The Diabetes Treatment Satisfaction Questionnaire change version (DTSQc) evaluated in insulin glargine trials shows greater responsiveness to improvements than the original DTSQ

Comparing Continuous Glucose Monitoring and Blood Glucose Monitoring in Adults With Inadequately Controlled, Insulin-Treated Type 2 Diabetes (Steno2tech Study): A 12-Month, Single-Center, Randomized Controlled Trial

OBJECTIVE

To compare the 12-month effects of continuous glucose monitoring (CGM) versus blood glucose monitoring (BGM) in adults with insulin-treated type 2 diabetes.

RESEARCH DESIGN AND METHODS

This is a single-center, parallel, open-label, randomized controlled trial including adults with inadequately controlled, insulin-treated type 2 diabetes from the outpatient clinic at Steno Diabetes Center Copenhagen, Denmark. Inclusion criteria were ≥18 years of age, insulin-treated type 2 diabetes, and HbA1c ≥7.5% (58 mmol/mol). Participants were randomly assigned (1:1) to 12 months of either CGM or BGM. All participants received a diabetes self-management education course and were followed by their usual health care providers. Primary outcome was between-group differences in change in time in range (TIR) 3.9-10.0 mmol/L, assessed at baseline, after 6 and 12 months by blinded CGM. The prespecified secondary outcomes were differences in change in several other glycemic, metabolic, and participant-reported outcomes.

RESULTS

The 76 participants had a median baseline HbA1c of 8.3 (7.8, 9.1)% (67 [62-76] mmol/mol), and 61.8% were male. Compared with BGM, CGM usage was associated with significantly greater improvements in TIR (between-group difference 15.2%, 95% CI 4.6; 25.9), HbA1c (-0.9%, -1.4; -0.3 [-9.4 mmol/mol, -15.2; -3.5]), total daily insulin dose (-10.6 units/day, -19.9; -1.3), weight (-3.3 kg, -5.5; -1.1), and BMI (-1.1 kg/m2, -1.8; -0.3) and greater self-rated diabetes-related health, well-being, satisfaction, and health behavior.

CONCLUSIONS

In adults with inadequately controlled insulin-treated type 2 diabetes, the 12-month impact of CGM was superior to BGM in improving glucose control and other crucial health parameters. The findings support the use of CGM in the insulin-treated subgroup of type 2 diabetes.

Emotional Distress Predicts Reduced Type 2 Diabetes Treatment Adherence in the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE)

OBJECTIVE

We examined longitudinal associations between emotional distress (specifically, depressive symptoms and diabetes distress) and medication adherence in Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE), a large randomized controlled trial comparing four glucose-lowering medications added to metformin in adults with relatively recent-onset type 2 diabetes mellitus (T2DM).

RESEARCH DESIGN AND METHODS

The Emotional Distress Substudy assessed medication adherence, depressive symptoms, and diabetes distress in 1,739 GRADE participants via self-completed questionnaires administered biannually up to 3 years. We examined baseline depressive symptoms and diabetes distress as predictors of medication adherence over 36 months. Bidirectional visit-to-visit relationships were also examined. Treatment satisfaction, beliefs about medication, diabetes care self-efficacy, and perceived control over diabetes were evaluated as mediators of longitudinal associations.

RESULTS

At baseline, mean ± SD age of participants (56% of whom were White, 17% Hispanic/Latino, 18% Black, and 66% male) was 58.0 ± 10.2 years, diabetes duration 4.2 ± 2.8 years, HbA1c 7.5% ± 0.5%, and medication adherence 89.9% ± 11.1%. Higher baseline depressive symptoms and diabetes distress were independently associated with lower adherence over 36 months (P < 0.001). Higher depressive symptoms and diabetes distress at one visit predicted lower adherence at the subsequent 6-month visit (P < 0.0001) but not vice versa. Treatment assignment did not moderate relationships. Patient-reported concerns about diabetes medications mediated the largest percentage (11.9%-15.5%) of the longitudinal link between emotional distress and adherence.

CONCLUSIONS

Depressive symptoms and diabetes distress both predict lower adherence to glucose-lowering medications over time among adults with T2DM. Addressing emotional distress and concerns about anticipated negative effects of taking these treatments may be important to support diabetes treatment adherence.

Glycemic outcomes and patient satisfaction and self-management improves in transition from standard to virtual multidisciplinary care

AIMS

With advances in cloud-based technologies, there has been a rise in remote T1D care. We hypothesized that transitioning T1DM care to a virtual, multidisciplinary clinic could improve measures beyond HbA1c.

METHODS

To assess the impact of transitioning from standard to virtual T1DM care, we evaluated glycemic measures and patient reported outcomes.

RESULTS

Sixty-one adults with T1DM were included, with mean age 40.2 ± 13.5 years and diabetes duration 16.9 ± 9.0 years. Most patients were treated with insulin pumps and CGM. The number of annual diabetes care encounters rose from 2.1 ± 4.2 to 12.8 ± 5.5. Baseline HbA1c was 7.9 ± 1.6 %(63 ± 16.9 mmol/mol), declining to 7.3 ± 1.1 %(56 ± 8.5 mmol/mol) and 7.1 ± 1.0 %(54 ± 7.7 mmol/mol) at 6 and 12 months respectively (p < 0.001 for both). In parallel, TIR improved from 63.1 ± 19.3 % to 69.2 ± 13.8 % (p < 0.001) and 67.5 ± 19.4 % (p = 0.03) at 6 and 12 months respectively, while TBR declined. Scores from validated diabetes treatment and self-management questionnaires rose significantly and these rises were associated with a reduction in HbA1c, the latter score was also associated with increased TIR. There was a trend toward a correlation between encounter frequency and improvement in HbA1c and TIR.

CONCLUSIONS

Transitioning from standard to virtual, coordinated, multidisciplinary T1DM care is associated with increased visit frequency, improving glycemic control, treatment satisfaction and self-care behaviors.

Person-reported outcomes in diabetes care: What are they and why are they so important?

In this review, we aim to show how person-reported outcomes (PROs) and person-reported experiences (PREs) can significantly contribute to the way diabetes care is delivered, the involvement of people with diabetes in diabetes care, and the collaboration between health care professionals and people with diabetes. This review focuses on the definition and measurement of PROs and PREs, the importance of PROs and PREs for person-centred diabetes care, and integrating the perspectives of people with diabetes in the evaluation of medical, psychological and technological interventions. PROs have been increasingly accepted by Health Technology Assessment bodies and are therefore valued in the context of reimbursement decisions and consequently by regulators and other health care stakeholders for the allocation of health care resources. Furthermore, the review identified current challenges to the assessment and use of PROs and PREs in clinical care and research. These challenges relate to the combination of questionnaires and ecological momentary assessment for measuring PROs and PREs, lack of consensus on a core outcome set, limited sensitivity to change within many measures and insufficient standardization of what can be considered a minimal clinically important difference. Another issue that has not been sufficiently addressed is the involvement of people with diabetes in the design and development of measures to assess PROs and PREs.

Treatment Satisfaction and Quality of Life with Tirzepatide Versus Dulaglutide Among Japanese Patients with Type 2 Diabetes: Exploratory Evaluation of the SURPASS J-mono Trial

INTRODUCTION

Treatment satisfaction in diabetes management is vital to achieving long-term clinical outcomes. This analysis evaluated treatment satisfaction among patients with type 2 diabetes (T2D) after 52 weeks of treatment with once-weekly tirzepatide (5, 10, and 15 mg) compared with dulaglutide 0.75 mg.

METHODS

This exploratory analysis of the phase 3 SURPASS J-mono trial assessed treatment satisfaction using the Japanese translation of the Diabetes Treatment Satisfaction Questionnaire status (DTSQs) and change versions (DTSQc). Subgroup analyses were post hoc and conducted for the DTSQc overall treatment satisfaction score based on age (< 65 or ≥ 65 years), sex (male or female), baseline body mass index (BMI; < 25 or ≥ 25 kg/m2), and baseline glycated hemoglobin (≤ 8.5% or > 8.5%).

RESULTS

Baseline DTSQs scores were similar among patients across all treatment arms. Overall, trends showed higher satisfaction among patients who received any tirzepatide dose compared with those who received dulaglutide after 52 weeks of treatment. Mean overall DTSQc treatment satisfaction scores at week 52 were significantly higher with tirzepatide 5, 10, and 15 mg versus dulaglutide 0.75 mg (11.5, 12.1, and 12.3, respectively, vs 8.9; P < 0.001). The DTSQc perceived frequency scores for unacceptable hyperglycemia were significantly lower with tirzepatide 5, 10, and 15 mg versus dulaglutide 0.75 mg (- 1.7, - 1.8, and - 2.3, respectively, vs - 0.6; P < 0.001), while scores for unacceptable hypoglycemia were similar across all treatment arms, ranging from - 0.8 to - 1.1. Subgroup analyses showed increased treatment satisfaction with tirzepatide compared with dulaglutide in the < 65 years (P < 0.001) and baseline BMI ≥ 25 kg/m2 subgroups (P < 0.01 or < 0.001) and similar treatment satisfaction across treatment arms in the ≥ 65 years and BMI < 25 kg/m2 subgroups.

CONCLUSION

Patients with T2D reported higher treatment satisfaction with once-weekly tirzepatide (5, 10, and 15 mg) compared with dulaglutide 0.75 mg after 52 weeks of treatment.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03861052.

Guideline Development for Medical Device Technology: Issues for Consideration

Advances in the development of innovative medical devices and telehealth technologies create the potential to improve the quality and efficiency of diabetes care through collecting, aggregating, and interpreting relevant health data in ways that facilitate more informed decisions among all stakeholder groups. Although many medical societies publish guidelines for utilizing these technologies in clinical practice, we believe that the methodologies used for the selection and grading of the evidence should be revised. In this article, we discuss the strengths and limitations of the various types of research commonly used for evidence selection and grading and present recommendations for modifying the process to more effectively address the rapid pace of device and technology innovation and new product development.

Impact of school-supervised ultra-long-acting basal insulin injections on ketosis in youth with T1D and elevated haemoglobin A1c: A pilot study

BACKGROUND

In youth with type 1 diabetes (T1D), high haemoglobin A1c (HbA1c) levels are associated with an increased risk for diabetic ketoacidosis (DKA).

AIMS

This study examined whether daily school-supervised basal insulin injections were feasible and if they reduced the risk of morning ketosis in children and adolescents with high HbA1c levels. We hypothesized that supervised glargine and degludec would reduce the risk of ketosis and that the prolonged action of degludec would protect from ketosis after consecutive days of unsupervised injections.

MATERIALS & METHODS

After a 2-4-week run-in, youth (10-18 years, HbA1c ≥ 8.5%) managing T1D with injections were randomized to school-supervised administration of degludec or glargine for 4 months. School nurses observed daily blood β-hydroxybutyrate (BHB) and glucose checks. During COVID closures, the research team supervised procedures remotely.

RESULTS

Data from 28 youth (age 14.3 ± 2.3 years, HbA1c 11.4 ± 1.9%, 64% F) were analysed. School-supervised injections of both basal insulins for 1-4 days progressively lowered the percent of participants with elevated BHB. The percent of participants with elevated BHB (≥0.6 mmol/L) after 2 days of unsupervised basal insulin doses at home was greater in the glargine than degludec group but had a high p-value (17.2% vs. 9.0%, p = 0.3). HbA1c was unchanged in both groups.

DISCUSSION

In youth with T1D at high risk for DKA, daily supervised long-acting insulin administration decreased the probability of elevated ketone levels on subsequent school days, regardless of basal insulin type. A larger sample size may have demonstrated that the longer action profile of degludec would offer additional protection from ketosis during days of not attending school.

CONCLUSION

Engaging school-based caregivers in management of youth with T1D on injected insulin may decrease clinically significant ketosis and minimize acute complications of diabetes.

