Early versus delayed insulin pump therapy in children with newly diagnosed type 1 diabetes: results from the multicentre, prospective diabetes follow-up DPV registry

Retrospective Comparison of Commercially Available Automated Insulin Delivery With Open-Source Automated Insulin Delivery Systems in Type 1 Diabetes

BACKGROUND

Automated insulin delivery (AID) systems have shown to improve glycemic control in a range of populations and settings. At the start of this study, only one commercial AID system had entered the Austrian market (MiniMed 670G, Medtronic). However, there is an ever-growing community of people living with type 1 diabetes (PWT1D) using open-source (OS) AID systems.

MATERIALS AND METHODS

A total of 144 PWT1D who used either the MiniMed 670G (670G) or OS-AID systems routinely for a period of at least three to a maximum of six months, between February 18, 2020 and January 15, 2023, were retrospectively analyzed (116 670G aged from 2.6 to 71.8 years and 28 OS-AID aged from 3.4 to 53.5 years). The goal is to evaluate and compare the quality of glycemic control of commercially available AID and OS-AID systems and to present all data by an in-depth descriptive analysis of the population. No statistical tests were performed.

RESULTS

The PWT1D using OS-AID systems spent more time in range (TIR)70-180 mg/dL (81.7% vs 73.9%), less time above range (TAR)181-250 mg/dL (11.1% vs 19.6%), less TAR>250 mg/dL (2.5% vs 4.3%), and more time below range (TBR)54-69 mg/dL (2.2% vs 1.7%) than PWT1D using the 670G system. The TBR<54 mg/dL was comparable in both groups (0.3% vs 0.4%). In the OS-AID group, median glucose level and glycated hemoglobin (HbA1c) were lower than in the 670G system group (130 vs 150 mg/dL; 6.2% vs 7.0%).

CONCLUSION

In conclusion, both groups were able to achieve satisfactory glycemic outcomes independent of age, gender, and diabetes duration. However, the PWT1D using OS-AID systems attained an even better glycemic control with no clinical safety concerns.

The double burden: type 1 diabetes and heart failure-a comprehensive review

Heart failure (HF) is increasing at an alarming rate, primary due to the rising in aging, obesity and diabetes. Notably, individuals with type 1 diabetes (T1D) face a significantly elevated risk of HF, leading to more hospitalizations and increased case fatality rates. Several risk factors contribute to HF in T1D, including poor glycemic control, female gender, smoking, hypertension, elevated BMI, and albuminuria. However, early and intensive glycemic control can mitigate the long-term risk of HF in individuals with T1D. The pathophysiology of diabetes-associated HF is complex and multifactorial, and the underlying mechanisms in T1D remain incompletely elucidated. In terms of treatment, much of the evidence comes from type 2 diabetes (T2D) populations, so applying it to T1D requires caution. Sodium-glucose cotransporter 2 inhibitors have shown benefits in HF outcomes, even in non-diabetic populations. However, most of the information about HF and the evidence from cardiovascular safety trials related to glucose lowering medications refer to T2D. Glycemic control is key, but the link between hypoglycemia and HF hospitalization risk requires further study. Glycemic variability, common in T1D, is an independent HF risk factor. Technological advances offer the potential to improve glycemic control, including glycemic variability, and may play a role in preventing HF. In summary, HF in T1D is a complex challenge with unique dimensions. This review focuses on HF in individuals with T1D, exploring its epidemiology, risk factors, pathophysiology, diagnosis and treatment, which is crucial for developing tailored prevention and management strategies for this population.

Home Insulin Pump Use in Hospitalized Children With Type 1 Diabetes

Importance

Pediatric data on inpatient home insulin pumps are absent in the literature. Understanding safety of home insulin pumps, managed by patients or caregivers, during times of illness will help diabetes technology securely move into pediatric hospitals.

Objective

To examine whether insulin can be safely and accurately delivered to hospitalized children through home insulin pumps when managed by patients or caregivers.

Design, Setting, and Participants

This single-center, retrospective, observational cohort study included children with insulin-dependent diabetes admitted to a tertiary children's hospital from January 1, 2016, to December 31, 2021. In all these patients, diabetes was the primary or secondary diagnosis on admission.

Exposure

Insulin delivery via home insulin pump, hospital insulin pump, or subcutaneous injection.

