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Utzschneider KM, Younes N, Butera NM, Balasubramanyam A, Bergenstal RM, Barzilay J, DeSouza C, DeFronzo RA, Elasy T, Krakoff J, Kahn SE, Rasouli N, Valencia WM, Sivitz WI. Impact of Insulin Sensitivity and β-Cell Function Over Time on Glycemic Outcomes in the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE): Differential Treatment Effects of Dual Therapy. Diabetes Care 2024; 47:571-579. [PMID: 38190619 PMCID: PMC10973903 DOI: 10.2337/dc23-1059] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 06/08/2023] [Accepted: 10/10/2023] [Indexed: 01/10/2024]
Abstract
OBJECTIVE To compare the effects of insulin sensitivity and β-cell function over time on HbA1c and durability of glycemic control in response to dual therapy. RESEARCH DESIGN AND METHODS GRADE participants were randomized to glimepiride (n = 1,254), liraglutide (n = 1,262), or sitagliptin (n = 1,268) added to baseline metformin and followed for mean ± SD 5.0 ± 1.3 years, with HbA1c assessed quarterly and oral glucose tolerance tests at baseline, 1, 3, and 5 years. We related time-varying insulin sensitivity (HOMA 2 of insulin sensitivity [HOMA2-%S]) and early (0-30 min) and total (0-120 min) C-peptide (CP) responses to changes in HbA1c and glycemic failure (primary outcome HbA1c ≥7% [53 mmol/mol] and secondary outcome HbA1c >7.5% [58 mmol/mol]) and examined differential treatment responses. RESULTS Higher HOMA2-%S was associated with greater initial HbA1c lowering (3 months) but not subsequent HbA1c rise. Greater CP responses were associated with a greater initial treatment response and slower subsequent HbA1c rise. Higher HOMA2-%S and CP responses were each associated with lower risk of primary and secondary outcomes. These associations differed by treatment. In the sitagliptin group, HOMA2-%S and CP responses had greater impact on initial HbA1c reduction (test of heterogeneity, P = 0.009 HOMA2-%S, P = 0.018 early CP, P = 0.001 total CP) and risk of primary outcome (P = 0.005 HOMA2-%S, P = 0.11 early CP, P = 0.025 total CP) but lesser impact on HbA1c rise (P = 0.175 HOMA2-%S, P = 0.006 early CP, P < 0.001 total CP) in comparisons with the glimepiride and liraglutide groups. There were no differential treatment effects on secondary outcome. CONCLUSIONS Insulin sensitivity and β-cell function affected treatment outcomes irrespective of drug assignment, with greater impact in the sitagliptin group on initial (short-term) HbA1c response in comparison with the glimepiride and liraglutide groups.
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Affiliation(s)
- Kristina M. Utzschneider
- VA Puget Sound Health Care System and Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, University of Washington, Seattle, WA
| | - Naji Younes
- The Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Rockville, MD
| | - Nicole M. Butera
- The Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Rockville, MD
| | - Ashok Balasubramanyam
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX
| | | | - Joshua Barzilay
- Department of Endocrinology, Kaiser Permanente of Georgia, Duluth, GA
| | - Cyrus DeSouza
- Division of Diabetes, Endocrinology and Metabolism, University of Nebraska and Omaha VA Medical Center, Omaha, NE
| | - Ralph A. DeFronzo
- Diabetes Division, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Tom Elasy
- Vanderbilt University Medical Center, Nashville, TN
| | - Jonathan Krakoff
- Division of General Internal Medicine and Public Health, Southwestern American Indian Center, Phoenix, AZ
| | - Steven E. Kahn
- VA Puget Sound Health Care System and Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, University of Washington, Seattle, WA
| | - Neda Rasouli
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado School of Medicine, and VA Eastern Colorado Health Care System, Aurora, CO
| | - Willy M. Valencia
- Geriatric Research Education and Clinical Center, Bruce W. Carter Department of Veterans Affairs Medical Center, Miami, FL
- Department of Public Health Sciences, University of Miami, Miami, FL
- Robert Stempel College of Public Health & Social Work, Florida International University, Miami, FL
- Endocrinology & Metabolism Institute, Cleveland Clinic, Cleveland, OH
| | - William I. Sivitz
- Department of Internal Medicine, Endocrinology and Metabolism, University of Iowa, Iowa City, IA
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2
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Warren ML, Bergenstal RM, Hager MR, Bashan E, Hodish I. A scalable application of Artificial Intelligence-Driven Insulin Titration Program to transform Type 2 Diabetes Management. Diabetes Technol Ther 2024. [PMID: 38452101 DOI: 10.1089/dia.2024.0041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
BACKGROUND Despite new pharmacotherapy, most patients with long-term Type 2 Diabetes are still hyperglycemic. This could have been solved by insulin with its unlimited potential efficacy, but its dynamic physiology demands frequent titrations which are overdemanding. This report provides a real-life account for a scalable transformation of diabetes care in a community-based endocrinology center by harnessing AI-based autonomous insulin titration. METHODS The center embedded the d-Nav® technology and its dedicated clinical support. Reported outcomes include treatment efficacy/safety in the first 600 patients and use of cardiorenal-risk reduction pharmacotherapy. FINDINGS Patients used d-Nav for 8.2±3.0 months with 82% retention. Age was 67.1±11.5 years and duration of diabetes was 19.8±11.0 years. During the last 3 years before d-Nav, HbA1c had been overall higher than 8% and at the beginning of the program it was as high as 8.6%±2.1% with 29.3% of the patients with HbA1c>9%. With d-Nav, HbA1c decreased to 7.3%±1.2% with 5.7% of patients with HbA1c>9%. During the first 3 months, d-Nav reduced total daily dose of insulin in 1 of every 5 patients due to relatively low glucose levels to minimize the risk of hypoglycemia. GLP-1 or dual GLP-1 and GIP receptor agonists were prescribed in about a half of the patients and SGLT2 inhibitor in a third. The frequency of hypoglycemia (<54mg/dl) was 0.4±0.6/month and severe hypoglycemia 1.7/100-patient-years. INTERPRETATION The use of d-Nav allowed for improvement in overall diabetes management with appropriate use of both insulin and non-insulin pharmacologic agents in a scalable way.
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Affiliation(s)
- Mark Lowe Warren
- Physicians East, PA, Endocrinology metabolism, 1006 WH Smith Boulevard Greenville, Greenville, North Carolina, United States, 27834;
| | - Richard M Bergenstal
- International Diabetes Center, 3800 Park Nicollet Blvd, Minneapolis , Minnesota, United States, 55416;
| | - Matthew R Hager
- Physicians East, PA, Endocrinology metabolism, Greenville, North Carolina, United States;
| | - Eran Bashan
- Hygieia Inc., Ann Arbor, Michigan, United States;
| | - Israel Hodish
- University of Michigan, Internal Medicine, Division of Metabolism, Endocrinology & Diabetes, 1150 W. Medical Center Drive, Ann Arbor, Michigan, United States, 48109-0678;
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Carlson AL, Graham TE, Akturk HK, Liljenquist DR, Bergenstal RM, Sulik B, Shah VN, Sulik M, Zhao P, Briggs P, Sassan-Katchalski R, Pinsker JE. Control-IQ Technology Use in Individuals With High Insulin Requirements: Results From the Multicenter Higher-IQ Trial. J Diabetes Sci Technol 2024:19322968241234072. [PMID: 38439656 DOI: 10.1177/19322968241234072] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Abstract
BACKGROUND Control-IQ technology version 1.5 allows for a wider range of weight and total daily insulin (TDI) entry, in addition to other changes to enhance performance for users with high basal rates. This study evaluated the safety and performance of the updated Control-IQ system for users with basal rates >3 units/h and high TDI in a multicenter, single arm, prospective study. METHODS Adults with type 1 diabetes (T1D) using continuous subcutaneous insulin infusion (CSII) and at least one basal rate over 3 units/h (N = 34, mean age = 39.9 years, 41.2% female, diabetes duration = 21.8 years) used the t:slim X2 insulin pump with Control-IQ technology version 1.5 for 13 weeks. Primary outcome was safety events (severe hypoglycemia and diabetic ketoacidosis (DKA)). Central laboratory hemoglobin A1c (HbA1c) was measured at system initiation and 13 weeks. Participants continued using glucagon-like peptide-1 (GLP-1) receptor agonists, sodium-glucose transport protein 2 (SGLT-2) inhibitors, or other medications for glycemic control and/or weight loss if on a stable dose. RESULTS All 34 participants completed the study. Fifteen participants used a basal rate >3 units/h for all 24 hours of the day. Nine participants used >300 units TDI on at least one day during the study. There were no severe hypoglycemia or DKA events. Time in range 70-180 mg/dL was 64.8% over the 13 weeks, with 1.0% time <70 mg/dL. Hemoglobin A1c decreased from 7.69% at baseline to 6.87% at 13 weeks (-0.82%, P < .001). CONCLUSIONS Control-IQ technology version 1.5, with wider range of weight and TDI input and enhancements for users with high insulin requirements, was safe in individuals with T1D in this study.
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Affiliation(s)
- Anders L Carlson
- International Diabetes Center, HealthPartners Institute, Minneapolis, MN, USA
| | | | | | | | | | - Becky Sulik
- Rocky Mountain Diabetes Center, Idaho Falls, ID, USA
| | - Viral N Shah
- Barbara Davis Center for Diabetes, Aurora, CO, USA
| | - Mark Sulik
- Rocky Mountain Diabetes Center, Idaho Falls, ID, USA
| | - Peter Zhao
- Tandem Diabetes Care, San Diego, CA, USA
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Dunn TC, Ajjan RA, Bergenstal RM, Xu Y. Is It Time to Move Beyond TIR to TITR? Real-World Data from Over 20,000 Users of Continuous Glucose Monitoring in Patients with Type 1 and Type 2 Diabetes. Diabetes Technol Ther 2024; 26:203-210. [PMID: 38444315 PMCID: PMC10877396 DOI: 10.1089/dia.2023.0565] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
The growing use of continuous glucose monitoring (CGM) has been supported by expert consensus and clinical guidelines on glycemic management in diabetes with time in range (TIR 70-180 mg/dL) representing a key CGM-derived glucose metric. Time in tight range (TITR) has also been proposed for clinical use, spanning largely normal glucose levels of 70-140 mg/dL. However, keeping such narrow glucose ranges can be challenging, and understanding the factors modulating TITR can help achieve these tight glycemic targets. Our real-life study aimed to evaluate the relationship between average glucose (AG) and TIR/TITR in a large cohort (n = 22,006) of CGM users, divided into four groups: self-identified as having type 1 diabetes (T1D) treated with insulin using multiple daily injections (MDI) or pumps; type 2 diabetes (T2D) on MDI or insulin pumps; T2D on basal insulin only; and T2D not on insulin treatment. The T2D groups, regardless of treatment type, displayed the highest TIR and TITR values, associated with lowest glycemic variability measured as glucose coefficient of variation (CV; 23-30%). The T1D group showed the lowest TIR and TITR, associated with the highest CVs (36-38%). Overall, higher CV was associated with lower TIR and TITR for AG values below 180 and 140 mg/dL, respectively, with the reverse holding true for AG values above these thresholds. The discordance between AG and TIR/TITR was less pronounced in T2D compared with T1D, attributed to lower CV in the former group. It was also observed that TITR has advantages over TIR for assessing glycemia status and progress toward more stringent A1C, particularly when approaching normal glucose levels. The data detail how CV affects the AG relationship with TIR/TITR, which has implications for CGM interpretation. In many instances TITR, rather than TIR, may be preferable to employ once AG falls below 140 mg/dL and near-normal glucose levels are required clinically.
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Affiliation(s)
- Timothy C. Dunn
- Clinical Affairs, Abbott Diabetes Care, Alameda, California, USA
| | - Ramzi A. Ajjan
- The LIGHT Laboratories, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Richard M. Bergenstal
- International Diabetes Center, HealthPartners Institute, Minneapolis, Minnesota, USA
| | - Yongjin Xu
- Clinical Affairs, Abbott Diabetes Care, Alameda, California, USA
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5
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Martens TW, Simonson GD, Carlson AL, Bergenstal RM. Primary Care and Diabetes Technologies and Treatments. Diabetes Technol Ther 2024; 26:S153-S171. [PMID: 38441457 DOI: 10.1089/dia.2024.2510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Indexed: 03/07/2024]
Affiliation(s)
- Thomas W Martens
- International Diabetes Center, HealthPartners Institute, Minneapolis, MN, USA
- Department of Internal Medicine, Park Nicollet Clinic, Brooklyn Center, MN, USA
| | - Gregg D Simonson
- International Diabetes Center, HealthPartners Institute, Minneapolis, MN, USA
| | - Anders L Carlson
- International Diabetes Center, HealthPartners Institute, Minneapolis, MN, USA
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6
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Beck RW, Raghinaru D, Calhoun P, Bergenstal RM. A Comparison of Continuous Glucose Monitoring-Measured Time-in-Range 70-180 mg/dL Versus Time-in-Tight-Range 70-140 mg/dL. Diabetes Technol Ther 2024; 26:151-155. [PMID: 37870460 DOI: 10.1089/dia.2023.0380] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
Objective: To evaluate the relationship between continuous glucose monitoring (CGM)-measured time-in-range 70-180 mg/dL (TIR) and time-in-tight-range 70-140 mg/dL (TITR). Methods: TIR and TITR were calculated from CGM data collected using blinded or unblinded Dexcom sensors from 9 studies with 912 participants with type 1 diabetes (T1D) and 2 studies with 184 participants with type 2 diabetes (T2D). The TIR-TITR relationship was assessed overall and stratified by coefficient of variation (CV) and by time below range <70 mg/dL (TBR). Results: The correlation between TIR and TITR was 0.94. TITR was higher for a given TIR for T2D compared with T1D. However, after adjusting for the differences in CV or TBR, both of which were higher with T1D than T2D, the differences were minimized. The TIR-TITR relationship was nonlinear, with a higher ratio of TITR:TIR observed as TIR increased ranging from 0.42 when TIR was 20% to 0.66 when TIR was 80%. Similarly, as TITR increased, the ratio of TIR:TITR decreased, varying from 2.6 with TITR of 10% to 1.3 for TITR of 70%. The TIR-TITR relationship varied according to CV and TBR, such that the higher the CV or higher the amount of TBR the greater was TITR for a given TIR. Conclusions: TIR and TITR are highly correlated, although the relationship is nonlinear. With knowledge of TIR, TITR can be estimated with reasonable precision.
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Affiliation(s)
- Roy W Beck
- JAEB Center for Health Research, Tampa, Florida, USA
| | - Dan Raghinaru
- JAEB Center for Health Research, Tampa, Florida, USA
| | - Peter Calhoun
- JAEB Center for Health Research, Tampa, Florida, USA
| | - Richard M Bergenstal
- International Diabetes Center, HealthPartners Institute, Minneapolis, Minnesota, USA
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7
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Buckingham BA, Bergenstal RM. Decreasing the Burden of Carbohydrate Counting and Meal Announcement with Automated Insulin Delivery, Meal Recognition, and Autocorrection Doses: A Case Study. Diabetes Technol Ther 2024; 26:97-101. [PMID: 38377320 DOI: 10.1089/dia.2023.0505] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
The use of automated insulin delivery (AID) has led to a decrease in the burden of diabetes, allowing for better sleep, decreased anxiety about hypoglycemia, and automatic corrections doses, and meal recognition algorithms have provided "forgiveness" for imprecise carbohydrate (CHO) entries and missed or late meal boluses. We provide a case report and review of the current literature assessing the effect of AID on the burden of meal bolus. The case also demonstrates how sensor and pump data provide insight into insulin bolus behavior, and access to integrated cloud-based data has allowed for virtual patient visits. Glucose sensor metrics provides time in range and time below range, and the sensor-derived glucose management indicator provides an assessment of the long-term risk of complications when a laboratory glycated hemoglobin is not available.
