Research Summaries

GIST OF ARTICLE:

This article reviews current diabetes technology, including the artificial pancreas.

SUMMARY:

The development of the modern continuous glucose monitor (CGM) has given type 1 diabetics (T1D), and their care team, a much greater amount of data to inform their decision making.

A barrier to common CGM use among T1D is the associated extra cost and lack of comprehensive insurance coverage.

Switching from multiple daily insulin injections (MDI) to pump technology has shown to be effective for T1D in terms of average HbA1c, and hypoglycemic episodes.

A study in Sweden showcased the economic benefit with the combination of pump and CGM technologies for T1D.

Artificial pancreas technology is currently feasible but the upfront costs, and lack of availability, are a deterrent. However, overall cost analysis will be the ultimate determinant in the widespread use of the artificial pancreas.

QUOTES:

“One of the major focuses on future technological development must be the need to reduce the burden of T1D” (p. 17).

“All steps in the artificial pancreas pathway have been shown to be feasible” (p. 17).

“Because of the pharmacokinetic limitations of current rapid acting insulin, closed-loop systems generally perform better during periods of fasting (such as overnight)” (p. 16).

“A full closed-loop system would not require the user to enter meal boluses and would deliver all insulin without the need for the patient to enter food or exercise events” (p. 16).

“Predictive economic analysis has shown that reduced hospital costs from visits to the emergency department and admissions caused by hypoglycemia and long-term complication reduction from improved HbA1c show a cost benefit for advanced diabetes technology including artificial pancreas systems” (p. 17).

REFERENCE:

Forlenza, G.P., Buckingham, B., & Maahs, D.M. (2016). Progress in diabetes technology: developments in insulin pumps, continuous glucose monitors, and progress towards the artificial pancreas. The Journal of Pediatrics 169. pp. 13-20.

GIST OF ARTICLE:

This article uses practice-level data from England to identify treatments that may cause variations in HbA1c.

SUMMARY:

The Diabetes Control and Complications Trial identified a glycaemic target of less than 7.5 and for those at increased risk of arterial disease, a glycaemic target of 6.5 or less. A follow-up study, titled Epidemiology of Diabetes Interventions and Complications also recognized the role of tightly controlled glycaemic levels in the reduction of complications. It is recognized, however, that these glycaemic targets are very difficult to achieve, and there have been little improvements in the last ten years.

The researchers drew upon data that is held for all patients of diabetes in England (note: it is unclear whether they reviewed data from entire UK or just England). There are 280,000 people with Type 1 diabetes in England. The researchers examined glycaemic control, variation among general practices, variation in therapy use (different insulin, number of test strips, pump use, etc), and general demographics (socio-economic status, age, etc). Authors note that the findings may be not be causal. Some of the key findings that were presented are:

• If all health care practices optimized service, 7% more people with Type 1 diabetes would achieve target glycaemic control (7.5) and 5% fewer people would have an HbA1c of 10.

• If all practices moved to the 90th percentile (9.3% of insulin use, corresponding to 36% of people using insulin pumps) 56,000 more people with Type 1 would be using insulin pumps, meaning a significant improvement in glycaemic control

• Health care practices that prescribed more blood glucose measurement strips had a higher number of patients with better glycaemic control and a lower number of patients with high glycaemic risk.

QUOTES:

“While control of blood glucose levels reduces the risk of diabetes complications, it can be very difficult to achieve” (p64).

“The epidemiological factors that were found to have a negative effect were socio-economic deprivation, lower age and lower percentage of people from non-white ethnic backgrounds” (p.68).

REFERENCE:

Heald, A., Livingston, M., Fryer, A., Moreno, G., Malipatil, N., Gadsby, R., Ollier, W., Lunt, M., Stedman, M., & Young, R. (2018). Route to improving Type 1 diabetes mellitus glycaemic outcomes: real-world evidence taken from the National Diabetes Audit, 35(1), 63-71.

GIST OF ARTICLE:

This article highlights both the emotional toll and role for partners of type 1 diabetics who experience severe hypoglycemia.

SUMMARY:

The data was gathered through comprehensive interviews of significant others of adults with type 1 diabetes.

The authors found that spouses identified severe hypoglycemia as a major source of marital distress. They also found that all of the partners had felt unprepared the first time they encountered severe hypoglycemia.

Many partners expressed that their role included educating others about severe hypoglycemia to try and eliminate common misconceptions.

