Effect of artificial pancreas systems on glycaemic control in patients with type 1 diabetes: a systematic review and meta-analysis of outpatient randomised controlled trials

Efficacy and Safety of a Non-Carbohydrate Counting Meal Bolus Strategy in Adults with Type 1 Diabetes Using Open-Source Automated Insulin Delivery

Aims: This study addressed the challenge of postprandial glycemic variability in type 1 diabetes (T1D), even with AID (automated insulin delivery). We evaluated the effectiveness of a non-carbohydrate counting (non-CC) meal bolus strategy in adults with T1D utilizing open-source AID. Methods: A total of 32 adults with T1D, aged 18 to 50 years, participated in a randomized crossover trial utilizing open-source AID. Following a 7-day run-in period, participants were randomly assigned to one of two groups: automatic mode (closed loop) or manual mode (open loop). After 2 weeks, the participants underwent a crossover to the alternate treatment mode. Prandial boluses were administered according to a sliding scale based on preprandial glucose levels, without utilizing either the exact carbohydrate content of meals or meal announcement buttons. The study compared the differences in time in range (TIR) and insulin dosage across the different phases. Results: Compared with the open-loop phase, the TIR for patients during the closed-loop phase increased significantly during the night (75.45% ± 12.08% vs. 83.05% ± 7.20%, P < 0.001) and 24 h (73.40% ± 9.98% vs. 79.21% ± 4.84%, P = 0.019), with a more pronounced effect observed at night. During the closed-loop phase, the frequency of 24-h hypoglycemic events (＜3.9 mmol/L) was reduced compared with the open-loop phase, with no difference in nocturnal hypoglycemic events. In addition, compared with the open-loop phase, there were no significant differences in average postprandial blood glucose and peak blood glucose levels during the closed-loop phase; however, the time to reach peak postprandial blood glucose was delayed (86.06 ± 20.80 min vs. 99.08 ± 15.05 min, P < 0.001). Conclusions: A non-CC meal bolus strategy based on preprandial glucose in adults with T1D utilizing open-source AID effectively prevents glycemic excursions and maintains a mean TIR over 70%.

Tips for successful use of commercial automated insulin delivery systems: An expert paper of the Italian working group on diabetes and technology

In recent years, automated insulin delivery (AID) systems have transformed diabetes care with demonstrated benefits in glucose control, hypoglycemia risk, and psychosocial outcomes. Given that different systems show peculiarities in terms of components, approved indications of use, type of algorithm, modifiable settings, and additional features, with this expert paper, we aim to provide healthcare professionals with device-specific recommendations for the optimization of insulin therapy and diabetes self-management with the five commercial AID systems most commonly used in Italy. In detail, we provide educational tips and suggestions for adjustment of insulin dosing parameters to address specific glucose patterns as depicted by continuous glucose monitoring data and effectively manage physical activity or exercise.

One-year real-world benefits of Tandem Control-IQ technology on glucose management and person-reported outcomes in adults with type 1 diabetes: a prospective observational cohort study

AIMS/HYPOTHESIS

This multicentre prospective observational cohort study aimed to evaluate real-world changes in glycaemic and person-reported outcomes after 1 year's use of Control-IQ technology in adults with type 1 diabetes.

METHODS

Adults who started with Control-IQ between December 2021 and December 2022 were consecutively recruited in 13 Belgian diabetes centres. Data were collected at start and after 4, 8 and 12 months. The primary endpoint was the evolution of time in range (TIR; glucose levels of 3.9-10.0 mmol/l). Data are reported as mean ± SD or least-squares mean (95% CI).

RESULTS

A total of 473 adults were included, with a mean age of 38.5 ± 13.1 years and of whom 57.3% were female. TIR increased from 58.8% (95% CI 56.7, 60.9) at start to 70.9% (69.1, 72.8) at 12 months (p<0.001). HbA1c decreased from 57.3 mmol/mol (56.1, 58.5) (7.4% [7.3, 7.5]) to 49.5 mmol/mol (48.5, 50.6) (6.7% [6.6, 6.8]) and time <3.9 mmol/l from 4.2% (3.9, 4.6) to 1.9% (1.8, 2.1) (all p<0.001). Participants scored better on the Hypoglycaemia Fear Survey version 2 worry (22.5 [21.3, 23.7] vs 18.1 points [17.0, 19.3]), the Problem Areas in Diabetes - Short Form (7.2 [6.7, 7.8] vs 6.1 points [5.5, 6.7]), and the Diabetes Treatment Satisfaction Questionnaire status (25.5 [24.8, 26.2] vs 31.0 points [30.4, 31.6]) (all p<0.001). The number of self-reported severe hypoglycaemia events (37.5 [21.3, 65.9] vs 15.7 [9.7, 25.3] events per 100 person-years, p=0.002) and work absenteeism days (116.3 [42.8, 315.5] vs 69.3 [25.4, 189.2] days per 100 person-years, p=0.034) decreased.

CONCLUSIONS/INTERPRETATION

One-year use of Control-IQ was associated with better glucose management, improved diabetes-related quality of life, more treatment satisfaction, less severe hypoglycaemia and less work absenteeism in adults with type 1 diabetes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04414280.

Social disadvantage and technology use among adults with type 1 diabetes in Quebec: A cross-sectional study using data from the Canadian T1D (BETTER) Registry

AIMS

We evaluated associations between social disadvantage and insulin pump and continuous glucose monitor (CGM) use among adults with type 1 diabetes (T1D) in Quebec, Canada, where public funding is available for CGM but not for insulin pumps.

MATERIALS AND METHODS

We conducted a cross-sectional analysis using self-reported survey data collected from April 2019 to October 2023. Primary exposures were social disadvantage indicators (Race, income, education, employment, insurance, immigration, rural/urban location). Primary outcomes were insulin pump and CGM use. Logistic regression was used to assess associations between social disadvantage indicators and the odds of insulin pump and CGM use.

RESULTS

Among 2380 adults with T1D, 37.4% used insulin pumps and 82.5% used CGM. Insulin pump use was lower among those with income <$80 000 (odds ratio [OR] 0.64 [95% confidence interval 0.50-0.82]), no post-secondary education (OR 0.62 [0.46-0.85]), non-White Race (OR 0.47 [0.30-0.73]) and public insurance (OR 0.47 [0.35-0.62]). CGM use was lower only among those with income <$80 000 (OR 0.61 [0.45-0.83]) and public insurance (OR 0.61 [0.45-0.83]). Odds of insulin pump and CGM use were successively lower with an increasing number of social disadvantage indicators. Insulin pump and CGM use were both associated with lower HbA1c but not severe hypoglycaemia or diabetes hospitalisation.

CONCLUSIONS

Social disadvantage is associated with lower uptake of insulin pumps and CGM among Quebec adults with T1D, though public funding partially mitigates disparities in CGM use. Given the benefits and increasing recommendations for automated insulin delivery, strategies to increase the uptake of diabetes technologies among socially disadvantaged individuals are required.

PLAIN LANGUAGE SUMMARY

Social disadvantage is linked to lower use of insulin pumps and CGM in adults with T1D in Quebec. Public funding narrows CGM disparities, but broader equity strategies are needed.

Real-world evidence supporting the use of advanced hybrid closed loop in poorly controlled type 1 diabetes patients

BACKGROUND

The advanced hybrid closed loop (a-HCL) algorithm includes automated basal and correction bolus insulin with customizable glucose targets. This study aimed to evaluate the effectiveness of a-HCL compared to predictive low glucose suspension (PLGS) and standard hybrid closed-loop (s-HCL) systems and to identify patient populations experiencing the greatest glycemic improvement after transitioning to a-HCL.

METHODS

This retrospective study included type 1 diabetes patients at the University Hospital Zurich, Switzerland, who transitioned from PLGS or s-HCL to a-HCL between January 2020 and December 2021. Glycemic metrics, including HbA1c, time in range (TIR), time above range (TAR), time below range (TBR), sensor glucose (SG), and coefficient of variation (CV), were analyzed pre-and post-a-HCL implementation, considering clinical parameters influencing outcomes.

RESULTS

Among 71 patients, a-HCL implementation significantly reduced in HbA1c (7.2 ± 0.9 % to 6.8 ± 0.5 %, p < 0.001), SG (8.8 ± 1.4 mmol/L to 7.8 ± 0.8 mmol/L, p < 0.001), TAR (26.3 % to 17.3 %, p < 0.001) and increased TIR (68.5 % to 79.8 %, p < 0.001). TBR and CV showed no significant changes. Improvements were most pronounced in patients with higher baseline HbA1c, SG, CV and lower TIR, all indicators of poor glycemic control, and a BMI > 30 kg/m2.

CONCLUSIONS

Our findings support a-HCL utilization across all patients, particularly in poorly controlled type 1 diabetes patients.

The Glycemic Impact of Protein Ingestion in People With Type 1 Diabetes

In individuals with type 1 diabetes, carbohydrate is commonly recognized as the primary macronutrient influencing postprandial glucose levels. Accumulating evidence indicates that protein ingestion also contributes to the increment in postprandial glucose levels, despite endocrine and metabolic responses different from those with carbohydrate ingestion. However, findings regarding protein ingestion's glycemic effect in people with type 1 diabetes are equivocal, with the magnitude of glycemic response seemingly dependent on the rate of absorption and composition of protein ingested. Therefore, the aim of this article is to outline the physiological mechanisms by which ingested protein influences blood glucose regulation in individuals with type 1 diabetes and provide clinical implications on use of dietary protein in the context of glycemic management. Specifically, protein ingestion raises plasma amino acid levels, which directly or indirectly (via gut hormones) stimulates glucagon secretion. Together with the increase in gluconeogenic precursors and an absent endogenous insulin response in individuals with type 1 diabetes, this provides a synergistic physiological environment for increased endogenous glucose production and subsequently increasing circulating glucose levels for several hours. While there is a dearth of well-controlled studies in this area, we provide clinical implications and directions for future research regarding the potential for using ingestion of fast-absorbing protein (such as whey protein) as a tool to prevent and mitigate overnight- and exercise-induced hypoglycemia in people with type 1 diabetes.

