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Lee MH, Gooley J, Obeyesekere V, Lu J, Paldus B, Hendrieckx C, MacIsaac RJ, McAuley SA, Speight J, Vogrin S, Jenkins AJ, Holmes-Walker DJ, O'Neal DN, Ward GM. Hybrid Closed Loop in Adults With Type 1 Diabetes and Severely Impaired Hypoglycemia Awareness. J Diabetes Sci Technol 2024:19322968241245627. [PMID: 38613225 DOI: 10.1177/19322968241245627] [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: 04/14/2024]
Abstract
BACKGROUND Benefits of hybrid closed-loop (HCL) systems in a high-risk group with type 1 diabetes and impaired awareness of hypoglycemia (IAH) have not been well-explored. METHODS Adults with Edmonton HYPO scores ≥1047 were randomized to 26-weeks HCL (MiniMed™ 670G) vs standard therapy (multiple daily injections or insulin pump) without continuous glucose monitoring (CGM) (control). Primary outcome was percentage CGM time-in-range (TIR; 70-180 mg/dL) at 23 to 26 weeks post-randomization. Major secondary endpoints included magnitude of change in counter-regulatory hormones and autonomic symptom responses to hypoglycemia at 26-weeks post-randomization. A post hoc analysis evaluated glycemia risk index (GRI) comparing HCL with control groups at 26 weeks post-randomization. RESULTS Nine participants (median [interquartile range (IQR)] age 51 [41, 59] years; 44% male; enrolment HYPO score 1183 [1058, 1308]; Clarke score 6 [6, 6]; n = 5 [HCL]; n = 4 [control]) completed the study. Time-in-range was higher using HCL vs control (70% [68, 74%] vs 48% [44, 50%], P = .014). Time <70 mg/dL did not differ (HCL 3.8% [2.7, 3.9] vs control 6.5% [4.3, 8.6], P = .14) although hypoglycemia episode duration was shorter (30 vs 50 minutes, P < .001) with HCL. Glycemia risk index was lower with HCL vs control (38.1 [30.0, 39.2] vs 70.8 [58.5, 72.4], P = .014). Following 6 months of HCL use, greater dopamine (24.0 [12.3, 27.6] vs -18.5 [-36.5, -4.8], P = .014), and growth hormone (6.3 [4.6, 16.8] vs 0.5 [-0.8, 3.0], P = .050) responses to hypoglycemia were observed. CONCLUSIONS Six months of HCL use in high-risk adults with severe IAH increased glucose TIR and improved GRI without increased hypoglycemia, and partially restored counter-regulatory responses. CLINICAL TRIAL REGISTRATION ACTRN12617000520336.
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Affiliation(s)
- Melissa H Lee
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
| | - Judith Gooley
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
| | - Varuni Obeyesekere
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
| | - Jean Lu
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
| | - Barbora Paldus
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
| | - Christel Hendrieckx
- School of Psychology, Deakin University, Geelong, VIC, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, VIC, Australia
| | - Richard J MacIsaac
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
| | - Sybil A McAuley
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Endocrinology & Diabetes, The Alfred, Melbourne, VIC, Australia
| | - Jane Speight
- School of Psychology, Deakin University, Geelong, VIC, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, VIC, Australia
| | - Sara Vogrin
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
| | - Alicia J Jenkins
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
- National Health and Medical Research Council Clinical Trials Centre, The University of Sydney, Sydney, NSW, Australia
| | - D Jane Holmes-Walker
- Department of Endocrinology, Westmead Hospital, The University of Sydney, Sydney, NSW, Australia
| | - David N O'Neal
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
| | - Glenn M Ward
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
- Department of Clinical Biochemistry, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
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Kubilay E, Trawley S, Ward GM, Fourlanos S, Colman PG, McAuley SA. Real-world lived experience of older adults with type 1 diabetes after an automated insulin delivery trial. Diabet Med 2024; 41:e15264. [PMID: 38073128 DOI: 10.1111/dme.15264] [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] [Received: 06/22/2023] [Accepted: 11/20/2023] [Indexed: 03/16/2024]
Abstract
AIMS First-generation closed-loop automated insulin delivery improves glycaemia and psychosocial outcomes among older adults with type 1 diabetes in clinical trials. However, no study has previously assessed real-world lived experience of older adults using closed-loop therapy outside a trial environment. METHODS Semi-structured interviews were conducted with older adults who were pre-existing insulin pump users and previously completed the OldeR Adult Closed-Loop (ORACL) randomised trial. Interviews focused on perceptions of diabetes technology use, and factors influencing decisions regarding continuation. RESULTS Twenty-eight participants, mean age 70 years (SD 5), were interviewed at median 650 days (IQR 608-694) after their final ORACL trial visit. At interview, 23 participants (82%) were still using a commercial closed-loop system (requiring manual input for prandial insulin bolus doses). Themes discussed in interviews relating to closed-loop system use included sustained psychosocial benefits, cost and retirement considerations and usability frustrations relating to sensor accuracy and system alarms. Of the five participants who had discontinued, reasons included cost, continuous glucose monitoring-associated difficulties and usability frustrations. Cost was the largest consideration regarding continued use; most participants considered the increased ease of diabetes management to be worth the associated costs, though cost was prohibitive for some. CONCLUSIONS Almost 2 years after completing a closed-loop clinical trial, closed-loop automated insulin delivery remains the preferred type 1 diabetes therapy for the majority of older adult participants. Chronological age is not a barrier to real-world successful use of diabetes technology. Identifying age-related barriers, and solutions, to diabetes technology use among older adults is warranted.
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Affiliation(s)
- Erin Kubilay
- Department of Psychology, The Cairnmillar Institute, Melbourne, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Steven Trawley
- Department of Psychology, The Cairnmillar Institute, Melbourne, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Glenn M Ward
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Spiros Fourlanos
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Australian Centre for Accelerating Diabetes Innovations, The University of Melbourne, Melbourne, Victoria, Australia
| | - Peter G Colman
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Sybil A McAuley
- Department of Psychology, The Cairnmillar Institute, Melbourne, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
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3
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Hendrieckx C, Husin HM, Russell-Green S, Halliday JA, Lam B, Trawley S, McAuley SA, Bach LA, Burt MG, Cohen ND, Colman PG, Holmes-Walker DJ, Jenkins AJ, Lee MH, McCallum RW, Stranks SN, Sundararajan V, Jones TW, O'Neal DN, Speight J. The diabetes management experiences questionnaire: Psychometric validation among adults with type 1 diabetes. Diabet Med 2024; 41:e15195. [PMID: 37562414 DOI: 10.1111/dme.15195] [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] [Received: 04/20/2023] [Revised: 08/01/2023] [Accepted: 08/07/2023] [Indexed: 08/12/2023]
Abstract
AIMS To examine the psychometric properties of the Diabetes Management Experiences Questionnaire (DME-Q). Adapted from the validated Glucose Monitoring Experiences Questionnaire, the DME-Q captures satisfaction with diabetes management irrespective of treatment modalities. METHODS The DME-Q was completed by adults with type 1 diabetes as part of a randomized controlled trial comparing hybrid closed loop (HCL) to standard therapy. Most psychometric properties were examined with pre-randomization data (n = 149); responsiveness was examined using baseline and 26-week follow-up data (n = 120). RESULTS Pre-randomization, participants' mean age was 44 ± 12 years, 52% were women. HbA1c was 61 ± 11 mmol/mol (7.8 ± 1.0%), diabetes duration was 24 ± 12 years and 47% used an insulin pump prior to the trial. A forced three-factor analysis revealed three expected domains, that is, 'Convenience', 'Effectiveness' and 'Intrusiveness', and a forced one-factor solution was also satisfactory. Internal consistency reliability was strong for the three subscales (α range = 0.74-0.84) and 'Total satisfaction'( α = 0.85). Convergent validity was demonstrated with moderate correlations between DME-Q 'Total satisfaction' and diabetes distress (PAID: rs = -0.57) and treatment satisfaction (DTSQ; rs = 0.58). Divergent validity was demonstrated with a weak correlation with prospective/retrospective memory (PRMQ: rs = -0.16 and - 0.13 respectively). Responsiveness was demonstrated, as participants randomized to HCL had higher 'Effectiveness' and 'Total satisfaction' scores than those randomized to standard therapy. CONCLUSIONS The 22-item DME-Q is a brief, acceptable, reliable measure with satisfactory structural and construct validity, which is responsive to intervention. The DME-Q is likely to be useful for evaluation of new pharmaceutical agents and technologies in research and clinical settings.
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Affiliation(s)
- Christel Hendrieckx
- School of Psychology, Deakin University, Victoria, Geelong, Australia
- The Australian Centre for Behavioural Research in Diabetes, Victoria, Carlton, Australia
- Institute for Health Transformation, Deakin University, Victoria, Geelong, Australia
| | - Hanafi M Husin
- School of Psychology, Deakin University, Victoria, Geelong, Australia
- The Australian Centre for Behavioural Research in Diabetes, Victoria, Carlton, Australia
| | - Sienna Russell-Green
- School of Psychology, Deakin University, Victoria, Geelong, Australia
- The Australian Centre for Behavioural Research in Diabetes, Victoria, Carlton, Australia
| | - Jennifer A Halliday
- School of Psychology, Deakin University, Victoria, Geelong, Australia
- The Australian Centre for Behavioural Research in Diabetes, Victoria, Carlton, Australia
- Institute for Health Transformation, Deakin University, Victoria, Geelong, Australia
| | - Benjamin Lam
- School of Psychology, Deakin University, Victoria, Geelong, Australia
- The Australian Centre for Behavioural Research in Diabetes, Victoria, Carlton, Australia
- Education Futures, University of South Australia, Adelaide, Australia
| | - Steven Trawley
- The Australian Centre for Behavioural Research in Diabetes, Victoria, Carlton, Australia
- The Cairnmillar Institute, Melbourne, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Sybil A McAuley
- The Cairnmillar Institute, Melbourne, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Leon A Bach
- Department of Endocrinology and Diabetes, The Alfred, Melbourne, Australia
- Department of Medicine (Alfred Medical Research and Education Precinct), Monash University, Melbourne, Australia
| | - Morton G Burt
- Southern Adelaide Diabetes and Endocrine Services, Flinders Medical Centre, Adelaide, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Neale D Cohen
- Baker Heart and Diabetes Institute, Melbourne, Australia
- School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
- School of Pharmacy, University of Queensland, Woolloongabba, Australia
| | - Peter G Colman
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, Australia
| | - D Jane Holmes-Walker
- Department of Diabetes and Endocrinology, Westmead Hospital, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
| | - Alicia J Jenkins
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Melissa H Lee
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Roland W McCallum
- Department of Diabetes and Endocrinology, Royal Hobart Hospital, Hobart, Australia
| | - Steve N Stranks
- Southern Adelaide Diabetes and Endocrine Services, Flinders Medical Centre, Adelaide, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | | | - Tim W Jones
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Australia
- School of Paediatrics and Child Health, University of Western Australia, Perth, Australia
- Telethon Kids Institute, University of Western Australia, Perth, Australia
| | - David N O'Neal
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Jane Speight
- School of Psychology, Deakin University, Victoria, Geelong, Australia
- The Australian Centre for Behavioural Research in Diabetes, Victoria, Carlton, Australia
- Institute for Health Transformation, Deakin University, Victoria, Geelong, Australia
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Kwon HJ, Trawley S, Vogrin S, Mohammad Alipoor A, Colman PG, Fourlanos S, Grills CA, Lee MH, MacIsaac RJ, O'Neal DN, O'Regan NA, Sundararajan V, Ward GM, McAuley SA. Driving-related glucose patterns among older adults with type 1 diabetes. Diabetes Technol Ther 2024. [PMID: 38315502 DOI: 10.1089/dia.2023.0416] [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: 02/07/2024]
Abstract
Older adults with type 1 diabetes may face challenges driving safely. Glucose "above 5 to drive" is often recommended for insulin-treated diabetes to minimize hypoglycemia while driving. However, the effectiveness of this recommendation among older adults has not been evaluated. Older drivers with type 1 diabetes were assessed while using sensor-augmented insulin pumps during a 2-week clinical trial run-in. Twenty-three drivers (median age 69 years [IQR 65-72]; diabetes duration 37 years [20-45]) undertook 618 trips (duration 10 min [5-21]). Most trips (n = 535; 87%) were <30-min duration; nine trips (1.5%) exceeded 90 min and three trips (0.5%) exceeded 120 min. Pre-trip continuous glucose monitoring (CGM) was >5.0 mmol/L for 577 trips (93%) and none of these had CGM <3.9 mmol/L during driving (including eight trips >90 min and three trips >120 min). During 41 trips with pre-trip CGM ≤5.0 mmol/L, 11 trips had CGM <3.9 mmol/L. Seventy-one CGM alerts occurred during 60 trips (10%), of which 54/71 (76%) were unrelated to hypoglycemia. Our findings support a glucose "above-5-to-drive" recommendation to avoid CGM-detected hypoglycemia among older drivers, including for prolonged drives, and highlight the importance of active CGM low-glucose alerts to prevent hypoglycemia during driving. Driving-related CGM usability and alert functionality warrants investigation.
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Affiliation(s)
- Hye Jin Kwon
- The University of Melbourne, 2281, Department of Medicine, Melbourne, Victoria, Australia
- St Vincent's Hospital Melbourne Pty Ltd, 60078, Department of Endocrinology & Diabetes, Melbourne, Victoria, Australia;
| | - Steven Trawley
- The University of Melbourne, 2281, Department of Medicine, Melbourne, Victoria, Australia
- Cairnmillar Institute, 179842, Department of Psychology, Melbourne, Victoria, Australia;
| | - Sara Vogrin
- The University of Melbourne, 2281, Department of Medicine, Melbourne, Victoria, Australia;
| | - Andisheh Mohammad Alipoor
- The University of Melbourne, 2281, Department of Medicine, Melbourne, Victoria, Australia
- St Vincent's Hospital Melbourne Pty Ltd, 60078, Department of Endocrinology & Diabetes, Melbourne, Victoria, Australia;
| | - Peter G Colman
- The University of Melbourne, 2281, Department of Medicine, Melbourne, Victoria, Australia
- The Royal Melbourne Hospital, 90134, Diabetes and Endocrinology, Melbourne, Victoria, Australia;
| | - Spiros Fourlanos
- The University of Melbourne, 2281, Department of Medicine, Melbourne, Victoria, Australia
- The Royal Melbourne Hospital, 90134, Diabetes and Endocrinology, Melbourne, Victoria, Australia
- The University of Melbourne, 2281, Australian Centre for Accelerating Diabetes Innovations, Melbourne, Victoria, Australia;
| | - Charlotte A Grills
- St Vincent's Hospital Melbourne Pty Ltd, 60078, Department of Endocrinology & Diabetes, Melbourne, Victoria, Australia;
| | - Melissa H Lee
- The University of Melbourne, 2281, Department of Medicine, Melbourne, Victoria, Australia
- St Vincent's Hospital Melbourne Pty Ltd, 60078, Department of Endocrinology & Diabetes, Melbourne, Victoria, Australia;
| | - Richard J MacIsaac
- The University of Melbourne, 2281, Department of Medicine, Melbourne, Victoria, Australia
- St Vincent's Hospital Melbourne Pty Ltd, 60078, Department of Endocrinology & Diabetes, Melbourne, Victoria, Australia
- The University of Melbourne, 2281, Australian Centre for Accelerating Diabetes Innovations, Melbourne, Victoria, Australia;
| | - David N O'Neal
- The University of Melbourne, 2281, Department of Medicine, Melbourne, Victoria, Australia
- St Vincent's Hospital Melbourne Pty Ltd, 60078, Department of Endocrinology & Diabetes, Melbourne, Victoria, Australia
- The University of Melbourne, 2281, Australian Centre for Accelerating Diabetes Innovations, Melbourne, Victoria, Australia;
| | - Niamh A O'Regan
- University Hospital Waterford, 58041, Department of Geriatric Medicine, Waterford Integrated Care for Older People, Waterford, Please Select, Ireland;
| | - Vijaya Sundararajan
- The University of Melbourne, 2281, Department of Medicine, Melbourne, Victoria, Australia
- La Trobe University, 2080, Department of Public Health, Melbourne, Victoria, Australia;
| | - Glenn M Ward
- The University of Melbourne, 2281, Department of Medicine, Melbourne, Victoria, Australia
- St Vincent's Hospital Melbourne Pty Ltd, 60078, Department of Endocrinology & Diabetes, Melbourne, Victoria, Australia;
| | - Sybil A McAuley
- The University of Melbourne, 2281, Department of Medicine, Melbourne, Victoria, Australia
- St Vincent's Hospital Melbourne Pty Ltd, 60078, Department of Endocrinology & Diabetes, Melbourne, Victoria, Australia
- Cairnmillar Institute, 179842, Department of Psychology, Melbourne, Victoria, Australia
- The Alfred, 5390, Department of Endocrinology & Diabetes, Melbourne, Victoria, Australia;
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Affiliation(s)
- Laura E. Donaldson
- The University of Melbourne, Melbourne, VIC, Australia
- St Vincent’s Hospital Melbourne, Melbourne, VIC, Australia
- The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Sara Vogrin
- The University of Melbourne, Melbourne, VIC, Australia
| | - Sybil A. McAuley
- The University of Melbourne, Melbourne, VIC, Australia
- St Vincent’s Hospital Melbourne, Melbourne, VIC, Australia
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Donaldson LE, Fourlanos S, Vogrin S, MacIsaac RJ, Colman PG, McAuley SA. Automated insulin delivery among adults with type 1 diabetes for up to 2 years: a real-world, multicentre study. Intern Med J 2024; 54:121-128. [PMID: 37255209 DOI: 10.1111/imj.16143] [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] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 05/16/2023] [Indexed: 06/01/2023]
Abstract
BACKGROUND AND AIMS Automated insulin delivery (AID) improves glycaemia among people with type 1 diabetes in clinical trials and overseas real-world studies. Whether improvements are sustained beyond 12 months in the real world, and whether they occur in the Australian context, has not yet been established. We aimed to observe, up to 2 years, the effectiveness of initiating first-generation AID for type 1 diabetes management. METHODS Retrospective, real-world, observational study using medical records, conducted across five sites in Australia. Adults with type 1 diabetes, who had AID initiated between February 2019 and December 2021, were observed for 6-24 months after initiation (until June 2022). Outcomes examined included glucose metrics assessed by glycated haemoglobin (HbA1c ) and continuous glucose monitoring (CGM), safety and therapy continuation. RESULTS Ninety-four adults were studied (median age 39 years (interquartile range, IQR: 31-51); pre-initiation HbA1c 7.8% (7.2-8.6)). After AID initiation, HbA1c decreased by mean 0.5 percentage points (95% confidence interval (CI): -0.7 to -0.2) at 3 months (P < 0.001); CGM time in range 3.9-10.0 mmol/L increased by 11 percentage points (9-14) at 1 month (P < 0.001); these improvements were maintained up to 24 months (all P < 0.02). Median CGM time below 3.9 mmol/L was <1.5% pre- and post-AID initiation. The subgroup with pre-initiation HbA1c above 8.5% had the greatest HbA1c improvement (-1.4 percentage points (-1.8 to -1.1) at 3 months). Twelve individuals (13%) discontinued AID, predominantly citing difficulties with CGM. During the 150 person-years observed, four diabetes-related emergencies were documented: three severe hypoglycaemic events and one hyperglycaemic event without ketoacidosis. CONCLUSIONS Early glucose improvements were observed after real-world AID initiation, sustained up to 2 years, without excess adverse events. The greatest benefits were observed among individuals with highest glycaemia before initiation. Future-generation systems with increased user-friendliness may enhance therapy continuation.
