reviewed insulin pump education programmes and their effects in two situations as follows: (1) basic education at the start of insulin pump therapy, providing the study design enabled us to separate the effects of insulin pump therapy itself from the effects of education and (2) re-education of experienced pump users. Population: individuals ≥16 years with type 1 diabetes using insulin pumps with or without continuous glucose monitoring. Systematic searches were run in MEDLINE, Embase, CINAHL and ERIC. Original studies reporting an effect of insulin pump education programmes were included if published in English between January 1999 and May 2019. Of 988 potentially relevant studies, 48 were assessed in full text. Nine studies fulfilled the inclusion criteria, including one randomised controlled trial. Educational approaches and settings were sparsely described in all studies, and the content was usually reported as teaching points. Two studies considered basic education, reporting evaluations of knowledge and application skills, and programme satisfaction. The remaining seven studies referred to re-education. Two studies measured severe hypoglycaemic events before and after a re-education intervention, both reporting a significant event reduction. HbA1c decreased significantly in three of four studies. Two studies reported increased knowledge and improved application skills. In conclusion, this review indicates benefits from basic education and from re-education. The strength of the conclusions is limited by the low number of studies and study designs. High-quality studies are needed comparing different approaches for insulin pump education.

Cutaneous Reactions to Continuous Glucose Monitoring and Continuous Subcutaneous Insulin Infusion Devices in Type 1 Diabetes Mellitus

BACKGROUND

Continuous glucose monitoring (CGM) and continuous subcutaneous insulin infusion (CSII) are the standard of care for type 1 diabetes in children. There is little reported on device-related skin complications and treatment options. This study documents cutaneous reactions to CGM and CSII devices in children and young adults with type 1 diabetes.

METHODS

One hundred and twenty-one subjects (3-25 years) with type 1 diabetes and CGM and/or CSII use were recruited over a three-month period from the Naomi Berrie Diabetes Center at Columbia University Irving Medical Center. A five-question survey was completed for each subject detailing demographic data, diabetes management, and device-related skin complications.

RESULTS

Sixty percent of subjects reported skin complications related to CGM and/or CSII use. Terms most frequently used to describe cutaneous reactions were "red," "itchy," "painful," and "rash." Subjects who used both CGM and CSII were more likely to report skin problems than those who used only CSII (odds ratio 2.9, [95% confidence interval: 1.2-6.7]; P = .015). There were no associations between skin complications and sex or race/ethnicity. Twenty-two percent of subjects with adverse skin event(s) discontinued use of a device due to their skin problem. Seven percent were evaluated by a dermatologist. Eighty-one percent used a range of products to treat their symptoms, with variable perceived clinical outcomes.

CONCLUSIONS

Skin complications related to CSII or CGM devices are commonly reported in pediatric patients with type 1 diabetes and may lead to interruption or discontinuation of device use. Future studies are needed to elucidate the causes of these reactions and determine the best methods for prevention.

American Association of Clinical Endocrinology Clinical Practice Guideline: The Use of Advanced Technology in the Management of Persons With Diabetes Mellitus

OBJECTIVE

To provide evidence-based recommendations regarding the use of advanced technology in the management of persons with diabetes mellitus to clinicians, diabetes-care teams, health care professionals, and other stakeholders.

METHODS

The American Association of Clinical Endocrinology (AACE) conducted literature searches for relevant articles published from 2012 to 2021. A task force of medical experts developed evidence-based guideline recommendations based on a review of clinical evidence, expertise, and informal consensus, according to established AACE protocol for guideline development.

MAIN OUTCOME MEASURES

Primary outcomes of interest included hemoglobin A1C, rates and severity of hypoglycemia, time in range, time above range, and time below range.

RESULTS

This guideline includes 37 evidence-based clinical practice recommendations for advanced diabetes technology and contains 357 citations that inform the evidence base.

RECOMMENDATIONS

Evidence-based recommendations were developed regarding the efficacy and safety of devices for the management of persons with diabetes mellitus, metrics used to aide with the assessment of advanced diabetes technology, and standards for the implementation of this technology.

