Hybrid Close-Loop Systems Versus Predictive Low-Glucose Suspend and Sensor-Augmented Pump Therapy in Patients With Type 1 Diabetes: A Single-Center Cohort Study

Glycemic variability and quality of life outcomes after changing to hybrid closed-loop system in Japanese individuals with type 1 diabetes using a conventional predictive low-glucose suspended insulin pump system

The hybrid closed-loop (HCL) system, Medtronic MiniMed™ 770G, has been available for use by Japanese individuals with type 1 diabetes mellitus since 2021. The aim of this study was to evaluate the effect of its use on glycemic variability and quality of life (QOL) in this population. This multicenter, open-label, prospective observational study included 14 Japanese individuals with type 1 diabetes mellitus treated with MiniMed™ 640G. Participants who switched to the 770G system were evaluated for time in range (TIR) and other glycemic outcomes at baseline and at 3 and 12 months post-transition. QOL was assessed using the Diabetes Therapy-Related QOL (DTR-QOL) scale. The mean baseline glycated hemoglobin was 7.52 ± 1.05%, and body mass index (BMI) was 21.78 ± 3.07 kg/m2. By study completion, individuals used the HCL system approximately 80% of the time in a day. TIR showed improvement, with an increased achievement ratio of TIR > 70% at 12 months. Hypoglycemia occurrence was minimal at 12 months. In addition, all-time sensor glucose measurements decreased after 12 months, and there were no significant changes in BMI or daily insulin dose. DTR-QOL scores did not significantly differ, possibly owing to increased total alarms and sensor calibration times. Transitioning to the Medtronic MiniMed™ 770G system led to an improved achievement ratio of TIR > 70% and reduced hyperglycemia at 12 months. However, no significant change in QOL was observed, probably because of the increased number of total alarms.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13340-024-00778-7.

Enhanced Metabolic Control in a Pediatric Population with Type 1 Diabetes Mellitus Using Hybrid Closed-Loop and Predictive Low-Glucose Suspend Insulin Pump Treatments

BACKGROUND

Insulin pumps coupled with continuous glucose monitoring sensors use algorithms to analyze real-time blood glucose levels. This allows for the suspension of insulin administration before hypoglycemic thresholds are reached or for adaptive tuning in hybrid closed-loop systems. This longitudinal retrospective study aims to analyze real-world glycemic outcomes in a pediatric population transitioning to such devices.

METHODS

We evaluated children with type 1 diabetes mellitus (T1D) admitted to the Pediatric Diabetes Department from a major University Hospital in Bucharest, Romania, who transitioned to hybrid closed-loop or predictive low-glucose suspend system from either non-automated insulin pumps or multiple daily injections. The primary outcome was assessing the change in glycated hemoglobin (HbA1c) after initiating these devices. Secondary outcomes analyzed changes in glucose metrics from the 90 days prior to the baseline and follow-up visit.

RESULTS

51 children were included (58.8% girls), the mean age was 10.3 ± 3.7 years, and the mean follow-up duration was 13.2 ± 4.5 months. The analyzed parameters, such as HbA1c (6.9 ± 0.7% vs. 6.7 ± 0.6%, p = 0.023), time in range (69.3 ± 11.2% vs. 76 ± 9.9%, p < 0.001), time in tight range (47.4 ± 10.9% vs. 53.7 ± 10.7%, p < 0.001), time below range (5.6 ± 2.9% vs. 3.5 ± 1.9%, p < 0.001), time above range (25 ± 11.2% vs. 20.4 ± 9.4%, p = 0.001), and coefficient of variation (37.9 ± 4.8% vs. 35.6 ± 4.6%, p = 0.001), showed significant improvements.

CONCLUSIONS

The application of these sensor-integrated insulin pumps can significantly enhance metabolic control in pediatric populations, minimizing glycemic variations to mitigate complications and enrich the quality of life.

Hybrid closed-loop systems for managing blood glucose levels in type 1 diabetes: a systematic review and economic modelling

Background

Hybrid closed-loop systems are a new class of technology to manage type 1 diabetes mellitus. The system includes a combination of real-time continuous glucose monitoring from a continuous glucose monitoring device and a control algorithm to direct insulin delivery through an insulin pump. Evidence suggests that such technologies have the potential to improve the lives of people with type 1 diabetes mellitus and their families.

