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Brown SA, Kovatchev BP, Raghinaru D, Lum JW, Buckingham BA, Kudva YC, Laffel LM, Levy CJ, Pinsker JE, Wadwa RP, Dassau E, Doyle FJ, Anderson SM, Church MM, Dadlani V, Ekhlaspour L, Forlenza GP, Isganaitis E, Lam DW, Kollman C, Beck RW. Six-Month Randomized, Multicenter Trial of Closed-Loop Control in Type 1 Diabetes. N Engl J Med 2019; 381:1707-1717. [PMID: 31618560 PMCID: PMC7076915 DOI: 10.1056/nejmoa1907863] [Citation(s) in RCA: 552] [Impact Index Per Article: 110.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Closed-loop systems that automate insulin delivery may improve glycemic outcomes in patients with type 1 diabetes. METHODS In this 6-month randomized, multicenter trial, patients with type 1 diabetes were assigned in a 2:1 ratio to receive treatment with a closed-loop system (closed-loop group) or a sensor-augmented pump (control group). The primary outcome was the percentage of time that the blood glucose level was within the target range of 70 to 180 mg per deciliter (3.9 to 10.0 mmol per liter), as measured by continuous glucose monitoring. RESULTS A total of 168 patients underwent randomization; 112 were assigned to the closed-loop group, and 56 were assigned to the control group. The age range of the patients was 14 to 71 years, and the glycated hemoglobin level ranged from 5.4 to 10.6%. All 168 patients completed the trial. The mean (±SD) percentage of time that the glucose level was within the target range increased in the closed-loop group from 61±17% at baseline to 71±12% during the 6 months and remained unchanged at 59±14% in the control group (mean adjusted difference, 11 percentage points; 95% confidence interval [CI], 9 to 14; P<0.001). The results with regard to the main secondary outcomes (percentage of time that the glucose level was >180 mg per deciliter, mean glucose level, glycated hemoglobin level, and percentage of time that the glucose level was <70 mg per deciliter or <54 mg per deciliter [3.0 mmol per liter]) all met the prespecified hierarchical criterion for significance, favoring the closed-loop system. The mean difference (closed loop minus control) in the percentage of time that the blood glucose level was lower than 70 mg per deciliter was -0.88 percentage points (95% CI, -1.19 to -0.57; P<0.001). The mean adjusted difference in glycated hemoglobin level after 6 months was -0.33 percentage points (95% CI, -0.53 to -0.13; P = 0.001). In the closed-loop group, the median percentage of time that the system was in closed-loop mode was 90% over 6 months. No serious hypoglycemic events occurred in either group; one episode of diabetic ketoacidosis occurred in the closed-loop group. CONCLUSIONS In this 6-month trial involving patients with type 1 diabetes, the use of a closed-loop system was associated with a greater percentage of time spent in a target glycemic range than the use of a sensor-augmented insulin pump. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases; iDCL ClinicalTrials.gov number, NCT03563313.).
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Affiliation(s)
- Sue A Brown
- From the University of Virginia Center for Diabetes Technology, Charlottesville (S.A.B., B.P.K., S.M.A.); the Jaeb Center for Health Research, Tampa, FL (D.R., J.W.L., C.K., R.W.B.); the Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford (B.A.B., L.E.), and the Sansum Diabetes Research Institute, Santa Barbara (J.E.P., M.C.) - both in California; the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN (Y.C.K., V.D.); the Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston (L.M.L., E.I.), and the Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge (E.D., F.J.D.) - both in Massachusetts; the Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York (C.J.L., D.W.L.); and the Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora (R.P.W., G.P.F.)
| | - Boris P Kovatchev
- From the University of Virginia Center for Diabetes Technology, Charlottesville (S.A.B., B.P.K., S.M.A.); the Jaeb Center for Health Research, Tampa, FL (D.R., J.W.L., C.K., R.W.B.); the Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford (B.A.B., L.E.), and the Sansum Diabetes Research Institute, Santa Barbara (J.E.P., M.C.) - both in California; the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN (Y.C.K., V.D.); the Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston (L.M.L., E.I.), and the Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge (E.D., F.J.D.) - both in Massachusetts; the Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York (C.J.L., D.W.L.); and the Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora (R.P.W., G.P.F.)
