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Effect of artificial pancreas
systems on glycemic
control in patients with
type 1 diabetes
The Lancet Diabetes & Endocrinology
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.
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.
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.
EDITOR’S PICKS
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VOL. 1 • NO. 1 • 2017