Better time in range with closed-loop therapy for older adults with type 1 diabetes
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Closed-loop insulin pump therapy is associated with more time in range compared with sensor-augmented therapy among older adults with type 1 diabetes, according to study findings published in Diabetes Care.
“Closed-loop insulin delivery provided significantly better glucose control than did sensor-augmented pump therapy,” Sybil A. McAuley, MBBS, PhD, FRACP, senior research fellow at the University of Melbourne in Australia, and colleagues wrote. “The time in range increase was equivalent to an extra 90 minutes per day in the closed-loop stage compared with the sensor-augmented pump stage, a difference considered clinically significant.”
Researchers conducted an open-label, randomized crossover trial comparing closed-loop insulin pump therapy with sensor-augmented pump insulin therapy with 30 adults aged 60 years and older with type 1 diabetes for at least 10 years who previously used an insulin pump with rapid-acting analog insulin and had an HbA1c of 10.5% or lower (63.3% women; mean age, 67 years). After a run-in period, data were collected with sensor-augmented pump therapy for 2 weeks. Participants were then randomly assigned to either closed-loop therapy with a MiniMed 670G (Medtronic), glucose sensor and transmitter for real-time continuous glucose monitoring, and an insulin delivery control algorithm, or sensor-augmented pump using the MiniMed 670G alone in manual mode for 4 months. At 4 months, participants crossed over to the opposite group for an additional 4 months. CGM metrics were compared between the closed-loop and sensor-augmented loop stages, with time in range as the primary outcome.
Closed-loop therapy was associated with better results in all CGM metrics compared with sensor-augmented therapy. Participants using the closed-loop system had better time in range (75.2% vs. 69%; P < .0001), and mean time in range overnight from midnight to 5:59 a.m. was 86.9%, 10.1 percentage points better than with sensor-augmented therapy (P < .0001). The time spent with glucose above 10 mmol/L was 5.4 percentage points lower during the closed-loop stage compared with the sensor-augmented pump stage (P < .0001). The time spent below three hypoglycemia thresholds and glucose variability were both less during closed-loop therapy. There was no significant difference in HbA1c between the two stages.
“While HbA1c measurement is independent of the pump-CGM system, and there is extensive evidence relating levels to long-term risk of diabetes-related complications, this trial focused on examining shorter-term intervention effects,” the researchers wrote. “In this regard, CGM has been shown to be a better tool than HbA1c to capture an individual’s average glucose and glucose trends.”
At baseline, 78% of participants said they were positive about using closed-loop therapy. Most participants remained positive at the end of the closed-loop stage, though the degree of positivity dropped to 68.2%.
There were no serious adverse events during the closed-loop stage and two during the sensor-augmented pump stage. Three severe hypoglycemia events occurred during closed-loop therapy and two during sensor-augmented therapy, and none required hospitalization.
The researchers noted the study cohort had no frailty as assessed by the fatigue, resistance, aerobic capacity, illnesses and loss of weight (FRAIL) scale, and 80% had normal cognitive functioning at baseline. They said more studies should be conducted in these populations, as well as older adults with less favorable glycemic control.
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