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Schneider-Utaka AK, Hanes S, Boughton CK, Hartnell S, Thabit H, Mubita WM, Draxlbauer K, Poettler T, Hayes J, Wilinska ME, Mader JK, Narendran P, Leelarathna L, Evans ML, Hovorka R, Hood KK. Patient-reported outcomes for older adults on CamAPS FX closed loop system. Diabet Med 2023; 40:e15126. [PMID: 37171467 DOI: 10.1111/dme.15126] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 04/25/2023] [Accepted: 05/02/2023] [Indexed: 05/13/2023]
Abstract
AIMS Use of the CamAPS FX hybrid closed loop (CL) system is associated with improved time in range and glycated haemoglobin A1c across the age span, but little is known about its effects on patient-reported outcomes (PROs). METHODS This open-label, randomized, multi-site study compared CamAPS FX to sensor-augmented pump (SAP) in a sample of older adults (≥60 years) with type 1 diabetes (T1D). Thirty-five older adults completed PROs surveys at the start of the study and after each period of 16 weeks using either CL or SAP. At the end of the study, 19 participated in interviews about their experiences with CL. RESULTS Results examining the 16 weeks of CL use showed that the overall Diabetes Distress Scale score and two subscales (powerlessness and physician distress) improved significantly along with trust on the Glucose Monitoring Satisfaction Survey. User experience interview responses were consistent in noting benefits of 'improved glycaemic control' and 'worrying less about diabetes'. CONCLUSION In this sample of older adults with T1D who have previously shown glycaemic benefit, there are indicators of improved PROs and subjective user experience benefits.
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Affiliation(s)
- A K Schneider-Utaka
- Division of Endocrinology and Diabetes, Stanford Diabetes Research Center, University, Stanford, California, USA
| | - S Hanes
- Division of Endocrinology and Diabetes, Stanford Diabetes Research Center, University, Stanford, California, USA
| | - C K Boughton
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Wolfson Diabetes and Endocrine Clinic, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - S Hartnell
- Wolfson Diabetes and Endocrine Clinic, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - H Thabit
- Diabetes, Endocrinology and Metabolism Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - W M Mubita
- Diabetes, Endocrinology and Metabolism Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - K Draxlbauer
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - T Poettler
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - J Hayes
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - M E Wilinska
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - J K Mader
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - P Narendran
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - L Leelarathna
- Diabetes, Endocrinology and Metabolism Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - M L Evans
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Wolfson Diabetes and Endocrine Clinic, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - R Hovorka
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - K K Hood
- Division of Endocrinology and Diabetes, Stanford Diabetes Research Center, University, Stanford, California, USA
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O'Carroll-Lolait A, Urwin A, Doughty I, Schofield J, Thabit H, Leelarathna L. Trends in HbA1c and other biochemical outcomes of individuals with newly diagnosed type 1 diabetes. Ir J Med Sci 2021; 190:999-1004. [PMID: 33231831 PMCID: PMC8302503 DOI: 10.1007/s11845-020-02434-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 11/11/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND There is limited data on glycaemic control and cardiovascular risk factor management in newly diagnosed individuals with type 1 diabetes in the first 2 years. METHODS Retrospective, single centre study from the North West of England, newly diagnosed with type 1 diabetes between 2014 and 2018 (n = 58). HbA1c, blood pressure, lipids and body mass index (BMI) data were collected from electronic patient records from the time of diagnosis until the end of 2 years, stratified by age 16-24 years or ≥ 25 years at presentation. RESULTS For those aged 16-24 years (n = 31), median (IQR), HbA1c improved at 6 months from 83 (63-93) to 51.5 (46-75) mmol/mol (p = 0.001) and remained stable 6-24 months. For those ≥ 25 years (n = 27), HbA1c declined from 91 (70-107) to 65 (50-89) mmol/mol, (p < 0.01) at 6 months and declined further to 52 mmol/mol (44-70) at 24 months. At 24 months, 27.8% of all individuals had an HbA1c ≥ 69 mmol/mol. Approximately, a third met LDL (< 2 mmol/L) and total cholesterol (< 4 mmol/L) targets. A total of 58.6% of individuals were overweight/obese (BMI > 25 kg/m2) at 24 months compared to 45.8% at baseline. There were no significant blood pressure changes during the follow-up. CONCLUSIONS In both age groups, significant improvement of HbA1c occurred within the first 6 months of diagnosis with no statistical difference between the two groups at any of the time points up to 24 months. Despite significant improvements in HbA1c, majority had levels > 53 mmol/mol at 24 months. Alongside the high incidence of obesity and dyslipidaemia, our data support the need for further intensification of therapy from diagnosis of type 1 diabetes.
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Affiliation(s)
- A O'Carroll-Lolait
- School of Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - A Urwin
- Manchester Diabetes Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - I Doughty
- Royal Manchester Children's Hospital, Manchester University NHS foundation Trust, Manchester, UK
| | - J Schofield
- Manchester Diabetes Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - H Thabit
- Manchester Diabetes Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - L Leelarathna
- Manchester Diabetes Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.