Understanding inequities in access to diabetes technologies in children and young people with type 1 diabetes: Qualitative study of healthcare professionals' perspectives and views

AIMS

We explored healthcare professionals' perceptions and understandings of the factors and considerations underlying inequities in technology access in children and young people (CYP) with type 1 diabetes.

METHODS

We interviewed (n = 29) healthcare professionals working in paediatric diabetes in England recruited from (n = 15) purposively selected sites. We analysed data thematically.

RESULTS

Interviewees highlighted multiple, often overlapping barriers to accessing technology faced by CYP with type 1 diabetes from deprived and/or ethnic minority backgrounds. They described the impacts of deprivation on technology uptake, together with the complex social, ethnic and cultural factors that could also reinforce disparities in technology access. Interviewees further highlighted staffing shortfalls as a significant barrier to supporting CYP to use technology, especially those from under-represented groups who they perceived as requiring more staff time to be trained to use technology. While interviewees suggested that unconscious bias has become less prominent, they reported being less likely to recommend technology (especially pumps) to CYP/caregivers who they feared would not use it safely and effectively (e.g. those with low literacy levels). Interviewees also highlighted geographical variability in the technology commissioning process (a 'postcode lottery').

CONCLUSIONS

Our findings suggest that without targeted interventions, technology inequities may continue to persist amongst CYP from the most and least deprived areas and from white and ethnic minority groups in the United Kingdom. Additionally, our findings suggest that closing the technology gap will require large-scale governmental and health policies aimed at fostering socioeconomic, ethnic and cultural equality alongside targeted measures to improve technology accessibility.

Review of Patient Perspectives and Psychosocial Experiences With Automated Insulin Delivery in Pregnancy With Type 1 Diabetes

Pregnancy adds unique medical and psychosocial complexity to the management of type 1 diabetes (TID). Automated insulin delivery (AID) use in pregnancy increasingly shows promise both in improving clinical outcomes and the patient experience for individuals living with T1D. Survey and qualitative data on psychosocial correlates of AID use in pregnancy demonstrate patient benefits compared with other glucose management strategies (such as multiple daily injections, continuous subcutaneous insulin infusion, or sensor-augmented pump therapy). Benefits include improved patient well-being, flexibility, and improved collaboration with health care provider teams. However, burdens have also been identified, including technical glitches, device maintenance, device bulk/visibility, frequent alarms, and the overwhelming quantity of available data. This review describes the lived experiences and perspectives of pregnant individuals with T1D using AID systems. Ongoing education and support for both patients and providers may help to maximize the psychosocial benefits of AID use and reduce potentially negative aspects for pregnant individuals with T1D. While AID represents a significant opportunity for optimizing glucose management for individuals with T1D, both patients and providers need to have realistic expectations based on evidence of what such systems can and cannot do.

A Multidisciplinary Approach of Type 1 Diabetes: The Intersection of Technology, Immunotherapy, and Personalized Medicine

Background: Type 1 diabetes (T1D) is a chronic autoimmune disorder characterized by the destruction of pancreatic β-cells, leading to absolute insulin deficiency. Despite advancements in insulin therapy and glucose monitoring, achieving optimal glycemic control remains a challenge. Emerging technologies and novel therapeutic strategies are transforming the landscape of T1D management, offering new opportunities for improved outcomes. Methods: This review synthesizes recent advancements in T1D treatment, focusing on innovations in continuous glucose monitoring (CGM), automated insulin delivery systems, smart insulin formulations, telemedicine, and artificial intelligence (AI). Additionally, we explore biomedical approaches such as stem cell therapy, gene editing, immunotherapy, gut microbiota modulation, nanomedicine-based interventions, and trace element-based therapies. Results: Advances in digital health, including CGM integration with hybrid closed-loop insulin pumps and AI-driven predictive analytics, have significantly improved real-time glucose management. AI and telemedicine have enhanced personalized diabetes care and patient engagement. Furthermore, regenerative medicine strategies, including β-cell replacement, CRISPR-based gene editing, and immunomodulatory therapies, hold potential for disease modification. Probiotics and microbiome-targeted therapies have demonstrated promising effects in maintaining metabolic homeostasis, while nanomedicine-based trace elements provide additional strategies to regulate insulin sensitivity and oxidative stress. Conclusions: The future of T1D management is shifting toward precision medicine and integrated technological solutions. While these advancements present promising therapeutic avenues, challenges such as long-term efficacy, safety, accessibility, and clinical validation must be addressed. A multidisciplinary approach, combining biomedical research, artificial intelligence, and nanotechnology, will be essential to translate these innovations into clinical practice, ultimately improving the quality of life for individuals with T1D.

Automated Insulin Delivery in Pregnancies Complicated by Type 1 Diabetes

Automated insulin delivery (AID) systems adapt insulin delivery via a predictive algorithm integrated with continuous glucose monitoring and an insulin pump. Automated insulin delivery has become standard of care for glycemic management of people with type 1 diabetes (T1D) outside pregnancy, leading to improvements in time in range, with lower risk for hypoglycemia and improved treatment satisfaction. The use of AID facilitates optimal preconception care, thus more women of reproductive age are becoming pregnant while using AID. The effectiveness and safety in pregnant populations of using AID systems with algorithms for non-pregnant populations may be impacted by requirements for lower glucose targets and existence of increased insulin resistance during gestation. The CamAPS FX is the only AID system approved for use in pregnancy. A large randomized controlled trial (RCT) with this AID system demonstrated a 10.5% increase in time in pregnancy range (an additional 2.5 hours/day) compared with standard insulin therapy in pregnant women with T1D with a baseline glycated hemoglobin A1c (HbA1c) ≥48 mmol/mol (6.5%). A RCT of AID not approved for use in pregnancy (MiniMed 780G) has also demonstrated some benefits of AID compared with standard insulin therapy with improved time in pregnancy range overnight (24 minutes), less hypoglycemia, and improved treatment satisfaction. There is also increasing evidence that AID can be safely continued during delivery and postpartum, while maintaining glycemic goals with lower risk for hypoglycemia. More AID systems are needed with flexible glucose targets in the pregnancy range and possibly with algorithms that better adapt to changing insulin requirements. More evidence is needed on the impact of AID on maternal and neonatal outcomes. We review the current evidence on the use of AID in pregnancy and postpartum.

Efficacy and Safety of Automated Insulin Delivery Systems in Patients with Type 1 Diabetes Mellitus: A Systematic Review and Meta-Analysis

BACKGRUOUND

Automated insulin delivery (AID) systems studies are upsurging, half of which were published in the last 5 years. We aimed to evaluate the efficacy and safety of AID systems in patients with type 1 diabetes mellitus (T1DM).

METHODS

We searched PubMed, Embase, Cochrane Library, Web of Science, and ClinicalTrials.gov until August 31, 2023. Randomized clinical trials that compared AID systems with other insulin-based treatments in patients with T1DM were considered eligible. Studies characteristics and glycemic metrics was extracted by three researchers independently.

RESULTS

Sixty-five trials (3,623 patients) were included. The percentage of time in range (TIR) was 11.74% (95% confidence interval [CI], 9.37 to 14.12; P<0.001) higher with AID systems compared with control treatments. Patients on AID systems had more pronounced improvement of time below range when diabetes duration was more than 20 years (-1.80% vs. -0.86%, P=0.031) and baseline glycosylated hemoglobin lower than 7.5% (-1.93% vs. -0.87%, P=0.033). Dual-hormone full closed-loop systems revealed a greater improvement in TIR compared with hybrid closed-loop systems (-19.64% vs. -10.87%). Notably, glycemia risk index (GRI) (-3.74; 95% CI, -6.34 to -1.14; P<0.01) was also improved with AID therapy.

CONCLUSION

AID systems showed significant advantages compared to other insulin-based treatments in improving glucose control represented by TIR and GRI in patients with T1DM, with more favorable effect in euglycemia by dual-hormone full closedloop systems as well as less hypoglycemia for patients who are within target for glycemic control and have longer diabetes duration.

Cost-effectiveness of advanced hybrid closed loop therapy compared to standard insulin therapy for type 1 diabetes in pregnancy: an economic evaluation of the CRISTAL trial

Background

A multicentre, randomised controlled trial (the CRISTAL trial), demonstrated the safety and efficacy of MiniMed™ 780G advanced hybrid closed loop (AHCL) therapy during pregnancy, showing improved glycaemic control overnight, less hypoglycaemia, and improved treatment satisfaction compared to standard insulin therapy (SoC, mainly open-loop insulin pump therapy). This study aimed to assess the cost-effectiveness of AHCL, which has a higher initial cost, compared to SoC in pregnant women with type 1 diabetes (T1D).

Methods

A decision tree model was developed to estimate the cost-effectiveness of AHCL compared to SoC in pregnant women with T1D, covering pregnancy to birth and postpartum hospital discharge (a time horizon of 28 weeks). Total costs per strategy (in 2024 euros, €) were calculated from a healthcare payer perspective. The base-case analysis derived prevalence of pregnancy complications and hospitalisations directly related to diabetes management from the CRISTAL trial. Uncertainty was analysed by exploring multiple scenarios and sensitivity analyses.

Findings

In the base-case analysis, the cost of using AHCL during pregnancy was estimated at €13,988.75 (95% CI: €12,240 to €16,062) compared to €14,221.33 (95% CI: €12,380 to €16,420) for SoC, indicating cost-savings of €232.57 per individual, alongside the demonstrated clinical benefits of AHCL. The primary cost driver was the AHCL device cost. This cost was offset by savings from shorter and less frequent hospital admissions (mainly due to severe hypoglycaemia and dysregulated diabetes) in the AHCL group compared to SoC. In our probabilistic sensitivity analysis, AHCL was dominant in 73% of the simulated cost-effectiveness pairs.

Interpretation

AHCL might be cost-saving compared to SoC for pregnant women with T1D. However, more robust data are needed to assess the potential impact of AHCL therapy on pregnancy and long-term health outcomes.

Funding

Diabetes Liga Research Fund and Medtronic.

