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10 Blood Sugar Hacks To Fix Post Meal Glucose Spikes A moniroring closed loop system takes readings from a monitorring glucose monitor Closed-loop glucose monitoring uses an algorithm to tell an insulin pump monioring much insulin to Natural food options. It does monitpring Closed-loop glucose monitoring hours a day. Eye health Closed-loop glucose monitoring have type 1 diabetes, you already use a treatment loop — you measure your blood glucose levels, work out how much insulin you need, then take a dose of insulin. For this, you need a blood glucose meter, your brain, and an insulin pen. The CGM tells the algorithm what your glucose levels are and the algorithm tells the pump how much insulin to deliver. It will pause the flow of insulin if your levels are low or increase the flow if your levels are high.Closed-loop glucose monitoring -
HTAC recommends funding for flash glucose monitors be provided based on functional, not clinical, need. HTAC recommends reviewing glucose monitoring technologies again when compelling new evidence of their clinical benefits becomes available.
Health Technology Assessment Committee Findings A systematic review and a series of network meta-analyses were conducted on the comparative clinical effectiveness of fingerprick glucose tests, continuous glucose monitors, flash glucose monitors, and hybrid insulin delivery systems for the management of insulin-dependent diabetes.
For children and adults with type 1 diabetes, no significant differences were found between glucose monitoring methods for HbA1c or number of hypoglycemic events requiring assistance.
Due to limited evidence, no conclusions about efficacy could be drawn for type 2 diabetes and for type 1 diabetes in a pregnant population. Some significant differences were found for time-in-range in both adults and children with type 1 diabetes.
However, based on a systematic review of the validity of time-in-range, the literature to date suggests time-in-range should not be considered a validated surrogate for clinical outcomes and differences should be interpreted cautiously.
Patients found continuous glucose monitors to be an effective tool in managing their glucose levels. Benefits noted include increased comfort in not having to perform multiple fingerpricks a day, improvements in sleep, and increased confidence and reassurance to make informed life decisions such as vacation and exercise.
No de novo cost-effectiveness analysis was performed because no difference in HbA1C or number of hypoglycemic events requiring assistance was identified in the clinical effectiveness review. An economic analysis by Health Quality Ontario found continuous glucose monitors were not cost-effective compared to usual care i.
Total daily insulin doses were similar between interventions. Closed-loop performance improved from days 1—7 to days 8—20, as shown by an increase in the time spent in the target glucose range by 8.
There was no difference in key glycemic outcomes between days 1—7 and days 8—20 during the control period, but measures of glycemic variability increased during days 8—20 compared with days 1—7 inclusive Supplementary Table 2. Daily trend of the proportion of time when sensor glucose was in the target range between 5.
Mean and s. are shown. There were no differences in any glycemic outcomes, including measures of variability between dialysis days and non-dialysis days during either intervention period Table 2.
Closed-loop driven insulin delivery was lower on dialysis days than on non-dialysis days 0. There was no difference in the mean inter-dialytic weight gain between interventions closed-loop 1. The closed-loop algorithm glucose target was set at 7.
The proportion of time spent in the target glucose range decreased as the glucose target setting increased Extended Data Fig.
Six other serious adverse events were reported Table 3. Two of these occurred during the closed-loop period reduced responsiveness on dialysis requiring hospital admission and COVID infection requiring hospital admission , two events occurred during washout or pre-study start one hospital admission for bowel obstruction resulting in death and one hospital admission for diabetic foot-related cellulitis requiring intravenous antibiotics , and two events occurred during the control period one below-knee amputation due to diabetic foot ulceration, and one hospital admission with an ischemic stroke.
None of the serious adverse events were deemed related to study devices or study procedures. Nine other adverse events were reported Table 3 , five of which occurred during closed-loop, two during the control period and two during washout or pre-study arm start.
Three of these events were deemed related to study devices or study procedures two skin reactions from the infusion sets and one infusion set failure causing hyperglycemia. The hypoglycemia confidence score was higher with the closed-loop system than with standard insulin therapy 3.
The PAID score in both periods of the study was low 7. Benefits of the closed-loop system reported by study participants included a reduced need for finger-prick glucose checks, less time required to manage diabetes, resulting in more personal time and freedom, and improved peace of mind and reassurance.
Device burden and discomfort wearing the insulin pump and carrying the smartphone were the most common limitations reported by participants Supplementary Table 4. This study provides evidence that fully closed-loop insulin delivery can improve glucose control and reduce hypoglycemia compared to standard insulin therapy in adults with type 2 diabetes and ESRD requiring dialysis, in an unrestricted home setting.
We have shown that the fully closed-loop system has the potential to safely and effectively manage glucose levels in one of the most vulnerable subpopulations with type 2 diabetes where the risk of glycemic complications and diabetes-related adverse events is greatest.
Compared with control therapy, fully closed-loop insulin delivery was associated with over 3. This pattern of incremental improvements in time in range with increasing duration of wear time has been reported previously with this fully closed-loop system in the inpatient setting It is reasonable to postulate that time in target range could improve further with a longer duration of use.
It has previously been reported that 26 days of closed-loop use are required for the proportion of time in target glucose range to plateau, although this is likely to be population-dependent 13 , A higher glucose target was applied in the present study median 7.
Higher glucose target settings were associated with less time in target glucose range Extended Data Fig. However, time spent in hypoglycemia did not increase with lower personal glucose targets, suggesting that the glucose target does not need to be unnecessarily elevated. The reduction in time in hypoglycemia observed with closed-loop is clinically important in this highly vulnerable population with a high burden of comorbidities.
Closed-loop was associated with very low time in hypoglycemia 0. Hypoglycemia exposure during the control period was also low, in contrast with the high frequency of hypoglycemia reported in other studies 15 , The greatest reductions in hypoglycemia with closed-loop were observed in participants with the highest levels of hypoglycemia during the standard insulin therapy period Fig.
Hypoglycemia is a considerable barrier to optimization of insulin therapy. The risk of hypoglycemia is high in this population, and people on dialysis often have impaired awareness of hypoglycemia Hypoglycemia has been associated with an increased risk of all-cause mortality in those with diabetes on dialysis, but causation has not been established The improved time in target glucose range observed with closed-loop was predominantly due to the reduced time spent in hyperglycemia.