Aim

The aim of this appraisal was to assess the clinical effectiveness and cost-effectiveness of hybrid closed-loop systems for managing glucose in people who have type 1 diabetes mellitus and are having difficulty managing their condition despite prior use of at least one of the following technologies: continuous subcutaneous insulin infusion, real-time continuous glucose monitoring or flash glucose monitoring (intermittently scanned continuous glucose monitoring).

Methods

A systematic review of clinical effectiveness and cost-effectiveness evidence following predefined inclusion criteria informed by the aim of this review. An independent economic assessment using iQVIA CDM to model cost-effectiveness.

Results

The clinical evidence identified 12 randomised controlled trials that compared hybrid closed loop with continuous subcutaneous insulin infusion + continuous glucose monitoring. Hybrid closed-loop arm of randomised controlled trials achieved improvement in glycated haemoglobin per cent [hybrid closed loop decreased glycated haemoglobin per cent by 0.28 (95% confidence interval -0.34 to -0.21), increased per cent of time in range (between 3.9 and 10.0 mmol/l) with a MD of 8.6 (95% confidence interval 7.03 to 10.22), and significantly decreased time in range (per cent above 10.0 mmol/l) with a MD of -7.2 (95% confidence interval -8.89 to -5.51), but did not significantly affect per cent of  time below range (< 3.9 mmol/l)]. Comparator arms showed improvements, but these were smaller than in the hybrid closed-loop arm. Outcomes were superior in the hybrid closed-loop arm compared with the comparator arm. The cost-effectiveness search identified six studies that were included in the systematic review. Studies reported subjective cost-effectiveness that was influenced by the willingness-to-pay thresholds. Economic evaluation showed that the published model validation papers suggest that an earlier version of the iQVIA CDM tended to overestimate the incidences of the complications of diabetes, this being particularly important for severe visual loss and end-stage renal disease. Overall survival's medium-term modelling appeared good, but there was uncertainty about its longer-term modelling. Costs provided by the National Health Service Supply Chain suggest that hybrid closed loop is around an annual average of £1500 more expensive than continuous subcutaneous insulin infusion + continuous glucose monitoring, this being a pooled comparator of 90% continuous subcutaneous insulin infusion + intermittently scanned continuous glucose monitoring and 10% continuous subcutaneous insulin infusion + real-time continuous glucose monitoring due to clinical effectiveness estimates not being differentiated by continuous glucose monitoring type. This net cost may increase by around a further £500 for some systems. The Evidence Assessment Group base case applies the estimate of -0.29% glycated haemoglobin for hybrid closed loop relative to continuous subcutaneous insulin infusion + continuous glucose monitoring. There was no direct evidence of an effect on symptomatic or severe hypoglycaemia events, and therefore the Evidence Assessment Group does not include these in its base case. The change in glycated haemoglobin results in a gain in undiscounted life expectancy of 0.458 years and a gain of 0.160 quality-adjusted life-years. Net lifetime treatment costs are £31,185, with reduced complications leading to a net total cost of £28,628. The cost-effectiveness estimate is £179,000 per quality-adjusted life-year.

Conclusions

Randomised controlled trials of hybrid closed-loop interventions in comparison with continuous subcutaneous insulin infusion + continuous glucose monitoring achieved a statistically significant improvement in glycated haemoglobin per cent in time in range between 3.9 and 10 mmol/l, and in hyperglycaemic levels.

Study registration

This study is registered as PROSPERO CRD42021248512.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Evidence Synthesis programme (NIHR award ref: NIHR133547) and is published in full in Health Technology Assessment; Vol. 28, No. 80. See the NIHR Funding and Awards website for further award information.

The impact of closed-loop automated insulin delivery systems on hypoglycaemia awareness in people living with type 1 diabetes: A systematic review and meta-analysis

OBJECTIVES

Impaired awareness of hyperglycaemia (IAH) affects approximately 20-40% of people living with type 1 diabetes (T1D), predisposing them to severe hypoglycaemia. This systematic review evaluated the efficacy of closed-loop automated insulin delivery systems (CL-AID) in restoring IAH compared with standard diabetes care, including other diabetes technologies.