First validity testing of GluciQuizz, a French self-questionnaire evaluating carb-counting for patients with type 1 diabetes

OBJECTIVE

Carbohydrate intake remains one of the most influential factors affecting post-meal glucose levels in type 1 diabetes (T1D). To individualize and optimize patient education on carbohydrate counting, it is essential to assess their knowledge of carbohydrate counting. For this purpose, we aimed to produce and validate a questionnaire for French-speaking individuals based on the American AdultCarbQuiz questionnaire (43 items).

DESIGN

The translation and cross-cultural adaptation of the American questionnaire were followed by an analysis conducted by patient and diabetologist expert groups.

PARTICIPANTS

190 participants living with T1D, Diabetologist expert group.

MAIN OUTCOME MEASURE(S)

Internal consistency and reliability were verified by administering the adapted French version of the questionnaire to 190 participants living with T1D.

ANALYSIS

Clinical validity was verified by examining the correlation between the questionnaire score and the time in range (TIR) of these participants.

RESULTS

Translation and back-translation demonstrated good consistency with the original questionnaire. Typical American food items were replaced with foods commonly consumed in France. All items were validated by both patient and diabetologist experts. After analyzing the responses of 190 participant, seven items were considered non-discriminatory and were therefore removed. Internal consistency, assessed by Cronbach's α, was high, with α =  0.785, 95 CI [0.738-0.826]. Finally, we produced a 36 item French questionnaire named GluciQuizz. TIR correlated with the GluciQuizz score (r =  0.3; p  <  0.0001).

CONCLUSIONS AND IMPLICATIONS

This study validates a French-language self-administered questionnaire (GluciQuizz), which evaluates different domains of carbohydrate knowledge in a 15-minute quiz for people living with T1D.

Metabolic syndrome in type 1 diabetes: higher time above range and glycemic variability revealed by continuous glucose monitoring (CGM)

AIMS

To investigate the glucose profile of Chinese individuals with type 1 diabetes (T1D) who also have metabolic syndrome.

MATERIALS AND METHODS

Type 1 diabetes participants from Peking University People's Hospital were recruited from Jan 2017 to Jan 2024. The diagnosis of metabolic syndrome was developed based on the updated National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATPIII) criteria. Demographic data, anthropometric measurements, clinical information and continuous glucose monitoring (CGM) data were collected and compared between participants with metabolic syndrome and those without.

RESULTS

The median age of the participants was 50.0 years (IQR 35.0-63.3), and the median duration was 10.0 years (IQR 2.0-17.0). Compared to those without metabolic syndrome, participants with metabolic syndrome were older (63.0 years, IQR 41.0-69.0 vs. 48.5 years, IQR 35.0-60.0; P < 0.001) and had a longer duration (13.0 years, IQR 5.0-22.0 vs. 9.0 years, IQR 2.0-15.0; P = 0.011). The comparison of CGM metrics suggested significantly higher time above range (TAR, 48.9%, IQR 35.3-59.5 vs. 32.8%, IQR 16.1-47.6; P < 0.001), standard deviation (SD, 3.6 ± 0.9 mmol/L vs. 3.2 ± 1.0 mmol/L; P = 0.022) and interquartile range (IQR, 4.2 mmol/L, IQR 3.2-4.8 vs. 3.7 mmol/L, IQR 3.0-4.5; P = 0.046) in those with metabolic syndrome. And the Logistic regression analysis showed that TAR (OR 1.53, 95% CI 1.02-2.23, per 20% increase), SD ( OR 1.75, 95% CI 1.07-2.84, P = 0.025) and IQR (OR 1.50, 95% CI 1.03-2.19, P = 0.036) were positively associated with metabolic syndrome after adjusting for age, sex, diabetes duration, BMI and complication status.

CONCLUSIONS

Our findings suggested that in T1D participants, metabolic syndrome was associated with higher glucose level and glycemic variability. Personalized diabetes education including optimal meal planning and sufficient physical activity should be emphasized to improve glycemic control in T1D with metabolic syndrome.

The epidemiology of type 1 diabetes mellitus in older adults

Although type 1 diabetes mellitus (T1DM) is traditionally viewed as a youth-onset disorder, the number of older adults being diagnosed with this disease is growing. Improvements in the average life expectancy of people with T1DM have also contributed to the growing number of older people living with this disease. We summarize the evidence regarding the epidemiology (incidence, prevalence and excess mortality) of T1DM in older adults (ages ≥60 years) as well as the genetics, immunology and diagnostic challenges. Several studies report an incidence peak of T1DM in older adults of a similar size to or exceeding that in children, and population prevalence generally increases with increasing age. Glutamic acid decarboxylase antibody positivity is frequently observed in adult-onset T1DM. Guidelines for differentiating T1DM from type 2 diabetes mellitus in older adults recommend measuring levels of C-peptide and autoantibodies, including glutamic acid decarboxylase antibodies. However, there is no gold standard for differentiating T1DM from type 2 diabetes mellitus in people aged 60 years and over. As such, the global variation observed in T1DM epidemiology might be in part explained by misclassification, which increases with increasing age of diabetes mellitus onset. With a growing global population of older adults with T1DM, improved genetic and immunological evidence is needed to differentiate diabetes mellitus type at older ages so that a clear epidemiological picture can emerge.

Simplified meal announcement study (SMASH) using hybrid closed-loop insulin delivery in youth and young adults with type 1 diabetes: a randomised controlled two-centre crossover trial

AIMS/HYPOTHESIS

The majority of hybrid closed-loop systems still require carbohydrate counting (CC) but the evidence for its justification remains limited. Here, we evaluated glucose control with simplified meal announcement (SMA) vs CC in youth and young adults with type 1 diabetes using the mylife CamAPS FX system.

METHODS

We conducted a two-centre, randomised crossover, non-inferiority trial in two University Hospitals in Switzerland in 46 participants (aged 12-20 years) with type 1 diabetes using multiple daily injections (n=35), sensor-augmented pump (n=4) or hybrid closed-loop (n=7) therapy before enrolment. Participants underwent two 3 month periods with the mylife CamAPS FX system (YpsoPump, Dexcom G6) to compare SMA (individualised carbohydrate meal sizes) with CC, in a randomly assigned order using computer-generated sequences. The primary endpoint was the proportion of time glucose was in target range (3.9-10.0 mmol/l) with a non-inferiority margin of 5 percentage points. Secondary endpoints were other sensor glucose and insulin metrics, usability and safety endpoints.

RESULTS

Forty-three participants (18 women and girls) completed the trial. In the intention-to-treat analysis, time in range (mean±SD) was 69.9±12.4% with SMA and 70.7±13.0% with CC (estimated mean difference -0.6 percentage points [95% CI -2.4, 1.1], demonstrating non-inferiority). Time <3.9 mmol/l (median [IQR] 1.8 [1.2-2.2]% vs 1.9 [1.6-2.5]%) and >10.0 mmol/l (28.2±12.6% vs 27.2±13.4%) was similar between periods. Total daily insulin dose was higher with SMA (54.0±14.7 U vs 51.7±12.1 U, p=0.037). Three participants experienced serious adverse events, none of which were intervention-related.

CONCLUSIONS/INTERPRETATION

Glucose control using the CamAPS FX algorithm with SMA was non-inferior to its use with CC in youth and young adults with type 1 diabetes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05481034.

FUNDING

The study was supported by the Swiss Diabetes Foundation and by a YTCR grant from the Bangerter-Rhyner Foundation and the Swiss Academy of Medical Sciences. Dexcom and Ypsomed provided product support.

The Feasibility of an Experimental Hypobaric Simulation to Evaluate the Safety of Closed-Loop Insulin Delivery Systems in Flight-Related Atmospheric Pressure Changes

Hybrid closed-loop (HCL) systems remain underexplored within aviation, and as atmospheric pressure changes can independently affect insulin pumps and continuous glucose monitoring readings, this preliminary study assessed the feasibility of HCL safety evaluation, in both fasting and post-prandial states, by using hypobaric chamber to simulate flights. Participants with type 1 diabetes and on HCL were studied: Medtronic Guardian 4-Medtronic 780G-SmartGuard (n = 4), Dexcom G6-Omnipod DASH-Android APS (n = 1), and Dexcom G6-Ypsomed Pump-CamAPS (n = 1). Flight cabin pressures of 550 mmHg and 750 mmHg were simulated in a hypobaric chamber. Seven-hundred-50 glucose measurements were taken, with glucose levels demonstrating a stable decline to 4 mmol/L during fasting. To maintain a tight fasting and post-prandial glucose range across the different pressure settings, the HCL administered insulin as expected. While not demonstrating any apparent issues, repeating flight simulation protocol with other systems, examining longer flights, and undertaking larger, powered randomised controlled trials can confirm their safety in aviation.

The Use of Freestyle Libre Glucose Monitoring System and Diabetes Treatment Progression in Type 2 Diabetes Mellitus: A Retrospective Cohort Study in Saudi Arabia

Background Type 2 diabetes mellitus (T2DM) is a prevalent chronic metabolic disease in Saudi Arabia, with a prevalence rate of approximately 25%. Traditional blood glucose monitoring methods, such as finger stick tests, provide limited insights into blood glucose measurements and fluctuations contributing to clinical inertia. The advent of continuous glucose monitoring (CGM) systems, such as the FreeStyle Libre glucose monitoring system, has transformed diabetes management by offering comprehensive exposure of glucose data to healthcare providers. Objective This study aims to evaluate the impact of the FreeStyle Libre glucose monitoring system on diabetes management intensification and treatment progression provided by healthcare specialists among T2DM patients in primary healthcare settings in Riyadh, Saudi Arabia. Methods An observational, retrospective, 24-week, two-arm study was conducted at Prince Sultan Military Medical City. The study involved 188 T2DM patients who were either using standard capillary glucose monitoring or transitioned to the FreeStyle Libre system, and it was based on clinical discretion rather than randomization. The primary outcomes were to evaluate the effect of FreeStyle Libre on treatment intensification provided by healthcare providers and changes in HbA1c levels. Data analysis included descriptive statistics and hypothesis testing using R software. Results Participants using the FreeStyle Libre glucose monitoring system experienced higher rates of medication intensification, and the use of insulin correction doses, and a significant reduction in median HbA1c levels was observed at three months (9.19% vs. 9.6%, p=0.047). However, at six months, the median HbA1c further reduced to 9.07%, though the difference between groups was not statistically significant. Despite these improvements, healthcare provider visits due to hyperglycemia were higher in the FreeStyle Libre group (p<0.001). There were no significant differences in hypoglycemia-related visits between the two groups (p=0.09). Conclusion The FreeStyle Libre glucose monitoring system was associated with increased treatment intensification and a significant reduction in HbA1c at three months compared to standard glucometers. However, by six months, the reduction in HbA1c was no longer statistically significant between groups. The increased healthcare provider visits in the FreeStyle Libre group may be attributed to heightened glucose monitoring awareness rather than the true worsening of hyperglycemia. While CGM offers advantages in diabetes management, its impact on long-term glycemic control remains uncertain. Further research is needed to confirm these findings, assess patient adherence, and evaluate the long-term effectiveness of continuous glucose monitoring in diabetes care.

