Association of Achieving Time in Range Clinical Targets With Treatment Modality Among Youths With Type 1 Diabetes

Abstract

ImportanceContinuous glucose monitoring (CGM) devices have demonstrated efficacy in adults and more recently in youths and older adults with type 1 diabetes. In adults with type 1 diabetes, the use of real-time CGM compared with intermittently scanned CGM was associated with improved glycemic control, but there are limited data available for youths.ObjectiveTo assess real-world data on achievement of time in range clinical targets associated with different treatment modalities in youths with type 1 diabetes.Design, Setting, and ParticipantsThis multinational cohort study included children, adolescents, and young adults younger than 21 years (hereinafter referred to collectively as youths) with type 1 diabetes for a duration of at least 6 months who provided CGM data between January 1, 2016, and December 31, 2021. Participants were enrolled from the international Better Control in Pediatric and Adolescent Diabetes: Working to Create Centers of Reference (SWEET) registry. Data from 21 countries were included. Participants were divided into 4 treatment modalities: intermittently scanned CGM with or without insulin pump use and real-time CGM with or without insulin pump use.ExposuresType 1 diabetes and the use of CGM with or without an insulin pump.Main Outcomes and MeasuresProportion of individuals in each treatment modality group achieving recommended CGM clinical targets.ResultsAmong the 5219 participants (2714 [52.0%] male; median age, 14.4 [IQR, 11.2-17.1] years), median duration of diabetes was 5.2 (IQR, 2.7-8.7) years and median hemoglobin A1c level was 7.4% (IQR, 6.8%-8.0%). Treatment modality was associated with the proportion of individuals achieving recommended clinical targets. Adjusted for sex, age, diabetes duration, and body mass index standard deviation score, the proportion achieving the recommended greater than 70% time in range target was highest with real-time CGM plus insulin pump use (36.2% [95% CI, 33.9%-38.4%]), followed by real-time CGM plus injection use (20.9% [95% CI, 18.0%-24.1%]), intermittently scanned CGM plus injection use (12.5% [95% CI, 10.7%-14.4%]), and intermittently scanned CGM plus insulin pump use (11.3% [95% CI, 9.2%-13.8%]) (P < .001). Similar trends were observed for less than 25% time above (real-time CGM plus insulin pump, 32.5% [95% CI, 30.4%-34.7%]; intermittently scanned CGM plus insulin pump, 12.8% [95% CI, 10.6%-15.4%]; P < .001) and less than 4% time below range target (real-time CGM plus insulin pump, 73.1% [95% CI, 71.1%-75.0%]; intermittently scanned CGM plus insulin pump, 47.6% [95% CI, 44.1%-51.1%]; P < .001). Adjusted time in range was highest among real-time CGM plus insulin pump users (64.7% [95% CI, 62.6%-66.7%]). Treatment modality was associated with the proportion of participants experiencing severe hypoglycemia and diabetic ketoacidosis events.Conclusions and RelevanceIn this multinational cohort study of youths with type 1 diabetes, concurrent use of real-time CGM and an insulin pump was associated with increased probability of achieving recommended clinical targets and time in range target as well as lower probability of severe adverse events compared with other treatment modalities.

Real‐world glycaemic outcomes in patients with type 1 diabetes using glucose sensors—Experience from a single centre in Dublin

“…In a multinational cohort study including 5219 children, adolescents, and young adults with T1D, the proportion of individuals achieving the recommended time in range target was found to be associated with treatment modality. Users of RT‐CGM concurrently with an insulin pump were the most likely to achieve >70% time in range 22 . In recent years, we have seen a widespread use of advanced hybrid closed loop (ACHL) technology that demonstrates real‐world success in safely achieving these glycaemic targets, 23–26 and is a potential tool to further improve the HbA 1 c levels.…”

“…19,20 Despite observing significant improvements in HbA 1 c levels over time with the introduction of glucose sensor technology, achieving the recommended goals for all glycaemic metrics, as defined by the ADA standards of care (2021), 21 the most likely to achieve >70% time in range. 22 In recent years, we have seen a widespread use of advanced hybrid closed loop (ACHL) technology that demonstrates real-world success in safely achieving these glycaemic targets, [23][24][25][26] and is a potential tool to further improve the HbA 1 c levels. This trend suggests that the use of insulin pumps and closed loop technologies with glucose sensors may be required, for the more precise glycaemic control required to achieve recommended clinical targets.…”

Comparing the glycaemic outcomes between real‐time continuous glucose monitoring (rt‐CGM) and intermittently scanned continuous glucose monitoring (isCGM) among adults and children with type 1 diabetes: A systematic review and meta‐analysis of randomized controlled trials

“…In addition, while CGM has diverged in the last decade, this may be less relevant going forward with the growing importance and efficacy of advanced hybrid closed loop applications, the reducing cost of rtCGM, and second and third generation Freestyle Libre now offering rtCGM. 28,29 This potentially means standalone isCGM in all forms will have less clinical relevance into the future, with potentially less importance given to conducting further head-to-head trials. Given the b GRADE Working Group grades of evidence:High level: We are very confident that the true effect lies close to that of effect estimate.…”

“…How this technological development would impact upon our findings remains unknown given no head‐to‐head studies have been done to date. In addition, while CGM has diverged in the last decade, this may be less relevant going forward with the growing importance and efficacy of advanced hybrid closed loop applications, the reducing cost of rtCGM, and second and third generation Freestyle Libre now offering rtCGM 28,29 . This potentially means standalone isCGM in all forms will have less clinical relevance into the future, with potentially less importance given to conducting further head‐to‐head trials.…”

A Bioartificial Pancreas with “Immune Stealth” and Continuous Oxygen Supply for Islet Transplantation

“…[ 1,2 ] Exogenous insulin treatment stands as the paramount approach for T1DM therapy, serving as the critical remedy essential for the survival of T1DM patients. [ 3 ] A hybrid “closed‐loop” system has recently been developed to manage blood glucose levels, which automatically senses blood glucose through a continuous glucose monitoring sensor and drives a body worn insulin pump to deliver insulin to the body. [ 4 ] Nevertheless, while the tremendous efforts for achieving target glycemic control, exogenous insulin therapy does not fully mimic the stimulus‐coupled insulin secretion of normal β‐cells under physiological conditions, often resulting in fatal hypoglycemia and hyperglycemia.…”