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Affiliation(s)
- Laura E Donaldson
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
- Department of Diabetes and Endocrinology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Spiros Fourlanos
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Diabetes and Endocrinology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Australian Centre for Accelerating Diabetes Innovations (ACADI), The University of Melbourne, Melbourne, Victoria, Australia
| | - Sara Vogrin
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Richard J MacIsaac
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
- Australian Centre for Accelerating Diabetes Innovations (ACADI), The University of Melbourne, Melbourne, Victoria, Australia
| | - Peter G Colman
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Diabetes and Endocrinology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Sybil A McAuley
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
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Trawley S, Kubilay E, Colman PG, Lee MH, O'Neal DN, Sundararajan V, Vogrin S, McAuley SA. What difference does sleep make? Continuous glucose monitoring metrics during fixed-overnight time versus sleep periods among older adults with type 1 diabetes. J Sleep Res 2023:e14106. [PMID: 38050705 DOI: 10.1111/jsr.14106] [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] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 10/18/2023] [Accepted: 11/02/2023] [Indexed: 12/06/2023]
Abstract
Hypoglycaemia during sleep is a common and clinically important issue for people living with insulin-treated diabetes. Continuous glucose monitoring devices can help to identify nocturnal hypoglycaemia and inform treatment strategies. However, sleep is generally inferred, with diabetes researchers and physicians using a fixed-overnight period as a proxy for sleep-wake status when analysing and interpretating continuous glucose monitoring data. No study to date has validated such an approach with established sleep measures. Continuous glucose monitoring and research-grade actigraphy devices were worn and sleep diaries completed for 2 weeks by 28 older adults (mean age 67 years [SD 5]; 17 (59%) women) with type 1 diabetes. Using continuous glucose monitoring data from a total of 356 nights, fixed-overnight (using the recommended period of 00:00 hours-06:00 hours) and objectively-measured sleep periods were compared. The fixed-overnight period approach missed a median 57 min per night (interquartile range: 49-64) of sleep for each participant, including five continuous glucose monitoring-detected hypoglycaemia episodes during objectively-measured sleep. Twenty-seven participants (96%) had at least 1 night with continuous glucose monitoring time-in-range and time-above-range discrepancies both ≥ 10 percentage points, a clinically significant discrepancy. The utility of fixed-overnight time continuous glucose monitoring as a proxy for sleep-awake continuous glucose monitoring is inadequate as it consistently excludes actual sleep time, obscures glycaemic patterns, and misses sensor hypoglycaemia episodes during sleep. The use of validated measures of sleep to aid interpretation of continuous glucose monitoring data is encouraged.
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Affiliation(s)
- Steven Trawley
- Department of Psychology, The Cairnmillar Institute, Melbourne, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Erin Kubilay
- Department of Psychology, The Cairnmillar Institute, Melbourne, Victoria, Australia
| | - Peter G Colman
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Melissa H Lee
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - David N O'Neal
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Vijaya Sundararajan
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Public Health, La Trobe University, Melbourne, Victoria, Australia
| | - Sara Vogrin
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Sybil A McAuley
- Department of Psychology, The Cairnmillar Institute, Melbourne, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
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8
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Donaldson LE, Vogrin S, So M, Ward GM, Krishnamurthy B, Sundararajan V, MacIsaac RJ, Kay TW, McAuley SA. Continuous glucose monitoring-based composite metrics: a review and assessment of performance in recent-onset and long-duration type 1 diabetes. Diabetes Technol Ther 2023. [PMID: 37010375 DOI: 10.1089/dia.2022.0563] [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: 04/04/2023]
Abstract
This study examined correlations between continuous glucose monitoring (CGM)-based composite metrics and standard glucose metrics within CGM data sets from individuals with recent-onset and long-duration type 1 diabetes. First, a literature review and critique of published CGM-based composite metrics was undertaken. Second, composite metric results were calculated for the two CGM data sets and correlations with six standard glucose metrics were examined. Fourteen composite metrics met selection criteria; these metrics focused on overall glycemia (n = 8), glycemic variability (n = 4), and hypoglycemia (n = 2), respectively. Results for the two diabetes cohorts were similar. All eight metrics focusing on overall glycemia strongly correlated with glucose time in range; none strongly correlated with time below range. The eight overall glycemia-focused and two hypoglycemia-focused composite metrics were all sensitive to automated insulin delivery therapeutic intervention. Until a composite metric can adequately capture both achieved target glycemia and hypoglycemia burden, the current two-dimensional CGM assessment approach may offer greatest clinical utility.
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Affiliation(s)
- Laura E Donaldson
- The University of Melbourne, 2281, Department of Medicine, Melbourne, Victoria, Australia
- St Vincent's Hospital Melbourne Pty Ltd, 60078, Department of Endocrinology & Diabetes, Melbourne, Victoria, Australia;
| | - Sara Vogrin
- The University of Melbourne, 2281, Department of Medicine, Melbourne, Victoria, Australia;
| | - Michelle So
- St Vincent's Institute of Medical Research, 85092, Melbourne, Victoria, Australia
- The Royal Melbourne Hospital, 90134, Department of Diabetes and Endocrinology, Parkville, Victoria, Australia
- Northern Health NCHER, 569275, Department of Endocrinology and Diabetes, Melbourne, Victoria, Australia;
| | - Glenn M Ward
- The University of Melbourne, 2281, Department of Medicine, Melbourne, Victoria, Australia
- St Vincent's Hospital Melbourne Pty Ltd, 60078, Department of Endocrinology & Diabetes, Melbourne, Victoria, Australia;
| | - Balasubramanian Krishnamurthy
- The University of Melbourne, 2281, Department of Medicine, Melbourne, Victoria, Australia
- St Vincent's Institute of Medical Research, 85092, Melbourne, Victoria, Australia;
| | - Vijaya Sundararajan
- The University of Melbourne, 2281, Department of Medicine, Melbourne, Victoria, Australia;
| | - Richard J MacIsaac
- The University of Melbourne, 2281, Department of Medicine, Melbourne, Victoria, Australia
- St Vincent's Hospital Melbourne Pty Ltd, 60078, Department of Endocrinology & Diabetes, Melbourne, Victoria, Australia;
| | - Thomas Wh Kay
- St Vincent's Institute of Medical Research, 85092, Melbourne, Victoria, Australia;
| | - Sybil A McAuley
- The University of Melbourne, 2281, Department of Medicine, Melbourne, Victoria, Australia
- St Vincent's Hospital Melbourne Pty Ltd, 60078, Department of Endocrinology & Diabetes, Melbourne, Victoria, Australia;
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9
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Kubilay E, Trawley S, Ward GM, Fourlanos S, Grills CA, Lee MH, MacIsaac RJ, O'Neal DN, O'Regan NA, Sundararajan V, Vogrin S, Colman PG, McAuley SA. Lived experience of older adults with type 1 diabetes using closed-loop automated insulin delivery in a randomised trial. Diabet Med 2023; 40:e15020. [PMID: 36468784 DOI: 10.1111/dme.15020] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 10/25/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022]
Abstract
AIM To explore the lived experience of older adults with type 1 diabetes using closed-loop automated insulin delivery, an area previously receiving minimal attention. METHODS Semi-structured interviews were conducted with adults aged 60 years or older with long-duration type 1 diabetes who participated in a randomised, open-label, two-stage crossover trial comparing first-generation closed-loop therapy (MiniMed 670G) versus sensor-augmented pump therapy. Interview recordings were transcribed, thematically analysed and assessed. RESULTS Twenty-one older adults participated in interviews after using closed-loop therapy. Twenty were functionally independent, without frailty or major cognitive impairment; one was dependent on caregiver assistance, including for diabetes management. Quality of life benefits were identified, including improved sleep and reduced diabetes-related psychological burden, in the context of experiencing improved glucose levels. Gaps between expectations and reality of closed-loop therapy were also experienced, encountering disappointment amongst some participants. The cost was perceived as a barrier to continued closed-loop access post-trial. Usability issues were identified, such as disruptive overnight alarms and sensor inaccuracy. CONCLUSIONS The lived experience of older adults without frailty or major cognitive impairment using first-generation closed-loop therapy was mainly positive and concordant with glycaemic benefits found in the trial. Older adults' lived experience using automated insulin delivery beyond trial environments requires exploration; moreover, the usability needs of older adults should be considered during future device development.
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Affiliation(s)
- Erin Kubilay
- Department of Psychology, The Cairnmillar Institute, Melbourne, Australia
| | - Steven Trawley
- Department of Psychology, The Cairnmillar Institute, Melbourne, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Australia
| | - Glenn M Ward
- Department of Medicine, The University of Melbourne, Melbourne, Australia
- Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Spiros Fourlanos
- Department of Medicine, The University of Melbourne, Melbourne, Australia
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, Australia
- Australian Centre for Accelerating Diabetes Innovations, The University of Melbourne, Melbourne, Australia
| | - Charlotte A Grills
- Department of Medicine, The University of Melbourne, Melbourne, Australia
- Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Melissa H Lee
- Department of Medicine, The University of Melbourne, Melbourne, Australia
- Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Richard J MacIsaac
- Department of Medicine, The University of Melbourne, Melbourne, Australia
- Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
- Australian Centre for Accelerating Diabetes Innovations, The University of Melbourne, Melbourne, Australia
| | - David N O'Neal
- Department of Medicine, The University of Melbourne, Melbourne, Australia
- Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Niamh A O'Regan
- Department of Geriatric Medicine, Waterford Integrated Care for Older People, University Hospital Waterford, Waterford, Ireland
| | - Vijaya Sundararajan
- Department of Medicine, The University of Melbourne, Melbourne, Australia
- Department of Public Health, La Trobe University, Melbourne, Australia
| | - Sara Vogrin
- Department of Medicine, The University of Melbourne, Melbourne, Australia
| | - Peter G Colman
- Department of Medicine, The University of Melbourne, Melbourne, Australia
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, Australia
| | - Sybil A McAuley
- Department of Psychology, The Cairnmillar Institute, Melbourne, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Australia
- Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
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10
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Smith G, Abraham MB, de Bock MI, Fairchild J, King BR, Ambler GR, Cameron FJ, McAuley SA, Keech A, Jenkins AJ, Davis EA, O'Neal DN, Jones TW. Impact of missing data on the accuracy of glucose metrics from continuous glucose monitoring assessed over a two-week period. Diabetes Technol Ther 2023; 25:356-362. [PMID: 36802246 DOI: 10.1089/dia.2022.0101] [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: 02/23/2023]
Abstract
OBJECTIVE To explore the impact of missing data on the accuracy of continuous glucose monitoring (CGM) metrics collected over a 2-week period in a clinical trial. RESEARCH DESIGN AND METHODS Simulations were conducted to examine the effect of various patterns of missingness on the accuracy of CGM metrics as compared to a 'complete' dataset. The proportion of missing data, the 'block size' in which the data were missing, and the missing mechanism were modified for each 'scenario'. The degree of agreement between simulated and 'true' glycemic measures under each scenario was presented as R2. RESULTS Under all missing patterns, R2 declined as the proportion of missing data increased, however, as the 'block size' of missing data increased, the percentage of missing data had a more pronounced effect on the agreement between measures. For a 14-day CGM dataset to be considered representative for percent time in range, at least 70% of CGM data should be available over at least 10 days (R2 > 0.9). Skewed outcome measures, such as percent time below range and coefficient of variation, were more affected by missing data than the less skewed measures (percent time in range, percent time above range, mean glucose). CONCLUSIONS Both the degree and pattern of missing data impact upon the accuracy of recommended CGM-derived glycemic measures. In planning research, an understanding of patterns of missing data in the study population is required to gauge the likely effects of missing data on outcome accuracy.
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Affiliation(s)
- Grant Smith
- Telethon Kids Institute, 117610, Children's Diabetes Centre, Perth Children's Hospital, 15 Hospital Avenue, Nedlands, Nedlands, Western Australia, Australia, 6009
- Telethon Kids Institute, University of Western Australia, Perth Children's Hospital, 15 Hospital Avenue;
| | - Mary Binsu Abraham
- Princess Margaret Hospital, Endocrinology and Diabetes, Perth, Western Australia, Australia
- Telethon Kids Institute, 117610, Children's Diabetes Centre, Nedlands, Western Australia, Australia
- The University of Western Australia, 2720, 3Division of Paediatrics, within the Medical School, Nedlands, Western Australia, Australia;
| | - Martin Isaac de Bock
- University of Otago, Department of Paediatrics , Dunedin, Christchurch, New Zealand;
| | - Jan Fairchild
- Women's and Children's Hospital Adelaide, 6053, Endocrinology and Diabetes, 72 King William Road, North Adelaide, South Australia, Australia, 5006;
| | - Bruce R King
- John Hunter Children's Hospital, Diabetes and Endocrinology, Lookout Road, New Lambton, Newcastle, New South Wales, Australia, 2310
- University of Newcastle, Callighan, Newcastle, New South Wales, Australia, 2310;
| | - Geoffrey R Ambler
- The Children's Hospital at Westmead, Institute of Endocrinology and Diabetes, Locked Bag 4001, Westmead, New South Wales, Australia, 2145
- The University of Sydney, Discipline of Paediatrics and Child Health, Sydney, New South Wales, Australia;
| | - Fergus J Cameron
- Royal Children's Hospital Melbourne and Murdoch Childrens Research Institute, Dept of Endocrinology and Diabetes, 50 Flemington Rd, Parkville, Victoria, Australia, 3052;
| | - Sybil A McAuley
- University of Melbourne, Department of Medicine, 29 Regent St, Melbourne, Victoria, Australia, 3065
- St Vincent's Hospital Melbourne, Department of Endocrinology, Melbourne, Victoria, Australia;
| | - Anthony Keech
- The University of Sydney, NHMRC Clinical Trials Centre, Faculty of Medicine and Health, Sydney, New South Wales, Australia;
| | - Alicia J Jenkins
- University of Melbourne, Department of Medicine, Melbourne, Victoria, Australia
- St Vincent's Hospital Melbourne, Department of Endocrinology, Melbourne, Victoria, Australia
- The University of Sydney, 4334, NHMRC Clinical Trials Centre, Faculty of Medicine and Health, Sydney, New South Wales, Australia;
| | - Elizabeth A Davis
- Perth Children's Hospital, 60081, HOD Department of Endocrinology and Diabetes, 15 Hospital Avenue, Nedlands, Nedlands, Western Australia, Australia, 6009
- Telethon Kids Institute, 117610, Children's Diabetes Centre, 15 Hospital Avenue, Nedlands, Nedlands, Western Australia, Australia, 6009;
| | - David N O'Neal
- University of Melbourne, Department of Melbourne (St Vincent's Hospital), Fitzroy, Victoria, Australia
- St Vincent's Hospital Melbourne, Department of Endocrinology, Melbourne, Victoria, Australia;
| | - Timothy W Jones
- Perth Children's Hospital, 60081, Medical Co-Director/Endocrinology and Diabetes, 15 Hospital Avenue, Nedlands, Nedlands, Western Australia, Australia, 6009
- Telethon Kids Institute, 117610, Children's Diabetes Centre, 15 Hospital Avenue, Nedlands, Nedlands, Western Australia, Australia, 6009;
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11
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Donaldson LE, McAuley SA, Goodman DJ, Howe K, Loudovaris T, MacIsaac RJ, Kay TWH, Ward GM. Sustained hypoglycaemia improvement 15 years after islet transplantation for type 1 diabetes. Intern Med J 2023; 53:293-295. [PMID: 36822610 DOI: 10.1111/imj.16017] [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] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 11/11/2022] [Indexed: 02/25/2023]
Affiliation(s)
- Laura E Donaldson
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Medicine, St Vincent's Hospital, The University of Melbourne, Melbourne, Victoria, Australia
| | - Sybil A McAuley
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Medicine, St Vincent's Hospital, The University of Melbourne, Melbourne, Victoria, Australia
| | - David J Goodman
- Department of Nephrology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Kathy Howe
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | | | - Richard J MacIsaac
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Medicine, St Vincent's Hospital, The University of Melbourne, Melbourne, Victoria, Australia.,Australian Centre for Accelerating Diabetes Innovations (ACADI), School of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Thomas W H Kay
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Medicine, St Vincent's Hospital, The University of Melbourne, Melbourne, Victoria, Australia.,St Vincent's Institute, Melbourne, Victoria, Australia
| | - Glenn M Ward
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Medicine, St Vincent's Hospital, The University of Melbourne, Melbourne, Victoria, Australia
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12
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Morrison D, Paldus B, Zaharieva DP, Lee MH, Vogrin S, Jenkins AJ, Gerche AL, MacIsaac RJ, McAuley SA, Ward GM, Colman PG, Smart CEM, Seckold R, Grosman B, Roy A, King BR, Riddell MC, O'Neal DN. Late Afternoon Vigorous Exercise Increases Postmeal but Not Overnight Hypoglycemia in Adults with Type 1 Diabetes Managed with Automated Insulin Delivery. Diabetes Technol Ther 2022; 24:873-880. [PMID: 36094458 DOI: 10.1089/dia.2022.0279] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [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: 11/12/2022]
Abstract
Aim: To compare evening and overnight hypoglycemia risk after late afternoon exercise with a nonexercise control day in adults with type 1 diabetes using automated insulin delivery (AID). Methods: Thirty adults with type 1 diabetes using AID (Minimed 670G) performed in random order 40 min high intensity interval aerobic exercise (HIE), resistance (RE), and moderate intensity aerobic exercise (MIE) exercise each separated by >1 week. The closed-loop set-point was temporarily increased 2 h pre-exercise and a snack eaten if plasma glucose was ≤126 mg/dL pre-exercise. Exercise commenced at ∼16:00. A standardized meal was eaten at ∼20:40. Hypoglycemic events were defined as a continuous glucose monitor (CGM) reading <70 mg/dL for ≥15 min. Four-hour postevening meal and overnight (00:00-06:00) CGM metrics for exercise were compared with the prior nonexercise day. Results: There was no severe hypoglycemia. Between 00:00 and 06:00, the proportion of nights with hypoglycemia did not differ postexercise versus control for HIE (18% vs. 11%; P = 0.688), RE (4% vs. 14%; P = 0.375), and MIE (7% vs. 14%; P = 0.625). Time in range (TIR) (70-180 mg/dL), >75% for all nights, did not differ between exercise conditions and control. Hypoglycemia episodes postmeal after exercise versus control did not differ for HIE (22% vs. 7%; P = 0.219) and MIE (10% vs. 14%; P > 0.999), but were greater post-RE (39% vs. 10%; P = 0.012). Conclusions: Overnight TIR was excellent with AID without increased hypoglycemia postexercise between 00:00 and 06:00 compared with nonexercise days. In contrast, hypoglycemia risk was increased after the first meal post-RE, suggesting the importance of greater vigilance and specific guidelines for meal-time dosing, particularly with vigorous RE. ACTRN12618000905268.