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Wilmot EG, Evans M, Barnard-Kelly K, Burns M, Cranston I, Elliott RA, Gkountouras G, Kanumilli N, Krishan A, Kotonya C, Lumley S, Narendran P, Neupane S, Rayman G, Sutton C, Taxiarchi VP, Thabit H, Leelarathna L. Flash glucose monitoring with the FreeStyle Libre 2 compared with self-monitoring of blood glucose in suboptimally controlled type 1 diabetes: the FLASH-UK randomised controlled trial protocol. BMJ Open 2021; 11:e050713. [PMID: 34261691 PMCID: PMC8280849 DOI: 10.1136/bmjopen-2021-050713] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Optimising glycaemic control in type 1 diabetes (T1D) remains challenging. Flash glucose monitoring with FreeStyle Libre 2 (FSL2) is a novel alternative to the current standard of care self-monitoring of blood glucose (SMBG). No randomised controlled trials to date have explored the potential benefits of FSL2 in T1D. We aim to assess the impact of FSL2 in people with suboptimal glycaemic control T1D in comparison with SMBG. METHODS This open-label, multicentre, randomised (via stochastic minimisation), parallel design study conducted at eight UK secondary and primary care centres will aim to recruit 180 people age ≥16 years with T1D for >1 year and glycated haemoglobin (HbA1c) 7.5%-11%. Eligible participants will be randomised to 24 weeks of FSL2 (intervention) or SMBG (control) periods, after 2-week of blinded sensor wear. Participants will be assessed virtually or in-person owing to the COVID-19 pandemic. HbA1c will be measured at baseline, 12 and 24 weeks (primary outcome). Participants will be contacted at 4 and 12 weeks for glucose optimisation. Control participants will wear a blinded sensor during the last 2 weeks. Psychosocial outcomes will be measured at baseline and 24 weeks. Secondary outcomes include sensor-based metrics, insulin doses, adverse events and self-report psychosocial measures. Utility, acceptability, expectations and experience of using FSL2 will be explored. Data on health service resource utilisation will be collected. ANALYSIS Efficacy analyses will follow intention-to-treat principle. Outcomes will be analysed using analysis of covariance, adjusted for the baseline value of the corresponding outcome, minimisation factors and other known prognostic factors. Both within-trial and life-time economic evaluations, informed by modelling from the perspective of the National Health Service setting, will be performed. ETHICS The study was approved by Greater Manchester West Research Ethics Committee (reference 19/NW/0081). Informed consent will be sought from all participants. TRIAL REGISTRATION NUMBER NCT03815006. PROTOCOL VERSION 4.0 dated 29 June 2020.
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Affiliation(s)
- Emma G Wilmot
- Diabetes Department, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
- University of Nottingham Faculty of Medicine and Health Sciences, Nottingham, UK
| | - Mark Evans
- Wellcome Trust-MRC Institute of Metabolic Science, NIHR Cambridge Biomedicl Research Centre, Cambridge University Hospitals and University of Cambridge, Cambridge, Cambridgeshire, UK
| | | | - M Burns
- Manchester Clinical Trials Unit, University of Manchester, Manchester, UK
| | - Iain Cranston
- Academic Department of Diabetes and Endocrinology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Rachel Ann Elliott
- Manchester Centre for Health Economics, Divison of Population Health, University of Manchester, Manchester, UK
| | - G Gkountouras
- Manchester Centre for Health Economics, Divison of Population Health, University of Manchester, Manchester, UK
| | | | - A Krishan
- Manchester Centre for Health Economics, Divison of Population Health, University of Manchester, Manchester, UK
| | - C Kotonya
- Diabetes Department, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | | | - P Narendran
- Institute of Immunology and Immunotherapy, University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
| | - Sankalpa Neupane
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospital NHS Trust, Norwich, Norfolk, UK
| | - Gerry Rayman
- The Ipswich Diabetes Centre and Research Unit, Ipswich Hospital NHS Trust, Suffolk, Ipswich, UK
| | - Christopher Sutton
- Manchester Centre for Health Economics, Divison of Population Health, University of Manchester, Manchester, UK
| | - V P Taxiarchi
- Manchester Centre for Health Economics, Divison of Population Health, University of Manchester, Manchester, UK
| | - H Thabit
- Manchester Diabetes Centre, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, Greater Manchester, UK
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - L Leelarathna
- Manchester Clinical Trials Unit, University of Manchester, Manchester, UK
- Manchester Diabetes Centre, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, Greater Manchester, UK
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4
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Leelarathna L, Thabit H, Hovorka R, Evans M. Estimated HbA 1c and glucose management indicator (GMI): are they the same? Diabet Med 2021; 38:e14423. [PMID: 33058254 DOI: 10.1111/dme.14423] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/27/2020] [Accepted: 10/12/2020] [Indexed: 11/30/2022]
Affiliation(s)
- L Leelarathna
- Diabetes, Endocrinology and Metabolism Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - H Thabit
- Diabetes, Endocrinology and Metabolism Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - R Hovorka
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Wolfson Diabetes and Endocrinology Clinic, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - M Evans
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Wolfson Diabetes and Endocrinology Clinic, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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5
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Lawton J, Blackburn M, Rankin D, Allen J, Campbell F, Leelarathna L, Tauschmann M, Thabit H, Wilinska ME, Hovorka R. The impact of using a closed-loop system on food choices and eating practices among people with Type 1 diabetes: a qualitative study involving adults, teenagers and parents. Diabet Med 2019; 36:753-760. [PMID: 30575114 PMCID: PMC6510609 DOI: 10.1111/dme.13887] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/18/2018] [Indexed: 01/11/2023]
Abstract
AIMS We explored whether, how and why moving onto and using a hybrid day-and-night closed-loop system affected people's food choices and dietary practices to better understand the impact of this technology on everyday life and inform recommendations for training and support given to future users. METHODS Twenty-four adults, adolescents and parents were interviewed before commencing use of the closed-loop system and following its 3-month use. Data were analysed thematically and longitudinally. RESULTS While participants described preparing and/or eating similar meals to those consumed prior to using a closed-loop, many described feeling more normal and less burdened by diabetes in dietary situations. Individuals also noted how the use of this technology could lead to deskilling (less precise carbohydrate counting) and less healthy eating (increased snacking and portion sizes and consumption of fatty, energy-dense foods) because of the perceived ability of the system to deal with errors in carbohydrate counting and address small rises in blood glucose without a corrective dose needing to be administered. CONCLUSIONS While there may be quality-of-life benefits to using a closed-loop, individuals might benefit from additional nutritional and behavioural education to help promote healthy eating. Refresher training in carbohydrate counting may also be necessary to help ensure that users are able to undertake diabetes management in situations where the technology might fail or that they take a break from using it.
