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Laugesen C, Ritschel T, Ranjan A, Hsu LJ, Jørgensen JB, Svensson J, Ekhlaspour L, Buckingham BA, Norgaard K. Impact of Missed and Late Meal Boluses on Glycemic Outcomes in Automated Insulin Delivery-Treated Children and Adolescents with Type 1 Diabetes: A Two-Center, Population-Based, Cohort Study. Diabetes Technol Ther 2024. [PMID: 38805311 DOI: 10.1089/dia.2024.0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/30/2024]
Abstract
OBJECTIVE To evaluate the impact of missed or late meal boluses (MLBs) on glycemic outcomes in children and adolescents with type 1 diabetes using automated insulin delivery (AID) systems. RESEARCH DESIGN AND METHODS AID-treated (Tandem Control-IQ or Medtronic MiniMed 780G) children and adolescents (aged 6-21 years) from Stanford Medical Center and Steno Diabetes Center Copenhagen with ≥10 days of data were included in this two-center, binational, population-based, retrospective, 1-month cohort study. The primary outcome was the association between number of algorithm-detected MLBs and time in target glucose range (TIR; 70-180 mg/dL). RESULTS The study included 189 children and adolescents (48% females with a mean ± SD age of 13 ± 4 years). Overall, the mean number of MLBs per day in the cohort was 2.2 ± 0.9. For each additional MLB per day, TIR decreased by 9.7%-points (95% CI 11.3; 8.1), and compared to the quartile with fewest MLBs (Q1), the quartile with most (Q4) had 22.9% less TIR (95% CI 27.2; 18.6). The age-, sex-, and treatment modality-adjusted probability of achieving a TIR of >70% in Q4 was 1.4% compared to 74.8% in Q1 (p<0.001). CONCLUSIONS MLBs significantly impacted glycemic outcomes in AID-treated children and adolescents. The results emphasize the importance of maintaining a focus on bolus behavior to achieve higher TIR, and supports the need for further research in technological or behavioral support tools to handle missed and late meal boluses.
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Affiliation(s)
- Christian Laugesen
- Steno Diabetes Center Copenhagen, Clinical Research, Herlev, Denmark
- Stanford University, Division of Endocrinology and Diabetes, Department of Pediatrics, Stanford, California, United States;
| | - Tobias Ritschel
- Technical University of Denmark, Department of Applied Mathematics and Computer Science, Lyngby, Denmark;
| | - Ajenthen Ranjan
- Steno Diabetes Center Copenhagen, Clinical Research, Herlev, Denmark
- Steno Diabetes Center Copenhagen, Gentofte, Denmark;
| | - Liana J Hsu
- Stanford University, Division of Endocrinology and Diabetes, Department of Pediatrics, Stanford, California, United States;
| | - John Bagterp Jørgensen
- Technical University of Denmark, Department of Applied Mathematics and Computer Science, Lyngby, Denmark;
| | - Jannet Svensson
- Steno Diabetes Center Copenhagen, Clinical research, Herlev, Denmark
- University of Copenhagen, Department of Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen, Denmark;
| | - Laya Ekhlaspour
- University of California San Francisco, Division of Endocrinology, San Francisco, California, United States;
| | - Bruce A Buckingham
- Stanford University, Division of Endocrinology and Diabetes, Department of Pediatrics, Stanford, California, United States;
| | - Kirsten Norgaard
- Steno Diabetes Center Copenhagne, Clinical research, Herlev, Denmark
- University of Copenhagen, Department of Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen, Denmark;
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Ibrahim M, Beneyto A, Contreras I, Vehi J. An ensemble machine learning approach for the detection of unannounced meals to enhance postprandial glucose control. Comput Biol Med 2024; 171:108154. [PMID: 38382387 DOI: 10.1016/j.compbiomed.2024.108154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 02/02/2024] [Accepted: 02/12/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND Hybrid automated insulin delivery systems enhance postprandial glucose control in type 1 diabetes, however, meal announcements are burdensome. To overcome this, we propose a machine learning-based automated meal detection approach; METHODS:: A heterogeneous ensemble method combining an artificial neural network, random forest, and logistic regression was employed. Trained and tested on data from two in-silico cohorts comprising 20 and 47 patients. It accounted for various meal sizes (moderate to high) and glucose appearance rates (slow and rapid absorbing). To produce an optimal prediction model, three ensemble configurations were used: logical AND, majority voting, and logical OR. In addition to the in-silico data, the proposed meal detector was also trained and tested using the OhioT1DM dataset. Finally, the meal detector is combined with a bolus insulin compensation scheme; RESULTS:: The ensemble majority voting obtained the best meal detector results for both the in-silico and OhioT1DM cohorts with a sensitivity of 77%, 94%, 61%, precision of 96%, 89%, 72%, F1-score of 85%, 91%, 66%, and with false positives per day values of 0.05, 0.19, 0.17, respectively. Automatic meal detection with insulin compensation has been performed in open-loop insulin therapy using the AND ensemble, chosen for its lower false positive rate. Time-in-range has significantly increased 10.48% and 16.03%, time above range was reduced by 5.16% and 11.85%, with a minimal time below range increase of 0.35% and 2.69% for both in-silico cohorts, respectively, compared to the results without a meal detector; CONCLUSION:: To increase the overall accuracy and robustness of the predictions, this ensemble methodology aims to take advantage of each base model's strengths. All of the results point to the potential application of the proposed meal detector as a separate module for the detection of meals in automated insulin delivery systems to achieve improved glycemic control.
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Affiliation(s)
- Muhammad Ibrahim
- Modeling, Identification and Control Engineering Laboratory (MICELab), Institut d'Informàtica i Aplicacions, Universitat de Girona, Girona, Spain
| | - Aleix Beneyto
- Modeling, Identification and Control Engineering Laboratory (MICELab), Institut d'Informàtica i Aplicacions, Universitat de Girona, Girona, Spain
| | - Ivan Contreras
- Modeling, Identification and Control Engineering Laboratory (MICELab), Institut d'Informàtica i Aplicacions, Universitat de Girona, Girona, Spain
| | - Josep Vehi
- Modeling, Identification and Control Engineering Laboratory (MICELab), Institut d'Informàtica i Aplicacions, Universitat de Girona, Girona, Spain; Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Madrid, Spain.