Automated insulin delivery in pregnant women with type 1 diabetes: a systematic review and meta-analysis

AIM

The outcomes of automated insulin delivery (AID) systems in pregnant women with type 1 diabetes (T1D) have not been systematically evaluated. This study aims to evaluate the efficacy and safety of AID in pregnancy.

MATERIAL AND METHODS

Literature searches were conducted until July 5, 2024, on Embase, PubMed, Cochrane Library, and ClinicalTrials.gov website. We included clinical trials and observational studies evaluating AID systems in T1D pregnant individuals. Time in the target range (TIR, 3.5-7.8 mmol/L) was the primary outcome. Secondary outcomes included time below range (TBR, < 3.5 mmol/L), time above range (TAR, > 7.8 mmol/L), and maternal and neonatal outcomes.

RESULTS

Eighteen studies (550 participants) were included. Compared with standard care, AID did not improve 24-h TIR (mean differences [MD] 3.56%, 95% CI - 0.60 to 7.72). However, the overnight TIR increased by 10.05% (95% CI 6.57 to 13.53). The association between AID and decreased TBR (MD - 0.90%, 95% CI - 1.60 to - 0.20) was found, but not with deceased TAR. Only 7 of the 17 studies achieved the goal of a 24-h TIR above 70%. Additionally, the maternal and neonatal outcomes were comparable between AID and standard care, and AID might reduce maternal weight gain (MD - 2.54 kg, 95% CI - 3.96 to - 1.11).

CONCLUSIONS

AID did not exhibit favourable TIR when compared to standard care. However, AID could increase overnight TIR and decrease TBR. Available evidence indicates that employing AID to meet the target of a 24-h TIR above 70% remains challenging.

Addressing Disparities Using Continuous Glucose Monitors and Remote Patient Monitoring for Youth With Type 1 Diabetes

BACKGROUND

Youth with type 1 diabetes (T1D) and public insurance have lower diabetes technology use. This pilot study assessed the feasibility of a program to support continuous glucose monitor (CGM) use with remote patient monitoring (RPM) to improve glycemia for youth with established T1D and public insurance.

METHODS

From August 2020 to June 2023, we provided CGM with RPM support via patient portal messaging for youth with established T1D on public insurance with challenges obtaining consistent CGM supplies. We prospectively collected hemoglobin A1c (HbA1c), standard CGM metrics, and diabetes technology use over 12 months.

RESULTS

The cohort included 91 youths with median age at enrollment 14.7 years, duration of diabetes 4.4 years, 33% non-English speakers, and 44% Hispanic. Continuous glucose monitor data were consistently available (≥70%) in 23% of the participants. For the 64% of participants with paired HbA1c values at enrollment and study end, the median HbA1c decreased from 9.8% to 9.0% (P < .001). Insulin pump users increased from 31 to 48 and automated insulin delivery users increased from 11 to 38.

CONCLUSIONS

We established a program to support CGM use in youth with T1D and barriers to consistent CGM supplies, offering lessons for other clinics to address disparities with team-based, algorithm-enabled, remote T1D care. This real-world pilot and feasibility study noted challenges with low levels of protocol adherence and obtaining complete data in this cohort. Future iterations of the program should explore RPM communication methods that better align with this population's preferences to increase participant engagement.

Hypoglycemia in Pregnant Women with Type 1 Diabetes: Is It Inevitable?

The human body has abundant mechanisms to counteract hypoglycemia and prevent neuroglycopenia primarily involving the secretion of glucagon and adrenalin. Within several years from the onset of diabetes, people with type 1 diabetes lose their ability to mount a counterregulatory response to hypoglycemia and develop hypoglycemia unawareness, thus being at risk for deteriorating to a state of severe hypoglycemia and neuroglycopenia. Pregnant individuals with type 1 diabetes are particularly prone to experience severe hypoglycemia during the first half of pregnancy. This may be not only due to the institution of strict glycemic control and the nausea and vomiting prevalent during the early months of pregnancy, but also because the counterregulatory responses are further diminished during pregnancy. Severe hypoglycemia during early pregnancy does not appear to increase the risks of spontaneous abortion or congenital fetal malformations, but the potential long-term effects on the fetus are unknown. Recent technological advances have contributed to improved glycemic control and time in range as well as decreased risk of hypoglycemia in people with diabetes. These advances include treatment with insulin analogs, use of continuous glucose monitors, and closed-loop systems for administration of insulin. Limited studies have demonstrated that pregnant individuals with type 1 diabetes may also benefit from these modalities. While ongoing research continues to explore the adjustment of closed-loop systems for optimal use during pregnancy, more effort is needed to explore the optimal use of these modalities in pregnancy. KEY POINTS: · People with type 1 diabetes have diminished counterregulatory responses to hypoglycemia and frequently develop hypoglycemia unawareness.. · Pregnant individuals with type 1 diabetes are at increased risk for severe hypoglycemia particularly during the first half of pregnancy.. · Use of insulin analogs and newer technologies for insulin administration may lower the risk of hypoglycemia in pregnant individuals with type 1 diabetes..

Beyond Expected Patterns in Insulin Needs of People With Type 1 Diabetes: Temporal Analysis of Automated Insulin Delivery Data

Background

Type 1 diabetes (T1D) is a chronic condition in which the body produces too little insulin, a hormone needed to regulate blood glucose. Various factors such as carbohydrates, exercise, and hormones impact insulin needs. Beyond carbohydrates, most factors remain underexplored. Regulating insulin is a complex control task that can go wrong and cause blood glucose levels to fall outside a range that protects people from adverse health effects. Automated insulin delivery (AID) has been shown to maintain blood glucose levels within a narrow range. Beyond clinical outcomes, data from AID systems are little researched; such systems can provide data-driven insights to improve the understanding and treatment of T1D.

Objective

The aim is to discover unexpected temporal patterns in insulin needs and to analyze how frequently these occur. Unexpected patterns are situations where increased insulin does not result in lower glucose or where increased carbohydrate intake does not raise glucose levels. Such situations suggest that factors beyond carbohydrates influence insulin needs.

Methods

We analyzed time series data on insulin on board (IOB), carbohydrates on board (COB), and interstitial glucose (IG) from 29 participants using the OpenAPS AID system. Pattern frequency in hours, days (grouped via k-means clustering), weekdays, and months were determined by comparing the 95% CI of the mean differences between temporal units. Associations between pattern frequency and demographic variables were examined. Significant differences in IOB, COB, and IG across temporal dichotomies were assessed using Mann-Whitney U tests. Effect sizes and Euclidean distances between variables were calculated. Finally, the forecastability of IOB, COB, and IG for the clustered days was analyzed using Granger causality.

Results

On average, 13.5 participants had unexpected patterns and 9.9 had expected patterns. The patterns were more pronounced (d>0.94) when comparing hours of the day and similar days than when comparing days of the week or months (0.3

Conclusions

Our study shows that unexpected patterns in the insulin needs of people with T1D are as common as expected patterns. Unexpected patterns cannot be explained by carbohydrates alone. Our results highlight the complexity of glucose regulation and emphasize the need for personalized treatment approaches. Further research is needed to identify and quantify the factors that cause these patterns.

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Key Words

• OpenAPS
• clustering
• data-driven
• insulin needs
• k-means
• machine learning
• multivariate time series
• open dataset
• temporal patterns
• type 1 diabetes

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MESH Headings Collapse

Grants Collapse

Affiliation(s)

Isabella Degen Interactive Artificial Intelligence Centre for Doctoral Training, School of Computer Science, Faculty of Science and Engineering, University of Bristol, 1 Cathedral Square, College Green, Bristol, BS1 5DD, United Kingdom, 44 7726100905
Kate Robson Brown University College Dublin President's Office, College of Engineering and Architecture, University College Dublin, Dublin, Ireland
Henry W J Reeve School of Mathematics, Faculty of Science and Engineering, University of Bristol, Bristol, United Kingdom
Zahraa S Abdallah School of Engineering Mathematics and Technology, Faculty of Science and Engineering, University of Bristol, Bristol, United Kingdom

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Collaborators Collapse

Automated Insulin Delivery for Pregnant Women With Type 1 Diabetes: Where Do We Stand?

Automated insulin delivery (AID) systems mimic an artificial pancreas via a predictive algorithm integrated with continuous glucose monitoring (CGM) and an insulin pump, thereby providing AID. Outside of pregnancy, AID has led to a paradigm shift in the management of people with type 1 diabetes (T1D), leading to improvements in glycemic control with lower risk for hypoglycemia and improved quality of life. As the use of AID in clinical practice is increasing, the number of women of reproductive age becoming pregnant while using AID is also expected to increase. The requirement for lower glucose targets than outside of pregnancy and for frequent adjustments of insulin doses during pregnancy may impact the effectiveness and safety of AID when using algorithms for non-pregnant populations with T1D. Currently, the CamAPS® FX is the only AID approved for use in pregnancy. A recent randomized controlled trial (RCT) with CamAPS® FX demonstrated a 10% increase in time in range in a pregnant population with T1D and a baseline glycated hemoglobin (HbA1c) ≥ 48 mmol/mol (6.5%). Off-label use of AID not approved for pregnancy are currently also being evaluated in ongoing RCTs. More evidence is needed on the impact of AID on maternal and neonatal outcomes. We review the current evidence on the use of AID in pregnancy and provide an overview of the completed and ongoing RCTs evaluating AID in pregnancy. In addition, we discuss the advantages and challenges of the use of current AID in pregnancy and future directions for research.