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Affiliation(s)
- J. Lawton
- Usher Institute of Population Health Sciences and InformaticsUniversity of EdinburghEdinburghUK
| | - M. Blackburn
- Usher Institute of Population Health Sciences and InformaticsUniversity of EdinburghEdinburghUK
| | - D. Rankin
- Usher Institute of Population Health Sciences and InformaticsUniversity of EdinburghEdinburghUK
| | - J. Allen
- Wellcome Trust‐MRC Institute of Metabolic ScienceUniversity of CambridgeCambridgeUK
- Department of PaediatricsUniversity of CambridgeCambridgeUK
| | | | - L. Leelarathna
- Manchester Diabetes CentreManchester University NHS Foundation Trust and University of ManchesterManchester Academic Health Science CentreManchesterUK
| | - M. Tauschmann
- Wellcome Trust‐MRC Institute of Metabolic ScienceUniversity of CambridgeCambridgeUK
- Department of PaediatricsUniversity of CambridgeCambridgeUK
| | - H. Thabit
- Manchester Diabetes CentreManchester University NHS Foundation Trust and University of ManchesterManchester Academic Health Science CentreManchesterUK
| | - M. E. Wilinska
- Wellcome Trust‐MRC Institute of Metabolic ScienceUniversity of CambridgeCambridgeUK
- Department of PaediatricsUniversity of CambridgeCambridgeUK
| | - R. Hovorka
- Wellcome Trust‐MRC Institute of Metabolic ScienceUniversity of CambridgeCambridgeUK
- Department of PaediatricsUniversity of CambridgeCambridgeUK
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6
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Nadeem F, Urwin A, Marshall M, Doughty I, Thabit H, Rutter MK, Leelarathna L. Risk factor control and outpatient attendance in young adults with diabetes. Acta Diabetol 2019; 56:597-600. [PMID: 30574663 PMCID: PMC6451702 DOI: 10.1007/s00592-018-1261-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Accepted: 11/16/2018] [Indexed: 11/29/2022]
Affiliation(s)
- F Nadeem
- School of Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - A Urwin
- Manchester Diabetes Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - M Marshall
- Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - I Doughty
- Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - H Thabit
- Manchester Diabetes Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - M K Rutter
- Manchester Diabetes Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - L Leelarathna
- Manchester Diabetes Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.
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7
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Paisley AN, Beynon J, Fullwood C, Hindle A, Alam T, Urwin A, Chapman A, Morris J, Thabit H, Rutter MK, Leelarathna L. Impact of social deprivation, demographics and centre on HbA 1c outcomes with continuous subcutaneous insulin infusion. Diabet Med 2019; 36:383-387. [PMID: 30307056 DOI: 10.1111/dme.13833] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2018] [Indexed: 01/16/2023]
Abstract
AIMS To assess the impact of social deprivation, demographics and centre on HbA1c outcomes with continuous subcutaneous insulin infusion (CSII) in adults with Type 1 diabetes. METHODS Demographic data, postcode-derived English Index of Multiple Deprivation data and 12-month average HbA1c (mmol/mol) pre- and post-CSII were collated from three diabetes centres in the north west of England, University Hospital of South Manchester (UHSM), Salford Royal Foundation Hospital (SRFT) and Manchester Royal Infirmary (MRI). Univariable and multivariable regression models explored relationships between demographics, Index of Multiple Deprivation, centre and HbA1c outcomes. RESULTS Data were available for 693 (78%) individuals (UHSM, n = 90; SRFT, n = 112; and MRI, n = 491) of whom 59% were women. Median age at CSII start was 39 (IQR 29.5-49.0) years and median diabetes duration was 20 (11-29) years. Median Index of Multiple Deprivation was 15 193 (6313-25 727). Overall median HbA1c improved from 69 to 64 mmol/mol (8.5% to 8.0%) within the first year of CSII. In multivariable analysis, higher pre-CSII HbA1c was significantly associated with higher deprivation (P = 0.036), being female (P < 0.001), and centre (MRI; P = 0.005). Following pre-CSII HbA1c adjustment, post-CSII HbA1c or HbA1c change were not related to demographic factors and deprivation, but remained significantly related to the centre; UHSM and SRFT had larger reductions in HbA1c with CSII compared with MRI [median -7.0 (-0.6%) vs. -6.0 (-0.55%) vs. -4.5 (-0.45%) mmol/mol; P = 0.005]. CONCLUSIONS Higher pre-CSII HbA1c levels were associated with higher deprivation and being female. CSII improves HbA1c irrespective of social deprivation and demographics. Significant differences in HbA1c improvements were observed between centres. Further work is warranted to explain these differences and minimize variation in clinical outcomes with CSII.
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Affiliation(s)
| | - J Beynon
- University Hospital of South Manchester, Manchester, UK
| | - C Fullwood
- Research and Innovation, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Centre for Biostatistics, Manchester, UK
| | - A Hindle
- The School of Medical Sciences, University of Manchester, Manchester, UK
| | - T Alam
- The School of Medical Sciences, University of Manchester, Manchester, UK
| | - A Urwin
- Manchester Diabetes Centre, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - A Chapman
- Manchester Diabetes Centre, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - J Morris
- Manchester Diabetes Centre, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - H Thabit
- Manchester Diabetes Centre, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK
| | - M K Rutter
- Manchester Diabetes Centre, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK
| | - L Leelarathna
- Manchester Diabetes Centre, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK
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8
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Leelarathna L, Wilmot EG. Reply to Argento. Flash forward, with caution. Diabet Med 2018; 35:1132-1134. [PMID: 29687494 DOI: 10.1111/dme.13655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- L Leelarathna
- Manchester Diabetes Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - E G Wilmot
- Derby Teaching Hospitals NHS Foundation Trust, Royal Derby Hospital, Derby, UK
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9
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Abstract
The FreeStyle Libre flash glucose monitor became available on prescription (subject to local health authority approval) in all four nations of the UK from November 2017, a watershed moment in the history of diabetes care. Calibration free, the FreeStyle Libre is a disc worn on the arm for 14 days which is designed largely to replace the recommended 4-10 painful finger-stick blood glucose tests required each day for the self-management of diabetes. This review discusses clinical data from randomized and observational studies, considers device accuracy metrics and deliberates its popularity and the potential challenges that this new device brings to diabetes care in the UK. In randomized trials, FreeStyle Libre use is associated with a reduction in hypoglycaemia and, in observational studies, improvements in HbA1c levels. User satisfaction is high and adverse events are low. Accuracy of the FreeStyle Libre is comparable to currently available real-time continuous glucose monitors in adults, children and during pregnancy; the cost of the FreeStyle Libre is lower. Glucose data can be visualized in multiple devices and platforms, and summarized in an ambulatory glucose profile to aid pattern recognition and insulin dose adjustment. There is a need for appropriate education, of both users and healthcare professionals, to harness the full benefits. Further randomized studies to assess the long-term impact on HbA1c , particularly in those with high baseline HbA1c and in specific age groups, such as adolescents and young adults, are warranted. The potential impact on complications, is yet to be realized.
