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Hjort A, Iggman D, Rosqvist F. Glycemic variability assessed using continuous glucose monitoring in individuals without diabetes and associations with cardiometabolic risk markers: A systematic review and meta-analysis. Clin Nutr 2024; 43:915-925. [PMID: 38401227 DOI: 10.1016/j.clnu.2024.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 02/06/2024] [Accepted: 02/13/2024] [Indexed: 02/26/2024]
Abstract
BACKGROUND & AIMS Continuous glucose monitoring (CGM) provides data on short-term glycemic variability (GV). GV is associated with adverse outcomes in individuals with diabetes. Whether GV is associated with cardiometabolic risk in individuals without diabetes is unclear. We systematically reviewed the literature to assess whether GV is associated with cardiometabolic risk markers or outcomes in individuals without diabetes. METHODS Searches were performed in PubMed/Medline, Embase and Cochrane from inception through April 2022. Two researchers were involved in study selection, data extraction and quality assessment. Studies evaluating GV using CGM for ≥24 h were included. Studies in populations with acute and/or critical illness were excluded. Both narrative synthesis and meta-analyzes were performed, depending on outcome. RESULTS Seventy-one studies were included; the majority were cross-sectional. Multiple measures of GV are higher in individuals with compared to without prediabetes and GV appears to be inversely associated with beta cell function. In contrast, GV is not clearly associated with insulin sensitivity, fatty liver disease, adiposity, blood lipids, blood pressure or oxidative stress. However, GV may be positively associated with the degree of atherosclerosis and cardiovascular events in individuals with coronary disease. CONCLUSION GV is elevated in prediabetes, potentially related to beta cell dysfunction, but less clearly associated with obesity or traditional risk factors. GV is associated with coronary atherosclerosis development and may predict cardiovascular events and type 2 diabetes. Prospective studies are warranted, investigating the predictive power of GV in relation to incident disease. GV may be an important risk measure also in individuals without diabetes.
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Affiliation(s)
- Anna Hjort
- Department of Biology and Biological Engineering, Division of Food and Nutrition Science, Chalmers University of Technology, Kemivägen 10, 41296 Gothenburg, Sweden.
| | - David Iggman
- Center for Clinical Research Dalarna, Uppsala University, Nissers väg 3, 79182 Falun, Sweden; Department of Public Health and Caring Sciences, Clinical Nutrition and Metabolism, Uppsala University, Husargatan 3, BMC, Box 564, 75122 Uppsala, Sweden.
| | - Fredrik Rosqvist
- Department of Public Health and Caring Sciences, Clinical Nutrition and Metabolism, Uppsala University, Husargatan 3, BMC, Box 564, 75122 Uppsala, Sweden.
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Hoppe JE, Sjoberg J, Hong G, Poch K, Zemanick ET, Thee S, Edmondson C, Patel D, Sathe M, Borowitz D, Putman MS, Lechtzin N, Riekert KA, Basile M, Goss CH, Jarosz ME, Rosenfeld M. Remote endpoints for clinical trials in cystic fibrosis: Report from the U.S. CF foundation remote endpoints task force. J Cyst Fibros 2024:S1569-1993(24)00023-7. [PMID: 38429150 DOI: 10.1016/j.jcf.2024.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 01/18/2024] [Accepted: 02/19/2024] [Indexed: 03/03/2024]
Abstract
The COVID-19 pandemic necessitated a rapid shift in clinical research to perform virtual visits and remote endpoint assessments, providing a key opportunity to optimize the use of remote endpoints for clinical trials in cystic fibrosis. The use of remote endpoints could allow more diverse participation in clinical trials while minimizing participant burden but must be robustly evaluated to ensure adequate performance and feasibility. In response, the Cystic Fibrosis Foundation convened the Remote Endpoint Task Force (Supplemental Table 1), a multidisciplinary group of CF researchers with remote endpoint expertise and community members tasked to better understand the current and future use of remote endpoints for clinical research. Here, we describe the current use of remote endpoints in CF clinical research, address key unanswered questions regarding their use and feasibility, and discuss the next steps to determine clinical trial readiness.
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Affiliation(s)
- Jordana E Hoppe
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora CO, USA.