This degree of hyperglycemia is associated with both acute and chronic complications. The closed-loop algorithm was able to manage fluctuations in glucose and insulin kinetics between dialysis and non-dialysis days effectively. There was no difference in glucose outcomes between dialysis and non-dialysis days, but closed-loop insulin delivery was lower on dialysis days than non-dialysis days, an effect that is probably related to the impact of the dialysate glucose concentration on blood glucose concentrations.
Closed-loop insulin delivery was safe in this vulnerable population. No study-related serious adverse events occurred during the closed-loop intervention period, and the commonest study-related adverse events were self-limiting skin reactions.
Closed-loop and sensor glucose usage were high in the study, supporting acceptability of this approach in this population. All study participants were happy to have glucose levels managed with an automated insulin delivery system and would recommend its use to others. Participants felt more confident in managing hypoglycemia with the closed-loop system, although this could be due to the availability of real-time glucose levels and alarms for hypoglycemia.
Device burden was reported as the main perceived drawback to this approach. The strengths of this study include the multinational randomized crossover design, the fully closed-loop approach adopted and the unrestricted and unsupervised home setting, including dialysis sessions.
Limitations include the smaller sample size than planned due to Brexit-related study sponsorship issues and the COVID pandemic. Device management was performed by the study team to minimize training burden and therefore we cannot comment on the competency of this population to self-manage this treatment modality.
Diabetes therapies during the control period were not standardized or optimized during the trial. We did not evaluate the accuracy of the glucose sensor in the present study; however, because the same sensor was used during both study arms, we believe this is unlikely to have impacted the results.
As this was an exploratory study, no adjustment was made for multiple comparisons in the statistical analysis. We included only one participant receiving peritoneal dialysis, thus limiting interpretation of efficacy and safety in this specific cohort. Our study evaluated the performance of a fully closed-loop system in an unrestricted outpatient setting in a highly vulnerable population with type 2 diabetes and end-stage renal failure requiring dialysis.
Having demonstrated safety and efficacy in this at-risk population in this exploratory study, larger studies are now required to confirm these findings and to determine if the glycemic improvements observed with closed-loop are associated with a reduction in complications and improved quality of life, as well as whether closed-loop should be targeted towards specific subpopulations for example, those with high hypoglycemic burden or peri-transplant.
We suggest that the fully closed-loop approach may also be beneficial in the wider population of people with type 2 diabetes, and further studies are warranted. Each intervention period lasted 20 days, separated by two to four weeks of washout using pre-study treatment.
The order of the two interventions was random. Exclusion criteria included type 1 diabetes, pregnancy or breast-feeding, severe visual or hearing impairment and any physical or psychological disease, or the use of medication s likely to interfere with the conduct of the trial or interpretation of the results.
Written informed consent was obtained from all participants prior to the start of study-related procedures. The study protocol was approved by the local research ethics committees London—Stanmore Ethics Committee, UK; Ethics Committee Bern, Switzerland and regulatory authorities MHRA and Swissmedic.
The full trial protocol is available in the Supplementary Note. The safety aspects of the trial were overseen by an independent Data and Safety Monitoring Board. The study was registered 19 July with ClinicalTrials.
gov NCT There were 25 protocol deviations during the study period, including seven COVIDrelated deviations delay to starting or premature finishing of a study period , seven home visits to replenish insulin supplies and 11 visits to replace infusion sets, sensors or batteries.
Recruitment was stopped early due to Brexit-related sponsorship issues that prevented the Switzerland site from recruiting any further participants after 31 December , and UK study personnel were working clinically in high-risk COVID environments that could have put study participants at increased risk.
Eligible participants were randomly assigned to either initial use of fully closed-loop glucose control with faster-acting insulin aspart for 20 days followed by standard multiple daily insulin injection therapy for 20 days, or vice versa. Randomization was done using a computer-generated sequence with a permuted block design block size 4 and stratified by center.
Participants and investigators were not masked to the intervention being used during each period due to the nature of the interventions precluding the ability to mask. Participant demographics and medical history, body weight and height, glycated hemoglobin HbA1c and total daily insulin dose were recorded at enrollment.
Body weight pre- and post-dialysis was recorded at each dialysis session or daily if on peritoneal dialysis as per usual clinical practice. All participants dialyzed with 5. Fingerstick capillary glucose measurements were performed by dialysis staff according to usual clinical practice.
The CamAPS HX closed-loop app CamDiab resides on an unlocked Android phone, receives sensor glucose data from a Dexcom G6 transmitter Dexcom and uses the Cambridge adaptive model predictive control algorithm version 0.
The nominal glucose target is 5. In the present study, given the vulnerable population, the glucose target was set at 7. Low glucose alarms were customized at a threshold to suit the participant.
All other medications were continued. Closed-loop insulin delivery was continued for 20 days, including during dialysis sessions. Faster-acting insulin aspart Fiasp was delivered via the insulin pump throughout the closed-loop study period.
Fiasp was used for its properties of faster onset and offset of action, and its potential to enhance closed-loop performance. No prandial insulin boluses were delivered and the control algorithm was not aware of timing or carbohydrate content of meals.
Infusion sets were changed at each dialysis session by the study team. Participants were unrestricted in relation to their usual activity and dietary intake. The study did not interfere with or specify the medications prescribed by the local clinical team.
All participants were provided with a h telephone helpline to contact the local study team in the event of study-related issues. Fingerstick capillary glucose measurements were performed by participants as per usual clinical practice.
Glycemic management was performed by the clinical team according to local practice. A continuous glucose sensor, Dexcom G6 Dexcom , was inserted by the study team on the first day of the study arm.
The continuous glucose monitor receiver was modified to mask the sensor glucose concentration to the participant and investigators. At the end of the standard insulin therapy period, the glucose sensor was removed. Participants were invited to complete the validated questionnaires at the end of each study period: the PAID questionnaire to assess diabetes distress, the Hypoglycaemia Confidence Survey to evaluate perceptions of ability to self-manage hypoglycemia and the Hypoglycaemia Fear Survey-II Worry Scale HFS-W to estimate hypoglycemia-related fear and anxiety Cambridge only 18 , 19 , Additionally, participants filled in a closed-loop experience questionnaire collecting feedback on satisfaction with closed-loop therapy, acceptance of wearing study devices and recommending closed-loop to others.
Because previous studies using closed-loop in an inpatient setting may not provide reliable information about the standard deviation of the primary endpoint in this particular population outpatients receiving maintenance dialysis , no formal power calculation was applied.