Expressions of the emotional toll being quite high were common, due to the constant urge to check on their partners safety. Also, many partners felt like they were almost working another job in trying to help their partner manage their severe hypoglycemia episodes.

QUOTES

“Episodes of severe hypoglycemia were found to turn the participants’ lives upside down. The inability of the individual with diabetes to manage severe hypoglycemia required the significant other to detect and treat these episodes” (p. 688).

“When severe hypoglycemia occurs, treatment is reliant on the significant other’s ability to recognize the signs of hypoglycemia” (p. 699).

“Spouses identified that the experience of severe hypoglycemia was the scariest aspect of their partners’ diabetes” (p. 699).

“For some participants, the ability to remain calm had a positive effect on the person with diabetes in reducing his or her level of agitation or anxiety” (p. 702).

“Some participants mentioned that their expectations of what a severe hypoglycemia episode would be was very different from the reality of their first experience” (p. 702).

“The risk that a severe hypoglycemia event would occur in the significant others’ absence meant that the participants were constantly worried about the person with diabetes, as they feared for his or her safety” (p. 702).

“Understanding the significant others’ initial urge to panic provides diabetes educators with insight to emphasize the importance of remaining calm and to reassure the significant other that there is time to read the glucagon instructions, for example, and to think through the necessary steps to take” (p.704).

REFERENCE

King, J., Overland, J., Fisher, M., & White, K. (2015). Severe Hypoglycemia and the Role of the Significant Other: Expert, Sentry, and Protector. The Diabetes Educator, 41(6), 698–705. https://doi.org/10.1177/0145721715606223

GIST OF ARTICLE:

This comment summary highlighted the emerging field of clinical study of hybrid closed-loop technology.

SUMMARY:

In 2016, hybrid closed-loop technology was approved by the US Food and Drug Administration for patients with type 1 diabetes who were 15 years or older. The approval of this system was largely built around safety, and an ongoing issue is that previous clinical trials did not sufficiently represent the real-world of those with type 1. Due to the volume of patients with type 1 that frequently do not achieve glycaemic targets (including young adults), it is difficult generalize results from many closed-loop trials.

In one research study, a controlled trial compared hybrid closed-loop and sensor-augmented pump therapy patients ages 6 and older who had an HbA1c of 7.5-10. Approximately half of the group got hybrid closed-loop and half got sensor-augmented pump. The hybrid closed-loop were in target glycaemic range 11% more often than the sensor-augmented group, but this increased to 20% during subgroup analysis of those with HbA1c of more than 8.5% at baseline. Participants in the hybrid group had more frequent contact with researchers, and this is likely due to technical issues.

QUOTES:

“A growing number of clinical trials have shown that home use of hybrid closed-loop insulin delivery systems reduces time spent in hypoglycaemia and improves time in target ranges for those with type 1 diabetes” (p1282).

“Evidence on use of these systems (hybrid closed loop) in preadolescents falls short, as does the inclusion of patients with suboptimal glycaemic control” (p1282).

“Data from the Type 1 Diabetes Exchange indicate that fewer than 30% of patients achieve glycaemic targets, with even lower frequency in youth and emerging adults” (p1283).

“The suspension of insulin delivery feasible with these systems minimises the risk of hypoglycaemia, fear of which might lead both patients, and providers, to settle for safety with permissive hyperglycaemia” (p1283).

REFERENCE:

Galderisi, A., & Sherr, J. (2018). Enlarging the loop: closed-loop insulin delivery for type 1 diabetes. The Lancet, 392, 1282-1283.

GIST OF ARTICLE:

Researchers examined a nation-wide registry of persons with type 1 diabetes to determine if age-of-diagnosis played a significant role in on the onset of complications.

SUMMARY:

The researchers utilized data obtained from Sweden, a nation that holds a registry of all persons with type 1 diabetes. The data was used to capture the levels of “all-cause mortality, acute myocardial infarction, stroke, cardiovascular disease, coronary heart disease, heart failure, and atrial fibrillation”(p479). The individuals with type 1 numbered 27,195, and they were broken down into age at diagnosis (0-10years, 11-15 years, 16-20 years, 21-25 years, and 26-30 years). The data also captured the sex and socioeconomic status and histories of the type 1 group. Some of the key findings are as follows:

–Men who were diagnosed with type 1 before age 10 had a life span that was 14.2 years less than those without type 1, and women had a life span of 17.7 years less. Compare this to those who were diagnosed at age 26-30 years, where men had 9.4 years and women had 10.1 years shortened from their life span.