CONCLUSIONS

Advanced diabetes technology can assist persons with diabetes to safely and effectively achieve glycemic targets, improve quality of life, add greater convenience, potentially reduce burden of care, and offer a personalized approach to self-management. Furthermore, diabetes technology can improve the efficiency and effectiveness of clinical decision-making. Successful integration of these technologies into care requires knowledge about the functionality of devices in this rapidly changing field. This information will allow health care professionals to provide necessary education and training to persons accessing these treatments and have the required expertise to interpret data and make appropriate treatment adjustments.

The Use of Technology in Managing Diabetes in Youth Part 2-Insulin Pump Technologies: Information and Tips for the School Nurse

Insulin pump technologies are commonly used by youth with type 1 diabetes (T1D) for intensive insulin therapy, the gold standard for T1D care. Insulin pump technologies are advancing rapidly, with new insulin pumps becoming available every year offering improvements in glycemic control. School nurses must understand the basics of insulin pump therapy and distinguish between advanced pump technologies to best support their students with T1D. This is the second article in a three-part series on the use of technology in managing diabetes in youth. The first article described continuous glucose monitoring (CGM) devices and provided tips for the school nurses in incorporating CGM into the student's individualized healthcare plan. The purpose of this article is to summarize insulin pump technologies, from conventional insulin pump therapy to advanced automated insulin delivery systems and to describe keys to success with insulin pump technologies. Part 3 will focus on special considerations and problem solving related to technology use in the school setting.

How does a predictive low glucose suspend (PLGS) system tackle pediatric lifespan challenges in diabetes treatment? Real world data analysis

OBJECTIVES

The aim of the study was to assess the benefits of a predictive low glucose suspend (PLGS) system in real-life in children and adolescents with type 1 diabetes of different age and age-related clinical challenges.

METHODS

Real life retrospective and descriptive analysis included 44 children (26 girls) with type 1 diabetes who were introduced to PLGS system. We divided them in three age groups: I (3-6 years old, n = 12), II (7-10 y/o, n = 16), III (11-19 y/o, n = 16). All children and their caregivers received unified training in self-management during PLGS therapy. Patients' data included: age, HbA1C levels, sex. While from the CGM metric, we obtained: time of sensor use (SENSuse), time in range (TiR): in, below and over target range and average blood glycemia (AVG), insulin suspension time (INSsusp).

RESULTS

SENSuse was 93% in total, with 92%, 94%, and 87% in age groups I, II, III, respectively. In total the reduction of mean HbA1C from 7.61% to 6.88% (P < .05), while for the I, II, and III it was 7.46% to 6.72%, 6.91% to 6.41%, and 8.46 to 7.44%, respectively (P < .05). Although we observed a significant reduction of HbA1C, the time below target range was minimal. Specific findings included: group I-longest INSsusp (17%), group II-lowest glycemic variability (CV) (36%), and group III-highest AVG (169 mg/dL). There was a reverse correlation between suspend before low and age (-0.32, P < .05). In group I CV reduced TiR in target range (TiRin) (-0.82, P < .05), in group II use of complex boluses increased TiRin (0.52, P < .05). In group III higher CV increased HbA1C (0.64, P < .05) while reducing TiRin (-0.72, P < .05).

CONCLUSIONS

PLGS is a suitable and safe therapeutic option for children with diabetes of all age and it is effective in addressing age-specific challenges. PLGS improves glycemic control in children of all age, positively affecting its different parameters.

The Development and Psychometric Validation of the Diabetes Impact and Device Satisfaction Scale for Individuals with Type 1 Diabetes

BACKGROUND

With the rapid development of new insulin delivery technology, measuring patient experience has become especially pertinent. The current study reports on item development, psychometric validation, and intended use of the newly developed Diabetes Impact and Device Satisfaction (DIDS) Scale.

METHOD

The DIDS Scale was informed by a comprehensive literature review, and field tested as part of two focus groups. The finalized measure was used at baseline and 6 months post-assessment with a large US cohort. Exploratory factor analyses (EFAs) were conducted to determine and confirm factor structure and item selection. Internal reliability, test-retest reliability, and convergent/divergent validity of the emerged factors were tested with demographics, diabetes-specific information, and diabetes behavioral and satisfaction measures.