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Affiliation(s)
- Bruce A Buckingham
- Division of Pediatric Endocrinology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Richard M Bergenstal
- International Diabetes Center, HealthPartners Institute, Bloomington, Minnesota, USA
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8
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Xu Y, Dunn TC, Bergenstal RM, Cheng A, Dabiri Y, Ajjan RA. Time in Range, Time in Tight Range, and Average Glucose Relationships Are Modulated by Glycemic Variability: Identification of a Glucose Distribution Model Connecting Glycemic Parameters Using Real-World Data. Diabetes Technol Ther 2024. [PMID: 38315505 DOI: 10.1089/dia.2023.0564] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
Background: Time in range (TIR), time in tight range (TITR), and average glucose (AG) are used to adjust glycemic therapies in diabetes. However, TIR/TITR and AG can show a disconnect, which may create management difficulties. We aimed to understand the factors influencing the relationships between these glycemic markers. Materials and Methods: Real-world glucose data were collected from self-identified diabetes type 1 and type 2 diabetes (T1D and T2D) individuals using flash continuous glucose monitoring (FCGM). The effects of glycemic variability, assessed as glucose coefficient of variation (CV), on the relationship between AG and TIR/TITR were investigated together with the best-fit glucose distribution model that addresses these relationships. Results: Of 29,164 FCGM users (16,367 T1D, 11,061 T2D, and 1736 others), 38,259 glucose readings/individual were available. Comparing low and high CV tertiles, TIR at AG of 150 mg/dL varied from 80% ± 5.6% to 62% ± 6.8%, respectively (P < 0.001), while TITR at AG of 130 mg/dL varied from 65% ± 7.5% to 49% ± 7.0%, respectively (P < 0.001). In contrast, higher CV was associated with increased TIR and TITR at AG levels outside the upper limit of these ranges. Gamma distribution was superior to six other models at explaining AG and TIR/TITR interactions and demonstrated nonlinear interplay between these metrics. Conclusions: The gamma model accurately predicts interactions between CGM-derived glycemic metrics and reveals that glycemic variability can significantly influence the relationship between AG and TIR with opposing effects according to AG levels. Our findings potentially help with clinical diabetes management, particularly when AG and TIR appear mismatched.
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Affiliation(s)
- Yongjin Xu
- Abbott Diabetes Care, Alameda, California, USA
| | | | - Richard M Bergenstal
- International Diabetes Center, HealthPartners Institute, Minneapolis, Minnesota, USA
| | - Alan Cheng
- Abbott Diabetes Care, Alameda, California, USA
| | | | - Ramzi A Ajjan
- The LIGHT Laboratories, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
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9
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Criego AB, Carlson AL, Brown SA, Forlenza GP, Bode BW, Levy CJ, Hansen DW, Hirsch IB, Bergenstal RM, Sherr JL, Mehta SN, Laffel LM, Shah VN, Bhargava A, Weinstock RS, MacLeish SA, DeSalvo DJ, Jones TC, Aleppo G, Buckingham BA, Ly TT. Two Years with a Tubeless Automated Insulin Delivery System: A Single-Arm Multicenter Trial in Children, Adolescents, and Adults with Type 1 Diabetes. Diabetes Technol Ther 2024; 26:11-23. [PMID: 37850941 PMCID: PMC10794844 DOI: 10.1089/dia.2023.0364] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
Background: The Omnipod® 5 Automated Insulin Delivery (AID) System was shown to be safe and effective following 3 months of use in people with type 1 diabetes (T1D); however, data on the durability of these results are limited. This study evaluated the long-term safety and effectiveness of Omnipod 5 use in people with T1D during up to 2 years of use. Materials and Methods: After a 3-month single-arm, multicenter, pivotal trial in children (6-13.9 years) and adolescents/adults (14-70 years), participants could continue system use in an extension phase. HbA1c was measured every 3 months for up to 15 months; continuous glucose monitor metrics were collected for up to 2 years. Results: Participants (N = 224) completed median (interquartile range) 22.3 (21.7, 22.7) months of AID. HbA1c was reduced in the pivotal trial from 7.7% ± 0.9% in children and 7.2% ± 0.9% in adolescents/adults to 7.0% ± 0.6% and 6.8% ± 0.7%, respectively, (P < 0.0001), and was maintained at 7.2% ± 0.7% and 6.9% ± 0.6% after 15 months (P < 0.0001 from baseline). Time in target range (70-180 mg/dL) increased from 52.4% ± 15.6% in children and 63.6% ± 16.5% in adolescents/adults at baseline to 67.9% ± 8.0% and 73.8% ± 10.8%, respectively, during the pivotal trial (P < 0.0001) and was maintained at 65.9% ± 8.9% and 72.9% ± 11.3% during the extension (P < 0.0001 from baseline). One episode of diabetic ketoacidosis and seven episodes of severe hypoglycemia occurred during the extension. Children and adolescents/adults spent median 96.1% and 96.3% of time in Automated Mode, respectively. Conclusion: Our study supports that long-term use of the Omnipod 5 AID System can safely maintain improvements in glycemic outcomes for up to 2 years of use in people with T1D. Clinical Trials Registration Number: NCT04196140.
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Affiliation(s)
- Amy B. Criego
- Department of Pediatric Endocrinology, International Diabetes Center, Park Nicollet, Minneapolis, Minnesota, USA
| | - Anders L. Carlson
- International Diabetes Center, Park Nicollet, HealthPartners, Minneapolis, Minnesota, USA
| | - Sue A. Brown
- Division of Endocrinology, Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
| | - Gregory P. Forlenza
- Department of Pediatrics, Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | | | - Carol J. Levy
- Division of Endocrinology, Diabetes, and Metabolism, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - David W. Hansen
- Department of Pediatrics, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Irl B. Hirsch
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Richard M. Bergenstal
- International Diabetes Center, Park Nicollet, HealthPartners, Minneapolis, Minnesota, USA
| | - Jennifer L. Sherr
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut, USA
| | - Sanjeev N. Mehta
- Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Lori M. Laffel
- Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Viral N. Shah
- Department of Pediatrics, Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | | | - Ruth S. Weinstock
- Department of Medicine, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Sarah A. MacLeish
- Department of Pediatrics, University Hospitals Cleveland Medical Center, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Daniel J. DeSalvo
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Thomas C. Jones
- Department of Research, East Coast Institute for Research at The Jones Center, Macon, Georgia, USA
| | - Grazia Aleppo
- Division of Endocrinology, Metabolism, and Molecular Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Bruce A. Buckingham
- Division of Pediatric Endocrinology, Department of Pediatrics, Stanford University, Stanford, California, USA
| | - Trang T. Ly
- Insulet Corporation, Acton, Massachusetts, USA
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Bergenstal RM. Roadmap to the Effective Use of Continuous Glucose Monitoring: Innovation, Investigation, and Implementation. Diabetes Spectr 2023; 36:327-336. [PMID: 37982061 PMCID: PMC10654130 DOI: 10.2337/dsi23-0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
For 25 years, continuous glucose monitoring (CGM) has been evolving into what it is now: a key tool to both measure individuals' glycemic status and to help guide their day-to-day management of diabetes. Through a series of engineering innovations, clinical investigations, and efforts to optimize workflow implementation, the use of CGM is helping to transform diabetes care. This article presents a roadmap to the effective use of CGM that outlines past, present, and possible future advances in harnessing the potential of CGM to improve the lives of many people with diabetes, with an emphasis on ensuring that CGM technology is available to all who could benefit from its use.
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11
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Bergenstal RM. Roadmaps to Continuous Glucose Monitoring's Role in Transforming Diabetes Management. Diabetes Spectr 2023; 36:284-286. [PMID: 37982067 PMCID: PMC10654114 DOI: 10.2337/dsi23-0007] [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: 11/21/2023]
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12
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Giorgino F, Battelino T, Bergenstal RM, Forst T, Green JB, Mathieu C, Rodbard HW, Schnell O, Wilmot EG. The Role of Ultra-Rapid-Acting Insulin Analogs in Diabetes: An Expert Consensus. J Diabetes Sci Technol 2023:19322968231204584. [PMID: 37937585 DOI: 10.1177/19322968231204584] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
Ultra-rapid-acting insulin analogs (URAA) are a further development and refinement of rapid-acting insulin analogs. Because of their adapted formulation, URAA provide an even faster pharmacokinetics and thus an accelerated onset of insulin action than conventional rapid-acting insulin analogs, allowing for a more physiologic delivery of exogenously applied insulin. Clinical trials have confirmed the superiority of URAA in controlling postprandial glucose excursions, with a safety profile that is comparable to the rapid-acting insulins. Consequently, many individuals with diabetes mellitus may benefit from URAA in terms of prandial glycemic control. Unfortunately, there are only few available recommendations from authoritative sources for use of URAA in clinical practice. Therefore, this expert consensus report aims to define populations of people with diabetes mellitus for whom URAA may be beneficial and to provide health care professionals with concrete, practical recommendations on how best to use URAA in this context.
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Affiliation(s)
- Francesco Giorgino
- Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari Aldo Moro, Bari, Italy
| | - Tadej Battelino
- Department of Endocrinology, Diabetes and Metabolism, UCH-University Medical Center Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | | | - Thomas Forst
- Department of Endocrinology and Metabolic Diseases, Johannes Gutenberg University Medical Center, Mainz, Germany
- Clinical Research Services, Mannheim, Germany
| | - Jennifer B Green
- Division of Endocrinology and Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Chantal Mathieu
- Clinical and Experimental Endocrinology, University Hospital Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium
| | | | - Oliver Schnell
- Forschergruppe Diabetes eV at the Helmholtz Centre, Munich-Neuherberg, Germany
| | - Emma G Wilmot
- Department of Diabetes & Endocrinology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
- Academic Unit for Translational Medical Sciences, University of Nottingham, Nottingham, England, UK
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Bergenstal RM, Bode BW, Bhargava A, Wang Q, Knights AW, Chang AM. Assessing Time in Range with Postprandial Glucose-Focused Titration of Ultra Rapid Lispro (URLi) in People with Type 1 Diabetes. Diabetes Ther 2023; 14:1933-1945. [PMID: 37740871 PMCID: PMC10570246 DOI: 10.1007/s13300-023-01476-4] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 09/07/2023] [Indexed: 09/25/2023] Open
Abstract
INTRODUCTION To assess time in range (TIR) (70-180 mg/dL) with postprandial glucose (PPG)-focused titration of ultra rapid lispro (URLi; Lyumjev®) in combination with insulin degludec in people with type 1 diabetes (T1D). METHODS This phase 2, single-group, open-label, exploratory study was conducted in 31 participants with T1D on multiple daily injection therapy. Participants were treated with insulin degludec and Lispro for an 11-day lead-in and then URLi for a 46-day treatment period consisting of 35-day titration and 11-day endpoint maintenance period. Glucose targets for the titration period were PPG < 140 mg/dL or < 20% increase from premeal, fasting glucose 80-110 mg/dL, and overnight excursion ± 30 mg/dL or less. Participants used the InPen™ bolus calculator and Dexcom G6 continuous glucose monitoring (CGM). RESULTS Primary endpoint mean TIR (70-180 mg/dL) with URLi during the maintenance period was 70.2%. TIR (70-180 mg/dL) and times below/above range were not significantly different with URLi (maintenance) versus lispro (lead-in). HbA1c decreased from 7.1% at screening to 6.8% at endpoint (least squares mean [LSM] change from baseline, - 0.36%; P < 0.001). Fructosamine and 1,5-anhydroglucitol improved (P < 0.001). Mean hourly glucose using CGM was reduced from 8:00 AM to 4:00 PM with URLi. Overall highest PPG excursion across meals was significantly reduced at URLi endpoint compared with lispro lead-in (mean 56.5 vs 72.4 mg/dL; P < 0.001). Insulin-to-carbohydrate ratio (U/X g) was reduced (more insulin given) at breakfast at URLi endpoint vs lead-in (LSM 9.0 vs 9.7 g; P = 0.002) and numerically decreased at other meals. Total daily insulin dose (TDD) was higher at URLi endpoint compared with lispro lead-in (mean 50.2 vs 47.0 U; P = 0.046) with similar prandial/TDD ratio (mean 52.1% vs 51.2%). There were no severe hypoglycemia events during the study. CONCLUSIONS URLi in a basal-bolus regimen focusing on PPG targets demonstrated improved overall glycemic control and reduced PPG excursions without increased hypoglycemia in participants with T1D. TRIAL REGISTRATION ClinicalTrial.gov, NCT04585776.
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Affiliation(s)
| | - Bruce W Bode
- Atlanta Diabetes Associates Hospital, Atlanta, GA, USA
| | - Anuj Bhargava
- Iowa Diabetes and Endocrinology Research Center, West Des Moines, IA, USA
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Aleppo G, Gal RL, Raghinaru D, Kruger D, Beck RW, Bergenstal RM, Cushman T, Hood KK, Johnson ML, McArthur T, Bradshaw A, Olson BA, Oser SM, Oser TK, Kollman C, Weinstock RS. Comprehensive Telehealth Model to Support Diabetes Self-Management. JAMA Netw Open 2023; 6:e2336876. [PMID: 37792375 PMCID: PMC10551767 DOI: 10.1001/jamanetworkopen.2023.36876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 05/30/2023] [Accepted: 08/28/2023] [Indexed: 10/05/2023] Open
Abstract
Importance As the number of patients with diabetes continues to increase in the United States, novel approaches to clinical care access should be considered to meet the care needs for this population, including support for diabetes-related technology. Objective To evaluate a virtual clinic to facilitate comprehensive diabetes care, support continuous glucose monitoring (CGM) integration into diabetes self-management, and provide behavioral health support for diabetes-related issues. Design, Setting, and Participants This cohort study was a prospective, single-arm, remote study involving adult participants with type 1 or type 2 diabetes who were referred through community resources. The study was conducted virtually from August 24, 2020, to May 26, 2022; analysis was conducted at the clinical coordinating center. Intervention Training and education led by a Certified Diabetes Care and Education Specialist for CGM use through a virtual endocrinology clinic structure, which included endocrinologists and behavioral health team members. Main Outcomes and Measures Main outcomes included CGM-measured mean glucose level, coefficient of variation, and time in range (TIR) of 70 to 180 mg/dL, time with values greater than 180 mg/dL or 250 mg/dL, and time with values less than 70 mg/dL or 54 mg/dL. Hemoglobin A1c was measured at baseline and at 12 and 24 weeks. Results Among the 234 participants, 160 had type 1 diabetes and 74 had type 2 diabetes. The mean (SD) age was 47 (14) years, 123 (53%) were female, and median diabetes duration was 20 years. Median (IQR) CGM use over 6 months was 96% (91%-98%) for participants with type 1 diabetes and 94% (85%-97%) for those with type 2 diabetes. Mean (SD) hemoglobin A1c (HbA1c) in those with type 1 diabetes decreased from 7.8% (1.6%) at baseline to 7.1% (1.0%) at 3 months and 7.1% (1.0%) at 6 months (mean change from baseline to 6 months, -0.6%, 95% CI, -0.8% to -0.5%; P < .001), with an 11% mean TIR increase over 6 months (95% CI, 9% to 14%; P < .001). Mean HbA1c in participants with type 2 diabetes decreased from 8.1% (1.7%) at baseline to 7.1% (1.0%) at 3 months and 7.1% (0.9%) at 6 months (mean change from baseline to 6 months, -1.0%; 95% CI, -1.4% to -0.7%; P < .001), with an 18% TIR increase over 6 months (95% CI, 13% to 24%; P < .001). In participants with type 1 diabetes, mean percentage of time with values less than 70 mg/dL and less than 54 mg/dL decreased over 6 months by 0.8% (95% CI, -1.2% to -0.4%; P = .001) and by 0.3% (95% CI, -0.5% to -0.2%, P < .001), respectively. In the type 2 diabetes group, hypoglycemia was rare (mean [SD] percentage of time <70 mg/dL, 0.5% [0.6%]; and <54 mg/dL, 0.07% [0.14%], over 6 months). Conclusions and Relevance Results from this cohort study demonstrated clinical benefits associated with implementation of a comprehensive care model that included diabetes education. This model of care has potential to reach a large portion of patients with diabetes, facilitate diabetes technology adoption, and improve glucose control.