–Risk factors for women were higher, with a 60 times increased risk of coronary artery disease and a 90 times increased risk of myocardial infarction, when compared to the general population.

–70% of all causes of death for those diagnosed at 0-10 years of age were due to circulatory and endocrine causes, compared to 61% who were diagnosed at age 26-30 years.

–Ten years after diagnosis, children and adolescents start exhibiting subclinical (not severe enough to be visibly present) cardiovascular disease abnormalities.

This study suggests that there needs to be more targeted efforts to reduce cardiovascular risk in those who were diagnosed in childhood. These efforts may include statins (lipid lowering medication), blood pressure medication, insulin pumps, and continuous glucose monitors. The authors recognize that statins are likely not going to be prescribed to children but should be considered when individuals with type 1 reach 30-40 years of age. Currently, only 10-20% of persons appear to be on statins by 40 years age. More than half had blood pressure greater than 120mm Hg.

QUOTES:

“Mortality in type 1 diabetes is still increased by two to eight times, which is reflected by a loss of life expectancy at age 20 years of approximately 12 years” (p477).

“Cardiovascular disease is the main driver of morbidity and mortality in people with type 1 diabetes. European and American guidelines therefore recommend aggressive management of cardiovascular risk factors in people with type 1 diabetes, especially in individuals older than 40 years or with evidence of microvascular complications” (p477).

“Our risk estimates for the subgroup with age of onset at 0-10 years are higher than those presented in the most recent statement from the American Heart Association and American Diabetes Association, which note that men with type 1 diabetes were at a three-times increased risk and women at seven-times increase risk of developing coronary heart disease” (p483)

“Duration of diabetes is a component of total glycaemic load. Defined as the cumulative exposure of the vasculature to glucose, glycaemic load is a function of diabetes duration and glycaemic variability. The longer the duration of diabetes, the greater the glycaemic load and thus the damage” (p484).

REFERENCE:

Rawshani, A., Sattar, N., Franzen, S., Rawshani., Aidin, Hattersley, A., Svensson, A., Eliasson, B., Gudbjornsdottir, S. (2018). Excess mortality and cardiovascular disease in young adults with type 1 diabetes in relation to age at onset: a nationwide, register-based cohort study. Lancet, 392, p477-486.

GIST OF ARTICLE:

This research questions why some individuals who have insulin-positive islets still rapidly progress to having serious complications.

SUMMARY:

The researchers drew upon information gathered from the case study of an African American woman who died from complications of diabetic ketoacidosis at the age of 26 after having type 1 diabetes for 15 years. The woman had cardiovascular disease including congestive heart failure, hypertension, and hyperlipidemia. She had C-peptide present in a low range, but the Diabetes Control and Complications Trial showed that patients with even low amounts of C-peptide developed fewer microvascular complications and less severe hypoglycemia. Even with C-peptide, however, the woman had significant cardiovascular comorbidities, which suggests a rapid progression of type 1.

The authors were curious as to why this woman would have such advanced and severe comorbidities and an early death despite there being insulin-positive B-cells, C-peptide, and HLA that protects against type 1 diabetes. The authors presented a few possibilities:

It may have been due to poor glycemic control

It might have been due to insulin resistance and/or B-cell dysfunction

It might have been due to Flatbush diabetes (definition in quotes below).

QUOTES:

“Residual C-peptide secretion of this level (.48ng/mL) is generally detectable in only 3-9% of patients diagnosed prior to 18 years of age after 10-19 years duration; however recent studies using ultrasensitive assays have demonstrated prolonged secretion of small amounts of C-peptide even three to four decades after diabetes onset. The Diabetes Control and Complications Trial showed that those patients with type 1 diabetes with even low levels of persistent stimulated C-peptide developed fewer microvascular complications (retinopathy, nephropathy) and less severe hypoglycemia)” (p1293).

“Classic type 1 diabetes clinical progression is though to eventually reach a state of absolute insulin deficiency, and the rate at which this state is reached is dependent on many factors, most notably glycemic control and age at onset; however, more literature on long-term insulin microsecretors is emerging” (p1294).

“Flatbush diabetes, also referred to as atypical or ketosis-prone diabetes, is a subgroup of diabetes with clinical features of type 2 diabetes but severe presentations of ketoacidosis followed by periods of recovery where B-cells are function, insulin is secreted, and exogenous insulin treatment is not necessary” (p1294).

“Perhaps not all long-standing diabetes reaches absolute insulin deficiency” (p1295).