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Affiliation(s)
- L Leelarathna
- Manchester Diabetes Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, University of Manchester, Manchester
| | - E G Wilmot
- Derby Teaching Hospitals NHS Foundation Trust, Royal Derby Hospital, Derby, UK
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10
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Bally L, Thabit H, Ruan Y, Mader JK, Kojzar H, Dellweg S, Benesch C, Hartnell S, Leelarathna L, Wilinska ME, Evans ML, Arnolds S, Pieber TR, Hovorka R. Bolusing frequency and amount impacts glucose control during hybrid closed-loop. Diabet Med 2018; 35:347-351. [PMID: 28755444 PMCID: PMC5788742 DOI: 10.1111/dme.13436] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/25/2017] [Indexed: 12/16/2022]
Abstract
AIM To compare bolus insulin delivery patterns during closed-loop home studies in adults with suboptimally [HbA1c 58-86 mmol/mol (7.5%-10%)] and well-controlled [58 mmol/mol (< 7.5%)] Type 1 diabetes. METHODS Retrospective analysis of daytime and night-time insulin delivery during home use of closed-loop over 4 weeks. Daytime and night-time controller effort, defined as amount of insulin delivered by closed-loop relative to usual basal insulin delivery, and daytime bolus effort, defined as total bolus insulin delivery relative to total daytime insulin delivery were compared between both cohorts. Correlation analysis was performed between individual bolus behaviour (bolus effort and frequency) and daytime controller efforts, and proportion of time spent within and below sensor glucose target range. RESULTS Individuals with suboptimally controlled Type 1 diabetes had significantly lower bolus effort (P = 0.038) and daily bolus frequency (P < 0.001) compared with those with well-controlled diabetes. Controller effort during both daytime (P = 0.007) and night-time (P = 0.005) were significantly higher for those with suboptimally controlled Type 1 diabetes. Time when glucose was within the target range (3.9-10.0 mmol/L) during daytime correlated positively with bolus effort (r = 0.37, P = 0.016) and bolus frequency (r = 0.33, P = 0.037). Time when glucose was below the target range during daytime was comparable in both groups (P = 0.36), and did not correlate significantly with bolus effort (r = 0.28, P = 0.066) or bolus frequency (r = -0.21, P = 0.19). CONCLUSION More frequent bolusing and higher proportion of insulin delivered as bolus during hybrid closed-loop use correlated positively with time glucose was in target range. This emphasises the need for user input and educational support to benefit from this novel therapeutic modality.
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Affiliation(s)
- L. Bally
- Wellcome Trust–MRC Institute of Metabolic ScienceUniversity of CambridgeCambridgeUK
- Department of Diabetes & EndocrinologyCambridge University Hospitals NHS Foundation TrustCambridgeUK
- Department of Diabetes & EndocrinologyClinical Nutrition and Metabolism, InselspitalBern University HospitalUniversity of BernBernSwitzerland
| | - H. Thabit
- Wellcome Trust–MRC Institute of Metabolic ScienceUniversity of CambridgeCambridgeUK
- Department of Diabetes & EndocrinologyCambridge University Hospitals NHS Foundation TrustCambridgeUK
| | - Y. Ruan
- Wellcome Trust–MRC Institute of Metabolic ScienceUniversity of CambridgeCambridgeUK
- Department of PaediatricsUniversity of CambridgeCambridgeUK
| | - J. K. Mader
- Department of Internal MedicineDivision of Endocrinology & DiabetologyMedical University of GrazGrazAustria
| | - H. Kojzar
- Department of Internal MedicineDivision of Endocrinology & DiabetologyMedical University of GrazGrazAustria
| | - S. Dellweg
- Profil Institut fuer Stoffwechselforschung GmbHNeussGermany
| | - C. Benesch
- Profil Institut fuer Stoffwechselforschung GmbHNeussGermany
| | - S. Hartnell
- Department of Diabetes & EndocrinologyCambridge University Hospitals NHS Foundation TrustCambridgeUK
| | - L. Leelarathna
- Central Manchester University Hospitals NHS foundation Trust and University of ManchesterManchesterUK
| | - M. E. Wilinska
- Wellcome Trust–MRC Institute of Metabolic ScienceUniversity of CambridgeCambridgeUK
- Department of PaediatricsUniversity of CambridgeCambridgeUK
| | - M. L. Evans
- Wellcome Trust–MRC Institute of Metabolic ScienceUniversity of CambridgeCambridgeUK
- Department of Diabetes & EndocrinologyCambridge University Hospitals NHS Foundation TrustCambridgeUK
| | - S. Arnolds
- Profil Institut fuer Stoffwechselforschung GmbHNeussGermany
| | - T. R. Pieber
- Department of Internal MedicineDivision of Endocrinology & DiabetologyMedical University of GrazGrazAustria
| | - R. Hovorka
- Wellcome Trust–MRC Institute of Metabolic ScienceUniversity of CambridgeCambridgeUK
- Department of PaediatricsUniversity of CambridgeCambridgeUK
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11