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3
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Visentin R, Cobelli C, Sieber J, Dalla Man C. Short- and Long-Term Effects on Glucose Control of Nonadherence to Insulin Therapy in People With Type 2 Diabetes An In Silico Study. J Diabetes Sci Technol 2024; 18:309-317. [PMID: 38284154 DOI: 10.1177/19322968231223936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
BACKGROUND Strict adherence to multiple daily insulin (MDI) therapy is a cornerstone for the achievement of good glucose control in people with advanced type 2 diabetes (T2D). Here, we aim to in silico assess glucose control in T2D subjects with poor adherence to MDI therapy. METHODS We tuned the Padova T2D Simulator, originally describing early-stage T2D physiology, around advanced T2D people. One hundred in silico advanced T2D subjects were generated and equipped with optimal MDI therapy: specifically, basal and bolus insulin amounts and injection times were individualized for each subject by applying titration algorithms that iteratively update insulin dose based on glucose deviation from its target. Then, the effect of nonadhering to MDI therapy was assessed using standard glucose control metrics calculated in two 6-month 3-meal/day in silico scenarios: in Scenario 1, subjects received the optimal basal and prandial insulin bolus at each meal; in Scenario 2, subjects received optimal basal insulin and randomly delayed or skipped the prandial insulin bolus in 3 lunches during working days and 1 dinner during weekends. RESULTS A statistically significant degradation was found in all glucose control outcome metrics in Scenario 2 versus Scenario 1: e.g., percent time above 180 mg/dL increased by 22.2% and glucose management index by 0.2%. CONCLUSIONS Impaired adherence to MDI therapy in T2D leads to glucose control deteriorations in both short and long terms. Interestingly, short-term hyperglycemia seems being contrasted by residual endogenous insulin secretion, which statistically increased by 3-fold after delayed/skipped insulin boluses compared with optimal ones.
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Affiliation(s)
- Roberto Visentin
- Department of Information Engineering, University of Padua, Padua, Italy
| | - Claudio Cobelli
- Department of Woman and Child's Health, University of Padua, Padua, Italy
| | | | - Chiara Dalla Man
- Department of Information Engineering, University of Padua, Padua, Italy
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Giorgino F, Battelino T, Bergenstal RM, Forst T, Green JB, Mathieu C, Rodbard HW, Schnell O, Wilmot EG. The Role of Ultra-Rapid-Acting Insulin Analogs in Diabetes: An Expert Consensus. J Diabetes Sci Technol 2023:19322968231204584. [PMID: 37937585 DOI: 10.1177/19322968231204584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
Ultra-rapid-acting insulin analogs (URAA) are a further development and refinement of rapid-acting insulin analogs. Because of their adapted formulation, URAA provide an even faster pharmacokinetics and thus an accelerated onset of insulin action than conventional rapid-acting insulin analogs, allowing for a more physiologic delivery of exogenously applied insulin. Clinical trials have confirmed the superiority of URAA in controlling postprandial glucose excursions, with a safety profile that is comparable to the rapid-acting insulins. Consequently, many individuals with diabetes mellitus may benefit from URAA in terms of prandial glycemic control. Unfortunately, there are only few available recommendations from authoritative sources for use of URAA in clinical practice. Therefore, this expert consensus report aims to define populations of people with diabetes mellitus for whom URAA may be beneficial and to provide health care professionals with concrete, practical recommendations on how best to use URAA in this context.
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Affiliation(s)
- Francesco Giorgino
- Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari Aldo Moro, Bari, Italy
| | - Tadej Battelino
- Department of Endocrinology, Diabetes and Metabolism, UCH-University Medical Center Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | | | - Thomas Forst
- Department of Endocrinology and Metabolic Diseases, Johannes Gutenberg University Medical Center, Mainz, Germany
- Clinical Research Services, Mannheim, Germany
| | - Jennifer B Green
- Division of Endocrinology and Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Chantal Mathieu
- Clinical and Experimental Endocrinology, University Hospital Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium
| | | | - Oliver Schnell
- Forschergruppe Diabetes eV at the Helmholtz Centre, Munich-Neuherberg, Germany
| | - Emma G Wilmot
- Department of Diabetes & Endocrinology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
- Academic Unit for Translational Medical Sciences, University of Nottingham, Nottingham, England, UK
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Dutta D, Nagendra L, Bhattacharya S, Sharma M. Efficacy and Safety of Ultra-rapid Lispro Insulin in Managing Type-1 and Type-2 Diabetes: A Systematic Review and Meta-Analysis. Indian J Endocrinol Metab 2023; 27:467-475. [PMID: 38371177 PMCID: PMC10871017 DOI: 10.4103/ijem.ijem_225_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/26/2023] [Accepted: 10/25/2023] [Indexed: 02/20/2024] Open
Abstract
Background Mechanistically, subcutaneous ultra-rapid lispro (URLi) is faster than lispro. Whether this translates into a better post-prandial glucose (PPG) and glycemic control in type-1 diabetes (T1DM) and type-2 diabetes (T2DM) is unclear. Hence, we undertook this meta-analysis. Methods Databases were searched for randomized controlled trials (RCTs) involving patients with T1DM/T2DM receiving URLi in intervention-arm, and placebo/prandial insulin as control. The primary outcome was a change in PPG. Secondary outcomes were alterations in glycated haemoglobin (HbA1c), fasting plasma glucose (FPG), time in range (TIR), and adverse events. Results Data from six RCTs (3687 patients) were analyzed. Lispro was the control arm in all RCTs. T1DM patients receiving mealtime URLi had lower HbA1c [mean difference (MD) -0.07%; 95% confidence interval (CI): -0.12 to - 0.01; P = 0.02; I2 = 42%] and 1-h PPG [MD - 1.18 mmol/L; 95% CI: -1.91 to - 0.44; P = 0.002; I2 = 100%]. T1DM patients receiving post-meal URLi had comparable HbA1c [MD 0.07%; 95% CI: -0.01 to 0.15; P = 0.07; I2 = 55%] and 1-h PPG [MD 0.22 mmol/L; 95% CI: -0.80 to 1.24; P = 0.67; I2 = 100%). T1DM patients on pumps receiving URLi had comparable TIR [MD 1.70; 95% CI: -0.29 to 3.69; P = 0.09; I2 = 98%], lower time in blood glucose <3 mmol/L with increased infusion-set reactions. T2DM patients receiving mealtime URLi had lower 1-h PPG [MD - 0.66 mmol/L; 95% CI: -0.69 to - 0.63; P < 0.00001; I2 = 0%(LH), 2-h-PPG [MD - 0.96 mmol/L; 95% CI: -1.00 to - 0.92; P < 0.00001; I2 = 0%], higher FPG [MD 0.18 mmol/L; 95% CI: 0.11-0.24; P < 0.00001; I2 = 20%], and higher HbA1c [MD 0.07%; 95% CI: -0.06 to 0.08; P < 0.00001; I2 = 0%]. Conclusion Pre-meal URLi is better than lispro with regard to PPG control. Post-meal URLi is as good as lispro for PPG control. Post-meal URLi is inferior to pre-meal URLi for PPG control.