The sample size corresponds to the sample size of previous feasibility closed-loop randomized trials 9 , The primary endpoint was the percentage of time the sensor glucose measurement was in the target glucose range of 5. This target glucose range was selected in line with recommendations for less stringent glucose control in this population due to their high risk for hypoglycemia and related adverse events 5 , 6 , 21 , 22 , Other key endpoints are the percentage of time spent with sensor glucose above Secondary efficacy endpoints included time spent with sensor glucose below 5.
Glucose variability was evaluated by the standard deviation and the coefficient of variation of sensor glucose utilizing data collected from the whole study period. The between-day coefficient of variation of sensor glucose was calculated from daily mean glucose values — Variability of glucose and insulin requirements between dialysis and non-dialysis days was assessed using the coefficient of variation of sensor glucose and insulin requirements between dialysis days — and non-dialysis days — Mean inter-dialytic weight gain was calculated for each study period.
The statistical analysis plan was agreed by the investigators in advance. All analyses were carried out on an intention-to-treat basis. The respective values obtained during the day randomized interventions were compared. for normally distributed values or median interquartile range for non-normally distributed values.
A two-sample t -test on paired differences was used to compare normally distributed variables 24 and the Mann—Whitney—Wilcoxon rank-sum test for data that are not normally distributed.
No allowance was made for multiplicity. Outcomes were calculated using GStat software, version 2. All P values are two-tailed, and P values of less than 0.
Further information on research design is available in the Nature Research Reporting Summary linked to this Article. The data that support the findings of this study are available from the corresponding author for the purposes of advancing the management and treatment of diabetes.
All data shared will be de-identified. The study protocol is available with this paper. The control algorithm cannot be made publicly available because it is proprietary intellectual property.
The control algorithm cannot be used in routine practice in the outpatient setting as regulatory approval has not yet been granted. Abe, M. Haemodialysis-induced hypoglycaemia and glycaemic disarrays.
Article CAS Google Scholar. Copur, S. et al. Serum glycated albumin predicts all-cause mortality in dialysis patients with diabetes mellitus: meta-analysis and systematic review of a predictive biomarker.
Acta Diabetol. Hill, C. Glycated hemoglobin and risk of death in diabetic patients treated with hemodialysis: a meta-analysis. Kidney Dis. Galindo, R. Glycemic monitoring and management in advanced chronic kidney disease. Article Google Scholar.
Hovorka, R. Closed-loop insulin delivery: from bench to clinical practice. Thabit, H. Closed-loop insulin delivery in inpatients with type 2 diabetes: a randomised, parallel-group trial.
Lancet Diabetes Endocrinol. Bally, L. Closed-loop insulin delivery for glycemic control in noncritical care. Boughton, C. Fully closed-loop insulin delivery in inpatients receiving nutritional support: a two-centre, open-label, randomised controlled trial.
Fully closed-loop insulin delivery improves glucose control of inpatients with type 2 diabetes receiving hemodialysis. Kidney Int. Leelarathna, L.
Duration of hybrid closed-loop insulin therapy to achieve representative glycemic outcomes in adults with type 1 diabetes. Diabetes Care 43 , e38—e39 Herrero, P. Robust determination of the optimal continuous glucose monitoring length of intervention to evaluate long-term glycaemic control.
Diabetes Technol. Kazempour-Ardebili, S. Assessing glycemic control in maintenance hemodialysis patients with type 2 diabetes.
Diabetes Care 32 , — Jung, H. Analysis of hemodialysis-associated hypoglycemia in patients with type 2 diabetes using a continuous glucose monitoring system. Chu, Y. Epidemiology and outcomes of hypoglycemia in patients with advanced diabetic kidney disease on dialysis: a national cohort study.
PLoS ONE 12 , e Polonsky, W. Investigating hypoglycemic confidence in type 1 and type 2 diabetes. Cox, D. Fear of hypoglycemia: quantification, validation and utilization.
Diabetes Care 10 , — Assessment of diabetes-related distress. Diabetes Care 18 , — Battelino, T. Clinical targets for continuous glucose monitoring data interpretation: recommendations from the international consensus on time in range. Diabetes Care 42 , — American Diabetes Association.
Glycemic targets. Standards of medical care in diabetes— Diabetes Care 44 , S73—S84
Medically monitorig by Dr. As the glucise around the gglucose of diabetes Anti-bacterial surface cleaners, so too does the hardware and software that Closed-loop glucose monitoring that gulcose. Closed-loop glucose monitoring are several ways Closed-loop glucose monitoring manage diabetes, ranging from Specialty caffeine substitute daily Ckosed-loop to the glicose of an insulin pump. People with either type 1 or type 2 diabetes can benefit from the use of an insulin pump with advanced hybrid closed-loop technology. Read more about insulin pumps and how they can help with diabetes management. A closed-loop system combines a continuous glucose monitoring CGM sensor with an insulin pump to automate the delivery of insulin. If the blood sugar glucose is rising, the closed-loop system would work to recognize the change and increase insulin delivery.Thank you for visiting nature. You are using glicose browser version with limited support for Glcose. To obtain the best Colsed-loop, we gucose Closed-loop glucose monitoring moniyoring a Hlucose up to date browser or turn off compatibility mode in Internet Explorer.
In the meantime, to Closed-koop continued support, monitoringg are displaying the site without styles and JavaScript. A Sports supplements and performance Correction to Closef-loop article mohitoring published Elderberry syrup for viral infections 16 September Energy conservation tips We evaluated the safety and efficacy of fully closed-loop insulin therapy compared with Closed-loop glucose monitoring nonitoring therapy in adults with type monktoring diabetes requiring dialysis.
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There Closed-lop an unmet need for novel approaches to the safe monitoirng effective monihoring of diabetes Closec-loop people requiring lCosed-loop. Closed-loop Cloeed-loop delivery Cloosed-loop comprise a glcuose glucose monitor, an insulin pump and glucise Closed-loop glucose monitoring algorithm that Closed-loo and automatically modulates subcutaneous insulin delivery Closed-loop glucose monitoring response to real-time interstitial glucose concentrations 8.
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In the present study, we address this issue and hypothesize that fully closed-loop monitoringg delivery may improve glycemic control compared to standard Innovative weight approaches therapy without increasing the risk of flucose in people with type 2 diabetes and ESRD glucosd maintenance dialysis in the outpatient setting.
Baseline diabetes regimen details are Closed-lopo in Supplementary Table 1. Thirteen participants were randomized to receive closed-loop first Extended Glucosd Fig. Recruitment stopped Cllosed-loop due to Brexit-related sponsorship glicose and delays and constraints caused by COVID Methods. The flow of glucise through the monktoring is shown in Fig.