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Lawton J, Blackburn M, Allen J, Campbell F, Elleri D, Leelarathna L, Rankin D, Tauschmann M, Thabit H, Hovorka R. Patients' and caregivers' experiences of using continuous glucose monitoring to support diabetes self-management: qualitative study. BMC Endocr Disord 2018; 18:12. [PMID: 29458348 PMCID: PMC5819241 DOI: 10.1186/s12902-018-0239-1] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 02/08/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Continuous glucose monitoring (CGM) enables users to view real-time interstitial glucose readings and provides information on the direction and rate of change of blood glucose levels. Users can also access historical data to inform treatment decisions. While the clinical and psychological benefits of CGM are well established, little is known about how individuals use CGM to inform diabetes self-management. We explored participants' experiences of using CGM in order to provide recommendations for supporting individuals to make optimal use of this technology. METHODS In-depth interviews (n = 24) with adults, adolescents and parents who had used CGM for ≥4 weeks; data were analysed thematically. RESULTS Participants found CGM an empowering tool because they could access blood glucose data effortlessly, and trend arrows enabled them to see whether blood glucose was rising or dropping and at what speed. This predicative information aided short-term lifestyle planning and enabled individuals to take action to prevent hypoglycaemia and hyperglycaemia. Having easy access to blood glucose data on a continuous basis also allowed participants to develop a better understanding of how insulin, activity and food impacted on blood glucose. This understanding was described as motivating individuals to make dietary changes and break cycles of over-treating hypoglycaemia and hyperglycaemia. Participants also described how historical CGM data provided a more nuanced picture of blood glucose control than was possible with blood glucose self-monitoring and, hence, better information to inform changes to background insulin doses and mealtime ratios. However, while participants expressed confidence making immediate adjustments to insulin and lifestyle to address impending hypoglycaemia and hypoglycaemia, most described needing and expecting health professionals to interpret historical CGM data and determine changes to background insulin doses and mealtime ratios. While alarms could reinforce a sense of hypoglycaemic safety, some individuals expressed ambivalent views, especially those who perceived alarms as signalling personal failure to achieve optimal glycaemic control. CONCLUSIONS CGM can be an empowering and motivational tool which enables participants to fine-tune and optimize their blood glucose control. However, individuals may benefit from psycho-social education, training and/or technological support to make optimal use of CGM data and use alarms appropriately.
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Affiliation(s)
- J. Lawton
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - M. Blackburn
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - J. Allen
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | | | - D. Elleri
- Royal Hospital for Sick Children, Edinburgh, UK
| | - L. Leelarathna
- Manchester Diabetes Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - D. Rankin
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - M. Tauschmann
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - H. Thabit
- Manchester Diabetes Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - R. Hovorka
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Department of Paediatrics, University of Cambridge, Cambridge, UK
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Leelarathna L, Roberts SA, Hindle A, Markakis K, Alam T, Chapman A, Morris J, Urwin A, Jinadev P, Rutter MK. Comparison of different insulin pump makes under routine care conditions in adults with Type 1 diabetes. Diabet Med 2017. [PMID: 28636773 DOI: 10.1111/dme.13412] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
AIMS To compare long-term HbA1c changes associated with different insulin pumps during routine care in a large cohort of adults with Type 1 diabetes representative of other clinic populations. METHODS Observational, retrospective study of 508 individuals starting pump therapy between 1999 and 2014 (mean age, 40 years; 55% women; diabetes duration, 20 years; 94% Type 1 diabetes; median follow-up, 3.7 years). Mixed linear models compared covariate-adjusted HbA1c changes associated with different pump makes. RESULTS The pumps compared were: 50% Medtronic, 24% Omnipod, 14% Roche and 12% Animas. Overall HbA1c levels improved and improvements were maintained during a follow-up extending to 10 years (HbA1c : pre-continuous subcutaneous insulin infusion (pre-CSII) vs. 12 months post CSII, 71 (61, 82) vs. 66 (56, 74) mmol/mol; 8.7 (7.7, 9.6) vs. 8.2 (7.3, 8.9)%; P < 0.0001). The percentage of individuals with HbA1c ≥ 64 mmol/mol (8.0%) reduced from a pre-CSII level of 68% to 55%. After adjusting for baseline confounders, there were no between-pump differences in HbA1c lowering (P = 0.44), including a comparison of patch pumps with traditional catheter pumps (P = 0.63). There were no significant (P < 0.05) between-pump differences in HbA1c lowering in pre-specified subgroups stratified by pre-pump HbA1c , age or diabetes duration. HbA1c lowering was positively related to baseline HbA1c (P < 0.001) and diabetes duration (P = 0.017), and negatively related to the number of years of CSII use (P = 0.024). CONCLUSIONS Under routine care conditions, there were no covariate-adjusted differences in HbA1c lowering when comparing different pump makes, including a comparison of patch pumps vs. traditional catheter pumps. Therefore, the choice of CSII make should not be influenced by the desired degree of HbA1c lowering.