Study design and baseline profile for adults with type 2 diabetes in the once-weekly subcutaneous SEmaglutide randomized PRAgmatic (SEPRA) trial

INTRODUCTION

Once-weekly subcutaneous semaglutide, a glucagon-like peptide-1 analog, is approved in the USA as an adjunct to diet and exercise for adults with inadequately controlled type 2 diabetes (T2D) to improve glycemic control and reduce the risk of major adverse cardiovascular events in people with T2D and established cardiovascular disease. The Semaglutide Unabated Sustainability in Treatment of Type 2 Diabetes (SUSTAIN) phase III clinical trial program demonstrated the efficacy and safety of once-weekly subcutaneous semaglutide; however, determining its effectiveness in a real-world setting could support decision-making by clinicians, payers and policy makers in routine clinical practice.

RESEARCH DESIGN AND METHODS

SEmaglutide PRAgmatic (SEPRA) is an ongoing open-label, randomized, pragmatic clinical trial designed to compare the effects of once-weekly subcutaneous semaglutide versus standard of care in US health-insured adults with T2D and physician-determined inadequate glycemic control. The primary end point is the proportion of participants achieving glycated hemoglobin (HbA1c) <7.0% at year 1; other key outcomes include glycemic control, weight loss, healthcare utilization, and patient-reported outcomes. Individual-level data will be collected from routine clinical practice and health insurance claims. The last patient last visit is expected by June 2023.

RESULTS

Between July 2018 and March 2021, 1278 participants were enrolled from 138 study sites across the USA. At baseline, 54% were male with mean±SD age 57.4±11.1 years and body mass index 35.7±8.0 kg/m². Mean diabetes duration was 7.4±6.0 years and mean HbA1c was 8.5±1.6%. At baseline, concomitant antidiabetes medications included metformin, sulfonylureas, sodium-glucose co-transporter-2 inhibitors, and dipeptidyl peptidase-4 inhibitors. The majority of participants had hypertension and dyslipidemia. The trial design was self-assessed using the PRagmatic Explanatory Continuum Indicator Summary-2 tool by the study steering group and was scored 4-5 in all domains suggesting a highly pragmatic study.

CONCLUSIONS

SEPRA, a highly pragmatic ongoing study, will provide data on the effects of once-weekly subcutaneous semaglutide in a real-world setting when used during routine management of T2D.

TRIAL REGISTRATION NUMBER

NCT03596450.

TRIAL REGISTRATION NUMBER

Once-Weekly Semaglutide Use in Type 2 Diabetes: Real-World Data from the SURE Netherlands Observational Study

INTRODUCTION

SURE Netherlands (NCT03929679) evaluated the use of once-weekly (OW) semaglutide, a glucagon-like peptide 1 receptor agonist (GLP-1RA), in routine clinical care for individuals with type 2 diabetes (T2D).

METHODS

Adults (age ≥ 18 years) with T2D were enrolled into the single-arm study. The primary endpoint was change from baseline to end of study (EOS;  approx. 30 weeks) in glycated haemoglobin (HbA_1c). Secondary endpoints were change from baseline to EOS in body weight (BW) and waist circumference (WC). Proportions of participants achieving predefined HbA_1c targets and weight-loss responses at EOS, safety, health-related quality of life (HRQoL) and treatment satisfaction were assessed.

RESULTS

In total, 211 participants (mean age 60.5 years; diabetes duration 13.3 years) initiated semaglutide; most were receiving metformin (82.9%) and/or basal insulin (59.2%) at baseline, and 6.2% switched from another GLP-1RA. Mean baseline HbA_1c, BW and WC were 8.6%, 105.2 kg and 118.8 cm. In the 186 (88.2%) participants receiving semaglutide at EOS, mean reduction in HbA_1c with semaglutide was - 1.2%-points (95% [confidence interval] CI - 1.3; - 1.0; p < 0.0001), with 124 (70.5%), 95 (54.0%) and 65 (36.9%) participants achieving HbA_1c targets of < 8.0%, < 7.5% and < 7.0%, respectively. Mean reduction in BW was - 7.8 kg [95% CI - 8.7; - 6.8; p < 0.0001], corresponding to relative reduction of - 7.5% [95% CI - 8.4; - 6.6; p < 0.0001]. Improvements in WC (- 8.8 cm [95% CI - 10.4; - 7.2; p < 0.0001]), HRQoL and treatment satisfaction were observed, including across most Short-Form 36 Health Survey domains. One serious adverse drug reaction (cholecystitis) was reported. Eight participants (all receiving concomitant insulin) experienced severe or documented hypoglycaemia.

CONCLUSION

Individuals with T2D treated with OW semaglutide experienced significant and clinically relevant improvements in glycaemic control and BW from baseline. These results from a diverse real-world population in the Netherlands support the use of OW semaglutide in treating adults with T2D in routine clinical practice.

Outcomes of Cooking Matters for Diabetes: A 6-week Randomized, Controlled Cooking and Diabetes Self-Management Education Intervention

BACKGROUND

Diabetes self-management education and support is the cornerstone of diabetes care, yet only 1 in 2 adults with diabetes attain hemoglobin A1c (HbA1c) targets. Food insecurity makes diabetes management and HbA1c control more difficult.

OBJECTIVE

Our aim was to test whether a cooking intervention with food provision and diabetes self-management education and support improves HbA1c and diabetes management.

DESIGN

This was a waitlist-controlled, randomized trial.

PARTICIPANTS/SETTING

Participants were 48 adults with type 1 or type 2 diabetes.

INTERVENTION

Cooking Matters for Diabetes was adapted from Cooking Matters and the American Diabetes Association diabetes self-management education and support intervention into a 6-week program with weekly food provision (4 servings).

MAIN OUTCOME MEASURES

Surveys (ie, Summary of Diabetes Self-Care Activities; Medical Outcomes Study Short Form Health Survey, version 1; Diet History Questionnaire III; 10-item US Adult Food Security Survey Module; and Stanford Diabetes Self-Efficacy Scale) were administered and HbA1c was measured at baseline, post intervention, and 3-month follow-up.

STATISTICAL ANALYSIS

Mixed-effects linear regression models controlling for sex and study wave were used.

RESULTS

Mean (SD) age of participants was 57 (12) years; 65% identified as female, 52% identified as White, 40% identified as Black, and 19 (40%) were food insecure at baseline. Intervention participants improved Summary of Diabetes Self-Care Activities general diet score (0 to 7 scale) immediately post intervention (+1.51; P = .015) and 3 months post intervention (+1.23; P = .05), and improved Medical Outcomes Study Short Form Health Survey, version 1, mental component score (+6.7 points; P = .025) compared with controls. Healthy Eating Index 2015 total vegetable component score improved at 3 months (+0.917; P = .023) compared with controls. At baseline, food insecure participants had lower self-efficacy (5.6 vs 6.9 Stanford Diabetes Self-Efficacy Scale; P = .002) and higher HbA1c (+0.77; P = .025), and demonstrated greater improvements in both post intervention (+1.2 vs +0.4 Stanford Diabetes Self-Efficacy Scale score; P = .002, and -0.12 vs +0.39 HbA1c; P = .25) compared with food secure participants.

CONCLUSIONS

Cooking Matters for Diabetes may be an effective method of improving diet-related self-care and health-related quality of life, especially among food insecure patients, and should be tested in larger randomized controlled trials.

A personalised intervention programme aimed at improving adherence to oral antidiabetic and/or antihypertensive medication in people with type 2 diabetes mellitus, the INTENSE study: study protocol for a randomised controlled trial

BACKGROUND

Medication non-adherence is a prevalent health problem in people with type 2 diabetes mellitus (T2DM). Interventions have previously been developed to improve medication adherence, but inconsistent outcomes have been reported. A potential explanation for this inconsistency is a 'one size fits all' approach, with interventions not tailored to the needs and preferences of individuals. Therefore, the aim of this study is to evaluate the effectiveness of a personalised intervention programme aimed at improving adherence to oral antidiabetic and/or antihypertensive medication in people with T2DM.

METHODS

A parallel-group randomised controlled trial will be conducted in 40-50 community pharmacies in the Netherlands and the United Kingdom (UK). A total of 300 participants will be included and followed up for a period of 6 months. Participants will be people with T2DM identified as non-adherent to oral antidiabetic and/or antihypertensive medication, aged 35-75 years and mobile phone users. The intervention group will receive a personalised intervention programme that is based on one or more of the participants' pre-defined non-adherence profile(s), namely (I) Knowledge and perceptions, (II) Practical problems, (III) Side effects and (IV) Negative mood and beliefs. The intervention comprises of one or more supporting modules, namely (I) Brief messaging, (II) Clinical medication review, (III) Medication schedule, (IV) Reminding messaging, (V) Medication dispensing systems, (VI) Smart messaging, (VII) Referral to general practitioner and (VIII) Unguided web-based Self Help Application for low mood. The control group will receive usual care including access to a publicly available informative diabetes website. The primary study outcome is medication adherence measured with a telephone pill count. Secondary outcomes are systolic blood pressure, HbA1c level, self-reported medication adherence, attitude and beliefs toward medication, satisfaction with diabetes treatment, health status and medical consumption and productivity cost. In addition, a process evaluation will be undertaken to establish the fidelity, reach and the extent to which intervention delivery is normalised in the daily practice of community pharmacy teams.

DISCUSSION

The study can lead to a personalised intervention programme that improves medication adherence in people with T2DM that are non-adherent to oral antidiabetic and/or antihypertensive medication.

TRIAL REGISTRATION

Dutch Trial Register, Trial NL8747 , registered 02 July, 2020; ISRCTN Registry, ISRCTN36009809 , registered 05 February, 2020.

How introduction of automated insulin delivery systems may influence psychosocial outcomes in adults with type 1 diabetes: Findings from the first investigation with the Omnipod® 5 System

AIMS

To evaluate psychosocial outcomes for adults with type 1 diabetes (T1D) using the tubeless Omnipod® 5 Automated Insulin Delivery (AID) System.

METHODS

A single-arm, multicenter (across the United States), prospective safety and efficacy study of the tubeless AID system included 115 adults with T1D. Participants aged 18-70 years completed questionnaires assessing psychosocial outcomes - diabetes distress (T1-DDS), hypoglycemic confidence (HCS), well-being (WHO-5), sleep quality (PSQI), insulin delivery satisfaction (IDSS), diabetes treatment satisfaction (DTSQ), and system usability (SUS) - before and after 3 months of AID use. Associations among participant characteristics, psychosocial measures and glycemic outcomes were evaluated using linear regression analyses.

RESULTS

Adults using the tubeless AID system demonstrated improvements in diabetes-specific psychosocial measures, including diabetes distress, hypoglycemic confidence, insulin delivery satisfaction, diabetes treatment satisfaction, and system usability after 3 months (all P < 0.001). No changes in general well-being or sleep quality were observed. The psychosocial outcomes assessed were not consistently associated with baseline participant characteristics (i.e., age, sex, diabetes duration, glycemic outcomes including percent time in range 70-180 mg/dL, percent time below range < 70 mg/dL, hemoglobin A1c, or insulin regimen).

CONCLUSIONS

Use of the Omnipod 5 AID system was associated with significant improvements in diabetes-related psychosocial outcomes for adults with T1D.

CLINICAL TRIALS REGISTRATION NUMBER

NCT04196140.

Protocol paper: multi-Centre randomised controlled trial evaluating a pre-clinic diabetes assessment and mapped care planning intervention amongst adults with type 1, type 2 or pre-diabetes

BACKGROUND

Existing therapeutic interventions to treat diabetes are well known, yet the majority of people with diabetes do not consistently achieve blood glucose targets (even individual therapy targets) for optimal health, despite the large range of treatment options available. Such outcomes have remained stubbornly poor for decades with <25% adults with diabetes achieving glycaemic targets. Patient behaviour, individually supported in routine clinical care, is an important missing component to improved outcomes, in a medical healthcare model not ideally suited to supporting successful diabetes management.