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Affiliation(s)
- Grazia Aleppo
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Robin L Gal
- Jaeb Center for Health and Research, Tampa, Florida
| | | | | | - Roy W Beck
- Jaeb Center for Health and Research, Tampa, Florida
| | | | | | - Korey K Hood
- Stanford University School of Medicine, Stanford, California
| | | | | | | | | | - Sean M Oser
- University of Colorado School of Medicine, Aurora
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15
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Aleppo G, Hirsch IB, Parkin CG, McGill J, Galindo R, Kruger DF, Levy CJ, Forlenza GP, Umpierrez GE, Grunberger G, Bergenstal RM. Coverage for Continuous Glucose Monitoring for Individuals with Type 2 Diabetes Treated with Nonintensive Therapies: An Evidence-Based Approach to Policymaking. Diabetes Technol Ther 2023; 25:741-751. [PMID: 37471068 PMCID: PMC10611973 DOI: 10.1089/dia.2023.0268] [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] [Indexed: 07/21/2023]
Abstract
Numerous studies have demonstrated the clinical benefits of continuous glucose monitoring (CGM) in individuals with type 1 diabetes (T1D) and type 2 diabetes (T2D) who are treated with intensive insulin regimens. Based on this evidence, CGM is now a standard of care for individuals within these diabetes populations and widely covered by commercial and public insurers. Moreover, recent clinical guidelines from the American Diabetes Association and American Association of Clinical Endocrinology now endorse CGM use in individuals treated with nonintensive insulin regimens. However, despite increasing evidence supporting CGM use for individuals treated with less-intensive insulin therapy or noninsulin medications, insurance coverage is limited or nonexistent. This narrative review reports key findings from recent randomized, observational, and retrospective studies investigating use of CGM in T2D individuals treated with basal insulin only and/or noninsulin therapies and presents an evidence-based rationale for expanding access to CGM within this population.
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Affiliation(s)
- Grazia Aleppo
- Division of Endocrinology, Metabolism and Molecular Medicine, Feinberg School of Medicine Northwestern University, Chicago, Illinois, USA
| | | | | | - Janet McGill
- Division of Endocrinology, Metabolism and Lipid Research, Washington University in St. Louis, School of Medicine, St. Louis, Missouri, USA
| | - Rodolfo Galindo
- Lennar Medical Center, UMiami Health System, Jackson Memorial Health System, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Davida F. Kruger
- Division of Endocrinology, Diabetes, Bone & Mineral, Henry Ford Health System, Detroit, Michigan, USA
| | - Carol J. Levy
- Division of Endocrinology, Diabetes, and Metabolism, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Gregory P. Forlenza
- Division of Pediatric Endocrinology, Department of Pediatrics, Barbara Davis Center, University of Colorado Denver, Aurora, Colorado, USA
| | - Guillermo E. Umpierrez
- Division of Endocrinology, Metabolism Emory University School of Medicine, Grady Memorial Hospital, Atlanta, Georgia, USA
| | | | - Richard M. Bergenstal
- International Diabetes Center at Park Nicollet, HealthPartners Institute, Minneapolis, Minnesota, USA
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16
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Virdi N, Poon Y, Abaniel R, Bergenstal RM. Prevalence, Cost, and Burden of Diabetic Ketoacidosis. Diabetes Technol Ther 2023; 25:S75-S84. [PMID: 37306442 DOI: 10.1089/dia.2023.0149] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Diabetic ketoacidosis (DKA) is a life-threatening complication, which is most common in individuals with type 1 diabetes (T1D) and is a significant risk for morbidity and mortality, and it is an economic burden on individuals, health care systems, and payers. Younger children, minority ethnic groups, and those with limited insurance are at the greatest risk for presentation of DKA at T1D diagnosis. Although monitoring ketone levels is an essential part of acute illness management and for both early detection and prevention of a DKA episode, studies have reported poor adherence to ketone monitoring. Ketone monitoring is particularly important for patients treated with sodium glucose cotransporter 2 inhibitor (SGLT2i) medications, in which DKA can present with only moderately elevated glucose levels, referred to as euglycemic DKA (euDKA). A majority of people with T1D and many with type 2 diabetes (T2D), particularly those using insulin therapy, are using continuous glucose monitoring (CGM) as their preferred method for measurement and management of glycemia. These devices provide a continuous stream of glucose data that enables users to take immediate action to mitigate and/or prevent severe hyperglycemic or hypoglycemic events. An international consensus of leading diabetes experts has recommended the development of continuous ketone monitoring systems, ideally a system that combines CGM technology with measurement of 3-β-OHB into a single sensor. In this narrative review of current literature, we report on the prevalence and burden of DKA, examine challenges to detecting and diagnosing this condition, and discuss a new monitoring option for DKA prevention.
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Affiliation(s)
| | - Yeesha Poon
- Abbott Diabetes Care, Alameda, California, USA
| | | | - Richard M Bergenstal
- International Diabetes Center, HealthPartners Institute, Minneapolis, Minnesota, USA
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17
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Dunn TC, Xu Y, Bergenstal RM, Ogawa W, Ajjan RA. Personalized Glycated Hemoglobin in Diabetes Management: Closing the Gap with Glucose Management Indicator. Diabetes Technol Ther 2023; 25:S65-S74. [PMID: 37306444 DOI: 10.1089/dia.2023.0146] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Glycated hemoglobin (HbA1c) has played a central role in the management of diabetes since the end of the landmark Diabetes Control and Complications Trial 30 years ago. However, it is known to be subject to distortions related to altered red blood cell (RBC) properties, including changes in cellular lifespan. On occasion, the distortion of HbA1c is associated with a clinical pathological condition affecting RBCs, however, the more frequent scenario is related to interindividual RBC variations that alter HbA1c-average glucose relationship. Clinically, these variations can potentially lead to over- or underestimating glucose exposure of the individual to the extent that may put the person at excess risk of over- or undertreatment. Furthermore, the variable association between HbA1c and glucose levels across different groups of people may become an unintentional driver of inequitable health care delivery, outcomes, and incentives. The subclinical effects within the normal expected physiological range of RBCs can be large enough to alter clinical interpretation of HbA1c and addressing this will help with individualized care and decision making. This review describes a new glycemic measure, personalized HbA1c (pA1c), that may address the clinical inaccuracies of HbA1c by taking into account interindividual variability in RBC glucose uptake and lifespan. Therefore, pA1c represents a more sophisticated understanding of glucose-HbA1c relationship at an individual level. Future use of pA1c, after adequate clinical validation, has the potential to refine glycemic management and the diagnostic criteria in diabetes.
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Affiliation(s)
- Timothy C Dunn
- Clinical Affairs, Abbott Diabetes Care, Alameda, California, USA
| | - Yongjin Xu
- Clinical Affairs, Abbott Diabetes Care, Alameda, California, USA
| | - Richard M Bergenstal
- International Diabetes Center, HealthPartners Institute, Minneapolis, Minnesota, USA
| | - Wataru Ogawa
- Division of Diabetes and Endocrinology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Ramzi A Ajjan
- The LIGHT Laboratories, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
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18
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Bergenstal RM, Hachmann-Nielsen E, Kvist K, Peters A, Tarp JM, Buse JB. Increased Derived Time in Range is Associated with Reduced Risk of Major Adverse Cardiovascular Events, Severe Hypoglycemia, and Microvascular Events in Type 2 Diabetes: A Post Hoc Analysis of DEVOTE. Diabetes Technol Ther 2023. [PMID: 37017470 PMCID: PMC10398723 DOI: 10.1089/dia.2022.0447] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/06/2023]
Abstract
Time spent in glycemic target range (time in range [TIR]; plasma glucose 70-180 mg/dL [3.9-10.0 mmol/L]) as a surrogate endpoint for long-term diabetes-related outcomes requires validation. This post hoc analysis investigated the association between TIR, derived from 8-point glucose profiles (dTIR) at 12 months, and time to cardiovascular or severe hypoglycemic episodes in people with type 2 diabetes in the DEVOTE trial. At 12 months, dTIR was significantly negatively associated with time to first major adverse cardiovascular event (P = 0.0087), severe hypoglycemic episode (P < 0.0001), or microvascular event (P = 0.024). A non-significant trend was seen towards association between 12-month hemoglobin A1c (HbA1c) and these outcomes, but this was no longer seen after addition of dTIR to the model. The results support targeting TIR >70% and suggest dTIR could be used in addition to, or in some instances in place of, HbA1c as a clinical biomarker.
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Affiliation(s)
- Richard M Bergenstal
- International Diabetes Center, HealthPartners Institute, Minneapolis , Minnesota, United States;
| | | | | | - Anne Peters
- USC Keck School of Medicine, 12223, Los Angeles, California, United States;
| | | | - John B Buse
- University of North Carolina at Chapel Hill School of Medicine, 6797, Department of Medicine, Chapel Hill, North Carolina, United States;
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19
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Khan M, Wahid N, Musser T, Bergenstal RM, Ebekozien O, Snow K, Thomas K, Aprigliano C. Advancing Diabetes Quality Measurement in the Era of Continuous Glucose Monitoring. Sci Diabetes Self Manag Care 2023; 49:112-125. [PMID: 36988200 DOI: 10.1177/26350106231163518] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Abstract
PURPOSE The purpose of this research is to develop a set of continuous glucose monitoring (CGM)-related measure concepts to be tested in a health care system. Existing measures assessing the quality of diabetes care do not include modern approaches to diabetes management, such as CGM. Continuous glucose monitors rival traditional methods of measuring diabetes management by providing real-time, longitudinal data and demonstrating glucose variability over time. The Improving Diabetes Quality Initiative seeks to address this gap in diabetes quality measurement. METHODS A Technical Expert Panel (TEP) was convened to curate a diabetes quality measures portfolio and conceptualize three new CGM-related quality measures within the portfolio. From the additional measure concepts identified in the portfolio, the TEP prioritized three for conceptualization. High-level measure concept specifications were made available during a public comment period. RESULTS The measure concepts prioritized by the TEP included a shared decision-making measure to assess the value of initiating CGM for disease management, a utilization measure to address disparities in access and use of CGM, and a patient-provider review of CGM data to promote routine consideration of these assessments in treatment and ongoing management. Clinical literature, public comments, and TEP feedback informed full measure specifications. CONCLUSIONS The evolution of diabetes technology reflects the need to shift diabetes quality of care. The measure concepts will be tested in a flexible pilot setting to understand the future of diabetes care and communicate the value of CGM to people with diabetes, providers, and payers.
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Affiliation(s)
| | | | - Taylor Musser
- National Committee for Quality Assurance, Washington, DC
| | | | | | | | - Kate Thomas
- Association of Diabetes Care & Education Specialists, Chicago, Illinois
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20
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Goldenberg RM, Aroda VR, Billings LK, Donatsky AM, Frederiksen M, Klonoff DC, Kalyanam B, Bergenstal RM. Correlation Between Time in Range and HbA1c in People with Type 2 Diabetes on Basal Insulin: Post Hoc Analysis of the SWITCH PRO Study. Diabetes Ther 2023; 14:915-924. [PMID: 36905485 PMCID: PMC10126196 DOI: 10.1007/s13300-023-01389-2] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 02/16/2023] [Indexed: 03/12/2023] Open
Abstract
INTRODUCTION Use of continuous glucose monitoring (CGM) in people with diabetes may provide a more complete picture of glycemic control than glycated hemoglobin (HbA1c) measurements, which do not capture day-to-day fluctuations in blood glucose levels. The randomized, crossover, phase IV SWITCH PRO study assessed time in range (TIR), derived from CGM, following treatment with insulin degludec or insulin glargine U100 in patients with type 2 diabetes at risk for hypoglycemia. This post hoc analysis evaluated the relationship between TIR and HbA1c, following treatment intensification during the SWITCH PRO study. METHODS Correlation between absolute values for TIR (assessed over 2-week intervals) and HbA1c, at baseline and at the end of maintenance period 1 (M1; week 18) or maintenance period 2 (M2; week 36), were assessed by linear regression and using the Spearman correlation coefficient (rs). These methods were also used to assess correlation between change in TIR and change in HbA1c from baseline to the end of M1, both in the full cohort and in subgroups stratified by baseline median HbA1c (≥ 7.5% [≥ 58.5 mmol/mol] or < 7.5% [< 58.5 mmol/mol]). RESULTS A total of 419 participants were included in the analysis. A moderate inverse linear correlation was observed between TIR and HbA1c at baseline (rs -0.54), becoming stronger following treatment intensification during maintenance periods M1 (weeks 17-18: rs -0.59) and M2 (weeks 35-36: rs -0.60). Changes in TIR and HbA1c from baseline to end of M1 were also linearly inversely correlated in the full cohort (rs -0.40) and the subgroup with baseline HbA1c ≥ 7.5% (rs -0.43). This was less apparent in the subgroup with baseline HbA1c < 7.5% (rs -0.17) (p-interaction = 0.07). CONCLUSION Results from this post hoc analysis of data from SWITCH PRO, one of the first large interventional clinical studies to use TIR as the primary outcome, further support TIR as a valid clinical indicator of glycemic control. TRIAL REGISTRATION ClinicalTrials.gov identifier, NCT03687827.