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Affiliation(s)
- L Leelarathna
- Manchester Diabetes Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester
| | - S A Roberts
- Centre for Biostatistics, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - A Hindle
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester
| | - K Markakis
- Manchester Diabetes Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre
| | - T Alam
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester
| | - A Chapman
- Manchester Diabetes Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre
| | - J Morris
- Manchester Diabetes Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre
| | - A Urwin
- Manchester Diabetes Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre
| | - P Jinadev
- Manchester Diabetes Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre
| | - M K Rutter
- Manchester Diabetes Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester
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13
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Elleri D, Biagioni M, Allen JM, Kumareswaran K, Leelarathna L, Caldwell K, Nodale M, Wilinska ME, Haidar A, Calhoun P, Kollman C, Jackson NC, Umpleby AM, Acerini CL, Dunger DB, Hovorka R. Safety, efficacy and glucose turnover of reduced prandial boluses during closed-loop therapy in adolescents with type 1 diabetes: a randomized clinical trial. Diabetes Obes Metab 2015; 17:1173-9. [PMID: 26257323 PMCID: PMC4832358 DOI: 10.1111/dom.12549] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 07/20/2015] [Accepted: 07/31/2015] [Indexed: 01/27/2023]
Abstract
AIMS To evaluate safety, efficacy and glucose turnover during closed-loop with meal announcement using reduced prandial insulin boluses in adolescents with type 1 diabetes (T1D). METHODS We conducted a randomized crossover study comparing closed-loop therapy with standard prandial insulin boluses versus closed-loop therapy with prandial boluses reduced by 25%. Eight adolescents with T1D [3 males; mean (standard deviation) age 15.9 (1.5) years, glycated haemoglobin 74 (17) mmol/mol; median (interquartile range) total daily dose 0.9 (0.7, 1.1) IU/kg/day] were studied on two 36-h-long visits. In random order, subjects received closed-loop therapy with either standard or reduced insulin boluses administered with main meals (50-80 g carbohydrates) but not with snacks (15-30 g carbohydrates). Stable-label tracer dilution methodology measured total glucose appearance (Ra_total) and glucose disposal (Rd). RESULTS The median (interquartile range) time spent in target (3.9-10 mmol/l) was similar between the two interventions [74 (66, 84)% vs 80 (65, 96)%; p = 0.87] as was time spent above 10 mmol/l [21.8 (16.3, 33.5)% vs 18.0 (4.1, 34.2)%; p = 0.87] and below 3.9 mmol/l [0 (0, 1.5)% vs 0 (0, 1.8)%; p = 0.88]. Mean plasma glucose was identical during the two interventions [8.4 (0.9) mmol/l; p = 0.98]. Hypoglycaemia occurred once 1.5 h post-meal during closed-loop therapy with standard bolus. Overall insulin delivery was lower with reduced prandial boluses [61.9 (55.2, 75.0) vs 72.5 (63.6, 80.3) IU; p = 0.01] and resulted in lower mean plasma insulin concentration [186 (171, 260) vs 252 (198, 336) pmol/l; p = 0.002]. Lower plasma insulin was also documented overnight [160 (136, 192) vs 191 (133, 252) pmol/l; p = 0.01, pooled nights]. Ra_total was similar [26.3 (21.9, 28.0) vs 25.4 (21.0, 29.2) µmol/kg/min; p = 0.19] during the two interventions as was Rd [25.8 (21.0, 26.9) vs 25.2 (21.2, 28.8) µmol/kg/min; p = 0.46]. CONCLUSIONS A 25% reduction in prandial boluses during closed-loop therapy maintains similar glucose control in adolescents with T1D whilst lowering overall plasma insulin levels. It remains unclear whether closed-loop therapy with a 25% reduction in prandial boluses would prevent postprandial hypoglycaemia.
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Affiliation(s)
- D Elleri
- Department of Paediatrics, University of Cambridge, Cambridge, UK
- Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
| | - M Biagioni
- Department of Paediatrics, University of Cambridge, Cambridge, UK
- Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
| | - J M Allen
- Department of Paediatrics, University of Cambridge, Cambridge, UK
- Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
| | - K Kumareswaran
- Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
| | - L Leelarathna
- Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
| | - K Caldwell
- Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
| | - M Nodale
- Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
| | - M E Wilinska
- Department of Paediatrics, University of Cambridge, Cambridge, UK
- Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
| | - A Haidar
- Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
| | - P Calhoun
- The Jaeb Center for Health Research, Tampa, FL, USA
| | - C Kollman
- The Jaeb Center for Health Research, Tampa, FL, USA
| | - N C Jackson
- Diabetes and Metabolic Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - A M Umpleby
- Diabetes and Metabolic Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - C L Acerini
- Department of Paediatrics, University of Cambridge, Cambridge, UK
- Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
| | - D B Dunger
- Department of Paediatrics, University of Cambridge, Cambridge, UK
- Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
| | - R Hovorka
- Department of Paediatrics, University of Cambridge, Cambridge, UK
- Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
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14
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Thabit H, Tauschmann M, Allen JM, Leelarathna L, Hartnell S, Wilinska ME, Acerini CL, Dellweg S, Benesch C, Heinemann L, Mader JK, Holzer M, Kojzar H, Exall J, Yong J, Pichierri J, Barnard KD, Kollman C, Cheng P, Hindmarsh PC, Campbell FM, Arnolds S, Pieber TR, Evans ML, Dunger DB, Hovorka R. Home Use of an Artificial Beta Cell in Type 1 Diabetes. N Engl J Med 2015; 373:2129-2140. [PMID: 26379095 PMCID: PMC4697362 DOI: 10.1056/nejmoa1509351] [Citation(s) in RCA: 315] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The feasibility, safety, and efficacy of prolonged use of an artificial beta cell (closed-loop insulin-delivery system) in the home setting have not been established. METHODS In two multicenter, crossover, randomized, controlled studies conducted under free-living home conditions, we compared closed-loop insulin delivery with sensor-augmented pump therapy in 58 patients with type 1 diabetes. The closed-loop system was used day and night by 33 adults and overnight by 25 children and adolescents. Participants used the closed-loop system for a 12-week period and sensor-augmented pump therapy (control) for a similar period. The primary end point was the proportion of time that the glucose level was between 70 mg and 180 mg per deciliter for adults and between 70 mg and 145 mg per deciliter for children and adolescents. RESULTS Among adults, the proportion of time that the glucose level was in the target range was 11.0 percentage points (95% confidence interval [CI], 8.1 to 13.8) greater with the use of the closed-loop system day and night than with control therapy (P<0.001). The mean glucose level was lower during the closed-loop phase than during the control phase (difference, -11 mg per deciliter; 95% CI, -17 to -6; P<0.001), as were the area under the curve for the period when the glucose level was less than 63 mg per deciliter (39% lower; 95% CI, 24 to 51; P<0.001) and the mean glycated hemoglobin level (difference, -0.3%; 95% CI, -0.5 to -0.1; P=0.002). Among children and adolescents, the proportion of time with the nighttime glucose level in the target range was higher during the closed-loop phase than during the control phase (by 24.7 percentage points; 95% CI, 20.6 to 28.7; P<0.001), and the mean nighttime glucose level was lower (difference, -29 mg per deciliter; 95% CI, -39 to -20; P<0.001). The area under the curve for the period in which the day-and-night glucose levels were less than 63 mg per deciliter was lower by 42% (95% CI, 4 to 65; P=0.03). Three severe hypoglycemic episodes occurred during the closed-loop phase when the closed-loop system was not in use. CONCLUSIONS Among patients with type 1 diabetes, 12-week use of a closed-loop system, as compared with sensor-augmented pump therapy, improved glucose control, reduced hypoglycemia, and, in adults, resulted in a lower glycated hemoglobin level. (Funded by the JDRF and others; AP@home04 and APCam08 ClinicalTrials.gov numbers, NCT01961622 and NCT01778348.).