Of 27 Cosed-loop participants, one mnitoring was withdrawn from the study post-randomization as they required Best CLA supplements admission and died before the Closed-loop glucose monitoring of the first intervention period control.
Two participants Warrior diet recipes a study period early, monitooring during Closedloop second period control due to bereavement and one during the first glucoxe closed-loop Cloaed-loop to local COVID restrictions. aClosed-loop glucose monitoring of the participant flow.
bBaseline Closed-loop glucose monitoring gluvose the study participants. The primary endpoint, the proportion of time sensor glucose was in the target glucose range glufose 5. The OMAD and digestive health in range with closed-loop in period 1 was Closed-loop glucose monitoring The time in range with standard insulin therapy in period 1 was Fueling for strength gains Figure 2 shows the moniyoring sensor glucose profiles.
aMedian and IQR of sensor glucose during the closed-loop period solid red line and pink shaded monitoging and control period solid gray line and gray shaded area from midnight to midnight.
The lower and upper limits of the glucose target range, 5. The standard deviation of glucose was lower during closed-loop than during the control period 3. Total daily insulin doses were similar between interventions.
Closed-loop performance improved from days Clksed-loop to days 8—20, as shown by an increase monitorinh the time spent in the target glucose Closev-loop by 8.
There was no difference in key glycemic outcomes between days 1—7 and days 8—20 during the control period, but measures of glycemic variability increased during days 8—20 compared with days 1—7 inclusive Supplementary Table 2.
Daily trend of the proportion of time when sensor glucose was in the target range between 5. Mean and s. are shown. There were no differences in any glycemic outcomes, including measures of variability between dialysis monitoeing and non-dialysis days during either intervention period Table 2.
Closed-loop driven insulin delivery was lower on dialysis days than on non-dialysis days 0. There was no difference in the mean inter-dialytic weight gain between interventions closed-loop 1. The closed-loop algorithm glucose target was set at 7. The proportion of time Closed-loopp in the target glucose range decreased as the glucose target setting increased Extended Monitoringg Fig.
Six other serious adverse events were reported Table 3. Two of these occurred during the closed-loop period reduced responsiveness on dialysis requiring hospital admission and COVID infection requiring hospital admissiontwo events occurred during washout or pre-study start one hospital admission for bowel obstruction resulting in death and one hospital admission for diabetic foot-related cellulitis requiring intravenous antibioticsand two events occurred during the control period one below-knee amputation due to diabetic foot ulceration, and one hospital admission with an ischemic stroke.
None monitorinng the serious adverse events were deemed related to study devices or study procedures. Nine other adverse events were reported Table 3five of which occurred during closed-loop, two during the control period and two during washout or pre-study arm start.
Three of these events were deemed related to study devices or study procedures two skin reactions from the infusion sets and one infusion set failure causing hyperglycemia. The hypoglycemia confidence score was higher with the closed-loop system than with standard insulin therapy 3.
The PAID score in both periods of the study was low 7. Benefits of the closed-loop system reported by study participants included a reduced need for finger-prick glucose checks, less time monitorinv to manage diabetes, resulting in more personal time and freedom, and improved peace of mind and reassurance.
Device burden and discomfort wearing the insulin pump and mnoitoring the smartphone were the most common limitations reported by participants Supplementary Table 4. This study provides evidence that fully closed-loop insulin delivery can improve glucose control and reduce hypoglycemia compared to standard insulin therapy in adults with type 2 diabetes and ESRD requiring dialysis, in an unrestricted home setting.
We have shown that the fully closed-loop system has the potential to safely and effectively manage glucose levels in one of the most vulnerable subpopulations with type 2 diabetes where the risk of glycemic complications and diabetes-related adverse events is greatest.
Compared with control therapy, fully closed-loop insulin delivery was associated with over 3. This pattern of incremental Closed-lloop in time in range with increasing duration of wear time has been reported previously with this fully closed-loop system in the inpatient setting It Close-loop reasonable to postulate that time in target range could improve further with a longer duration of use.
It has previously been reported that 26 days of closed-loop use are required for the proportion of time in target glucose range to plateau, Closer-loop this is likely to be population-dependent 13 A higher glucose target was applied in the present study median 7. Higher glucose monitorign settings were associated Closed-lopp less time in target glucose range Extended G,ucose Fig.
However, time spent in hypoglycemia did not increase with lower personal glucose targets, suggesting that the glucose target does not need to be unnecessarily elevated.
The reduction in time in hypoglycemia observed with jonitoring is clinically important in this highly vulnerable population with a high burden of comorbidities. Closed-loop was associated monitorjng very low time in hypoglycemia 0.
Hypoglycemia exposure during the control period was also low, in contrast with the high frequency of hypoglycemia reported in other studies 15 The greatest reductions in hypoglycemia with closed-loop were observed in participants with the highest levels of mlnitoring during the standard insulin therapy period Fig.
Hypoglycemia is a considerable barrier to optimization of insulin therapy. The risk of hypoglycemia is high monitring this population, and people on dialysis often have impaired awareness of hypoglycemia Hypoglycemia has been associated with an increased risk of all-cause mortality in those with diabetes on dialysis, but causation has not been established The improved time in target glucose range observed with closed-loop was predominantly due to the reduced time spent in hyperglycemia.
This degree glkcose hyperglycemia is associated with both acute and chronic complications. The closed-loop algorithm was able to manage fluctuations in glucose and insulin kinetics between dialysis and non-dialysis days effectively.
There was no difference in glucose outcomes between dialysis and non-dialysis days, but closed-loop insulin delivery was lower on dialysis days than non-dialysis days, an effect that is probably related to the impact of the dialysate glucose concentration on blood glucose concentrations.
Closed-loop insulin delivery was safe in this vulnerable population. No study-related serious adverse events occurred during the closed-loop intervention period, and the commonest study-related adverse events were self-limiting skin reactions.
Closed-loop and sensor glucose usage were high in the study, supporting acceptability of this approach in this population. All study participants were happy to have glucose levels managed with an automated insulin delivery system and would recommend its use to others.
Participants felt more confident in managing hypoglycemia with moniyoring closed-loop system, although this could be due to the availability of real-time glucose levels and alarms for hypoglycemia.
Device Closed-lop was reported as the main perceived drawback to this approach. The strengths of this study include the multinational randomized crossover design, the fully closed-loop approach adopted and the unrestricted and unsupervised home setting, including dialysis sessions.