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Affiliation(s)
- Ronald M Goldenberg
- LMC Diabetes & Endocrinology, 5-1600 Steeles Ave. West, Concord, ON, L4K 4M2, Canada.
| | - Vanita R Aroda
- Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | - Liana K Billings
- NorthShore University HealthSystem/University of Chicago Pritzker School of Medicine, Evanston, IL, USA
| | | | | | - David C Klonoff
- Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA, USA
| | | | - Richard M Bergenstal
- International Diabetes Center and HealthPartners Institute, Minneapolis, MN, USA
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21
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Phillip M, Nimri R, Bergenstal RM, Barnard-Kelly K, Danne T, Hovorka R, Kovatchev BP, Messer LH, Parkin CG, Ambler-Osborn L, Amiel SA, Bally L, Beck RW, Biester S, Biester T, Blanchette JE, Bosi E, Boughton CK, Breton MD, Brown SA, Buckingham BA, Cai A, Carlson AL, Castle JR, Choudhary P, Close KL, Cobelli C, Criego AB, Davis E, de Beaufort C, de Bock MI, DeSalvo DJ, DeVries JH, Dovc K, Doyle FJ, Ekhlaspour L, Shvalb NF, Forlenza GP, Gallen G, Garg SK, Gershenoff DC, Gonder-Frederick LA, Haidar A, Hartnell S, Heinemann L, Heller S, Hirsch IB, Hood KK, Isaacs D, Klonoff DC, Kordonouri O, Kowalski A, Laffel L, Lawton J, Lal RA, Leelarathna L, Maahs DM, Murphy HR, Nørgaard K, O’Neal D, Oser S, Oser T, Renard E, Riddell MC, Rodbard D, Russell SJ, Schatz DA, Shah VN, Sherr JL, Simonson GD, Wadwa RP, Ward C, Weinzimer SA, Wilmot EG, Battelino T. Consensus Recommendations for the Use of Automated Insulin Delivery Technologies in Clinical Practice. Endocr Rev 2023; 44:254-280. [PMID: 36066457 PMCID: PMC9985411 DOI: 10.1210/endrev/bnac022] [Citation(s) in RCA: 79] [Impact Index Per Article: 79.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 07/22/2022] [Indexed: 02/06/2023]
Abstract
The significant and growing global prevalence of diabetes continues to challenge people with diabetes (PwD), healthcare providers, and payers. While maintaining near-normal glucose levels has been shown to prevent or delay the progression of the long-term complications of diabetes, a significant proportion of PwD are not attaining their glycemic goals. During the past 6 years, we have seen tremendous advances in automated insulin delivery (AID) technologies. Numerous randomized controlled trials and real-world studies have shown that the use of AID systems is safe and effective in helping PwD achieve their long-term glycemic goals while reducing hypoglycemia risk. Thus, AID systems have recently become an integral part of diabetes management. However, recommendations for using AID systems in clinical settings have been lacking. Such guided recommendations are critical for AID success and acceptance. All clinicians working with PwD need to become familiar with the available systems in order to eliminate disparities in diabetes quality of care. This report provides much-needed guidance for clinicians who are interested in utilizing AIDs and presents a comprehensive listing of the evidence payers should consider when determining eligibility criteria for AID insurance coverage.
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Affiliation(s)
- Moshe Phillip
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children’s Medical Center of Israel, 49202 Petah Tikva, Israel
- Sacker Faculty of Medicine, Tel-Aviv University, 39040 Tel-Aviv, Israel
| | - Revital Nimri
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children’s Medical Center of Israel, 49202 Petah Tikva, Israel
- Sacker Faculty of Medicine, Tel-Aviv University, 39040 Tel-Aviv, Israel
| | - Richard M Bergenstal
- International Diabetes Center, HealthPartners Institute, Minneapolis, MN 55416, USA
| | | | - Thomas Danne
- AUF DER BULT, Diabetes-Center for Children and Adolescents, Endocrinology and General Paediatrics, Hannover, Germany
| | - Roman Hovorka
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Boris P Kovatchev
- Center for Diabetes Technology, School of Medicine, University of Virginia, Charlottesville, VA 22903, USA
| | - Laurel H Messer
- Barbara Davis Center for Diabetes, University of Colorado Denver—Anschutz Medical Campus, Aurora, CO 80045, USA
| | | | | | | | - Lia Bally
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Roy W Beck
- Jaeb Center for Health Research Foundation, Inc., Tampa, FL 33647, USA
| | - Sarah Biester
- AUF DER BULT, Diabetes-Center for Children and Adolescents, Endocrinology and General Paediatrics, Hannover, Germany
| | - Torben Biester
- AUF DER BULT, Diabetes-Center for Children and Adolescents, Endocrinology and General Paediatrics, Hannover, Germany
| | - Julia E Blanchette
- College of Nursing, University of Utah, Salt Lake City, UT 84112, USA
- Center for Diabetes and Obesity, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Emanuele Bosi
- Diabetes Research Institute, IRCCS San Raffaele Hospital and San Raffaele Vita Salute University, Milan, Italy
| | - Charlotte K Boughton
- Wellcome Trust-MRC Institute of Metabolic Science, Addenbrooke’s Hospital, University of Cambridge Metabolic Research Laboratories, Cambridge, UK
| | - Marc D Breton
- Center for Diabetes Technology, School of Medicine, University of Virginia, Charlottesville, VA 22903, USA
| | - Sue A Brown
- Center for Diabetes Technology, School of Medicine, University of Virginia, Charlottesville, VA 22903, USA
- Division of Endocrinology, University of Virginia, Charlottesville, VA 22903, USA
| | - Bruce A Buckingham
- Division of Endocrinology, Department of Pediatrics, Stanford University, School of Medicine, Stanford, CA 94304, USA
| | - Albert Cai
- The diaTribe Foundation/Close Concerns, San Diego, CA 94117, USA
| | - Anders L Carlson
- International Diabetes Center, HealthPartners Institute, Minneapolis, MN 55416, USA
| | - Jessica R Castle
- Harold Schnitzer Diabetes Health Center, Oregon Health & Science University, Portland, OR 97239, USA
| | - Pratik Choudhary
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Kelly L Close
- The diaTribe Foundation/Close Concerns, San Diego, CA 94117, USA
| | - Claudio Cobelli
- Department of Woman and Child’s Health, University of Padova, Padova, Italy
| | - Amy B Criego
- International Diabetes Center, HealthPartners Institute, Minneapolis, MN 55416, USA
| | - Elizabeth Davis
- Telethon Kids Institute, University of Western Australia, Perth Children’s Hospital, Perth, Australia
| | - Carine de Beaufort
- Diabetes & Endocrine Care Clinique Pédiatrique DECCP/Centre Hospitalier Luxembourg, and Faculty of Sciences, Technology and Medicine, University of Luxembourg, Esch sur Alzette, GD Luxembourg/Department of Paediatrics, UZ-VUB, Brussels, Belgium
| | - Martin I de Bock
- Department of Paediatrics, University of Otago, Christchurch, New Zealand
| | - Daniel J DeSalvo
- Division of Pediatric Diabetes and Endocrinology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX 77598, USA
| | - J Hans DeVries
- Amsterdam UMC, University of Amsterdam, Internal Medicine, Amsterdam, The Netherlands
| | - Klemen Dovc
- Department of Pediatric Endocrinology, Diabetes and Metabolic Diseases, UMC - University Children’s Hospital, Ljubljana, Slovenia, and Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Francis J Doyle
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA 02138, USA
| | - Laya Ekhlaspour
- Lucile Packard Children’s Hospital—Pediatric Endocrinology, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - Naama Fisch Shvalb
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children’s Medical Center of Israel, 49202 Petah Tikva, Israel
| | - Gregory P Forlenza
- Barbara Davis Center for Diabetes, University of Colorado Denver—Anschutz Medical Campus, Aurora, CO 80045, USA
| | | | - Satish K Garg
- Barbara Davis Center for Diabetes, University of Colorado Denver—Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Dana C Gershenoff
- International Diabetes Center, HealthPartners Institute, Minneapolis, MN 55416, USA
| | - Linda A Gonder-Frederick
- Center for Diabetes Technology, School of Medicine, University of Virginia, Charlottesville, VA 22903, USA
| | - Ahmad Haidar
- Department of Biomedical Engineering, McGill University, Montreal, Canada
| | - Sara Hartnell
- Wolfson Diabetes and Endocrine Clinic, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Simon Heller
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Irl B Hirsch
- Department of Medicine, University of Washington Diabetes Institute, University of Washington, Seattle, WA, USA
| | - Korey K Hood
- Stanford Diabetes Research Center, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Diana Isaacs
- Cleveland Clinic, Endocrinology and Metabolism Institute, Cleveland, OH 44106, USA
| | - David C Klonoff
- Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA 94010, USA
| | - Olga Kordonouri
- AUF DER BULT, Diabetes-Center for Children and Adolescents, Endocrinology and General Paediatrics, Hannover, Germany
| | | | - Lori Laffel
- Joslin Diabetes Center, Harvard Medical School, Boston, MA 02215, USA
| | - Julia Lawton
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Rayhan A Lal
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Lalantha Leelarathna
- Manchester University Hospitals NHS Foundation Trust/University of Manchester, Manchester, UK
| | - David M Maahs
- Division of Endocrinology, Department of Pediatrics, Stanford University, School of Medicine, Stanford, CA 94304, USA
| | - Helen R Murphy
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Kirsten Nørgaard
- Steno Diabetes Center Copenhagen and Department of Clinical Medicine, University of Copenhagen, Gentofte, Denmark
| | - David O’Neal
- Department of Medicine and Department of Endocrinology, St Vincent’s Hospital Melbourne, University of Melbourne, Melbourne, Australia
| | - Sean Oser
- Department of Family Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Tamara Oser
- Department of Family Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Eric Renard
- Department of Endocrinology, Diabetes, Nutrition, Montpellier University Hospital, and Institute of Functional Genomics, University of Montpellier, CNRS, INSERM, Montpellier, France
| | - Michael C Riddell
- School of Kinesiology & Health Science, Muscle Health Research Centre, York University, Toronto, Canada
| | - David Rodbard
- Biomedical Informatics Consultants LLC, Potomac, MD, USA
| | - Steven J Russell
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Desmond A Schatz
- Department of Pediatrics, College of Medicine, Diabetes Institute, University of Florida, Gainesville, FL 02114, USA
| | - Viral N Shah
- Barbara Davis Center for Diabetes, University of Colorado Denver—Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Jennifer L Sherr
- Department of Pediatrics, Yale University School of Medicine, Pediatric Endocrinology, New Haven, CT 06511, USA
| | - Gregg D Simonson
- International Diabetes Center, HealthPartners Institute, Minneapolis, MN 55416, USA
| | - R Paul Wadwa
- Barbara Davis Center for Diabetes, University of Colorado Denver—Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Candice Ward
- Institute of Metabolic Science, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Stuart A Weinzimer
- Department of Pediatrics, Yale University School of Medicine, Pediatric Endocrinology, New Haven, CT 06511, USA
| | - Emma G Wilmot
- Department of Diabetes & Endocrinology, University Hospitals of Derby and Burton NHS Trust, Derby, UK
- Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, England, UK
| | - Tadej Battelino
- Department of Pediatric Endocrinology, Diabetes and Metabolic Diseases, UMC - University Children’s Hospital, Ljubljana, Slovenia, and Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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22
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Shah VN, Vigers T, Pyle L, Calhoun P, Bergenstal RM. Discordance Between Glucose Management Indicator and Glycated Hemoglobin in People Without Diabetes. Diabetes Technol Ther 2023; 25:324-328. [PMID: 36790875 DOI: 10.1089/dia.2022.0544] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [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] [Indexed: 02/16/2023]
Abstract
Background: In recent years, continuous glucose monitor (CGM) use is increasing in people without diabetes to promote healthy lifestyle. CGM metrics such as glucose management indicator (GMI), a statistical formula to estimate glycated hemoglobin (HbA1c) from sensor glucose, is commonly used to approximate HbA1c. This study was aimed to evaluate discordance between GMI and HbA1c in people without diabetes. Methods: Children and nonpregnant adults (age ≥6 years) without diabetes (laboratory HbA1c <5.7% and negative islet antibodies) were invited to participate in a multicenter prospective study aimed to evaluate glycemic profiles in nondiabetic individuals. Each participant wore a blinded Dexcom G6 for up to 10 days. GMI was calculated from mean sensor glucose and discordance between GMI and HbA1c was analyzed. Results: Of 201 screened participants, 153 participants (mean age 31.2 ± 21.0 years, 66.0% female, HbA1c 5.1% ± 0.3%) were included in the analysis. Mean GMI was 0.59% higher than laboratory HbA1c in participants without diabetes. The discordance between GMI and HbA1c of 0.4% or greater was 71% in participants without diabetes compared with 39% in the original GMI development cohort. Conclusion: GMI does not accurately estimate HbA1c in healthy people without diabetes. Clinical trial registration number is: NCT00717977.
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Affiliation(s)
- Viral N Shah
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Tim Vigers
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Laura Pyle
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Peter Calhoun
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - Richard M Bergenstal
- International Diabetes Center, HealthPartners Institute, Minneapolis, Minnesota, USA
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23
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Beck RW, Raghinaru D, Calhoun P, Bergenstal RM. The Relationship Between Percent Time <70 mg/dL and Percent Time <54 mg/dL Measured by Continuous Glucose Monitoring. Diabetes Technol Ther 2023; 25:157-160. [PMID: 36576488 DOI: 10.1089/dia.2022.0462] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Objective: While it is recognized that there is a strong relationship between the amount of time glucose levels are <70 mg/dL (T<70) and the amount of time <54 mg/dL (T<54), the association has not been well quantified. Methods: Datasets with Dexcom continuous glucose monitoring (CGM) data from nine type 1 diabetes randomized trials were pooled to evaluate the relationship between CGM-measured T<70 and T<54. Penalized B-spline regression lines were fitted to assess the relationship between T<70 and T<54 for blinded CGM use, unblinded CGM use without an automated insulin delivery (AID) system, and unblinded CGM use with an AID system. Results: For blinded data, the T<54 : T<70 ratio varied from 19% when the amount of T<70 was <1% to 44% when the amount of T<70 was ≥7% whereas for unblinded data the ratio varied from 15% to 42%, respectively. When T<70 was 4%, the predicted T<54 was 1.18%, 0.94%, and 0.91% for the blinded, unblinded, and AID data, respectively (P<0.001 comparing blinded versus unblinded and AID). Conclusions: The T<54 : T<70 ratio increases with greater T<70, and the ratio generally is higher with blinded than unblinded CGM data, with the latter appearing to be similar to AID system data. The finding of greater T<54 for a given T<70 with blinded CGM data is presumed to be due to an action being taken by the unblinded CGM user and/or by the AID system to minimize hypoglycemia which will have the effect of reducing the amount of T<54.
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Affiliation(s)
- Roy W Beck
- JAEB Center for Health Research, Tampa, Florida, USA
| | - Dan Raghinaru
- JAEB Center for Health Research, Tampa, Florida, USA
| | - Peter Calhoun
- JAEB Center for Health Research, Tampa, Florida, USA
| | - Richard M Bergenstal
- International Diabetes Center, HealthPartners Institute, Minneapolis, Minnesota, USA
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24
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Kerr D, Klonoff DC, Bergenstal RM, Choudhary P, Ji L. A Roadmap to an Equitable Digital Diabetes Ecosystem. Endocr Pract 2023; 29:179-184. [PMID: 36584818 DOI: 10.1016/j.eprac.2022.12.016] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 12/21/2022] [Accepted: 12/22/2022] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Diabetes management presents a substantial burden to individuals living with the condition and their families, health care professionals, and health care systems. Although an increasing number of digital tools are available to assist with tasks such as blood glucose monitoring and insulin dose calculation, multiple persistent barriers continue to prevent their optimal use. METHODS As a guide to creating an equitable connected digital diabetes ecosystem, we propose a roadmap with key milestones that need to be achieved along the way. RESULTS During the Coronavirus 2019 pandemic, there was an increased use of digital tools to support diabetes care, but at the same time, the pandemic also highlighted problems of inequities in access to and use of these same technologies. Based on these observations, a connected diabetes ecosystem should incorporate and optimize the use of existing treatments and technologies, integrate tasks such as glucose monitoring, data analysis, and insulin dose calculations, and lead to improved and equitable health outcomes. CONCLUSIONS Development of this ecosystem will require overcoming multiple obstacles, including interoperability and data security concerns. However, an integrated system would optimize existing devices, technologies, and treatments to improve outcomes.