METHODS

A multi-centre, parallel group, individually randomised trial comparing consultation duration in adults with type 1, type 2 or pre-diabetes using the Spotlight Consultations pre-clinic assessment compared to usual care in the Spotlight-AQ study. Two hundred adults with type 1, type 2 or pre-diabetes attending routine care outpatient appointments across up to ten participating sites will be invited to participate.

INTERVENTION

An outpatient pre-clinic intervention delivered within 1 week prior to scheduled routine outpatient appointment.

PRIMARY OUTCOME MEASURE

Duration of routine outpatient consultation.

SECONDARY OUTCOME MEASURES

Functional health status Diabetes distress Depression Treatment satisfaction Impact on self-care behaviours HCP burnout HCP treatment satisfaction and burden Hypoglycaemia (time less than 70mg/dL) Hyperglycaemia (time above 180 mg/dL) Change in weight Change in HbA_1c Cost effectiveness of intervention DISCUSSION: Results from the study will provide valuable insights into patient-professional communication practices within routine care and recommendations will be made, as necessary, for improvements to that. If the intervention is shown to be clinically and cost-effective, the feedback from participants and healthcare professionals will be used to make any improvements prior to its deployment to support improved communication and associated health outcomes.

ETHICS AND DISSEMINATION

The trial was approved by the Wales REC7 Research Ethics Committee (21/WA/0020). Results will be disseminated through national and international conferences, scientific journals, newsletters, magazines and social media. Target audiences include consultants and other clinicians in diabetes, and medical professionals or scientists overall.

TRIAL REGISTRATION

ISRCTN15511689 . Registered on 10 November 2021.

Efficacy and Sustainability of Diabetes-Specific Meal Replacement on Obese and Overweight Type-2 Diabetes Mellitus Patients: Study Approaches for a Randomised Controlled Trial and Impact of COVID-19 on Trial Progress

Meal replacement (MR) is widely used in weight and diabetes management programs due to its ease of compliance and handling. However, little is known about its impact on outcomes other than glycaemic control and weight loss. Furthermore, not many studies evaluate its cost-effectiveness and sustainability. This study aimed to evaluate the efficacy of a diabetes-specific MR for the weight reduction and glycaemic controls of overweight and obese T2DM patients, as compared to routine dietary consultation. Other health outcomes, the cost effectiveness, and the sustainability of the MR will also be evaluated. Materials and Methods: This randomised controlled clinical trial will involve 156 participants who have been randomised equally into the intervention and control groups. As a baseline, both groups will receive diet consultation. Additionally, the intervention group will receive an MR to replace one meal for 5 days a week. The duration of intervention will be 12 weeks, with 36 weeks of follow-up to monitor the sustainability of the MR. The primary endpoints are weight and Hemoglobin A1c (HbA1c) reduction, while the secondary endpoints are anthropometry, biochemical measurements, satiety, hormone changes, quality of life, and cost-effectiveness. The impact of the COVID-19 pandemic on study design is also discussed in this paper. This study has obtained human ethics approval from RECUKM (JEP-2019-566) and is registered at the Thai Clinical Trials Registry (TCTR ID: TCTR20210921004).

Evaluation of Patient-Reported Satisfaction and Clinical Efficacy of Once-Weekly Semaglutide in Patients with Type 2 Diabetes: An Ambispective Study

INTRODUCTION

The method of therapy administration and injection device characteristics have been documented to influence perceptions and preference of treatment among patients with type 2 diabetes (T2D). We aimed to assess the metabolic effectiveness and patient-reported satisfaction of once-weekly semaglutide compared to liraglutide in suboptimally controlled patients with T2D.

METHODS

We conducted this single-center cohort study at diabetes center clinics at a tertiary care hospital between February 2021 and August 2021. We included suboptimally controlled patients with T2D who had been treated with liraglutide for at least 3 months at baseline, then shifted to once-weekly semaglutide and followed up for the same period. Ambulatory glucose profile (AGP) metrics [i.e., mean glucose level, glycemic variability (GV), time above range (TAR), and time in range (TIR)] for baseline and follow-up were compared. To assess the satisfaction with shifting, we used the valid Arabic version of the Diabetes Treatment Satisfaction Questionnaire status (DTSQs) and change (DTSQc) while the injection device preference was assessed using the Diabetes Injection Device Preference Questionnaire (DID-PQ).

RESULTS

We included 52 patients (25 male and 27 female), with a mean age of 48 (± 6) years and a mean diabetes mellitus duration of 7.27 (± 3.79) years. We observed a significantly decreased mean HbA1c level following semaglutide treatment (7.79% at study end vs. 8.07% at baseline, p < 0.001) and body weight (84.64 ± 7.68 vs. 87.15 ± 8.011, p < 0.001). Compared to the glucometrics data at baseline, we observed a significantly improved mean average glucose, GV, TAR, and TIR (p < 0.001). Data from the DTSQs and DTSQc questionnaires showed a high level of patient-reported satisfaction after shifting to semaglutide treatment. All patients preferred/strongly preferred once-weekly semaglutide over liraglutide in most DID-PQ questionnaire domains.

CONCLUSIONS

Switching from once-daily liraglutide to once-weekly semaglutide led to improvements in both clinical measures of glycemic control and patient-reported satisfaction.

Development and Validation of the Diabetes Pen Experience Measure (DPEM): A New Patient-Reported Outcome Measure

BACKGROUND

Satisfaction with insulin-delivery devices has been shown to improve treatment adherence, translating into better glycemic control. The Diabetes Pen Experience Measure (DPEM) is a new patient-reported outcome measure to evaluate patients' experience when using an injection device.

METHODS

The DPEM was developed using literature review and concept elicitation interviews with clinical experts and patients. This led to a theoretical model and a draft measure of the diabetes pen experience, which was refined following cognitive debriefing. Validation entailed a web-based, noninterventional survey; psychometric analyses conducted according to a statistical analysis plan; and refinement and finalization of the DPEM and theoretical model.

RESULTS

In total, 42 patients participated in concept elicitation interviews. Analysis of the qualitative interviews resulted in a preliminary theoretical model. Based on this model, DPEM items were generated; the preliminary version of the DPEM contained 30 items. Following cognitive debriefing, the validation-ready version comprised 28 items. These were later reduced to 7 higher-order items owing to ceiling/floor effects. In total, 300 patients participated in the web-based validation study. The item statistics were all adequate. Item-to-item correlations were good. Item-to-total correlations displayed acceptable associations between each item against the rest of the items, with correlations of 0.68 to 0.79. The internal consistency was adequate, with a Cronbach's alpha of 0.91. The DPEM is scored by summing the 7 item scores and transforming the sum onto a 100-point scale.

CONCLUSION

The evidence presented supports the use of the DPEM in clinical trials to evaluate the patients' experience with diabetes injection devices.

Switching from predictive low glucose suspend to advanced hybrid closed loop control: Effects on glucose control and patient reported outcomes

AIMS

Automated insulin delivery improves glucose control. Aim of this study was to compare in real life the effects on glucose control and patient reported outcomes of an advanced hybrid closed loop system (Control-IQ), versus a simpler system with predictive low glucose suspend function (Basal-IQ).

METHODS

Thirty-one type 1 diabetic subjects were studied during Basal-IQ and after switching to Control-IQ. Variables analyzed were time spent in range (70-180 mg/dL), in tight range (70-140 mg/dL), above range (>180 mg/dL), below range (<70 mg/dL), mean glucose, coefficient of variation and glycated hemoglobin. Questionnaires were administered regarding therapy satisfaction (Diabetes Treatment Satisfaction Questionnaire in status/change form), fear of hypoglycemia (Hypoglycemia Fear Survey), quality of sleep (Pittsburgh Sleep Quality Index).

RESULTS

After 12 weeks of Control-IQ, time in range increased from 62.7 to 74.0%, p < 0.0001, time in tight range increased from 37.1 to 44.6 %, p < 0.001, time above range decreased from 35.6 to 24.4% p < 0.0001. Improvements were observed in mean glucose and glucose variability. Glycated hemoglobin decreased from 7.0% (53 mmol/mol) to 6.6% (49 mmol/mol), p < 0.0001. Subjects using Control-IQ manifested greater satisfaction and less fear of hypoglycemia.

CONCLUSION

Compared to Basal-IQ, Control-IQ improves glucose control and therapy satisfaction.

Insulin-GLP-1 receptor agonist relay and GLP-1 receptor agonist first regimens in individuals with type 2 diabetes: a randomized, open-label trial study

Aims/Introduction

Glucagon‐like peptide‐1 receptor agonists (GLP‐1 RA) might be less effective in patients with severe hyperglycemia, because hyperglycemia downregulated the GLP‐1 receptor in an animal study. To examine this hypothesis clinically, we compared the glucose‐lowering effects of GLP‐1 receptor agonist liraglutide with and without prior glycemic control.

Materials and Methods

In an open‐label, parallel trial, participants with poorly controlled type 2 diabetes were recruited and randomized to receive once‐daily insulin therapy, degludec (Insulin–GLP‐1 RA relay group, mean 16.8 ± 11.4 IU/day), for 12 weeks and then liraglutide for 12 weeks or subcutaneous injections of GLP‐1 RA, liraglutide (GLP‐1 RA first group, 0.9 mg), for 24 weeks. The primary efficacy end‐points consisted of changes in the levels of fasting plasma glucose and glycated hemoglobin (HbA1c).

Results

The median fasting plasma glucose and HbA1c before the study were 210.0 mg/dL and 9.8%, respectively. The levels of fasting plasma glucose and HbA1c significantly decreased in the Insulin–GLP‐1 RA relay group (P < 0.001) and GLP‐1 RA first group (P < 0.001) by week 24, although no intergroup differences were observed. The reduction of HbA1c in the Insulin–GLP‐1 RA relay group tended to be larger than that in the GLP‐1 RA first group in the lowest CPR (C‐peptide immunoreactivity) quartile (P = 0.072). The adverse events consisted of gastrointestinal problems, followed by hypoglycemia.

Conclusions

The GLP‐1 receptor agonist is overall effective without prior glycemic control with insulin in participants with poorly controlled type 2 diabetes. However, in participants with insulinopenic type 2 diabetes, prior glycemic control with insulin might overcome glucose toxicity‐induced GLP‐1 resistance.

Flash glucose monitoring and automated bolus calculation in type 1 diabetes treated with multiple daily insulin injections: a 26 week randomised, controlled, multicentre trial

AIMS/HYPOTHESIS

We aimed to compare the effects of intermittently scanned continuous glucose monitoring (isCGM) and carbohydrate counting with automated bolus calculation (ABC) with usual care.

METHODS

In a randomised, controlled, open-label trial carried out at five diabetes clinics in the Capital Region of Denmark, 170 adults with type 1 diabetes for ≥1 year, multiple daily insulin injections and HbA_1c > 53 mmol/mol (7.0%) were randomly assigned 1:1:1:1 with centrally prepared envelopes to usual care (n = 42), ABC (n = 41), isCGM (n = 48) or ABC+isCGM (n = 39). Blinded continuous glucose monitoring data, HbA_1c and patient-reported outcomes were recorded at baseline and after 26 weeks. The primary outcome was change in time in range using isCGM vs usual care.

RESULTS

Baseline characteristics were comparable across arms: mean age 47 (SD 13.7) years, median (IQR) diabetes duration 18 (10-28) years and HbA_1c 65 (61-72) mmol/mol (8.1% [7.7-8.7%]). Change in time in range using isCGM was comparable to usual care (% difference of 3.9 [-12-23], p = 0.660). The same was true for the ABC and ABC+isCGM arms and for hypo- and hyperglycaemia. Also compared with usual care, using ABC+isCGM reduced HbA_1c (4 [95% CI 1, 8] mmol/mol) (0.4 [0.1, 0.7] %-point) and glucose CV (11% [4%, 17%]) and improved treatment satisfaction, psychosocial self-efficacy and present life quality. Treatment satisfaction also improved by using isCGM alone vs usual care. Statistical significance was maintained after multiple testing adjustment concerning glucose CV and treatment satisfaction with ABC+isCGM, and treatment satisfaction with isCGM. Discontinuation was most common among ABC only users, and among completers the ABC was used 4 (2-5) times/day and the number of daily isCGM scans was 5 (1-7) at study end.