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Affiliation(s)
- Dale Morrison
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Barbora Paldus
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Fitzroy, Australia
| | - Dessi P Zaharieva
- School of Kinesiology and Health Science, Muscle Health Research Centre, York University, Toronto, Canada
| | - Melissa H Lee
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Fitzroy, Australia
| | - Sara Vogrin
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Alicia J Jenkins
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Fitzroy, Australia
- NHMRC Clinical Trials Centre, University of Sydney, Sydney
| | - André La Gerche
- Department of Cardiology, St Vincent's Hospital Melbourne, Melbourne, Australia
- Clinical Research Domain, Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Richard J MacIsaac
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Fitzroy, Australia
- Australian Centre for Accelerating Diabetes Innovations, University of Melbourne, Melbourne, Australia
| | - Sybil A McAuley
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Fitzroy, Australia
| | - Glenn M Ward
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Peter G Colman
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Parkville, Australia
| | - Carmel E M Smart
- Department of Endocrinology, John Hunter Children's Hospital, Newcastle, Australia
- Department of Endocrinology, Hunter Medical Research Institute, Newcastle, Australia
| | - Rowen Seckold
- Department of Endocrinology, John Hunter Children's Hospital, Newcastle, Australia
- Department of Endocrinology, Hunter Medical Research Institute, Newcastle, Australia
| | | | | | - Bruce R King
- Department of Endocrinology, John Hunter Children's Hospital, Newcastle, Australia
- Department of Endocrinology, Hunter Medical Research Institute, Newcastle, Australia
| | - Michael C Riddell
- School of Kinesiology and Health Science, Muscle Health Research Centre, York University, Toronto, Canada
| | - David Norman O'Neal
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Fitzroy, Australia
- Australian Centre for Accelerating Diabetes Innovations, University of Melbourne, Melbourne, Australia
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13
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Trawley S, Ward GM, Vogrin S, Colman PG, Fourlanos S, Grills CA, Lee MH, MacIsaac RJ, Alipoor AM, O'Neal DN, O'Regan NA, Sundararajan V, McAuley SA. Glucose profiles of older adults with type 1 diabetes using sensor-augmented pump therapy in Australia: pre-randomisation results from the ORACL study. Lancet Healthy Longev 2022; 3:e839-e848. [PMID: 36410370 DOI: 10.1016/s2666-7568(22)00266-5] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 10/27/2022] [Accepted: 10/27/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Older adults with type 1 diabetes are recommended modified glucose targets. However, data on the effects of diabetes technology in older age are scarce. We assessed older adults established on sensor-augmented insulin pump therapy during clinical trial run-in and compared their continuous glucose monitoring (CGM) profiles with consensus recommendations. We aimed to provide insight into the applicability of currently recommended CGM-based targets while accounting for current Diabetes UK guidelines. METHODS In this analysis, adults aged 60 years or older with type 1 diabetes with a duration of at least 10 years and entering the Older Adult Closed Loop (ORACL) trial were studied. The trial was done at two tertiary hospitals in Australia. Individuals who were independent with diabetes self-management, as well as those receiving caregiver assistance for their diabetes management, were eligible for inclusion. Participants underwent baseline clinical assessment, which included medical history and examination, testing for frailty, functional ability, cognitive functioning, psychosocial wellbeing, and subjective sleep quality; fasting venous blood samples were collected for C-peptide, glucose, and glycated haemoglobin A1c measurement. Sensor-augmented pumps, carbohydrate-counting education, and diabetes education were provided to participants by diabetes nurse educators, dietitians, and endocrinologists experienced in type 1 diabetes clinical care. CGM data were subsequently collected for 2 weeks during sensor-augmented pump therapy. The ORACL trial is registered with the Australian New Zealand Clinical Trial Registry, ACTRN12619000515190. FINDINGS Our analysis included all 30 participants who completed the ORACL trial run-in-19 (63%) women and 11 (37%) men (mean age 67 years [SD 5], median diabetes duration 38 years [IQR 20-47], and insulin total daily dose 0·55 units [0·41-0·66] per kg bodyweight). Ten (33%) of 30 participants had impaired hypoglycaemia awareness and six (20%) were pre-frail; none were frail. The median CGM time in range 3·9-10·0 mmol/L was 71% (IQR 64-79). The time spent with glucose above 10·0 mmol/L was 27% (18-35) and above 13·9 mmol/L was 3·9% (2·4-10·2). The time with glucose below 3·9 mmol/L was 2·0% (1·2-3·1) and the time below 3·0 mmol/L was 0·2% (0·1-0·4). Only two (7%) of 30 participants met all CGM-based consensus recommendations modified for older adults. Time in hypoglycaemia was lower among the 16 participants with predictive low-glucose alerts enabled than among the 14 participants not using predictive low-glucose alerts (median difference -1·1 percentage points [95% CI -2·0 to -0·1]; p=0·038). This difference was even greater overnight (-2·3 percentage points [-3·2 to -1·0]; p=0·0018). One serious adverse event occurred (elective cardiac stent). INTERPRETATION Using sensor-augmented pumps after multidisciplinary education, this group of older adults without frailty achieved a time in range far exceeding minimum consensus recommendations. However, the current stringent hypoglycaemia recommendations for all older adults were not met. Predictive low alerts could reduce hypoglycaemia, particularly overnight. Investigation into the effectiveness of CGM-based targets that consider frailty, functional status, and diabetes therapies for older adults is warranted. FUNDING JDRF and Diabetes Australia.
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Affiliation(s)
- Steven Trawley
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia; Department of Psychology, The Cairnmillar Institute, Melbourne, VIC Australia
| | - Glenn M Ward
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia; Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
| | - Sara Vogrin
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
| | - Peter G Colman
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia; Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Spiros Fourlanos
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia; Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, VIC, Australia; Australian Centre for Accelerating Diabetes Innovations, Melbourne, VIC, Australia
| | - Charlotte A Grills
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia; Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
| | - Melissa H Lee
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia; Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
| | - Richard J MacIsaac
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia; Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia; Australian Centre for Accelerating Diabetes Innovations, Melbourne, VIC, Australia
| | - Andisheh Mohammad Alipoor
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia; Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
| | - David N O'Neal
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia; Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
| | - Niamh A O'Regan
- Department of Geriatric Medicine, Waterford Integrated Care for Older People, University Hospital Waterford, Waterford, Ireland
| | - Vijaya Sundararajan
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia; Department of Public Health, La Trobe University, Melbourne, VIC Australia
| | - Sybil A McAuley
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia; Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia; Department of Psychology, The Cairnmillar Institute, Melbourne, VIC Australia.
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14
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Chakrabarti A, Trawley S, Kubilay E, Mohammad Alipoor A, Vogrin S, Fourlanos S, Lee MH, O'Neal DN, O'Regan NA, Sundararajan V, Ward GM, MacIsaac RJ, Colman PG, McAuley SA. Closed-Loop Insulin Delivery Effects on Glycemia During Sleep and Sleep Quality in Older Adults with Type 1 Diabetes: Results from the ORACL Trial. Diabetes Technol Ther 2022; 24:666-671. [PMID: 35575751 DOI: 10.1089/dia.2022.0110] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Sleep-related effects of closed-loop therapy among older adults with type 1 diabetes have not been well established. In the OldeR Adult Closed-Loop (ORACL) randomized, crossover trial of first-generation closed-loop therapy (MiniMed 670G), participants wore actigraphy and completed sleep diaries for 14-day periods at stage end. During objectively measured sleep (actigraphy) with closed-loop versus sensor-augmented pump therapy, glucose time-in-range 70-180 mg/dL (3.9-10.0 mmol/L) was greater (90.3% vs. 78.7%, respectively; difference 8.2 percentage points [95% confidence interval {CI} 1.5 to 13.0]; P = 0.008), and there were fewer sensor hypoglycemia episodes (18 vs. 43, respectively; incident rate ratio 0.40 [95% CI 0.20 to 0.55]; P = 0.007). Sleep quality recorded daily was worse with closed-loop therapy (P = 0.006); Pittsburgh Sleep Quality Index did not differ. There were 30% more system alarms during monitored sleep with closed-loop therapy (P < 0.001). First-generation closed-loop therapy has important glycemic benefits during sleep for older adults, with deterioration in some sleep quality measures. Sleep quality warrants prioritization and investigation during advancement of closed-loop technology.
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Affiliation(s)
- Anindita Chakrabarti
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Steven Trawley
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Psychology, The Cairnmillar Institute, Melbourne, Victoria, Australia
| | - Erin Kubilay
- Department of Psychology, The Cairnmillar Institute, Melbourne, Victoria, Australia
| | - Andisheh Mohammad Alipoor
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Sara Vogrin
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Spiros Fourlanos
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Australian Centre for Accelerating Diabetes Innovations, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Melissa H Lee
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - David N O'Neal
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Niamh A O'Regan
- Department of Geriatric Medicine, Waterford Integrated Care for Older People, University Hospital Waterford, Waterford, Ireland
| | - Vijaya Sundararajan
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Public Health, La Trobe University, Melbourne, Victoria, Australia
| | - Glenn M Ward
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Richard J MacIsaac
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
- Australian Centre for Accelerating Diabetes Innovations, The University of Melbourne, Melbourne, Victoria, Australia
| | - Peter G Colman
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Sybil A McAuley
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
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15
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Abraham MB, Smith GJ, Fairchild JM, King BR, Ambler GR, Cameron FJ, McAuley SA, Keech AC, Jenkins A, de Bock M, Davis EA, O'Neal DN, Jones TW. Snapshot of CGM Metrics in Adolescents and Adults Achieving Target HbA1c Versus Those Not Meeting Target HbA1c. Diabetes Technol Ther 2022; 24:677-679. [PMID: 35758719 DOI: 10.1089/dia.2022.0169] [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)
- Mary B Abraham
- Children's Diabetes Centre, Telethon Kids Institute, The University of Western Australia, Perth, Australia
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Australia
- Division of Paediatrics, Medical School, The University of Western Australia, Perth, Australia
| | - Grant J Smith
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Australia
| | - Janice M Fairchild
- Department of Endocrinology and Diabetes, Women's and Children's Hospital, Adelaide, Australia
| | - Bruce R King
- Department of Endocrinology and Diabetes, John Hunter Children's Hospital, Newcastle, Australia
| | - Geoffrey R Ambler
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, The University of Sydney, Sydney, Australia
| | - Fergus J Cameron
- Department of Endocrinology and Diabetes, Royal Children's Hospital, Melbourne, Australia
| | - Sybil A McAuley
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Anthony C Keech
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Australia
| | - Alicia Jenkins
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital, Melbourne, Victoria, Australia
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Australia
| | - Martin de Bock
- Children's Diabetes Centre, Telethon Kids Institute, The University of Western Australia, Perth, Australia
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Australia
- Division of Paediatrics, Medical School, The University of Western Australia, Perth, Australia
| | - Elizabeth A Davis
- Children's Diabetes Centre, Telethon Kids Institute, The University of Western Australia, Perth, Australia
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Australia
- Division of Paediatrics, Medical School, The University of Western Australia, Perth, Australia
| | - David N O'Neal
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Timothy W Jones
- Children's Diabetes Centre, Telethon Kids Institute, The University of Western Australia, Perth, Australia
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Australia
- Division of Paediatrics, Medical School, The University of Western Australia, Perth, Australia
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16
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Roberts A, Fried L, Dart J, de Bock M, Fairchild J, King B, Ambler GR, Cameron F, McAuley SA, Keech AC, Jenkins A, O Neal DN, Davis EA, Jones TW, Abraham MB. Hybrid closed-loop therapy with a first-generation system increases confidence and independence in diabetes management in youth with type 1 diabetes. Diabet Med 2022; 39:e14907. [PMID: 35757899 DOI: 10.1111/dme.14907] [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] [Received: 12/25/2021] [Accepted: 06/20/2022] [Indexed: 11/30/2022]
Abstract
AIM Hybrid closed-loop (HCL) therapy improves glycaemic control in adolescents with type 1 diabetes; however, little is known about their lived experience using these systems. The aim of this study was to explore the lived experiences of youth with type 1 diabetes using HCL therapy, and their parents, to provide insight into their lived experiences. METHODS Adolescents and young adults aged 12-25 years, who used Medtronic MiniMed™ 670G HCL system during a 6-month randomised clinical trial, and their parents, were invited to participate in a semi-structured interview at the end of the study. Open-ended questions were used to explore the lived experiences of families using HCL. The interviews were audio-recorded, transcribed and analysed using thematic analysis to determine the main themes. RESULTS In all, 17 young people with type 1 diabetes mean ± SD age: 17.5 ± 4.2 years, diabetes duration: 11.0 ± 4.9 years and HbA1c 64 ± 9 mmol/mol (8.0 ± 0.8%) and 10 parents were interviewed. Three themes were identified: (1) 'Developing confidence and trust in the system', (2) 'Reduction in anxiety' and (3) 'Issues with device'. They reported a positive experience using HCL, with improvements in glucose levels and increased independence with diabetes management. However, frustration around the number of alarms and notifications associated with the system were also identified as issues. CONCLUSION Both youth and parents acknowledged the benefits of this first-generation HCL system in improving glycaemic outcomes and in providing flexibility and independence. These lived experiences provide valuable information in the introduction and provision of targeted education with HCL therapy.