REFERENCE:

Jacobsen, L., Atkinson, M., Campbell-Thompson, M., & Schatz, D. (2016). Presumptive type 1 diabetes with comorbidities and rapid progression despite numerous insulin-positive islets. Diabetes Care, 39, 1292-1294.

GIST OF ARTICLE:

This article from England highlights what the researchers did to help local exercise facilities become more inclusive for youth with type 1 diabetes.

SUMMARY:

England has instituted a plan to help combat childhood obesity. One of the plans key recommendations is that children and youth do 60 minutes of physical activity per day. This is especially important for youth with type 1 diabetes due to the increased risk for cardiovascular complications.

The local exercise facilities were proving problematic for youth to access because of their outdated policies surrounding people with diabetes (both type 1 and type 2).

The diabetes care team offered a proper training package to these facilities. This package included the following:

-The importance of physical activity for health in young people with diabetes.

-The successes of athletes with type 1 diabetes to demonstrate that type 1 diabetes should not be a barrier to exercise or performance

-What type 1 diabetes is and the difference between type 1 and type 2 diabetes.

-Basic physiology around carbohydrates, insulin and blood glucose.

-A brief introduction to insulin treatments and technologies.

-How different types of exercise usually affect blood glucose (aerobic and anaerobic).

-Education around the guidelines, including pre-exercise targets and actions, during-exercise actions and general information around exercising with diabetes.

-Hypoglycaemia symptoms and treatment

The facilities staff were very receptive and excited to facilitate training sessions for young people with type 1 diabetes. They were also eager to put future staff through this training.

QUOTES:

“It is essential that paediatric diabetes multidisciplinary teams encourage and facilitate physical activity in young people through the provision of evidence-based advice for glucose management. Individualising advice based on blood glucose results around physical activity is crucial for minimising barriers to exercise” (p2).

“Although the benefits of physical activity are significant, there are many perceived barriers

for people with diabetes. For young people with type 1 diabetes, undertaking physical activity poses additional challenges for blood glucose management” (p2).

“For those young people wearing continuous glucose monitoring and flash glucose monitoring devices, specific guidance was developed. These contained caveats for actions depending on the direction of trend arrows” (p3)

“Although we acknowledged that risk of nocturnal hypoglycaemia has been found to increase with exercise performed in the afternoon we did not want to place further barriers to the young people exercising. This risk is something that is discussed with young people and their families, and strategies are put in place to prevent nocturnal hypoglycaemia, such as a low-glycaemic-index evening meal, bedtime snack incorporating carbohydrate and protein, and bolus and basal insulin reductions” (p4)

REFERENCE:

Brown J, Thornton H (2018) Facilitating physical activity for young people with Type 1 diabetes: Development of a training programme and guidelines for local gyms. Journal of Diabetes Nursing 22: JDN033

GIST OF ARTICLE:

This 2005 study draws upon existing literature as well as a case study to explore depression in adolescents with type 1 diabetes.

SUMMARY:

The literature review indicates several reasons why depression may occur in adolescents with type 1 diabetes, including differences in hippocampal functioning, insulin delivery errors, drugs/alcohol, insulin resistance due to puberty, increased autonomy, and demands due to adaptation in school and leisure programs.

Approximately 18% of youth with type 1 diabetes have depression, and the rates of suicide or suicidal ideation is ten times that of the general population. The majority of persons with diabetes who are depressed do not receive treatment for their depression by their primary care physician. At diagnosis, patients, families and service providers should be aware of the higher rates of depression. Keeping parents involved is critical as maintaining good communication and problem solving in families is central in decreasing stress.

For health care professionals, the following actions are recommended to help adolescents with type 1 diabetes: screening for mental illness, in part by having a strong client-provider relationship; ensuring the patient has coping skills training; encouraging peer group involvement and interventions; providing cognitive behaviour therapy as appropriate, and; providing pharmaceutical interventions (authors note that some drugs have adverse effects on hypoglycaemia awareness as well as appetite). It is further recommended that families have as much involvement as possible as it is not feasible for children with type 1 diabetes to manage the disease on their own.

QUOTES:

“The Centers for Disease Control and Prevention stated that primary care physicians are not able to provide all the care needed for the diabetic patient; they recommend a team that includes a physician, nurse, and dietician (at least one of whom is a certified diabetes educator) is necessary for adequate care” (p140).