| | | | - Gina Hong
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia Pennsylvania, USA
| | - Katie Poch
- Department of Medicine, National Jewish Health, Denver CO, USA
| | - Edith T Zemanick
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora CO, USA
| | - Stephanie Thee
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine and Cystic Fibrosis Center, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Claire Edmondson
- Department of Paediatric Respiratory Medicine, Great Ormond Street Hospital, London WC1N3JH, USA
| | - Dhiren Patel
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cardinal Glennon Children's Medical Center, Saint Louis University School of Medicine, St. Louis MO, USA
| | - Meghana Sathe
- Pediatric Gastroenterology and Nutrition, University of Texas Southwestern/Children's Health, Dallas Texas, USA
| | - Drucy Borowitz
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo New York, USA
| | - Melissa S Putman
- Division of Pediatric Endocrinology, Boston Children's Hospital, Boston MA, USA
| | - Noah Lechtzin
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore Maryland, USA
| | - Kristin A Riekert
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore Maryland, USA
| | - Melissa Basile
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset NY, USA
| | - Christopher H Goss
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington Medical Center, Seattle Washington, USA; Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Research Institute, Seattle Washington, USA
| | | | - Margaret Rosenfeld
- Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Research Institute, Seattle Washington, USA
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Scully KJ, Brenner L, Martin K, Ruazol M, Sawicki GS, Uluer A, Neuringer I, Yonker LM, Sicilian L, Putman MS. Continuous glucose monitoring and advanced glycation endproducts for prediction of clinical outcomes and development of cystic fibrosis-related diabetes in adults with CF. Front Endocrinol (Lausanne) 2024; 15:1293709. [PMID: 38379863 PMCID: PMC10876871 DOI: 10.3389/fendo.2024.1293709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 01/17/2024] [Indexed: 02/22/2024] Open
Abstract
Introductions Cystic fibrosis-related diabetes (CFRD) is associated with pulmonary decline, compromised nutritional status, and earlier mortality. Onset is often insidious, so screening for early detection of glycemic abnormalities is important. Continuous glucose monitoring (CGM) has been validated in people with CF and has been shown to detect early glycemic variability otherwise missed on 2-hour oral glucose tolerance testing (OGTT). We previously reported that CGM measures of hyperglycemia and glycemic variability are superior to hemoglobin A1c (HbA1c) in distinguishing those with and without CFRD. However, little is known about the long-term predictive value of CGM measures of glycemia for both the development of CFRD and their effect on key clinical outcomes such as weight maintenance and pulmonary function. In addition, there have been no studies investigating advanced glycation endproducts (AGE) assessed by skin autofluorescence in people with CF. Methods In this prospective observational study, CGM and HbA1c were measured at 2 to 3 time points 3 months apart in 77 adults with CF. Participants who did not have CFRD at the time of enrollment underwent OGTT at the baseline visit, and all participants had AGE readings at baseline. Follow up data including anthropometric measures, pulmonary function and CFRD status were collected by review of medical records 1- and 2-years after the baseline visits. We applied multivariable linear regression models correlating glycemic measures to change in key clinical outcomes (weight, BMI, FEV1) accounting for age, gender and elexacaftor/tezacaftor/ivacaftor (ETI) use. We also conducted logistic regression analyses comparing baseline glycemic data to development of CFRD during the 2-year follow up period. Results Of the 77 participants, 25 had pre-existing CFRD at the time of enrollment, and six participants were diagnosed with CFRD by the OGTT performed at the baseline visit. When adjusting for age, gender, and ETI use, multiple CGM measures correlated with weight and BMI decline after one year but not after two years. CGM and HbA1c at baseline did not predict decline in FEV1 (p>0.05 for all). In the 46 participants without a diagnosis of CFRD at baseline, two participants were diagnosed with CFRD over the following two years, but CGM measures at baseline did not predict progression to CFRD. Baseline AGE values were higher in individuals with CFRD and correlated with multiple measures of dysglycemia (HbA1c, AG, SD, CV, TIR, % time >140, >180, >250) as well as weight. AGE values also correlated with FEV1 decline at year 1 and weight decline at year 1 and year 2. Conclusions Several key CGM measures of hyperglycemia and glycemic variability were predictive of future decline in weight and BMI over one year in this population of adults with CF with and without CFRD. None of the baseline glycemic variables predicted progression to CFRD over 2 years. To our knowledge, this is the first report correlating AGE levels with key clinical and glycemic measures in CF. Limitations of these analyses include the small number of participants who developed CFRD (n=2) during the follow up period and the initiation of ETI by many participants, affecting their trajectory in weight and pulmonary function. These results provide additional data supporting the potential role for CGM in identifying clinically significant dysglycemia in CF. Future studies are needed to investigate CGM as a diagnostic and screening tool for CFRD and to understand the implications of AGE measures in this patient population.
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Affiliation(s)
- Kevin J. Scully
- Division of Endocrinology, Hasbro Children’s Hospital, Providence, RI, United States
| | - Laura Brenner
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Kimberly Martin
- Diabetes Research Center, Massachusetts General Hospital, Boston, MA, United States
| | - Melanie Ruazol
- Diabetes Research Center, Massachusetts General Hospital, Boston, MA, United States
| | - Gregory S. Sawicki
- Division of Pulmonary Medicine, Boston Children’s Hospital, Boston, MA, United States
| | - Ahmet Uluer
- Division of Pulmonary Medicine, Boston Children’s Hospital, Boston, MA, United States
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, MA, United States
| | - Isabel Neuringer
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Lael M. Yonker
- Division of Pediatric Pulmonary Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Leonard Sicilian
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Melissa S. Putman
- Diabetes Research Center, Massachusetts General Hospital, Boston, MA, United States
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4
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Wilschanski M, Munck A, Carrion E, Cipolli M, Collins S, Colombo C, Declercq D, Hatziagorou E, Hulst J, Kalnins D, Katsagoni CN, Mainz JG, Ribes-Koninckx C, Smith C, Smith T, Van Biervliet S, Chourdakis M. ESPEN-ESPGHAN-ECFS guideline on nutrition care for cystic fibrosis. Clin Nutr 2024; 43:413-445. [PMID: 38169175 DOI: 10.1016/j.clnu.2023.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 12/13/2023] [Accepted: 12/18/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Nutritional status is paramount in Cystic Fibrosis (CF) and is directly correlated with morbidity and mortality. The first ESPEN-ESPGHAN-ECFS guidelines on nutrition care for infants, children, and adults with CF were published in 2016. An update to these guidelines is presented. METHODS The study was developed by an international multidisciplinary working group in accordance with officially accepted standards. Literature since 2016 was reviewed, PICO questions were discussed and the GRADE system was utilized. Statements were discussed and submitted for on-line voting by the Working Group and by all ESPEN members. RESULTS The Working Group updated the nutritional guidelines including assessment and management at all ages. Supplementation of vitamins and pancreatic enzymes remains largely the same. There are expanded chapters on pregnancy, CF-related liver disease, and CF-related diabetes, bone disease, nutritional and mineral supplements, and probiotics. There are new chapters on nutrition with highly effective modulator therapies and nutrition after organ transplantation.