Persistent disparities in insulin pump uptake despite a universal pump programme for type 1 diabetes in Ontario, Canada

AIM

To evaluate associations between social disadvantage and insulin pump use among adults with type 1 diabetes (T1D) in the context of a universal publicly funded insulin pump programme in Ontario, Canada, and to ascertain whether social disparities in insulin pump programme enrolment have decreased over time.

METHODS

Population-based cross-sectional studies were conducted using administrative healthcare data in Ontario, Canada. First, among adults aged older than 18 years diagnosed with T1D before 31 March 2021, logistic regression was used to assess the association between neighbourhood social disadvantage (Ontario marginalization index quintiles) and insulin pump use. Second, among all paediatric and adult applicants to the insulin pump programme from 1 September 2006 to 31 March 2022, ordinal logistic regression was used to evaluate associations between year of insulin pump initiation and social disadvantage.

RESULTS

Among 27 453 adults with T1D, 60% used insulin pumps. Greater social disadvantage was associated with lower odds of insulin pump use (adjusted odds ratio [OR] 0.44 [95% confidence interval {CI} 0.39-0.48] for greatest vs. lowest social disadvantage quintile). Among 21 002 paediatric and adult applicants to the insulin pump programme, social disparities in pump use decreased in the first 3 years of the programme, plateaued until 2020, then increased from 2020 to 2022, with no change in the odds of being in a higher social deprivation quintile for 2022 relative to 2007 (OR 1.09 [95% CI 0.83-1.44]).

CONCLUSIONS

Despite a universal pump programme for individuals with T1D, disparities by social disadvantage persist. Residual financial and non-financial barriers must be addressed to promote equitable insulin pump uptake.

Clinical evidence for high-risk CE-marked medical devices for glucose management: A systematic review and meta-analysis

AIMS

To conduct a systematic review and meta-analysis, within the Coordinating Research and Evidence for Medical Devices (CORE-MD) project, evaluating CE-marked high-risk devices for glucose management.

MATERIALS AND METHODS

We identified interventional and observational studies evaluating the efficacy and safety of eight automated insulin delivery (AID) systems, two implantable insulin pumps, and three implantable continuous glucose monitoring (CGM) devices. We meta-analysed randomized controlled trials (RCTs) comparing AID systems with other treatments.

RESULTS

A total of 182 studies published between 2009 and 2024 were included, comprising 166 studies on AID systems, six on insulin pumps, and 10 on CGM devices; 26% reported industry funding; 18% were pre-market; 37% had a comparator group. Of the studies identified, 29% were RCTs, 24% were non-randomized trials, and 47% were observational studies. The median (interquartile range) sample size was 48 (28-102), age 34.8 (14-44.2) years, and study duration 17.5 (12-26) weeks. AID systems lowered glycated haemoglobin by 0.5 percentage points (absolute mean difference [MD] = -0.5; 21 RCTs; I2 = 86%) and increased time in target range for sensor glucose level by 13.4 percentage points (MD = 13.4; 14 RCTs; I2 = 90%). At least one safety outcome was assessed in 71% of studies.

CONCLUSIONS

High-risk devices for glucose monitoring or insulin dosing, in particular AID systems, improve glucose control safely, but evidence on diabetes-related end-organ damage is lacking due to short study durations. Methodological heterogeneity highlights the need for developing standards for future pre- and post-market investigations of diabetes-specific high-risk medical devices.

Use of diabetes technology in children

Children with type 1 diabetes and their caregivers face numerous challenges navigating the unpredictability of this complex disease. Although the burden of managing diabetes remains significant, new technology has eased some of the load and allowed children with type 1 diabetes to achieve tighter glycaemic management without fear of excess hypoglycaemia. Continuous glucose monitor use alone improves outcomes and is considered standard of care for paediatric type 1 diabetes management. Similarly, automated insulin delivery (AID) systems have proven to be safe and effective for children as young as 2 years of age. AID use improves not only blood glucose levels but also quality of life for children with type 1 diabetes and their caregivers and should be strongly considered for all youth with type 1 diabetes if available and affordable. Here, we review key data on the use of diabetes technology in the paediatric population and discuss management issues unique to children and adolescents.

Real-world glycaemic outcomes of automated insulin delivery in type 1 diabetes: A meta-analysis

AIM

To evaluate the real-world effectiveness of automated insulin delivery (AID) systems in patients with type 1 diabetes (T1D).

MATERIALS AND METHODS

PubMed, Embase, the Cochrane Library, and ClinicalTrials.gov were searched for studies published up until 2 March 2024. We included pragmatic randomized controlled trials (RCTs), cohort studies, and before-after studies that compared AID systems with conventional insulin therapy in real-world settings and reported continuous glucose monitoring outcomes. Percent time in range (TIR; 3.9-10 mmol/L), time below range (TBR; <3.9 mmol/L), time above range (TAR; >10 mmol/L), and glycated haemoglobin (HbA1c) level were extracted. Data were summarized as mean differences (MDs) with 95% confidence interval.

RESULTS

A total of 23 before-after studies (101 704 participants) were included in the meta-analysis. AID systems were associated with an increased percentage of TIR (11.61%, 10.47 to 12.76; p < 0.001). The favourable effect of AID systems was consistently observed when used continuously for 6 (11.76%) or 12 months (11.33%), and in both children (12.16%) and adults (11.04%). AID systems also showed favourable effects on TBR (-0.53%, -0.63 to -0.42), TAR (-9.65%, -10.63 to -8.67) and HbA1c level (-0.42%, -0.47 to -0.37) when compared with previous treatments.

CONCLUSIONS

Similar improvements in glycaemic parameters were observed in real-world settings in RCTs using AID systems in T1D. AID systems benefit both children and adults by increasing TIR for both short- and long-term interventions.

Three months use of Hybrid Closed Loop Systems improves glycated hemoglobin levels in adolescents and children with type 1 diabetes: A meta-analysis

BACKGROUND

Longer outpatient studies have demonstrated that hybrid closed loop (HCL) use has led to a concomitant reduction in glycated hemoglobin(HbA1c) by 0.3%-0.7%. However, reports have also indicated that HbA1c levels are not declined in the long-term use of HCL. Therefore, we wonder that 3 months use of HCL could improve glycated hemoglobin levels in adolescents and children with T1D.

METHODS

Relevant studies were searched electronically in the Cochrane Library, PubMed, and Embase utilizing the key words "Pediatrics or Child or Adolescent", "Insulin Infusion Systems" and "Diabetes Mellitus" from inception to 17th March 2024 to evaluate the performance of HCL on HbA1c in adolescents, and children with T1D.

RESULTS

Nine studies involving 927 patients were identified. Three months use of HCL show a beneficial effect on HbA1c management (p <0.001) as compared to standard of care in adolescents and children with T1D, without evidence of heterogeneity between articles (I2 = 40%, p = 0.10). HCL did significantly increase the overall average percentage of hypoglycemic time between 70 and 180 mg/dL (TIR) (p <0.001; I2 = 51%). HCL did not show a beneficial effect on hypoglycemic time <70 mg/dL and <54 mg/dL (p >0.05). The overall percentage of hyperglycemic time was significantly decreased in HCL group compared to the control group when it was defined as >180 mg/dL (p <0.001; I2 = 83%), >250 mg/dL (p = 0.007, I2 = 86%) and >300 mg/dL (p = 0.005; I2 = 76%). The mean glucose level was significantly decreased by HCL (p <0.001; I2 = 58%), however, no significant difference was found in coefficient of variation of sensor glucose (p = 0.82; I2 = 71%) and daily insulin dose (p = 0.94; I2 <0.001) between the HCL group and the control group.

CONCLUSIONS

HCL had a beneficial effect on HbA1c management and TIR without increased hypoglycemic time as compared to standard of care in adolescents and children with T1D when therapy duration of HCL was not less than three months.

TRIAL NUMBER AND REGISTRY URL

CRD42022367493; https://www.crd.york.ac.uk/PROSPERO, Principal investigator: Zhen-feng Zhou, Date of registration: October 30, 2022.

Advancements in Insulin Pumps: A Comprehensive Exploration of Insulin Pump Systems, Technologies, and Future Directions

Insulin pumps have transformed the way diabetes is managed by providing a more accurate and individualized method of delivering insulin, in contrast to conventional injection routines. This research explores the progression of insulin pumps, following their advancement from initial ideas to advanced contemporary systems. The report proceeds to categorize insulin pumps according to their delivery systems, specifically differentiating between conventional, patch, and implantable pumps. Every category is thoroughly examined, emphasizing its unique characteristics and capabilities. A comparative examination of commercially available pumps is provided to enhance informed decision making. This section provides a thorough analysis of important specifications among various brands and models. Considered factors include basal rate and bolus dosage capabilities, reservoir size, user interface, and compatibility with other diabetes care tools, such as continuous glucose monitoring (CGM) devices and so on. This review seeks to empower healthcare professionals and patients with the essential information to improve diabetes treatment via individualized pump therapy options. It provides a complete assessment of the development, categorization, and full specification comparisons of insulin pumps.

Automated insulin delivery in children with type 1 diabetes during physical activity: a meta-analysis

OBJECTIVES

The aim of this study was to evaluate the performance of the automated insulin delivery (AID) in adolescents, and children with type 1 diabetes (T1D) during physical activity.

METHODS

Relevant studies were searched electronically in the Cochrane Library, PubMed, and Embase utilizing the key words "Child", "Insulin Infusion Systems", and "Diabetes Mellitus" from inception to 17th March 2024 to evaluate the performance of the AID in adolescents, and children with T1D during physical activity.

RESULTS

Twelve studies involving 514 patients were identified. AID did not show a beneficial effect on duration of hypoglycemia<70 mg/dL during study period (p>0.05; I2=96 %) and during the physical activity (p>0.99). Percentage of sensor glucose values in TIR was higher in AID than the non-AID pumps during study period (p<0.001; I2=94 %). The duration of hyperglycemic time was significantly decreased in AID group compared to the non-AID pumps group during study period (p<0.05; I2>50 %).