METHODS

Six electronic databases were searched for published and unpublished observational and randomised-control studies (RCTs) from inception to 29th of May 2024. The results of observational studies and RCTs were meta-analysed separately to calculate the effect of CL-AID on IAH in people living with T1D. Quality assessment of studies was performed using the Joanna-Briggs appraisal tool for cohort studies and the Risk of Bias (Rob-2) tool for RCTs.

RESULTS

Meta-analysis of four prospective observations studies (n = 583) demonstrated a statistically significant improvement in hypoglycaemia awareness upon transition to a hybrid closed-loop (HCL) system compared with standard diabetes care in people with T1D, Clarke score mean difference (MD) of -0.45 (-0.69 to -0.22, p = 0.0001). However, this was less than 1 point, which is the minimum clinically important difference (MCID) of Clarke score. Meta-analysis of three RCTs (n = 55) comparing standard diabetes care did not demonstrate any statistically significant effect on hypoglycaemia awareness, Clarke score MD of -0.69 (-1.89 to 0.50, p = 0.26).

CONCLUSIONS

This systematic review demonstrated that transition from standard diabetes care to HCL has the potential to improve hypoglycaemia awareness in people with T1D and IAH, but this might not be of major clinical significance. Hence, psychoeducational interventions continue to be the cornerstone of IAH management. Novel therapeutic modalities, such as bi-hormonal automated delivery systems, need to be further explored to help restore hypoglycaemia awareness.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40200-024-01492-6.

Elevated urinary albumin predicts increased time in range after initiation of SGLT2 inhibitors in individuals with type 1 diabetes on sensor-augmented pump therapy

Aims

We aimed to investigate potential predictors of effectiveness of SGLT2 inhibitors (SGLT2i) in individuals with type 1 diabetes (T1D) on sensor-augmented pump (SAP) therapy.

Methods

We included individuals with T1D receiving SAP therapy at our hospital who were newly initiated on SGLT2i between 2019 and 2020 and were followed for at least 1 year. Data on BMI, blood tests, and continuous glucose monitoring (CGM) were compared before and 12 months after initiation of SGLT2i. Predictors of incremental increases in time in range (ΔTIR) were explored using a multiple regression analysis. Cutoff values for the predictors were determined using an ROC curve analysis.

Results

A total of 17 individuals (females, 70.6%; median age, 44.0 years) were included, excluding three individuals who discontinued SGLT2i due to side effects. During follow-up, their median BMI decreased significantly (P = 0.013), while no significant change was seen in their total daily dose of insulin, basal-to-total insulin ratio. Again, their HbA1c, TIR, and time above range (TAR) improved significantly (P = 0.004, P = 0.003, and P = 0.003, respectively), while their time below range (TBR) showed no significant change. The predictor of increased ΔTIR was high urinary albumin-to-creatinine ratio (UACR) at baseline (P = 0.026) only, with the cutoff value determined to be 28.0 mg/g Cr or higher (AUC = 0.82, P = 0.003).

Conclusions

It may be suggested that individuals with T1D on SAP therapy and having near-microalbuminuria or higher could be expected to show significant improvement in TIR.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13340-024-00743-4.

Exploring the Impact of Glycemic Control on Diabetic Retinopathy: Emerging Models and Prognostic Implications

This review addresses the complexities of type 1 diabetes (T1D) and its associated complications, with a particular focus on diabetic retinopathy (DR). This review outlines the progression from non-proliferative to proliferative diabetic retinopathy and diabetic macular edema, highlighting the role of dysglycemia in the pathogenesis of these conditions. A significant portion of this review is devoted to technological advances in diabetes management, particularly the use of hybrid closed-loop systems (HCLSs) and to the potential of open-source HCLSs, which could be easily adapted to different patients' needs using big data analytics and machine learning. Personalized HCLS algorithms that integrate factors such as patient lifestyle, dietary habits, and hormonal variations are highlighted as critical to reducing the incidence of diabetes-related complications and improving patient outcomes.

Glycaemic outcomes in adults with type 1 diabetes transitioning towards advanced automated insulin delivery systems - a real-world analysis at a Swiss tertiary centre

AIMS OF THE STUDY

To assess glucose levels in adults with diabetes at a Swiss tertiary hospital when transitioning from insulin delivery with a sensor-augmented pump with (predictive) low-glucose suspend ([P]LGS) to a hybrid-closed loop (HCL) and from a HCL to an advanced hybrid-closed loop (AHCL).