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Affiliation(s)
- Michael Wilschanski
- Pediatric Gastroenterology, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
| | - Anne Munck
- Cystic Fibrosis Centre, Hopital Necker-Enfants Malades, AP-HP, Paris, France
| | - Estefania Carrion
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada
| | - Marco Cipolli
- Cystic Fibrosis Center, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Sarah Collins
- CF Therapies Team, Royal Brompton & Harefield Hospital, London, UK
| | - Carla Colombo
- University of Milan, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Dimitri Declercq
- Cystic Fibrosis Reference Centre, Ghent University Hospital and Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Elpis Hatziagorou
- Cystic Fibrosis Unit, 3rd Pediatric Dept, Hippokration Hospital, Aristotle University of Thessaloniki, Greece
| | - Jessie Hulst
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada; Department of Pediatrics and Department of Nutritional Sciences, The University of Toronto, Toronto, Canada
| | - Daina Kalnins
- Department of Clinical Dietetics, The Hospital for Sick Children, Toronto, Canada
| | - Christina N Katsagoni
- Department of Clinical Nutrition, Agia Sofia Children's Hospital, Athens, Greece; EFAD, European Specialist Dietetic Networks (ESDN) for Gastroenterology, Denmark
| | - Jochen G Mainz
- Brandenburg Medical School, University Hospital. Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
| | - Carmen Ribes-Koninckx
- Pediatric Gastroenterology and Paediatric Cystic Fibrosis Unit. La Fe Hospital & La Fe Research Institute, Valencia, Spain
| | - Chris Smith
- Department of Dietetics, Royal Alexandra Children's Hospital, Brighton, UK
| | - Thomas Smith
- Independent Patient Consultant Working at Above-disease Level, UK
| | | | - Michael Chourdakis
- School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
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5
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Lurquin F, Gohy S, Hermans MP, Preumont V. Novel time-saving OGTT sparing HbA1c-HOMA2 based algorithm for the diagnosis of cystic fibrosis-related diabetes. Diabetes Res Clin Pract 2024; 208:111124. [PMID: 38309533 DOI: 10.1016/j.diabres.2024.111124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/25/2024] [Accepted: 01/29/2024] [Indexed: 02/05/2024]
Abstract
AIMS The diagnosis of cystic fibrosis-related diabetes (CFRD) faces several challenges. We propose a novel screening algorithm to alleviate the burden of cystic fibrosis (CF). METHODS Through a retrospective cross-sectional single-centre study, HbA1c and HOMA2 indices were assessed in multiple models as alternative diagnostic tools from OGTT data. We sought to establish specific thresholds for CFRD screening with oral glucose tolerance test (OGTT) as gold standard. We evaluated various straightforward or sequential approaches, in terms of diagnostic accuracy while also quantify the potential reduction in OGTTs through these different methods. RESULTS HOMA indices were recovered in 72 patients. We devised a composite index that combines HbA1c and HOMA-B: Diabetes Predicting Index in cystic fibrosis (DIPIc) = (HbA1c(%) × 3.455) - (HOMA-B(%) × 0.020) - 19.294. This index yields the highest screening accuracy according to receiver-operating characteristics curves. Using a stepwise algorithm that incorporates DIPIc decreases the requirement for annual OGTTs. A CFRD exclusion cutoff less than -1.7445 (sensitivity 98 %), in conjunction with a CFRD diagnostic threshold greater than 0.4543 (specificity 98 %) allows for 71 % OGTT sparing. CONCLUSION The composite index DIPIc is a suitable, less invasive screening method for CFRD, which enables to avoid many OGTTs.
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Affiliation(s)
- Fabian Lurquin
- Department of Endocrinology and Nutrition, Cliniques universitaires Saint-Luc, Institut de recherche expérimentale et clinique, UCLouvain, Brussels, Belgium.