CONCLUSIONS/INTERPRETATION

isCGM alone did not improve time in range, but treatment satisfaction increased in technology-naive people with type 1 diabetes and suboptimal HbA_1c. The combination of ABC+isCGM appears advantageous regarding glycaemic variables and patient-reported outcomes, but many showed resistance towards ABC.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03682237.

FUNDING

The study is investigator initiated and financed by the Capital Region of Denmark.

Real-World Use of Once-Weekly Semaglutide in Type 2 Diabetes: Results from the SURE UK Multicentre, Prospective, Observational Study

INTRODUCTION

Once-weekly (OW) semaglutide was associated with clinically relevant improvements in glycaemic control and body weight versus comparators in the SUSTAIN randomised controlled trials (RCTs). SURE UK, which is one of a series of individual studies that comprise the SURE programme, evaluated the use of OW semaglutide in a real-world patient population with type 2 diabetes (T2D) in the UK.

METHODS

In this prospective, observational study, adults (≥ 18 years) with ≥ 1 documented glycated haemoglobin (HbA1c) value ≤ 12 weeks before semaglutide initiation were enrolled. The primary endpoint was change in HbA1c from baseline to end of study (EOS; ~ 30 weeks, although due to the COVID-19 pandemic, visits up to week 52 were permitted). Secondary endpoints included change in body weight, waist circumference and patient-reported outcomes (PROs). Physicians were to report all episodes of documented or severe hypoglycaemia, fatal events, serious adverse drug reactions, pregnancies and adverse events (AEs) in foetuses/newborn infants; other AEs during the study period could be reported on a voluntary basis.

RESULT

The estimated mean change in HbA1c from baseline to EOS was - 16.3 mmol/mol [95% confidence interval (CI): - 18.22, - 14.37] (- 1.5%-points [95% CI - 1.67, - 1.31]; p < 0.0001) among the 171 enrolled patients who completed the study on treatment. Mean body weight change was - 5.8 kg (95% CI - 6.75, - 4.94; p < 0.0001). Sensitivity analyses showed similar results. Improvements were also observed in other secondary endpoints, including PROs. No new safety concerns were identified with semaglutide treatment.

CONCLUSION

Patients receiving OW semaglutide experienced statistically significant and clinically relevant reductions from baseline in HbA1c and body weight. These results are in line with those of the SUSTAIN RCTs and support the use of OW semaglutide in routine clinical practice in adults with T2D in the UK.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT03876015.

Real-world use of once-weekly semaglutide in patients with type 2 diabetes: Results from the SURE Denmark/Sweden multicentre, prospective, observational study

AIMS

As part of the SURE programme, SURE Denmark/Sweden aimed to study the real-world use of once-weekly (OW) semaglutide in adults with type 2 diabetes (T2D) in Denmark/Sweden.

METHODS

SURE Denmark/Sweden was an ∼30-week, prospective, multicentre, open-label, observational study, enrolling adults with T2D and ≥1 documented HbA_1c value ≤12 weeks before initiating semaglutide at their physician's discretion. Primary (change in HbA_1c) and secondary (including change in body weight, glycaemic and weight-loss target achievement) endpoints were assessed between baseline and end of study (EOS).

RESULTS

Of the 331 patients initiating semaglutide, 282 (85%) completed the study on treatment. For the latter, estimated mean changes [95% confidence interval] in HbA_1c and body weight between baseline and EOS were -1.2 [-1.3; -1.1]%-points (-13 [-14; -12] mmol/mol) and -5.4 [-6.0; -4.7] kg (both p < 0.0001), respectively, with similar results in Denmark and Sweden. At EOS, 67.5% of patients achieved HbA_1c <7%; 49.4% achieved a weight reduction of ≥5%. Reported adverse events were consistent with the known safety profile of semaglutide.

CONCLUSIONS

In routine clinical practice in Denmark/Sweden, use of OW semaglutide was associated with glycaemic and weight-loss benefits in a wide range of adults with T2D, supporting real-world use. CLINICALTRIALS.

GOV IDENTIFIER

NCT03648281.

Real-world use of once-weekly semaglutide in patients with type 2 diabetes: Results from the SURE Switzerland multicentre, prospective, observational study

AIMS

SURE Switzerland (NCT03631186) investigated real-world once-weekly (OW) semaglutide use in adults with type 2 diabetes (T2D).

METHODS

This multicentre, prospective, observational study enrolled adults with T2D with ≥ 1 documented HbA_1c value ≤ 12 weeks before semaglutide initiation. Primary endpoint was change in HbA_1c from baseline to end of study (EOS; ~30 weeks). Secondary endpoints included changes in body weight (BW) and waist circumference (WC), and the proportion of patients achieving HbA_1c < 8.0%, <7.5% and <7.0% at EOS. Semaglutide dose at EOS was a prespecified exploratory endpoint.

RESULTS

Overall, 214 patients initiated semaglutide (baseline HbA_1c 7.8% [62 mmol/mol], BW 99.9 kg and WC 117.4 cm); 187 attended the EOS visit. At EOS, 175 (81.8%) were still receiving semaglutide (mean [SD] dose 0.78 [0.29] mg); in those patients, mean HbA_1c reduced by -0.8 [95% CI - 1.01;-0.68] %-points (-9 [-11;-7] mmol/mol), BW by -5.0 kg [-5.73;-4.24] and WC by -4.8 cm [-5.75;-3.79] (all p < 0.0001). At EOS, 85.9%, 76.5% and 55.9% patients achieved, respectively, HbA_1c < 8.0%, <7.5% and < 7.0%. No new safety signals were identified.

CONCLUSIONS

Patients with T2D in Switzerland initiating OW semaglutide experienced clinically relevant glycaemic control and BW improvements in a real-world setting, supporting semaglutide use in routine clinical practice.

Metabolic and sympathovagal effects of bolus insulin glulisine versus basal insulin glargine therapy in people with type 2 diabetes: A randomized controlled study

AIMS/INTRODUCTION

This study compares the effects of two different insulin regimens - basal versus bolus insulin - on metabolic and cardiovascular autonomic function in Japanese participants with type 2 diabetes.

MATERIALS AND METHODS

Participants were randomly assigned to groups for therapy with insulin glulisine (IGlu) or insulin glargine (IGla). The primary efficacy end-point was glycemic variability, including M-values, mean of glucose levels, and a blood glucose profile of seven time points before and after the intervention. The secondary end-points included pleiotropic effects, including endothelial and cardiac autonomic nerve functions.

RESULTS

Blood glucose levels at all time points significantly decreased in both groups. Post-lunch, post-dinner, and bedtime blood glucose levels were significantly lower in the IGlu group than in the IGla group. Nadir fasting blood glucose levels at the end-point were significantly lower in the IGla group than in the IGlu group. The M-value and mean blood glucose levels were significantly decreased from baseline in both groups, although the former was significantly lower in the IGlu group than in the IGla group. IGla, but not IGlu, was found to elevate 24-h parasympathetic tone, especially during night-time, and it decreased 24-h sympathetic nerve activity, especially at dawn.

CONCLUSIONS

Both IGlu and IGla regimens reduced glucose variability, with IGlu bringing a greater reduction in M-value. IGla, but not IGlu, increased parasympathetic tone during night-time and decreased sympathetic nerve activity at dawn. These findings shed light on the previously unrecognized role of night-time basal insulin supplementation on sympathovagal activity in type 2 diabetes patients.

The Impact of Flash Glucose Monitoring on Markers of Glycaemic Control and Patient Satisfaction in Type 2 Diabetes

INTRODUCTION

The effect of flash glucose monitoring on glycaemic control and patient satisfaction in insulin-treated type 2 diabetes (T2D) from Saudi Arabia is uncertain. The aim of this prospective observational study was to evaluate the change in HbA1c (Hemoglobin A1c) and satisfaction with treatment following the initiation of flash glucose monitoring.

METHODS

This single-arm, single-centre prospective observational study included flash glucose monitoring-naive adult patients with T2D managed with multiple daily injections of insulin therapy (MDI) and HbA1c ≥7%. HbA1c was measured, and the Diabetes Treatment Satisfaction Questionnaire (DTSQ, Arabic version) and Glucose Monitoring Satisfaction Survey (GMSS) were completed at baseline and 12 weeks.

RESULTS

For participants (n=54) from one diabetes centre, HbA1c significantly improved by 0.44% from 8.22%±0.69 (mean±SD) at baseline to 7.78%±0.71 at 12 weeks, p<0.001. Confirmed hypoglycaemic episodes reduced from 4.43±1.51 episodes/month to 1.24±1.15 (-3.19, p<0.001). Glucose monitoring frequency improved, indicated by the number of scans per day, with a mean increase of 5.13 (p <0.001) tests/day. GMSS scores improved across all four categories, as did overall treatment satisfaction (p<0.001 for all categories). Patients perceived clear improvements across all questions relating to satisfaction and frequency of hypo- or hyperglycaemic episodes.

CONCLUSION

Following initiation of flash glucose monitoring in patients with T2D and MDI insulin therapy, HbA1c improved with reduced hypoglycaemic events and increased patient-reported satisfaction. This study contributes valuable data on the use of flash glucose monitoring in this population, and a larger multicentre study is warranted to inform future health policy for T2D in Saudi Arabia.

Patient-Reported Outcomes Through 1 Year of an HIV-1 Clinical Trial Evaluating Long-Acting Cabotegravir and Rilpivirine Administered Every 4 or 8 Weeks (ATLAS-2M)

BACKGROUND

Advances in HIV-1 therapeutics have led to the development of a range of daily oral treatment regimens, which share similar high efficacy rates. Consequently, more emphasis is being placed upon the individual's experience of treatment and impact on quality of life. The first long-acting injectable antiretroviral therapy for HIV-1 (long-acting cabotegravir + rilpivirine [CAB + RPV LA]) may address challenges associated with oral treatment for HIV-1, such as stigma, pill burden/fatigue, drug-food interactions, and adherence. Patient-reported outcomes (PROs) collected in an HIV-1 clinical trial (ATLAS-2M; NCT03299049) comparing participants' experience with two dosing regimens (every 4 weeks [Q4W] vs. every 8 weeks [Q8W]) of CAB + RPV LA are presented herein.

METHODS

PRO endpoints evaluated through 48 weeks of therapy included treatment satisfaction (HIV Treatment Satisfaction Questionnaire [HIVTSQ]), treatment acceptance ("General Acceptance" domain of the Chronic Treatment Acceptance [ACCEPT^®] questionnaire), acceptability of injections (Perception of Injection [PIN] questionnaire), treatment preference (questionnaire), and reasons for switching to/continuing long-acting therapy (exploratory endpoint; questionnaire). Participants were randomized 1:1 to receive CAB + RPV LA Q8W or Q4W. Results were stratified by prior CAB + RPV exposure in either preplanned or post hoc analyses.