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Affiliation(s)
- Deep Dutta
- Department of Endocrinology, Center for Endocrinology, Diabetes, Arthritis and Rheumatism (CEDAR) Super-speciality Healthcare, Dwarka, Delhi, India
| | - Lakshmi Nagendra
- Department of Endocrinology, JSS Academy of Higher Education and Research, Mysore, Karnataka, India
| | - Saptarshi Bhattacharya
- Department of Endocrinology, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi, India
| | - Meha Sharma
- Department of Rheumatology, Center for Endocrinology, Diabetes, Arthritis and Rheumatism (CEDAR) Super-speciality Healthcare, Dwarka, Delhi, India
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Rachmiel M, Lebenthal Y, Mazor-Aronovitch K, Brener A, Levek N, Jacobi-Polishook T, Ben Ari T, Abiri S, Landau Z, Pinhas-Hamiel O. MiniMed 780G Advanced Hybrid Closed-Loop System Outcomes According to Pubertal Status: Awesome Study Group Real-Life Experience. Diabetes Technol Ther 2023; 25:643-651. [PMID: 37219952 DOI: 10.1089/dia.2023.0081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Background and Aims: Achieving good glycemic control is a major challenge for adolescents with type 1 diabetes (TID). The introduction of the MiniMed 780G system, an advanced hybrid closed-loop (AHCL) that enables an automatic correction of insulin, gave hope for improved glycemic outcomes in adolescents. We assessed specific characteristics associated with glycemic measures in youth with T1D switching to Minimed 780G. Methods: This retrospective observational real-life multicenter study from the AWeSoMe Group assessed continuous glucose monitoring (CGM) metrics of 22 patients (59% females, median age 13.9 interquartile range [IQR 11,18] years), from a high socioeconomic background. CGM metrics were recorded for 2-week periods before AHCL, after 1, 3, 6 months, and at the end of follow-up (median 10.9 [IQR 5.4, 17.4] months). Delta-variables (Δ) were calculated as the difference between the end of follow-up and baseline. Results: Time in range (TIR)70-180mg/dL increased from 65% [52, 72] to 75% [63, 80], P = 0.008, from baseline to end of follow-up. Time above range>180mg/dL decreased from 28% [20, 46] to 22% [14, 35], P = 0.047. Advanced pubertal stage was correlated with less improvement in ΔTAR>180mg/dL, r = 0.47, P = 0.05, and less CGM usage r = -0.57, P = 0.05. A longer disease duration was associated with less improvement in ΔTAR180-250mg/dL, r = 0.48, P = 0.05. Lower pump site change frequency was associated with higher glucose management indicator, r = 0.5, P = 0.03, and lower TIR70-180mg/dL r = -0.52, P = 0.08. Conclusion: The use of AHCL enabled improvements in TIR70-180mg/dL in youth with T1D. More advanced pubertal stages, longer disease duration, and less compliance were associated with less improvement, stressing the need for continuous support, and re-education in this age group.
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Affiliation(s)
- Marianna Rachmiel
- Pediatric Endocrinology Unit, Shamir (Assaf Harofeh) Medical Center, Beer Yaakov, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Lebenthal
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Kineret Mazor-Aronovitch
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- National Juvenile Diabetes Center, Maccabi Health Care Services, Ra'anana, Israel
- Pediatric Endocrine and Diabetes Unit, Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Ramat-Gan, Israel
| | - Avivit Brener
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Noah Levek
- National Juvenile Diabetes Center, Maccabi Health Care Services, Ra'anana, Israel
- Pediatric Endocrine and Diabetes Unit, Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Ramat-Gan, Israel
| | - Talia Jacobi-Polishook
- Pediatric Endocrinology Unit, Shamir (Assaf Harofeh) Medical Center, Beer Yaakov, Israel
| | - Tal Ben Ari
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Endocrine and Diabetes Unit, E. Wolfson Medical Center, Holon, Israel
| | - Shirli Abiri
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Endocrine and Diabetes Unit, E. Wolfson Medical Center, Holon, Israel
| | - Zohar Landau
- National Juvenile Diabetes Center, Maccabi Health Care Services, Ra'anana, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Orit Pinhas-Hamiel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- National Juvenile Diabetes Center, Maccabi Health Care Services, Ra'anana, Israel
- Pediatric Endocrine and Diabetes Unit, Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Ramat-Gan, Israel
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Litmanovitch E, Geva R, Leshem A, Lezinger M, Heyman E, Gidron M, Yarmolovsky J, Sasson E, Tal S, Rachmiel M. Missed meal boluses and poorer glycemic control impact on neurocognitive function may be associated with white matter integrity in adolescents with type 1 diabetes. Front Endocrinol (Lausanne) 2023; 14:1141085. [PMID: 37091855 PMCID: PMC10113499 DOI: 10.3389/fendo.2023.1141085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 03/13/2023] [Indexed: 04/25/2023] Open
Abstract
Background The notion that pediatric type 1 diabetes impacts brain function and structure early in life is of great concern. Neurological manifestations, including neurocognitive and behavioral symptoms, may be present from childhood, initially mild and undetectable in daily life. Despite intensive management and technological therapeutic interventions, most pediatric patients do not achieve glycemic control targets for HbA1c. One of the most common causes of such poor control and frequent transient hyperglycemic episodes may be lifestyle factors, including missed meal boluses. Objective The aim of this study was to assess the association between specific neurocognitive accomplishments-learning and memory, inhibition ability learning, and verbal and semantic memory-during meals with and without bolusing, correlated to diffusion tensor imaging measurements of major related tracts, and glycemic control in adolescents with type 1 diabetes compared with their healthy siblings of similar age. Study design and methods This is a case-control study of 12- to 18-year-old patients with type 1 diabetes (N = 17, 8 male patients, diabetes duration of 6.53 ± 4.1 years) and their healthy siblings (N = 13). All were hospitalized for 30 h for continuous glucose monitoring and repeated neurocognitive tests as a function of a missed or appropriate pre-meal bolus. This situation was mimicked by controlled, patient blinded manipulation of lunch pre-meal bolus administration to enable capillary glucose level of <180 mg/dl and to >240 mg/d 2 hours after similar meals, at a similar time. The diabetes team randomly and blindly manipulated post-lunch glucose levels by subcutaneous injection of either rapid-acting insulin or 0.9% NaCl solution before lunch. A specific neurocognitive test battery was performed twice, after each manipulation, and its results were compared, along with additional neurocognitive tasks administered during hospitalization without insulin manipulation. Participants underwent brain imaging, including diffusion tensor imaging and tractography. Results A significant association was demonstrated between glycemic control and performance in the domains of executive functions, inhibition ability, learning and verbal memory, and semantic memory. Inhibition ability was specifically related to food management. Poorer glycemic control (>8.3%) was associated with a slower reaction time. Conclusion These findings highlight the potential impairment of brain networks responsible for learning, memory, and controlled reactivity to food in adolescents with type 1 diabetes whose glycemic control is poor.