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Affiliation(s)
- Alison Roberts
- Children's Diabetes Centre, Telethon Kids Institute, University of Western Australia, Perth, Australia
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Australia
| | - Leanne Fried
- Children's Diabetes Centre, Telethon Kids Institute, University of Western Australia, Perth, Australia
| | - Julie Dart
- Children's Diabetes Centre, Telethon Kids Institute, University of Western Australia, Perth, Australia
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Australia
| | - Martin de Bock
- Children's Diabetes Centre, Telethon Kids Institute, University of Western Australia, Perth, Australia
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Australia
- Discipline of Paediatrics, Medical School, The University of Western Australia, Perth, Australia
| | - Janice Fairchild
- Department of Endocrinology and Diabetes, Women's and Children's Hospital, Adelaide, Australia
| | - Bruce King
- Department of Endocrinology and Diabetes, John Hunter Children's Hospital, Newcastle, Australia
| | - Geoffrey R Ambler
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, The University of Sydney, Sydney, Australia
| | - Fergus Cameron
- Department of Endocrinology and Diabetes, Royal Children's Hospital, Melbourne, Australia
| | - Sybil A McAuley
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Anthony C Keech
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Alicia Jenkins
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital, Melbourne, Victoria, Australia
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - David N O Neal
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Elizabeth A Davis
- Children's Diabetes Centre, Telethon Kids Institute, University of Western Australia, Perth, Australia
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Australia
- Discipline of Paediatrics, Medical School, The University of Western Australia, Perth, Australia
| | - Timothy W Jones
- Children's Diabetes Centre, Telethon Kids Institute, University of Western Australia, Perth, Australia
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Australia
- Discipline of Paediatrics, Medical School, The University of Western Australia, Perth, Australia
| | - Mary B Abraham
- Children's Diabetes Centre, Telethon Kids Institute, University of Western Australia, Perth, Australia
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Australia
- Discipline of Paediatrics, Medical School, The University of Western Australia, Perth, Australia
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17
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Chakrabarti A, MacIsaac RJ, McAuley SA. Insulin pump troubleshooting: a case vignette and systematic approach. Med J Aust 2022; 216:595-596. [DOI: 10.5694/mja2.51559] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 01/22/2022] [Accepted: 02/15/2022] [Indexed: 11/17/2022]
Affiliation(s)
| | - Richard J MacIsaac
- University of Melbourne Melbourne VIC
- Vincent’s Hospital Melbourne Melbourne VIC
| | - Sybil A McAuley
- University of Melbourne Melbourne VIC
- Vincent’s Hospital Melbourne Melbourne VIC
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18
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McAuley SA, Trawley S. Closed-loop therapy in older adults with type 1 diabetes: hypoglycaemia benefits and risk stratification. Lancet Healthy Longev 2022; 3:e378. [PMID: 36098315 DOI: 10.1016/s2666-7568(22)00092-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 03/24/2022] [Indexed: 01/14/2023] Open
Affiliation(s)
- Sybil A McAuley
- Department of Medicine, The University of Melbourne, Melbourne, VIC 3065, Australia; Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia.
| | - Steven Trawley
- Department of Medicine, The University of Melbourne, Melbourne, VIC 3065, Australia; Department of Psychology, The Cairnmillar Institute, Melbourne, VIC, Australia
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19
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Chakrabarti A, Mohammad Alipoor A, Sandra Segaran TR, Fourlanos S, MacIsaac RJ, Colman PG, McAuley SA. Exercise habits and glucose management among older adults with type 1 diabetes using insulin pumps. Acta Diabetol 2022; 59:865-868. [PMID: 35233639 PMCID: PMC9085699 DOI: 10.1007/s00592-022-01858-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 01/21/2022] [Indexed: 11/23/2022]
Affiliation(s)
- Anindita Chakrabarti
- Department of Medicine, The University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | | | | | - Spiros Fourlanos
- Department of Medicine, The University of Melbourne, Melbourne, Australia
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, Australia
| | - Richard J MacIsaac
- Department of Medicine, The University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Peter G Colman
- Department of Medicine, The University of Melbourne, Melbourne, Australia
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, Australia
| | - Sybil A McAuley
- Department of Medicine, The University of Melbourne, Melbourne, Australia.
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia.
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20
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Roem K, Compton R, Fourlanos S, McAuley SA. Carbohydrate-counting education for older adults with type 1 diabetes starting first-generation closed-loop therapy: Observations from the ORACL trial. Nutr Diet 2022; 79:647-649. [PMID: 35543111 DOI: 10.1111/1747-0080.12744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 03/19/2022] [Accepted: 04/12/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Kerryn Roem
- Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Robyn Compton
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Spiros Fourlanos
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Sybil A McAuley
- Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
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21
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Trawley S, Stephens AN, McAuley SA, Speight J, Hendrieckx C, Vogrin S, Lee MH, Paldus B, Bach LA, Burt MG, Cohen ND, Colman PG, Davis EA, Holmes-Walker DJ, Jenkins AJ, Kaye J, Keech AC, Kumareswaran K, MacIsaac RJ, McCallum RW, Sims CM, Stranks SN, Sundararajan V, Ward GM, Jones TW, O'Neal DN. Driving with Type 1 Diabetes: Real-World Evidence to Support Starting Glucose Level and Frequency of Monitoring During Journeys. Diabetes Technol Ther 2022; 24:350-356. [PMID: 35156852 DOI: 10.1089/dia.2021.0460] [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: 11/12/2022]
Abstract
There is limited evidence supporting the recommendation that drivers with insulin-treated diabetes need to start journeys with glucose >90 mg/dL. Glucose levels of drivers with type 1 diabetes were monitored for 3 weeks using masked continuous glucose monitoring (CGM). Eighteen drivers (median [IQR] age 40 [35, 51] years; 11 men) undertook 475 trips (duration 15 [13, 21] min). Hypoglycemia did not occur in any trip starting with glucose >90 mg/dL (92%; n = 436). Thirteen drivers recorded at least one trip (total n = 39) starting with glucose <90 mg/dL. Among these, driving glucose was <70 mg/dL in five drivers (38%) during 10 trips (26%). Among five drivers (28%), a ≥ 36 mg/dL drop was observed within 20 min of starting their journey. Journey duration was positively associated with maximum glucose change. These findings support current guidelines to start driving with glucose >90 mg/dL, and to be aware that glucose levels may change significantly within 20 min. A CGM-based, in-vehicle display could provide glucose information and alerts that are compatible with safe driving. Clinical Trial Registration number: ACTRN12617000520336.
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Affiliation(s)
- Steven Trawley
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Cairnmillar Institute, Melbourne, Australia
- Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Australia
| | | | - Sybil A McAuley
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Jane Speight
- Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Australia
- School of Psychology, Deakin University, Geelong, Australia
| | - Christel Hendrieckx
- Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Australia
- School of Psychology, Deakin University, Geelong, Australia
| | - Sara Vogrin
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Melissa H Lee
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Barbora Paldus
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Leon A Bach
- Department of Endocrinology and Diabetes, Alfred Hospital, Melbourne, Australia
- Department of Medicine (Alfred), Monash University, Melbourne, Australia
| | - Morton G Burt
- Southern Adelaide Diabetes and Endocrine Services, Flinders Medical Centre, Adelaide, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Neale D Cohen
- Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Peter G Colman
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, Australia
| | - Elizabeth A Davis
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Australia
- Telethon Kids Institute, University of Western Australia, Perth, Australia
- School of Paediatrics and Child Health, University of Western Australia, Perth, Australia
| | - D Jane Holmes-Walker
- Department of Diabetes and Endocrinology, Westmead Hospital, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
| | - Alicia J Jenkins
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Joey Kaye
- Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Perth, Australia
| | - Anthony C Keech
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Kavita Kumareswaran
- Department of Endocrinology and Diabetes, Alfred Hospital, Melbourne, Australia
- Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Richard J MacIsaac
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Roland W McCallum
- Department of Diabetes and Endocrinology, Royal Hobart Hospital, Hobart, Australia
| | - Catriona M Sims
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Stephen N Stranks
- Southern Adelaide Diabetes and Endocrine Services, Flinders Medical Centre, Adelaide, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | | | - Glenn M Ward
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Timothy W Jones
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Australia
- Telethon Kids Institute, University of Western Australia, Perth, Australia
- School of Paediatrics and Child Health, University of Western Australia, Perth, Australia
| | - David N O'Neal
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
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22
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McAuley SA, Trawley S, Vogrin S, Ward GM, Fourlanos S, Grills CA, Lee MH, Alipoor AM, O'Neal DN, O'Regan NA, Sundararajan V, Colman PG, MacIsaac RJ. Closed-Loop Insulin Delivery Versus Sensor-Augmented Pump Therapy in Older Adults With Type 1 Diabetes (ORACL): A Randomized, Crossover Trial. Diabetes Care 2022; 45:381-390. [PMID: 34844995 DOI: 10.2337/dc21-1667] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [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: 08/09/2021] [Accepted: 11/01/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To assess the efficacy and safety of closed-loop insulin delivery compared with sensor-augmented pump therapy among older adults with type 1 diabetes. RESEARCH DESIGN AND METHODS This open-label, randomized (1:1), crossover trial compared 4 months of closed-loop versus sensor-augmented pump therapy. Eligible adults were aged ≥60 years, with type 1 diabetes (duration ≥10 years), using an insulin pump. The primary outcome was continuous glucose monitoring (CGM) time in range (TIR; 3.9-10.0 mmol/L). RESULTS There were 30 participants (mean age 67 [SD 5] years), with median type 1 diabetes duration of 38 years (interquartile range [IQR] 20-47), randomized (n = 15 to each sequence); all completed the trial. The mean TIR was 75.2% (SD 6.3) during the closed-loop stage and 69.0% (9.1) during the sensor-augmented pump stage (difference of 6.2 percentage points [95% CI 4.4 to 8.0]; P < 0.0001). All prespecified CGM metrics favored closed loop over the sensor-augmented pump; benefits were greatest overnight. Closed loop reduced CGM time <3.9 mmol/L during 24 h/day by 0.5 percentage points (95% CI 0.3 to 1.1; P = 0.0005) and overnight by 0.8 percentage points (0.4 to 1.1; P < 0.0001) compared with sensor-augmented pump. There was no significant difference in HbA1c between closed-loop versus sensor-augmented pump stages (7.3% [IQR, 7.1-7.5] (56 mmol/mol [54-59]) vs. 7.5% [7.1-7.9] (59 mmol/mol [54-62]), respectively; P = 0.13). Three severe hypoglycemia events occurred during the closed-loop stage and two occurred during the sensor-augmented pump stage; no hypoglycemic events required hospitalization. One episode of diabetic ketoacidosis occurred during the sensor-augmented pump stage; no serious adverse events occurred during the closed-loop stage. CONCLUSIONS Closed-loop therapy is an effective treatment option for older adults with long-duration type 1 diabetes, and no safety issues were identified. These older adults had higher TIR accompanied by less time below range during closed loop than during sensor-augmented pump therapy. Of particular clinical importance, closed loop reduced the time spent in hypoglycemic range overnight.
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Affiliation(s)
- Sybil A McAuley
- Department of Medicine, The University of Melbourne, Melbourne, Australia.,Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Steven Trawley
- Department of Medicine, The University of Melbourne, Melbourne, Australia.,Department of Psychology, Cairnmillar Institute, Melbourne, Australia
| | - Sara Vogrin
- Department of Medicine, The University of Melbourne, Melbourne, Australia
| | - Glenn M Ward
- Department of Medicine, The University of Melbourne, Melbourne, Australia.,Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Spiros Fourlanos
- Department of Medicine, The University of Melbourne, Melbourne, Australia.,Department of Diabetes and Endocrinology, The Royal Melbourne Hospital, Melbourne, Australia
| | - Charlotte A Grills
- Department of Medicine, The University of Melbourne, Melbourne, Australia.,Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Melissa H Lee
- Department of Medicine, The University of Melbourne, Melbourne, Australia.,Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Andisheh Mohammad Alipoor
- Department of Medicine, The University of Melbourne, Melbourne, Australia.,Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - David N O'Neal
- Department of Medicine, The University of Melbourne, Melbourne, Australia.,Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Niamh A O'Regan
- Department of Geriatric Medicine, Waterford Integrated Care for Older People, University Hospital Waterford, Waterford, Ireland
| | - Vijaya Sundararajan
- Department of Medicine, The University of Melbourne, Melbourne, Australia.,Department of Public Health, La Trobe University, Melbourne, Australia
| | - Peter G Colman
- Department of Medicine, The University of Melbourne, Melbourne, Australia.,Department of Diabetes and Endocrinology, The Royal Melbourne Hospital, Melbourne, Australia
| | - Richard J MacIsaac
- Department of Medicine, The University of Melbourne, Melbourne, Australia.,Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
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23
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Paldus B, Morrison D, Zaharieva DP, Lee MH, Jones H, Obeyesekere V, Lu J, Vogrin S, La Gerche A, McAuley SA, MacIsaac RJ, Jenkins AJ, Ward GM, Colman P, Smart CEM, Seckold R, King BR, Riddell MC, O'Neal DN. A Randomized Crossover Trial Comparing Glucose Control During Moderate-Intensity, High-Intensity, and Resistance Exercise With Hybrid Closed-Loop Insulin Delivery While Profiling Potential Additional Signals in Adults With Type 1 Diabetes. Diabetes Care 2022; 45:194-203. [PMID: 34789504 DOI: 10.2337/dc21-1593] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [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: 08/01/2021] [Accepted: 10/27/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To compare glucose control with hybrid closed-loop (HCL) when challenged by high intensity exercise (HIE), moderate intensity exercise (MIE), and resistance exercise (RE) while profiling counterregulatory hormones, lactate, ketones, and kinetic data in adults with type 1 diabetes. RESEARCH DESIGN AND METHODS This study was an open-label multisite randomized crossover trial. Adults with type 1 diabetes undertook 40 min of HIE, MIE, and RE in random order while using HCL (Medtronic MiniMed 670G) with a temporary target set 2 h prior to and during exercise and 15 g carbohydrates if pre-exercise glucose was <126 mg/dL to prevent hypoglycemia. Primary outcome was median (interquartile range) continuous glucose monitoring time-in-range (TIR; 70-180 mg/dL) for 14 h post-exercise commencement. Accelerometer data and venous glucose, ketones, lactate, and counterregulatory hormones were measured for 280 min post-exercise commencement. RESULTS Median TIR was 81% (67, 93%), 91% (80, 94%), and 80% (73, 89%) for 0-14 h post-exercise commencement for HIE, MIE, and RE, respectively (n = 30), with no difference between exercise types (MIE vs. HIE; P = 0.11, MIE vs. RE, P = 0.11; and HIE vs. RE, P = 0.90). Time-below-range was 0% for all exercise bouts. For HIE and RE compared with MIE, there were greater increases, respectively, in noradrenaline (P = 0.01 and P = 0.004), cortisol (P < 0.001 and P = 0.001), lactate (P ≤ 0.001 and P ≤ 0.001), and heart rate (P = 0.007 and P = 0.015). During HIE compared with MIE, there were greater increases in growth hormone (P = 0.024). CONCLUSIONS Under controlled conditions, HCL provided satisfactory glucose control with no difference between exercise type. Lactate, counterregulatory hormones, and kinetic data differentiate type and intensity of exercise, and their measurement may help inform insulin needs during exercise. However, their potential utility as modulators of insulin dosing will be limited by the pharmacokinetics of subcutaneous insulin delivery.
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Affiliation(s)
- Barbora Paldus
- 1Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,2Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Dale Morrison
- 1Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Dessi P Zaharieva
- 3School of Kinesiology and Health Science, Muscle Health Research Centre, York University, Toronto, Ontario, Canada
| | - Melissa H Lee
- 1Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,2Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Hannah Jones
- 1Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,2Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Varuni Obeyesekere
- 2Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Jean Lu
- 1Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,2Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Sara Vogrin
- 1Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - André La Gerche
- 4Department of Cardiology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,5Clinical Research Domain, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Sybil A McAuley
- 1Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,2Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Richard J MacIsaac
- 1Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,2Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Alicia J Jenkins
- 1Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,6NHMRC Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
| | - Glenn M Ward
- 1Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Peter Colman
- 7Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Carmel E M Smart
- 8John Hunter Children's Hospital, Newcastle, New South Wales, Australia
| | - Rowen Seckold
- 8John Hunter Children's Hospital, Newcastle, New South Wales, Australia
| | - Bruce R King
- 8John Hunter Children's Hospital, Newcastle, New South Wales, Australia
| | - Michael C Riddell
- 3School of Kinesiology and Health Science, Muscle Health Research Centre, York University, Toronto, Ontario, Canada
| | - David N O'Neal
- 1Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,2Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
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24
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Abraham MB, de Bock M, Smith GJ, Dart J, Fairchild JM, King BR, Ambler GR, Cameron FJ, McAuley SA, Keech AC, Jenkins A, Davis EA, O’Neal DN, Jones TW. Effect of a Hybrid Closed-Loop System on Glycemic and Psychosocial Outcomes in Children and Adolescents With Type 1 Diabetes: A Randomized Clinical Trial. JAMA Pediatr 2021; 175:1227-1235. [PMID: 34633418 PMCID: PMC8506294 DOI: 10.1001/jamapediatrics.2021.3965] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [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: 11/14/2022]
Abstract
IMPORTANCE Hybrid closed-loop (HCL) therapy has improved glycemic control in children and adolescents with type 1 diabetes; however, the efficacy of HCL on glycemic and psychosocial outcomes has not yet been established in a long-term randomized clinical trial. OBJECTIVE To determine the percentage of time spent in the target glucose range using HCL vs current conventional therapies of continuous subcutaneous insulin infusion or multiple daily insulin injections with or without continuous glucose monitoring (CGM). DESIGN, SETTING, AND PARTICIPANTS This 6-month, multicenter, randomized clinical trial included 172 children and adolescents with type 1 diabetes; patients were recruited between April 18, 2017, and October 4, 2019, in Australia. Data were analyzed from July 25, 2020, to February 26, 2021. INTERVENTIONS Eligible participants were randomly assigned to either the control group for conventional therapy (continuous subcutaneous insulin infusion or multiple daily insulin injections with or without CGM) or the intervention group for HCL therapy. MAIN OUTCOMES AND MEASURES The primary outcome was the percentage of time in range (TIR) within a glucose range of 70 to 180 mg/dL, measured by 3-week masked CGM collected at the end of the study in both groups. Secondary outcomes included CGM metrics for hypoglycemia, hyperglycemia, and glycemic variability and psychosocial measures collected by validated questionnaires. RESULTS A total of 135 patients (mean [SD] age, 15.3 [3.1] years; 76 girls [56%]) were included, with 68 randomized to the control group and 67 to the HCL group. Patients had a mean (SD) diabetes duration of 7.7 (4.3) years and mean hemoglobin A1c of 64 (11) mmol/mol, with 110 participants (81%) receiving continuous subcutaneous insulin infusion and 72 (53%) receiving CGM. In the intention-to-treat analyses, TIR increased from a mean (SD) of 53.1% (13.0%) at baseline to 62.5% (12.0%) at the end of the study in the HCL group and from 54.6% (12.5%) to 56.1% (12.2%) in the control group, with a mean adjusted difference between the 2 groups of 6.7% (95% CI, 2.7%-10.8%; P = .002). Hybrid closed-loop therapy also reduced the time that patients spent in a hypoglycemic (<70 mg/dL) range (difference, -1.9%; 95% CI, -2.5% to -1.3%) and improved glycemic variability (coefficient of variation difference, -5.7%; 95% CI, -10.2% to -0.9%). Hybrid closed-loop therapy was associated with improved diabetes-specific quality of life (difference, 4.4 points; 95% CI, 0.4-8.4 points), with no change in diabetes distress. There were no episodes of severe hypoglycemia or diabetic ketoacidosis in either group. CONCLUSIONS AND RELEVANCE In this randomized clinical trial, 6 months of HCL therapy significantly improved glycemic control and quality of life compared with conventional therapy in children and adolescents with type 1 diabetes. TRIAL REGISTRATION ANZCTR identifier: ACTRN12616000753459.