| | - Sophie Gohy
- Department of Pneumology, CF Reference Centre, Cliniques universitaires Saint-Luc, Institut de recherche expérimentale et clinique, UCLouvain, Brussels, Belgium
| | - Michel P Hermans
- Department of Endocrinology and Nutrition, Cliniques universitaires Saint-Luc, Institut de recherche expérimentale et clinique, UCLouvain, Brussels, Belgium
| | - Vanessa Preumont
- Department of Endocrinology and Nutrition, Cliniques universitaires Saint-Luc, Institut de recherche expérimentale et clinique, UCLouvain, Brussels, Belgium
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6
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Lurquin F, Buysschaert M, Preumont V. Advances in cystic fibrosis-related diabetes: Current status and future directions. Diabetes Metab Syndr 2023; 17:102899. [PMID: 37939435 DOI: 10.1016/j.dsx.2023.102899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 10/25/2023] [Accepted: 10/26/2023] [Indexed: 11/10/2023]
Abstract
AIMS The aim of this review is to give an update of the recent advances in the pathophysiology, prognosis, diagnosis and treatments of cystic fibrosis-related diabetes (CFRD). METHODS The literature survey focuses on original and review articles dealing with CFRD between 2006 and 2023, and in particular with: pathophysiology, risk and predictive factors, screening, chronic complications of CFRD, management and the effects of CFTR channel modulator therapies on glucose homeostasis, using PubMed®. RESULTS The rising prevalence of CFRD is due to prolonged life survival among patients with cystic fibrosis (CF). Advances in the understanding of the pathophysiology highlight the singularity of CFRD. Adherence to diagnostic guidelines remains challenging. Besides the classical OGTT, alternative diagnostic tests are being considered: HbA1c measurement, continuous glucose monitoring (CGM), intermediate measurements of alternative glucose tolerance stages through OGTT and homeostatic model assessment (HOMA). Early treatment of (pre)diabetes in CF patients is mandatory. The advent of CFTR channel modulator therapies have created a paradigm shift in the management of CF: they seem to improve glucose homeostasis, but the mechanism remains unclear. CONCLUSION CFRD management is an ongoing concern. Optimal care has reduced the negative impact of CFRD on lung function, nutrition, and survival. Increasing prevalence of CFRD and prolonged lifespan lead to more microvascular complications. New screening tools (Hba1c, CGM, HOMA) show potential for better classification of patients. The effect of CFTR modulators on glucose metabolism warrants further research.
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Affiliation(s)
- F Lurquin
- Department of Endocrinology and Nutrition, Cliniques Universitaires Saint-Luc, Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium.
| | - M Buysschaert
- Department of Endocrinology and Nutrition, Cliniques Universitaires Saint-Luc, Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
| | - V Preumont
- Department of Endocrinology and Nutrition, Cliniques Universitaires Saint-Luc, Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
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7
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Klonoff DC, Nguyen KT, Xu NY, Gutierrez A, Espinoza JC, Vidmar AP. Use of Continuous Glucose Monitors by People Without Diabetes: An Idea Whose Time Has Come? J Diabetes Sci Technol 2023; 17:1686-1697. [PMID: 35856435 PMCID: PMC10658694 DOI: 10.1177/19322968221110830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Continuous glucose monitor (CGM) systems were originally intended only for people with diabetes. Recently, there has been interest in monitoring glucose concentrations in a variety of other situations. As data accumulate to support the use of CGM systems in additional states unrelated to diabetes, the use of CGM systems is likely to increase accordingly. METHODS PubMed and Google Scholar were searched for articles about the use of CGM in individuals without diabetes. Relevant articles that included sufficient details were queried to identify what cohorts of individuals were adopting CGM use and to define trends of use. RESULTS Four clinical user cases were identified: (1) metabolic diseases related to diabetes with a primary dysregulation of the insulin-glucose axis, (2) metabolic diseases without a primary pathophysiologic derangement of the insulin-glucose axis, (3) health and wellness, and (4) elite athletics. Seven trends in the use of CGM systems in people without diabetes were idenfitied which pertained to both FDA-cleared medical grade products as well as anticipated future products, which may be regulated differently based on intended populations and indications for use. CONCLUSIONS Wearing a CGM has been used not only for diabetes, but with a goal of improving glucose patterns to avoid diabetes, improving mental or physical performance, and promoting motivate healthy behavioral changes. We expect that clinicians will become increasingly aware of (1) glycemic patterns from CGM tracings that predict an increased risk of diabetes, (2) specific metabolic glucotypes from CGM tracings that predict an increased risk of diabetes, and (3) new genetic and genomic biomarkers in the future.