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Affiliation(s)
- Edna Litmanovitch
- The Gonda Multidisciplinary Brain Research Center, Bar Ilan University, Ramat Gan, Israel
| | - Ronny Geva
- The Gonda Multidisciplinary Brain Research Center, Bar Ilan University, Ramat Gan, Israel
- Department of Psychology, The Developmental Neuropsychology Lab, Bar Ilan University, Ramat Gan, Israel
| | - Avital Leshem
- Pediatric Endocrinology and Diabetes Institute, Shamir (Assaf Harofeh) Medical Center, Be'er Ya'akov, Israel
| | - Mirit Lezinger
- Pediatric Neurology and Epilepsy Department, Shamir (Assaf Harofeh) Medical Center, Be’er Ya’akov, Israel
| | - Eli Heyman
- Pediatric Neurology and Epilepsy Department, Shamir (Assaf Harofeh) Medical Center, Be’er Ya’akov, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Maor Gidron
- Department of Psychology, The Developmental Neuropsychology Lab, Bar Ilan University, Ramat Gan, Israel
| | - Jessica Yarmolovsky
- Department of Psychology, The Developmental Neuropsychology Lab, Bar Ilan University, Ramat Gan, Israel
| | - Efrat Sasson
- Radiology Department, Shamir (Assaf Harofeh) Medical Center, Be'er Ya'akov, Israel
| | - Sigal Tal
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Radiology Department, Shamir (Assaf Harofeh) Medical Center, Be'er Ya'akov, Israel
| | - Marianna Rachmiel
- Pediatric Endocrinology and Diabetes Institute, Shamir (Assaf Harofeh) Medical Center, Be'er Ya'akov, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- *Correspondence: Marianna Rachmiel,
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Mozzillo E, Franceschi R, Di Candia F, Ricci A, Leonardi L, Girardi M, Rosanio FM, Marcovecchio ML. Optimal Prandial Timing of Insulin Bolus in Youths with Type 1 Diabetes: A Systematic Review. J Pers Med 2022; 12:jpm12122058. [PMID: 36556278 PMCID: PMC9781659 DOI: 10.3390/jpm12122058] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 11/30/2022] [Accepted: 12/12/2022] [Indexed: 12/15/2022] Open
Abstract
The aim of this systematic review was to report the evidence on optimal prandial timing of insulin bolus in youths with type 1 diabetes. A systematic search was performed including studies published in the last 20 years (2002-2022). A PICOS framework was used in the selection process and evidence was assessed using the GRADE system. Up to one third of children and adolescents with type 1 diabetes injected rapid-acting insulin analogues after a meal. Moderate-high level quality studies showed that a pre-meal bolus compared with a bolus given at the start or after the meal was associated with a lower peak blood glucose after one to two hours, particularly after breakfast, as well as with reduced HbA1c, without any difference in the frequency of hypoglycemia. There were no differences related to the timing of bolus in total daily insulin and BMI, although these results were based on a single study. Data on individuals' treatment satisfaction were limited but did not show any effect of timing of bolus on quality of life. In addition, post-prandial administration of fast-acting analogues was superior to rapid-acting analogues on post-prandial glycemia. There was no evidence for any difference in outcomes related to the timing of insulin bolus across age groups in the two studies. In conclusion, prandial insulin injected before a meal, particularly at breakfast, provides better post-prandial glycemia and HbA1c without increasing the risk of hypoglycemia, and without affecting total daily insulin dose and BMI. For young children who often have variable eating behaviors, fast-acting analogues administered at mealtime or post-meal could provide an additional advantage.
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Affiliation(s)
- Enza Mozzillo
- Department of Translational Medical Science, Section of Pediatrics, Regional Center of Pediatric Diabetes, Federico II University of Naples, 80131 Naples, Italy
| | - Roberto Franceschi
- Pediatric Diabetology Unit, Pediatric Department, Santa Chiara General Hospital of Trento, 38122 Trento, Italy
- Correspondence: ; Tel.: +39-0461-903542
| | - Francesca Di Candia
- Department of Translational Medical Science, Section of Pediatrics, Regional Center of Pediatric Diabetes, Federico II University of Naples, 80131 Naples, Italy
| | - Alessia Ricci
- Pediatric Diabetology Unit, Pediatric Department, Santa Chiara General Hospital of Trento, 38122 Trento, Italy
| | - Letizia Leonardi
- Pediatric Diabetology Unit, Pediatric Department, Santa Chiara General Hospital of Trento, 38122 Trento, Italy
| | - Martina Girardi
- Pediatric Diabetology Unit, Pediatric Department, Santa Chiara General Hospital of Trento, 38122 Trento, Italy
| | - Francesco Maria Rosanio
- Department of Translational Medical Science, Section of Pediatrics, Regional Center of Pediatric Diabetes, Federico II University of Naples, 80131 Naples, Italy
| | - Maria Loredana Marcovecchio
- Department of Pediatrics, University of Cambridge and Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
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Montanari VA, Gabbay MAL, Dib SA. Comparison of three insulin bolus calculators to increase time in range of glycemia in a group of poorly controlled adults Type 1 diabetes in a Brazilian public health service. Diabetol Metab Syndr 2022; 14:129. [PMID: 36100854 PMCID: PMC9469814 DOI: 10.1186/s13098-022-00903-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 08/29/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A main factor contributing to insufficient glycemic control, during basal/bolus insulin therapy, is poor self-management bolus. Insulin bolus administration frequency is strongly associated with glycated hemoglobin (A1c) in Type 1 Diabetes (T1D). In the present study, we analyzed the performance of two-bolus calculator's software that could be accessible to T1D patients from a Public Health Service to improve glycemic time in range (TIR) and A1c. METHODS This prospective, controlled, randomized, parallel intervention clinical trial was carried out with 111 T1D participants on basal/bolus therapy [multiple daily insulin injections (MDI) or subcutaneous infusion pump (CSII)] with basal A1c ≥ 8.5% for 24 weeks. Patients were divided into 3 groups: 2 interventions: COMBO® (bolus calculator) and GLIC (mobile application) and 1 control (CSII group). Anthropometrics and metabolic variables were assessed on basal, 3 and 6 months of follow-up. RESULTS TIR was increased in 9.42% in COMBO group (29 ± 12% to 38.9 ± 12.7%; p < 0.001) in 8.39% in the GLIC® group (28 ± 15% to 36.6 ± 15.1%; p < 0.001) while remained stable in CSII group (40 ± 11% to 39.3 ± 10.3%). A1c decrease in 1.08% (p < 0.001), 0.64% (p < 0.001) and 0.38% (p = 0.01) at 6 months in relation to basal in the COMBO, GLIC and CSII respectively. Daily basal insulin dose was reduced by 8.8% (p = 0.01) in the COMBO group. CONCLUSION The COMBO and a mobile applicative (GLIC) bolus calculator had a similar and a good performance to optimize the intensive insulin treatment of T1D in the public health system with increase in the TIR and reduction in A1C without increase hypoglycemia prevalence.