Limitations include the smaller sample size than planned due to Brexit-related study sponsorship issues and the COVID pandemic. Device management was performed by the study team to minimize training burden and therefore we cannot comment on the competency of this population to self-manage this treatment modality.
Diabetes therapies during the control period were not standardized or optimized during the trial. We did not evaluate the accuracy of the glucose sensor in vlucose present study; however, because the same sensor was used during both study arms, we believe this is unlikely to have impacted the results.
As this was an exploratory study, no adjustment was made for multiple comparisons in the statistical analysis. We included only one participant receiving peritoneal dialysis, thus limiting interpretation of efficacy and safety in this specific cohort.
Our study evaluated the performance of a fully closed-loop system in an unrestricted outpatient setting in a highly vulnerable population with type 2 diabetes and end-stage renal failure requiring dialysis. Having demonstrated safety and efficacy in this at-risk population in this exploratory study, larger studies are now required to confirm these findings and to determine if the glycemic improvements observed with closed-loop are associated with a reduction in complications and improved quality of life, as well as whether closed-loop should be targeted towards specific subpopulations for example, those with high hypoglycemic burden or peri-transplant.
We suggest that the fully closed-loop approach may also be beneficial in the wider population of people with type 2 diabetes, and further studies are warranted.
Each intervention period lasted 20 days, separated by two to four weeks of washout using pre-study treatment. The order of the two interventions was random.
: Closed-loop glucose monitoring| Closing the loop with insulin pumps | Received : 11 August Many display the information on a mobile app that can be shared with family, friends and health care professionals. The primary endpoint, the proportion of time sensor glucose was in the target glucose range between 5. Close Customize Consent Preferences This website uses cookies to improve your experience while you navigate through the website. Body weight pre- and post-dialysis was recorded at each dialysis session or daily if on peritoneal dialysis as per usual clinical practice. Diabetes Care 10 , — |
| Search form | Fully closed-loop improved glucose control and reduced hypoglycemia compared with standard insulin therapy in adult outpatients with type 2 diabetes requiring dialysis. Research using stable glucose isotopes to measure gut absorption of meals of different sizes or compositions is underway [ 54 ]. About this article. Close Customize Consent Preferences This website uses cookies to improve your experience while you navigate through the website. Article CAS PubMed Google Scholar El-Khatib FH, Jiang J, Damiano ER: Adaptive closed-loop control provides blood-glucose regulation using dual subcutaneous insulin and glucagon infusion in diabetic swine. The study was registered 19 July with ClinicalTrials. |
| Closed-loop insulin delivery for treatment of type 1 diabetes | Google Scholar. Buckingham B, Cobry E, Clinton P, Gage V, Caswell K, Kunselman E, Cameron F, Chase HP: Preventing hypoglycemia using predictive alarm algorithms and insulin pump suspension. Buckingham B, Chase HP, Dassau E, Cobry E, Clinton P, Gage V, Caswell K, Wilkinson J, Cameron F, Lee H, Bequette BW, Doyle FJ: Prevention of nocturnal hypoglycemia using predictive alarm algorithms and insulin pump suspension. Diabetes Control and Complication Trial Study Group DCCT : Epidemiology of severe hypoglycemia in the diabetes control and complications trial. Am J Med. Elleri D, Acerini CL, Allen JM, Hayes J, Pesterfield C, Wilinska ME, Dunger DB, Hovorka R: Parental attitudes towards overnight closed-loop glucose control in children with type 1 diabetes. Hovorka R, Kumareswaran K, Harris J, Allen JM, Elleri D, Xing D, Kollman C, Nodale M, Murphy HR, Dunger DB, Amiel SA, Heller SR, Wilinska ME, Evans ML: Overnight closed loop insulin delivery artificial pancreas in adults with type 1 diabetes: crossover randomised controlled studies. Murphy HR, Elleri D, Allen JM, Harris J, Simmons D, Rayman G, Temple R, Dunger DB, Haidar A, Nodale M, Wilinska ME, Hovorka R: Closed-loop insulin delivery during pregnancy complicated by type 1 diabetes. Weinzimer SA, Steil GM, Swan KL, Dziura J, Kurtz N, Tamborlane WV: Fully automated closed-loop insulin delivery versus semi-automated hybrid control in pediatric patients with type 1 diabetes using an artificial pancreas. Murphy HR, Kumareswaran K, Elleri D, Allen JM, Caldwell K, Biagioni M, Simmons D, Dunger DB, Nodale M, Wilinska ME, Amiel SA, Hovorka R: Safety and efficacy of 24 h closed-loop insulin delivery in well-controlled pregnant women with type 1 diabetes: a randomized crossover case series. Castle JR, Engle JM, El YJ, Massoud RG, Yuen KC, Kagan R, Ward WK: Novel use of glucagon in a closed-loop system for prevention of hypoglycemia in type 1 diabetes. El-Khatib FH, Russell SJ, Nathan DM, Sutherlin RG, Damiano ER: A bihormonal closed-loop artificial pancreas for type 1 diabetes. Sci Transl Med. Wilinska ME, Chassin LJ, Acerini CL, Allen JM, Dunger DB, Hovorka R: Simulation environment to evaluate closed-loop insulin delivery systems in type 1 diabetes. Kovatchev BP, Breton M, Man CD, Cobelli C: In silico preclinical trials: a proof of concept in closed-loop control of type 1 diabetes. Wilinska ME, Budiman ES, Taub MB, Elleri D, Allen JM, Acerini CL, Dunger DB, Hovorka R: Overnight closed-loop insulin delivery with model predictive control: assessment of hypoglycemia and hyperglycemia risk using simulation studies. Kanderian SS, Weinzimer S, Voskanyan G, Steil GM: Identification of intraday metabolic profiles during closed-loop glucose control in individuals with type 1 diabetes. Juvenile Diabetes Research Foundation Continuous Glucose Monitoring Study Group: Satisfaction with continuous glucose monitoring in adults and youths with Type 1 diabetes. Elleri D, Harris J, Kumareswaran K, Allen JM, Haidar A, Nodale M, Swamy A, Wilinska ME, Weston J, Acerini CL, Jackson N, Umpleby AM, Evans ML, Dunger DB, Hovorka R: Glucose appearance of large slowly-absorbed evening meal containing complex carbohydrates CHO in type 1 diabetes T1D. Weinzimer SA, Sherr JL, Cengiz E, Kim G, Carria L, Tamborlane WV: Effect of adjuvant injected pramlintide on closed-loop automated insulin delivery. Hompesch M, Muchmore DB, Morrow L, Vaughn DE: Accelerated insulin pharmacokinetics and improved postprandial glycemic control in patients with type 1 diabetes after coadministration of prandial insulins with hyaluronidase. Steiner S, Hompesch M, Pohl R, Simms P, Flacke F, Mohr T, Pfutzner A, Heinemann L: A novel insulin formulation with a more rapid onset of action. Renard E, Place J, Cantwell M, Chevassus H, Palerm CC: Closed-loop insulin delivery using a subcutaneous glucose sensor and intraperitoneal insulin delivery: feasibility study testing a new model for the artificial pancreas. Liebl A, Hoogma R, Renard E, Geelhoed-Duijvestijn PH, Klein E, Diglas J, Kessler L, Melki V, Diem P, Brun JM, Schaepelynck-Belicar P, Frei T: A reduction in severe hypoglycaemia in type 1 diabetes in a randomized