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Affiliation(s)
- David C. Klonoff
- Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA, USA
| | | | - Nicole Y. Xu
- Diabetes Technology Society, Burlingame, CA, USA
| | | | - Juan C. Espinoza
- University of Southern California, Los Angeles, CA, USA
- Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | - Alaina P. Vidmar
- University of Southern California, Los Angeles, CA, USA
- Children’s Hospital Los Angeles, Los Angeles, CA, USA
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8
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Kutney K, Kaminski BA, Casey T, O'Riordan M, Gubitosi-Klug R. Reproducibility of in-home CFRD screening using continuous glucose monitoring and mixed meal tolerance test. J Clin Transl Endocrinol 2023; 33:100323. [PMID: 37705602 PMCID: PMC10495624 DOI: 10.1016/j.jcte.2023.100323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 07/23/2023] [Accepted: 08/24/2023] [Indexed: 09/15/2023] Open
Abstract
Background Cystic fibrosis related diabetes (CFRD) is associated with insulin-remediable pulmonary decline, so early detection is critical. Continuous glucose monitors (CGM) have shown promise in screening but are not recommended by clinical practice guidelines. Little is known about the reproducibility of CGM results for a given patient. Methods Twenty non-insulin treated adults and adolescents with CF placed an in-home CGM and wore it for two 14-day periods. Participants underwent a mixed meal tolerance test (MMTT) on day 5 of each 14-day period. Glycemic data from CGM 1 and CGM 2 were compared regarding published thresholds to define abnormality: percent time >140 mg/dL of ≥4.5%, percent time >140 mg/dL of >17.5%, and percent time >180 mg/dL of >3.4%. Results of the repeat MMTT were compared for peak glucose and 2-hour glucose thresholds: >140 mg/dL, >180 mg/dL, and >200 mg/dL. Results For percent time >140 mg/dL of ≥ 4.5%, five of 20 subjects had conflicting results between CGM 1 and CGM 2. For percent time >140 mg/dL of >17.5% and >180 mg/dL of >3.4%, only one of 20 subjects had conflicting results between CGM 1 and CGM 2. On the MMTT, few participants had a 2-hour glucose >140 mg/dL. Peak glucose >140 mg/dL, 180 mg/dL, and 200 mg/dL were more common, with 10-37% of participants demonstrating disagreement between CGM 1 and CGM 2. Conclusions Repeated in-home CGM acquisitions show reasonable reproducibility regarding the more stringent thresholds for time >140 mg/dL and >180 mg/dL. More data is needed to determine thresholds for abnormal mixed meal tolerance tests in CFRD screening.
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Affiliation(s)
- Katherine Kutney
- Case Western Reserve University, Cleveland OH, United States
- University Hospitals Rainbow Babies and Children’s Hospital, Cleveland OH, United States
| | - Beth A. Kaminski
- Case Western Reserve University, Cleveland OH, United States
- University Hospitals Rainbow Babies and Children’s Hospital, Cleveland OH, United States
| | - Terri Casey
- Case Western Reserve University, Cleveland OH, United States
- University Hospitals Rainbow Babies and Children’s Hospital, Cleveland OH, United States
| | - MaryAnn O'Riordan
- Case Western Reserve University, Cleveland OH, United States
- University Hospitals Rainbow Babies and Children’s Hospital, Cleveland OH, United States
| | - Rose Gubitosi-Klug
- Case Western Reserve University, Cleveland OH, United States
- University Hospitals Rainbow Babies and Children’s Hospital, Cleveland OH, United States
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9
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Grancini V, Alicandro G, Porcaro LL, Zazzeron L, Gramegna A, Morlacchi LC, Rossetti V, Gaglio A, Resi V, Daccò V, Blasi F, Orsi E. Effects of insulin therapy optimization with sensor augmented pumps on glycemic control and body composition in people with cystic fibrosis-related diabetes. Front Endocrinol (Lausanne) 2023; 14:1228153. [PMID: 37720540 PMCID: PMC10501717 DOI: 10.3389/fendo.2023.1228153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 08/11/2023] [Indexed: 09/19/2023] Open
Abstract
Objective Cystic fibrosis (CF)-related diabetes (CFRD) resulting from partial-to-complete insulin deficiency occurs in 40-50% of adults with CF. In people with CFRD, poor glycemic control leads to a catabolic state that may aggravate CF-induced nutritional impairment and loss of muscle mass. Sensor augmented pump (SAP) therapy may improve glycemic control as compared to multiple daily injection (MDI) therapy. Research design and methods This non-randomized clinical trial was aimed at evaluating the effects of insulin therapy optimization with SAP therapy, combined with a structured educational program, on glycemic control and body composition in individuals with insulin-requiring CFRD. Of 46 participants who were offered to switch from MDI to SAP therapy, 20 accepted and 26 continued the MDI therapy. Baseline demographic and clinical characteristics were balanced between groups using a propensity score-based overlap weighting procedure and weighted mixed-effects regression models were used to estimate changes in study outcomes. Results After 24 months changes in HbA1c were: -1.1% (-12.1 mmol/mol) (95% CI: -1.5; -0.8) and -0.1% (-1 mmol/mol) (95% CI: -0.5; 0.3) in the SAP and MDI therapy group, respectively, with a between-group difference of -1.0 (-10 mmol/mol) (-1.5; -0.5). SAP therapy was also associated with a decrease in mean glucose (between group difference: -32 mg/dL; 95% CI: -44; -20) and an increase in TIR (between group difference: 19.3%; 95% CI 13.9; 24.7) and in fat-free mass (between group difference: +5.5 Kg, 95% CI: 3.2; 7.8). Conclusion Therapy optimization with SAP led to a significant improvement in glycemic control, which was associated with an increase in fat-free mass.