Main Outcomes and Measures

Hyperglycemia (glucose, >250 mg/dL) and hypoglycemia (glucose, <45 mg/dL) rates (quantified as the proportion of total insulin-days), glucose variability, and diabetic ketoacidosis (DKA) recurrences were compared for hospital pumps (manual mode), home pumps (manual mode), and subcutaneous injections using bivariate tests.

Results

There were 18 096 insulin-days among 2738 patients aged 0.5 to 25 years (median age, 15.8 years [IQR, 12.3-18.3 years]). Overall, 990 (5.5%) of insulin-days involved hospital insulin pumps, and 775 (4.3%) involved home pumps. A total of 155 insulin-days (15.7%) involving hospital pumps were hyperglycemic, compared with 209 (27.0%) involving home pumps and 7374 (45.2%) involving injections (P < .001). Moderate hypoglycemia days comprised 31 insulin-days (3.1%) involving hospital pumps compared with 35 (4.5%) involving home pumps and 830 (5.1%) involving injections (P = .02). Severe hypoglycemia did not differ significantly according to insulin delivery method. Two patients using injections (0.01%) developed DKA; no patients using hospital or home pumps developed DKA.

Conclusions and Relevance

In this cohort study, home insulin pump use was found to be safe in a children's hospital regarding hyperglycemia and hypoglycemia. These data support use of home insulin pumps during pediatric admissions in patients who do not require intensive care and without active DKA.

Insulin Pump Utilization in 2017-2021 for More Than 22,000 Children and Adults With Type 1 Diabetes: A Multicenter Observational Study

This large type 1 diabetes cohort study showed that insulin pump utilization has increased over time and that use differs by sex, insurance type, and race/ethnicity. Insulin pump use was associated with more optimal A1C, increased use of continuous glucose monitoring (CGM), and lower rates of diabetic ketoacidosis and severe hypoglycemia. People who used an insulin pump with CGM had lower rates of acute events than their counterparts who used an insulin pump without CGM. These findings highlight the need to improve access of diabetes technology through provider engagement, multidisciplinary approaches, and efforts to address health inequities.

Efficacy and safety of faster aspart in insulin pumps in children and adolescents with type 1 diabetes mellitus: A single-center study with real-world data

AIMS

To assess the efficacy and safety of faster aspart (FIAsp) in paediatric population with type 1 diabetes mellitus (T1DM) and insulin pumps in real-world settings.

METHODS

Of 44 patients, 20 used FIAsp, 16 of which switched from aspart to FIAsp and 24 used aspart/lispro. We performed within-groups and between-groups analyses in three time points for anthropometric data, % of 24-h time in range of 70-180 mg/dl (TIR), time < 70 mg/dl and <54 mg/dl and time > 180 mg/dl and >250 mg/dl, bolus and basal insulins doses (units/kg/day and %), total daily dose (TDD, units/kg/day), glycaemic variability, frequency of set changes, sensor wear per week and meals per day.

RESULTS

Use of FIAsp over time increased TIR (P = 0.002) and TDD (P = 0.008 and P = 0.004, respectively for three months after the switch and recent use) and decreased time in hyperglycaemia (>180 P = 0.003 and > 250 mg/dl, P = 0.004). Frequency of set changes differ in the first 3 months (P = 0.042). Patients with FIAsp consumed more meals per day compared to those with aspart/lispro (P = 0.032).

CONCLUSION

Real-world data confirm that use of FIAsp in insulin pumps in paediatric populations improves glycaemic control long-term.

Consensus Recommendations for the Use of Automated Insulin Delivery Technologies in Clinical Practice

The significant and growing global prevalence of diabetes continues to challenge people with diabetes (PwD), healthcare providers, and payers. While maintaining near-normal glucose levels has been shown to prevent or delay the progression of the long-term complications of diabetes, a significant proportion of PwD are not attaining their glycemic goals. During the past 6 years, we have seen tremendous advances in automated insulin delivery (AID) technologies. Numerous randomized controlled trials and real-world studies have shown that the use of AID systems is safe and effective in helping PwD achieve their long-term glycemic goals while reducing hypoglycemia risk. Thus, AID systems have recently become an integral part of diabetes management. However, recommendations for using AID systems in clinical settings have been lacking. Such guided recommendations are critical for AID success and acceptance. All clinicians working with PwD need to become familiar with the available systems in order to eliminate disparities in diabetes quality of care. This report provides much-needed guidance for clinicians who are interested in utilizing AIDs and presents a comprehensive listing of the evidence payers should consider when determining eligibility criteria for AID insurance coverage.