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Affiliation(s)
| | | | - Sérgio Atala Dib
- Endocrinology Division of Universidade Federal de São Paulo-UNIFESP, São Paulo, Brazil
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10
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Heise T, Piras de Oliveira C, Juneja R, Ribeiro A, Chigutsa F, Blevins T. What is the value of faster acting prandial insulin? Focus on ultra rapid lispro. Diabetes Obes Metab 2022; 24:1689-1701. [PMID: 35593434 PMCID: PMC9540401 DOI: 10.1111/dom.14773] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/14/2022] [Accepted: 05/17/2022] [Indexed: 01/09/2023]
Abstract
Rapid-acting insulins (RAIs) have been instrumental in the management of diabetes because of their improved postprandial glucose (PPG) control compared with regular human insulin. However, their absorption rate and time action following subcutaneous administration still falls short of the normal physiological response to meal consumption, increasing the risk of early postmeal hyperglycaemia and late postmeal hypoglycaemia. Increased demand for faster acting insulins, which can quickly control PPG excursions without increasing the risk of late hypoglycaemia, led to the development of ultra-rapid-acting insulins, including ultra-rapid lispro (URLi). URLi is a novel formulation of insulin lispro with accelerated absorption driven by two excipients: treprostinil, which increases local vasodilation, and citrate, which increases local vascular permeability. Clinical pharmacology studies consistently showed an earlier onset and shorter duration of action with URLi compared with Lispro. In a head-to-head study with Faster aspart, Aspart and Lispro, URLi was absorbed faster, provided earlier insulin action, and more closely matched physiological glucose response than the other insulins tested. URLi's unique pharmacokinetic properties increase its potential for improved PPG control beyond that achieved with RAIs. Indeed, in pivotal phase 3 trials, URLi was superior to Lispro for PPG control both at 1 and 2 hours after a meal in type 1 and type 2 diabetes with multiple daily injections, and in type 1 diabetes with continuous subcutaneous insulin infusion. This was achieved without increasing the risk of hypoglycaemia. In this review, we focus on the clinical and pharmacological evidence for URLi in the treatment of diabetes and discuss the potential benefits and considerations with URLi compared with RAIs.
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11
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Fayyaz F, Aghamahdi F, Noorian S, Tabatabaei-Malazy O, Qorbani M. Associated factors to insulin adherence in type 1 diabetes in Tehran and Karaj, Iran. J Diabetes Metab Disord 2022; 21:1591-1597. [PMID: 36065331 PMCID: PMC9430011 DOI: 10.1007/s40200-022-01105-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 07/21/2022] [Accepted: 08/03/2022] [Indexed: 10/28/2022]
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12
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Daniels J, Herrero P, Georgiou P. A Deep Learning Framework for Automatic Meal Detection and Estimation in Artificial Pancreas Systems. SENSORS (BASEL, SWITZERLAND) 2022; 22:466. [PMID: 35062427 PMCID: PMC8781086 DOI: 10.3390/s22020466] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/27/2021] [Accepted: 01/05/2022] [Indexed: 05/13/2023]
Abstract
Current artificial pancreas (AP) systems are hybrid closed-loop systems that require manual meal announcements to manage postprandial glucose control effectively. This poses a cognitive burden and challenge to users with T1D since this relies on frequent user engagement to maintain tight glucose control. In order to move towards fully automated closed-loop glucose control, we propose an algorithm based on a deep learning framework that performs multitask quantile regression, for both meal detection and carbohydrate estimation. Our proposed method is evaluated in silico on 10 adult subjects from the UVa/Padova simulator with a Bio-inspired Artificial Pancreas (BiAP) control algorithm over a 2 month period. Three different configurations of the AP are evaluated -BiAP without meal announcement (BiAP-NMA), BiAP with meal announcement (BiAP-MA), and BiAP with meal detection (BiAP-MD). We present results showing an improvement of BiAP-MD over BiAP-NMA, demonstrating 144.5 ± 6.8 mg/dL mean blood glucose level (-4.4 mg/dL, p< 0.01) and 77.8 ± 6.3% mean time between 70 and 180 mg/dL (+3.9%, p< 0.001). This improvement in control is realised without a significant increase in mean in hypoglycaemia (+0.1%, p= 0.4). In terms of detection of meals and snacks, the proposed method on average achieves 93% precision and 76% recall with a detection delay time of 38 ± 15 min (92% precision, 92% recall, and 37 min detection time for meals only). Furthermore, BiAP-MD handles hypoglycaemia better than BiAP-MA based on CVGA assessment with fewer control errors (10% vs. 20%). This study suggests that multitask quantile regression can improve the capability of AP systems for postprandial glucose control without increasing hypoglycaemia.
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Affiliation(s)
- John Daniels
- Centre for Bio-Inspired Technology, Department of Electrical and Electronic Engineering, Imperial College London, London SW7 2AZ, UK; (P.H.); (P.G.)