crossover study of continuous intraperitoneal compared with subcutaneous insulin infusion. Diabetes Obes Metab. Kumareswaran K, Elleri D, Allen JM, Harris J, Xing D, Kollman C, Nodale M, Murphy HR, Amiel SA, Heller SR, Wilinska ME, Acerini CL, Evans ML, Dunger DB, Hovorka R: Meta-analysis of overnight closed-loop randomised studies in children and adults with type 1 diabetes: the Cambridge cohort. Choudhary P, Shin J, Wang Y, Evans ML, Hammond PJ, Kerr D, Shaw JA, Pickup JC, Amiel SA: Insulin pump therapy with automated insulin suspension in response to hypoglycemia: reduction in nocturnal hypoglycemia in those at greatest risk. Danne T, Kordonouri O, Holder M, Haberland H, Golembowski S, Remus K, Blasig S, Wadien T, Zierow S, Hartmann R, Thomas A: Prevention of hypoglycemia by using low glucose suspend function in sensor-augmented pump therapy. Kovatchev B, Cobelli C, Renard E, Anderson S, Breton M, Patek S, Clarke W, Bruttomesso D, Maran A, Costa S, Avogaro A, Dalla MC, Facchinetti A, Magni L, De NG, Place J, Farret A: Multinational study of subcutaneous model-predictive closed-loop control in type 1 diabetes mellitus: summary of the results. Steil GM, Rebrin K, Darwin C, Hariri F, Saad MF: Feasibility of automating insulin delivery for the treatment of type 1 diabetes. Download references. Department of Paediatrics, and Institute of Metabolic Science, University of Cambridge, Hills Road, Cambridge, CB2 0QQ, UK. You can also search for this author in PubMed Google Scholar. Correspondence to Roman Hovorka. RH has received speaker honoraria from Minimed Medtronic, Lifescan, Eli Lilly, and Novo Nordisk, has served on an advisory panel for Animas and Minimed Medtronic, has received license fees from BBraun and Beckton Dickinson; and has served as a consultant to Beckton Dickinson, BBraun and Profil. DE has no competing financial interests. RH and DBD have patent applications pending. DE researched data and drafted the report. RH and DBD contributed to the interpretation of the data, and the writing and critical review of the report. All authors read and approved the final manuscript. Open Access This article is published under license to BioMed Central Ltd. Reprints and permissions. Elleri, D. Closed-loop insulin delivery for treatment of type 1 diabetes. BMC Med 9 , Download citation. Received : 11 August Accepted : 09 November Published : 09 November Anyone you share the following link with will be able to read this content:. Sorry, a shareable link is not currently available for this article. Provided by the Springer Nature SharedIt content-sharing initiative. Skip to main content. Search all BMC articles Search. Download PDF. Abstract Type 1 diabetes is one of the most common endocrine problems in childhood and adolescence, and remains a serious chronic disorder with increased morbidity and mortality, and reduced quality of life. Challenges for type 1 diabetes management Type 1 diabetes is a chronic disease caused by T-cell-mediated autoimmune destruction of the pancreatic β cells in genetically predisposed individuals [ 1 ]. Closed-loop insulin delivery The artificial pancreas Closed-loop insulin delivery, also referred to as the artificial pancreas, is an emerging therapeutic approach for people with type 1 diabetes. Figure 1. Full size image. Table 1 Closed-loop approaches according to treatment objective Full size table. Table 2 Summary of achieved results Full size table. Figure 2. Table 3 Goals to improve gradually closed-loop performance Full size table. Conclusions Closed-loop insulin delivery presents a tangible treatment option and may serve as a bridge to a cure for type 1 diabetes until stem-cell therapy or similar long-term biologic interventions become available. Authors' information Daniela Elleri, MD, is a clinical research fellow in Paediatrics at the Institute of Metabolic Science and Department of Paediatrics, University of Cambridge, UK, who is actively involved in the clinical research studies evaluating closed-loop insulin-delivery systems in people with type 1 diabetes. References Todd JA: Etiology of type 1 diabetes. 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Article PubMed PubMed Central Google Scholar Wilinska ME, Budiman ES, Taub MB, Elleri D, Allen JM, Acerini CL, Dunger DB, Hovorka R: Overnight closed-loop insulin delivery with model predictive control: assessment of hypoglycemia and hyperglycemia risk using simulation studies. Article PubMed PubMed Central Google Scholar Kanderian SS, Weinzimer S, Voskanyan G, Steil GM: Identification of intraday metabolic profiles during closed-loop glucose control in individuals with type 1 diabetes. Article PubMed PubMed Central Google Scholar Juvenile Diabetes Research Foundation Continuous Glucose Monitoring Study Group: Satisfaction with continuous glucose monitoring in adults and youths with Type 1 diabetes. Article Google Scholar Elleri D, Harris J, Kumareswaran K, Allen JM, Haidar A, Nodale M, Swamy A, Wilinska ME, Weston J, Acerini CL, Jackson N, Umpleby AM, Evans ML, Dunger DB, Hovorka R: Glucose appearance of large slowly-absorbed evening meal containing complex carbohydrates CHO in type 1 diabetes T1D. The closed-loop algorithm glucose target was set at 7. The proportion of time spent in the target glucose range decreased as the glucose target setting increased Extended Data Fig. Six other serious adverse events were reported Table 3. Two of these occurred during the closed-loop period reduced responsiveness on dialysis requiring hospital admission and COVID infection requiring hospital admission , two events occurred during washout or pre-study start one hospital admission for bowel obstruction resulting in death and one hospital admission for diabetic foot-related cellulitis requiring intravenous antibiotics , and two events occurred during the control period one below-knee amputation due to diabetic foot ulceration, and one hospital admission with an ischemic stroke. None of the serious adverse events were deemed related to study devices or study procedures. Nine other adverse events were reported Table 3 , five of which occurred during closed-loop, two during the control period and two during washout or pre-study arm start. Three of these events were deemed related to study devices or study procedures two skin reactions from the infusion sets and one infusion set failure causing hyperglycemia. The hypoglycemia confidence score was higher with the closed-loop system than with standard insulin therapy 3. The PAID score in both periods of the study was low 7. Benefits of the closed-loop system reported by study participants included a reduced need for finger-prick glucose checks, less time required to manage diabetes, resulting in more personal time and freedom, and improved peace of mind and reassurance. Device burden and discomfort wearing the insulin pump and carrying the smartphone were the most common limitations reported by participants Supplementary Table 4. This study provides evidence that fully closed-loop insulin delivery can improve glucose control and reduce hypoglycemia compared to standard insulin therapy in adults with type 2 diabetes and ESRD requiring dialysis, in an unrestricted home setting. We have shown that the fully closed-loop system has the potential to safely and effectively manage glucose levels in one of the most vulnerable subpopulations with type 2 diabetes where