While insulin replacement therapy is a cornerstone of diabetes treatment, replacement of the function of both amylin and insulin may allow a more complete restoration of the normal physiology of glucose control.
These data showed that a pie-shaped graph of the HBG data can be useful as a clinical parameter in helping patients and families attain desired HbA1c values.
Background: The first hybrid closed loop (HCL) system became commercially available in the U.S. in 2017, and there is no standard process for training patients. The goal of this quality improvement project was to optimize transition to HCL for pediatric patients at a large diabetes center. Methods: Our multidisciplinary team developed a novel HCL training program, meeting monthly over 4 months to review data and refine training with a Plan-Do-Study-Act model. The HCL training plan for current insulin pump users included 1) in-person group class to reinforce conventional insulin pump and CGM use on the new system, 2) a live videoconference class to teach HCL use, 3) three follow-up phone calls in the first 6 weeks after HCL training to assess system use, make insulin adjustments, and provide targeted re-education. Results: Seventy-two patients (age 14 ± 4.3y; 46% female) with type 1 diabetes (HbA1c 8.7 ± 1.4%) were trained over 4 months. Mean sensor wear time was 83% and HCL time was 73%. Sensor time in target range (70-180 mg/dl) increased from 49% to 62% between week 1 and week 4 (p= <.001). Sensor wear and HCL time did not change. All patients completed both classes, and 79% and 48% completed 2 and 3 follow-up calls respectively. Mean phone call time was 16 minutes. Trainers strengthened carbohydrate ratios to increase mealtime insulin doses in 75% of patients, with most changes made at breakfast (68% of patients). The most common reason for HCL exit was high sensor glucose (1.98/week). The most common topics during calls were importance of meal boluses, correction boluses for high blood glucose, and responding to system alerts to prevent HCL exits. Conclusion: Ongoing educational support is vital in the early weeks of HCL use. Scheduled telephone contact helped address barriers and reinforce behaviors essential for success. Patients benefited from increased meal boluses in HCL compared to traditional pump mode. Future work will clarify the support necessary to optimize long- term outcomes with HCL. Disclosure C. Berget: None. S. Thomas: None. L.H. Messer: Other Relationship; Self; Medtronic MiniMed, Inc.. S. Owen: None. K. Thivener: None. R.H. Slover: None. R. Wadwa: Advisory Panel; Self; Eli Lilly and Company. Research Support; Self; MannKind Corporation, Dexcom, Inc., Xeris Pharmaceuticals, Inc., Bigfoot Biomedical. G.T. Alonso: None.
Normally, the release of glucagon is halted at the beginning of a meal by a direct mechanism: insulin secretion from the beta cells within the pancreas inhibits the release of glucagon from the beta cells. An "indirect" mechanism--amylin (a neuroendocrine hormone also secreted from the beta cells)--suppresses the release of glucagon through the central nervous system. In type 2 diabetes, the first phase insulin release is absent, and as amylin is released in direct proportion to insulin, both mechanisms to suppress glucagon are absent. The result is that glucagon secretion and, ultimately, the stimulation of hepatic glucose release continue, resulting in extreme postprandial hyperglycemia. It has been shown that amylin supplementation with injections of the human amylin analogue pramlintide, in patients with insulin-requiring type 2 diabetes, helps limit postprandial hyperglycemia. Amylin supplementation not only suppresses glucagon secretion but also slows the absorption of glucose in the intestines and limits nutrient intake by providing a feeling of satiety, resulting in a moderate reduction in body weight for many patients. Recently approved by the FDA, pramlintide is now available for clinical use. However, it is important that pramlintide be prescribed only for selected patients and that these patients are thoroughly educated in the use of this agent, especially during initiation of treatment. Patients suited to pramlintide use are those who have not achieved adequate glycemic control despite optimal insulin use, are under the care of a professional health care provider skilled in the use of insulin and a diabetes educator, and are well-disciplined in diabetes self-management.
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