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Affiliation(s)
- Mary B. Abraham
- Children’s Diabetes Centre, Telethon Kids Institute, University of Western Australia, Perth, Australia,Department of Endocrinology and Diabetes, Perth Children’s Hospital, Perth, Australia,Division of Paediatrics, University of Western Australia Medical School, Perth, Australia
| | - Martin de Bock
- Children’s Diabetes Centre, Telethon Kids Institute, University of Western Australia, Perth, Australia,Department of Endocrinology and Diabetes, Perth Children’s Hospital, Perth, Australia,Division of Paediatrics, University of Western Australia Medical School, Perth, Australia
| | - Grant J. Smith
- Department of Endocrinology and Diabetes, Perth Children’s Hospital, Perth, Australia
| | - Julie Dart
- Children’s Diabetes Centre, Telethon Kids Institute, University of Western Australia, Perth, Australia,Department of Endocrinology and Diabetes, Perth Children’s Hospital, Perth, Australia
| | - Janice M. Fairchild
- Department of Endocrinology and Diabetes, Women’s and Children’s Hospital, Adelaide, Australia
| | - Bruce R. King
- Department of Endocrinology and Diabetes, John Hunter Children’s Hospital, Newcastle, Australia
| | - Geoffrey R. Ambler
- Institute of Endocrinology and Diabetes, Children’s Hospital at Westmead, University of Sydney, Sydney, Australia
| | - Fergus J. Cameron
- Department of Endocrinology and Diabetes, Royal Children’s Hospital, Melbourne, Australia
| | - Sybil A. McAuley
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia,Department of Endocrinology and Diabetes, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Anthony C. Keech
- National Health and Medical Research Council Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Australia
| | - Alicia Jenkins
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia,Department of Endocrinology and Diabetes, St Vincent's Hospital, Melbourne, Victoria, Australia,National Health and Medical Research Council Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Australia
| | - Elizabeth A. Davis
- Children’s Diabetes Centre, Telethon Kids Institute, University of Western Australia, Perth, Australia,Department of Endocrinology and Diabetes, Perth Children’s Hospital, Perth, Australia,Division of Paediatrics, University of Western Australia Medical School, Perth, Australia
| | - David N. O’Neal
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia,Department of Endocrinology and Diabetes, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Timothy W. Jones
- Children’s Diabetes Centre, Telethon Kids Institute, University of Western Australia, Perth, Australia,Department of Endocrinology and Diabetes, Perth Children’s Hospital, Perth, Australia,Division of Paediatrics, University of Western Australia Medical School, Perth, Australia
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Paldus B, Lee MH, Morrison D, Zaharieva DP, Jones H, Obeyesekere V, Lu J, Vogrin S, LaGerche A, McAuley SA, MacIsaac RJ, Jenkins AJ, Ward GM, Colman P, O’Neal DN. First Randomized Controlled Trial of Hybrid Closed Loop Versus Multiple Daily Injections or Insulin Pump Using Self-Monitoring of Blood Glucose in Free-Living Adults with Type 1 Diabetes Undertaking Exercise. J Diabetes Sci Technol 2021; 15:1399-1401. [PMID: 34315271 PMCID: PMC8655292 DOI: 10.1177/19322968211035110] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Barbora Paldus
- Department of Medicine, University of
Melbourne, Melbourne, VIC, Australia
- Department of Endocrinology & Diabetes,
St Vincent’s Hospital Melbourne, Melbourne, VIC, Australia
| | - Melissa H. Lee
- Department of Medicine, University of
Melbourne, Melbourne, VIC, Australia
- Department of Endocrinology & Diabetes,
St Vincent’s Hospital Melbourne, Melbourne, VIC, Australia
| | - Dale Morrison
- Department of Medicine, University of
Melbourne, Melbourne, VIC, Australia
| | - Dessi P. Zaharieva
- Department of Pediatrics, Division of
Endocrinology, School of Medicine, Stanford University, Stanford, CA, USA
| | - Hannah Jones
- Department of Medicine, University of
Melbourne, Melbourne, VIC, Australia
- Department of Endocrinology & Diabetes,
St Vincent’s Hospital Melbourne, Melbourne, VIC, Australia
| | - Varuni Obeyesekere
- Department of Endocrinology & Diabetes,
St Vincent’s Hospital Melbourne, Melbourne, VIC, Australia
| | - Jean Lu
- Department of Medicine, University of
Melbourne, Melbourne, VIC, Australia
- Department of Endocrinology & Diabetes,
St Vincent’s Hospital Melbourne, Melbourne, VIC, Australia
| | - Sara Vogrin
- Department of Medicine, University of
Melbourne, Melbourne, VIC, Australia
| | - André LaGerche
- Department of Cardiology, St Vincent’s
Hospital Melbourne, Melbourne, VIC, Australia
- Clinical Research Domain, Baker Heart and
Diabetes Institute, Melbourne, VIC, Australia
| | - Sybil A. McAuley
- Department of Medicine, University of
Melbourne, Melbourne, VIC, Australia
- Department of Endocrinology & Diabetes,
St Vincent’s Hospital Melbourne, Melbourne, VIC, Australia
| | - Richard J. MacIsaac
- Department of Medicine, University of
Melbourne, Melbourne, VIC, Australia
- Department of Endocrinology & Diabetes,
St Vincent’s Hospital Melbourne, Melbourne, VIC, Australia
| | - Alicia J. Jenkins
- Department of Medicine, University of
Melbourne, Melbourne, VIC, Australia
- University of Sydney, NHMRC Clinical Trials
Centre, Sydney, NSW, Australia
| | - Glenn M. Ward
- Department of Medicine, University of
Melbourne, Melbourne, VIC, Australia
| | - Peter Colman
- The Deparment Diabetes and Endocrinology,
Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - David N. O’Neal
- Department of Medicine, University of
Melbourne, Melbourne, VIC, Australia
- Department of Endocrinology & Diabetes,
St Vincent’s Hospital Melbourne, Melbourne, VIC, Australia
- David N. O’Neal, MBBS, MD, FRACP, PhD, Department
of Medicine, University of Melbourne, Level 4, Daly Wing North, Melbourne, VIC, Australia.
Department of Endocrinology & Diabetes, St Vincent’s Hospital Melbourne, 35 Victoria
Pde, Fitzroy, VIC 3065, Australia.
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26
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Lu JC, Vogrin S, McAuley SA, Lee MH, Paldus B, Bach LA, Burt MG, Clarke PM, Cohen ND, Colman PG, de Bock MI, Jane Holmes-Walker D, Jenkins AJ, Kaye J, Keech AC, Kumareswaran K, MacIsaac RJ, McCallum RW, Roem K, Sims C, Stranks SN, Trawley S, Ward GM, Sundararajan V, Jones TW, O'Neal DN. Meal-time glycaemia in adults with type 1 diabetes using multiple daily injections vs insulin pump therapy following carbohydrate-counting education and bolus calculator provision. Diabetes Res Clin Pract 2021; 179:109000. [PMID: 34455185 DOI: 10.1016/j.diabres.2021.109000] [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: 12/13/2020] [Revised: 05/14/2021] [Accepted: 08/06/2021] [Indexed: 11/17/2022]
Abstract
AIMS To compare meal-time glycaemia in adults with type 1 diabetes mellitus (T1D) managed with multiple daily injections (MDI) vs. insulin pump therapy (IPT), using self-monitoring blood glucose (SMBG), following diabetes education. METHODS Adults with T1D received carbohydrate-counting education and a bolus calculator: MDI (Roche Aviva Expert) and IPT (pump bolus calculator). All then wore 3-weeks of masked-CGM (Enlite, Medtronic). Meal-times were assessed by two approaches: 1) Set time-blocks (breakfast 06:00-10:00hrs; lunch 11:00-15:00hrs; dinner 17:00-21:00hrs) and 2) Bolus-calculator carbohydrate entries signalling meal commencement. Post-meal masked-CGM time-in-range (TIR) 3.9-10.0 mmol/L was the primary outcome. RESULTS MDI(n = 61) and IPT (n = 59) participants were equivalent in age, sex, diabetes duration and HbA1c. Median (IQR) education time provided did not differ (MDI: 1.1 h (0.75, 1.5) vs. IPT: 1.1 h (1.0, 2.0); p = 0.86). Overall, daytime (06:00-24:00hrs), lunch and dinner TIR did not differ for MDI vs. IPT participants but was greater for breakfast with IPT in both analyses with a mean difference of 12.8%, (95 CI 4.8, 20.9); p = 0.002 (time-block analysis). CONCLUSION After diabetes education, MDI and IPT use were associated with similar day-time glycemia, though IPT users had significantly greater TIR during the breakfast period. With education, meal-time glucose levels are comparable with use of MDI vs. pumps.
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Affiliation(s)
- Jean C Lu
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia; Department of Medicine, University of Melbourne, Fitzroy, Victoria, Australia
| | - Sara Vogrin
- Department of Medicine, University of Melbourne, Fitzroy, Victoria, Australia
| | - Sybil A McAuley
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia; Department of Medicine, University of Melbourne, Fitzroy, Victoria, Australia
| | - Melissa H Lee
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia; Department of Medicine, University of Melbourne, Fitzroy, Victoria, Australia
| | - Barbora Paldus
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia; Department of Medicine, University of Melbourne, Fitzroy, Victoria, Australia
| | - Leon A Bach
- Department of Endocrinology and Diabetes, Alfred Hospital, Melbourne, Victoria, Australia; Department of Medicine (Alfred), Monash University, Melbourne, Victoria, Australia
| | - Morton G Burt
- Southern Adelaide Diabetes and Endocrine Services, Flinders Medical Centre, Adelaide, South Australia, Australia; School of Medicine, Flinders University, Adelaide, South Australia, Australia
| | - Philip M Clarke
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Neale D Cohen
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Peter G Colman
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Martin I de Bock
- Department of Paediatrics, University of Otago, Christchurch, New Zealand
| | - D Jane Holmes-Walker
- Department of Diabetes and Endocrinology, Westmead Hospital, Sydney, New South Wales, Australia; Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Alicia J Jenkins
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia; Department of Medicine, University of Melbourne, Fitzroy, Victoria, Australia; NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Joey Kaye
- Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Anthony C Keech
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Kavita Kumareswaran
- Department of Endocrinology and Diabetes, Alfred Hospital, Melbourne, Victoria, Australia; Department of Medicine (Alfred), Monash University, Melbourne, Victoria, Australia
| | - Richard J MacIsaac
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia; Department of Medicine, University of Melbourne, Fitzroy, Victoria, Australia
| | - Roland W McCallum
- Department of Diabetes and Endocrinology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Kerryn Roem
- Department of Medicine, University of Melbourne, Fitzroy, Victoria, Australia
| | - Catriona Sims
- Department of Medicine, University of Melbourne, Fitzroy, Victoria, Australia
| | - Stephen N Stranks
- Southern Adelaide Diabetes and Endocrine Services, Flinders Medical Centre, Adelaide, South Australia, Australia; School of Medicine, Flinders University, Adelaide, South Australia, Australia
| | | | - Glenn M Ward
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia; Department of Medicine, University of Melbourne, Fitzroy, Victoria, Australia; Department of Pathology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Vijaya Sundararajan
- Department of Medicine, University of Melbourne, Fitzroy, Victoria, Australia; Department of Public Health, La Trobe University, Australia
| | - Timothy W Jones
- Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children, Perth, Western Australia, Australia; Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia; School of Paediatrics and Child Health, University of Western Australia, Perth, Western Australia, Australia
| | - David N O'Neal
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia; Department of Medicine, University of Melbourne, Fitzroy, Victoria, Australia; NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia.
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27
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McAuley SA, Vogrin S, Lee MH, Paldus B, Trawley S, de Bock MI, Abraham MB, Bach LA, Burt MG, Cohen ND, Colman PG, Davis EA, Hendrieckx C, Holmes-Walker DJ, Jenkins AJ, Kaye J, Keech AC, Kumareswaran K, MacIsaac RJ, McCallum RW, Sims CM, Speight J, Stranks SN, Sundararajan V, Ward GM, Jones TW, O'Neal DN. Less Nocturnal Hypoglycemia but Equivalent Time in Range Among Adults with Type 1 Diabetes Using Insulin Pumps Versus Multiple Daily Injections. Diabetes Technol Ther 2021; 23:460-466. [PMID: 33351699 DOI: 10.1089/dia.2020.0589] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 11/12/2022]
Abstract
Background: This prerandomization analysis from the Australian HCL-Adult trial (registration number: ACTRN12617000520336) compared masked continuous glucose monitoring (CGM) metrics among adults using insulin pumps versus multiple daily injections (MDIs), who were all self-monitoring blood glucose (SMBG). Methods: Adults with type 1 diabetes, using an insulin pump or MDIs without real-time CGM (and entering a trial of closed-loop technology), were eligible. MDI users were given an insulin dosage calculator. All participants received diabetes and carbohydrate-counting education, then wore masked CGM sensors for 3 weeks. Ethics Approval: HREC-D 088/16 Results: Adults using MDIs (n = 61) versus pump (n = 59) did not differ by age, sex, diabetes duration, insulin total daily dose, or HbA1c at baseline. After education, median (interquartile range) CGM time in range (TIR) 70-180 mg/dL (3.9-10.0 mmol/L) was 54% (47, 62) for those using MDIs and 56% (48, 66) for those using pump (P = 0.40). All CGM metrics were equivalent for 24 h/day for MDI and pump users. Overnight, those using MDIs (vs. pump) spent more time with glucose <54 mg/dL (<3.0 mmol/L): 1.4% (0.1, 5.1) versus 0.5% (0.0, 2.0), respectively (P = 0.012). They also had more CGM hypoglycemia episodes (121 vs. 54, respectively; incidence rate ratio [95% confidence interval] 2.48 [1.51, 4.06]; P < 0.001). Conclusions: Adults with type 1 diabetes using pumps versus MDIs in conjunction with SMBG experienced less nocturnal hypoglycemia, measured by masked CGM, after equivalent diabetes and dietary education in conjunction with insulin dosage calculator provision to all. However, both groups had equivalent TIR. This observation may reflect advantages afforded by flexibility in basal insulin delivery provided by pumps.