METHODS

Continuous glucose monitoring data for 44 adults with type 1 diabetes transitioning from (P)LGS to hybrid-closed loop and from hybrid-closed loop to advanced hybrid-closed loop were analysed, including the percentage of time spent within, below, and above glucose ranges. In addition, a subgroup analysis (n = 14) of individuals undergoing both transitions was performed.

RESULTS

The transition from a (P)LGS to a hybrid-closed loop was associated with increased time in range (6.6% [2.6%-12.7%], p <0.001) and decreased time above range (5.6% [2.3%-12.7%], p <0.001). The transition from a hybrid-closed loop to an advanced hybrid-closed loop was associated with increased time in range (1.6% [-0.5%-4.5%], p = 0.046) and decreased time above range (1.5% [-1.8%-5.6%], p = 0.050). Both transitions did not change the time below range. In the subgroup analysis ([P]LGS → HCL → AHCL), the time in range increased from 69.4% (50.3%-79.2%) to 76.5% (65.3%-81.3%) and 78.7% (69.7%-85.8%), respectively (p <0.001).

CONCLUSIONS

Glucose levels significantly improved when transitioning from a (P)LGS to a hybrid-closed loop. Glucose levels improved further when switching from a hybrid-closed loop to an advanced hybrid-closed loop. However, the added benefit of an advanced hybrid-closed loop was comparably smaller. This pattern was also reflected in the subgroup analysis.

Daytime hypoglycemic episodes during the use of an advanced hybrid closed loop system

AIMS

The use of advanced hybrid closed loop systems is spreading due to the beneficial effects on glycometabolic control obtained in patients with type 1 diabetes. However, hypoglycemic episodes can be sometimes a matter of concern. We aim to compare the hypoglycemic risk of an advanced hybrid closed loop system and a predictive low glucose suspend sensor augmented pump.

METHODS

In this retrospective three months observational study, we included 30 patients using Medtronic Minimed™ 780G advanced hybrid closed loop system and 30 patients using a Medtronic Minimed™ predictive low glucose suspend sensor augmented pump.

RESULTS

The advanced hybrid closed loop system reduced the time spent above 180 mg/dL threshold and increased the time in range as compared to the predictive low glucose suspend. No severe hypoglycemia occurred in both groups and no differences were observed in the percentage of time spent below 70 mg/dl and 54 mg/dl glucose threshold. Nevertheless, more hypoglycemic episodes were recorded during daytime, but not in nighttime, with the use of the advanced hybrid closed loop system.

CONCLUSIONS

Our results confirmed the general improvement of glycemic outcomes obtained with the advanced hybrid closed loop system; however more hypoglycemic episodes during daytime were evident.

Glucose control during Ramadan in a pediatric cohort with type 1 diabetes on MiniMed standard and advanced hybrid closed‑loop systems: A pilot study

BACKGROUND

Hybrid closed-loop (HCL) systems have revolutionized the treatment of diabetes, enabling doctors to cope with challenging conditions that were previously almost impossible to manage or were very risky and difficult.

AIMS

To assess the efficacy and safety of a hybrid closed-loop (HCL) system during Ramadan fasting in a pediatric cohort with type 1 diabetes (T1D).

RESEARCH DESIGN AND METHODS

Glucose control outcomes in older children and adolescents aged 8-16 years with automated insulin delivery for T1D were analyzed during Ramadan and 1 month before Ramadan. Participants on MiniMed standard HCL (670G) or advanced HCL (780G) systems of Medtronic were categorized as fasting or nonfasting.

RESULTS

The average age of the 19 participants (8 and 11 were on standard and advanced HCL systems, respectively) was 11.35 ± 2 years. Eleven patients fasted during Ramadan. Pump setup and sensor statistics were the same during Ramadan and the month before; no significant difference was found between the two groups in terms of insulin and glucose control metrics, with practically the same coefficient of variation, time in range (TIR) and time spent in hypoglycemia, maintained within the international recommended targets. Total daily doses were paradoxically higher in patients who fasted during Ramadan (p = 0.01), without repercussions on glucose control metrics.