CONCLUSIONS

AID improved TIR and decreased the duration of hyperglycemic time, but did not appear to have a significant beneficial effect on the already low post-exercise duration of hypoglycemia achievable by open loop or sensor-augmented pumps in adolescents and children with T1D during physical activity; further research is needed to confirm the beneficial effect of AID on duration of hypoglycemia.

Comparing advanced hybrid closed loop therapy and standard insulin therapy in pregnant women with type 1 diabetes (CRISTAL): a parallel-group, open-label, randomised controlled trial

BACKGROUND

Advanced hybrid closed loop (AHCL) therapy can improve glycaemic control in pregnant women with type 1 diabetes. However, data are needed on the efficacy and safety of AHCL systems as these systems, such as the MiniMed 780G, are not currently approved for use in pregnant women. We aimed to investigate whether the MiniMed 780G can improve glycaemic control with less hypoglycaemia in pregnant women with type 1 diabetes.

METHODS

CRISTAL was a double-arm, parallel-group, open-label, randomised controlled trial conducted in secondary and tertiary care specialist endocrinology centres at 12 hospitals (11 in Belgium and one in the Netherlands). Pregnant women aged 18-45 years with type 1 diabetes were randomly assigned (1:1) to AHCL therapy (MiniMed 780G) or standard insulin therapy (standard of care) at a median of 10·1 (IQR 8·6-11·6) weeks of gestation. Randomisation was done centrally with minimisation dependent on baseline HbA1c, insulin administration method, and centre. Participants and study teams were not masked to group allocation. The primary outcome was proportion of time spent in the pregnancy-specific target glucose range (3·5-7·8 mmol/L), measured by continuous glucose monitoring (CGM) at 14-17 weeks, 20-23 weeks, 26-29 weeks, and 33-36 weeks. Key secondary outcomes were overnight time in target range, and time below glucose range (<3·5 mmol/L) overall and overnight. Analyses were conducted on an intention-to-treat basis. This trial is registered with ClinicalTrials.gov (NCT04520971).

FINDINGS

Between Jan 15, 2021 and Sept 30, 2022, 101 participants were screened, and 95 were randomly assigned to AHCL therapy (n=46) or standard insulin therapy (n=49). 43 patients assigned to AHCL therapy and 46 assigned to standard insulin therapy completed the study. At baseline, 91 (95·8%) participants used insulin pumps, and the mean HbA1c was 6·5% (SD 0·6). The mean proportion of time spent in the target range (averaged over four time periods) was 66·5% (SD 10·0) in the AHCL therapy group compared with 63·2% (12·4) in the standard insulin therapy group (adjusted mean difference 1·88 percentage points [95% CI -0·82 to 4·58], p=0·17). Overnight time in the target range was higher (adjusted mean difference 6·58 percentage points [95% CI 2·31 to 10·85], p=0·0026), and time below range overall (adjusted mean difference -1·34 percentage points [95% CI, -2·19 to -0·49], p=0·0020) and overnight (adjusted mean difference -1·86 percentage points [95% CI -2·90 to -0·81], p=0·0005) were lower with AHCL therapy than with standard insulin therapy. Participants assigned to AHCL therapy reported higher treatment satisfaction. No unanticipated safety events occurred with AHCL therapy.

INTERPRETATION

In pregnant women starting with tighter glycaemic control, AHCL therapy did not improve overall time in target range but improved overnight time in target range, reduced time below range, and improved treatment satisfaction. These data suggest that the MiniMed 780G can be safely used in pregnancy and provides some additional benefits compared with standard insulin therapy; however, it will be important to refine the algorithm to better align with pregnancy requirements.

FUNDING

Diabetes Liga Research Fund and Medtronic.

Protocol for a prospective, multicenter, parallel-group, open-label randomized controlled trial comparing standard care with Closed lOoP In chiLdren and yOuth with Type 1 diabetes and high-risk glycemic control: the CO-PILOT trial

Purpose

Advanced hybrid closed loop (AHCL) systems have the potential to improve glycemia and reduce burden for people with type 1 diabetes (T1D). Children and youth, who are at particular risk for out-of-target glycemia, may have the most to gain from AHCL. However, no randomized controlled trial (RCT) specifically targeting this age group with very high HbA1c has previously been attempted. Therefore, the CO-PILOT trial (Closed lOoP In chiLdren and yOuth with Type 1 diabetes and high-risk glycemic control) aims to evaluate the efficacy and safety of AHCL in this group.

Methods

A prospective, multicenter, parallel-group, open-label RCT, comparing MiniMed™ 780G AHCL to standard care (multiple daily injections or continuous subcutaneous insulin infusion). Eighty participants aged 7-25 years with T1D, a current HbA1c ≥ 8.5% (69 mmol/mol), and naïve to automated insulin delivery will be randomly allocated to AHCL or control (standard care) for 13 weeks. The primary outcome is change in HbA1c between baseline and 13 weeks. Secondary outcomes include standard continuous glucose monitor glycemic metrics, psychosocial factors, sleep, platform performance, safety, and user experience. This RCT will be followed by a continuation phase where the control arm crosses over to AHCL and all participants use AHCL for a further 39 weeks to assess longer term outcomes.

Conclusion

This study will evaluate the efficacy and safety of AHCL in this population and has the potential to demonstrate that AHCL is the gold standard for children and youth with T1D experiencing out-of-target glucose control and considerable diabetes burden.

Trial registration

This trial was prospectively registered with the Australian New Zealand Clinical Trials Registry on 14 November 2022 (ACTRN12622001454763) and the World Health Organization International Clinical Trials Registry Platform (Universal Trial Number U1111-1284-8452).

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-024-01397-4.

An intelligent wearable artificial pancreas patch based on a microtube glucose sensor and an ultrasonic insulin pump

In order to improve the living standards of diabetes patients and reduce the negative health effects of this disease, the medical community has been actively searching for more effective treatments. In recent years, an artificial pancreas has emerged as an important approach to managing diabetes. Despite these recent advances, meeting the requirements for miniaturized size, accurate sensing and large-volume pumping capability remains a great challenge. Here, we present a novel miniaturized artificial pancreas based on a long microtube sensor integrated with an ultrasonic pump. Our device meets the requirements of achieving both accurate sensing and high pumping capacity. The artificial pancreas is constructed based on a long microtube that is low cost, painless and simple to operate, where the exterior of the microtube is fabricated as a glucose sensor for detecting diabetes and the interior of the microtube is used as a channel for delivering insulin through an ultrasonic pump. This work successfully achieved closed-loop control of blood glucose and treatment of diabetes in rats. It is expected that this work can open up new methodologies for the development of microsystems, and advance the management approach for diabetes patients.

Diabetes technology and sexual health: which role?

PURPOSE

The aim of this review is to evaluate the effects of new technology used in the management of diabetes mellitus (DM), including the use of continuous glucose monitoring (CGM) and the administration of insulin through continuous subcutaneous insulin infusion (CSII), on male and female sexual function.

METHODS

This narrative review was performed for all available prospective, retrospective and review articles, published up to June 2023 in PubMed. Data were extracted from the text and from the tables of the manuscript.

RESULTS

Sexual dysfunctions are an underestimated comorbidity of DM in both male and female. Although erectile dysfunction (ED) is recognized by the guidelines as a complication of DM, female sexual dysfunction (FSD) is poorly investigated in clinical setting. In addition to the complications of DM, the different types of therapies can also influence male and female sexual response. Furthermore, insulin therapy can be administered through multiple-daily injections (MDI) or a CSII. The new technologies in the field of DM allow better glycemic control which results in a reduction in the occurrence or aggravation of complications of DM. Despite this evidence, few data are available on the impact of new technologies on sexual dysfunctions.

CONCLUSIONS

The use of DM technology might affect sexual function due to the risk of a worse body image, as well as discomfort related to CSII disconnection during sexual activity. However, the use is related to an improved metabolic control, which, in the long-term associates to a reduction in all diabetes complications, including sexual function.

Long-term assessment of the NHS hybrid closed-loop real-world study on glycaemic outcomes, time-in-range, and quality of life in children and young people with type 1 diabetes

Hybrid closed-loop (HCL) systems seamlessly interface continuous glucose monitoring (CGM) with insulin pumps, employing specialised algorithms and user-initiated automated insulin delivery. This study aimed to assess the efficacy of HCLs at 12 months post-initiation on glycated haemoglobin (HbA1c), time-in-range (TIR), hypoglycaemia frequency, and quality of life measures among children and young people (CYP) with type 1 diabetes mellitus (T1DM) and their caregivers in a real-world setting. Conducted between August 1, 2021, and December 10, 2022, the prospective recruitment took place in eight paediatric diabetes centres across England under the National Health Service England's (NHSE) HCL pilot real-world study. A cohort of 251 CYP (58% males, mean age 12.3 years) with T1DM participated (89% white, 3% Asian, 4% black, 3% mixed ethnicity, and 1% other). The study utilised three HCL systems: (1) Tandem Control-IQ AP system, which uses the Tandem t:slim X2 insulin pump (Tandem Diabetes Care, San Diego, CA, USA) with the Dexcom G6® CGM (Dexcom, San Diego, CA, USA) sensor; (2) Medtronic MiniMed™ 780G with the Guardian 4 sensor (Medtronic, Northridge, CA, USA); and (3) the CamAPS FX (CamDiab, Cambridge, UK) with the Ypsomed insulin pump (Ypsomed Ltd, Escrick, UK) and Dexcom G6® CGM.All systems were fully funded by the NHS. Results demonstrated significant improvements in HbA1c (average reduction at 12 months 7 mmol/mol; P < 0.001), time-in-range (TIR) (average increase 13.4%; P < 0.001), hypoglycaemia frequency (50% reduction), hypoglycaemia fear, and quality of sleep (P < 0.001) among CYP over a 12-month period of HCL usage. Additionally, parents and carers experienced improvements in hypoglycaemia fear and quality of sleep after 6 and 12 months of use. In addition to the improvements in glycaemic management, these findings underscore the positive impact of HCL systems on both the well-being of CYP with T1DM and the individuals caring for them.