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Affiliation(s)
- Sybil A McAuley
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Sara Vogrin
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Melissa H Lee
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Barbora Paldus
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Steven Trawley
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Australian Centre for Behavioural Research in Diabetes, Melbourne, Australia
- The Cairnmillar Institute, Melbourne, Australia
| | - Martin I de Bock
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Australia
- Telethon Kids Institute, University of Western Australia, Perth, Australia
- School of Paediatrics and Child Health, University of Western Australia, Perth, Australia
- Department of Paediatrics and Child Health, University of Otago, Christchurch, New Zealand
| | - Mary B Abraham
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Australia
- Telethon Kids Institute, University of Western Australia, Perth, Australia
- School of Paediatrics and Child Health, University of Western Australia, Perth, Australia
| | - Leon A Bach
- Department of Endocrinology and Diabetes, The Alfred, Melbourne, Australia
- Department of Medicine (Alfred Medical Research and Education Precinct), Monash University, Melbourne, Australia
| | - Morton G Burt
- Southern Adelaide Diabetes and Endocrine Services, Flinders Medical Centre, Adelaide, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Neale D Cohen
- Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Peter G Colman
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, Australia
| | - Elizabeth A Davis
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Australia
- Telethon Kids Institute, University of Western Australia, Perth, Australia
- School of Paediatrics and Child Health, University of Western Australia, Perth, Australia
| | - Christel Hendrieckx
- Australian Centre for Behavioural Research in Diabetes, Melbourne, Australia
- School of Psychology, Deakin University, Geelong, Australia
| | - D Jane Holmes-Walker
- Department of Diabetes and Endocrinology, Westmead Hospital, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
| | - Alicia J Jenkins
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Joey Kaye
- Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Perth, Australia
| | - Anthony C Keech
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Kavita Kumareswaran
- Department of Endocrinology and Diabetes, The Alfred, Melbourne, Australia
- Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Richard J MacIsaac
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Roland W McCallum
- Department of Diabetes and Endocrinology, Royal Hobart Hospital, Hobart, Australia
| | - Catriona M Sims
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Jane Speight
- Australian Centre for Behavioural Research in Diabetes, Melbourne, Australia
- School of Psychology, Deakin University, Geelong, Australia
| | - Stephen N Stranks
- Southern Adelaide Diabetes and Endocrine Services, Flinders Medical Centre, Adelaide, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | | | - Glenn M Ward
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Timothy W Jones
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Australia
- Telethon Kids Institute, University of Western Australia, Perth, Australia
- School of Paediatrics and Child Health, University of Western Australia, Perth, Australia
| | - David N O'Neal
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
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28
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McAuley SA, Lee MH, Paldus B, Vogrin S, de Bock MI, Abraham MB, Bach LA, Burt MG, Cohen ND, Colman PG, Davis EA, Hendrieckx C, Holmes-Walker DJ, Kaye J, Keech AC, Kumareswaran K, MacIsaac RJ, McCallum RW, Sims CM, Speight J, Stranks SN, Sundararajan V, Trawley S, Ward GM, Jenkins AJ, Jones TW, O'Neal DN. Six Months of Hybrid Closed-Loop Versus Manual Insulin Delivery With Fingerprick Blood Glucose Monitoring in Adults With Type 1 Diabetes: A Randomized, Controlled Trial. Diabetes Care 2020; 43:3024-3033. [PMID: 33055139 DOI: 10.2337/dc20-1447] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [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: 06/12/2020] [Accepted: 09/16/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To investigate glycemic and psychosocial outcomes with hybrid closed-loop (HCL) versus user-determined insulin dosing with multiple daily injections (MDI) or insulin pump (i.e., standard therapy for most adults with type 1 diabetes). RESEARCH DESIGN AND METHODS Adults with type 1 diabetes using MDI or insulin pump without continuous glucose monitoring (CGM) were randomized to 26 weeks of HCL (Medtronic 670G) or continuation of current therapy. The primary outcome was masked CGM time in range (TIR; 70-180 mg/dL) during the final 3 weeks. RESULTS Participants were randomized to HCL (n = 61) or control (n = 59). Baseline mean (SD) age was 44.2 (11.7) years, HbA1c was 7.4% (0.9%) (57 [10] mmol/mol), 53% were women, and 51% used MDI. HCL TIR increased from (baseline) 55% (13%) to (26 weeks) 70% (10%) with the control group unchanged: (baseline) 55% (12%) and (26 weeks) 55% (13%) (difference 15% [95% CI 11, 19]; P < 0.0001). For HCL, HbA1c was lower (median [95% CI] difference -0.4% [-0.6, -0.2]; -4 mmol/mol [-7, -2]; P < 0.0001) and diabetes-specific positive well-being was higher (difference 1.2 [95% CI 0.4, 1.9]; P < 0.0048) without a deterioration in diabetes distress, perceived sleep quality, or cognition. Seventeen (9 device-related) versus 13 serious adverse events occurred in the HCL and control groups, respectively. CONCLUSIONS In adults with type 1 diabetes, 26 weeks of HCL improved TIR, HbA1c, and their sense of satisfaction from managing their diabetes compared with those continuing with user-determined insulin dosing and self-monitoring of blood glucose. For most people living with type 1 diabetes globally, this trial demonstrates that HCL is feasible, acceptable, and advantageous.
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Affiliation(s)
- Sybil A McAuley
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Melissa H Lee
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Barbora Paldus
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Sara Vogrin
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Martin I de Bock
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Nedlands, Western Australia, Australia.,Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia.,School of Paediatrics and Child Health, University of Western Australia, Nedlands, Western Australia, Australia.,Department of Paediatrics and Child Health, University of Otago, Wellington, New Zealand
| | - Mary B Abraham
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Nedlands, Western Australia, Australia.,Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia.,School of Paediatrics and Child Health, University of Western Australia, Nedlands, Western Australia, Australia
| | - Leon A Bach
- Department of Endocrinology and Diabetes, The Alfred, Melbourne, Victoria, Australia.,Department of Medicine (Alfred Medical Research and Education Precinct), Monash University, Melbourne, Victoria, Australia
| | - Morton G Burt
- Southern Adelaide Diabetes and Endocrine Services, Flinders Medical Centre, Bedford Park, South Australia, Australia.,College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Neale D Cohen
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Peter G Colman
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Elizabeth A Davis
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Nedlands, Western Australia, Australia.,Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia.,School of Paediatrics and Child Health, University of Western Australia, Nedlands, Western Australia, Australia
| | - Christel Hendrieckx
- School of Psychology, Deakin University, Geelong, Victoria, Australia.,Australian Centre for Behavioural Research in Diabetes, North Melbourne, Victoria, Australia
| | - D Jane Holmes-Walker
- Department of Diabetes and Endocrinology, Westmead Hospital, Westmead, New South Wales, Australia.,Sydney Medical School, University of Sydney, Camperdown, New South Wales, Australia
| | - Joey Kaye
- Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Anthony C Keech
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
| | - Kavita Kumareswaran
- Department of Endocrinology and Diabetes, The Alfred, Melbourne, Victoria, Australia.,Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Richard J MacIsaac
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Roland W McCallum
- Department of Diabetes and Endocrinology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Catriona M Sims
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Jane Speight
- School of Psychology, Deakin University, Geelong, Victoria, Australia.,Australian Centre for Behavioural Research in Diabetes, North Melbourne, Victoria, Australia
| | - Stephen N Stranks
- Southern Adelaide Diabetes and Endocrine Services, Flinders Medical Centre, Bedford Park, South Australia, Australia.,College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Vijaya Sundararajan
- Department of Public Health, La Trobe University, Melbourne, Victoria, Australia
| | - Steven Trawley
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Australian Centre for Behavioural Research in Diabetes, North Melbourne, Victoria, Australia.,The Cairnmillar Institute, Hawthorn East, Victoria, Australia
| | - Glenn M Ward
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Alicia J Jenkins
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia.,Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Timothy W Jones
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Nedlands, Western Australia, Australia.,Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia.,School of Paediatrics and Child Health, University of Western Australia, Nedlands, Western Australia, Australia
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Lee MH, Vogrin S, Paldus B, Jayawardene D, Jones HM, McAuley SA, Obeyesekere V, Gooley J, La Gerche A, MacIsaac RJ, Sundararajan V, Jenkins AJ, Ward GM, O'Neal DN. Glucose and Counterregulatory Responses to Exercise in Adults With Type 1 Diabetes and Impaired Awareness of Hypoglycemia Using Closed-Loop Insulin Delivery: A Randomized Crossover Study. Diabetes Care 2020; 43:480-483. [PMID: 31796571 DOI: 10.2337/dc19-1433] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [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: 07/21/2019] [Accepted: 11/03/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To evaluate exercise-related glucose and counterregulatory responses (CRR) in adults with type 1 diabetes with impaired awareness of hypoglycemia (IAH) using hybrid closed-loop (HCL) insulin delivery to maintain glucose homeostasis. RESEARCH DESIGN AND METHODS Twelve participants undertook 45-min high-intensity intermittent exercise (HIIE) and moderate-intensity exercise (MIE) in random order. The primary outcome was continuous glucose monitoring (CGM) time in range (70-180 mg/dL) for 24-h post-exercise commencement. RESULTS CGM time in range was similar for HIIE and MIE (median 79.5% [interquartile range 73.2, 87.6] vs. 76.1% [70.3, 83.9], P = 0.37), and time with levels <54mg/dL post-exercise commencement was 0%. HIIE induced greater increases in cortisol (P = 0.002), noradrenaline (P = 0.005), and lactate (P = 0.002), with no differences in adrenaline, dopamine, growth hormone, or glucagon responses. CONCLUSIONS IAH adults using HCL undertaking HIIE and MIE exhibit heterogeneity in CRR. Novel findings were a preserved cortisol response and variable catecholamine responses to HIIE.
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Affiliation(s)
- Melissa H Lee
- University of Melbourne, Department of Medicine, Melbourne, Australia.,Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Sara Vogrin
- University of Melbourne, Department of Medicine, Melbourne, Australia
| | - Barbora Paldus
- University of Melbourne, Department of Medicine, Melbourne, Australia
| | | | - Hannah M Jones
- University of Melbourne, Department of Medicine, Melbourne, Australia.,Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Sybil A McAuley
- University of Melbourne, Department of Medicine, Melbourne, Australia.,Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Varuni Obeyesekere
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Judith Gooley
- University of Melbourne, Department of Medicine, Melbourne, Australia
| | - André La Gerche
- Department of Cardiology, St Vincent's Hospital Melbourne, Melbourne, Australia.,Clinical Research Domain, Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Richard J MacIsaac
- University of Melbourne, Department of Medicine, Melbourne, Australia.,Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Vijaya Sundararajan
- University of Melbourne, Department of Medicine, Melbourne, Australia.,Department of Public Health, La Trobe University, Melbourne, Australia
| | - Alicia J Jenkins
- University of Melbourne, Department of Medicine, Melbourne, Australia.,Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia.,NHMRC Clinical Trials Centre at the University of Sydney, Sydney, Australia
| | - Glenn M Ward
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia.,Department of Pathology, University of Melbourne, Melbourne, Australia
| | - David N O'Neal
- University of Melbourne, Department of Medicine, Melbourne, Australia .,Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
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Lee MH, Vogrin S, Paldus B, Jones HM, Obeyesekere V, Sims C, Wyatt SA, Ward GM, McAuley SA, MacIsaac RJ, Krishnamurthy B, Sundararajan V, Jenkins AJ, O'Neal DN. Glucose Control in Adults with Type 1 Diabetes Using a Medtronic Prototype Enhanced-Hybrid Closed-Loop System: A Feasibility Study. Diabetes Technol Ther 2019; 21:499-506. [PMID: 31264889 DOI: 10.1089/dia.2019.0120] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [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: Experience from first-generation closed-loop (CL) systems informs refinements to enhance glucose control and user acceptance. A next-generation prototype enhanced-hybrid CL (E-HCL) system incorporates iterative changes to the Medtronic MiniMed 670G CL system, including automated correction boluses, lower target glucose level, and user enhancements. The aim was to explore safety, system performance, and glucose control using E-HCL in adults with type 1 diabetes. Methods: Twelve adults underwent this first in-human feasibility study. After a 1-week run-in using open-loop (OL), E-HCL was activated at the start of a supervised 1-week hotel phase, followed by 3 weeks free living at home. Supervised challenges included two meal interventions (unannounced and late meal bolus) and a sensor calibration intervention. Primary outcome was sensor glucose time-in-range (TIR); OL run-in and E-HCL at home were compared by Wilcoxon signed-rank test. Results: Twelve adults (seven men; median [interquartile range] age 48 [39, 57] years; HbA1c 6.8 [6.2, 7.2]%, 51 [44, 55] mmol/mol; diabetes duration 31 [13, 41] years) completed the protocol. E-HCL resulted in greater TIR (85.3 [79.4, 88.4]% vs. 75.0 [66.6, 83.7]%, P = 0.003) and lower mean sensor glucose (123.0 [119.3, 129.6] mg/dL vs. 143.5 [135.8, 154.5] mg/dL, P = 0.002) than OL. Time spent <70 mg/dL increased using E-HCL (4.4 [3.3, 6.1]% vs. 3.0 [1.8, 3.8]%, P = 0.02) with no difference in time <54 mg/dL (P = 0.64). Time in CL was 99.98 [99.0, 100.0]%. All participants were satisfied using E-HCL. Conclusions: In adults with well-controlled HbA1c levels, a prototype E-HCL resulted in high TIR, few CL exits, and positive user experiences at the expense of increased hypoglycemia (<70 mg/dL). E-HCL represents a positive step in the journey toward optimizing glucose control in people living with type 1 diabetes.
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Affiliation(s)
- Melissa H Lee
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Sara Vogrin
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Barbora Paldus
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Hannah M Jones
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Varuni Obeyesekere
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Catriona Sims
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Sue-Anne Wyatt
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Glenn M Ward
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
- Department of Pathology, University of Melbourne, Melbourne, Australia
| | - Sybil A McAuley
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Richard J MacIsaac
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Balasubramanian Krishnamurthy
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Vijaya Sundararajan
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Public Health, La Trobe University, Melbourne, Australia
| | - Alicia J Jenkins
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - David N O'Neal
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
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Lee MH, Paldus B, Krishnamurthy B, McAuley SA, Shah R, Jenkins AJ, O’Neal DN. The Clinical Case for the Integration of a Ketone Sensor as Part of a Closed Loop Insulin Pump System. J Diabetes Sci Technol 2019; 13:967-973. [PMID: 30628470 PMCID: PMC6955455 DOI: 10.1177/1932296818822986] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [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: 11/15/2022]
Abstract
Closed loop (CL) systems deliver insulin with a rapid onset and offset in action. Although favorable overall, the absence of a long-acting insulin increases the risk of diabetic ketoacidosis (DKA) which can occur with insulin delivery failure, acute illness, low carbohydrate diets, sodium glucose-linked transporter inhibitors, and high intensity exercise. A CL system relying entirely on interstitial glucose measurements may not provide an alert for DKA and many people with type 1 diabetes (T1D) do not carry a blood ketone meter and test-strips. Ketone sensing is theoretically feasible. A multianalyte platform incorporating a ketone sensor could provide an additional CL input without an increase in burden for the person with T1D, warning of impending DKA to allow remedial action to be taken. We outline the clinical case for inclusion of continuous ketone sensing as part of future CL systems.
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Affiliation(s)
- Melissa H. Lee
- Department of Medicine, University of Melbourne, St. Vincent’s Hospital Melbourne, Fitzroy, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent’s Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Barbora Paldus
- Department of Medicine, University of Melbourne, St. Vincent’s Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Balasubramanium Krishnamurthy
- Department of Medicine, University of Melbourne, St. Vincent’s Hospital Melbourne, Fitzroy, Victoria, Australia
- St Vincent’s Institute, Melbourne, Fitzroy, Victoria, Australia
| | - Sybil A. McAuley
- Department of Medicine, University of Melbourne, St. Vincent’s Hospital Melbourne, Fitzroy, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent’s Hospital Melbourne, Fitzroy, Victoria, Australia
| | | | - Alicia J. Jenkins
- Department of Medicine, University of Melbourne, St. Vincent’s Hospital Melbourne, Fitzroy, Victoria, Australia
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - David N. O’Neal
- Department of Medicine, University of Melbourne, St. Vincent’s Hospital Melbourne, Fitzroy, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent’s Hospital Melbourne, Fitzroy, Victoria, Australia
- David N. O’Neal, MD, FRACP, University of Melbourne Department of Medicine, St. Vincent’s Hospital Melbourne, 4th Floor Clinical Sciences Building, 29 Princess St, Fitzroy, 3065, Victoria, Australia.
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Turner G, Quigg S, Davoren P, Basile R, McAuley SA, Coombes JS. Resources to Guide Exercise Specialists Managing Adults with Diabetes. Sports Med Open 2019; 5:20. [PMID: 31161377 PMCID: PMC6546780 DOI: 10.1186/s40798-019-0192-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 05/10/2019] [Indexed: 12/16/2022]
Abstract
Exercise is an important element to optimize health and well-being, though navigating exercise safely can be challenging for exercise specialists working with people with diabetes. Measuring glucose levels before an exercise session assists in the determination of whether exercise is safe for a person with diabetes. A number of organizations have recently developed guidelines to provide exercise and diabetes recommendations based on glucose levels and other relevant factors. However, there are limited easy-to-use resources to assist exercise specialists to determine whether exercise should be started and continued by people with diabetes. The type of diabetes, pre-exercise glucose level, medications and their timing, recent food intake and general sense of wellness all warrant consideration when determining the approach to each exercise session. An expert group was convened to review the published literature and develop resources to guide exercise specialists in assessing the safety of an adult with diabetes starting exercise, and indications to cease exercise, based upon glucose levels and other factors. Contraindications to people with diabetes starting or continuing exercise are (1) glucose < 4.0 mmol/L; (2) glucose > 15.0 mmol/L with symptoms of weakness/tiredness, or with ketosis; (3) hypoglycaemic event within the previous 24 h that required assistance from another person to treat and (4) feeling unwell. To optimize diabetes and exercise safety, recommendations (stratified by pre-exercise glucose level) are provided regarding carbohydrate ingestion, glucose monitoring and medication adjustment.
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Affiliation(s)
- Grant Turner
- Chronic Disease and Post Acute Programs, Diagnostic, Emergency and Medical Services, Gold Coast Health, Queensland Health, Robina, Australia
| | - Scott Quigg
- Metro North Hospital and Health Service, Community, Indigenous and Subacute Service, Diabetes Service, North Lakes Health Precinct, Queensland Health, North Lakes, Australia
| | - Peter Davoren
- Division Medicine, Gold Coast Health, Queensland Health, Robina, Australia
| | - Renata Basile
- Diabetes Centre, Gold Coast University Hospital, Southport, Australia
| | - Sybil A McAuley
- Department of Medicine, University of Melbourne, Melbourne, Australia.,Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Jeff S Coombes
- School of Human Movement and Nutrition Sciences, University of Queensland, Brisbane, 4072, Australia.