| | - Dan Raghinaru
- From the University of Virginia Center for Diabetes Technology, Charlottesville (S.A.B., B.P.K., S.M.A.); the Jaeb Center for Health Research, Tampa, FL (D.R., J.W.L., C.K., R.W.B.); the Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford (B.A.B., L.E.), and the Sansum Diabetes Research Institute, Santa Barbara (J.E.P., M.C.) - both in California; the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN (Y.C.K., V.D.); the Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston (L.M.L., E.I.), and the Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge (E.D., F.J.D.) - both in Massachusetts; the Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York (C.J.L., D.W.L.); and the Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora (R.P.W., G.P.F.)
| | - John W Lum
- From the University of Virginia Center for Diabetes Technology, Charlottesville (S.A.B., B.P.K., S.M.A.); the Jaeb Center for Health Research, Tampa, FL (D.R., J.W.L., C.K., R.W.B.); the Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford (B.A.B., L.E.), and the Sansum Diabetes Research Institute, Santa Barbara (J.E.P., M.C.) - both in California; the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN (Y.C.K., V.D.); the Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston (L.M.L., E.I.), and the Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge (E.D., F.J.D.) - both in Massachusetts; the Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York (C.J.L., D.W.L.); and the Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora (R.P.W., G.P.F.)
| | - Bruce A Buckingham
- From the University of Virginia Center for Diabetes Technology, Charlottesville (S.A.B., B.P.K., S.M.A.); the Jaeb Center for Health Research, Tampa, FL (D.R., J.W.L., C.K., R.W.B.); the Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford (B.A.B., L.E.), and the Sansum Diabetes Research Institute, Santa Barbara (J.E.P., M.C.) - both in California; the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN (Y.C.K., V.D.); the Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston (L.M.L., E.I.), and the Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge (E.D., F.J.D.) - both in Massachusetts; the Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York (C.J.L., D.W.L.); and the Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora (R.P.W., G.P.F.)
| | - Yogish C Kudva
- From the University of Virginia Center for Diabetes Technology, Charlottesville (S.A.B., B.P.K., S.M.A.); the Jaeb Center for Health Research, Tampa, FL (D.R., J.W.L., C.K., R.W.B.); the Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford (B.A.B., L.E.), and the Sansum Diabetes Research Institute, Santa Barbara (J.E.P., M.C.) - both in California; the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN (Y.C.K., V.D.); the Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston (L.M.L., E.I.), and the Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge (E.D., F.J.D.) - both in Massachusetts; the Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York (C.J.L., D.W.L.); and the Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora (R.P.W., G.P.F.)
| | - Lori M Laffel
- From the University of Virginia Center for Diabetes Technology, Charlottesville (S.A.B., B.P.K., S.M.A.); the Jaeb Center for Health Research, Tampa, FL (D.R., J.W.L., C.K., R.W.B.); the Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford (B.A.B., L.E.), and the Sansum Diabetes Research Institute, Santa Barbara (J.E.P., M.C.) - both in California; the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN (Y.C.K., V.D.); the Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston (L.M.L., E.I.), and the Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge (E.D., F.J.D.) - both in Massachusetts; the Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York (C.J.L., D.W.L.); and the Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora (R.P.W., G.P.F.)
| | - Carol J Levy
- From the University of Virginia Center for Diabetes Technology, Charlottesville (S.A.B., B.P.K., S.M.A.); the Jaeb Center for Health Research, Tampa, FL (D.R., J.W.L., C.K., R.W.B.); the Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford (B.A.B., L.E.), and the Sansum Diabetes Research Institute, Santa Barbara (J.E.P., M.C.) - both in California; the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN (Y.C.K., V.D.); the Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston (L.M.L., E.I.), and the Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge (E.D., F.J.D.) - both in Massachusetts; the Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York (C.J.L., D.W.L.); and the Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora (R.P.W., G.P.F.)
| | - Jordan E Pinsker
- From the University of Virginia Center for Diabetes Technology, Charlottesville (S.A.B., B.P.K., S.M.A.); the Jaeb Center for Health Research, Tampa, FL (D.R., J.W.L., C.K., R.W.B.); the Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford (B.A.B., L.E.), and the Sansum Diabetes Research Institute, Santa Barbara (J.E.P., M.C.) - both in California; the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN (Y.C.K., V.D.); the Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston (L.M.L., E.I.), and the Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge (E.D., F.J.D.) - both in Massachusetts; the Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York (C.J.L., D.W.L.); and the Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora (R.P.W., G.P.F.)