“Traditionally, health care providers have focused on education as the primary means of achieving individual control. Teens often have difficulty applying theoretical knowledge to social situations because they have not had experience applying this knowledge” (p142).

REFERENCE:

Massengale, J. (2005). Depression and the adolescent with Type 1 Diabetes: The covert comorbidity. Issues in Mental Health Nursing, 26(2), 137-148. doi:10.1080/01612840590901590

GIST OF ARTICLE:

This study examines quality of life and diabetes care differences between Canadian and Americans who have had type 1 diabetes for more than fifty years.

SUMMARY:

This study utilized cross-sectional data from surveys given to 668 Americans and 361 Canadians who have had type 1 diabetes for more than 50 years. Canadians reported a lower quality of life than Americans, had higher HbA1c, and had lower rates of pump use. Canadian also had significantly lower rates of coronary artery disease. The rates of nephropathy, neuropathy, peripheral arterial disease, and proliferative retinopathy were similar between Canadians and Americans.

QUOTES:

“In subjects with long-standing type 1 diabetes (>50years duration), 25% do not have complications, and this is not clearly attributed to superior glycemic control, although data are limited by a lack of longitudinal, historical glycemic control measurement” (p89).

“Though the HbA1c level was higher in Canadians, it is reassuring that complication rates (particularly for coronary artery disease) were similar between Canadians and Americans. This corroborates previous studies, which have found that current HbA1c level does not correlate with complications in observational studies of long-standing type 1 diabetes” (p92).

“Canadians had worse glycemic control, lower quality of life, and less insulin pump use, yet superior achievement of nonglycemic targets” (p94).

REFERENCE:

Weisman, A., Leif, L., Keenan. H., Tinsley, L., D’Eon, S., Boulet, G., Farooqi, M., Lovshin, J., Orszag, A., Lytvyn, Y., Brent, M., Paul, N., Bril, V., Cherney, D., & Perkins, B. (2018). Diabetes care disparities in long-standing type 1 diabetes in Canada and the U.S.: A cross-sectional comparison, 41, 88-95. doi:10.2337/dc17-1074

GIST OF ARTICLE:

This study drew on randomized controlled trials to determine benefits and harms of tight glycaemic control.

SUMMARY:

To date, most treatments are based on the singular, long-term study Diabetes Control and Complications Trial (DCCT), which led to the understanding that tightly controlled glycaemic numbers reduce microvascular complications.

After reviewing numerous studies external to DCCT, the authors found “no statistically significant effect of targeting an intensive glycaemic control compared with conventional control on all-cause and cardiovascular mortality” (p18). The researchers did, however, find that there were possible positive effects of intensive control on macrovascular complications and neuropathy. Further, they found statistically significant more severe hypoglycaemia and increase in BMI in patients treated with intensive therapy. The researchers also found that reviewed trials had poor control bias and lack of reporting on patient outcome.

QUOTES:

“Patients with type 1 diabetes mellitus are at increased risk of developing microvascular and macrovascular complications, as well as an increased risk of all-cause mortality compared with the background population” (p1).

“Based on this study (the DCCT) it has been generally accepted that tight glycaemic control should be the preferred glycaemic approach for patients with type 1 diabetes mellitus, in order to reduce the risk of complications and death” (p1).

“There is currently no up-to-date comprehensive systematic review investigating the benefits and harms of targeting intensive glycemic control compared with conventional glycaemic control in randomised clinical trials, regardless of the length of intervention and the age of participants.” (p2)

“Intensive glycaemic control may cause increase risk of hypoglycaemia” (p2).

REFERENCE:

Kahler, P., Grevstad, B., Almdal. T., Gluud, C., Wetterslev, J., Lund. (2014). Targeting intensive versus conventional glycaemic control for type 1 diabetes mellitus: A systematic review with meta-analysis and trial sequential analyses of randomised clinical trials. BMJ Open, 4( , e004806-e004806. doi:10.1136/bmjopen-2014-004806

GIST OF ARTICLE:

Access to affordable insulin varies around the world, as type 1 diabetes has not had the same global response as communicable diseases.