RESULTS

Overall, 1045 participants were randomized to the Q8W (n = 522) and Q4W (n = 523) regimens; 37% (n = 391/1045) had previously received CAB + RPV in ATLAS. For participants without prior CAB + RPV exposure, large increases from baseline were reported in treatment satisfaction in both long-acting arms (HIVTSQ status version), with Q8W dosing statistically significantly favored at Weeks 24 (p = 0.036) and 48 (p = 0.004). Additionally, improvements from baseline were also observed in the "General Acceptance" domain of the ACCEPT questionnaire in both long-acting arms for participants without prior CAB + RPV exposure; however, no statistically significant difference was observed between arms at either timepoint (Week 24, p = 0.379; Week 48, p = 0.525). Significant improvements (p < 0.001) in the "Acceptance of Injection Site Reactions" domain of the PIN questionnaire were observed from Week 8 to Weeks 24 and 48 in both arms for participants without prior CAB + RPV exposure. Participants with prior CAB + RPV exposure reported high treatment satisfaction (mean [HIVTSQ status version]: Q8W 62.2/66.0; Q4W 62.0/66.0), treatment acceptance (mean: Q8W 89.3/100; Q4W 91.2/100), and acceptance of injection site reactions (mean [5 = not at all acceptable; 1 = totally acceptable]: Q8W 1.72; Q4W 1.59) at baseline/Week 8 that were maintained over time. Participants without prior CAB + RPV exposure who received Q8W dosing preferred this regimen over oral CAB + RPV (98%, n = 300/306). Among those with prior Q4W exposure, 94% (n = 179/191) preferred Q8W dosing versus Q4W dosing (3%, n = 6/191) or oral CAB + RPV (2%, n = 4/191).

CONCLUSIONS

Both long-acting regimens provided high treatment satisfaction and acceptance, irrespective of prior CAB + RPV exposure, with most participants preferring Q8W dosing over both the Q4W regimen and their previous daily oral regimen. The PRO data collected at Week 48 support the therapeutic potential of CAB + RPV LA.

FUNDING

ViiV Healthcare and Janssen.

TRIAL REGISTRATION

ATLAS-2M: ClinicalTrials.gov NCT03299049, registered October 2, 2017.

Study of emotional distress in a comparative effectiveness trial of diabetes treatments: Rationale and design

Emotional distress, including depression and diabetes-specific distress (e.g., feeling overwhelmed by living with diabetes, feelings of failure related to diabetes self-care), is a significant and prevalent problem for patients with type 2 diabetes. Both depression and diabetes distress have been associated with metabolic/glycemic control, diabetes complications, mortality, and quality of life. Recent findings further suggest that risk for emotional distress is influenced by diabetes treatment. The GRADE Study (Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study) is generating prospective data that will provide a unique opportunity to examine the relationships between emotional distress, diabetes treatment, and outcomes in an experimental design. The GRADE study is a randomized clinical trial that will compare the metabolic effects of four common anti-hyperglycemic drugs when combined with metformin. This sub-study recruited a subset (n = 1739) of GRADE participants and will examine patient-level variation in baseline emotional distress as a predictor of glycemic control and other health outcomes, independent of treatment effects. The study will also provide an experimental examination of treatment regimen effects on emotional distress over time as part of the overall evaluation of comparative effectiveness. Evaluation of emotional distress using validated measures will allow us to disentangle the roles of depressive symptoms and diabetes distress, factors that share significant overlap but require distinct approaches to screening and treatment. Study findings may directly influence practice decisions regarding screening and treatment for emotional distress as part of diabetes care. ClinicalTrials.gov Identifier: NCT01794143.

Evaluation of a Diabetes Remote Monitoring Program Facilitated by Connected Glucose Meters for Patients With Poorly Controlled Type 2 Diabetes: Randomized Crossover Trial

BACKGROUND

Patients with poorly controlled type 2 diabetes (T2D) experience increased morbidity, increased mortality, and higher cost of care. Self-monitoring of blood glucose (SMBG) is a critical component of diabetes self-management with established diabetes outcome benefits. Technological advancements in blood glucose meters, including cellular-connected devices that automatically upload SMBG data to secure cloud-based databases, allow for improved sharing and monitoring of SMBG data. Real-time monitoring of SMBG data presents opportunities to provide timely support to patients that is responsive to abnormal SMBG recordings. Such diabetes remote monitoring programs can provide patients with poorly controlled T2D additional support needed to improve critical outcomes.

OBJECTIVE

To evaluate 6 months of a diabetes remote monitoring program facilitated by cellular-connected glucose meter, access to a diabetes coach, and support responsive to abnormal blood glucose recordings greater than 400 mg/dL or below 50 mg/dL in adults with poorly controlled T2D.

METHODS

Patients (N=119) receiving care at a diabetes center of excellence participated in a two-arm, 12-month randomized crossover study. The intervention included a cellular-connected glucose meter and phone-based diabetes coaching provided by Livongo Health. The coach answered questions, assisted in goal setting, and provided support in response to abnormal glucose levels. One group received the intervention for 6 months before returning to usual care (IV/UC). The other group received usual care before enrolling in the intervention (UC/IV) for 6 months. Change in hemoglobin A_1c (HbA_1c) was the primary outcome, and change in treatment satisfaction was the secondary outcome.

RESULTS

Improvements in mean HbA_1c were seen in both groups during the first 6 months (IV/UC -1.1%, SD 1.5 vs UC/IV -0.8%, SD 1.5; P<.001). After crossover, there was no significant change in HbA_1c in IV/UC (mean HbA_1c change +0.2, SD 1.7, P=.41); however, those in UC/IV showed further improvement (mean HbA_1c change -0.4%, SD 1.0, P=.008). A mixed-effects model showed no significant treatment effect (IV vs UC) over 12 months (P=.06). However, participants with higher baseline HbA_1c and those in the first time period experienced greater improvements in HbA_1c. Both groups reported similar improvements in treatment satisfaction throughout the study.

CONCLUSIONS

Patients enrolled in the diabetes remote monitoring program intervention experienced improvements in HbA_1c and treatment satisfaction similar to usual care at a specialty diabetes center. Future studies on diabetes remote monitoring programs should incorporate scheduled coaching components and involve family members and caregivers.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03124043; https://clinicaltrials.gov/ct2/show/NCT03124043.

(Ultra-)long-acting insulin analogues for people with type 1 diabetes mellitus

BACKGROUND

People with type 1 diabetes mellitus (T1DM) need treatment with insulin for survival. Whether any particular type of (ultra-)long-acting insulin provides benefit especially regarding risk of diabetes complications and hypoglycaemia is unknown.

OBJECTIVES

To compare the effects of long-term treatment with (ultra-)long-acting insulin analogues to NPH insulin (neutral protamine Hagedorn) or another (ultra-)long-acting insulin analogue in people with type 1 diabetes mellitus.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Scopus, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform and the reference lists of systematic reviews, articles and health technology assessment reports. We explored the US Food and Drug Administration (FDA) and European Medical Agency (EMA) web pages. We asked pharmaceutical companies, EMA and investigators for additional data and clinical study reports (CSRs). The date of the last search of all databases was 24 August 2020.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) with a duration of 24 weeks or more comparing one (ultra-)long-acting insulin to NPH insulin or another (ultra-)long-acting insulin in people with T1DM.

DATA COLLECTION AND ANALYSIS

Two review authors assessed risk of bias using the new Cochrane 'Risk of bias' 2 (RoB 2) tool and extracted data. Our main outcomes were all-cause mortality, health-related quality of life (QoL), severe hypoglycaemia, non-fatal myocardial infarction/stroke (NFMI/NFS), severe nocturnal hypoglycaemia, serious adverse events (SAEs) and glycosylated haemoglobin A1c (HbA1c). We used a random-effects model to perform meta-analyses and calculated risk ratios (RRs) and odds ratios (ORs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, using 95% confidence intervals (CIs) and 95% prediction intervals for effect estimates. We evaluated the certainty of the evidence applying the GRADE instrument.

MAIN RESULTS

We included 26 RCTs. Two studies were unpublished. We obtained CSRs, clinical study synopses or both as well as medical reviews from regulatory agencies on 23 studies which contributed to better analysis of risk of bias and improved data extraction. A total of 8784 participants were randomised: 2428 participants were allocated to NPH insulin, 2889 participants to insulin detemir, 2095 participants to insulin glargine and 1372 participants to insulin degludec. Eight studies contributing 21% of all participants comprised children. The duration of the intervention varied from 24 weeks to 104 weeks. Insulin degludec versus NPH insulin: we identified no studies comparing insulin degludec with NPH insulin. Insulin detemir versus NPH insulin (9 RCTs): five deaths reported in two studies including adults occurred in the insulin detemir group (Peto OR 4.97, 95% CI 0.79 to 31.38; 9 studies, 3334 participants; moderate-certainty evidence). Three studies with 870 participants reported QoL showing no true beneficial or harmful effect for either intervention (low-certainty evidence). There was a reduction in severe hypoglycaemia in favour of insulin detemir: 171/2019 participants (8.5%) in the insulin detemir group compared with 138/1200 participants (11.5%) in the NPH insulin group experienced severe hypoglycaemia (RR 0.69, 95% CI 0.52 to 0.92; 8 studies, 3219 participants; moderate-certainty evidence). The 95% prediction interval ranged between 0.34 and 1.39. Only 1/331 participants in the insulin detemir group compared with 0/164 participants in the NPH insulin group experienced a NFMI (1 study, 495 participants; low-certainty evidence). No study reported NFS. A total of 165/2094 participants (7.9%) in the insulin detemir group compared with 102/1238 participants (8.2%) in the NPH insulin group experienced SAEs (RR 0.95, 95% CI 0.75 to 1.21; 9 studies, 3332 participants; moderate-certainty evidence). Severe nocturnal hypoglycaemia was observed in 70/1823 participants (3.8%) in the insulin detemir group compared with 60/1102 participants (5.4%) in the NPH insulin group (RR 0.67, 95% CI 0.39 to 1.17; 7 studies, 2925 participants; moderate-certainty evidence). The MD in HbA1c comparing insulin detemir with NPH insulin was 0.01%, 95% CI -0.1 to 0.1; 8 studies, 3122 participants; moderate-certainty evidence. Insulin glargine versus NPH insulin (9 RCTs): one adult died in the NPH insulin group (Peto OR 0.14, 95% CI 0.00 to 6.98; 8 studies, 2175 participants; moderate-certainty evidence). Four studies with 1013 participants reported QoL showing no true beneficial effect or harmful effect for either intervention (low-certainty evidence). Severe hypoglycaemia was observed in 122/1191 participants (10.2%) in the insulin glargine group compared with 145/1159 participants (12.5%) in the NPH insulin group (RR 0.84, 95% CI 0.67 to 1.04; 9 studies, 2350 participants; moderate-certainty evidence). No participant experienced a NFMI and one participant in the NPH insulin group experienced a NFS in the single study reporting this outcome (585 participants; low-certainty evidence). A total of 109/1131 participants (9.6%) in the insulin glargine group compared with 110/1098 participants (10.0%) in the NPH insulin group experienced SAEs (RR 1.08, 95% CI 0.63 to 1.84; 8 studies, 2229 participants; moderate-certainty evidence). Severe nocturnal hypoglycaemia was observed in 69/938 participants (7.4%) in the insulin glargine group compared with 83/955 participants (8.7%) in the NPH insulin group (RR 0.83, 95% CI 0.62 to 1.12; 6 studies, 1893 participants; moderate-certainty evidence). The MD in HbA1c comparing insulin glargine with NPH insulin was 0.02%, 95% CI -0.1 to 0.1; 9 studies, 2285 participants; moderate-certainty evidence. Insulin detemir versus insulin glargine (2 RCTs),insulin degludec versus insulin detemir (2 RCTs), insulin degludec versus insulin glargine (4 RCTs): there was no evidence of a clinically relevant difference for all main outcomes comparing (ultra-)long-acting insulin analogues with each other. For all outcomes none of the comparisons indicated differences in tests of interaction for children versus adults.

AUTHORS' CONCLUSIONS

Comparing insulin detemir with NPH insulin for T1DM showed lower risk of severe hypoglycaemia in favour of insulin detemir (moderate-certainty evidence). However, the 95% prediction interval indicated inconsistency in this finding. Both insulin detemir and insulin glargine compared with NPH insulin did not show benefits or harms for severe nocturnal hypoglycaemia. For all other main outcomes with overall low risk of bias and comparing insulin analogues with each other, there was no true beneficial or harmful effect for any intervention. Data on patient-important outcomes such as QoL, macrovascular and microvascular diabetic complications were sparse or missing. No clinically relevant differences were found between children and adults.