Entwicklung der Insulintherapie in der pädiatrischen Diabetologie- Auswertung des DPV-Registers von 1995-2021

Der Einsatz von Insulin zur Therapie des Diabetes mellitus Typ 1 beim Menschen hat vor 100 Jahren erstmals zum Überleben betroffener Patienten nach Manifestation der Erkrankung geführt. War zuvor die Diagnose mit der Gewissheit verknüpft, dass es sich um eine unmittelbar lebensbedrohliche Erkrankung handelt, wurde mit dem Einsatz des Hormons Insulin ab 1922 die Perspektive eröffnet, den Verlauf der Erkrankung zu beeinflussen und die Prognose für die Patienten damit zu verbessern.

Ziel der vorliegenden Arbeit ist die Analyse von 92366 Patienten eines pädiatrischen Patientenkollektivs aus Deutschland, Österreich, Luxemburg und der Schweiz im Hinblick auf den Einsatz der verschiedenen Insulinarten im Zeitraum 1995–2021.

Der Anteil der Insulinanaloga stieg insbesondere seit dem Jahr 2000 stark an, auch da die Nutzung von Insulinpumpen mit Analoginsulin im Vergleich zur intensivierten Insulintherapie mit Pen für alle Altersgruppen deutlich anstieg. Bereits im Jahr 2010 betrug der Anteil der Insulinanaloga in der Diabetestherapie bei Kindern insgesamt > 60 %.

Im Jahr 2022 können Diabetologen auf mehr als zehn Insulinarten und mindestens fünf verschiedene Therapieformen zur Behandlung des Diabetes mellitus Typ 1 zurückgreifen.

Continuous Glucose Monitor, Insulin Pump, and Automated Insulin Delivery Therapies for Type 1 Diabetes: An Update on Potential for Cardiovascular Benefits

PURPOSE OF REVIEW

The incidence of type 1 diabetes (T1D) is rising in all age groups. T1D is associated with chronic microvascular and macrovascular complications but improving glycemic trends can delay the onset and slow the progression of these complications. Utilization of technological devices for diabetes management, such as continuous glucose monitors (CGM) and insulin pumps, is increasing, and these devices are associated with improvements in glycemic trends. Thus, device use may be associated with long-term prevention of T1D complications, yet few studies have investigated the direct impacts of devices on chronic complications in T1D. This review will describe common diabetes devices and combination systems, as well as review relationships between device use and cardiovascular outcomes in T1D.

RECENT FINDINGS

Findings from existing cohort and national registry studies suggest that pump use may aid in improving cardiovascular risk factors such as hypertension and dyslipidemia. Furthermore, pump users have been shown to have lower arterial stiffness and better measures of myocardial function. In registry and case-control longitudinal data, pump use has been associated with fewer cardiovascular events and reduction of cardiovascular disease (CVD) and all-cause mortality. CVD is the leading cause of morbidity and mortality in T1D. Consistent use of diabetes devices may protect against the development and progression of macrovascular complications such as CVD through improvement in glycemic trends. Existing literature is limited, but findings suggest that pump use may reduce acute cardiovascular risk factors as well as chronic cardiovascular complications and overall mortality in T1D.

The automated pancreas: A review of technologies and clinical practice

Insulin pumps and glucose sensors are effective in improving diabetes therapy and reducing acute complications. The combination of both devices using an algorithm-driven interoperable controller makes automated insulin delivery (AID) systems possible. Many AID systems have been tested in clinical trials and have proven safety and effectiveness. However, currently, none of these systems are available for routine use in children younger than 6 years in Europe. For continued use, both users and prescribers must have sound knowledge of the features of the individual AID systems. Presently, all systems require various user interactions (e.g. meal announcements) because fully automated systems are not yet developed. Open-source systems are non-regulated variants to circumvent existing regulatory conditions. There are risks here for both users and prescribers. To evaluate AID therapy, the metric data of the glucose sensors, 'time in target range' and 'glucose management index', are novel recognized and suitable parameters allowing a consultation based on real glucose and insulin pump download data from the daily life of people with diabetes. Read out via cloud-based software or automatic download of such individual treatment data provides the ideal technical basis for shared decision-making through telemedicine, which must be further evaluated for general use.

Deterioration in glycemic control on schooldays among children and adolescents with type 1 diabetes: A continuous glucose monitoring-based study

BACKGROUND

To investigate the effect of school life by comparing the glycemic control between holidays and schooldays in children and adolescents with type 1 diabetes (T1D).