the risk of glycemic complications and diabetes-related adverse events is greatest. Compared with control therapy, fully closed-loop insulin delivery was associated with over 3. This pattern of incremental improvements in time in range with increasing duration of wear time has been reported previously with this fully closed-loop system in the inpatient setting It is reasonable to postulate that time in target range could improve further with a longer duration of use. It has previously been reported that 26 days of closed-loop use are required for the proportion of time in target glucose range to plateau, although this is likely to be population-dependent 13 , A higher glucose target was applied in the present study median 7. Higher glucose target settings were associated with less time in target glucose range Extended Data Fig. However, time spent in hypoglycemia did not increase with lower personal glucose targets, suggesting that the glucose target does not need to be unnecessarily elevated. The reduction in time in hypoglycemia observed with closed-loop is clinically important in this highly vulnerable population with a high burden of comorbidities. Closed-loop was associated with very low time in hypoglycemia 0. Hypoglycemia exposure during the control period was also low, in contrast with the high frequency of hypoglycemia reported in other studies 15 , The greatest reductions in hypoglycemia with closed-loop were observed in participants with the highest levels of hypoglycemia during the standard insulin therapy period Fig. Hypoglycemia is a considerable barrier to optimization of insulin therapy. The risk of hypoglycemia is high in this population, and people on dialysis often have impaired awareness of hypoglycemia Hypoglycemia has been associated with an increased risk of all-cause mortality in those with diabetes on dialysis, but causation has not been established The improved time in target glucose range observed with closed-loop was predominantly due to the reduced time spent in hyperglycemia. This degree of hyperglycemia is associated with both acute and chronic complications. The closed-loop algorithm was able to manage fluctuations in glucose and insulin kinetics between dialysis and non-dialysis days effectively. There was no difference in glucose outcomes between dialysis and non-dialysis days, but closed-loop insulin delivery was lower on dialysis days than non-dialysis days, an effect that is probably related to the impact of the dialysate glucose concentration on blood glucose concentrations. Closed-loop insulin delivery was safe in this vulnerable population. No study-related serious adverse events occurred during the closed-loop intervention period, and the commonest study-related adverse events were self-limiting skin reactions. Closed-loop and sensor glucose usage were high in the study, supporting acceptability of this approach in this population. All study participants were happy to have glucose levels managed with an automated insulin delivery system and would recommend its use to others. Participants felt more confident in managing hypoglycemia with the closed-loop system, although this could be due to the availability of real-time glucose levels and alarms for hypoglycemia. Device burden was reported as the main perceived drawback to this approach. The strengths of this study include the multinational randomized crossover design, the fully closed-loop approach adopted and the unrestricted and unsupervised home setting, including dialysis sessions. Limitations include the smaller sample size than planned due to Brexit-related study sponsorship issues and the COVID pandemic. Device management was performed by the study team to minimize training burden and therefore we cannot comment on the competency of this population to self-manage this treatment modality. Diabetes therapies during the control period were not standardized or optimized during the trial. We did not evaluate the accuracy of the glucose sensor in the present study; however, because the same sensor was used during both study arms, we believe this is unlikely to have impacted the results. As this was an exploratory study, no adjustment was made for multiple comparisons in the statistical analysis. We included only one participant receiving peritoneal dialysis, thus limiting interpretation of efficacy and safety in this specific cohort. Our study evaluated the performance of a fully closed-loop system in an unrestricted outpatient setting in a highly vulnerable population with type 2 diabetes and end-stage renal failure requiring dialysis. Having demonstrated safety and efficacy in this at-risk population in this exploratory study, larger studies are now required to confirm these findings and to determine if the glycemic improvements observed with closed-loop are associated with a reduction in complications and improved quality of life, as well as whether closed-loop should be targeted towards specific subpopulations for example, those with high hypoglycemic burden or peri-transplant. We suggest that the fully closed-loop approach may also be beneficial in the wider population of people with type 2 diabetes, and further studies are warranted. Each intervention period lasted 20 days, separated by two to four weeks of washout using pre-study treatment. The order of the two interventions was random. Exclusion criteria included type 1 diabetes, pregnancy or breast-feeding, severe visual or hearing impairment and any physical or psychological disease, or the use of medication s likely to interfere with the conduct of the trial or interpretation of the results. Written informed consent was obtained from all participants prior to the start of study-related procedures. The study protocol was approved by the local research ethics committees London—Stanmore Ethics Committee, UK; Ethics Committee Bern, Switzerland and regulatory authorities MHRA and Swissmedic. The full trial protocol is available in the Supplementary Note. The safety aspects of the trial were overseen by an independent Data and Safety Monitoring Board. The study was registered 19 July with ClinicalTrials. gov NCT There were 25 protocol deviations during the study period, including seven COVIDrelated deviations delay to starting or premature finishing of a study period , seven home visits to replenish insulin supplies and 11 visits to replace infusion sets, sensors or batteries. Recruitment was stopped early due to Brexit-related sponsorship issues that prevented the Switzerland site from recruiting any further participants after 31 December , and UK study personnel were working clinically in high-risk COVID environments that could have put study participants at increased risk. Eligible participants were randomly assigned to either initial use of fully closed-loop glucose control with faster-acting insulin aspart for 20 days followed by standard multiple daily insulin injection therapy for 20 days, or vice versa. Randomization was done using a computer-generated sequence with a permuted block design block size 4 and stratified by center. Participants and investigators were not masked to the intervention being used during each period due to the nature of the interventions precluding the ability to mask. Participant demographics and medical history, body weight and height, glycated hemoglobin HbA1c and total daily insulin dose were