Real-time continuous glucose monitoring versus self-monitoring of blood glucose in adults with insulin-treated type 2 diabetes: a protocol for a randomised controlled single-centre trial

INTRODUCTION

Medical treatment options for type 2 diabetes (T2D) have increased over the last decade and enhance the possibility of individualised treatment strategies where insulin is still one of them. In spite of the advancements in treatment options, less than one-third of the population with T2D obtain their optimal glycaemic goal. In persons with type 1 diabetes, continuous glucose monitoring (CGM) has shown to be the most important driver for improvement in glycaemic control, even more than insulin-pump therapy. The use of technology in T2D has only been investigated in few studies.The overall objective of the research study is to examine the effectiveness of the use of CGM versus self-monitoring of blood glucose (SMBG) in persons with insulin-treated T2D on glycaemic variables and patient-reported outcomes on treatment satisfaction, health behaviour and well-being. The independent effect of peer support will also be studied.

METHODS AND ANALYSIS

The study is a single centre, prospective, randomised, open-labelled, three-armed study with the randomisation 2:1:2 in group A with CGM, group B with CGM and peer support, and group C as a control group with SMBG. The participants receive a training course unique for the allocation group. The study runs for 12 months and includes 100 adult participants with insulin-treated T2D, treated at the outpatient clinic at Steno Diabetes Center Copenhagen. Primary outcome is difference in change in time in range. Recruitment begins in August 2020 and ends in July 2021. Final 12-month follow-up is anticipated to be in August 2022.

ETHICS AND DISSEMINATION

The study will be carried out in accordance with the Helsinki Declaration and is approved by the Scientific Ethics Committee of the Capital Region (H-20000843). Data collection and handling will be performed in accordance with the General Data Protection Regulation and is approved by the Danish Data Protection Agency (J-2020-100). Dissemination will be in international peer-reviewed journals, conferences and a plain-language summary for participants.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT04331444).

PROTOCOL VERSION

V.3, 11 December 2020.

Patient-reported outcomes for diabetes and hypertension care in low- and middle-income countries: A scoping review

INTRODUCTION

Patient-reported outcome measures (PROMs) assess patients' perspectives on their health status, providing opportunities to improve the quality of care. While PROMs are increasingly used in high-income settings, limited data are available on PROMs use for diabetes and hypertension in low-and middle-income countries (LMICs). This scoping review aimed to determine how PROMs are employed for diabetes and hypertension care in LMICs.

METHODS

We searched PubMed, EMBASE, and ClinicalTrials.gov for English-language studies published between August 2009 and August 2019 that measured at least one PROM related to diabetes or hypertension in LMICs. Full texts of included studies were examined to assess study characteristics, target population, outcome focus, PROMs used, and methods for data collection and reporting.

RESULTS

Sixty-eight studies met the inclusion criteria and reported on PROMs for people diagnosed with hypertension and/or diabetes and receiving care in health facilities. Thirty-nine (57%) reported on upper-middle-income countries, 19 (28%) reported on lower-middle-income countries, 4 (6%) reported on low-income countries, and 6 (9%) were multi-country. Most focused on diabetes (60/68, 88%), while 4 studies focused on hypertension and 4 focused on diabetes/hypertension comorbidity. Outcomes of interest varied; most common were glycemic or blood pressure control (38), health literacy and treatment adherence (27), and acute complications (22). Collectively the studies deployed 55 unique tools to measure patient outcomes. Most common were the Morisky Medication Adherence Scale (7) and EuroQoL-5D-3L (7).

CONCLUSION

PROMs are deployed in LMICs around the world, with greatest reported use in LMICs with an upper-middle-income classification. Diabetes PROMs were more widely deployed in LMICs than hypertension PROMs, suggesting an opportunity to adapt PROMs for hypertension. Future research focusing on standardization and simplification could improve future comparability and adaptability across LMIC contexts. Incorporation into national health information systems would best establish PROMs as a means to reveal the effectiveness of person-centered diabetes and hypertension care.

A model of culturally-informed integrated diabetes education and eye screening in indigenous primary care services and specialist diabetes clinics: Study protocol

AIMS

To improve diabetes management in Indigenous Australians using an integrated nurse-led model of diabetes education and eye screening in indigenous primary care and specialist diabetes clinics.

DESIGN

A pre-post study.

METHODS

This study will be implemented in indigenous primary care and specialist diabetes clinics in Victoria, Australia. Participants recruited to the study will be existing adult patient with diagnosed diabetes attending study sites. A nurse-credentialled diabetes educator and certified retinal imager will deliver three study components: (a) retinal photography as a diabetic retinopathy screening and patient engagement tool; (b) lifestyle and behaviour surveys, administered at baseline and at the final visit, in 12 months. Findings from the surveys and participants' retinal images will be used to guide; and (c) personalized diabetes education. The primary outcomes are participant adherence to diabetic eye screening recommendations and health service diabetic retinopathy screening coverage. Secondary outcomes are baseline DR prevalence and changes in clinical and lifestyle risk factor levels, diabetes knowledge and satisfaction with diabetes care.

DISCUSSION

Compared with non-indigenous Australians, Indigenous Australians have a high prevalence of diabetic retinopathy and blindness, low adherence to eye screening recommendations and suboptimal health literacy. Nurse-credentialled diabetes educators can be trained to incorporate retinal imaging and eye screening into their clinical practice to give image-based diabetes education to facilitate diabetic retinopathy management.

IMPACT

Credentialled nurse diabetes educators who integrate eye screening and diabetes education can facilitate timelier diabetic retinopathy screening, referral pathways and treatment of sight-threatening retinopathy. We believe that this model of integrated diabetes education and eye screening will also improve adherence to eye screening recommendations, population screening coverage, health literacy, risk factor levels and diabetes self-care.

CLINICAL TRIAL REGISTRATION

ANZCTRN1261800120435.

Confirmatory Factor Analysis and Reliability of the Diabetes Treatment Satisfaction Questionnaire (DTSQ) for Arabic Speaking Patients with Type II Diabetes

Background

Treatment satisfaction is an important indicator for treatment compliance and glycemic control. Although psychometric properties of the Diabetes Treatment Satisfaction Questionnaire have been confirmed in several languages, it remains unclear the extent to which the factorial structure of this tool is valid for Arabic speaking populations.

Purpose

This study set out to confirm the construct validity of the Arabic version of the Diabetes Treatment Satisfaction Questionnaire (DTSQ) by investigating the fit of published factor structures and the reliability of responses in patients diagnosed with type 2 diabetes.

Methods

Data were from a large cross-sectional study of 1002 patients with diabetes in Jordan. Confirmatory factor analysis was used to compare three different models of the 8-item questionnaire (one factor, two factors, three factors) across patients treated with insulin and patients treated with oral hypoglycaemic medications.

Results

Statistics covered the factorial validity and omega reliability coefficient (Ω_w) of the DTSQ. We were able to replicate the three different models of the 8-item Diabetes Treatment Satisfaction Questionnaire reported in previous studies, yet a two-factor model provided the best fit to the data in our sample with omega reliability coefficient (Ω_w) of the subscales above 0.70.

Conclusion

The finding suggests a cross-cultural invariance of the factor structure of the Arabic version of the Diabetes Treatment Satisfaction Questionnaire, as we were able to replicate the same factor structure using the Arabic translated version of the tool and using non-English speaking participants. Within known limitations and gaps in the literature, healthcare professionals working with Arabic speaking patients may find this tool useful for identification of high-risk patients and those in need for interventions to promote glycemic control.

A virtual clinic for the management of diabetes-type 1: study protocol for a randomised wait-list controlled clinical trial

BACKGROUND

Diabetes is a serious chronic disease. Medical treatment and good psychosocial support are needed to cope with acute and long-term effects of diabetes. Self-management is a large part of diabetes management, with healthcare providers playing a supportive role. Young adults with type 1 diabetes are of special interest as they tend to have higher mean glycosylated haemoglobin values than other patients with type 1 diabetes, and they often miss visits in traditional diabetes care. A well-designed virtual solution may improve a range of measures (e.g. glycaemic control and perceived health) and reduce hospitalisations.

METHOD

This randomised controlled trial with a control group using a wait list design will recruit 100 young adults from a hospital in Sweden. All participants will receive usual diabetes care besides the virtual clinic. The primary objective is to evaluate the effect of a virtual diabetes clinic on glycaemic control, treatment satisfaction and quality of life in young adults (aged 18-25 years) with type-1 diabetes. The secondary objective is to determine the effects of virtual care on the patient experience.

DISCUSSION

Virtual tools are becoming increasingly common in healthcare; however, it remains unclear if these tools improve diabetes self-management. The results of this study will build understanding of how healthcare providers can use a virtual clinic to improve diabetes self-management.

TRIAL REGISTRATION

Current controlled trials: ISRCTN, number: 73435627, registered 23 October 2019. https://doi.org/10.1186/ISRCTN73435627.

Patient-Reported Outcomes with Insulin Glargine 300 U/mL in People with Type 2 Diabetes: The MAGE Multicenter Observational Study

INTRODUCTION

MAGE was a Multicenter, single-Arm, observational 6-month (plus 6-month extension) study that aimed to assess treatment satisfaction, efficacy, and safety of insulin Glargine 300 U/mL (Gla-300) in people with type 2 diabetes (T2DM) receiving basal-bolus insulin in a rEal-world setting.

MATERIALS AND METHODS

Participants were at least 18 years old, with T2DM for more than 1 year, HbA_1c 7.0-10.0%. The primary endpoint was change in Diabetes Treatment Satisfaction Questionnaire status version (DTSQs) total score (baseline to month 6). Secondary endpoints included reasons for starting Gla-300, changes in the DTSQ change version (DTSQc) total score, Hypoglycemia Fear Survey-II (HFS-II) total behavior and worry scores at months 6 and 12, HbA_1c changes at months 3, 6, 9, and 12, and safety.

RESULTS

MAGE included 87 adults (mean T2DM duration 17 years). The primary endpoint of DTSQs mean (standard deviation) total score improvement at month 6 was achieved (2.80 [5.46] points; p < 0.0001). The main reasons for Gla-300 initiation were to decrease HbA_1c (89.7% of participants) and reduce the number of hypoglycemic events (35.6% of participants). Significant improvements were observed in the DTSQc total score and perceived hyperglycemia/hypoglycemia (baseline to month 6, p < 0.05). Significant changes in HFS-II behavior, worry, and total scores at 6 and 12 months were also observed (p < 0.05). There were no statistically significant changes in HbA_1c. Safety outcomes, including hypoglycemia, were comparable to previously reported trials.

CONCLUSIONS

The MAGE study indicates that Gla-300, as part of a basal-bolus regimen, results in improved treatment satisfaction and reduced hypoglycemia fear in people with advanced T2DM.

Study protocol for optimising glycaemic control in type 1 diabetes treated with multiple daily insulin injections: intermittently scanned continuous glucose monitoring, carbohydrate counting with automated bolus calculation, or both? A randomised controlled trial

INTRODUCTION

There are beneficial effects of advanced carbohydrate counting with an automatic bolus calculator (ABC) and intermittently scanned continuous glucose monitoring (isCGM) in persons with type 1 diabetes. We aim to compare the effects of isCGM, training in carbohydrate counting with ABC and the combination of the two concepts with standard care.

