PracticeUpdate: Endocrinology

DIABETES

10

Insulin infusion and glucose monitoring: a guideline for diabetes technologies Comment by Jennifer Sherr, MD, PhD In this modern day of diabetes management, healthcare providers are faced with a vast array of tools to assist our patients as we strive to help themmeet prescribed glycaemic targets. Yet, determination of who would benefit from the application of diabetes technologies to their regimens is, at times, less clear. T o help address this question, the Endocrine Society ap- pointed a Task Force of seven

categories, and thus be considered a candidate for pump therapy. Pump use was suggested to be considered in those with type 2 diabetes (T2D) who failed to achieve targeted gly- caemic control despite adherence to a prescribed medical regimen, in- cluding glucose monitoring, lifestyle modifications, and use of intensive insulin therapy in conjunction with oral or injectable agents. Addition- ally, continuation of pumps during hospitalisation is also feasible, as long as a protocol for this and safety measures are in place. In the case of RT-CGM, for those with T1D, the same criteria for the use of pumps was applied to sensor use contingent on the patient being willing to use the device on a nearly daily basis. However, in those with T2D, only short-term, intermittent use of these devices for those with A1c >7% was suggested. Educating patients on the various features that pumps and RT-CGM is essential. Indeed, the guidelines highlight that the use of bolus cal- culators is suggested for those on

pump therapy. Only by educating our patients on pump features (bo- lus calculators, advanced boluses, the ability to have multiple basal rates, temporary basal rates, etc) and RT-CGM features (real time alarms and retrospective review of reports), can we expect them to reap the full benefit of these technologies. If one were to merely manually bolus with an insulin pump, it would be like using a smartphone simply to make calls. Determination of who would be an acceptable candidate and thus benefit from these technologies is essential, especially due to the cost

associated with their use. Impor- tantly, based on the guidelines it seems most adults with T1D who are motivated and willing to use them would be candidates for both pump and RT-CGM use. Preparing patients by integrating use of these technologies into their daily lives now will be critical as we move to- wards the marriage of these devices through closed loop insulin delivery systems. Dr Sherr is Instructor, Pediatrics (Endocrinology), Yale University School of Medicine, New Haven, Connecticut.

experts, a methodologist, and a medical writer. Use of two diabe- tes technologies was considered: continuous subcutaneous insulin infusions (insulin pumps) and real- time continuous glucose monitors (RT-CGM). To quantify the degree with which the task force endorsed a certain recommendation, the terms “we recommend” was indicative of a strong recommendation, whereas a weak recommendation was identi- fied by the phrase “we suggest.” For those with type 1 diabetes (T1D), the guidelines recommend consideration of pump use in those who have not achieved their A1c goal and in those who have reached target but experience severe hypo- glycaemia or high glucose variability. Both of these recommendations were qualified by the statement that the patient needed to be “willing and able to use the device.” Most individuals living with T1D would fall into one of these two

Diabetes technology – continuous subcutaneous insulin infusion therapy and continuous glucose monitoring in adults: an Endocrine Society clinical practice guideline The Journal of Clinical Endocrinology and Metabolism Take-home message • Current treatments such as continuous subcutaneous insulin infusion and continuous glucose monitoring play an important part in the manage- ment of diabetes. This evidence-based, clinical practice guideline offers a literature review and recommendations for use in adult patients. • Data on the use of medical devices are limited. However, current studies do support the use of technology for the treatment of diabetes. Abstract

CONSENSUS PROCESS One group meet- ing, several conference calls, and e-mail communications enabled con- sensus. Committees and members of the Endocrine Society, the American Association for Clinical Chemistry, the American Association of Diabetes Educators, and the European Society of Endocrinology reviewed and com- mented on preliminary drafts of these guidelines. CONCLUSIONS Continuous subcutane- ous insulin infusion and continuous glucose monitoring have an important role in the treatment of diabetes. Data from randomized controlled trials are limited on the use of medical devices, but existing studies support the use of diabetes technology for a wide variety of indications. This guideline presents a review of the literature and practice recommendations for appropriate device use. J Clin Endocrinol Metab 2016 Sep 02;[Epub ahead of print], Peters AL, Ahmann AJ, Battelino T, et al.

OBJECTIVE To formulate clinical practice guidelines for the use of continuous glucose monitoring and continuous subcutaneous insulin infusion in adults with diabetes. PARTICIPANTS The participants include an Endocrine Society-appointed Task Force of seven experts, a methodolo- gist, and a medical writer. The Ameri- can Association for Clinical Chemistry, the American Association of Diabetes Educators, and the European Society of Endocrinology co-sponsored this guideline. EVIDENCE The Task Force developed this evidence-based guideline using the Grading of Recommendations, As- sessment, Development, and Evalua- tion system to describe the strength of recommendations and the quality of evidence. The Task Force commis- sioned one systematic review and used the best available evidence from other published systematic reviews and individual studies.

JOURNAL SCAN Increased mortality in people with impaired glucose tolerance after the onset of diabetes Diabetes Care Take-home message • This study included 542 patients with impaired glucose tolerance participating in a lifestyle diabetes prevention trial who were followed for 23 years. Of these patients, 174 died during follow-up. The overall death rate was 15.9/1000 person-years, with age- adjusted death rates of 11.1/1000 person-years before development of type 2 diabetes and 19.4/1000 person-years after diabetes development. An adjusted, time-dependent multivariate analysis revealed that development of type 2 diabetes was associated with a 73% increased risk of death. • This study demonstrates that a large portion of the increased mortality risk in patients with impaired glucose tolerance is attribut- able to development of type 2 diabetes. Abstract

before and 19.4/1,000 person-years (95% CI 11.9–23.3) after the de- velopment of type 2 diabetes. The cumulative mortality was 37.8% (95% CI 33.1–42.2%) in participants who developed type 2 diabetes during first 10 years of follow-up, 28.6% (95% CI 21.6–35.0%) in those who progressed to type 2 diabetes in 10–20 years, and 13.9% (95% CI 7.0–20.3%) in those who did not develop to type 2 diabetes within 20 years. Time-dependent multivariate Cox proportional hazards analyses, with adjustment for baseline age, sex, intervention, and other potential confounding risk factors, showed that the development of type 2 diabetes was associated with a 73% higher risk of death (hazard ratio 1.73 [95% CI 1.18–2.52]). CONCLUSIONS As elsewhere, IGT is associated with increased risk of mortality in China, but much of this excess risk is attributable to the development of type 2 diabetes. Changes in mortality in people with IGT before and after the onset of diabetes during the 23-year follow-up of the Da Qing Diabetes Prevention Study Diabetes Care 2016;39:1550-1555, Gong Q, Zhang V, Wang J, et al.

OBJECTIVE People with impaired glucose tolerance (IGT) have in- creased risk of mortality and a high risk of progression to diabetes, but the extent that the excess mortality is associated with IGT per se or is the result of subsequent diabetes is unclear. RESEARCH DESIGN AND METHODS We compared mortality before and after the development of diabetes among 542 persons with IGT

initially who participated in a 6-year lifestyle diabetes prevention trial and were followed-up from 1986 to 2009. RESULTS During the 23-year follow-up, 174 (32.1%) died, with an overall death rate of 15.9/1,000 person-years. The majority of deaths (74.7%; 130 of 174) occurred after progression to type 2 diabetes, with age- adjusted death rates of 11.1/1,000 person-years (95% CI 8.2–12.0)

PRACTICEUPDATE ENDOCRINOLOGY