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13
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Costa C, Linhares MI, Bastos F, Cardoso R, Dinis I, Santos AP, Mirante A, Serra-Caetano J. Effect of ultra-rapid insulin aspart on glycemic control in children with type 1 diabetes: the experience of a Portuguese tertiary centre. Diabetol Int 2022; 13:531-537. [PMID: 35036267 PMCID: PMC8740860 DOI: 10.1007/s13340-021-00565-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 12/16/2021] [Indexed: 12/01/2022]
Abstract
Background Postprandial hyperglycemia is one of the biggest challenges in children with type 1 diabetes (T1D). Ultra-fast-acting aspartic insulin (faster aspart) has a quicker onset of action and an earlier maximum activity. The aim of this study is to analyze the impact of faster aspart in metabolic control of pediatric patients with T1D in a “real-world” setting. Methods Retrospective analysis of 60 pediatric patients with T1D who changed their insulin analogue to faster aspart. Anthropometric data, insulin doses, capillary and interstitial glucose recordings and average glycated hemoglobin before and after insulin analogue’s switch were obtained. After all population analyses, patients were analyzed separately according to the type of treatment, multiple daily injections (MDI) and continuous subcutaneous insulin infusion (CSII), and according to age group. Results Faster aspart significantly improved metabolic control, increasing time in range (TIR) (42 vs.54%, respectively; P = 0.007) and decreasing time above range (TAR) (52 vs.40%, respectively; P = 0.009), without an increased time in hypoglycemia (7% before and after faster aspart’s introduction; P = 0.933). This was reassured in the adolescent years (n = 45), with an increase in TIR (37 vs. 47%, respectively; P = 0.034) and decrease in TAR (51 vs. 45%, respectively; P = 0.022). Patients on CSII (n = 47), also demonstrated an increase in TIR (38 vs. 50%, respectively; P = 0.010). The reduction of A1c was not statistically significant. Conclusion Although the advantage of faster aspart had already been demonstrated in pediatric patients under MDI, “real-world” studies, including patients under CSII, are still lacking. This study highlights the important impact of faster aspart on metabolic control in children with T1D, particularly among adolescents under CSII.
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Affiliation(s)
- Cláudia Costa
- Serviço de Endocrinologia, Instituto Português de Oncologia do Porto Francisco Gentil, Rua Dr. António Bernardino de Almeida 865, 4200-072 Porto, Portugal
| | | | - Filipa Bastos
- Serviço de Endocrinologia, Hospital Garcia de Orta, Almada, Portugal
| | - Rita Cardoso
- Unidade de Endocrinologia Pediátrica de Endocrinologia, Hospital Pediátrico de Coimbra-CHUC, Coimbra, Portugal
| | - Isabel Dinis
- Unidade de Endocrinologia Pediátrica de Endocrinologia, Hospital Pediátrico de Coimbra-CHUC, Coimbra, Portugal
| | - Ana Paula Santos
- Serviço de Endocrinologia, Instituto Português de Oncologia do Porto Francisco Gentil, Rua Dr. António Bernardino de Almeida 865, 4200-072 Porto, Portugal
| | - Alice Mirante
- Unidade de Endocrinologia Pediátrica de Endocrinologia, Hospital Pediátrico de Coimbra-CHUC, Coimbra, Portugal
| | - Joana Serra-Caetano
- Unidade de Endocrinologia Pediátrica de Endocrinologia, Hospital Pediátrico de Coimbra-CHUC, Coimbra, Portugal
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14
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Robinson S, Newson RS, Liao B, Kennedy-Martin T, Battelino T. Missed and Mistimed Insulin Doses in People with Diabetes: A Systematic Literature Review. Diabetes Technol Ther 2021; 23:844-856. [PMID: 34270324 DOI: 10.1089/dia.2021.0164] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background: Development of coordinated management approaches is important to facilitate self-care in people with diabetes (PwD). Gaining a better understanding of suboptimal insulin use is key in this endeavor. This review aimed, for the first time, to systematically identify and narratively summarize real-world evidence on the extent of suboptimal insulin use (missed and mistimed insulin) in PwD. Methods: A systematic literature search of MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews identified studies reporting on missed and mistimed insulin dosing. Results: From 3305 studies, 37 publications reporting on 30 unique studies that involved 58,617 PwD were included. Studies were conducted across 12 different countries and most employed cross-sectional surveys. Observations regarding missed and mistimed insulin doses were reported in 25 and 10 studies, respectively. PwD reported missing insulin doses, but rates varied due to differences in reporting methods, participant populations, and insulin regimens. The association between missed dosing and glycemic control was evaluated in ten studies in which the authors reported lower glycated hemoglobin (HbA1c) levels in PwD who did not omit insulin. The proportion of PwD reporting mistiming of insulin was in the range of 20-45%, depending on the study; this was associated with higher rates of hypoglycemia and higher HbA1c as reported by study authors. Reasons for suboptimal insulin use were multifactorial, occurring due to disrupted daily routines, social situations, and hypoglycemia avoidance. Conclusions: This review suggests that suboptimal insulin use is widespread and that PwD using insulin may still be struggling with disease management. There is an unmet need for better integrated support in managing the complexities of insulin therapy and for the development of systems (e.g. digital solutions) that empower people to take control of insulin-treated diabetes.
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Affiliation(s)
- Susan Robinson
- Kennedy-Martin Health Outcomes Limited, Brighton, United Kingdom
| | - Rachel S Newson
- Global Patient Outcomes and Real-World Evidence, Eli Lilly, Sydney, Australia
| | - Birong Liao
- Medical Affairs, Eli Lilly, Indianapolis, IN, USA
| | | | - Tadej Battelino
- University Medical Center Ljubljana, and Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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Klonoff DC, Zhang JY, Shang T, Mehta C, Kerr D. Pharmacoadherence: An Opportunity for Digital Health to Inform the Third Dimension of Pharmacotherapy for Diabetes. J Diabetes Sci Technol 2021; 15:177-183. [PMID: 33289578 PMCID: PMC7783015 DOI: 10.1177/1932296820973185] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The basis of pharmacotherapy requires knowledge of two properties of a drug: pharmacokinetics (PK) and pharmacodynamics (PD). In the era of precision medicine, there is growing interest in determining between-individual variations in PK and PD. While these two dimensions of pharmacotherapy are key foci of investigation, a third property is also emerging as a critical factor in understanding how a drug affects an individual. This third property of a drug is known as phamacoadherence (PA). There can be wide variation in PA among people with diabetes, whether they are using oral or injectable medications. The use of new digital health interventions and telehealth communication tools, such as smart insulin pens, is now creating opportunities for health care professionals to have a more complete understanding of the PA of drugs, which allows for more personalized prescribing practices.