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Affiliation(s)
- David Kerr
- Diabetes Technology Society, Burlingame, California.
| | - David C Klonoff
- Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, California
| | | | - Pratik Choudhary
- Leicester Diabetes Centre, University of Leicester, Leicester General Hospital, Leicester, UK
| | - Linong Ji
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China
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25
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Salam M, Bailey R, Calhoun P, McGill JB, Bergenstal RM, Price D, Beck RW. A Comparison of Continuous Glucose Monitoring Estimated Hemoglobin A1c in Adults with Type 1 or Type 2 Diabetes. Diabetes Technol Ther 2023; 25:178-185. [PMID: 36472504 DOI: 10.1089/dia.2022.0387] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background: The relationship of mean glucose measured with continuous glucose monitoring (CGM) and hemoglobin A1c (HbA1c) shows considerable variability between individuals with diabetes and may be influenced by race-related factors. Whether the relationship of mean glucose with HbA1c varies according to type 1 diabetes (T1D) or type 2 diabetes (T2D) has not been well evaluated. Methods: Data from 343 participants in four clinical trials (191 with T1D and 152 with T2D) were analyzed. Least squares linear regression models were fit with HbA1c as the dependent variable and mean glucose as the independent variable. Results: Mean age was 57 ± 15 years in the T1D cohort and 58 ± 10 years in the T2D cohort. The T1D cohort was 89% White non-Hispanic, 5% African American, 3% Hispanic, and 3% other or mixed race compared with 52%, 16%, 22%, and 9%, respectively, in the T2D cohort. The relationship between CGM-measured mean glucose and laboratory-measured HbA1c significantly differed between T1D and T2D cohorts, with HbA1c on average being higher with T2D than T1D for the same mean glucose (P = 0.002). However, this difference was largely attributable to the difference in the proportion of African Americans between T1D and T2D; and after stratifying by race, the mean glucose-HbA1c relationship showed only a small difference between T1D non-African Americans and T2D non-African Americans. The mean glucose-HbA1c relationship appeared similar for White non-Hispanic and Hispanic individuals. Conclusion: HbA1c on average was higher in T2D than T1D for a given mean glucose, but after accounting for race, there was no meaningful difference in the mean glucose-HbA1c relationship comparing T1D and T2D. The mean glucose-HbA1c relationship differs in African American compared with White individuals, but does not appear to differ comparing White non-Hispanic to Hispanic individuals. The published glucose management indicator formula appears to be suitable for both T1D and T2D.
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Affiliation(s)
- Maamoun Salam
- Division of Endocrinology, Metabolism and Lipid Research, Washington University School of Medicine, St. Louis, MO
| | - Ryan Bailey
- Jaeb Center for Health Research, Tampa, Florida
| | | | - Janet B McGill
- Division of Endocrinology, Metabolism and Lipid Research, Washington University School of Medicine, St. Louis, MO
| | - Richard M Bergenstal
- International Diabetes Center, HealthPartners Institute, Minneapolis, Minnesota, USA
| | | | - Roy W Beck
- Jaeb Center for Health Research, Tampa, Florida
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26
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Huang J, Yeung AM, Bergenstal RM, Castorino K, Cengiz E, Dhatariya K, Niu I, Sherr JL, Umpierrez GE, Klonoff DC. Update on Measuring Ketones. J Diabetes Sci Technol 2023:19322968231152236. [PMID: 36794812 DOI: 10.1177/19322968231152236] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Ketone bodies are an energy substrate produced by the liver and used during states of low carbohydrate availability, such as fasting or prolonged exercise. High ketone concentrations can be present with insulin insufficiency and are a key finding in diabetic ketoacidosis (DKA). During states of insulin deficiency, lipolysis increases and a flood of circulating free fatty acids is converted in the liver into ketone bodies-mainly beta-hydroxybutyrate and acetoacetate. During DKA, beta-hydroxybutyrate is the predominant ketone in blood. As DKA resolves, beta-hydroxybutyrate is oxidized to acetoacetate, which is the predominant ketone in the urine. Because of this lag, a urine ketone test might be increasing even as DKA is resolving. Point-of-care tests are available for self-testing of blood ketones and urine ketones through measurement of beta-hydroxybutyrate and acetoacetate and are cleared by the US Food and Drug Administration (FDA). Acetone forms through spontaneous decarboxylation of acetoacetate and can be measured in exhaled breath, but currently no device is FDA-cleared for this purpose. Recently, technology has been announced for measuring beta-hydroxybutyrate in interstitial fluid. Measurement of ketones can be helpful to assess compliance with low carbohydrate diets; assessment of acidosis associated with alcohol use, in conjunction with SGLT2 inhibitors and immune checkpoint inhibitor therapy, both of which can increase the risk of DKA; and to identify DKA due to insulin deficiency. This article reviews the challenges and shortcomings of ketone testing in diabetes treatment and summarizes emerging trends in the measurement of ketones in the blood, urine, breath, and interstitial fluid.
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Affiliation(s)
| | | | | | | | - Eda Cengiz
- University of California San Francisco, San Francisco, CA, USA
| | - Ketan Dhatariya
- Norfolk and Norwich University Hospitals NHS Foundation Trust and Norwich Medical School, University of East Anglia, Norfolk, UK
| | - Isabella Niu
- University of California San Francisco, San Francisco, CA, USA
| | | | | | - David C Klonoff
- Diabetes Technology Society, Burlingame, CA, USA
- Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA, USA
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27
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Simonson GD, Martens TW, Carlson AL, Bergenstal RM. Primary Care and Diabetes Technologies and Treatments. Diabetes Technol Ther 2023; 25:S161-S175. [PMID: 36802179 DOI: 10.1089/dia.2023.2510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Indexed: 02/23/2023]
Affiliation(s)
- Gregg D Simonson
- International Diabetes Center, HealthPartners Institute, Minneapolis, MN, USA
| | - Thomas W Martens
- International Diabetes Center, HealthPartners Institute, Minneapolis, MN, USA
- Department of Internal Medicine, Park Nicollet Clinic, Brooklyn Center, MN, USA
| | - Anders L Carlson
- International Diabetes Center, HealthPartners Institute, Minneapolis, MN, USA
- Bright HealthCare, Minneapolis, MN, USA
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28
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Battelino T, Danne T, Edelman SV, Choudhary P, Renard E, Westerbacka J, Mukherjee B, Pilorget V, Coudert M, Bergenstal RM. Continuous glucose monitoring-based time-in-range using insulin glargine 300 units/ml versus insulin degludec 100 units/ml in type 1 diabetes: The head-to-head randomized controlled InRange trial. Diabetes Obes Metab 2023; 25:545-555. [PMID: 36263928 PMCID: PMC10100006 DOI: 10.1111/dom.14898] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 10/05/2022] [Accepted: 10/14/2022] [Indexed: 02/02/2023]
Abstract
AIM To use continuous glucose monitoring (CGM)-based time-in-range (TIR) as a primary efficacy endpoint to compare the second-generation basal insulin (BI) analogues insulin glargine 300 U/ml (Gla-300) and insulin degludec 100 U/ml (IDeg-100) in adults with type 1 diabetes (T1D). MATERIALS AND METHODS InRange was a 12-week, multicentre, randomized, active-controlled, parallel-group, open-label study comparing glucose TIR and variability between Gla-300 and IDeg-100 using blinded 20-day CGM profiles. The inclusion criteria consisted of adults with T1D treated with multiple daily injections, using BI once daily and rapid-acting insulin analogues for at least 1 year, with an HbA1c of 7% or higher and of 10% or less at screening. RESULTS Overall, 343 participants were randomized: 172 received Gla-300 and 171 IDeg-100. Non-inferiority (10% relative margin) of Gla-300 versus IDeg-100 was shown for the primary endpoint (percentage TIR ≥ 70 to ≤ 180 mg/dl): least squares (LS) mean (95% confidence interval) 52.74% (51.06%, 54.42%) for Gla-300 and 55.09% (53.34%, 56.84%) for IDeg-100; LS mean difference (non-inferiority): 3.16% (0.88%, 5.44%) (non-inferiority P = .0067). Non-inferiority was shown on glucose total coefficient of variation (main secondary endpoint): LS mean 39.91% (39.20%, 40.61%) and 41.22% (40.49%, 41.95%), respectively; LS mean difference (non-inferiority) -5.44% (-6.50%, -4.38%) (non-inferiority P < .0001). Superiority of Gla-300 over IDeg-100 was not shown on TIR. Occurrences of self-measured and CGM-derived hypoglycaemia were comparable between treatment groups. Safety profiles were consistent with known profiles, with no unexpected findings. CONCLUSIONS Using clinically relevant CGM metrics, InRange shows that Gla-300 is non-inferior to IDeg-100 in people with T1D, with comparable hypoglycaemia and safety profiles.
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Affiliation(s)
- Tadej Battelino
- UMC-University Children's Hospital, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Thomas Danne
- Diabetes Centre for Children and Adolescents, Children's and Youth Hospital "Auf Der Bult", Hannover, Germany
| | | | - Pratik Choudhary
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Eric Renard
- Department of Endocrinology, Diabetes and Nutrition, Montpellier University Hospital, University of Montpellier, Montpellier, France
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29
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Abstract
We compared the glucose management indicator (GMI) calculated using 14 days of continuous glucose monitor (CGM) data with GMI calculated using <14 days. Analysis included 581 individuals with type 1 diabetes or type 2 diabetes from five clinical trials. The correlation between the 14- and 7-day GMI was 0.95 and the correlation between 14 days versus 10, 5, and 3 days GMI was 0.98, 0.91, and 0.86, respectively. The percentages of GMI values within 0.3% of the 14-day GMI were 98% with 10-day GMI, 87% with 7-day GMI, 77% with 5-day GMI, and 60% with 3-day GMI. Minimal differences were observed between GMI computed using 14 days of data compared with GMI computed with 7 days. Although 10-14 days of CGM data are preferred for computing GMI, for most patients a satisfactory estimate of HbA1c can be obtained with 7 days of data.
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Affiliation(s)
- Ryan Bailey
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - Peter Calhoun
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - Richard M Bergenstal
- International Diabetes Center, HealthPartners Institute, Minneapolis, Minnesota, USA
| | - Roy W Beck
- Jaeb Center for Health Research, Tampa, Florida, USA
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30
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Sherr JL, Heinemann L, Fleming GA, Bergenstal RM, Bruttomesso D, Hanaire H, Holl RW, Petrie JR, Peters AL, Evans M. Automated insulin delivery: benefits, challenges, and recommendations. A Consensus Report of the Joint Diabetes Technology Working Group of the European Association for the Study of Diabetes and the American Diabetes Association. Diabetologia 2023; 66:3-22. [PMID: 36198829 PMCID: PMC9534591 DOI: 10.1007/s00125-022-05744-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/07/2022] [Indexed: 01/15/2023]
Abstract
A technological solution for the management of diabetes in people who require intensive insulin therapy has been sought for decades. The last 10 years have seen substantial growth in devices that can be integrated into clinical care. Driven by the availability of reliable systems for continuous glucose monitoring, we have entered an era in which insulin delivery through insulin pumps can be modulated based on sensor glucose data. Over the past few years, regulatory approval of the first automated insulin delivery (AID) systems has been granted, and these systems have been adopted into clinical care. Additionally, a community of people living with type 1 diabetes has created its own systems using a do-it-yourself approach by using products commercialised for independent use. With several AID systems in development, some of which are anticipated to be granted regulatory approval in the near future, the joint Diabetes Technology Working Group of the European Association for the Study of Diabetes and the American Diabetes Association has created this consensus report. We provide a review of the current landscape of AID systems, with a particular focus on their safety. We conclude with a series of recommended targeted actions. This is the fourth in a series of reports issued by this working group. The working group was jointly commissioned by the executives of both organisations to write the first statement on insulin pumps, which was published in 2015. The original authoring group was comprised by three nominated members of the American Diabetes Association and three nominated members of the European Association for the Study of Diabetes. Additional authors have been added to the group to increase diversity and range of expertise. Each organisation has provided a similar internal review process for each manuscript prior to submission for editorial review by the two journals. Harmonisation of editorial and substantial modifications has occurred at both levels. The members of the group have selected the subject of each statement and submitted the selection to both organisations for confirmation.
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Affiliation(s)
| | | | | | - Richard M Bergenstal
- International Diabetes Center and HealthPartners Institute, Minneapolis, MN, USA
| | - Daniela Bruttomesso
- Unit of Metabolic Diseases, Department of Medicine, University of Padova, Padova, Italy
| | - Hélène Hanaire
- Department of Diabetology, University Hospital of Toulouse, University of Toulouse, Toulouse, France
| | - Reinhard W Holl
- Institute of Epidemiology and Medical Biometry, Central Institute of Biomedical Engineering (ZIBMT), University of Ulm, Ulm, Germany
- German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
| | - John R Petrie
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Anne L Peters
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Mark Evans
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK.
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31
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Battelino T, Alexander CM, Amiel SA, Arreaza-Rubin G, Beck RW, Bergenstal RM, Buckingham BA, Carroll J, Ceriello A, Chow E, Choudhary P, Close K, Danne T, Dutta S, Gabbay R, Garg S, Heverly J, Hirsch IB, Kader T, Kenney J, Kovatchev B, Laffel L, Maahs D, Mathieu C, Mauricio D, Nimri R, Nishimura R, Scharf M, Del Prato S, Renard E, Rosenstock J, Saboo B, Ueki K, Umpierrez GE, Weinzimer SA, Phillip M. Continuous glucose monitoring and metrics for clinical trials: an international consensus statement. Lancet Diabetes Endocrinol 2023; 11:42-57. [PMID: 36493795 DOI: 10.1016/s2213-8587(22)00319-9] [Citation(s) in RCA: 128] [Impact Index Per Article: 128.0] [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: 08/29/2022] [Revised: 10/27/2022] [Accepted: 10/28/2022] [Indexed: 12/12/2022]
Abstract
Randomised controlled trials and other prospective clinical studies for novel medical interventions in people with diabetes have traditionally reported HbA1c as the measure of average blood glucose levels for the 3 months preceding the HbA1c test date. The use of this measure highlights the long-established correlation between HbA1c and relative risk of diabetes complications; the change in the measure, before and after the therapeutic intervention, is used by regulators for the approval of medications for diabetes. However, with the increasing use of continuous glucose monitoring (CGM) in clinical practice, prospective clinical studies are also increasingly using CGM devices to collect data and evaluate glucose profiles among study participants, complementing HbA1c findings, and further assess the effects of therapeutic interventions on HbA1c. Data is collected by CGM devices at 1-5 min intervals, which obtains data on glycaemic excursions and periods of asymptomatic hypoglycaemia or hyperglycaemia (ie, details of glycaemic control that are not provided by HbA1c concentrations alone that are measured continuously and can be analysed in daily, weekly, or monthly timeframes). These CGM-derived metrics are the subject of standardised, internationally agreed reporting formats and should, therefore, be considered for use in all clinical studies in diabetes. The purpose of this consensus statement is to recommend the ways CGM data might be used in prospective clinical studies, either as a specified study endpoint or as supportive complementary glucose metrics, to provide clinical information that can be considered by investigators, regulators, companies, clinicians, and individuals with diabetes who are stakeholders in trial outcomes. In this consensus statement, we provide recommendations on how to optimise CGM-derived glucose data collection in clinical studies, including the specific glucose metrics and specific glucose metrics that should be evaluated. These recommendations have been endorsed by the American Association of Clinical Endocrinologists, the American Diabetes Association, the Association of Diabetes Care and Education Specialists, DiabetesIndia, the European Association for the Study of Diabetes, the International Society for Pediatric and Adolescent Diabetes, the Japanese Diabetes Society, and the Juvenile Diabetes Research Foundation. A standardised approach to CGM data collection and reporting in clinical trials will encourage the use of these metrics and enhance the interpretability of CGM data, which could provide useful information other than HbA1c for informing therapeutic and treatment decisions, particularly related to hypoglycaemia, postprandial hyperglycaemia, and glucose variability.