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Affiliation(s)
- V. Grancini
- Diabetes Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - G. Alicandro
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Pediatrics, Gastroenterology, Hepatology, Pediatric Transplantation and Cystic Fibrosis Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - L. L. Porcaro
- Diabetes Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - L. Zazzeron
- Pediatrics, Gastroenterology, Hepatology, Pediatric Transplantation and Cystic Fibrosis Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - A. Gramegna
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - L. C. Morlacchi
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - V. Rossetti
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - A. Gaglio
- Diabetes Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - V. Resi
- Diabetes Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - V. Daccò
- Pediatrics, Gastroenterology, Hepatology, Pediatric Transplantation and Cystic Fibrosis Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - F. Blasi
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - E. Orsi
- Diabetes Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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10
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Klupa T, Czupryniak L, Dzida G, Fichna P, Jarosz-Chobot P, Gumprecht J, Mysliwiec M, Szadkowska A, Bomba-Opon D, Czajkowski K, Malecki MT, Zozulinska-Ziolkiewicz DA. Expanding the Role of Continuous Glucose Monitoring in Modern Diabetes Care Beyond Type 1 Disease. Diabetes Ther 2023:10.1007/s13300-023-01431-3. [PMID: 37322319 PMCID: PMC10299981 DOI: 10.1007/s13300-023-01431-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 05/31/2023] [Indexed: 06/17/2023] Open
Abstract
Application of continuous glucose monitoring (CGM) has moved diabetes care from a reactive to a proactive process, in which a person with diabetes can prevent episodes of hypoglycemia or hyperglycemia, rather than taking action only once low and high glucose are detected. Consequently, CGM devices are now seen as the standard of care for people with type 1 diabetes mellitus (T1DM). Evidence now supports the use of CGM in people with type 2 diabetes mellitus (T2DM) on any treatment regimen, not just for those on insulin therapy. Expanding the application of CGM to include all people with T1DM or T2DM can support effective intensification of therapies to reduce glucose exposure and lower the risk of complications and hospital admissions, which are associated with high healthcare costs. All of this can be achieved while minimizing the risk of hypoglycemia and improving quality of life for people with diabetes. Wider application of CGM can also bring considerable benefits for women with diabetes during pregnancy and their children, as well as providing support for acute care of hospital inpatients who experience the adverse effects of hyperglycemia following admission and surgical procedures, as a consequence of treatment-related insulin resistance or reduced insulin secretion. By tailoring the application of CGM for daily or intermittent use, depending on the patient profile and their needs, one can ensure the cost-effectiveness of CGM in each setting. In this article we discuss the evidence-based benefits of expanding the use of CGM technology to include all people with diabetes, along with a diverse population of people with non-diabetic glycemic dysregulation.
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Affiliation(s)
- Tomasz Klupa
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland.
| | - Leszek Czupryniak
- Department of Diabetology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Grzegorz Dzida
- Department of Internal Diseases, Medical University of Lublin, Lublin, Poland
| | - Piotr Fichna
- Department of Pediatric Diabetes and Obesity, Poznan University of Medical Sciences, Poznan, Poland
| | | | - Janusz Gumprecht
- Department of Internal Medicine, Diabetology and Nephrology, Medical University of Silesia, Katowice, Poland
| | - Malgorzata Mysliwiec
- Department of Pediatrics, Diabetology and Endocrinology, Medical University of Gdansk, Gdansk, Poland
| | - Agnieszka Szadkowska
- Department of Pediatrics, Diabetology, Endocrinology and Nephrology, Medical University of Lodz, Lodz, Poland
| | - Dorota Bomba-Opon
- 1st Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
| | - Krzysztof Czajkowski
- 2nd Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
| | - Maciej T Malecki
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland
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11
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Weiss L, Reix P, Mosnier-Pudar H, Ronsin O, Beltrand J, Reynaud Q, Mely L, Burgel PR, Stremler N, Rakotoarisoa L, Galderisi A, Perge K, Bendelac N, Abely M, Kessler L. Screening strategies for glucose tolerance abnormalities and diabetes in people with cystic fibrosis. DIABETES & METABOLISM 2023; 49:101444. [PMID: 37030530 DOI: 10.1016/j.diabet.2023.101444] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 02/21/2023] [Accepted: 03/24/2023] [Indexed: 04/09/2023]
Abstract
The increase in life expectancy of patients with cystic fibrosis has come with new comorbidities, particularly diabetes. The gradual development of glucose tolerance abnormalities means that 30 to 40% of adults will be diabetic. Cystic fibrosis-related diabetes is a major challenge in the care of these patients because it is a morbidity and mortality factor at all stages of the disease. Early glucose tolerance abnormalities observed from childhood, before the stage of diabetes, are also associated with a poor pulmonary and nutritional outcome. The long asymptomatic period justifies systematic screening with an annual oral glucose tolerance test from the age of 10 years. However, this strategy does not take into account the new clinical profiles of patients with cystic fibrosis, recent pathophysiological knowledge of glucose tolerance abnormalities, and the emergence of new diagnostic tools in diabetology. In this paper, we summarise the challenges of screening in the current context of new patient profiles - patients who are pregnant, have transplants, or are being treated with fibrosis conductance transmembrane regulator modulators - and put forward an inventory of the various screening methods for cystic fibrosis-related diabetes, including their applications, limitations and practical implications.
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12
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Peckham D, Spoletini G. Impact of Digital Technologies on Clinical Care for Adults with Cystic Fibrosis. Semin Respir Crit Care Med 2023; 44:217-224. [PMID: 36535666 DOI: 10.1055/s-0042-1758730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The coronavirus disease 2019 pandemic accelerated the implementation of digital technologies, which have now become embedded as essential tools for the management of chronic disease, including cystic fibrosis (CF). Despite subsequent easing of restrictions and because of improved clinical stability resulting from the introduction of highly effective modulator therapy, digital technologies including video and telephone consultations and remote monitoring are likely to remain integral to the future delivery of CF health care. In this article, we explore some of the key developments in digital technologies, barriers to their adoption, and how the CF community is likely to embrace lessons learned from the recent pandemic to help modernize and reshape the future of CF care.