SUMMARY:

Although insulin is an essential medical for persons with type 1 diabetes, for many in the world it is not something that can be easily acquired. Communicable diseases have held global attention, but medicines for non-communicable diseases such as type 1 diabetes have not effected a global market. Global policy documents are now attentive to non-communicable diseases, but there are a number of reasons why insulin is not attainable worldwide. The entire world’s insulin is provided by three multinational companies, which may restrict competition. Some studies have identified costly analogue insulin as being no more effective than human insulin, while other studies have said there are statistically significant differences. Duties, taxes, mark-ups and supply chain costs are also considerations in the price ticket of insulin. An individual’s ability to pay for insulin is complex and may be country-specific. For example, in Zambia, the public sector price of insulin is $23.89/year, but “69% of the population live below the international poverty line of $1.25 per day” (p278). In addition to being affordable, insulin must also be obtainable. Access to insulin is based on complex national and global factors, but one of the reasons it may not be obtainable is the global control of the market. An example of how this global control might affect drug availability is found in Mali, where in 2004 “the Central Medical Store purchased insulin for the first time in 2-3 years” (p279). A number of international bodies have committed to ensuring worldwide access to insulin, but these efforts have not yet yielded an adequate response.

Though far from perfect, communicable diseases such as HIV and AIDS have had a swift global response. For type 1 diabetes, a global disease fund (such as Global Fund that provided antiretroviral medical for HIV and AIDS) might be unwanted however, as the emphasis is on “universal health coverage and an integrated approach to health” (p282).

QUOTES:

“For type 1 diabetes an absolute need for the drug exists, because without insulin people will die in a matter of weeks” (p276).

“Little is known about why insulin has remained consistently expensive over the years. One possible explanation is the market domination by three multinational companies, which control 99% of the global insulin market in terms of value and 96% in terms of volume” (p.276).

“Insulin is essential for the management of type 1 diabetes and provides a rare case of a drug in which absolute need exists” (p282)

REFERENCE:

Beran, D., Ewan, M., & Laing, R. (2016). Constraints and challenges in access to insulin: a global perspective. Lancet Diabetes & Endocrinology, 4(3), 275-285. doi:10.1016/S2213-8587(15)00521-5

GIST OF ARTICLE:

This study determines if continuous glucose monitors reduce hypoglycaemic events. According to this study, CGMS do reduce hypoglycaemic events.

SUMMARY:

This study examined the effectiveness of real-time continuous glucose monitoring (rtCGM) in avoidance of hypoglycaemia in persons with Type 1 Diabetes who treat with Multiple Daily Injections (MDI) and who have problematic hypoglycaemia. Problematic hypoglycaemia is defined as “having had at least one severe hypoglycaemia event requiring third party assistance for recovery in the previous year” (p1369).

MDI therapy was chosen because 70-99% of persons with Type 1 Diabetes worldwide rely on MDI. The control group used self-monitoring of blood glucose (SMBG, ubiquitously known as ‘finger poke’). The remainder received an rtCGM in the form of a Dexcom G-5. Over the course of the study, the groups were gauged for hypoglycaemic events. The rtCGM group showed significant reduction in nocturnal hypoglycaemic events. There were 24 severe hypoglycaemic events in the rtCGM group and 39 in the control group. For severe hypoglycaemic events that required third-party assistance, the control group had 36 and the rtCGM group had 19. Of the eight severe hypoglycaemic events that required medical assistance, five occurred in the rtCGM group and three in the control group. This study shows that real-time continuous glucose monitors are effective in reducing incidence of hypoglycaemia.

QUOTES:

“In the absence of third-party assistance, severe hypoglycaemia has a high probability of resulting in a life-threatening condition such as a coma or seizure. Thus, a reduction in the frequency of hypoglycaemic episodes requiring any third-party assistance could also be protective against further deterioration of severe hypoglycaemia resulting in coma or seizure” (p1375).

“Individuals with type 1 diabetes treated by MDI and with impaired hypoglycaemia awareness or severe hypoglycaemia can minimise both biochemical and clinical hypoglycaemia through use of rtCGM without compromising overall glycaemic control” (p1376).

“The finding that substantial benefits for avoidance of hypoglycaemia can be achieved by rtCGM in standalone mode in patients with type 1 diabetes treated with MDI and with impaired hypoglycaemia awareness or severe hypoglycaemia is both clinically and economically meaningful” (p1368).

REFERENCE:

Heinemann, L., Freckmann, G., Ehrmann, D., Faber-Heinemann, G., Guerra, S., Waldenmaier, D., & Hermanns, N. (2018). Real-time continuous glucose monitoring in adults with type 1 diabetes and impaired hypoglycaemia awareness or severe hypoglycaemia treated with multiple daily insulin injections (HypoDE): A multicentre, randomised controlled trial. The Lancet, 391, 1367-1377. doi:10.1016.S0140-6736(18)30297-6