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Affiliation(s)
- Tadej Battelino
- Department of Pediatric Endocrinology, Diabetes and Metabolism, University Children's Hospital, University Medical Centre Ljubljana, and Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.
| | | | | | - Guillermo Arreaza-Rubin
- Division of Diabetes, Endocrinology and Metabolic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, USA
| | - Roy W Beck
- Jaeb Center for Health Research, Tampa, FL, USA
| | | | - Bruce A Buckingham
- Division of Endocrinology and Diabetes, Department of Pediatrics, Stanford Medical Center, Stanford, CA, USA
| | | | | | - Elaine Chow
- Phase 1 Clinical Trial Centre, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Pratik Choudhary
- Leicester Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Kelly Close
- diaTribe Foundation, San Francisco, CA, USA; Close Concerns, San Francisco, CA, USA
| | - Thomas Danne
- Diabetes Centre for Children and Adolescents, Auf der Bult, Hanover, Germany
| | | | - Robert Gabbay
- American Diabetes Association, Arlington, VA, USA; Harvard Medical School, Harvard University, Boston, MA, USA
| | - Satish Garg
- Barbara Davis Centre for Diabetes, University of Colorado Denver, Aurora, CO, USA
| | | | - Irl B Hirsch
- Division of Metabolism, Endocrinology and Nutrition, University of Washington School of Medicine, University of Washington, Seattle, WA, USA
| | - Tina Kader
- Jewish General Hospital, Montreal, QC, Canada
| | | | - Boris Kovatchev
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA, USA
| | - Lori Laffel
- Pediatric, Adolescent and Young Adult Section, Joslin Diabetes Center, Harvard Medical School, Harvard University, Boston, MA, USA
| | - David Maahs
- Department of Pediatrics, Stanford Diabetes Research Center, Stanford, CA, USA
| | - Chantal Mathieu
- Clinical and Experimental Endocrinology, KU Leuven, Leuven, Belgium
| | - Dídac Mauricio
- Department of Endocrinology and Nutrition, CIBERDEM (Instituto de Salud Carlos III), Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
| | - Revital Nimri
- National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Rimei Nishimura
- The Jikei University School of Medicine, Jikei University, Tokyo, Japan
| | - Mauro Scharf
- Centro de Diabetes Curitiba and Division of Pediatric Endocrinology, Hospital Nossa Senhora das Graças, Curitiba, Brazil
| | - Stefano Del Prato
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Eric Renard
- Department of Endocrinology, Diabetes and Nutrition, Montpellier University Hospital, Montpellier, France; Institute of Functional Genomics, University of Montpellier, Montpellier, France; INSERM Clinical Investigation Centre, Montpellier, France
| | - Julio Rosenstock
- Velocity Clinical Research, Medical City, Dallas, TX; University of Texas Southwestern Medical Center, University of Texas, Dallas, TX, USA
| | - Banshi Saboo
- Dia Care, Diabetes Care and Hormone Clinic, Ahmedabad, India
| | - Kohjiro Ueki
- Diabetes Research Center, National Center for Global Health and Medicine, Tokyo, Japan
| | | | - Stuart A Weinzimer
- Department of Pediatrics, Yale University School of Medicine, Yale University, New Haven, CT, USA
| | - Moshe Phillip
- National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Sherr JL, Heinemann L, Fleming GA, Bergenstal RM, Bruttomesso D, Hanaire H, Holl RW, Petrie JR, Peters AL, Evans M. Automated Insulin Delivery: Benefits, Challenges, and Recommendations. A Consensus Report of the Joint Diabetes Technology Working Group of the European Association for the Study of Diabetes and the American Diabetes Association. Diabetes Care 2022; 45:3058-3074. [PMID: 36202061 DOI: 10.2337/dci22-0018] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/07/2022] [Indexed: 02/03/2023]
Abstract
A technological solution for the management of diabetes in people who require intensive insulin therapy has been sought for decades. The last 10 years have seen substantial growth in devices that can be integrated into clinical care. Driven by the availability of reliable systems for continuous glucose monitoring, we have entered an era in which insulin delivery through insulin pumps can be modulated based on sensor glucose data. Over the past few years, regulatory approval of the first automated insulin delivery (AID) systems has been granted, and these systems have been adopted into clinical care. Additionally, a community of people living with type 1 diabetes has created its own systems using a do-it-yourself approach by using products commercialized for independent use. With several AID systems in development, some of which are anticipated to be granted regulatory approval in the near future, the joint Diabetes Technology Working Group of the European Association for the Study of Diabetes and the American Diabetes Association has created this consensus report. We provide a review of the current landscape of AID systems, with a particular focus on their safety. We conclude with a series of recommended targeted actions. This is the fourth in a series of reports issued by this working group. The working group was jointly commissioned by the executives of both organizations to write the first statement on insulin pumps, which was published in 2015. The original authoring group was comprised by three nominated members of the American Diabetes Association and three nominated members of the European Association for the Study of Diabetes. Additional authors have been added to the group to increase diversity and range of expertise. Each organization has provided a similar internal review process for each manuscript prior to submission for editorial review by the two journals. Harmonization of editorial and substantial modifications has occurred at both levels. The members of the group have selected the subject of each statement and submitted the selection to both organizations for confirmation.
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Affiliation(s)
| | | | | | | | - Daniela Bruttomesso
- Unit of Metabolic Diseases, Department of Medicine, University of Padova, Padova, Italy
| | - Hélène Hanaire
- Department of Diabetology, University Hospital of Toulouse, University of Toulouse, Toulouse, France
| | - Reinhard W Holl
- Institute of Epidemiology and Medical Biometry, Central Institute of Biomedical Engineering (ZIBMT), University of Ulm, Ulm, Germany.,German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
| | - John R Petrie
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, U.K
| | - Anne L Peters
- Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Mark Evans
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, U.K
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Raghinaru D, Calhoun P, Bergenstal RM, Beck RW. The Optimal Duration of a Run-In Period to Initiate Continuous Glucose Monitoring for a Randomized Trial. Diabetes Technol Ther 2022; 24:868-872. [PMID: 35920822 DOI: 10.1089/dia.2022.0274] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objective: To determine the optimal duration of a run-in period for initiation of real-time continuous glucose monitoring (CGM) before the start of a randomized controlled trial (RCT) in type 1 diabetes (T1D) or type 2 diabetes (T2D). Methods: Data sets were pooled from 8 RCTs, which had a blinded CGM wear period followed by at least 3 months of unblinded CGM use. Across all participants, mean time in range 70-180 mg/dL (TIR) and mean time <54 mg/dL (T < 54) as well as other key CGM metrics were computed for the initial period of blinded CGM wear and from the subsequent 13 weeks of unblinded CGM use. Results: The analysis cohort included data from 485 participants: 348 with T1D and 137 with T2D, ranging in age from 2 to 82 years. Mean TIR was 49% with blinded CGM before initiation of unblinded CGM use, increased to 55% by the end of the first week of unblinded CGM use, and then showed little change through 13 weeks. Mean T < 54 decreased from 1.4% with blinded CGM to 0.8% 1 week and 0.6% 2 weeks after initiating unblinded CGM use, which matched the value in month 3. Similar results were obtained for mean glucose, time >180 mg/dL, time >250 mg/dL, and time <70 mg/dL, with the mean improvement in hyperglycemia metrics plateauing slightly faster than hypoglycemia metrics. Findings were largely similar for T1D and T2D. Conclusion: When initiating unblinded real-time CGM, improvement in key CGM metrics occurs rapidly, with maximal effect on the mean of each metric achieved within 1-2 weeks. For a randomized trial in which all participants will use real-time unblinded CGM for glucose monitoring, a run-in period should be implemented before collecting baseline data for participants who are not CGM users. For such CGM-naive individuals, a 7- to 14-day acclimation period is sufficient followed by a 14-day period for collection of baseline unblinded CGM data.
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Affiliation(s)
- Dan Raghinaru
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - Peter Calhoun
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - Richard M Bergenstal
- International Diabetes Center, HealthPartners Institute, Minneapolis, Minnesota, USA
| | - Roy W Beck
- Jaeb Center for Health Research, Tampa, Florida, USA
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Dovc K, Battelino T, Beck RW, Sibayan J, Bailey RJ, Calhoun P, Turcotte C, Weinzimer S, Smigoc Schweiger D, Nimri R, Bergenstal RM. Impact of Temporary Glycemic Target Use in the Hybrid and Advanced Hybrid Closed-Loop Systems. Diabetes Technol Ther 2022; 24:848-852. [PMID: 35848991 PMCID: PMC9618368 DOI: 10.1089/dia.2022.0153] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The Medtronic advanced hybrid closed-loop (AHCL) and MiniMed™ 670G hybrid closed-loop (HCL) systems provide the option to temporarily increase the glucose target to 150 mg/dL (8.3 mmol/L). This analysis investigated the efficacy of the AHCL compared with that of the HCL after the use of this setting. Data from 60 participants in the Fuzzy Logic Automated Insulin Regulation (FLAIR) study were used to compare the AHCL and HCL systems after the use of the temporary target (TT), and during analogous periods where this setting was not used. Differences in time in range 70-180 mg/dL between the systems were similar after the use of the TT setting and during analogous non-TT periods (interaction P = 0.87). Similar trends were observed for mean glucose, percentage time >180 mg/dL, and percentage time >250 mg/dL. Differences between AHCL and HCL systems were similar after the use of the TT setting compared with those of non-TT periods. ClinicalTrials.gov NCT03040414.
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Affiliation(s)
- Klemen Dovc
- University Medical Center Ljubljana, University Children's Hospital, and Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Tadej Battelino
- University Medical Center Ljubljana, University Children's Hospital, and Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Roy W. Beck
- Jaeb Center for Health Research Foundation, Inc., Tampa, Florida, USA
| | - Judy Sibayan
- Jaeb Center for Health Research Foundation, Inc., Tampa, Florida, USA
| | - Ryan J. Bailey
- Jaeb Center for Health Research Foundation, Inc., Tampa, Florida, USA
| | - Peter Calhoun
- Jaeb Center for Health Research Foundation, Inc., Tampa, Florida, USA
| | - Christine Turcotte
- Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Stuart Weinzimer
- Department of Pediatrics, Yale University, New Haven, Connecticut, USA
| | - Darja Smigoc Schweiger
- University Medical Center Ljubljana, University Children's Hospital, and Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Revital Nimri
- Schneider Children's Medical Center, Petah Tikva, Israel
| | - Richard M. Bergenstal
- International Diabetes Center, HealthPartners Institute, Minneapolis, Minnesota, USA
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Bergenstal RM, Johnson ML, Aroda VR, Brazg RL, Dreon DM, Frias JP, Kruger DF, Molitch ME, Mullen DM, Peyrot M, Richter S, Rosenstock J, Serusclat P, Vance C, Weinstock RS, Levy BL. Comparing Patch vs Pen Bolus Insulin Delivery in Type 2 Diabetes Using Continuous Glucose Monitoring Metrics and Profiles. J Diabetes Sci Technol 2022; 16:1167-1173. [PMID: 34008442 PMCID: PMC9445326 DOI: 10.1177/19322968211016513] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE CeQur Simplicity™ (CeQur, Marlborough, MA) is a 3-day insulin delivery patch designed to meet mealtime insulin requirements. A recently reported 48-week, randomized, multicenter, interventional trial compared efficacy, safety and self-reported outcomes in 278 adults with type 2 diabetes (T2D) on basal insulin therapy who initiated and managed mealtime insulin therapy with a patch pump versus insulin pen. We assessed changes in key glycemic metrics among a subset of patients who wore a continuous glucose monitoring (CGM) device. METHODS Study participants (patch, n = 49; pen, n = 48) wore a CGM device in masked setting during the baseline period and prior to week 24. Glycemic control was assessed using international consensus guidelines for percentage of Time In Range (%TIR: >70% at 70-180 mg/dL), Time Below Range (%TBR: <4% at <70 mg/dL; <1% at <54 mg/dL), and Time Above Range (%TAR: <25% at >180 mg/dL; <5% at >250 mg/dL). RESULTS Both the patch and pen groups achieved recommended targets in %TIR (74.1% ± 18.7%, 75.2 ± 16.1%, respectively) and marked reductions in %TAR >180 mg/dL (21.1% ± 19.9%, 19.7% ± 17.5%, respectively) but with increased %TBR <70 mg/dL (4.7% ± 5.2%, 5.1 ± 5.8, respectively), all P < .0001. No significant between-group differences in glycemic improvements or adverse events were observed. CONCLUSIONS CGM confirmed that the patch or pen can be used to safely initiate and optimize basal-bolus therapy using a simple insulin adjustment algorithm with SMBG. Preference data suggest that use of the patch vs pen may enhance treatment adherence.
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Affiliation(s)
- Richard M. Bergenstal
- International Diabetes Center, Park Nicollet, Minneapolis, MN, USA
- Richard M. Bergenstal, MD, International Diabetes Center, Park Nicollet, 3800 Park Nicollet Blvd, Minneapolis, MN 55416, USA.
| | - Mary L. Johnson
- International Diabetes Center, Park Nicollet, Minneapolis, MN, USA
| | | | | | - Darlene M. Dreon
- Calibra Medical, Johnson & Johnson Diabetes Care Companies, Wayne, PA, USA
| | | | - Davida F. Kruger
- Division of Endocrinology, Diabetes, Bone and Mineral Disease, Henry Ford Health System, Detroit, MI, USA
| | - Mark E. Molitch
- Division of Endocrinology, Metabolism and Molecular Medicine at the Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Mark Peyrot
- Loyola University Maryland, Department of Sociology, Baltimore, MD, USA
| | - Sara Richter
- Professional Data Analysts, GBC, Minneapolis, MN, USA
| | - Julio Rosenstock
- Dallas Diabetes Research Center at Medical City, Dallas, TX, USA
| | - Pierre Serusclat
- Groupe Hospitalier Mutualiste Les Portes du Sud, Ve’nissieux, France
| | - Carl Vance
- Rocky Mountain Diabetes Center, Idaho Falls, Idaho, USA
| | - Ruth S. Weinstock
- Department of Endocrinology, Diabetes and Metabolism, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Brian L. Levy
- Calibra Medical, Johnson & Johnson Diabetes Care Companies, Wayne, PA, USA
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Xu Y, Bergenstal RM, Dunn TC, Ram Y, Ajjan RA. Interindividual variability in average glucose-glycated haemoglobin relationship in type 1 diabetes and implications for clinical practice. Diabetes Obes Metab 2022; 24:1779-1787. [PMID: 35546274 PMCID: PMC9546041 DOI: 10.1111/dom.14763] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 04/22/2022] [Accepted: 05/08/2022] [Indexed: 12/25/2022]
Abstract
AIM Glycated haemoglobin (HbA1c) can fail to reflect average glucose levels, potentially compromising management decisions. We analysed variability in the relationship between mean glucose and HbA1c in individuals with diabetes. MATERIALS AND METHODS Three months of continuous glucose monitoring and HbA1c data were obtained from 216 individuals with type 1 diabetes. Universal red blood cell glucose transporter-1 Michaelis constant KM and individualized apparent glycation ratio (AGR) were calculated and compared across age, racial and gender groups. RESULTS The mean age (range) was 30 years (8-72) with 94 younger than 19 years, 78 between 19 and 50 years, and 44 were >50 years. The group contained 120 women and 96 men with 106 white and 110 black individuals. The determined KM value was 464 mg/dl and AGR was (mean ± SD) 72.1 ± 7 ml/g. AGR, which correlated with red blood cell lifespan marker, was highest in those aged >50 years at 75.4 ± 6.9 ml/g, decreasing to 73.2 ± 7.8 ml/g in 19-50 years, with a further drop to 71.0 ± 5.8 ml/g in the youngest group (p <0 .05). AGR differed between white and black groups (69.9 ± 5.8 and 74.2 ± 7.1 ml/g, respectively; p < .001). In contrast, AGR values were similar in men and women (71.5 ± 7.5 and 72.5 ± 6.6 ml/g, respectively; p = .27). Interestingly, interindividual AGR variation within each group was at least four-fold higher than average for between-group variation. CONCLUSIONS In this type 1 diabetes cohort, ethnicity and age, but not gender, alter the HbA1c-glucose relationship with even larger interindividual variations found within each group than between groups. Clinical application of personalized HbA1c-glucose relationships has the potential to optimize glycaemic care in the population with diabetes.