Comparative Effectiveness of Hybrid Closed-Loop Automated Insulin Delivery Systems Among Patients with Type 1 Diabetes

BACKGROUND

Clinical trials have demonstrated the efficacy and safety of hybrid closed-loop (HCL) systems, yet few studies have compared outcomes in the real-world setting.

METHOD

This retrospective study analyzed patients from an academic endocrinology practice between January 1, 2018, and November 18, 2022. The inclusion criteria were diagnosis code for type I diabetes (T1D), >18 years of age, new to any HCL system [Medtronic 670G/770G (MT), Tandem Control IQ (CIQ), or Omnipod 5 (OP5)], and availability of a pump download within three months. The outcomes included %time in range (TIR) of 70 to 180 mg/dL, %time below range (TBR) <70 mg/dL at 90 days, and HbA1c for 91 to 180 days.

RESULT

Of the 176 participants, 47 were MT, 74 CIQ, and 55 OP5. Median (25%, 75%) change in HbA1c was -0.1 (-0.8, 0.3), -0.6 (-1.1, -0.15), and -0.55 (-0.98, 0)% for MT, CIQ, and OP5, respectively, (P = .04). TIR was 70 (57, 76), 67 (59, 75), and 68 (60, 76)% (P = .95) at 90 days while TBR was 2 (1, 3), 1 (0, 2), and 1 (0, 1)%, respectively, (P = .002). The %time in automated delivery was associated with TIR and change in HbA1c. After controlling other factors including %time in automated delivery, HCL type was not an independent predictor of change in HbA1c nor TIR but remained a significant predictor of TBR.

CONCLUSION

There were significant reductions in HbA1c in CIQ and OP5. TIR was similar across pumps, but TBR was highest with MT. The %time in automated delivery likely explains differences in change in HbA1c but not TBR between HCL systems.

Carbohydrate counting knowledge and ambulatory glucose profile in persons living with type 1 diabetes

CONTEXT

The amount of consumed carbohydrates is the strongest factor influencing glucose levels during the four hours following a meal. Our aim was to evaluate the association between carbohydrate counting knowledge and continuous glucose monitoring (CGM) parameters in patients with type 1 diabetes (T1D) using different insulin regimens.

METHOD

In this multicenter prospective study, the GluciQuizz questionnaire was used to evaluate carbohydrate knowledge. CGM data for the 14 days preceding completion of the questionnaire were analyzed. The primary endpoint was evaluation of the correlation between the GluciQuizz total score and time in range (TIR) in the study population.

RESULTS

The mean age of the 170 participants was 40.7 ± 14.8 years and duration of T1D 18.8 ± 12.1 years. The mean GluciQuizz total score for all participants was 66 ± 13 %. Mean TIR was 58.6 ± 18.7 %. GluciQuizz total score positively correlated with TIR (r = 0.3001; p < 0.0001). This correlation was observed in CSII users (r = 0.2526; p < 0.05) but not in MDI (r = 0.2510; p = 0.1134) and HCL users (r = -0.1065; p = 0.4914). TIR was also negatively correlated with the mean carb count error in all study participants (r = -0.2317; p < 0.01).

CONCLUSION

In conclusion, as the Gluciquizz score was associated with metabolic control, this easy-to-use self-administered questionnaire could be used widely on a routine basis to assess the carbohydrate knowledge of T1D patients and to offer them targeted education tailored to their needs.

Glucagon: Delivery advancements for hypoglycemia management

As the 100th anniversary of glucagon's discovery approaches, we reflect on the remarkable journey of understanding its pivotal role in glucose regulation. Advancements in glucagon delivery systems for managing hypoglycemia are unfolding with promise, albeit accompanied by formulation and implementation challenges. Recent developments include non-injectable methods like BAQSIMI® (Nasal glucagon) offers a user-friendly option, but stability, bioavailability, and rapid onset remain formulation hurdles. Closed-loop systems, combining glucagon with insulin, aim to automate glucose control, demanding stable and precise formulations compatible with complex algorithms. However, achieving co-delivery harmony and effective dual-hormone responses poses substantial challenges. Ogluo® and Gvoke HypoPen® are auto-injector pens, a ready-to-use solution that can rapidly control hypoglycemia and eliminate the need for mixing powder and liquid. GlucaGen® Hypokit® and Glucagon Emergency Kits are traditional deliveries that possess complexity during administration and are still widely used in clinical practice. In addition to this advancement, we have covered the recent patents and clinical trials of glucagon delivery. The synergy of patent innovation and clinical validation offers a glimpse into the transformative potential of glucagon delivery yet underscores the intricate path toward widespread adoption and improved diabetes care. Finally, this review will help the formulation scientist, clinicians, healthcare providers, and patient to manage hypoglycemia using glucagon.

Continuous Glucose Profiles in Healthy People With Fixed Meal Times and Under Everyday Life Conditions

BACKGROUND

The increased use of continuous glucose monitoring (CGM) and automated insulin delivery systems raises the question about therapeutic targets for glucose profiles in people with diabetes. This study aimed to assess averaged pre- and postprandial glucose profiles in people without diabetes to provide guidance for normal glucose patterns in clinical practice. For that, number and timing of meal intake were predefined.

MATERIAL AND METHODS

To assess glucose traces in 36 participants without diabetes (mean age = 23.7 ± 5.7 years), CGM was performed for up to 14 days, starting with a run-in phase (first 3 days, excluded from analysis) followed by 4 days with fixed meal times at 8:00 am, 1:00 pm, and 6:00 pm and the remaining 7 days spent under everyday life conditions. Data from two simultaneously worn CGM sensors were averaged and adjusted to capillary plasma-equivalent glucose values. Glucose data were evaluated through descriptive statistics.

RESULTS

Median glucose concentration on days with fixed meal times and under everyday life conditions was 95.0 mg/dL (91.6-99.1 mg/dL, interquartile range) and 98.1 mg/dL (93.7-100.8 mg/dL), respectively. On days with fixed meal times, mean premeal glucose was 92.8 ± 9.4 mg/dL, and mean peak postmeal glucose was 143.3 ± 23.5 mg/dL.

CONCLUSIONS

By defining the time of meal intake, a clear pattern of distinct postprandial glucose excursions in participants without diabetes could be demonstrated and analyzed. The presented glucose profiles might be helpful as an estimate for adequate clinical targets in people with diabetes.

Hypoglycemia Unawareness-A Review on Pathophysiology and Clinical Implications

Hypoglycemia is a particular problem in people with diabetes while it can also occur in other clinical circumstances. Hypoglycemia unawareness describes a condition in which autonomic and neuroglycopenic symptoms of hypoglycemia decrease and hence are hardly perceivable. A failure to recognize hypoglycemia in time can lead to unconsciousness, seizure, and even death. The risk factors include intensive glycemic control, prior episodes of severe hypoglycemia, long duration of diabetes, alcohol consumption, exercise, renal failure, and sepsis. The pathophysiological mechanisms are manifold, but mainly concern altered brain glucose sensing, cerebral adaptations, and an impaired hormonal counterregulation with an attenuated release of glucagon, epinephrine, growth hormone, and other hormones, as well as impaired autonomous and neuroglycopenic symptoms. Physiologically, this counterregulatory response causes blood glucose levels to rise. The impaired hormonal counterregulatory response to recurrent hypoglycemia can lead to a vicious cycle of frequent and poorly recognized hypoglycemic episodes. There is a shift in glycemic threshold to trigger hormonal counterregulation, resulting in hypoglycemia-associated autonomic failure and leading to the clinical syndrome of hypoglycemia unawareness. This clinical syndrome represents a particularly great challenge in diabetes treatment and, thus, prevention of hypoglycemia is crucial in diabetes management. This mini-review provides an overview of hypoglycemia and the associated severe complication of impaired hypoglycemia awareness and its symptoms, pathophysiology, risk factors, consequences, as well as therapeutic strategies.

Effect of artificial pancreas system use on glycaemic control among pregnant women with type 1 diabetes mellitus: A meta-analysis of randomized controlled trials

AIM

To assess the efficacy of artificial pancreas systems (APS) use among pregnant women with type 1 diabetes mellitus (T1DM) by conducting a meta-analysis.

METHODS

We searched five databases, including EMBASE, Web of Science, PubMed, Cochrane Library and SCOPUS, for literature on APS use among pregnant women with T1DM before October 9, 2023. The primary endpoint was 24-hour time in range (TIR; 3.5-7.8 mmol/L). Secondary endpoints included glycaemic metrics for 24-hour (mean blood glucose [MBG], time above range [TAR], time below range [TBR]), and overnight TIR and TBR.

RESULTS

We identified four randomized controlled trials involving 164 participants; one study with 16 participants focused on overnight APS use, and the other three focused on 24-hour APS use. Compared with standard care, APS exhibited a favourable effect on 24-hour TIR (standard mean difference [SMD] = 0.53, 95% confidence interval [CI] 0.25, 0.80, P < 0.001), overnight TIR (SMD = 0.67, 95% CI 0.39, 0.95, P < 0.001), and overnight TBR (<3.5 mmol/L; SMD = -0.49, 95% CI -0.77, -0.21 P < 0.001), while there was no significant difference in 24-hour TAR, 24-hour TBR, or MBG between the two groups. We further conducted subgroup analyses after removing the trial focused on overnight APS use and showed that 24-hour APS use reduced not only the 24-hour TIR (SMD = 0.41, 95% CI 0.12, 0.71; P = 0.007) but also the 24-hour TBR (<2.8 mmol/L; SMD = -0.77, 95% CI -1.32, -0.23, P = 0.006).

CONCLUSION

Our findings suggest that APS might improve 24-hour TIR and overnight glycaemic control, and 24-hour APS use also significantly reduced 24-hour TBR (2.8 mmol/L) among pregnant women with T1DM.

Beneficial effects of automated insulin delivery over one-year follow-up in real life for youths and adults with type 1 diabetes irrespective of patient characteristics

AIM

To investigate glycaemic outcomes in youths and adults with type 1 diabetes with either MiniMed™ 780G or Tandem t:slim X2™ control-IQ automated insulin delivery (AID) systems and to evaluate clinical factors that migrate, mitigate the achievement of therapeutic goals.