METHODS AND ANALYSIS

A multi-centre randomised controlled trial with inclusion criteria: ≥18 years, type 1 diabetes ≥1 year, injection therapy, HbA1c >53 mmol/mol, whereas daily use of carbohydrate counting and/or CGM/isCGM wear are exclusion criteria. Inclusion was initiated in October 2018 and is ongoing. Eligible persons are randomised into four groups: standard care, ABC, isCGM or ABC+isCGM. Devices used are FreeStyle Libre Flash and smart phone diabetes application mySugr. Participants attend group courses according to treatment allocation with different educational contents. Participants are followed for 26 weeks with clinical visits and telephone consultations. At baseline and at study end, participants wear blinded CGM, have blood samples performed and fill in questionnaires on person-related outcomes, and at baseline also on personality traits and hypoglycaemia awareness. The primary outcome is the difference in time spent in normoglycaemia (4-10 mmol/L) at study end versus baseline between the isCGM group and the standard care group. Secondary outcomes will also be analysed. Results are expected in 2020.

ETHICS AND DISSEMINATION

Regional Scientific Ethics Committee approval (H-17040573). Results will be sought disseminated at conferences and in high impact journals.Trial registration numberClinicalTrial.gov registry (NCT03682237).

Feasibility of using a transition diabetes team to commence injectable therapies postdischarge from a tertiary hospital: a pilot, randomised controlled trial

OBJECTIVES

This study aimed to investigate if the use of a transition team was feasible for patients with diabetes being discharged from hospital on injectable diabetes therapies.

DESIGN

Pilot, randomised controlled trial.

SETTING

The trial was conducted between 2014 and 2016 conjointly by a tertiary referral hospital and a community healthcare provider.

PARTICIPANTS

Hospital inpatients (n=105) on new injectable diabetes therapies were randomised 1:1 to transition team or standard care. The transition team received in-home diabetes education 24-48 hours postdischarge, with endocrinologist review 2-4 weeks and 16 weeks postdischarge.

MAIN OUTCOME MEASURES

The primary outcome was feasibility, defined by percentage of patients successfully receiving the intervention. Secondary outcomes included safety, defined by hospital readmission and emergency department presentations within 16 weeks postrandomisation, and treatment satisfaction, measured using Diabetes Treatment Satisfaction Questionnaire (DTSQ). Exploratory outcomes included length of stay (LOS) and change in haemoglobin A1c (HbA1c) throughout the study.

RESULTS

The intervention was deemed feasible (85% (95% CI 73% to 94%)). No difference in safety between groups was detected. No difference in change in HbA1c between groups was detected (standard care median HbA1c -1.5% (IQR -3.7% to -0.2%) vs transition team median HbA1c -1.9% (IQR -3.8% to -0.2%), p=0.83). There was a trend towards reduced LOS in the transition team group (per protocol, standard care median LOS 8 (IQR 5.5-12); transition team median LOS 6 (IQR 3-12), p=0.06). There was a significant improvement in patient satisfaction in the transition team (standard care median 10.5 (IQR 8.5-16); transition team DTSQ change version median 15 (IQR 10-17.5), p=0.047), although interpretability is limited by missing data.

CONCLUSION

This study demonstrated that the use of a novel transition diabetes team is a feasible alternative model of care.

A Randomized Controlled, Treat-to-Target Study Evaluating the Efficacy and Safety of Insulin Glargine 300 U/mL (Gla-300) Administered Using Either Device-Supported or Routine Titration in People With Type 2 Diabetes

BACKGROUND

The efficacy/safety of device-supported versus routine titration with Gla-300 in type 2 diabetes (T2DM) was evaluated.

METHOD

AUTOMATIX was a 16-week, randomized, open-label, parallel-group, multicenter, noninferiority trial in insulin-treated or insulin-naïve people with T2DM. The fasting self-monitored plasma glucose (FSMPG) target was 90-130 mg/dL (5.0-7.2 mmol/L). Primary endpoint: proportion of participants achieving target FSMPG at week 16 without severe hypoglycemia. Secondary endpoints included: proportion reaching FSMPG target without confirmed (≤70 mg/dL [≤3.9 mmol/L]) or severe hypoglycemia; time to first achieve FSMPG target; mean FSMPG and HbA1c change (baseline to week 16). Safety endpoints included hypoglycemia and adverse events. Patient-reported outcomes (PROs) were also assessed.

RESULTS

Participants were randomized to device-supported (n = 75) or routine titration (n = 76); 17 participants in the device-supported group discontinued device use. Noninferiority was achieved for the primary endpoint (device-supported: 45.9%, routine: 36.8%; weighted difference: 9.04 [95% CI: -6.75, 24.83]), but not superiority (P = .262). The proportion reaching FSMPG target range without confirmed (≤70 mg/dL [≤3.9 mmol/L]) or severe hypoglycemia was 34.3% vs 14.5%, respectively. The time at which 50% of the participants achieved the FSMPG target was less in the device-supported than routine titration arm (10 vs 13 weeks). Least squares mean HbA1c reduction, safety profiles, and PROs were similar in both arms. Mean "ease of use" score for the device, assessed by healthcare professionals and participants on a scale of 1-7, was ≥6.

CONCLUSIONS

Device-supported self-titration had a good safety/efficacy profile, and was noninferior to routine titration and well accepted by diabetes specialists and patients.

Influence of Supervised Disease Understanding and Diabetes Self-Management on Adherence to Oral Glucose-Lowering Treatment in Patients with Type 2 Diabetes

INTRODUCTION

Systematic patient education has been reported to improve adherence to treatment, leading to better clinical outcomes. This cluster randomized real-world study investigated the effect of a systematic education program and telephone support on self-reported adherence to oral glucose-lowering treatment in patients with type 2 diabetes mellitus (T2DM).

METHODS

Centers were randomized (1:1) to provide either standard-of-care (control group) or standard-of-care along with the education program and telephone support (empowerment group). Adherence to treatment and satisfaction with treatment were assessed using the four-item Morisky Medication Adherence Scale (MMAS-4) and the Diabetes Treatment Satisfaction Questionnaire (DTSQ). The study population included 457 patients (258/199 male/female) with T2DM and non-optimal glycemic control, on oral antidiabetic treatment (age 62.7 [11.4]; disease duration 8.5 [6.5] years).

RESULTS

MMAS-4 high adherence rates for the control and empowerment groups were increased by 3.8% and 16.8% at 4 months (Breslow-Day test p = 0.04) and by 8.5% and 18.8% at 8 months of follow-up, respectively (Breslow-Day test p = 0.09), compared to baseline. Intense physical activity was increased in both control and empowerment groups by 2.3% and 13.9% at 4 months (Breslow-Day test p = 0.082) and by 4.0% and 22.5% at 8 months of follow-up (Breslow-Day test p < 0.001). Baseline mean (SD) HbA1c was significantly lower in the control group compared with the empowerment group [7.7% versus 8.0%, p = 0.001] and decreased in both groups at 4 months by 0.7% and 0.9%, respectively. The change from baseline in the mean DTSQ status score at 4 months was greater in the empowerment group, and the effect was sustained at 8 months (control group: 29.1, 30.5, and 30.9; empowerment group: 25.0, 28.7, and 29.4 at baseline, 4 and 8 months, respectively, p < 0.001).

CONCLUSION

Systematic education combined with telephone support delivered by physicians might be associated with improvement in treatment adherence and treatment satisfaction in patients with T2DM.

FUNDING

MSD, Greece.

Optimizing mHealth Technologies in Real-World Clinical Practices

IN BRIEF Therapeutic inertia and suboptimal treatment adherence remain the key drivers of chronic poor diabetes control. Advances in mHealth technologies have spurred the development of a new generation of blood glucose monitoring systems that enable individuals with diabetes to automatically transfer glucose data and other information from their smartphones to their health care providers for analysis and interpretation via diabetes data-management software. This report discusses key lessons learned from two investigations that assessed the effects of interventions using the Accu-Chek Connect diabetes-management system (Roche Diabetes Care, Indianapolis, Ind.) within diverse diabetes populations.

Older People With Type 2 Diabetes-Individualizing Management With a Specialized (OPTIMISE) Community Team: Protocol for a Safety and Feasibility Mixed Methods Study

Background

The prevalence of diabetes is rising in older people. In 2018, over 574,000 Australians reported having diabetes. The highest prevalence (19.4%) of diabetes has been observed in people aged 85 years and older. Clinical guidelines recommend that diabetes management should be individualized; however, there is limited information regarding the current management patterns of diabetes in older people, given most clinical trials exclude participants from this age group. Available data identify that few individuals achieve optimal glycemic levels in the general population, potentially leading to adverse health outcomes and impact on quality of life. The data on glycemic profiles of older population are limited.

Objective

The aim of this study is to examine individualized diabetes management intervention for older people through home visits with a credentialed diabetes educator (CDE) and telehealth consultations with an endocrinologist located at a tertiary hospital.

Methods

This paper describes the design and methodology of a mixed methods feasibility and safety study to identify the current management of type 2 diabetes in people aged 65 years or older. We will implement and evaluate a personalized approach to management in the community of an Australian metropolitan city. This management approach will utilize flash glucose monitoring and home visits with the support of a community home nursing service CDE and telehealth consultation with an endocrinologist located at a local tertiary hospital.

Results

The study commenced in February 2017 and has recruited 43 participants, with final data collection to be completed by July 2019. Data analysis will commence after final data collection, with results expected to be published by the end of 2019.

Conclusions

This study is the first of its kind to explore individualized diabetes management for community-dwelling older people, with an aim to achieve optimal glycemic levels (glycated hemoglobin between 53 and 69 mmol/mol [7%-8.5%] depending on the fitness and frailness of the older individual). The data drawn from this study may be used to inform policy makers, service providers, clinicians, and older adults living with diabetes.

International Registered Report Identifier (IRRID)

DERR1-10.2196/13986

German language questionnaires for assessing implementation constructs and outcomes of psychosocial and health-related interventions: a systematic review

Background

Over the past years, implementation science has gained more and more importance in German-speaking countries. Reliable and valid questionnaires are needed for evaluating the implementation of evidence-based practices. On an international level, several initiatives focused on the identification of questionnaires used in English-speaking countries but limited their search processes to mental health and public health settings. Our aim was to identify questionnaires used in German-speaking countries measuring the implementation of interventions in public health and health care settings in general and to assess their psychometric properties.

Methods

We searched five different bibliographic databases (from 1985 to August 2017) and used several other search strategies (e.g., reference lists, forward citation) to obtain our data. We assessed the instruments, which were identified in an independent dual review process, using 12 psychometric rating criteria. Finally, we mapped the instruments’ scales and subscales in regard to the constructs of the Consolidated Framework for Implementation Research (CFIR) and the Implementation Outcome Framework (IOF).

Results

We identified 31 unique instruments available for the assessment of implementation science constructs. Hospitals and other health care settings were the ones most often investigated (23 instruments), while education and childcare settings, workplace settings, and community settings lacked published instruments. Internal consistency, face and content validity, usability, and structural validity were the aspects most often described. However, most studies did not report on test-retest reliability, known-groups validity, predictive criterion validity, or responsiveness. Overall, the majority of studies did not reveal high-quality instruments, especially regarding the psychometric criteria internal consistency, structural validity, and criterion validity. In addition, we seldom detected instruments operationalizing the CFIR domains intervention characteristics, outer setting, and process, and the IOF constructs adoption, fidelity, penetration, and sustainability.

Conclusions

Overall, a sustained and continuous effort is needed to improve the reliability and validity of existing instruments to new ones. Instruments applicable to the assessment of implementation constructs in public health and community settings are urgently needed.

Trial registration

The systematic review protocol was registered in PROSPERO on October 19, 2017, under the following number: CRD42017075208.

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0837-3) contains supplementary material, which is available to authorized users.

A Systematic Review of Patient-Reported Satisfaction with Oral Medication Therapy in Patients with Type 2 Diabetes

OBJECTIVE

To provide a comprehensive comparative evaluation of the psychometric properties of satisfaction with medication surveys used for patients with type 2 diabetes (T2D) in clinical trials.

METHODS

Instruments identified through a comprehensive literature search were evaluated based on the following criteria: disease specificity, peer-reviewed publication (administered in English in patients with T2D on oral therapy), and availability of psychometric properties.