| | - R Paul Wadwa
- From the University of Virginia Center for Diabetes Technology, Charlottesville (S.A.B., B.P.K., S.M.A.); the Jaeb Center for Health Research, Tampa, FL (D.R., J.W.L., C.K., R.W.B.); the Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford (B.A.B., L.E.), and the Sansum Diabetes Research Institute, Santa Barbara (J.E.P., M.C.) - both in California; the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN (Y.C.K., V.D.); the Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston (L.M.L., E.I.), and the Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge (E.D., F.J.D.) - both in Massachusetts; the Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York (C.J.L., D.W.L.); and the Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora (R.P.W., G.P.F.)
| | - Eyal Dassau
- From the University of Virginia Center for Diabetes Technology, Charlottesville (S.A.B., B.P.K., S.M.A.); the Jaeb Center for Health Research, Tampa, FL (D.R., J.W.L., C.K., R.W.B.); the Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford (B.A.B., L.E.), and the Sansum Diabetes Research Institute, Santa Barbara (J.E.P., M.C.) - both in California; the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN (Y.C.K., V.D.); the Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston (L.M.L., E.I.), and the Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge (E.D., F.J.D.) - both in Massachusetts; the Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York (C.J.L., D.W.L.); and the Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora (R.P.W., G.P.F.)
| | - Francis J Doyle
- From the University of Virginia Center for Diabetes Technology, Charlottesville (S.A.B., B.P.K., S.M.A.); the Jaeb Center for Health Research, Tampa, FL (D.R., J.W.L., C.K., R.W.B.); the Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford (B.A.B., L.E.), and the Sansum Diabetes Research Institute, Santa Barbara (J.E.P., M.C.) - both in California; the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN (Y.C.K., V.D.); the Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston (L.M.L., E.I.), and the Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge (E.D., F.J.D.) - both in Massachusetts; the Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York (C.J.L., D.W.L.); and the Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora (R.P.W., G.P.F.)
| | - Stacey M Anderson
- From the University of Virginia Center for Diabetes Technology, Charlottesville (S.A.B., B.P.K., S.M.A.); the Jaeb Center for Health Research, Tampa, FL (D.R., J.W.L., C.K., R.W.B.); the Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford (B.A.B., L.E.), and the Sansum Diabetes Research Institute, Santa Barbara (J.E.P., M.C.) - both in California; the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN (Y.C.K., V.D.); the Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston (L.M.L., E.I.), and the Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge (E.D., F.J.D.) - both in Massachusetts; the Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York (C.J.L., D.W.L.); and the Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora (R.P.W., G.P.F.)
| | - Mei Mei Church
- From the University of Virginia Center for Diabetes Technology, Charlottesville (S.A.B., B.P.K., S.M.A.); the Jaeb Center for Health Research, Tampa, FL (D.R., J.W.L., C.K., R.W.B.); the Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford (B.A.B., L.E.), and the Sansum Diabetes Research Institute, Santa Barbara (J.E.P., M.C.) - both in California; the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN (Y.C.K., V.D.); the Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston (L.M.L., E.I.), and the Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge (E.D., F.J.D.) - both in Massachusetts; the Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York (C.J.L., D.W.L.); and the Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora (R.P.W., G.P.F.)
| | - Vikash Dadlani
- From the University of Virginia Center for Diabetes Technology, Charlottesville (S.A.B., B.P.K., S.M.A.); the Jaeb Center for Health Research, Tampa, FL (D.R., J.W.L., C.K., R.W.B.); the Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford (B.A.B., L.E.), and the Sansum Diabetes Research Institute, Santa Barbara (J.E.P., M.C.) - both in California; the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN (Y.C.K., V.D.); the Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston (L.M.L., E.I.), and the Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge (E.D., F.J.D.) - both in Massachusetts; the Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York (C.J.L., D.W.L.); and the Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora (R.P.W., G.P.F.)
| | - Laya Ekhlaspour
- From the University of Virginia Center for Diabetes Technology, Charlottesville (S.A.B., B.P.K., S.M.A.); the Jaeb Center for Health Research, Tampa, FL (D.R., J.W.L., C.K., R.W.B.); the Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford (B.A.B., L.E.), and the Sansum Diabetes Research Institute, Santa Barbara (J.E.P., M.C.) - both in California; the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN (Y.C.K., V.D.); the Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston (L.M.L., E.I.), and the Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge (E.D., F.J.D.) - both in Massachusetts; the Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York (C.J.L., D.W.L.); and the Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora (R.P.W., G.P.F.)