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MacIsaac RJ, Lee MH, McAuley SA, Ward GM, O'Neal DN. Empagliflozin as an adjunctive therapy for type 1 diabetes. Ann Transl Med 2019; 6:S134. [PMID: 30740455 DOI: 10.21037/atm.2018.12.52] [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] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Richard J MacIsaac
- Department of Endocrinology & Diabetes, St Vincent's Hospital, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Victoria, Australia
| | - Melissa H Lee
- Department of Endocrinology & Diabetes, St Vincent's Hospital, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Victoria, Australia
| | - Sybil A McAuley
- Department of Endocrinology & Diabetes, St Vincent's Hospital, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Victoria, Australia
| | - Glenn M Ward
- Department of Endocrinology & Diabetes, St Vincent's Hospital, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Victoria, Australia
| | - David N O'Neal
- Department of Endocrinology & Diabetes, St Vincent's Hospital, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Victoria, Australia
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Paldus B, Lee MH, Jones HM, McAuley SA, Horsburgh JC, Roem KL, Ward GM, MacIsaac RJ, Cohen N, Colman PG, Jenkins AJ, O'Neal DN. Glucose Control Using a Standard Versus an Enhanced Hybrid Closed Loop System: A Randomized Crossover Study. Diabetes Technol Ther 2019; 21:56-58. [PMID: 30620641 DOI: 10.1089/dia.2018.0279] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [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
Hybrid closed loop (HCL) insulin delivery with the Medtronic Minimed 670G system is effective and safe in people with type 1 diabetes (T1D). This study compared glucose control, closed loop (CL) exits, and alarm frequency with the standard HCL (s-HCL) versus enhanced HCL (e-HCL) Medtronic system. Pump-experienced T1D adults (n = 11; 9 female; mean [SD] age: 51 years [15 years]; HbA1c 7.5% [1.0%] or 58 mmol/mol [7.7 mmol/mol]) were assigned, in random order, s-HCL or e-HCL for 1 week each in a supervised live-in setting. e-HCL incorporated enhanced bolus reminders and iterative changes, broadening glucose and insulin delivery parameters permitting persistence in CL. For both s-HCL and e-HCL, insulin delivery was by a Medtronic pump with identical interventions (missed bolus, exercise, high-glycemic index, and high-fat meals), insulin action times, and insulin-carbohydrate ratios implemented. The primary outcome was continuous glucose monitoring time in target range. Analysis was by paired t-test for normally distributed data and Wilcoxon-signed rank test otherwise. e-HCL resulted in significantly fewer CL alerts and exits. Time in target and mean glucose favored e-HCL but did not reach statistical significance. No episodes of severe hypoglycemia or ketoacidosis occurred. Relative to s-HCL, e-HCL use significantly decreases CL exits and alerts, and tended to improve glycemia without compromising safety, despite multiple food and exercise challenges during the study. Longer term studies at home are merited.
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Affiliation(s)
- Barbora Paldus
- 1 Department of Medicine, St. Vincent's Hospital Melbourne, University of Melbourne, Fitzroy, Australia
- 2 Department of Endocrinology and Diabetes, St. Vincent's Hospital Melbourne, Fitzroy, Australia
| | - Melissa H Lee
- 1 Department of Medicine, St. Vincent's Hospital Melbourne, University of Melbourne, Fitzroy, Australia
- 2 Department of Endocrinology and Diabetes, St. Vincent's Hospital Melbourne, Fitzroy, Australia
| | - Hannah M Jones
- 1 Department of Medicine, St. Vincent's Hospital Melbourne, University of Melbourne, Fitzroy, Australia
- 2 Department of Endocrinology and Diabetes, St. Vincent's Hospital Melbourne, Fitzroy, Australia
| | - Sybil A McAuley
- 1 Department of Medicine, St. Vincent's Hospital Melbourne, University of Melbourne, Fitzroy, Australia
- 2 Department of Endocrinology and Diabetes, St. Vincent's Hospital Melbourne, Fitzroy, Australia
| | - Jodie C Horsburgh
- 1 Department of Medicine, St. Vincent's Hospital Melbourne, University of Melbourne, Fitzroy, Australia
- 2 Department of Endocrinology and Diabetes, St. Vincent's Hospital Melbourne, Fitzroy, Australia
| | - Kerryn L Roem
- 1 Department of Medicine, St. Vincent's Hospital Melbourne, University of Melbourne, Fitzroy, Australia
| | - Glenn M Ward
- 1 Department of Medicine, St. Vincent's Hospital Melbourne, University of Melbourne, Fitzroy, Australia
- 2 Department of Endocrinology and Diabetes, St. Vincent's Hospital Melbourne, Fitzroy, Australia
| | - Richard J MacIsaac
- 1 Department of Medicine, St. Vincent's Hospital Melbourne, University of Melbourne, Fitzroy, Australia
- 2 Department of Endocrinology and Diabetes, St. Vincent's Hospital Melbourne, Fitzroy, Australia
| | - Neale Cohen
- 3 Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Peter G Colman
- 4 Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Parkville, Australia
| | - Alicia J Jenkins
- 1 Department of Medicine, St. Vincent's Hospital Melbourne, University of Melbourne, Fitzroy, Australia
- 2 Department of Endocrinology and Diabetes, St. Vincent's Hospital Melbourne, Fitzroy, Australia
- 5 NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - David N O'Neal
- 1 Department of Medicine, St. Vincent's Hospital Melbourne, University of Melbourne, Fitzroy, Australia
- 2 Department of Endocrinology and Diabetes, St. Vincent's Hospital Melbourne, Fitzroy, Australia
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de Bock M, McAuley SA, Abraham MB, Smith G, Nicholas J, Ambler GR, Cameron FJ, Fairchild JM, King BR, Geelhoed EA, Davis EA, O'Neal DN, Jones TW. Effect of 6 months hybrid closed-loop insulin delivery in young people with type 1 diabetes: a randomised controlled trial protocol. BMJ Open 2018; 8:e020275. [PMID: 30104309 PMCID: PMC6091910 DOI: 10.1136/bmjopen-2017-020275] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [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] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Automated insulin delivery (also known as closed loop, or artificial pancreas) has shown potential to improve glycaemic control and quality of life in people with type 1 diabetes (T1D). Automated insulin delivery devices incorporate an insulin pump with continuous glucose monitoring(CGM) and an algorithm, and adjust insulin in real time. This study aims to establish the safety and efficacy of a hybrid closed-loop (HCL) system in a long-term outpatient trial in people with T1D aged 12 -<25 years of age, and compare outcomes with standard therapy for T1D as used in the contemporary community. METHODS AND ANALYSIS This is an open-label, multicentre, 6-month, randomised controlled home trial to test the MiniMed Medtronic 670G system (HCL) in people with T1D aged 12 -<25 years, and compare it to standard care (multiple daily injections or continuous subcutaneous insulin infusion (CSII), with or without CGM). Following a run-in period including diabetes and carbohydrate counting education, dosage optimisation and baseline glucose control data collection, participants are randomised to either HCL or to continue on their current treatment regimen. The primary aim of the study is to compare the proportion of time spent in target sensor glucose range (3.9-10.0 mmol/L) on HCL versus standard therapy. Secondary aims include a range of glucose control parameters, psychosocial measures, health economic measures, biomarker status, user/technology interactions and healthcare professional expectations. Analysis will be intention to treat. A study in adults with an aligned design is being conducted in parallel to this trial. ETHICS AND DISSEMINATION Ethics committee permissions were gained from respective institutional review boards. The findings of the study will provide high-quality evidence on the role of HCL in clinical practice.
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Affiliation(s)
- Martin de Bock
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Western Australia, Australia
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
- School of Paediatrics and Child Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Sybil A McAuley
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Mary Binsu Abraham
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Western Australia, Australia
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
- School of Paediatrics and Child Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Grant Smith
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
| | - Jennifer Nicholas
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Western Australia, Australia
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
| | - Geoff R Ambler
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Fergus J Cameron
- Department of Endocrinology and Diabets Centre for Hormone Research, Royal Children's Hospital and Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Jan M Fairchild
- Endocrinology and Diabetes Centre, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Bruce R King
- Department of Endocrinology and Diabetes, John Hunter Children's Hospital, Newcastle, New South Wales, Australia
- School of Allied Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Elizabeth A Geelhoed
- Endocrinology and Diabetes Centre, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Elizabeth A Davis
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Western Australia, Australia
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
- School of Paediatrics and Child Health, The University of Western Australia, Perth, Western Australia, Australia
| | - David Norman O'Neal
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Timothy W Jones
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Western Australia, Australia
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
- School of Paediatrics and Child Health, The University of Western Australia, Perth, Western Australia, Australia
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McAuley SA, de Bock MI, Sundararajan V, Lee MH, Paldus B, Ambler GR, Bach LA, Burt MG, Cameron FJ, Clarke PM, Cohen ND, Colman PG, Davis EA, Fairchild JM, Hendrieckx C, Holmes-Walker DJ, Horsburgh JC, Jenkins AJ, Kaye J, Keech AC, King BR, Kumareswaran K, MacIsaac RJ, McCallum RW, Nicholas JA, Sims C, Speight J, Stranks SN, Trawley S, Ward GM, Vogrin S, Jones TW, O'Neal DN. Effect of 6 months of hybrid closed-loop insulin delivery in adults with type 1 diabetes: a randomised controlled trial protocol. BMJ Open 2018; 8:e020274. [PMID: 29886443 PMCID: PMC6009467 DOI: 10.1136/bmjopen-2017-020274] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Manual determination of insulin dosing largely fails to optimise glucose control in type 1 diabetes. Automated insulin delivery via closed-loop systems has improved glucose control in short-term studies. The objective of the present study is to determine the effectiveness of 6 months' closed-loop compared with manually determined insulin dosing on time-in-target glucose range in adults with type 1 diabetes. METHODS AND ANALYSIS This open-label, seven-centre, randomised controlled parallel group clinical trial will compare home-based hybrid closed-loop versus standard diabetes therapy in Australia. Adults aged ≥25 years with type 1 diabetes using intensive insulin therapy (via multiple daily injections or insulin pump, total enrolment target n=120) will undertake a run-in period including diabetes and carbohydrate-counting education, clinical optimisation and baseline data collection. Participants will then be randomised 1:1 either to 26 weeks of MiniMed 670G hybrid closed-loop system therapy (Medtronic, Northridge, CA, USA) or continuation of their current diabetes therapy. The hybrid closed-loop system delivers insulin automatically to address basal requirements and correct to target glucose level, while bolus doses for meals require user initiation and carbohydrate estimation. Analysis will be intention to treat, with the primary outcome time in continuous glucose monitoring (CGM) target range (3.9-10.0 mmol/L) during the final 3 weeks of intervention. Secondary outcomes include: other CGM parameters, HbA1c, severe hypoglycaemia, psychosocial well-being, sleep, cognition, electrocardiography, costs, quality of life, biomarkers of vascular health and hybrid closed-loop system performance. Semistructured interviews will assess the expectations and experiences of a subgroup of hybrid closed-loop users. ETHICS AND DISSEMINATION The study has Human Research Ethics Committee approval. The study will be conducted in accordance with the principles of the Declaration of Helsinki and Good Clinical Practice. Results will be disseminated at scientific conferences and via peer-reviewed publications. TRIAL REGISTRATION NUMBER ACTRN12617000520336; Pre-results.
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Affiliation(s)
- Sybil A McAuley
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Martin I de Bock
- Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- School of Paediatrics and Child Health, University of Western Australia, Perth, Western Australia, Australia
| | - Vijaya Sundararajan
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Melissa H Lee
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Barbora Paldus
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Geoff R Ambler
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Leon A Bach
- Department of Endocrinology and Diabetes, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Medicine (Alfred), Monash University, Melbourne, Victoria, Australia
| | - Morton G Burt
- Southern Adelaide Diabetes and Endocrine Services, Flinders Medical Centre, Adelaide, South Australia, Australia
- School of Medicine, Flinders University, Adelaide, South Australia, Australia
| | - Fergus J Cameron
- Department ofEndocrinology and Diabetes and Centre for Hormone Research, Royal Children'sHospital, Melbourne, Victoria, Australia
- Murdoch Children'sResearch Institute, Melbourne, Victoria, Australia
- Department ofPaediatrics, University ofMelbourne, Melbourne, Victoria, Australia
| | - Philip M Clarke
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Neale D Cohen
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Peter G Colman
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Elizabeth A Davis
- Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- School of Paediatrics and Child Health, University of Western Australia, Perth, Western Australia, Australia
| | - Jan M Fairchild
- Endocrinology and Diabetes Centre, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Christel Hendrieckx
- School of Psychology, Deakin University, Geelong, Victoria, Australia
- Australian Centre for Behavioural Research in Diabetes, Melbourne, Victoria, Australia
| | - D Jane Holmes-Walker
- Department of Diabetes and Endocrinology, Westmead Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Jodie C Horsburgh
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Alicia J Jenkins
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Joey Kaye
- Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Anthony C Keech
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Bruce R King
- Department of Endocrinology and Diabetes, John Hunter Children's Hospital, Newcastle, New South Wales, Australia
| | - Kavita Kumareswaran
- Department of Endocrinology and Diabetes, Alfred Hospital, Melbourne, Victoria, Australia
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Richard J MacIsaac
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Roland W McCallum
- Department of Diabetes and Endocrinology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Jennifer A Nicholas
- Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | - Catriona Sims
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Jane Speight
- School of Psychology, Deakin University, Geelong, Victoria, Australia
- Australian Centre for Behavioural Research in Diabetes, Melbourne, Victoria, Australia
| | - Stephen N Stranks
- Southern Adelaide Diabetes and Endocrine Services, Flinders Medical Centre, Adelaide, South Australia, Australia
- School of Medicine, Flinders University, Adelaide, South Australia, Australia
| | - Steven Trawley
- Australian Centre for Behavioural Research in Diabetes, Melbourne, Victoria, Australia
- Cairnmillar Institute, Melbourne, Victoria, Australia
| | - Glenn M Ward
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
- Department of Pathology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Sara Vogrin
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Timothy W Jones
- Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | - David N O'Neal
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
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McAuley SA, Ward GM, Horsburgh JC, Gooley JL, Jenkins AJ, MacIsaac RJ, O'Neal DN. Asymmetric changes in circulating insulin levels after an increase compared with a reduction in insulin pump basal rate in people with Type 1 diabetes. Diabet Med 2017; 34:1158-1164. [PMID: 28453877 DOI: 10.1111/dme.13371] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2017] [Indexed: 11/30/2022]
Abstract
AIMS To investigate circulating insulin profiles after a clinically relevant insulin pump basal rate increase vs a reduction, and the associated glucose responses. METHODS A cohort of 12 adults with Type 1 diabetes undertook this two-stage university hospital study using Accu-Chek pumps (Roche Diagnostics, Mannheim, Germany) and insulin aspart. An insulin basal rate change of 0.2 unit/h (increase in first stage, reduction in second stage) was implemented at ~09:30 h, after a single overnight basal rate (without bolus insulin), while fasting participants rested. Frequent venous samples for the assessment of plasma free insulin, glucose and cortisol were collected from 60 min before until 300 min after rate change. The primary outcome was time to steady-state insulin. RESULTS The 0.2-unit/h rate change represented a mean ± sd alteration of 23 ± 6%. After the rate increase, the median (interquartile range) times to 80% and 90% steady-state insulin were 170 (45) min and 197 (87) min, respectively. By contrast, after rate reduction, 80% steady-state insulin was not achieved. After the rate increase, mean ± se insulin levels increased by 4.3 ± 3.1%, 12.0 ± 2.9% and 25.6 ± 2.6% at 60, 120 and 300 min, respectively (with no significant difference until 180 min). After the rate reduction, insulin decreased by 8.3 ± 3.0% at 300 min (with no significant difference until 300 min). After rate reduction, glucose levels paradoxically declined by 17.4 ± 3.7% after 300 min; cortisol levels also fell during observation (P = 0.0003). CONCLUSIONS The time to circulating insulin change after a 0.2-unit/h basal rate change was substantial, and was greater after a reduction than after an increase. Counter-regulatory hormone circadian variation may affect glycaemia when implementing minor changes at low basal rates. Both direction of basal rate change, and time of day, warrant consideration when anticipating the clinical effects of basal rate changes.
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Affiliation(s)
- S A McAuley
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - G M Ward
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
- Department of Pathology, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - J C Horsburgh
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - J L Gooley
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - A J Jenkins
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - R J MacIsaac
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - D N O'Neal
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
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Jayawardene DC, McAuley SA, Horsburgh JC, Gerche AL, Jenkins AJ, Ward GM, MacIsaac RJ, Roberts TJ, Grosman B, Kurtz N, Roy A, O'Neal DN. Closed-Loop Insulin Delivery for Adults with Type 1 Diabetes Undertaking High-Intensity Interval Exercise Versus Moderate-Intensity Exercise: A Randomized, Crossover Study. Diabetes Technol Ther 2017; 19:340-348. [PMID: 28574723 DOI: 10.1089/dia.2016.0461] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [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 We aimed to compare closed-loop glucose control for people with type 1 diabetes undertaking high-intensity interval exercise (HIIE) versus moderate-intensity exercise (MIE). METHODS Adults with type 1 diabetes established on insulin pumps undertook HIIE and MIE stages in random order during automated insulin delivery via a closed-loop system (Medtronic). Frequent venous sampling for glucose, lactate, ketones, insulin, catecholamines, cortisol, growth hormone, and glucagon levels was performed. The primary outcome was plasma glucose <4.0 mmol/L for ≥15 min, from exercise commencement to 120 min postexercise. Secondary outcomes included continuous glucose monitoring and biochemical parameters. RESULTS Twelve adults (age mean ± standard deviation 40 ± 13 years) were recruited; all completed the study. Plasma glucose of one participant fell to 3.4 mmol/L following MIE completion; no glucose levels were <4.0 mmol/L for HIIE (primary outcome). There were no glucose excursions >15.0 mmol/L for either stage. Mean (±standard error) plasma glucose did not differ between stages pre-exercise; was higher during exercise in HIIE than MIE (11.3 ± 0.5 mmol/L vs. 9.7 ± 0.6 mmol/L, respectively; P < 0.001); and remained higher until 60 min postexercise. There were no differences in circulating free insulin before, during, or postexercise. During HIIE compared with MIE, there were greater increases in lactate (P < 0.001), catecholamines (all P < 0.05), and cortisol (P < 0.001). Ketones increased more with HIIE than MIE postexercise (P = 0.031). CONCLUSIONS Preliminary findings suggest that closed-loop glucose control is safe for people undertaking HIIE and MIE. However, the management of the postexercise rise in ketones secondary to counter-regulatory hormone-induced insulin resistance observed with HIIE may represent a challenge for closed-loop systems.