MATERIALS AND METHODS

This retrospective, real-world, observational study was conducted in a specialized university type 1 diabetes centre with patients observed for 3-12 months post-initiation of an AID system. Primary outcomes were the percentage time in the target glucose range [TIR70-180 mg/dl (3.9-10 mmol/L)] as measured by continuous glucose monitoring, mean glucose management indicator (GMI) and glycated haemoglobin (HbA1c) levels.

RESULTS

Our study cohort consisted of 48 adolescents and 183 adults (55% females) aged 10-77 years. The mean (95% confidence interval) TIR70-180 mg/dl after 30 days was higher than baseline and by 14% points after 360 days with 71.33% (69.4-73.2) (n = 123, p < .001). HbA1c levels decreased by 0.7% and GMI by 0.6% after 360 days. The proportion of time spent <70 mg/dl (3.9 mmol/L) was not significantly different from baseline. During follow-up, 780G users had better continuous glucose monitoring results than control-IQ users but similar HbA1c levels, and an increased risk of weight gain. Age at onset influenced TIR70-180 mg/dl in univariate analysis but there was no significant relationship after adjusting on explanatory variables. Baseline body mass index did not influence the performance of AID systems.

CONCLUSIONS

This analysis showed the beneficial effects of two AID systems for people with type 1 diabetes across a broad spectrum of participant characteristics. Only half of the participants achieved international recommendations for glucose control with TIR70-180 mg/dl >70%, HbA1c levels or GMI <7%, which outlines the need to maintain strong educational and individual strategies.

New advances in type 1 diabetes

Type 1 diabetes is an autoimmune condition resulting in insulin deficiency and eventual loss of pancreatic β cell function requiring lifelong insulin therapy. Since the discovery of insulin more than 100 years ago, vast advances in treatments have improved care for many people with type 1 diabetes. Ongoing research on the genetics and immunology of type 1 diabetes and on interventions to modify disease course and preserve β cell function have expanded our broad understanding of this condition. Biomarkers of type 1 diabetes are detectable months to years before development of overt disease, and three stages of diabetes are now recognized. The advent of continuous glucose monitoring and the newer automated insulin delivery systems have changed the landscape of type 1 diabetes management and are associated with improved glycated hemoglobin and decreased hypoglycemia. Adjunctive therapies such as sodium glucose cotransporter-1 inhibitors and glucagon-like peptide 1 receptor agonists may find use in management in the future. Despite these rapid advances in the field, people living in under-resourced parts of the world struggle to obtain necessities such as insulin, syringes, and blood glucose monitoring essential for managing this condition. This review covers recent developments in diagnosis and treatment and future directions in the broad field of type 1 diabetes.

Does fully closed-loop automated insulin delivery improve glycaemic control in patients with type 2 diabetes? A meta-analysis of randomized controlled trials

AIMS

This meta-analysis investigated the efficacy and safety of fully closed-loop automated insulin delivery (AID) in patients with type 2 diabetes.

MATERIALS AND METHODS

We systemically searched PubMed, Scopus, Web of Science, and Cochrane Central from inception until April 26, 2023. We included randomized controlled trials (RCTs) comparing fully closed-loop AID versus conventional insulin therapy. The outcomes were pooled as the mean difference (MD) and risk ratio with 95% confidence interval (CI) in the random effect model. Our primary outcome was the proportion of time in the target glucose range (5.6-10 mmol/L, 3.9-10 mmol/L, or 3.9-8 mmol/L, depending on the study). Key secondary outcomes included the proportion of time spent in hyperglycaemia or hypoglycaemia.

RESULTS

We included seven RCTs (three crossover and four parallel design), compromising 390 patients. Our analysis showed that compared to the control group, fully closed-loop AID increased the proportion of time spent within the target glucose range by additional 337 min per 24 h (MD = 23.39%, 95% CI [16.64%, 30.14%], p < 0.01), additional 108 min overnight (MD = 22.40%, 95% CI [12.88%, 31.91%], p < 0.01), and additional 258 min during the daytime period (MD = 26.85%, 95% CI [21.06%, 32.63%], p < 0.01). Compared to the control group, the overall time in hyperglycaemia was shortened by 326 min per 24 h (MD = -22.67%, 95% CI [-30.87%, -14.46%], p < 0.01). There was no significant difference between the two groups in terms of overall, overnight, and daytime periods spent in hypoglycaemia.

CONCLUSIONS

Our meta-analysis suggests that fully closed-loop AID may improve glycaemic control in patients with type 2 diabetes, particularly for those with more challenging diabetes management. Further research is required to establish the feasibility of implementing these systems in clinical practice. [Correction added on 26 August 2023 after first online publication: Under Results, the first sentence "We included seven RCTs (three crossover and one parallel designs)" has been changed to "We included seven RCTs (three crossover and four parallel designs)".].

Real-world glycaemic outcomes in patients with type 1 diabetes using glucose sensors-Experience from a single centre in Dublin

AIMS

To evaluate changes in glycated haemoglobin (HbA1 c) and sensor-based glycaemic metrics after glucose sensor commencement in adults with T1D.

METHODS

We performed a retrospective observational single-centre study on HbA1 c, and sensor-based glycaemic data following the initiation of continuous glucose monitoring (CGM) in adults with T1D (n = 209).

RESULTS

We observed an overall improvement in HbA1 c from 66 (59-78) mmol/mol [8.2 (7.5-9.3)%] pre-sensor to 60 (53-71) mmol/mol [7.6 (7.0-8.6)%] on-sensor (p < .001). The pre-sensor HbA1 c improved from 66 (57-74) mmol/mol [8.2 (7.4-8.9)%] to 62 (54-71) mmol/mol [7.8 (7.1-8.7)%] within the first year of usage to 60 (53-69) mmol/mol [7.6 (7.0-8.4)%] in the following year (n = 121, p < .001). RT-CGM-user had a significant improvement in HbA1 c (Dexcom G6; p < .001, r = 0.33 and Guardian 3; p < .001, r = 0.59) while a non-significant reduction was seen in FGM-user (Libre 1; p = .279). Both MDI (p < .001, r = 0.33) and CSII group (p < .001, r = 0.41) also demonstrated significant HbA1 c improvement. Patients with pre-sensor HbA1 c of ≥64 mmol/mol [8.0%] (n = 125), had attenuation of pre-sensor HbA1 c from 75 (68-83) mmol/mol [9.0 (8.4-9.7)%] to 67 (59-75) mmol/mol [8.2 (7.6-9.0)%] (p < .001, r = 0.44). Altogether, 25.8% of patients achieved the recommended HbA1 c goal of ≤53 mmol/mol and 16.7% attained the recommended ≥70% time in range (3.9-10.0 mmol/L).

CONCLUSIONS

Our study demonstrated that minimally invasive glucose sensor technology in adults with T1D is associated with improvement in glycaemic outcomes. However, despite significant improvements in HbA1 c, achieving the recommended goals for all glycaemic metrics remained challenging.

Comparison of Control-IQ and open-source AndroidAPS automated insulin delivery systems in adults with type 1 diabetes: The CODIAC study

AIM

To compare open-source AndroidAPS (AAPS) and commercially available Control-IQ (CIQ) automated insulin delivery (AID) systems in a prospective, open-label, single-arm clinical trial.

METHODS

Adults with type 1 diabetes who had been using AAPS by their own decision entered the first 3-month AAPS phase then were switched to CIQ for 3 months. The results of this treatment were compared with those after the 3-month AAPS phase. The primary endpoint was the change in time in range (% TIR; 70-80 mg/dL).

RESULTS

Twenty-five people with diabetes (mean age 34.32 ± 11.07 years; HbA1c 6.4% ± 3%) participated in this study. CIQ was comparable with AAPS in achieving TIR (85.72% ± 7.64% vs. 84.24% ± 8.46%; P = .12). Similarly, there were no differences in percentage time above range (> 180 and > 250 mg/dL), mean sensor glucose (130.3 ± 13.9 vs. 128.3 ± 16.9 mg/dL; P = .21) or HbA1c (6.3% ± 2.1% vs. 6.4% ± 3.1%; P = .59). Percentage time below range (< 70 and < 54 mg/dL) was significantly lower using CIQ than AAPS. Even although participants were mostly satisfied with CIQ (63.6% mostly agreed, 9.1% strongly agreed), they did not plan to switch to CIQ.

CONCLUSIONS

The CODIAC study is the first prospective study investigating the switch between open-source and commercially available AID systems. CIQ and AAPS were comparable in achieving TIR. However, hypoglycaemia was significantly lower with CIQ.

The Path From Awareness to Action: Exploring Diabetic Patients' Awareness and Attitudes and Barriers to Utilization of Artificial Pancreas in the Beheira Governorate, Egypt

Background and objective There is scarce data on diabetic patients' awareness, attitude, and barriers to utilization regarding the artificial pancreas. In light of this, the current study aimed to explore the awareness, attitudes, and perceived barriers to utilization of the artificial pancreas experienced by diabetic patients. Methods A cross-sectional study design was employed to achieve the aim of the study. The study was conducted in Damanhur city, the Beheira Governorate, Egypt. The convenience sampling technique was used to include 385 diabetic patients. The researchers designed an interview questionnaire comprising four parts to collect data about knowledge, attitudes, and barriers to utilization. Results The findings showed that 61% of the participants had a satisfactory level of overall knowledge. Regarding overall attitude, 64.1% of participants exhibited a positive attitude toward the artificial pancreas. The data indicated that 37.7% of participants identified the associated high cost as a significant barrier. Additionally, 23.3% expressed concerns about the lack of healthcare provider support, 21.5% had reservations regarding maintenance, and 17.5% felt limited by their technical skills. Conclusions The study revealed a notable satisfactory level of knowledge and attitudes among about two-thirds of participants regarding the artificial pancreas. Concerns about the high cost emerged as a predominant barrier followed by a lack of healthcare provider support. Empowering both healthcare providers and patients through ongoing educational initiatives can play a pivotal role in fostering a positive attitude and addressing concerns related to artificial pancreas technology.