Practice Update: DIABETES

EDITOR’S PICKS 7

Effect of artificial pancreas systems on glycemic control in patients with type 1 diabetes Take-home message • This meta-analysis of randomized controlled trials eval- uated the efficacy of single- and dual-hormone artificial pancreas systems compared with conventional insulin pump therapy for glucose control in adults and children with type 1 diabetes. The results show that time in target glucose range was higher with artificial pancreas systems and was highest with dual-hormone systems. • The authors concluded that, regardless of varying clinical factors, artificial pancreas systems are superior to insulin pump therapy in glucose control. Abstract BACKGROUND Closed-loop artificial pancreas systems have been in development for several years, including assessment in numerous var- ied outpatient clinical trials. We aimed to summarise the efficacy and safety of artificial pancreas systems in outpatient settings and explore the clinical and technical factors that can affect their performance. METHODS We did a systematic review and meta-analysis of randomised controlled trials comparing artificial pancreas systems (insulin only or insulin plus glucagon) with conventional pump therapy (continuous subcu- taneous insulin infusion [CSII] with blinded continuous glucose monitoring [CGM] or unblinded sensor-augmented pump [SAP] therapy) in adults and children with type 1 diabetes. We searched Medline, Embase, and the Cochrane Central Register of Controlled Trials for studies published from 1946, to Jan 1, 2017. We excluded studies not published in English, those involving pregnant women or participants who were in hospital, and those testing adjunct medications other than glucagon. The primary outcome was the mean difference in percentage of time blood glucose concentration remained in target range (3.9–10 mmol/L or 3.9–8 mmol/L, depending on the study), assessed by random-effects meta-analysis. FINDINGS We identified984 reports; after exclusions, 27 comparisons from24 studies (23 crossover and one parallel design) including a total of 585 par- ticipants (219 in adult studies, 265 in paediatric studies, and 101 in combined studies) were eligible for analysis. Five comparisons assessed dual-hor- mone (insulin andglucagon), two comparisons assessedboth dual-hormone and single-hormone (insulin only), and 20 comparisons assessed single-hor- mone artificial pancreas systems. Time in target was 12.59% higher with artificial pancreas systems (95% CI 9.02–16.16; p<0.0001), from a weighted mean of 58.21% for conventional pump therapy (I(2)=84%). Dual-hormone artificial pancreas systems were associated with a greater improvement in time in target range compared with single-hormone systems (19.52% [95% CI 15.12–23.91] vs 11.06% [6.94 to 15.18]; p=0.006), although six of seven comparisons compared dual-hormone systems to CSII with blinded CGM, whereas 21 of 22 single-hormone comparisons had SAP as the compara- tor. Single-hormone studies had higher heterogeneity than dual-hormone studies (I(2) 79%vs 66%). Bias assessment characteristics were incompletely reported in 12 of 24 studies, no studies masked participants to the inter- vention assignment, and masking of outcome assessment was not done in 12 studies and was unclear in 12 studies. INTERPRETATION Artificial pancreas systems uniformly improved glucose control in outpatient settings, despite heterogeneous clinical and tech- nical factors. Effect of artificial pancreas systems on glycaemic control in patients with type 1 diabetes: a systematic review and meta-analysis of out- patient randomised controlled trials. Lancet Diabetes Endocrinol 2017 May 19;[EPub Ahead of Print], A Weisman, JW Bai, M Cardinez, et al. The Lancet Diabetes & Endocrinology

COMMENT By Raza M Shah MD A s a healthcare community, we’re failing our diabetics. Less than half of diabetics are getting their annual eye exams. For primary care providers, this means they’re failing their Health Effectiveness Data and Information Set (HEDIS) quality measures. For eye care providers, we’re failing to provide the care we’ve been trained and sworn to give. For patients, we’re falling prey to one of the leading causes of vision loss in the United States. We can come up with many excuses…patients aren’t following recommendations, referrals aren’t happening soon enough, access is limited in certain areas, etc. The bot- tom line is we can do better. We have to do better. But how? Thankfully, an answer to our question is already here...Intelligent Retinal Imaging Systems (IRIS). Microsoft recently awarded their prestigious 2017 Health Innovation Award for IRIS’s diagnostic solution. By providing the only FDA-approved system, they’ve created a safe, noninvasive, quick, and accurate way to help our diabetics. Essentially, they’ve created a way to integrate the diabetic eye exam with primary care. Instantly, HEDIS measures are met, people with previously undiagnosed disease can be identified, and blindness can be prevented. Diabetic screening involves taking a non-mydriatic photo in the office and having it sent to a reading center for evaluation. Within minutes, a report can be generated, which seamlessly integrates with a practice’s electronic medical record (EMR). We already know that over 99% of patients who’ve undergone this method like it enough to recommend it to a friend or col- league. We also know that seeing your disease with your own eyes is much more likely to put everything in perspective and help ensure you take an active role in fighting your disease. As with any condition, the earlier we’re able to diagnose and treat, the better our patients will do. As our young diabetic population continues to skyrocket, we need to be able to keep up and even- tually get ahead. It not only helps our patients, but can prevent the need for later-stage, expensive treatments and surgeries that will eventually cripple the healthcare system. Does it mean patients don’t need their annual eye exam? Abso- lutely not. This does not replace the skilled examinations needed to diagnose and treat many other eye conditions. It does, how- ever, help identify the nearly 60% of diabetics who previously were not being seen or treated by eye care providers and help reduce the risk of severe vision loss by nearly 90%. We owe this to our patients.

Dr Shah is Retina Surgeon at Mid Atlantic Retina Specialists in Maryland.

CONCLUSIONS AND RELEVANCE Despite possessing health insurance, many youths with diabetes are not receiving eye examinations by 6 years after initial diagnosis to monitor for DR. These data suggest that adherence to clinical practice guidelines is particularly challenging for racial minorities and youths from less affluent families. Ophthalmic screening patterns among youths with diabetes enrolled in a large US Managed Care Network. JAMA Ophthalmol 2017 Mar 23;[EPub Ahead of Print], SY Wang, CA Andrews, TW Gardner, et al.

VOL. 1 • NO. 1 • 2017