| | - Gregory P Forlenza
- From the University of Virginia Center for Diabetes Technology, Charlottesville (S.A.B., B.P.K., S.M.A.); the Jaeb Center for Health Research, Tampa, FL (D.R., J.W.L., C.K., R.W.B.); the Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford (B.A.B., L.E.), and the Sansum Diabetes Research Institute, Santa Barbara (J.E.P., M.C.) - both in California; the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN (Y.C.K., V.D.); the Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston (L.M.L., E.I.), and the Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge (E.D., F.J.D.) - both in Massachusetts; the Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York (C.J.L., D.W.L.); and the Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora (R.P.W., G.P.F.)
| | - Elvira Isganaitis
- From the University of Virginia Center for Diabetes Technology, Charlottesville (S.A.B., B.P.K., S.M.A.); the Jaeb Center for Health Research, Tampa, FL (D.R., J.W.L., C.K., R.W.B.); the Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford (B.A.B., L.E.), and the Sansum Diabetes Research Institute, Santa Barbara (J.E.P., M.C.) - both in California; the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN (Y.C.K., V.D.); the Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston (L.M.L., E.I.), and the Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge (E.D., F.J.D.) - both in Massachusetts; the Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York (C.J.L., D.W.L.); and the Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora (R.P.W., G.P.F.)
| | - David W Lam
- From the University of Virginia Center for Diabetes Technology, Charlottesville (S.A.B., B.P.K., S.M.A.); the Jaeb Center for Health Research, Tampa, FL (D.R., J.W.L., C.K., R.W.B.); the Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford (B.A.B., L.E.), and the Sansum Diabetes Research Institute, Santa Barbara (J.E.P., M.C.) - both in California; the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN (Y.C.K., V.D.); the Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston (L.M.L., E.I.), and the Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge (E.D., F.J.D.) - both in Massachusetts; the Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York (C.J.L., D.W.L.); and the Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora (R.P.W., G.P.F.)
| | - Craig Kollman
- From the University of Virginia Center for Diabetes Technology, Charlottesville (S.A.B., B.P.K., S.M.A.); the Jaeb Center for Health Research, Tampa, FL (D.R., J.W.L., C.K., R.W.B.); the Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford (B.A.B., L.E.), and the Sansum Diabetes Research Institute, Santa Barbara (J.E.P., M.C.) - both in California; the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN (Y.C.K., V.D.); the Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston (L.M.L., E.I.), and the Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge (E.D., F.J.D.) - both in Massachusetts; the Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York (C.J.L., D.W.L.); and the Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora (R.P.W., G.P.F.)
| | - Roy W Beck
- From the University of Virginia Center for Diabetes Technology, Charlottesville (S.A.B., B.P.K., S.M.A.); the Jaeb Center for Health Research, Tampa, FL (D.R., J.W.L., C.K., R.W.B.); the Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford (B.A.B., L.E.), and the Sansum Diabetes Research Institute, Santa Barbara (J.E.P., M.C.) - both in California; the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN (Y.C.K., V.D.); the Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston (L.M.L., E.I.), and the Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge (E.D., F.J.D.) - both in Massachusetts; the Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York (C.J.L., D.W.L.); and the Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora (R.P.W., G.P.F.)
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Zafar MU, Smith DA, Baber U, Sartori S, Chen K, Lam DW, Linares-Koloffon CA, Rey-Mendoza J, Jimenez Britez G, Escolar G, Fuster V, Badimon JJ. Impact of Timing on the Functional Recovery Achieved With Platelet Supplementation After Treatment With Ticagrelor. Circ Cardiovasc Interv 2018; 10:CIRCINTERVENTIONS.117.005120. [PMID: 28768756 DOI: 10.1161/circinterventions.117.005120] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 05/30/2017] [Indexed: 12/24/2022]
Abstract
BACKGROUND American College of Cardiology/American Heart Association guidelines advise waiting 5 to 7 days before operating on P2Y12 inhibitor-treated acute coronary syndrome patients, to allow dissipation of its antiplatelet effects. Platelet transfusion is often used to restore hemostasis during operations, but its effectiveness and optimal timing are unclear. We investigated the degree of functional gains obtained from platelet supplementation after loading and maintenance of dual antiplatelet therapy with ticagrelor and the influence of timing on this strategy. METHODS AND RESULTS After baseline platelet testing (Multiplate Analyzer and VerifyNow), cardiovascular disease patients (n=20; 56.9±7.9 years; 65% men; 75% diabetic) received dual antiplatelet therapy as a single loading dose (ticagrelor 180 mg plus aspirin 325 mg) and as daily/maintenance treatment for 5 to 7 days (maintenance therapy: ticagrelor 90 mg BID plus aspirin 81 mg QD). At 4, 6, 24, and 48 hours from (last) dosing, patients' blood samples were supplemented with concentrated platelets from healthy donors in vitro, raising platelet counts by 0% (unsupplemented control), 25%, 50%, and 75%, and the function retested. Reactivity in supplemented samples was compared with respective 0% sample and with the pretreatment baseline. Results under loading dose and maintenance therapy regimens were nearly identical. Platelet reactivity was higher (P<0.05) in nearly all supplemented samples versus respective controls. Aggregations with supplementation were 59% to 79% of baseline at 24 hours and equal to baseline at 48 hours. CONCLUSIONS Platelet reactivity of ticagrelor-treated patients can be restored using concentrated platelets after a loading dose/maintenance therapy in a time-dependent manner under in vitro testing. Although statistically significant improvements are evident 6 hours after (last) dosing, ≥24 hours maybe needed for clinically meaningful restoration in platelet function. CLINICAL TRIAL REGISTRATION URL: https://clinicaltrials.gov. Unique identifier: NCT02201394.
