Optimizing the use of technology to support people with diabetes: research recommendations from Diabetes UK's 2019 diabetes and technology workshop

Advanced hybrid closed loop therapy versus conventional treatment in adults with type 1 diabetes (ADAPT): a randomised controlled study

BACKGROUND

Adults with type 1 diabetes who are treated with multiple daily injections of insulin plus intermittently scanned continuous glucose monitoring (isCGM) can have suboptimal glucose control. We aimed to assess the efficacy of an advanced hybrid closed loop (AHCL) system compared with such therapy in this population.

METHODS

The Advanced Hybrid Closed Loop Study in Adult Population with Type 1 Diabetes (ADAPT) trial is a prospective, multicentre, open-label, randomised controlled trial that involved 14 centres in three European countries (France, Germany, and the UK). We enrolled patients who were at least 18 years of age, had a type 1 diabetes duration of at least 2 years, HbA_1c of at least 8% (64 mmol/mol), and were using multiple daily injections of insulin plus isCGM (cohort A) or real time continuous glucose monitoring (cohort B) for at least 3 months. Here, only results for cohort A are reported. Participants were randomly allocated 1:1 to AHCL therapy or continuation of multiple daily injections of insulin plus continuous glucose monitoring for 6 months with an investigator-blinded block randomisation procedure. Participants and treating clinicians could not be masked to the arm assignment. The primary endpoint was the between-group difference in mean HbA_1c change from baseline to 6 months in the intention-to-treat population using AHCL therapy and those using multiple daily injections of insulin plus isCGM. The primary endpoint was analysed using a repeated measures random-effects model with the study arm and period as factors. Safety endpoints included the number of device deficiencies, severe hypoglycaemic events, diabetic ketoacidosis, and serious adverse events. This study is registered with ClinicalTrials.gov, NCT04235504.

FINDINGS

Between July 13, 2020, and March 12, 2021, 105 people were screened and 82 randomly assigned to treatment (41 in each arm). At 6 months, mean HbA_1c had decreased by 1·54% (SD 0·73), from 9·00% to 7·32% in the AHCL group and 0·20% (0·80) in the multiple daily injections of insulin plus isCGM from 9·07% to 8·91% (model-based difference -1·42%, 95% CI -1·74 to -1·10; p<0·0001). No diabetic ketoacidosis, severe hypoglycaemia, or serious adverse events related to study devices occurred in either group; two severe hypoglycaemic events occurred in the run-in phase. 15 device-related non-serious adverse events occurred in the AHCL group, compared with three in the multiple daily injections of insulin plus isCGM group. Two serious adverse events occurred (one in each group), these were breast cancer (in one patient in the AHCL group) and intravitreous haemorrhage (in one patient in the multiple daily injections of insulin plus isCGM group).

INTERPRETATION

In people with type 1 diabetes using multiple daily injections of insulin plus isCGM and with HbA_1c of at least 8%, the use of AHCL confers benefits in terms of glycaemic control beyond those that can be achieved with multiple daily injections of insulin plus isCGM. These data support wider access to AHCL in people with type 1 diabetes not at target glucose levels.

FUNDING

Medtronic International Trading Sàrl.

The impact of socio-economic deprivation on access to diabetes technology in adults with type 1 diabetes

BACKGROUND

With advances in technology, there is an emerging concern that inequalities exist in provision and diabetes outcomes in areas of greater deprivation. We assess the relationship between socio-economic status and deprivation with access to diabetes technology and their outcomes in adults with type 1 diabetes.

METHODS

Retrospective, observational analysis of adults attending a tertiary centre, comprising three urban hospitals in the UK. Socio-economic deprivation was assessed by the English Indices of Deprivation 2019. Data analysis was performed using one-way ANOVAs and chi-squared tests.

RESULTS

In total, 1631 adults aged 44 ± 15 years and 758 (47%) women were included, with 391 (24%) using continuous subcutaneous insulin infusion, 312 (19%) using real-time continuous glucose monitoring and 558 (34%) using intermittently scanned continuous glucose monitoring. The highest use of diabetes technology was in the least deprived quintile compared to the most deprived quintile (67% vs. 45%, respectively; p < 0.001). HbA_1c outcomes were available in 400 participants; no association with deprivation was observed (p = 0.872). Participation in structured education was almost twice as high from the most deprived to the least deprived groups (23% vs. 43%; p < 0.001). Adults with white or mixed ethnicity were more likely to use technology compared to black ethnicity (60% vs. 40%; p < 0.001).

CONCLUSIONS

Adults living in the most deprived quintile had less technology use. Irrespective of socio-economic status or ethnicity, glycaemia was positively affected in all groups. It is imperative that health disparities are further addressed.