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Thabit H, Elleri D, Leelarathna L, Allen JM, Lubina-Solomon A, Stadler M, Walkinshaw E, Iqbal A, Choudhary P, Wilinska ME, Barnard KD, Heller SR, Amiel SA, Evans ML, Dunger DB, Hovorka R. Unsupervised home use of an overnight closed-loop system over 3-4 weeks: a pooled analysis of randomized controlled studies in adults and adolescents with type 1 diabetes. Diabetes Obes Metab 2015; 17:452-8. [PMID: 25492378 PMCID: PMC4510702 DOI: 10.1111/dom.12427] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 12/01/2014] [Accepted: 12/04/2014] [Indexed: 12/25/2022]
Abstract
AIMS To compare overnight closed-loop and sensor-augmented pump therapy in patients with type 1 diabetes by combining data collected during free-living unsupervised randomized crossover home studies. METHODS A total of 40 participants with type 1 diabetes, of whom 24 were adults [mean ± standard deviation (s.d.) age 43 ± 12 years and glycated haemoglobin (HbA1c) 8.0 ± 0.9%] and 16 were adolescents (mean ± s.d. age 15.6 ± 3.6 years and HbA1c 8.1 ± 0.8%), underwent two periods of sensor-augmented pump therapy in the home setting, in combination with or without an overnight closed-loop insulin delivery system that uses a model predictive control algorithm to direct insulin delivery. The order of the two interventions was random; each period lasted 4 weeks in adults and 3 weeks in adolescents. The primary outcome was time during which sensor glucose readings were in the target range of 3.9-8.0 mmol/l. RESULTS The proportion of time when sensor glucose was in the target range (3.9-8.0 mmol/l) overnight (between 24:00 and 08:00 hours) was 18.5% greater during closed-loop insulin delivery than during sensor-augmented therapy (p < 0.001). Closed-loop therapy significantly reduced mean overnight glucose levels by 0.9 mmol/l (p < 0.001), with no difference in glycaemic variability, as measured by the standard deviation of sensor glucose. Time spent above the target range was reduced (p = 0.001), as was time spent in hypoglycaemia (<3.9 mmol/l; p = 0.014) during closed-loop therapy. Lower mean overnight glucose levels during closed-loop therapy were brought about by increased overnight insulin delivery (p < 0.001) without changes to the total daily delivery (p = 0.84). CONCLUSION Overnight closed-loop insulin therapy at home in adults and adolescents with type 1 diabetes is feasible, showing improvements in glucose control and reducing the risk of nocturnal hypoglycaemia.
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Affiliation(s)
- H Thabit
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
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Thabit H, Kumareswaran K, Haidar A, Leelarathna L, Caldwell K, Elleri D, Allen JM, Nodale M, Wilinska ME, Jackson NC, Umpleby AM, Evans ML, Hovorka R. Glucose turnover after replacement of usual therapy by insulin in insulin-naive type 2 diabetes subjects. J Clin Endocrinol Metab 2014; 99:2225-32. [PMID: 24606105 DOI: 10.1210/jc.2013-4519] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
CONTEXT Discontinuation of anti-hyperglycemic oral agents and initiation of insulin is recommended in certain clinical situations for inpatients with type 2 diabetes (T2D). The effects on glucose turnover when these agents are acutely withdrawn are poorly understood and may be of importance when insulin therapy is initiated. OBJECTIVE Our objective was to investigate alterations in glucose turnover after acute withdrawal of noninsulin therapy. DESIGN AND SETTING This was a randomized crossover study at a clinical research facility. PARTICIPANTS Participants included 12 insulin-naive subjects with T2D. METHODS Subjects attended two 24-hour visits. Standard therapy was discontinued and replaced by closed-loop insulin delivery during the intervention visit. Usual anti-hyperglycemic therapy was continued during the control visit. Systemic glucose appearance (Ra) and glucose disposal (Rd) were measured using a tracer dilution technique with iv [6,6-(2)H2]glucose. RESULTS Plasma glucose profiles during both visits were comparable (P = .48). Glucose Ra increased during the day (21.4 [19.5, 23.5] vs 18.6 [17.0, 21.6) μmol/kg/min, P = .019) and decreased overnight (9.7 [8.5, 11.4] vs 11.6 [10.3, 12.9] μmol/kg/min, P = .004) when the usual therapy was discontinued and replaced with insulin. Increased daytime glucose Rd (21.2 [19.4, 23.9] vs 18.8 [18.3, 21.7] μmol/kg/min, P = .002) and decreased overnight Rd (10.4 [9.1, 12.0] vs 11.8 [10.7, 13.7] μmol/kg/min, P = .005) were observed when the usual therapy was discontinued, whereas daytime peripheral insulin sensitivity was reduced (47.8 [24.8, 66.1] vs 62.5 [34.8, 75.8] nmol/kg/min per pmol/L, P = .034). CONCLUSION In T2D, acute discontinuation of anti-hyperglycemic therapy and replacement with insulin increases postprandial Ra and reduces peripheral insulin sensitivity. Insulin dose initiation may need to compensate for these alterations.