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Affiliation(s)
- David C. Klonoff
- Mills-Peninsula Medical Center, San Mateo, CA, USA
- David C. Klonoff, MD, FACP, FRCP (Edin), Fellow AIMBE, Mills-Peninsula Medical Center, 100 South San Mateo Dr, Room 5147, San Mateo, CA 94401, USA.
| | | | - Trisha Shang
- Diabetes Technology Society, Burlingame, CA, USA
| | - Chhavi Mehta
- Mills-Peninsula Medical Center, San Mateo, CA, USA
| | - David Kerr
- Sansum Diabetes Research Institute, Santa Barbara, CA, USA
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16
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Toschi E, Slyne C, Greenberg JM, Greaves T, Atakov-Castillo A, Carl S, Dufour AB, Munshi M. Examining the Relationship Between Pre- and Postprandial Glucose Levels and Insulin Bolus Timing Using Bluetooth-Enabled Insulin Pen Cap Technology and Continuous Glucose Monitoring. Diabetes Technol Ther 2020; 22:19-24. [PMID: 31483167 DOI: 10.1089/dia.2019.0186] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background: Timing of insulin administration in persons using multiple daily injections (MDI) is self-reported. New technology enabling tracking and logging of insulin doses, combined with continuous glucose monitoring (CGM), may provide insight into the relationship between insulin administration and glucose levels. Methods: We performed a prospective observational study using Bluetooth-enabled pen caps, along with CGM, in participants with type 1 diabetes (T1D) on MDI to objectively assess the relationship between the timing of insulin administration and its impact on pre- and postprandial glucose levels for a 2-week period. Results: We evaluated 50 participants (age 40.3 ± 19 years; A1c 8.2% ± 1.5%, duration of T1D 20 ± 15 years). Thirty-seven percent of total boluses resulted in persistent hyperglycemia (glucose >180 mg/dL 3 h postprandially), while 10% resulted in clinically significant hypoglycemia (glucose <55 mg/dL 3 h postprandially) on CGM. Preprandial glucose levels at the time of the bolus did not correlate with postprandial glucose levels. Late boluses, defined as a rise in glucose of ≥50 mg/dL before a bolus, were seen two times/patient/week. Missed boluses, defined as a rise in glucose of ≥50 mg/dL without a bolus within 2 h, occurred 17 times/patient/week. Late and missed boluses were associated with worse glycemic control (A1c; R2 = 0.1, P = 0.02; R2 = 0.1, P = 0.02). Conclusions: The use of Bluetooth-enabled pen caps, with CGM, in persons with T1D on MDI can illustrate the relationship between insulin bolus timing and postprandial glucose. These data may help clinicians and patients understand the impact of timing of insulin doses on glucose levels and glycemic control.
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Affiliation(s)
- Elena Toschi
- Joslin Diabetes Center, Boston, Massachusetts
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | | | | | | | | | - Sam Carl
- Joslin Diabetes Center, Boston, Massachusetts
| | - Alyssa B Dufour
- Harvard Medical School, Boston, Massachusetts
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Medha Munshi
- Joslin Diabetes Center, Boston, Massachusetts
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Lecumberri Pascual E, Tejera Pérez C, Muñoz-Garach A, Javier Ampudia-Blasco F. How often patients on insulin therapy measure postprandial glycemia and modify insulin doses accordingly? From an on-line survey in insulin-treated diabetes patients in Spain. Diabetes Res Clin Pract 2019; 154:43-51. [PMID: 31226281 DOI: 10.1016/j.diabres.2019.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 06/02/2019] [Accepted: 06/13/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Controlling postprandial glycemia (PPG) is important to achieve optimal glycemic control, but few studies have evaluated how often is measured and evaluated. OBJECTIVES To evaluate how often patients on insulin therapy measure PPG and modify insulin doses accordantly. As secondary objectives, we evaluated the factors conditioning elevated PPG and associated issues. MATERIAL AND METHODS Cross-sectional observational study based on a web-based survey from an unselected sample of adult insulin-treated patients. A p-value of < 0.05 was significant. RESULTS 1251 patients (68% women, 38.9 ± 13 years [mean ± SD], body mass index (BMI) 24.2 ± 4.2 kg/m2, diabetes duration 17.4 ± 12.8 years, insulin dose 38 ± 18 IU) participated, 1104 with autoinmmune disease (AD) and 147 with non-autoinmmune diabetes (NAD). 59% of patients had HbA1c ≤ 7%, 92.7% of patients with AD and 55.8% with NAD were attended by specialists (p < 0.001). People with AD did more often blood glucose monitoring (BGM) (p < 0.0001) and used continuous glucose monitoring systems (CGMS) (p < 0.0001). 90.1% with AD and 68.0% with NAD received instructions on measuring PPG (p < 0.001), and more with AD received specific training to change the treatment (87% vs. 61.2%, p < 0.0001) and were more proactive. However, more with NAD discussed their postprandial glucose levels with their healthcare team during clinical visits (92.5% vs. 74.1%, p < 0.0001). Regarding bolus administration, 88.6% with AD and 68.7% with NAD injected the insulin bolus before meals (p < 0.001). CONCLUSIONS Patients with AD determine PPG more frequently. Diabetes type, follow-up setting, number of injections and CGMS use were the most important predictive factors for PPG measurement. Diabetes education programs should address how to best monitor PPG and appropriate corrective actions.
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Affiliation(s)
| | - Cristina Tejera Pérez
- Department of Endocrinology and Nutrition, Complejo Hospitalario Universitario de Ferrol, La Coruña, Spain.
| | - Araceli Muñoz-Garach
- Department of Endocrinology and Nutrition, Virgen de la Victoria University Hospital, Institute of Biomedical Research in Málaga (IBIMA), Málaga, Spain; Instituto de Salud Carlos III, Madrid, Spain
| | - F Javier Ampudia-Blasco
- Diabetes Reference Unit, Endocrinology & Nutrition Department, Hospital Clínico Universitario de Valencia, Valencia, Spain; Instituto de Investigación Sanitaria INCLIVA, Spain; Medicine Department, Medicine Faculty, University of Valencia, Spain
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18
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Gregory JM, Lautz M, Moore LM, Williams PE, Reddy P, Cherrington AD. Enterically delivered insulin tregopil exhibits rapid absorption characteristics and a pharmacodynamic effect similar to human insulin in conscious dogs. Diabetes Obes Metab 2019; 21:160-169. [PMID: 30095210 PMCID: PMC6281755 DOI: 10.1111/dom.13498] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 07/29/2018] [Accepted: 08/06/2018] [Indexed: 12/12/2022]
Abstract
AIMS Current therapy fails to emulate rapid (first-phase) insulin release in relation to a meal, a key defect in types 1 and 2 diabetes. We aimed to quantify the pharmacokinetic (PK) and pharmacodynamic (PD) profile of insulin tregopil, an enterically-absorbed insulin analog that restores the normal distribution of insulin between the hepatic portal and peripheral circulations. MATERIALS AND METHODS The PK and PD profiles of insulin tregopil were studied in overnight-fasted, catheterized, conscious canines using four approaches: (1) equimolar intraportal infusions of tregopil vs human insulin; (2) escalating doses of oral tregopil; (3) identical, consecutive enteric doses of tregopil; and (4) comparison of oral tregopil to inhaled and subcutaneous human insulin administration. RESULTS Equimolar intraportal infusions of tregopil and human insulin resulted in very similar PK profiles and PD profiles were nearly identical. Enteric delivery of tregopil brought about rapid absorption with tmax = 20 minutes in most cases. Median tmax was 20 minutes for oral tregopil and inhaled insulin and 88 minutes for subcutaneous human insulin. The time required for arterial plasma insulin levels to return to baseline was approximately 90, 210 and 360 minutes for oral tregopil, inhaled insulin and subcutaneous insulin, respectively. CONCLUSIONS Enterically delivered tregopil is rapidly absorbed and restores a portal-to-peripheral vascular distribution. These characteristics should improve postprandial hyperglycaemia in types 1 and 2 diabetes.