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Affiliation(s)
- Daniel Peckham
- Leeds Adult Cystic Fibrosis Unit, St James's University Hospital, Leeds, United Kingdom.,Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, United Kingdom
| | - Giulia Spoletini
- Leeds Adult Cystic Fibrosis Unit, St James's University Hospital, Leeds, United Kingdom
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13
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Kumar S, Pallin M, Soldatos G, Teede H. Comparison of continuous glucose monitoring to reference standard oral glucose tolerance test for the detection of dysglycemia in cystic Fibrosis: A systematic review. J Clin Transl Endocrinol 2022; 30:100305. [PMID: 36200022 PMCID: PMC9529501 DOI: 10.1016/j.jcte.2022.100305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 08/30/2022] [Accepted: 09/26/2022] [Indexed: 11/27/2022] Open
Abstract
Aims Increasing evidence for benefit of early detection of cystic fibrosis related diabetes (CFRD) coupled with limitations of current diagnostic investigations has led to interest and utilisation of continuous glucose monitoring (CGM). We conducted a systematic review to assess current evidence on CGM compared to reference standard oral glucose tolerance test for the detection of dysglycemia in people with cystic fibrosis without confirmed diabetes. Methods MEDLINE, Embase, CENTRAL, Evidence-Based Medicine Reviews, grey literature and six relevant journals were searched for studies published after year 2000. Studies reporting contemporaneous CGM metrics and oral glucose tolerance test results were included. Outcomes on oral glucose tolerance tests were categorised into a) normal, b) abnormal (indeterminate and impaired) or c) diabetic as defined by American Diabetes Association criteria. CGM outcomes were defined as hyperglycemia (≥1 peak sensor glucose ≥ 200 mg/dL), dysglycemia (≥1 peak sensor glucose ≥ 140–199 mg/dL) or normoglycemia (all sensor glucose peaks < 140 mg/dL). CGM hyperglycemia in people with normal or abnormal glucose tolerances was used to define an arbitrary CGM-diagnosis of diabetes. The Quality Assessment of Diagnostic Accuracy Studies tool was used to assess risk of bias. Primary outcome was relative risk of an arbitrary CGM-diagnosis of diabetes compared to the oral glucose tolerance test. Results We identified 1277 publications, of which 19 studies were eligible comprising total of 416 individuals with contemporaneous CGM and oral glucose tolerance test results. Relative risk of an arbitrary CGM-diagnosis of diabetes compared to oral glucose tolerance test was 2.92. Studies analysed were highly heterogenous, prone to bias and inadequately assessed longitudinal associations between CGM and relevant disease-specific sequela. Conclusions A single reading > 200 mg/dL on CGM is not appropriate for the diagnosis of CFRD. Prospective studies correlating CGM metrics to disease-specific outcomes are needed to determine appropriate cut-points.
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Affiliation(s)
- Shanal Kumar
- Monash Centre for Health Research and Implementation, Monash University
- Diabetes and Vascular Medicine Unit, Monash Health
| | | | - Georgia Soldatos
- Monash Centre for Health Research and Implementation, Monash University
- Diabetes and Vascular Medicine Unit, Monash Health
| | - Helena Teede
- Monash Centre for Health Research and Implementation, Monash University
- Diabetes and Vascular Medicine Unit, Monash Health
- Corresponding author at: Monash Centre for Health Research and Implementation, Level 1, 43-51 Kanooka Grove, Clayton, VIC 3168, Australia.
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14
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Ode KL, Ballman M, Battezzati A, Brennan A, Chan CL, Hameed S, Ismail HM, Kelly A, Moran AM, Rabasa-Lhoret R, Saxby NA, Craig ME. ISPAD Clinical Practice Consensus Guidelines 2022: Management of cystic fibrosis-related diabetes in children and adolescents. Pediatr Diabetes 2022; 23:1212-1228. [PMID: 36537525 PMCID: PMC10108242 DOI: 10.1111/pedi.13453] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/07/2022] [Indexed: 12/24/2022] Open
Affiliation(s)
- Katie Larson Ode
- University of Iowa Stead Family Children's Hospital, University of Iowa, Iowa City, Iowa, USA
| | - Manfred Ballman
- University Medicine Rostock, Rostock, Mecklenburg-Vorpommern, Germany
| | - Alberto Battezzati
- International Center for the Assessment of Nutritional Status, DeFENS, University of Milan, Milan, Italy
| | - Amanda Brennan
- Manchester Adult Cystic Fibrosis Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Christine L Chan
- University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Shihab Hameed
- Sydney Children's Hospital, Randwick and Royal North Shore Hospital, St. Leonards, New South Wales, Australia.,School of Clinical Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Pediatric Endocrinology, University of Sydney, Camperdown, Australia
| | - Heba M Ismail
- Department of Pediatrics, Pediatric Endocrinology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Andrea Kelly
- Department of Pediatrics, The University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Division of Endocrinology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Antoinette M Moran
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Remi Rabasa-Lhoret
- Division of Experiemental Medicine, Montreal Clinical Research institute, Montreal, Canada
| | - Nichole A Saxby
- Women's and Children's Services, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Maria E Craig