METHODS

This observational study enrolled school-aged students with T1D (aged 6-19) from September 2019 to July 2021. Continuous glucose monitoring (CGM) records were processed and divided into holidays and schooldays. Other information was collected via questionnaires. We compared the results using paired T-test, Wilcoxon paired test and logistic regression analysis.

RESULTS

78 paticipants were included (40 boys, mean age 9.95 years). A total of 142,945 h of CGM data were analyzed. Overall, TIR (3.9-7.8 mmol/L) during holidays was better than schooldays [56.97 (SD 15.03) vs. 55.87 (15.06), %, p = 0.039]. On nocturnal (0-6 am) glycemic fluctuation, TIR was longer in children aged 6-10 [60.54 (17.40) vs. 56.98 (SD 16.32), %, p = 0.012] during holiday and TAR (7.8 mmol/L) was shorter [31.54 (17.54) vs. 35.54 (16.95), %, p = 0.013], compared with schooldays. In adolescents aged 10-19 years, TAR was also significantly shorter during holidays. Stratified analysis showed that girls, patients with longer duration, and insulin pump users had more pronounced worsening of nighttime glycemia on schooldays. Logistic regression analysis showed that girls had higher risk of worse nocturnal glycemic control [3.26, 95% CI: (1.17, 9.72), p = 0.027] and nocturnal hyperglycemia [OR = 2.95, 95% CI: (1.08, 8.56), p = 0.039], compared to boys.

CONCLUSIONS

Children and adolescents with T1D were found to have worse glycemic control in nighttime during schooldays.

Is diabetic ketoacidosis a good predictor of 5-year metabolic control in children with newly diagnosed type 1 diabetes?

BACKGROUND

The study aimed to evaluate whether the presence of DKA at diabetes diagnosis was associated with poorer metabolic control during a 5-year follow-up.

METHODS

The study included children treated due to newly diagnosed T1D complicated with DKA between 2010 and 2014 with a complete 5-year follow-up. In every case we performed individual matching for age, gender and BMI with a person without DKA (nDKA) on recognition. We collected data regarding treatment modality, HbA_1C, total daily insulin dose, basal insulin and BMI-SDS.

RESULTS

85 children at the median age of 7.93 years had DKA at diabetes diagnosis. The median pH was 7.19.Continuous subcutaneous insulin infusion (CSII) was used in 87% of participants in each group. No differences in HbA_1C level (7,3%vs7,2%;p = .413) were noted after 5 years of disease duration. The severity of ketoacidosis exerted no significant effect on HbA_1C. The method of insulin delivery at baseline was significantly associated with HbA_1C levels after 5 years of observation, β_CSII = - 1.46,95%CI[- 2.01 to - 0.92],p < .001.

CONCLUSIONS

The presence of DKA at diabetes diagnosis is not associated with deteriorated long-term metabolic control in children using modern technologies. The early implementation of CSII into diabetes treatment may change the effect of DKA and lead to a long-term HbA_1C improvement.

100 Years of Insulin: Lifesaver, immune target, and potential remedy for prevention

In this review, we bring our personal experiences to showcase insulin from its breakthrough discovery as a life-saving drug 100 years ago to its uncovering as the autoantigen and potential cause of type 1 diabetes and eventually as an opportunity to prevent autoimmune diabetes. The work covers the birth of insulin to treat patients, which is now 100 years ago, the development of human insulin, insulin analogues, devices, and the way into automated insulin delivery, the realization that insulin is the primary autoimmune target of type 1 diabetes in children, novel approaches of immunotherapy using insulin for immune tolerance induction, the possible limitations of insulin immunotherapy, and an outlook how modern vaccines could remove the need for another 100 years of insulin therapy.

One hundred years since insulin discovery: An update on current and future perspectives for pharmacotherapy of diabetes mellitus

Diabetes mellitus was considered a fatal malady until the discovery, extraction and commercial availability of insulins. Numerous other classes of drugs ranging from sulfonylureas to sodium-glucose co-transporter-2 inhibitors were then marketed. However, with the prevalence of diabetes mellitus increasing every year, many more drugs and therapies are under investigation. This review article aimed to summarize the significant developments in the pharmacotherapy of diabetes mellitus and outline the progress made by the recent advances, 100 years since insulins were first extracted successfully. Insulin analogues and insulin delivery pumps have further improved glycaemic control in diabetes mellitus. Cardiovascular and renal outcome trials have changed the landscape of diabetology, with some of these drugs also efficacious in nondiabetics. Newer drug delivery systems are being evaluated to improve the efficacy and reduce the dosing frequency and adverse effects of antidiabetics. Some newer drugs with novel mechanisms of action targeting type 1 and type 2 diabetes have also shown promise in recent clinical trials. These drugs include dual glucose-dependent insulinotropic polypeptide and glucagon-like peptide 1-agonists, glucokinase activators, anti-CD3 monoclonal antibodies and glimins. Their efficacy needs to be evaluated in larger studies.

