A Randomized Controlled Trial Assessing the Impact of Continuous Glucose Monitoring with a Predictive Hypoglycemia Alert Function on Hypoglycemia in Physical Activity for People with Type 1 Diabetes (PACE)

An overview of the FreeStyle Libre monitoring system for individuals with type 1 and type 2 diabetes

INTRODUCTION

Diabetes is a chronic disease with high prevalence, necessitating advanced technology to achieve glycemic targets and reduce complications. Continuous glucose monitoring (CGM) has become a cornerstone in diabetes management, with the Freestyle Libre (FSL) systems being some of the most widely used devices.

AREAS COVERED

This review focuses on FSL systems, each including an all-in-one sensor and transmitter, a handheld reader and a Mobile Medical App (MMA). Glucose data are uploaded to a dedicated cloud-based platform for analysis. Over the years, FSL has evolved with new features offering valuable support for individuals with diabetes, caregivers, and healthcare providers. Clinical trials and real-world studies have demonstrated efficacy and safety across diverse populations, including individuals with type 1 and type 2 diabetes, adolescents, and pregnant women with diabetes.

EXPERT OPINION

FSL is a user-friendly system that meets the needs of patients and healthcare providers. The MMA allows a review of glucose metrics and pattern identification, and supports educational strategies and patient-tailored treatment. Future advancements, including ketone monitoring, integration with wearables and other devices, and telemedicine applications, will further optimize diabetes care and prevention.

Management and Medical Care for Individuals with Type 1 Diabetes Running a Marathon

Background: Limited data exist on managing type 1 diabetes mellitus (T1DM) during long-distance endurance events such as marathons. This study aimed to assess glycemic control and participant safety during a marathon. Methods: Five men with T1DM, participating in the 22nd Poznan Marathon, were recruited. They completed health questionnaires and received training on glycemic management. Their physical capacity was assessed (including maximal oxygen uptake on a cycle ergometer). Participants reduced their insulin doses and consumed breakfast 2.5-3 h before the race. During the marathon, self-monitoring blood glucose (SMBG) and ketone levels were measured at five checkpoints (start, 10 km, 19 km, 30 km, and finish). The medical team followed a pre-approved protocol, providing carbohydrate and fluid supplementation as needed. Glycemia was monitored by two continuous glucose monitoring (CGM) systems (FreeStyle Libre 2 and Dexcom G6) and SMBG. Results: The participants' median age was 44 years (34-48), with a diabetes duration of 10 years (6-14), and a BMI of 22.5 kg/m2 (22.0-23.3). All finished the marathon in an average time of 4:02:56 (±00:43:11). Mean SMBG was 125.6 (±43.5) mg/dL, while CGM readings were 149.6 (±17.9) mg/dL (FreeStyle Libre 2) and 155.4 (±12.9) mg/dL (Dexcom G6). One participant experienced prolonged hypoglycemia undetected by CGM, whereas another developed symptomatic hypoglycemia between SMBG measurements. Conclusions: Safe marathon completion in people with T1DM requires individualized insulin dose adjustments, appropriate carbohydrate supplementation, and dedicated medical support at checkpoints. Combining CGM with periodic SMBG measurements further enhances safety and helps to detect potential glycemic excursions.

Patient-reported outcomes in studies of diabetes technology: What matters

In recent years, diabetes technologies have revolutionized the care of people with type 1 diabetes (T1D). Emerging evidence suggests that people with type 2 diabetes (T2D) can experience similar benefits from these advances in technology. While glycaemic outcomes are often a primary focus, the lived experience of the person with diabetes is equally important. In this review, we describe the impact of diabetes technologies on patient-reported outcome measures (PROMs). We highlight that most of the published studies investigated PROMs as secondary outcomes. Continuous glucose monitoring systems may have an important role in improving PROMs in individuals with T1D, which may be driven by the prevention or proactive management of hypoglycaemia. In people with T2D, continuous glucose monitoring may also have an important role in improving PROMs, particularly in those treated with insulin therapy. The impact of insulin pumps on PROMs seems positive in T1D, while there is limited evidence in T2D. Studies of hybrid closed-loop therapies suggest increased treatment satisfaction, improved quality of life and decreased diabetes-related distress in T1D, but it is unclear whether these benefits are because of a 'class-effect' or individual systems. We conclude that PROMs deserve a more central role in trials and clinical practice, and we discuss directions for future research.

Criteria for Personalised Choice of a Continuous Glucose Monitoring System: An Expert Opinion

Despite the growing evidence supporting the outpatient use of continuous glucose monitoring (CGM) for improving glycaemic control and reducing hypoglycaemia, there is a need for a detailed understanding of the specific features of CGM devices that best meet individual patient needs. This expert opinion, based on a comprehensive literature review and the personal perspectives of clinicians, aims to provide the healthcare professionals (HCPs) with a comprehensive framework for selecting CGM devices. It evaluates the current state of CGM technology, categorizing features into essential features, major drivers of choice, and additional/useful features. Moreover, the practical model presented outlines a patient's journey with CGM, emphasising the importance of aligning device features with patient needs. This includes understanding the patient's lifestyle, clinical conditions, and personal preferences to optimize CGM use and improve diabetes management outcomes.