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Affiliation(s)
- Dilshani C Jayawardene
- 1 Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne , Melbourne, Australia
| | - Sybil A McAuley
- 1 Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne , Melbourne, Australia
- 2 University of Melbourne Department of Medicine, St. Vincent's Hospital, Melbourne, Australia
| | - Jodie C Horsburgh
- 2 University of Melbourne Department of Medicine, St. Vincent's Hospital, Melbourne, Australia
| | - André La Gerche
- 3 Department of Sports Cardiology, Baker Heart and Diabetes Institute , Melbourne, Australia
- 4 Department of Cardiology, St Vincent's Hospital Melbourne , Melbourne, Australia
| | - Alicia J Jenkins
- 1 Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne , Melbourne, Australia
- 2 University of Melbourne Department of Medicine, St. Vincent's Hospital, Melbourne, Australia
- 5 NHMRC Clinical Trials Centre, University of Sydney , Sydney, Australia
| | - Glenn M Ward
- 1 Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne , Melbourne, Australia
- 6 Department of Pathology, University of Melbourne , Melbourne, Australia
| | - Richard J MacIsaac
- 1 Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne , Melbourne, Australia
- 2 University of Melbourne Department of Medicine, St. Vincent's Hospital, Melbourne, Australia
| | - Timothy J Roberts
- 2 University of Melbourne Department of Medicine, St. Vincent's Hospital, Melbourne, Australia
- 4 Department of Cardiology, St Vincent's Hospital Melbourne , Melbourne, Australia
| | | | | | - Anirban Roy
- 7 Medtronic Diabetes , Northridge, California
| | - David N O'Neal
- 1 Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne , Melbourne, Australia
- 2 University of Melbourne Department of Medicine, St. Vincent's Hospital, Melbourne, Australia
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Graf A, McAuley SA, Sims C, Ulloa J, Jenkins AJ, Voskanyan G, O’Neal DN. Moving Toward a Unified Platform for Insulin Delivery and Sensing of Inputs Relevant to an Artificial Pancreas. J Diabetes Sci Technol 2017; 11:308-314. [PMID: 28264192 PMCID: PMC5478040 DOI: 10.1177/1932296816682762] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [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: 11/16/2022]
Abstract
Advances in insulin pump and continuous glucose monitoring technology have primarily focused on optimizing glycemic control for people with type 1 diabetes. There remains a need to identify ways to minimize the physical burden of this technology. A unified platform with closely positioned or colocalized interstitial fluid glucose sensing and hormone delivery components is a potential solution. Present challenges to combining these components are interference of glucose sensing from proximate insulin delivery and the large discrepancy between the life span of current insulin infusion sets and glucose sensors. Addressing these concerns is of importance given that the future physical burden of this technology is likely to be even greater with the ongoing development of the artificial pancreas, potentially incorporating multiple hormone delivery, glucose sensing redundancy, and sensing of other clinically relevant nonglucose biochemical inputs.
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Affiliation(s)
- Anneke Graf
- Department of Endocrinology & Diabetes, St Vincent’s Hospital Melbourne, Melbourne, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Sybil A. McAuley
- Department of Endocrinology & Diabetes, St Vincent’s Hospital Melbourne, Melbourne, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Catriona Sims
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | | | - Alicia J. Jenkins
- Department of Endocrinology & Diabetes, St Vincent’s Hospital Melbourne, Melbourne, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
- NHMRC Clinical Trials Centre, Sydney, Australia
| | | | - David N. O’Neal
- Department of Endocrinology & Diabetes, St Vincent’s Hospital Melbourne, Melbourne, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
- David N. O’Neal, MBBS, MD, Department of Medicine, University of Melbourne, 29 Regent St, Fitzroy, Melbourne, VIC 3065, Australia.
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McAuley SA, Horsburgh JC, Ward GM, La Gerche A, Gooley JL, Jenkins AJ, MacIsaac RJ, O'Neal DN. Insulin pump basal adjustment for exercise in type 1 diabetes: a randomised crossover study. Diabetologia 2016; 59:1636-44. [PMID: 27168135 DOI: 10.1007/s00125-016-3981-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [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: 01/29/2016] [Accepted: 03/29/2016] [Indexed: 01/16/2023]
Abstract
AIMS/HYPOTHESIS The aim of this study was to investigate the effects of exercise, vs rest, on circulating insulin and glucose, following pre-exercise insulin pump basal rate reduction. METHODS This was an open-label, two-stage randomised crossover study of 14 adults (seven women, seven men) with type 1 diabetes established on insulin pump therapy. In each stage, participants fasted and insulin delivery was halved following a single insulin basal rate overnight. Exercise (30 min moderate-intensity stationary bicycle exercise, starting 60 min post-basal reduction) and rest stages were undertaken in random order at a university hospital. Randomisation was computer-generated, and allocation concealed via sequentially numbered sealed opaque envelopes. Venous blood was collected at 15 min intervals from 60 min pre- until 210 min post-basal rate reduction. Changes in plasma free insulin (the primary outcome), and changes in plasma glucose, with exercise were compared with changes when resting. Outcomes were assessed blinded to group assignment. RESULTS Following basal rate reduction when rested, mean (± SE) free insulin decreased by 4.9 ± 2.9%, 16.2 ± 2.6% and 18.6 ± 3.2% at 1, 2 and 3 h, respectively (p < 0.05 after 75 min). With exercise, relative to rest, mean free insulin increased by 6 ± 2 pmol/l after 15 min and 5 ± 2 pmol/l after 30 min (p < 0.001), then declined post-exercise (p < 0.001). Three participants (mean baseline glucose 5.0 ± 0.1 mmol/l) required glucose supplementation to prevent or treat exercise-related hypoglycaemia. In the other 11 participants (mean baseline glucose 8.4 ± 0.5 mmol/l), glucose increased by 0.8 ± 0.3 mmol/l with exercise (p = 0.028). CONCLUSIONS/INTERPRETATION Halving the basal insulin rate 1 h prior to exercise did not significantly reduce circulating free insulin by exercise commencement. Exercise itself transiently increased insulin levels. In participants with low-normal glucose pre-exercise, hypoglycaemia was not prevented by insulin basal rate reduction alone. Greater insulin basal rate reduction and supplemental carbohydrate may be required to prevent exercise-induced hypoglycaemia. TRIAL REGISTRATION ANZCTR.org.au ACTRN12613000581763 FUNDING: Australian Diabetes Society, Hugh DT Williamson Foundation, Lynne Quayle Charitable Trust Fund.
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Affiliation(s)
- Sybil A McAuley
- Department of Medicine, St Vincent's Hospital, University of Melbourne, 29 Regent Street, Fitzroy, Melbourne, VIC, 3065, Australia
- Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
| | - Jodie C Horsburgh
- Department of Medicine, St Vincent's Hospital, University of Melbourne, 29 Regent Street, Fitzroy, Melbourne, VIC, 3065, Australia
| | - Glenn M Ward
- Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
- Department of Pathology, University of Melbourne, Melbourne, VIC, Australia
| | - André La Gerche
- Department of Medicine, St Vincent's Hospital, University of Melbourne, 29 Regent Street, Fitzroy, Melbourne, VIC, 3065, Australia
- Department of Cardiology, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
- Sports Cardiology, Baker IDI Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Judith L Gooley
- Department of Medicine, St Vincent's Hospital, University of Melbourne, 29 Regent Street, Fitzroy, Melbourne, VIC, 3065, Australia
| | - Alicia J Jenkins
- Department of Medicine, St Vincent's Hospital, University of Melbourne, 29 Regent Street, Fitzroy, Melbourne, VIC, 3065, Australia
- Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - Richard J MacIsaac
- Department of Medicine, St Vincent's Hospital, University of Melbourne, 29 Regent Street, Fitzroy, Melbourne, VIC, 3065, Australia
- Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
| | - David N O'Neal
- Department of Medicine, St Vincent's Hospital, University of Melbourne, 29 Regent Street, Fitzroy, Melbourne, VIC, 3065, Australia.
- Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia.
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McAuley SA, Dang TT, Horsburgh JC, Bansal A, Ward GM, Aroyan S, Jenkins AJ, MacIsaac RJ, Shah RV, O'Neal DN. Feasibility of an Orthogonal Redundant Sensor incorporating Optical plus Redundant Electrochemical Glucose Sensing. J Diabetes Sci Technol 2016; 10:679-88. [PMID: 26846821 PMCID: PMC5038539 DOI: 10.1177/1932296816629982] [Citation(s) in RCA: 4] [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] [Indexed: 11/15/2022]
Abstract
BACKGROUND Orthogonal redundancy for glucose sensing (multiple sensing elements utilizing distinct methodologies) may enhance performance compared to nonredundant sensors, and to sensors with multiple elements utilizing the same technology (simple redundancy). We compared the performance of a prototype orthogonal redundant sensor (ORS) combining optical fluorescence and redundant electrochemical sensing via a single insertion platform to an electrochemical simple redundant sensor (SRS). METHODS Twenty-one adults with type 1 diabetes wore an ORS and an SRS concurrently for 7 days. Following sensor insertion, and on Day 4 with a standardized meal, frequent venous samples were collected for reference glucose measurement (laboratory [YSI] and meter) over 3 and 4 hours, respectively. Between study visits reference capillary blood glucose testing was undertaken. Sensor data were processed prospectively. RESULTS ORS mean absolute relative difference (MARD) was (mean ± SD) 10.5 ± 13.2% versus SRS 11.0 ± 10.4% (P = .34). ORS values in Clarke error grid zones A and A+B were 88.1% and 97.6%, respectively, versus SRS 86.4% and 97.8%, respectively (P = .23 and P = .84). ORS Day 1 MARD (10.7 ± 10.7%) was superior to SRS (16.5 ± 13.4%; P < .0001), and comparable to ORS MARD for the week. ORS sensor survival (time-averaged mean) was 92.1% versus SRS 74.4% (P = .10). ORS display time (96.0 ± 5.8%) was equivalent to SRS (95.6 ± 8.9%; P = .87). CONCLUSIONS Combining simple and orthogonal sensor redundancy via a single insertion is feasible, with accuracy comparing favorably to current generation nonredundant sensors. Addition of an optical component potentially improves sensor reliability compared to electrochemical sensing alone. Further improvement in optical sensing performance is required prior to clinical application.
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Affiliation(s)
- Sybil A McAuley
- Department of Medicine, St Vincent's Hospital, University of Melbourne, Melbourne, Australia Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | | | - Jodie C Horsburgh
- Department of Medicine, St Vincent's Hospital, University of Melbourne, Melbourne, Australia
| | | | - Glenn M Ward
- Department of Medicine, St Vincent's Hospital, University of Melbourne, Melbourne, Australia Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | | | - Alicia J Jenkins
- Department of Medicine, St Vincent's Hospital, University of Melbourne, Melbourne, Australia Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Richard J MacIsaac
- Department of Medicine, St Vincent's Hospital, University of Melbourne, Melbourne, Australia Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | | | - David N O'Neal
- Department of Medicine, St Vincent's Hospital, University of Melbourne, Melbourne, Australia Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
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Sharifi A, Varsavsky A, Ulloa J, Horsburgh JC, McAuley SA, Krishnamurthy B, Jenkins AJ, Colman PG, Ward GM, MacIsaac RJ, Shah R, O'Neal DN. Redundancy in Glucose Sensing: Enhanced Accuracy and Reliability of an Electrochemical Redundant Sensor for Continuous Glucose Monitoring. J Diabetes Sci Technol 2016; 10:669-78. [PMID: 26499476 PMCID: PMC5038525 DOI: 10.1177/1932296815612096] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [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: 11/15/2022]
Abstract
BACKGROUND Current electrochemical glucose sensors use a single electrode. Multiple electrodes (redundancy) may enhance sensor performance. We evaluated an electrochemical redundant sensor (ERS) incorporating two working electrodes (WE1 and WE2) onto a single subcutaneous insertion platform with a processing algorithm providing a single real-time continuous glucose measure. METHODS Twenty-three adults with type 1 diabetes each wore two ERSs concurrently for 168 hours. Post-insertion a frequent sampling test (FST) was performed with ERS benchmarked against a glucose meter (Bayer Contour Link). Day 4 and 7 FSTs were performed with a standard meal and venous blood collected for reference glucose measurements (YSI and meter). Between visits, ERS was worn with capillary blood glucose testing ≥8 times/day. Sensor glucose data were processed prospectively. RESULTS Mean absolute relative deviation (MARD) for ERS day 1-7 (3,297 paired points with glucose meter) was (mean [SD]) 10.1 [11.5]% versus 11.4 [11.9]% for WE1 and 12.0 [11.9]% for WE2; P < .0001. ERS Clarke A and A+B were 90.2% and 99.8%, respectively. ERS day 4 plus day 7 MARD (1,237 pairs with YSI) was 9.4 [9.5]% versus 9.6 [9.7]% for WE1 and 9.9 [9.7]% for WE2; P = ns. ERS day 1-7 precision absolute relative deviation (PARD) was 9.9 [3.6]% versus 11.5 [6.2]% for WE1 and 10.1 [4.4]% for WE2; P = ns. ERS sensor display time was 97.8 [6.0]% versus 91.0 [22.3]% for WE1 and 94.1 [14.3]% for WE2; P < .05. CONCLUSIONS Electrochemical redundancy enhances glucose sensor accuracy and display time compared with each individual sensing element alone. ERS performance compares favorably with 'best-in-class' of non-redundant sensors.
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Affiliation(s)
- Amin Sharifi
- Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia Department of Medicine, St Vincent's Hospital, University of Melbourne, Melbourne, Australia
| | | | - Johanna Ulloa
- Sensor R & D, Medtronic Diabetes, Northridge, CA, USA
| | - Jodie C Horsburgh
- Department of Medicine, St Vincent's Hospital, University of Melbourne, Melbourne, Australia
| | - Sybil A McAuley
- Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia Department of Medicine, St Vincent's Hospital, University of Melbourne, Melbourne, Australia
| | | | - Alicia J Jenkins
- Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia Department of Medicine, St Vincent's Hospital, University of Melbourne, Melbourne, Australia NHMRC Clinical Trials Centre, Sydney, Australia
| | - Peter G Colman
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, Australia
| | - Glenn M Ward
- Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Richard J MacIsaac
- Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia Department of Medicine, St Vincent's Hospital, University of Melbourne, Melbourne, Australia
| | - Rajiv Shah
- Sensor R & D, Medtronic Diabetes, Northridge, CA, USA
| | - David N O'Neal
- Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia Department of Medicine, St Vincent's Hospital, University of Melbourne, Melbourne, Australia
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Gagnon C, Sims NA, Mumm S, McAuley SA, Jung C, Poulton IJ, Ng KW, Ebeling PR. Lack of sustained response to teriparatide in a patient with adult hypophosphatasia. J Clin Endocrinol Metab 2010; 95:1007-12. [PMID: 20089612 DOI: 10.1210/jc.2009-1965] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [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] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Hypophosphatasia (HPP) is a rare genetic disorder characterized by low serum alkaline phosphatase (ALP) and defective bone mineralization predisposing to poorly healing pseudofractures and fractures. Experience with teriparatide in HPP is limited. METHODS A 53-yr-old woman was diagnosed with HPP on the basis of repeatedly low serum ALP (6-8 IU/liter; normal, 30-120 IU/liter), high urine phosphoethanolamine (PEA) and serum pyridoxal 5'-phosphate (PLP) concentrations, and pseudofractures on the lateral aspect of both proximal femurs. Teriparatide (20 microg/d sc) was initiated 4 months after surgery for a painful nonhealing left femoral fracture sustained after minimal trauma. RESULTS The patient carried two missense mutations at exons 6 and 11 (Ala176Thr and Val423Ala) and one polymorphism at exon 12 (Val522Ala) of the tissue nonspecific ALP gene (TNSALP). Pain resolved and mobility improved with teriparatide treatment. Serum ALP doubled, and both urine PEA and serum PLP decreased. Markers of bone remodeling increased markedly. Comparison of bone biopsy before and 5 months after teriparatide revealed increased amounts of osteoid and osteoblast numbers. After 8 months, there was complete healing of the pseudofracture of the right femur, and bony callus was apparent on the left. Despite good compliance, serum ALP and PLP and urine PEA returned to baseline with between 8 and 13 months of treatment. CONCLUSION This is the first bone biopsy report of teriparatide response in adult HPP. In contrast to the two previously reported cases, biochemical response to teriparatide was unsustained, suggesting that response may be variable depending on the TNSALP gene mutation.
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Affiliation(s)
- Claudia Gagnon
- Department of Medicine, University of Melbourne, Western Hospital, Footscray VIC 3011, Australia
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