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Affiliation(s)
- Yongjin Xu
- Abbott Diabetes Care, Alameda, California, USA
| | - Richard M Bergenstal
- International Diabetes Center, Park Nicollet, HealthPartners, Minneapolis, Minnesota, USA
| | | | | | - Ramzi A Ajjan
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
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Weinzimer SA, Bailey RJ, Bergenstal RM, Nimri R, Beck RW, Schatz D, Ambler-Osborn L, Schweiger DS, von dem Berge T, Sibayan J, Johnson ML, Calhoun P, Phillip M. A Comparison of Postprandial Glucose Control in the Medtronic Advanced Hybrid Closed-Loop System Versus 670G. Diabetes Technol Ther 2022; 24:573-582. [PMID: 35363054 PMCID: PMC9353997 DOI: 10.1089/dia.2021.0568] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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] [Indexed: 12/16/2022]
Abstract
Background: We recently reported that use of an "advanced" hybrid closed-loop system reduced hyperglycemia without increasing hypoglycemia compared to a first-generation system. The aim of this analysis was to evaluate whether this improved performance was specifically related to better mealtime glycemic control. Methods: We conducted a secondary analysis of postprandial glycemic control in an open-label, multinational, randomized crossover trial of 112 participants with type 1 diabetes, aged 14-29, of the Medtronic MiniMed™ 670G hybrid closed-loop system (670G) versus the Medtronic advanced hybrid closed-loop (AHCL) system, for 12 weeks each. We compared glycemic and insulin delivery metrics over a 3 h horizon across all meals to assess system performance and outcomes. Results: Overall meal size and premeal insulin on board were similar during run-in and between 670G and AHCL arms. Compared with 670G arm, premeal, peak, and mean glucose levels were numerically lower in the AHCL arm (167 ± 23, 231 ± 23, and 177 ± 20 mg/dL vs. 175 ± 23, 235 ± 23, and 180 ± 19 mg/dL, respectively), with a trend to lower hyperglycemia level 2 in AHCL arm. Adjusting for premeal glucose level, all postmeal outcomes between 670G and AHCL were statistically similar. Prandial insulin delivery also was similar in both treatment arms (21 ± 9 vs. 23 ± 10 U), with a shift in basal/bolus ratio from 28%/71% in 670G arm to 20%/80% in AHCL arm. Conclusions: Reduced hyperglycemia with AHCL compared to 670G was not related to early postprandial glycemic excursions after adjusting for premeal glucose level (<3 h after meal), but likely to later (>3 h) postprandial or overnight improvements. Further refinements to mealtime bolus algorithms and strategies may more optimally control prandial glycemic excursions.
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Affiliation(s)
- Stuart A. Weinzimer
- Department of Pediatrics, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Ryan J. Bailey
- Jaeb Center for Health Research Foundation, Inc., Tampa, Florida, USA
| | - Richard M. Bergenstal
- International Diabetes Center, HealthPartners Institute, Minneapolis, Minnesota, USA
| | - Revital Nimri
- Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL
- Sacker Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Roy W. Beck
- Jaeb Center for Health Research Foundation, Inc., Tampa, Florida, USA
| | - Desmond Schatz
- University of Florida College of Medicine, Gainesville, Florida, USA
| | | | - Darja Smigoc Schweiger
- University Medical Center Ljubljana, University Children's Hospital, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | | | - Judy Sibayan
- Jaeb Center for Health Research Foundation, Inc., Tampa, Florida, USA
| | - Mary L. Johnson
- International Diabetes Center, HealthPartners Institute, Minneapolis, Minnesota, USA
| | - Peter Calhoun
- Jaeb Center for Health Research Foundation, Inc., Tampa, Florida, USA
| | - Moshe Phillip
- Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL
- Sacker Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Battelino T, Bergenstal RM, Rodríguez A, Fernández Landó L, Bray R, Tong Z, Brown K. Efficacy of once-weekly tirzepatide versus once-daily insulin degludec on glycaemic control measured by continuous glucose monitoring in adults with type 2 diabetes (SURPASS-3 CGM): a substudy of the randomised, open-label, parallel-group, phase 3 SURPASS-3 trial. Lancet Diabetes Endocrinol 2022; 10:407-417. [PMID: 35468321 DOI: 10.1016/s2213-8587(22)00077-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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: 12/17/2021] [Revised: 02/21/2022] [Accepted: 02/22/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Tirzepatide is a novel dual glucose-dependent insulinotropic polypeptide (GIP) and GLP-1 receptor agonist under development for the treatment of type 2 diabetes. In this study, we used continuous glucose monitoring (CGM) to compare the 24 h glucose profile for participants given tirzepatide compared with those given insulin degludec. METHODS This substudy of the open-label, parallel-group, phase 3 SURPASS-3 trial, was done at 45 sites across six countries (Hungary, Poland, Romania, Spain, Ukraine, and the USA). Eligible participants in the main study were adults with type 2 diabetes, a baseline HbA1c of 7·0-10·5% (53-91 mmol/mol), and a BMI of 25 kg/m2 or more, who were insulin-naive, and treated with metformin alone or in combination with a SGLT2 inhibitor for at least 3 months before screening. Participants in the main study were randomly assigned (1:1:1:1) to receive once-weekly subcutaneous injection of tirzepatide 5 mg, 10 mg, or 15 mg, or once-daily subcutaneous injection of titrated insulin degludec (100 U/mL), using an interactive web-response system. Participants were stratified by country, HbA1c concentration, and concomitant oral antihyperglycaemic medication. A subset of these patients with a normal wake-sleep cycle were enrolled into this substudy, and interstitial glucose values were collected by CGM for approximately 7 days at baseline, 24 weeks, and 52 weeks. The primary outcome was to compare pooled participants assigned to 10 mg and 15 mg tirzepatide versus insulin degludec for the proportion of time that CGM values were in the tight target range (71-140 mg/dL) at 52 weeks, assessed in all randomly assigned participants who received at least one dose of study drug and had an evaluable CGM session at either baseline or after baseline. The secondary outcomes were to compare tirzepatide (5 mg, 10 mg, and 15 mg) versus insulin degludec for the proportion and duration of time in tight target range at 24 and 52 weeks. This was a substudy of the trial registered with ClinicalTrials.gov, NCT03882970, and is complete. FINDINGS From April 1 to Nov 27, 2019, 313 participants were screened for eligibility, 243 of whom were enrolled in CGM substudy (tirzepatide 5 mg, n=64; tirzepatide 10 mg, n=51; tirzepatide 15 mg, n=73; and insulin degludec, n=55). Patients given once-weekly tirzepatide (pooled 10 mg and 15 mg groups) had a greater proportion of time in tight target range compared with patients given insulin degludec (estimated treatment difference 25% [95% CI 16-33]; p<0·0001). Participants assigned to tirzepatide spent significantly more time in tight target range at 52 weeks compared with those assigned to insulin degludec (5 mg 12% [1-22], p=0·031; 10 mg 24% [13-35], p<0·0001; and 15 mg 25% [14-35], p<0·0001). Participants assigned to tirzepatide 10 mg and 15 mg, but not to tirzepatide 5 mg, spent significantly more time in tight target range at 24 weeks compared with insulin degludec (10 mg 19% [8-30], p=0·0008; 15 mg 21% [11-31], p<0·0001). INTERPRETATION Once-weekly treatment with tirzepatide showed superior glycaemic control measured using CGM compared with insulin degludec in participants with type 2 diabetes on metformin, with or without a SGLT2 inhibitor. These new data provide additional evidence to the effect of tirzepatide and potential for achieving glycaemic targets without increase of hypoglycaemic risk compared with a basal insulin. FUNDING Eli Lilly and Company.
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Affiliation(s)
- Tadej Battelino
- Faculty of Medicine, University of Ljubljana, and University Medical Center Ljubljana, Ljubljana, Slovenia
| | | | | | | | - Ross Bray
- Eli Lilly and Company, Indianapolis, IN, USA
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39
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Nguyen KT, Xu NY, Zhang JY, Shang T, Basu A, Bergenstal RM, Castorino K, Chen KY, Kerr D, Koliwad SK, Laffel LM, Mathioudakis N, Midyett LK, Miller JD, Nichols JH, Pasquel FJ, Prahalad P, Prausnitz MR, Seley JJ, Sherr JL, Spanakis EK, Umpierrez GE, Wallia A, Klonoff DC. Continuous Ketone Monitoring Consensus Report 2021. J Diabetes Sci Technol 2022; 16:689-715. [PMID: 34605694 PMCID: PMC9294575 DOI: 10.1177/19322968211042656] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [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] [Indexed: 12/18/2022]
Abstract
This article is the work product of the Continuous Ketone Monitoring Consensus Panel, which was organized by Diabetes Technology Society and met virtually on April 20, 2021. The panel consisted of 20 US-based experts in the use of diabetes technology, representing adult endocrinology, pediatric endocrinology, advanced practice nursing, diabetes care and education, clinical chemistry, and bioengineering. The panelists were from universities, hospitals, freestanding research institutes, government, and private practice. Panelists reviewed the medical literature pertaining to ten topics: (1) physiology of ketone production, (2) measurement of ketones, (3) performance of the first continuous ketone monitor (CKM) reported to be used in human trials, (4) demographics and epidemiology of diabetic ketoacidosis (DKA), (5) atypical hyperketonemia, (6) prevention of DKA, (7) non-DKA states of fasting ketonemia and ketonuria, (8) potential integration of CKMs with pumps and automated insulin delivery systems to prevent DKA, (9) clinical trials of CKMs, and (10) the future of CKMs. The panelists summarized the medical literature for each of the ten topics in this report. They also developed 30 conclusions (amounting to three conclusions for each topic) about CKMs and voted unanimously to adopt the 30 conclusions. This report is intended to support the development of safe and effective continuous ketone monitoring and to apply this technology in ways that will benefit people with diabetes.
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Affiliation(s)
| | - Nicole Y. Xu
- Diabetes Technology Society,
Burlingame, CA, USA
| | | | - Trisha Shang
- Diabetes Technology Society,
Burlingame, CA, USA
| | - Ananda Basu
- University of Virginia,
Charlottesville, VA, USA
| | | | | | - Kong Y. Chen
- National Institute of Diabetes and
Digestive and Kidney Diseases, Bethesda, MD, USA
| | - David Kerr
- Sansum Diabetes Research Institute,
Santa Barbara, CA, USA
| | | | | | | | | | | | | | | | | | | | | | | | - Elias K. Spanakis
- Baltimore Veterans Affairs Medical
Center, Baltimore, MD, USA
- University of Maryland, Baltimore,
MD, USA
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40
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Bailey R, Calhoun P, Beck RW, Bergenstal RM, Aleppo G. Response to Comment on Aleppo et al. The Effect of Discontinuing Continuous Glucose Monitoring in Adults With Type 2 Diabetes Treated With Basal Insulin. Diabetes Care 2021;44:2729-2737. Diabetes Care 2022; 45:e85-e86. [PMID: 35349654 DOI: 10.2337/dci22-0006] [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: 02/03/2023]
Affiliation(s)
| | | | - Roy W Beck
- Jaeb Center for Health Research, Tampa, FL
| | | | - Grazia Aleppo
- Feinberg School of Medicine, Northwestern University, Chicago, IL
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41
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Bergenstal RM, Mullen DM, Strock E, Johnson ML, Xi MX. Randomized comparison of self-monitored blood glucose (BGM) versus continuous glucose monitoring (CGM) data to optimize glucose control in type 2 diabetes. J Diabetes Complications 2022; 36:108106. [PMID: 35131155 DOI: 10.1016/j.jdiacomp.2021.108106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 12/07/2021] [Accepted: 12/10/2021] [Indexed: 10/19/2022]
Abstract
AIMS Evaluate whether structured BGM testing (BGM) or real-time CGM (CGM) lead to improved glucose control (A1c). Determine which approach optimized glucose control more effectively. METHODS-MULTI-ARM PARALLEL: trial of three type 2 diabetes (T2D) therapies ± metformin: (1) sulfonylurea (SU), (2) incretin (DPP4 inhibitor or GLP-1 agonist), or (3) insulin. After a baseline CGM, 114 adult subjects were randomized to either BGM (4 times daily) or CGM (24/7) for 16 weeks with therapies adjusted every 4 weeks. RESULTS A1c means decreased from 8.19 to 7.07 (1.12% difference) with CGM (n = 59) and 7.85 to 7.03 (0.82% difference) with BGM (n = 55) (p < 0.001). BGM and CGM groups showed significant improvements in time in range and glucose variability-with no significant difference between the two groups. Clinically important hypoglycemia (<50 mg/dL) was significantly reduced for the CGM group compared with BGM (p < 0.01), particularly in subjects taking insulin or therapies with higher hypoglycemic risk (SU). CONCLUSION In T2D, structured, consistent use of glucose data regardless of device (structured BGM or CGM) leads to improvements in A1c control. CGM is more effective than BGM in minimizing hypoglycemia particularly for those using higher hypoglycemic risk therapies.
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Affiliation(s)
- Richard M Bergenstal
- International Diabetes Center, 3800 Park Nicollet Blvd., St. Louis Park, MN 55416, USA.
| | - Deborah M Mullen
- University of Tennessee At Chattanooga, Gary W. Rollins College of Business, 615 McCallie Ave, Fletcher Hall, 323-B, Chattanooga, TN 37403, USA.
| | - Ellie Strock
- International Diabetes Center, 3800 Park Nicollet Blvd., St. Louis Park, MN 55416, USA
| | - Mary L Johnson
- International Diabetes Center, 3800 Park Nicollet Blvd., St. Louis Park, MN 55416, USA.
| | - Min X Xi
- International Diabetes Center, 3800 Park Nicollet Blvd., St. Louis Park, MN 55416, USA.