Applying technologies to simplify strategies for exercise in type 1 diabetes

Challenges and fears related to managing glucose levels around planned and spontaneous exercise affect outcomes and quality of life in people living with type 1 diabetes. Advances in technology, including continuous glucose monitoring, open-loop insulin pump therapy and hybrid closed-loop (HCL) systems for exercise management in type 1 diabetes, address some of these challenges. In this review, three research or clinical experts, each living with type 1 diabetes, leverage published literature and clinical and personal experiences to translate research findings into simplified, patient-centred strategies. With an understanding of limitations in insulin pharmacokinetics, variable intra-individual responses to aerobic and anaerobic exercise, and the features of the technologies, six steps are proposed to guide clinicians in efficiently communicating simplified actions more effectively to individuals with type 1 diabetes. Fundamentally, the six steps centre on two aspects. First, regardless of insulin therapy type, and especially needed for spontaneous exercise, we provide an estimate of glucose disposal into active muscle meant to be consumed as extra carbohydrates for exercise ('ExCarbs'; a common example is 0.5 g/kg body mass per hour for adults and 1.0 g/kg body mass per hour for youth). Second, for planned exercise using open-loop pump therapy or HCL systems, we additionally recommend pre-emptive basal insulin reduction or using HCL exercise modes initiated 90 min (1-2 h) before the start of exercise until the end of exercise. Modifications for aerobic- and anaerobic-type exercise are discussed. The burden of pre-emptive basal insulin reductions and consumption of ExCarbs are the limitations of HCL systems, which may be overcome by future innovations but are unquestionably required for currently available systems.

Recommendations for recognizing, risk stratifying, treating, and managing children and adolescents with hypoglycemia

There has been continuous progress in diabetes management over the last few decades, not least due to the widespread dissemination of continuous glucose monitoring (CGM) and automated insulin delivery systems. These technological advances have radically changed the daily lives of people living with diabetes, improving the quality of life of both children and their families. Despite this, hypoglycemia remains the primary side-effect of insulin therapy. Based on a systematic review of the available scientific evidence, this paper aims to provide evidence-based recommendations for recognizing, risk stratifying, treating, and managing patients with hypoglycemia. The objective of these recommendations is to unify the behavior of pediatric diabetologists with respect to the timely recognition and prevention of hypoglycemic episodes and the correct treatment of hypoglycemia, especially in patients using CGM or advanced hybrid closed-loop systems. All authors have long experience in the specialty and are members of the Italian Society of Pediatric Endocrinology and Diabetology. The goal of treating hypoglycemia is to raise blood glucose above 70 mg/dL (3.9 mmol/L) and to prevent further decreases. Oral glucose at a dose of 0.3 g/kg (0.1 g/kg for children using "smart pumps" or hybrid closed loop systems in automated mode) is the preferred treatment for the conscious individual with blood glucose <70 mg/dL (3.9 mmol/L), although any form of carbohydrate (e.g., sucrose, which consists of glucose and fructose, or honey, sugary soft drinks, or fruit juice) containing glucose may be used. Using automatic insulin delivery systems, the oral glucose dose can be decreased to 0.1 g/kg. Practical flow charts are included to aid clinical decision-making. Although representing the official position of the Italian Society of Pediatric Endocrinology and Diabetology (ISPED), these guidelines are applicable to the global audience and are especially pertinent in the era of CGM and other advanced technologies.

The role of real-time continuous glucose monitoring in diabetes management and how it should link to integrated personalized diabetes management

Diabetes is a complex metabolic condition that demands tailored, individualized approaches for effective management. Real-time continuous glucose monitoring (rtCGM) systems have improved in terms of design, usability and accuracy over the years and play a pivotal role in the delivery of integrated personalized diabetes management (iPDM). iPDM is a comprehensive multidisciplinary approach that combines individualized care strategies utilizing technologies and interventions and encourages the active involvement of the person with diabetes in the care provided. The use of stand-alone rtCGM and its integration with other diabetes technologies, such as hybrid automated insulin delivery, have enabled improved glycaemic and quality of life outcomes for people with diabetes. As the uptake of rtCGM and associated technologies is increasing and becoming the standard of care for people with diabetes, it is important that efforts are focused on associated goals such as reducing health inequalities in terms of access, aligning structured education with rtCGM usage, choosing the right technology based on needs and preferences, and minimizing burden while aiming for optimal glucose outcomes. Utilizing rtCGM in other settings than outpatients and in diabetes cohorts beyond type 1 and type 2 diabetes needs further exploration. This review aims to provide an overview of the role of rtCGM and how best to link rtCGM to iPDM, highlighting its role in enhancing personalized treatment strategies.