CONCLUSIONS

Standard and advanced HCL use during Ramadan were safe and were associated with a maintained optimum TIR (>70 %) and no significant hypoglycemia in adolescents and older children with T1D.

Gender differences in reported frequency and consequences of hypoglycemia among adults living with type 1 diabetes: results from the BETTER registry

AIMS

To evaluate the frequency and consequences of level 2 (L2H, glucose level <3.0 mmol/L with autonomous management) and level 3 hypoglycemia (L3H requiring external assistance to treat), in adults living with type 1 diabetes (T1D), while investigating the role of gender.

METHODS

Cross-sectional analysis of self-reported retrospective data from a Canadian registry of 900 adults living with T1D using logistic regression models adjusted for age, T1D management modalities, hypoglycemia history, and validated patient-reported outcomes scales. Changes in diabetes management, seeking healthcare resources, and impacts on daily well-being were explored.

RESULTS

Of the 900 adults (66% women, mean age 43.7 ± 14.8 years, mean T1D duration 25.5 ± 14.6 years), 87% used wearable diabetes technology. L3H in the past year was reported by 15% participants, similar between genders. Women reported more L2Hstudy analysis than men (median (Q1, Q3): 4 (2, 10) vs 3 (1,8), p=0.015), and were more likely to report persistent fatigue after both L2H and L3H (Odds ratio [95% confidence interval]: 1.95 [1.16, 3.28] and 1.86 [1.25, 2.75], respectively) and anxiety (1.70 [1.05, 2.75]) after a L3H.

CONCLUSIONS

The findings suggest taking a gender-based differential approach when addressing hypoglycemia and its various consequences for people living with T1D.

Recent trends and advances in type 1 diabetes therapeutics: A comprehensive review

Type 1 diabetes (T1D) is a chronic autoimmune disease characterized by the destruction of pancreatic β-cells, leading to insulin deficiency. Insulin replacement therapy is the current standard of care for T1D, but it has significant limitations. However, stem cell-based replacement therapy has the potential to restore β-cell function and achieve glycaemic control eradicating the necessity for drugs or injecting insulin externally. While significant progress has been made in preclinical studies, the clinical translation of stem cell therapy for T1D is still in its early stages. In continuation, further research is essentially required to determine the safety and efficacy of stem cell therapies and to develop strategies to prevent immune rejection of stem cell-derived β-cells. The current review highlights the current state of cellular therapies for T1D including, different types of stem cell therapies, gene therapy, immunotherapy, artificial pancreas, and cell encapsulation being investigated, and their potential for clinical translation.

Long-term glucose-lowering effect of intermittently scanned continuous glucose monitoring for type 1 diabetes patients in poor glycaemic control from Region North Denmark: An observational real-world cohort study

BACKGROUND

Lowering glucose levels is a complex task for patients with type 1 diabetes, and they often lack contact with health care professionals. Intermittently scanned continuous glucose monitoring (isCGM) has the potential to aid them with blood glucose management at home. The aim of this study was to investigate the long-term effect of isCGM on HbA1c in type 1 diabetes patients with poor glycaemic control in a region-wide real-world setting.

METHODS

All patients with type 1 diabetes receiving an isCGM due to poor glycaemic control (≥70 mmol/mol [≥8.6%]) in the period of 2020-21 in Region North Denmark ("T1D-CGM") were compared with all type 1 diabetes patients without isCGM ("T1D-NOCGM") in the same period. A multiple linear regression model adjusted for age, sex, diabetes duration and use of continuous subcutaneous insulin infusion was constructed to estimate the difference in change from baseline HbA1c between the two groups and within subgroups of T1D-CGM.

RESULTS

A total of 2,527 patients (T1D-CGM: 897; T1D-NOCGM: 1,630) were included in the study. The estimated adjusted difference in change from baseline HbA1c between T1D-CGM vs T1D-NOCGM was -5.68 mmol/mol (95% CI: (-6.69 to -4.67 mmol/mol; p<0.0001)). Older patients using isCGM dropped less in HbA1c.

CONCLUSIONS

Our results indicate that patients with type 1 diabetes in poor glycaemic control from Region North Denmark in general benefit from using isCGM with a sustained 24-month improvement in HbA1c, but the effect on HbA1c may be less pronounced for older patients.