RESULTS

In all, 778 participants with type 1 diabetes (66% female, mean age 47.13 ± 17.76 years, 74% insulin pump users) completed surveys at both baseline and post-assessment. EFA highlighted two factors-Device Satisfaction (seven items, Cronbach's α = 0.85-0.90) and Diabetes Impact (four items, Cronbach's α = 0.71-0.75). DIDS Scale demonstrated good concurrent validity and test-retest reliability.

CONCLUSION

The DIDS Scale is a novel and a brief assessment tool with robust psychometric properties. It is recommended for use across all insulin delivery devices and is considered appropriate for use in longitudinal studies. Future studies are recommended to evaluate the performance of DIDS Scale in diverse populations with diabetes.

How Many Grays to Get to the Malfunction of Insulin Pumps? Determining the Effects of Radiation on Insulin Pump Function

BACKGROUND

The primary objective was to determine if exposure to radiation has an effect on insulin pump function.

METHOD

Four donated insulin pumps were filled with saline and set to identical program modes. They were attached together with a dosimeter and exposed to repeat CT scans.

RESULTS

Insulin Pump 1 experienced a "Prime" alarm and a darkened screen during CT scan radiation exposure; this pump was removed from further radiation exposure after 6 CT scans. Insulin Pumps 2, 3, and 4 all continued to receive 34 more consecutive CT scan exposures with no significant alarms, failures, or malfunctions. Insulin Pump 4 experienced "Low Battery" and "Stuck Button" alarms, both of which were easily fixed. Insulin Pumps 2, 3, and 4 received a total of at least 8576 mrem from 34 CT scans worth of radiation without any significant alarms, malfunctions, or failures. Insulin Pump 1 was monitored after being removed from the study and continued to function normally with the darkened screen.

CONCLUSIONS

It cannot be determined whether Insulin Pump 1 had minor malfunctions due to repetitive use as a demonstration model or due to the radiation exposure. Insulin Pumps 2, 3, and 4 were monitored for 2 additional months following radiation exposure and continued to function normally. Further research studies with a larger number of insulin pumps are warranted to determine the true effect of radiation exposure on insulin pump function.

Developing a Simple 3-Day Insulin Delivery Device to Meet the Needs of People With Type 2 Diabetes

AIM

We sought to design an insulin delivery method that would overcome barriers to insulin therapy and meet the needs of the users, adults with diabetes, and their health care providers (HCPs).

METHODS

We conducted focus groups and human factors studies with users to learn about their needs and requirements. We then designed an insulin delivery device, PAQ, with features that met the user's requirements. Iterative design and human factors testing (HFT) was performed with adults with diabetes on ⩾2 injections/day and HCPs. In parallel, studies were conducted to identify an adhesive that stayed adhered for 3 days and caused minimal, if any, dermal irritation. Pilot clinical studies were then initiated.

RESULTS

Users want a way to administer insulin that is simple, discreet, safe, and effective. A summative HFT found the device was easy to learn and use. All participants (30/30, 100%) successfully completed the key performance measures tested. An adhesive validation study in 30 adults with diabetes found 90% of the devices remained adhered to the participant's application site at the end of 3 days with minimal skin irritation. Data from 3 clinical studies revealed 74-75% transitioned from injectable insulin to the device with the first fixed basal rate selected, improved glycemic control, and participants' satisfaction with the device.

CONCLUSION

The collective data from the HFT, adhesive, and clinical studies demonstrated that the device provides a method of insulin delivery that overcomes barriers to injectable insulin, meets the needs of the user, and achieves glycemic control.

Patch Pumps: Are They All the Same?

Insulin pumps are used by a steadily increasing number of patients with diabetes. Avoiding certain disadvantages of conventional pumps (ie, the insulin infusion set) might make pump therapy even more attractive. Patch pumps are usually attached by means of an adhesive layer to the skin and have several additional advantages (smaller, more discrete, easier to use, and cheaper than conventional insulin pumps). This review provides a general overview of patch pumps, the technologies used, basic clinical requirements, why a number of developments failed, which clinical studies are needed to provide sufficient evidence for their usage, which costs are associated, what the patient preferences are (which might differ between certain patient groups), and what is the future of patch pumps (ie, artificial pancreas systems).