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Affiliation(s)
- M Urooj Zafar
- From the Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (M.U.Z., D.A.S., U.B., S.S., K.C., D.W.L., C.A.L.-K., J.R.-M., G.J.B., V.F., J.J.B.); and Department of Hematopathology, Hospital Clinic, Barcelona, Spain (G.E.)
| | - Donald A Smith
- From the Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (M.U.Z., D.A.S., U.B., S.S., K.C., D.W.L., C.A.L.-K., J.R.-M., G.J.B., V.F., J.J.B.); and Department of Hematopathology, Hospital Clinic, Barcelona, Spain (G.E.)
| | - Usman Baber
- From the Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (M.U.Z., D.A.S., U.B., S.S., K.C., D.W.L., C.A.L.-K., J.R.-M., G.J.B., V.F., J.J.B.); and Department of Hematopathology, Hospital Clinic, Barcelona, Spain (G.E.)
| | - Samantha Sartori
- From the Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (M.U.Z., D.A.S., U.B., S.S., K.C., D.W.L., C.A.L.-K., J.R.-M., G.J.B., V.F., J.J.B.); and Department of Hematopathology, Hospital Clinic, Barcelona, Spain (G.E.)
| | - Kevin Chen
- From the Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (M.U.Z., D.A.S., U.B., S.S., K.C., D.W.L., C.A.L.-K., J.R.-M., G.J.B., V.F., J.J.B.); and Department of Hematopathology, Hospital Clinic, Barcelona, Spain (G.E.)
| | - David W Lam
- From the Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (M.U.Z., D.A.S., U.B., S.S., K.C., D.W.L., C.A.L.-K., J.R.-M., G.J.B., V.F., J.J.B.); and Department of Hematopathology, Hospital Clinic, Barcelona, Spain (G.E.)
| | - Carlos A Linares-Koloffon
- From the Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (M.U.Z., D.A.S., U.B., S.S., K.C., D.W.L., C.A.L.-K., J.R.-M., G.J.B., V.F., J.J.B.); and Department of Hematopathology, Hospital Clinic, Barcelona, Spain (G.E.)
| | - Juan Rey-Mendoza
- From the Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (M.U.Z., D.A.S., U.B., S.S., K.C., D.W.L., C.A.L.-K., J.R.-M., G.J.B., V.F., J.J.B.); and Department of Hematopathology, Hospital Clinic, Barcelona, Spain (G.E.)
| | - Gustavo Jimenez Britez
- From the Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (M.U.Z., D.A.S., U.B., S.S., K.C., D.W.L., C.A.L.-K., J.R.-M., G.J.B., V.F., J.J.B.); and Department of Hematopathology, Hospital Clinic, Barcelona, Spain (G.E.)
| | - Gines Escolar
- From the Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (M.U.Z., D.A.S., U.B., S.S., K.C., D.W.L., C.A.L.-K., J.R.-M., G.J.B., V.F., J.J.B.); and Department of Hematopathology, Hospital Clinic, Barcelona, Spain (G.E.)
| | - Valentin Fuster
- From the Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (M.U.Z., D.A.S., U.B., S.S., K.C., D.W.L., C.A.L.-K., J.R.-M., G.J.B., V.F., J.J.B.); and Department of Hematopathology, Hospital Clinic, Barcelona, Spain (G.E.)
| | - Juan J Badimon
- From the Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (M.U.Z., D.A.S., U.B., S.S., K.C., D.W.L., C.A.L.-K., J.R.-M., G.J.B., V.F., J.J.B.); and Department of Hematopathology, Hospital Clinic, Barcelona, Spain (G.E.).
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