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Affiliation(s)
- H Thabit
- Metabolic Research Laboratories (H.T., K.K., L.L., K.C., D.E., J.M.A., M.N., M.E.W., M.L.E., R.H.), Wellcome Trust-Medical Research Council Institute of Metabolic Science, and Department of Paediatrics (D.E., J.M.A., M.E.W., R.H.), University of Cambridge, Cambridge CB2 0QQ, United Kingdom; Centre for Intelligent Machines (A.H.), McGill University, Montreal, Quebec H3A 0E9, Canada; and Postgraduate Medical School (N.C.J., A.M.U.), University of Surrey, Guildford GU2 7TE, United Kingdom
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Little SA, Leelarathna L, Barendse SM, Walkinshaw E, Tan HK, Lubina Solomon A, de Zoysa N, Rogers H, Choudhary P, Amiel SA, Heller SR, Evans M, Flanagan D, Speight J, Shaw JAM. Severe hypoglycaemia in type 1 diabetes mellitus: underlying drivers and potential strategies for successful prevention. Diabetes Metab Res Rev 2014; 30:175-90. [PMID: 24185859 DOI: 10.1002/dmrr.2492] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2013] [Revised: 10/23/2013] [Accepted: 10/25/2013] [Indexed: 02/03/2023]
Abstract
Hypoglycaemia remains an over-riding factor limiting optimal glycaemic control in type 1 diabetes. Severe hypoglycaemia is prevalent in almost half of those with long-duration diabetes and is one of the most feared diabetes-related complications. In this review, we present an overview of the increasing body of literature seeking to elucidate the underlying pathophysiology of severe hypoglycaemia and the limited evidence behind the strategies employed to prevent episodes. Drivers of severe hypoglycaemia including impaired counter-regulation, hypoglycaemia-associated autonomic failure, psychosocial and behavioural factors and neuroimaging correlates are discussed. Treatment strategies encompassing structured education, insulin analogue regimens, continuous subcutaneous insulin infusion pumps, continuous glucose sensing and beta-cell replacement therapies have been employed, yet there is little randomized controlled trial evidence demonstrating effectiveness of new technologies in reducing severe hypoglycaemia. Optimally designed interventional trials evaluating these existing technologies and using modern methods of teaching patients flexible insulin use within structured education programmes with the specific goal of preventing severe hypoglycaemia are required. Individuals at high risk need to be monitored with meticulous collection of data on awareness, as well as frequency and severity of all hypoglycaemic episodes.
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Affiliation(s)
- S A Little
- Institute of Cellular Medicine, Newcastle University, Newcastle, UK
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18
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Elleri D, Allen JM, Harris J, Kumareswaran K, Nodale M, Leelarathna L, Acerini CL, Haidar A, Wilinska ME, Jackson N, Umpleby AM, Evans ML, Dunger DB, Hovorka R. Absorption patterns of meals containing complex carbohydrates in type 1 diabetes. Diabetologia 2013; 56:1108-17. [PMID: 23435829 DOI: 10.1007/s00125-013-2852-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [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] [Received: 10/28/2012] [Accepted: 01/21/2013] [Indexed: 02/07/2023]
Abstract
AIMS/HYPOTHESIS Successful postprandial glycaemia management requires understanding of absorption patterns after meals containing variable complex carbohydrates. We studied eight young participants with type 1 diabetes to investigate a large low-glycaemic-load (LG) meal and another eight participants to investigate a high-glycaemic-load (HG) meal matched for carbohydrates (121 g). METHODS On Visit 1, participants consumed an evening meal. On follow-up Visit 2, a variable-target glucose clamp was performed to reproduce glucose and insulin levels from Visit 1. Adopting stable-label tracer dilution methodology, we measured endogenous glucose production on Visit 2 and subtracted it from total glucose appearance measured on Visit 1 to obtain meal-attributable glucose appearance. RESULTS After the LG meal, 25%, 50% and 75% of cumulative glucose appearance was at 88 ± 21, 175 ± 39 and 270 ± 54 min (mean ± SD), whereas glucose from the HG meal appeared significantly faster at 56 ± 12, 100 ± 25 and 153 ± 39 min (p < 0.001 to 0.003), and resulted in a 50% higher peak appearance (p < 0.001). Higher apparent bioavailability by 15% (p = 0.037) was observed after the LG meal. We documented a 20 min deceleration of dietary mixed carbohydrates compared with dietary glucose for the HG meal and a twofold deceleration for the LG meal. CONCLUSIONS/INTERPRETATION Absorption patterns may be influenced by glycaemic load and/or meal composition, affecting optimum prandial insulin dosing in type 1 diabetes.
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Affiliation(s)
- D Elleri
- University of Cambridge Metabolic Research Laboratories and NIHR Cambridge Biomedical Research Centre, Institute of Metabolic Science, Box 289, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
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Leelarathna L, English S, Thabit H, Caldwell K, Allen J, Kumareswaran K, Wilinska M, Nodale M, Mangat J, Evans M, Burnstein R, Hovorka R. Continuous glucose monitoring in critically ill adults: comparison of two different calibration protocols. Crit Care 2013. [PMCID: PMC3642847 DOI: 10.1186/cc12397] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Leelarathna L, Ward C, Davenport K, Donald S, Housden A, Finucane FM, Evans M. Reduced insulin requirements during participation in the DAFNE (dose adjustment for normal eating) structured education programme. Diabetes Res Clin Pract 2011; 92:e34-6. [PMID: 21269721 DOI: 10.1016/j.diabres.2011.01.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Revised: 12/19/2010] [Accepted: 01/04/2011] [Indexed: 10/18/2022]
Abstract
Dose adjustment for normal eating (DAFNE) is a well-established structured education programme for patients with type 1 diabetes. We conducted a retrospective analysis of insulin dose changes associated with DAFNE training. Our results show significant reductions in total, quick acting and basal insulin doses in patients undergoing DAFNE training.
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Affiliation(s)
- L Leelarathna
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge & Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
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Leelarathna L, Karalliede J, Kosky C, D'Cruz D, Carroll P. Pulmonary haemorrhage and vasculitis in Graves' disease. Breathe (Sheff) 2009. [DOI: 10.1183/18106838.0602.169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Abstract
Thomas Addison was first to describe adrenocortical failure in 1855. Despite advances in the treatment of this condition, the diagnosis is still often delayed and sometimes missed with potentially fatal consequences. From the same institution where Thomas Addison performed his original autopsy studies, we present four recent cases highlighting the wide clinical spectrum and discuss how modern biochemical and immunological tests could be utilized in early diagnosis and aetiological classification.
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Affiliation(s)
- L Leelarathna
- Department of Endocrinology, Guy's Hospital, London SE1 9RT, UK.
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