[Individualization of diabetes treatment by automated insulin delivery]

Insulinpumpen und Glucosesensoren haben sich in Registerdaten als effektiv in der Verbesserung der Diabetestherapie und Reduktion akuter Komplikationen gezeigt. In der pädiatrischen Diabetologie ist die Nutzung mindestens eines technischen Geräts Standard. Durch die Kombination beider Systeme ergibt sich Möglichkeit der automatischen Insulinabgabe („automated insulin delivery“, AID).

Viele AID-Systeme sind in klinischen Studien getestet und haben sich als sicher und effektiv erwiesen. Die Versorgungsituation in Deutschland erlaubt es derzeit nur, Mitgliedern der gesetzlichen Krankenversicherungen ein bestimmtes System zu verordnen; dieses ist für Kinder, die jünger als 7 Jahre sind, nicht geeignet. Gründe liegen in gesetzlichen Hürden und mangelnder Zertifizierung durch die Hersteller. Die CE-Zertifikate können Probleme bei der Insulinverordnung mit sich bringen. „Open-source“-Systeme sind Varianten, mit denen bestehende Regularien umgangen werden können. Daraus ergeben sich sowohl für Nutzer wie auch für Verordner Risiken.

Die dauerhafte Nutzung setzt sowohl auf Anwender- als auch auf Behandlerseite die fundierte Kenntnis der Eigenschaften der einzelnen AID-Systeme voraus. Eine vollständige Automatisierung funktioniert noch nicht. Zur Evaluation der AID-Therapie sind die metrischen Daten der Glucosesensoren, die „Zeit im Zielbereich“ und der „Glucose Management Indicator“ anerkannte und geeignete Parameter, da sie eine Beratung auf Basis der reellen Daten aus dem Alltag der Menschen mit Diabetes zulassen.

Da alle Glucosesensoren über Cloud-basierte Software ausgelesen werden oder die Daten automatisch aus einem telefonverbundenen Empfangsgerät beziehen, ist die ideale technische Grundlage für eine telemedizinische Betreuung geschaffen, die noch der Ausgestaltung bedarf.

AID(„automated insulin delivery“)-Systeme in der Diabetologie

Insulinpumpen und Glukosesensoren können laut Registerdaten die Diabetestherapie verbessern sowie die Rate akuter Komplikationen reduzieren. In der pädiatrischen Diabetologie ist daher die Nutzung mindestens eines dieser technischen Geräte Standard. Deren Kombination macht Systeme zur automatischen Insulinabgabe („automated insulin delivery“ [AID]) möglich. Viele AID-Systeme wurden in klinischen Studien getestet und erwiesen sich als sicher und effektiv. Die Versorgungsituation in Deutschland jedoch lässt derzeit nur ein System als Verordnung bei Versicherten der gesetzlichen Krankenversicherungen zu, und Kinder unter 7 Jahren können damit derzeit nicht versorgt werden. Gründe hierfür sind gesetzliche Hürden und die mangelnde Zertifizierung durch die Hersteller. Die CE-Zertifikate können zudem zu Problemen bei der Insulinverordnung führen. Open-Source-Systeme sind nicht geprüfte Varianten, um bestehende regulatorische Verhältnisse zu umgehen. Deren Anwendung geht mit Risiken sowohl für Nutzer als auch Verordner einher. Für ihren dauerhaften Einsatz müssen sowohl Anwender als auch Behandler über fundierte Kenntnisse der Eigenschaften der einzelnen AID-Systeme verfügen. Zur Evaluation der AID-Therapie sind die metrischen Daten der Glukosesensoren, die „time in range“ und der Glukosemanagementindex die anerkannten und geeigneten Parameter, da sie eine Beratung auf Basis der reellen Werte aus dem Alltag der Menschen mit Diabetes zulassen. Da alle Glukosesensoren über Cloud-basierte Software ausgelesen werden oder die Daten direkt automatisch übermitteln, ist hiermit die ideale technische Grundlage für eine telemedizinische Betreuung geschaffen, die noch der Ausgestaltung bedarf.