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Affiliation(s)
- Justin M. Gregory
- Vanderbilt Ian Burr Division of Pediatric Endocrinology and Diabetes, Vanderbilt University School of Medicine, Nashville, TN
| | - Margaret Lautz
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN
| | - L. Merkle Moore
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN
| | - Phillip E. Williams
- Section of Surgical Sciences, Vanderbilt University School of Medicine, Nashville, TN
| | | | - Alan D. Cherrington
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN
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Seckold R, Howley P, King BR, Bell K, Smith A, Smart CE. Dietary intake and eating patterns of young children with type 1 diabetes achieving glycemic targets. BMJ Open Diabetes Res Care 2019; 7:e000663. [PMID: 31321060 PMCID: PMC6606069 DOI: 10.1136/bmjdrc-2019-000663] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 05/11/2019] [Accepted: 06/03/2019] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Young children with type 1 diabetes (T1D) consume more saturated fat and less fruit and vegetables than recommended. A common challenge in this age group is unpredictable appetite potentially impacting the way parents manage diabetes cares at mealtimes. This small study aimed to assess nutritional intake and mealtime routines of young children with T1D in a clinic where the majority of children were achieving glycemic targets. A secondary aim was to explore association of eating pattern with HbA1c. METHODS A retrospective, cross-sectional review of children aged less than 7.0 years with T1D attending a pediatric diabetes service in Australia was performed (n=24). Baseline characteristics, glycated hemoglobin (HbA1c), a 3-day weighed food diary and a mealtime management survey were collected. RESULTS Twenty-two children (55% male) were included aged 4.9±1.3 years (mean±SD), HbA1c 47±10 mmol/mol (6.4%±0.9%), body mass index Z-score 0.8±0.9 and diabetes duration 1.7±1.1 years. Preprandial insulin use was reported in 95% of children. Macronutrient distribution (% energy intake) was carbohydrate (48%±4%), protein (16%±2%) and fat (33%±5%) with saturated fat (15%±3%). The majority of children did not meet vegetable and lean meat/protein intake recommendations (0% and 28%, respectively). HbA1c was not correlated with daily total carbohydrate, protein or fat intake (p>0.05). HbA1c was significantly higher in children offered food in a grazing pattern compared with those offered regular meals (mean 61 mmol/mol vs 43 mmol/mol (7.7% vs 6.1%), p=0.01). CONCLUSIONS Dietary quality is a concern in young children with T1D with excessive saturated fat and inadequate vegetable intake. Our results suggest that young children meeting glycemic targets give insulin before meals and follow a routine eating pattern.
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Affiliation(s)
- Rowen Seckold
- Department of Paediatric Diabetes and Endocrinology, John Hunter Children's Hospital, New Lambton Heights, New South Wales, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Peter Howley
- School of Mathematics and Physical Sciences/Statistics, University of Newcastle, Callaghan, New South Wales, Australia
| | - Bruce R King
- Department of Paediatric Diabetes and Endocrinology, John Hunter Children's Hospital, New Lambton Heights, New South Wales, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Kirstine Bell
- Department of Paediatric Diabetes and Endocrinology, John Hunter Children's Hospital, New Lambton Heights, New South Wales, Australia
| | - Angela Smith
- Department of Paediatric Diabetes and Endocrinology, John Hunter Children's Hospital, New Lambton Heights, New South Wales, Australia
| | - Carmel E Smart
- Department of Paediatric Diabetes and Endocrinology, John Hunter Children's Hospital, New Lambton Heights, New South Wales, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
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Forlenza GP, Messer LH, Berget C, Wadwa RP, Driscoll KA. Biopsychosocial Factors Associated With Satisfaction and Sustained Use of Artificial Pancreas Technology and Its Components: a Call to the Technology Field. Curr Diab Rep 2018; 18:114. [PMID: 30259309 PMCID: PMC6535227 DOI: 10.1007/s11892-018-1078-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
PURPOSE OF REVIEW Summarize biopsychosocial factors associated with using continuous glucose monitors (CGMs), insulin pumps, and artificial pancreas (AP) systems and provide a "call to the field" about their importance to technology uptake and maintained use. RECENT FINDINGS Insulin pumps and CGMs are becoming standard of care for individuals with type 1 diabetes (T1D). AP systems combining a CGM, insulin pump, and automated dosing algorithm are available for commercial use. Despite improved glycemic control with AP system use, numerous barriers exist which may limit their benefit. Studies on components of AP systems (pumps, CGMs) are limited and demonstrate mixed results of their impact on fear of hypoglycemia, adherence, quality of life, depression and anxiety, and diabetes distress. Studies examining biopsychological factors associated specifically with sustained use of AP systems are also sparse. Biological, psychological and social impacts of AP systems have been understudied and the information they provide has not been capitalized upon.
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Affiliation(s)
- Gregory P. Forlenza
- Barbara Davis Center, University of Colorado Denver, 1775 Aurora CT MS A140, Aurora, CO 80045, USA
| | - Laurel H. Messer
- Barbara Davis Center, University of Colorado Denver, 1775 Aurora CT MS A140, Aurora, CO 80045, USA
| | - Cari Berget
- Barbara Davis Center, University of Colorado Denver, 1775 Aurora CT MS A140, Aurora, CO 80045, USA
| | - R. Paul Wadwa
- Barbara Davis Center, University of Colorado Denver, 1775 Aurora CT MS A140, Aurora, CO 80045, USA
| | - Kimberly A. Driscoll
- Barbara Davis Center, University of Colorado Denver, 1775 Aurora CT MS A140, Aurora, CO 80045, USA
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Akturk HK, Shah VN. Severe Hypoglycemia in Adults With Type 1 Diabetes After Switching to Insulin Degludec. J Diabetes Sci Technol 2018; 12:733-734. [PMID: 29183157 PMCID: PMC6154225 DOI: 10.1177/1932296817742922] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Halis Kaan Akturk
- 1 Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- 2 School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Viral N Shah
- 1 Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- 2 School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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