RESULTS

Eight instruments (Diabetes Medication Satisfaction [DiabMedSat]; Diabetes Treatment Satisfaction Questionnaire, status version [DTSQs]; Diabetes Medication System Rating Questionnaire [DMSRQ]; Diabetes Medication System Rating Questionnaire-Short Form [DMSRQ-SF]; Diabetes Tablet Treatment Questionnaire [DTTQ]; Perceptions About Medications for Diabetes [PAM-D]; Satisfaction with Oral Anti-Diabetic Agent Scale [SOADAS]; Diabetes Medication Satisfaction Tool [DMSAT]) were included in the study based on the predefined inclusion criteria. Seven of the instruments (all but DTTQ) utilized patients in the survey development process. All eight instruments could be completed within 15 minutes and thus were considered practical. DiabMedSat, DMSRQ, and DMSRQ-SF encompassed broader aspects of satisfaction than the other instruments. All of the instruments reviewed showed substantial floor or ceiling effects, except for DMSAT and DiabMedSat, without complete information. The DMSRQ and DMSRQ-SF each satisfied the criteria for reliability. DiabMedSat, DTSQs, DMSRQ, DMSRQ-SF, SOADAS, and DMSAT showed favorable convergent and discriminant validity. All of the instruments except DTTQ were determined to satisfactorily meet the criteria of responsiveness.

CONCLUSION

Although it is up to researchers to decide which instrument to use according to the resources available and specific aims of their studies, DMSRQ and DSMRQ-SF were recommended based on the evaluative criteria employed in this study.

Protocol for Meal-time Administration of Exenatide for Glycaemic Control in Type 1 Diabetes Cases (The MAG1C trial): a randomised, double-blinded, placebo-controlled trial

INTRODUCTION

Persons with type 1 diabetes require intensive insulin therapy to achieve glycaemic control, but side effects, including hypoglycaemia and weight gain, may reduce treatment compliance. We hypothesise that add-on treatment of the short-acting glucagon-like peptide-1 receptor agonist, exenatide, to insulin therapy in persons with type 1 diabetes will reduce insulin requirements, glycaemic excursions and body weight and improve glycaemic control without increasing the risk of hypoglycaemia. The present article describes a protocol developed to test this hypothesis.

METHODS AND ANALYSIS

One-hundred adult persons with type 1 diabetes for more than 1 year, insufficient glycaemic control (glycated haemoglobin A1c (HbA1c) between 58 and 86 mmol/mol) and body mass index >22.0 kg/m² will be randomised to either exenatide 10 µg three times per day (at meal times) or placebo as add-on therapy to regular basal-bolus insulin treatment for 26 weeks. Primary endpoint is change in HbA1c between the two groups at end of treatment. Secondary endpoints include change in glycaemic excursions (assessed by continuous glucose monitoring); insulin dose; hypoglycaemic and adverse events; body weight, lean body and fat mass; dietary patterns; quality of life and treatment satisfaction; cardiovascular-disease risk profile; metabolomics; and arginine-tested plasma glucose, glucagon and C-peptide levels.

ETHICS AND DISSEMINATION

The study is approved by the Danish Medicines Agency, the Regional Scientific Ethics Committee of the Capital Region of Denmark and the Data Protection Agency. The study will be carried out under the surveillance and guidance of the good clinical practice (GCP) unit at Copenhagen University Hospital Bispebjerg in accordance with the ICH-GCP guidelines and the Helsinki Declaration. Positive, negative as well as inconclusive results will be sought disseminated at scientific meetings and in international peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

NCT03017352.

Long-term effects on glycaemic control and β-cell preservation of early intensive treatment in patients with newly diagnosed type 2 diabetes: A multicentre randomized trial

AIM

To determine the effects of early intensive glycaemic control with intensive insulin treatment (IIT) or initial combined oral antidiabetic drug (COAD) therapy on long-term glycaemic control and the preservation of β-cell function in people with type 2 diabetes mellitus (T2DM).

METHODS

Newly diagnosed drug-naïve patients with T2DM from 8 outpatient diabetes centres were randomized to receive either IIT (n = 50; glargine/glulisine) or COAD (n = 47; glimepiride/metformin) as intensive treatment until the termination criteria to ensure euglycaemia were met. After intensive treatment, the patients completed a follow-up period with either lifestyle modification (LSM) alone or rescue therapy to maintain target glycated haemoglobin levels of <7% (53 mmol/mol) up to week 104. The primary outcomes were analysed after excluding participants who were anti-glutamic acid decarboxylase autoantibody-positive.

RESULTS

Both intensive treatment methods were effective for short-term glycaemic control, but improvements in the disposition index (DI) were significantly greater in the IIT group than in the COAD group (P = .021). During the follow-up period after intensive treatment, the two groups significantly differed in rescue method regarding the maintenance of comparable levels of glycaemic control (P = .010) and more participants who received IIT exhibited well-controlled glycaemia with LSM alone. Additionally, the IIT group maintained a higher DI than the COAD group during the follow-up period. Cox regression analysis showed that the IIT method was associated with a 52.5% lower risk of failing to maintain drug-free glycaemic remission compared with the COAD method (P = .015).

CONCLUSIONS

The findings indicate that outpatient clinic-based IIT to ensure euglycaemia in newly diagnosed patients with T2DM might be an effective initial therapeutic option for improvements in β-cell function and glycaemic control over the long term, without serious adverse events.

Insulin Pump and Continuous Glucose Monitor Initiation in Hospitalized Patients with Type 2 Diabetes Mellitus

BACKGROUND

Insulin pumps and continuous glucose monitoring (CGM) are commonly used by patients with diabetes mellitus in the outpatient setting. The efficacy and safety of initiating inpatient insulin pumps and CGM in the nonintensive care unit setting is unknown.

MATERIALS AND METHODS

In a prospective pilot study, inpatients with type 2 diabetes were randomized to receive standard subcutaneous basal-bolus insulin and blinded CGM (group 1, n = 5), insulin pump and blinded CGM (group 2, n = 6), or insulin pump and nonblinded CGM (group 3, n = 5). Feasibility, glycemic control, and patient satisfaction were evaluated among groups.

RESULTS

Group 1 had lower mean capillary glucose levels, 144.5 ± 19.5 mg/dL, compared with groups 2 and 3, 191.5 ± 52.3 and 182.7 ± 59.9 mg/dL (P1 vs. 2+3 = 0.05). CGM detected 19 hypoglycemic episodes (glucose <70 mg/dL) among all treatment groups, compared with 12 episodes detected by capillary testing, although not statistically significant. No significant differences were found for the total daily dose of insulin or percentage of time spent below target glucose range (<90 mg/dL), in target glucose range (90-180 mg/dL), or above target glucose range (>180 mg/dL). On the Diabetes Treatment Satisfaction Questionnaire-Change, group 3 reported increased hyperglycemia and decreased hypoglycemia frequency compared with the other two groups, although the differences did not reach statistical significance.

CONCLUSIONS

Insulin pump and CGM initiation are feasible during hospitalization, although they are labor intensive. Although insulin pump initiation may not lead to improved glycemic control, there is a trend toward CGM detecting a greater number of hypoglycemic episodes. Larger studies are needed to determine whether use of this technology can lower inpatient morbidity and mortality.

Use of a Novel, Remotely Connected Diabetes Management System Is Associated with Increased Treatment Satisfaction, Reduced Diabetes Distress, and Improved Glycemic Control in Individuals with Insulin-Treated Diabetes: First Results from the Personal Diabetes Management Study

BACKGROUND

The ability to automatically transfer data to clinicians and receive timely guidance in therapy adjustments through remote and in-office consults can positively impact patients' perceptions about quality of care, which is positively associated with clinical outcomes. We assessed the impact of using the Accu-Chek Connect diabetes management system on treatment satisfaction, diabetes distress, and glycemic control in adults with type 1 diabetes and insulin-treated type 2 diabetes.

SUBJECTS AND METHODS

This 6-month, prospective, multicenter, single-arm study assessed the impact of using the system on treatment satisfaction and glycemic control among 87 adults with insulin-treated diabetes (multiple daily insulin injections and basal only), with 8.8% ± 1.6% glycated hemoglobin (HbA1c) at baseline. The Diabetes Treatment Satisfaction Questionnaire-status (DTSQs) and Diabetes Distress Scale (DDS) were administered at baseline, and the Diabetes Treatment Satisfaction Questionnaire-change (DTSQc) and DDS at 6 months. Changes in HbA1c, average blood glucose (BG), and other metrics were also assessed.

RESULTS

Improvements in DTSQc scores were observed at 6 months with a total mean (standard deviation) score of 14.3 ± 5.1. Significant reductions in total mean DDS scores from baseline to 6 months were also observed, from 2.0 ± 0.8 to 1.7 ± 0.7, P < 0.0001. A significant reduction in regimen-related distress was notable, from "moderate distress" (2.4 ± 1.0) to "not distressed" (1.9 ± 0.9), P < 0.0001). Significant reductions in mean HbA1c (-0.9 ± 1.6, P < 0.0001) and mean BG (-24.8 ± 50.8, P < 0.0001) were observed.

CONCLUSIONS

Use of the Accu-Chek Connect diabetes management system is associated with increased treatment satisfaction and improved glycemic control among individuals with insulin-treated diabetes. NCT02600845 ( www.clinicaltrials.gov ).

Essential parameters and risk factors of the patients for diabetes care and treatment

AIM

The aim was to explore the association between Type 2 Diabetes Mellitus [T2DM] treatment satisfactions of patients regarding their socio-economic, life-style, history medication and clinical outcome in a Turkish population SUBJECT AND METHODS: A cross-sectional study conducted from February 2016 to September 2016. Of the total 1500 diabetic patients approached, 1094 (72.9%) gave their consent. Data analysis included, sociodemographic, serum lipid profiles (LDL, HDL), calcium, uric acid, blood pressure and glycated hemoglobin (HbA1c) at baseline and after six months. The Diabetes Treatment Satisfaction Questionnaire (DTSQ) tools were used to measure the patient satisfaction.

RESULTS

The mean and standard deviation of age among gender, there were significant differences between males (51.81±14.40) and females (49.76±13.99) (p=0.024). There were statistically significant differences between males and females regarding place of living (city 76% vs town 26%) p<0.001) and consanguinity (p=0.040). Almost of the patients with diabetes were overweight (males 44.5% vs females 41.8%) while more than a quarter (31.2%) males were obese. Among patients with diabetes, significantly larger proportion were treated for DM with insulin (females 28.8% vs males 22.5%) and 'insulin & oral anti diabetic drugs' (females 21.6% vs males 18.4%%; p<0.001) in comparison. Reported average sleeping haours was significantly more among males (6.5±1.1 vs. 6.1±1.2; p<0.001) than females. Males and females reported significantly greater improvements in mean values of blood glucose (-2.07 p<0.001; vs. -2.36; p=0.007), HbA1c (-1.72 p<0.001; vs. -1.47 p=0.038), potassium (+0.98 p<0.001; vs. +0.93 p<0.005); albumin (-3.38 p<0.001; vs. -3.60; p<0.001); billirubin (-0.69 p=0.049; vs. -0.98; p<0.001); uric acid (+11.9 p=0.017; vs. +14.3; p<0.001); systolic blood pressure (-3.86 p<0.001; vs. -3.2 p<0.001) and diastolic blood pressure (-3.17 p<0.001; vs. -3.2 p<0.001) in comparison to 6 months before. Multivariate stepwise regression analysis showed that the satisfaction DTSQ scores for HbA1c (p<0.001), h of sleep (p<0.001), neuropathy (p=0.007), diabetic education (p=0.014), SBP (mmHg) (p=0.021) DBP (mmHg) (p=0.028) were identified as significantly associated with higher treatment satisfaction.

CONCLUSION

The study confirms a positive correlation between diabetes patient's satisfaction with care and treatment. Females DM patients compared to males had a better satisfaction score with current treatment, unacceptably low blood glucose level, flexibility in treatment and understanding of DM.