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42
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Gubitosi-Klug RA, Braffett BH, Bebu I, Johnson ML, Farrell K, Kenny D, Trapani VR, Meadema-Mayer L, Soliman EZ, Pop-Busui R, Lachin JM, Bergenstal RM, Tamborlane WV. Continuous Glucose Monitoring in Adults With Type 1 Diabetes With 35 Years Duration From the DCCT/EDIC Study. Diabetes Care 2022; 45:659-665. [PMID: 35076697 PMCID: PMC8918229 DOI: 10.2337/dc21-0629] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [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: 03/22/2021] [Accepted: 12/17/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We evaluated blinded continuous glucose monitoring (CGM) profiles in a subset of adults with type 1 diabetes from the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) study to characterize the frequency of glycemic excursions and contributing factors. RESEARCH DESIGN AND METHODS CGM-derived metrics were compared for daytime and nighttime periods using blinded CGM for a minimum of 6.5 days (average 11.9 days) and correlated with HbA1c levels, routine use of diabetes devices, and other characteristics in 765 participants. RESULTS Participants were 58.9 ± 6.5 years of age with diabetes duration 36.8 ± 4.9 years and HbA1c 7.8 ± 1.2%; 58% used insulin pumps, and 27% used personal, unblinded CGM. Compared with daytime, nighttime mean sensor glucose was lower, percent time in range 70-180 mg/dL (TIR) was similar, and hypoglycemia was more common. Over the entire recording period, only 9% of the 765 participants achieved >70% TIR and only 28% achieved <1% of observations of <54 mg/dL. Indeed, participants with the highest percentage of hypoglycemia had the lowest HbA1c levels. However, use of insulin pumps and CGM decreased the percent time at <54 mg/dL. CONCLUSIONS In adults with long-standing type 1 diabetes, short-term blinded CGM profiles revealed frequent clinically significant hypoglycemia (<54 mg/dL) during the night and more time in hyperglycemia during the day. The small subset of participants using routine CGM and insulin pumps had fewer hypoglycemic and hyperglycemic excursions and lower HbA1c levels. Thus, strategies to lower meal-stimulated hyperglycemia during the day and prevent hypoglycemia at night are relevant clinical goals in older patients with type 1 diabetes.
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Affiliation(s)
- Rose A. Gubitosi-Klug
- Rainbow Babies and Children’s Hospital, Case Western Reserve University, Cleveland, OH
| | | | - Ionut Bebu
- Biostatistics Center, George Washington University, Rockville, MD
| | | | - Kaleigh Farrell
- Rainbow Babies and Children’s Hospital, Case Western Reserve University, Cleveland, OH
| | - David Kenny
- Biostatistics Center, George Washington University, Rockville, MD
| | | | - Lynne Meadema-Mayer
- Rainbow Babies and Children’s Hospital, Case Western Reserve University, Cleveland, OH
| | | | | | - John M. Lachin
- Biostatistics Center, George Washington University, Rockville, MD
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43
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Simonson GD, Martens TW, Carlson AL, Bergenstal RM. Primary Care and Diabetes Technologies and Treatments. Diabetes Technol Ther 2022; 24:S143-S158. [PMID: 35475700 DOI: 10.1089/dia.2022.2509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Indexed: 11/13/2022]
Affiliation(s)
- Gregg D Simonson
- International Diabetes Center, HealthPartners Institute, Minneapolis, MN
| | - Thomas W Martens
- International Diabetes Center, HealthPartners Institute, Minneapolis, MN
- Department of Internal Medicine, Park Nicollet Clinic, Brooklyn Center, MN
| | - Anders L Carlson
- International Diabetes Center, HealthPartners Institute, Minneapolis, MN
- Department of Endocrinology, HealthPartners, Bloomington, MN
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44
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Affiliation(s)
- Roy W Beck
- JAEB Center for Health Research, Tampa, Florida, USA
| | - Richard M Bergenstal
- International Diabetes Center, HealthPartners Institute, Minneapolis, Minnesota, USA
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45
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Affiliation(s)
| | - Gregg D. Simonson
- International Diabetes Center, HealthPartners Institute, Minneapolis, MN, USA
| | - Lutz Heinemann
- Science-Consulting in Diabetes GmbH, Kaarst, Germany
- Lutz Heinemann, PhD, Science-Consulting in Diabetes GmbH, Geranienweg 7A, 41564 Kaarst, Germany.
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46
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Johnson ML, Bergenstal RM, Levy BL, Dreon DM. A Safe and Simple Algorithm for Adding and Adjusting Mealtime Insulin to Basal-Only Therapy. Clin Diabetes 2022; 40:489-497. [PMID: 36381310 PMCID: PMC9606561 DOI: 10.2337/cd21-0137] [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: 11/13/2022]
Affiliation(s)
- Mary L. Johnson
- International Diabetes Center, Park Nicollet, Minneapolis, MN
- Corresponding author: Mary L. Johnson,
| | | | - Brian L. Levy
- Calibra Medical, Johnson & Johnson Diabetes Care Companies, Wayne, PA
| | - Darlene M. Dreon
- Calibra Medical, Johnson & Johnson Diabetes Care Companies, Wayne, PA
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47
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DuBose SN, Bauza C, Verdejo A, Beck RW, Bergenstal RM, Sherr J. Real-World, Patient-Reported and Clinic Data from Individuals with Type 1 Diabetes Using the MiniMed 670G Hybrid Closed-Loop System. Diabetes Technol Ther 2021; 23:791-798. [PMID: 34524023 DOI: 10.1089/dia.2021.0176] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background: The purpose of this study was to collect 1 year of real-world data from individuals with type 1 diabetes (T1D) initiating the Medtronic 670G hybrid closed-loop insulin delivery system as part of usual care. We sought to expand current knowledge to understand how use of the system impacts patient-reported outcomes, in addition to clinical outcomes, for children and adults with T1D. Methods: Questionnaires were completed by the participant (and/or parent) before initiation of the 670G system (baseline) and at 6 weeks, 6 months, and 12 months from enrollment. Clinical data were obtained at routine clinical visits. Results: Of 132 participants who initiated Auto Mode, 80 completed the 12-month questionnaires while persisting with the system. Nearly all reported receiving adequate training on the 670G. Participant and parent-reported fear of hypoglycemia decreased by 6 and 11 points, respectively, from baseline to 12 months. More than half reported issues with sleep interruption at night due to alarms and 40% did not like frequent exits from Auto Mode. For the subset who had complete continuous glucose monitor data (n = 27), mean percent time in target range (70-180 mg/dL) was 66% at baseline, and 74% and 68% at 6 and 12 months, respectively. Conclusions: With this study, we have captured real-time feedback from patients with T1D who initiated the 670G system and continued to use it over 12 months regarding their experience with the system. This has helped to illuminate both benefits and burdens associated with the first commercially available hybrid closed-loop system.
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Affiliation(s)
| | - Colleen Bauza
- Jaeb Center for Health Research, Tampa, Florida, USA
| | | | - Roy W Beck
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - Richard M Bergenstal
- International Diabetes Center, Park Nicollet and HealthPartners, St. Louis Park, Minnesota, USA
| | - Jennifer Sherr
- Department of Pediatrics, Yale Children's Diabetes Program, New Haven, Connecticut, USA
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48
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Hood KK, Laffel LM, Danne T, Nimri R, Weinzimer SA, Sibayan J, Bailey RJ, Schatz D, Bratina N, Bello R, Punel A, Calhoun P, Beck RW, Bergenstal RM, Phillip M. Lived Experience of Advanced Hybrid Closed-Loop Versus Hybrid Closed-Loop: Patient-Reported Outcomes and Perspectives. Diabetes Technol Ther 2021; 23:857-861. [PMID: 34270328 PMCID: PMC9009590 DOI: 10.1089/dia.2021.0153] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [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] [Indexed: 01/20/2023]
Abstract
This article reports on the lived experience of Medtronic advanced hybrid closed-loop (AHCL) in comparison to first generation hybrid closed-loop (HCL) in a randomized, open-label, two-period crossover trial. Patient-reported outcome (PROs) measures were administered before randomization and at the end of each study period in 113 adolescents and young adults with type 1 diabetes. Glucose monitoring satisfaction subscales for emotional burden and behavioral burden improved significantly (P < 0.01) over time with use of AHCL versus HCL and co-occurred with glycemic improvements (reduced percent time above 180 mg/dL during the day and no change in % time less than 54 mg/dL across 24 h) and greater time in Auto Mode. PROs, including distress, technology attitudes, and hypoglycemia confidence, were not different. AHCL use was associated with improved glucose monitoring satisfaction. Satisfaction was greater in those participants who had more appreciable glycemic benefit and stayed in Auto Mode more often. Clinical Trial Registration number: NCT03040414.
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Affiliation(s)
- Korey K. Hood
- Departments of Pediatrics, Psychiatry and Behavioral Sciences, Stanford Diabetes Research Center, Stanford University School of Medicine, Stanford, California, USA
- Address correspondence to: Korey K. Hood, PhD, Departments of Pediatrics, Psychiatry and Behavioral Sciences, Stanford Diabetes Research Center, Stanford University School of Medicine, 780 Welch Road, Stanford, CA 94304, USA
| | - Lori M. Laffel
- Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas Danne
- Department of General Pediatrics and Endocrinology/Diabetelogy, Children's Hospital AUF DER BULt, Hannover, Germany
| | - Revital Nimri
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Stuart A. Weinzimer
- Pediatric Endocrinology & Diabetes, Yale University, New Haven, Connecticut, USA
| | - Judy Sibayan
- Jaeb Center for Health Research Foundation, Inc., Tampa, Florida, USA
| | - Ryan J. Bailey
- Jaeb Center for Health Research Foundation, Inc., Tampa, Florida, USA
| | - Desmond Schatz
- Department of Pediatrics, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Natasa Bratina
- University Medical Center Ljubljana, University Children's Hospital, and Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Rachel Bello
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Alina Punel
- International Diabetes Center, HealthPartners Institute, Minneapolis, Minnesota, USA
| | - Peter Calhoun
- Jaeb Center for Health Research Foundation, Inc., Tampa, Florida, USA
| | - Roy W. Beck
- Jaeb Center for Health Research Foundation, Inc., Tampa, Florida, USA
| | - Richard M. Bergenstal
- International Diabetes Center, HealthPartners Institute, Minneapolis, Minnesota, USA
| | - Moshe Phillip
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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49
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Aleppo G, Beck RW, Bailey R, Ruedy KJ, Calhoun P, Peters AL, Pop-Busui R, Philis-Tsimikas A, Bao S, Umpierrez G, Davis G, Kruger D, Bhargava A, Young L, Buse JB, McGill JB, Martens T, Nguyen QT, Orozco I, Biggs W, Lucas KJ, Polonsky WH, Price D, Bergenstal RM. The Effect of Discontinuing Continuous Glucose Monitoring in Adults With Type 2 Diabetes Treated With Basal Insulin. Diabetes Care 2021; 44:2729-2737. [PMID: 34588210 PMCID: PMC8669539 DOI: 10.2337/dc21-1304] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 09/07/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To explore the effect of discontinuing continuous glucose monitoring (CGM) after 8 months of CGM use in adults with type 2 diabetes treated with basal without bolus insulin. RESEARCH DESIGN AND METHODS This multicenter trial had an initial randomization to either real-time CGM or blood glucose monitoring (BGM) for 8 months followed by 6 months in which the BGM group continued to use BGM (n = 57) and the CGM group was randomly reassigned either to continue CGM (n = 53) or discontinue CGM with resumption of BGM for glucose monitoring (n = 53). RESULTS In the group that discontinued CGM, mean time in range (TIR) 70-180 mg/dL, which improved from 38% before initiating CGM to 62% after 8 months of CGM, decreased after discontinuing CGM to 50% at 14 months (mean change from 8 to 14 months -12% [95% CI -21% to -3%], P = 0.01). In the group that continued CGM use, little change was found in TIR from 8 to 14 months (baseline 44%, 8 months 56%, 14 months 57%, mean change from 8 to 14 months 1% [95% CI -11% to 12%], P = 0.89). Comparing the two groups at 14 months, the adjusted treatment group difference in mean TIR was -6% (95% CI -16% to 4%, P = 0.20). CONCLUSIONS In adults with type 2 diabetes treated with basal insulin who had been using real-time CGM for 8 months, discontinuing CGM resulted in a loss of about one-half of the initial gain in TIR that had been achieved during CGM use.
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Affiliation(s)
- Grazia Aleppo
- Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Roy W Beck
- Jaeb Center for Health Research, Tampa, FL
| | | | | | | | - Anne L Peters
- Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | | | | | - Shichun Bao
- Vanderbilt University Medical Center, Nashville, TN
| | | | | | | | | | - Laura Young
- University of North Carolina School of Medicine, Chapel Hill, NC
| | - John B Buse
- University of North Carolina School of Medicine, Chapel Hill, NC
| | | | - Thomas Martens
- International Diabetes Center, Park Nicollet Internal Medicine, Minneapolis, MN
| | | | - Ian Orozco
- Carteret Medical Group, Morehead City, NC
| | | | - K Jean Lucas
- Diabetes and Endocrinology Consultants, PC, Morehead City, NC
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50
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Goldenberg RM, Aroda VR, Billings LK, Christiansen ASL, Meller Donatsky A, Parvaresh Rizi E, Podgorski G, Raslova K, Klonoff DC, Bergenstal RM. Effect of insulin degludec versus insulin glargine U100 on time in range: SWITCH PRO, a crossover study of basal insulin-treated adults with type 2 diabetes and risk factors for hypoglycaemia. Diabetes Obes Metab 2021; 23:2572-2581. [PMID: 34322967 PMCID: PMC9290717 DOI: 10.1111/dom.14504] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 07/09/2021] [Accepted: 07/26/2021] [Indexed: 01/10/2023]
Abstract
AIMS To compare time in range (TIR) with use of insulin degludec U100 (degludec) versus insulin glargine U100 (glargine U100) in people with type 2 diabetes. MATERIALS AND METHODS We conducted a randomized, crossover, multicentre trial comparing degludec and glargine U100 in basal insulin-treated adults with type 2 diabetes and ≥1 hypoglycaemia risk factor. There were two treatment periods, each with 16-week titration and 2-week maintenance phases (with evaluation of glucose using blinded professional continuous glucose monitoring). The once-weekly titration (target: 3.9-5.0 mmol/L) was based on pre-breakfast self-measured blood glucose. The primary endpoint was percentage of TIR (3.9─10.0 mmol/L). Secondary endpoints included overall and nocturnal percentage of time in tight glycaemic range (3.9-7.8 mmol/L), and mean glycated haemoglobin (HbA1c) and glucose levels. RESULTS At baseline, participants (n = 498) had a mean (SD) age of 62.8 (9.8) years, a diabetes duration of 15.1 (7.7) years and an HbA1c level of 59.6 (11.0) mmol/mol (7.6 [1.0]%). Noninferiority and superiority were confirmed for degludec versus glargine U100 for the primary endpoint, with a mean TIR of 72.1% for degludec versus 70.7% for glargine U100 (estimated treatment difference [ETD] 1.43% [95% confidence interval (CI): 0.12, 2.74; P = 0.03] or 20.6 min/d). Overall time in tight glycaemic range favoured degludec versus glargine U100 (ETD 1.5% [95% CI: 0.15, 2.89] or 21.9 min/d). Degludec also reduced nocturnal time below range (TBR; <3.9 mmol/L) compared with glargine U100 (ETD -0.88% [95% CI: -1.34, -0.42] or 12.7 min/night; post hoc) and significantly fewer nocturnal hypoglycaemic episodes of <3.0 mmol/L were observed. CONCLUSIONS Degludec, compared with glargine U100, provided more TIR and time in tight glycaemic range, and reduced nocturnal TBR in insulin-treated people with type 2 diabetes.
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Affiliation(s)
| | - Vanita R. Aroda
- Diabetes Clinical Research, Division of Endocrinology, Diabetes & HypertensionBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Liana K. Billings
- Department of MedicineNorthShore University HealthSystem/University of Chicago Pritzker School of MedicineSkokieIllinoisUSA
| | | | | | | | | | | | - David C. Klonoff
- Diabetes Research InstituteMills‐Peninsula Medical CenterSan MateoCAUSA
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