- The Children's Hospital at Westmead, University of Sydney, Sydney, New South Wales, Australia.,School of Women's and Children's Health, University of NSW, Sydney, New South Wales, Australia
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15
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Scully KJ, Palani G, Zheng H, Moheet A, Putman MS. The Effect of Control IQ Hybrid Closed Loop Technology on Glycemic Control in Adolescents and Adults with Cystic Fibrosis-Related Diabetes. Diabetes Technol Ther 2022; 24:446-452. [PMID: 35020476 PMCID: PMC9208855 DOI: 10.1089/dia.2021.0354] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background: Cystic fibrosis-related diabetes (CFRD) is associated with pulmonary decline, compromised nutritional status, and earlier mortality. Although diabetes technology is increasingly being used in individuals with CFRD, there is a paucity of data investigating the impact of hybrid closed loop (HCL) technology on glycemia in this patient population. Materials and Methods: In this multicenter retrospective study of 13 adults and adolescents with CFRD, 14 days of continuous glucose monitor data were analyzed at baseline, 1 and 3 months after transition to the Tandem t:slim X2 pump with Control IQ™ technology, a HCL system. Results: Control IQ initiation was associated with a significant increase in % time in target range (70-180 mg/dL), as well as decreases in average glucose, % time in hyperglycemic ranges (% time >180 mg/dL, % time >250 mg/dL), and glycemic variability (standard deviation, coefficient of variation). There was no significant change in % time in hypoglycemia ranges (% time <54 mg/dL, % time <70 mg/dL). Conclusions: To our knowledge, this is the first study to report a beneficial effect of Food and Drug Administration (FDA)-approved HCL technology on glycemia in adults and adolescents with CFRD to date. Future studies are needed to understand the potential long-term glycemic benefits of HCL devices and to explore the impact of this technology on heath-related quality of life, pulmonary function, nutritional status, and mortality.
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Affiliation(s)
- Kevin J. Scully
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts, USA
- Address correspondence to: Kevin J. Scully, MB, BCh, BAO, Division of Endocrinology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115-5724, USA
| | - Gurunanthan Palani
- Division of Endocrinology, Diabetes and Metabolism, University of Minnesota, Minneapolis, Minnesota, USA
| | - Hui Zheng
- Biostatics Center, and Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Amir Moheet
- Division of Endocrinology, Diabetes and Metabolism, University of Minnesota, Minneapolis, Minnesota, USA
| | - Melissa S. Putman
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts, USA
- Diabetes Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA
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16
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Zhang L, Tian Q, Guo K, Wu J, Ye J, Ding Z, Zhou Q, Huang G, Li X, Zhou Z, Yang L. Analysis of detrended fluctuation function derived from continuous glucose monitoring may assist in distinguishing latent autoimmune diabetes in adults from T2DM. Front Endocrinol (Lausanne) 2022; 13:948157. [PMID: 36204110 PMCID: PMC9530584 DOI: 10.3389/fendo.2022.948157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 09/06/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND We aimed to explore the performance of detrended fluctuation function (DFF) in distinguishing patients with latent autoimmune diabetes in adults (LADA) from type 2 diabetes mellitus (T2DM) with glucose data derived from continuous glucose monitoring. METHODS In total, 71 LADA and 152 T2DM patients were enrolled. Correlations between glucose parameters including time in range (TIR), mean glucose, standard deviation (SD), mean amplitude of glucose excursions (MAGE), coefficient of variation (CV), DFF and fasting and 2-hour postprandial C-peptide (FCP, 2hCP) were analyzed and compared. Receiver operating characteristics curve (ROC) analysis and 10-fold cross-validation were employed to explore and validate the performance of DFF in diabetes classification respectively. RESULTS Patients with LADA had a higher mean glucose, lower TIR, greater SD, MAGE and CV than those of T2DM (P<0.001). DFF achieved the strongest correlation with FCP (r = -0.705, P<0.001) as compared with TIR (r = 0.485, P<0.001), mean glucose (r = -0.337, P<0.001), SD (r = -0.645, P<0.001), MAGE (r = -0.663, P<0.001) and CV (r = -0.639, P<0.001). ROC analysis showed that DFF yielded the greatest area under the curve (AUC) of 0.862 (sensitivity: 71.2%, specificity: 84.9%) in differentiating LADA from T2DM as compared with TIR, mean glucose, SD, MAGE and CV (AUC: 0.722, 0.650, 0.800, 0.820 and 0.807, sensitivity: 71.8%, 47.9%, 63.6%, 72.7% and 78.8%, specificity: 67.8%, 83.6%, 80.9%, 80.3% and 72.4%, respectively). The kappa test indicated a good consistency between DFF and the actual diagnosis (kappa = 0.551, P<0.001). Ten-fold cross-validation showed a stable performance of DFF with a mean AUC of 0.863 (sensitivity: 78.8%, specificity: 77.8%) in 10 training sets and a mean AUC of 0.866 (sensitivity: 80.9%, specificity: 84.1%) in 10 test sets. CONCLUSIONS A more violent glucose fluctuation pattern was marked in patients with LADA than T2DM. We first proposed the possible role of DFF in distinguishing patients with LADA from T2DM in our study population, which may assist in diabetes classification.
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