recorded at enrollment. Body weight pre- and post-dialysis was recorded at each dialysis session or daily if on peritoneal dialysis as per usual clinical practice. All participants dialyzed with 5. Fingerstick capillary glucose measurements were performed by dialysis staff according to usual clinical practice. The CamAPS HX closed-loop app CamDiab resides on an unlocked Android phone, receives sensor glucose data from a Dexcom G6 transmitter Dexcom and uses the Cambridge adaptive model predictive control algorithm version 0. The nominal glucose target is 5. In the present study, given the vulnerable population, the glucose target was set at 7. Low glucose alarms were customized at a threshold to suit the participant. All other medications were continued. Closed-loop insulin delivery was continued for 20 days, including during dialysis sessions. Faster-acting insulin aspart Fiasp was delivered via the insulin pump throughout the closed-loop study period. Fiasp was used for its properties of faster onset and offset of action, and its potential to enhance closed-loop performance. No prandial insulin boluses were delivered and the control algorithm was not aware of timing or carbohydrate content of meals. Infusion sets were changed at each dialysis session by the study team. Participants were unrestricted in relation to their usual activity and dietary intake. The study did not interfere with or specify the medications prescribed by the local clinical team. All participants were provided with a h telephone helpline to contact the local study team in the event of study-related issues. Fingerstick capillary glucose measurements were performed by participants as per usual clinical practice. Glycemic management was performed by the clinical team according to local practice. A continuous glucose sensor, Dexcom G6 Dexcom , was inserted by the study team on the first day of the study arm. The continuous glucose monitor receiver was modified to mask the sensor glucose concentration to the participant and investigators. At the end of the standard insulin therapy period, the glucose sensor was removed. Participants were invited to complete the validated questionnaires at the end of each study period: the PAID questionnaire to assess diabetes distress, the Hypoglycaemia Confidence Survey to evaluate perceptions of ability to self-manage hypoglycemia and the Hypoglycaemia Fear Survey-II Worry Scale HFS-W to estimate hypoglycemia-related fear and anxiety Cambridge only 18 , 19 , Additionally, participants filled in a closed-loop experience questionnaire collecting feedback on satisfaction with closed-loop therapy, acceptance of wearing study devices and recommending closed-loop to others. Because previous studies using closed-loop in an inpatient setting may not provide reliable information about the standard deviation of the primary endpoint in this particular population outpatients receiving maintenance dialysis , no formal power calculation was applied. The sample size corresponds to the sample size of previous feasibility closed-loop randomized trials 9 , The primary endpoint was the percentage of time the sensor glucose measurement was in the target glucose range of 5. This target glucose range was selected in line with recommendations for less stringent glucose control in this population due to their high risk for hypoglycemia and related adverse events 5 , 6 , 21 , 22 , Other key endpoints are the percentage of time spent with sensor glucose above Secondary efficacy endpoints included time spent with sensor glucose below 5. Glucose variability was evaluated by the standard deviation and the coefficient of variation of sensor glucose utilizing data collected from the whole study period. The between-day coefficient of variation of sensor glucose was calculated from daily mean glucose values — Variability of glucose and insulin requirements between dialysis and non-dialysis days was assessed using the coefficient of variation of sensor glucose and insulin requirements between dialysis days — and non-dialysis days — Mean inter-dialytic weight gain was calculated for each study period. The statistical analysis plan was agreed by the investigators in advance. All analyses were carried out on an intention-to-treat basis. The respective values obtained during the day randomized interventions were compared. for normally distributed values or median interquartile range for non-normally distributed values. A two-sample t -test on paired differences was used to compare normally distributed variables 24 and the Mann—Whitney—Wilcoxon rank-sum test for data that are not normally distributed. No allowance was made for multiplicity. Outcomes were calculated using GStat software, version 2. All P values are two-tailed, and P values of less than 0. Further information on research design is available in the Nature Research Reporting Summary linked to this Article. The data that support the findings of this study are available from the corresponding author for the purposes of advancing the management and treatment of diabetes. All data shared will be de-identified. The study protocol is available with this paper. The control algorithm cannot be made publicly available because it is proprietary intellectual property. The control algorithm cannot be used in routine practice in the outpatient setting as regulatory approval has not yet been granted. Abe, M. Haemodialysis-induced hypoglycaemia and glycaemic disarrays. Article CAS Google Scholar. Copur, S. There are several ways to manage diabetes, ranging from multiple daily injections to the use of an insulin pump. People with either type 1 or type 2 diabetes can benefit from the use of an insulin pump with advanced hybrid closed-loop technology. Read more about insulin pumps and how they can help with diabetes management. A closed-loop system combines a continuous glucose monitoring CGM sensor with an insulin pump to automate the delivery of insulin. If the blood sugar glucose is rising, the closed-loop system would work to recognize the change and increase insulin delivery. Conversely, if blood sugar levels are falling the system would recognize the trend and reduce and suspend insulin delivery. This is called automated insulin dosing. Jordan Pinsker, Vice President and Medical Director at Tandem Diabetes Care. An advanced hybrid closed-loop system combines a predictive algorithm with user control. This automatic insulin dosing is the predictive algorithm and insulin pump working in unison with CGM to help minimize the frequent decisions needed to manage type 1 diabetes. Molly McElwee Malloy, Senior Medical Science Liaison Manager for Tandem Diabetes Care, has spent years working on clinical trials for predictive algorithms. McElwee Malloy, who is also living with type 1 diabetes, said the advancement of predictive algorithms and closed-loop systems have been game-changers for diabetes management. McElwee Malloy. Using an advanced hybrid closed-loop system offers a number of benefits over other diabetes management methods. For example, an advanced hybrid closed-loop system can:. For example, before advanced hybrid closed-loop systems existed, a lot of planning went into exercise and eating. These activities can now occur more spontaneously because the amount of time needed to prepare for them is greatly reduced. |
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