PracticeUpdate Diabetes March 2019

EDITOR’S PICKS 6

Type 1 Diabetes Management and Outcomes Diabetes Technology & Therapeutics

Take-home message • Data from the Type 1 Diabetes Exchange Clinic-based Registry regarding diabetes management and general clinical outcomes from 22,697 registry participants from 2016 until 2018 were compared with similar data collected from 2010 until 2012. Mean HbA1c in 2016–2018 increased from 8.1% at the age of 5 years to 9.3% between ages 15 and 18 years, with a decrease to 8% by age 28 years and 7.5–7.9% beyond age 30 years. Children and adolescents achieved an HbA1c level of <7.5% only 17% of the time, and only 21% of adults achieved an HbA1c level of <7%. Insulin pump use increased from 57% in 2010–2012 to 63% in 2016–2018, and continuous glucose monitoring (CGM) use increased from 7% in 2010–2012 to 30% in 2016–2018. Glycemic control was significantly closer to goal in those patients who used CGM. • Results of this analysis indicate that only a minority of children, adolescents, and adults achieve the goals of care established by the American Diabetes Association. Individuals using CGM technology were able to achieve better glycemic control overall compared with people who did not use the technology, a finding supported by other large studies. Jason Sloane MD

" Because increases in insulin pump and CGM use individually have not

Abstract OBJECTIVE To provide a snapshot of the profile of adults and youth with type 1 diabetes (T1D) in the United States and assessment of longitu- dinal changes in T1D management and clinical outcomes in the T1D Exchange registry. RESEARCH DESIGN AND METHODS Data on diabe- tes management and outcomes from 22,697 registry participants (age 1-93 years) were col- lected between 2016 and 2018 and compared with data collected in 2010-2012 for 25,529 reg- istry participants. RESULTS Mean HbA1c in 2016-2018 increased from 65mmol/mol at the age of 5 years to 78mmol/mol between ages 15 and 18, with a decrease to 64 mmol/mol by age 28 and 58-63mmol/mol beyond age 30. The Ameri- can Diabetes Association (ADA) HbA1c goal of <58mmol/mol for youth was achieved by only 17% and the goal of <53mmol/mol for adults by only 21%. Mean HbA1c levels changed lit- tle between 2010-2012 and 2016-2018, except in adolescents who had a higher mean HbA1c in 2016-2018. Insulin pump use increased from 57% in 2010-2012 to 63% in 2016-2018. Contin- uous glucose monitoring (CGM) increased from 7% in 2010-2012 to 30% in 2016-2018, rising >10-fold in children <12 years old. HbA1c levels were lower in CGM users than nonusers. Severe hypoglycemia was most frequent in participants ≥50 years old and diabetic ketoacidosis was most common in adolescents and young adults. Racial differences were evident in use of pumps and CGM and HbA1c levels. CONCLUSIONS Data from the T1D Exchange reg- istry demonstrate that only a minority of adults and youth with T1D in the United States achieve ADA goals for HbA1c. State of Type 1 Diabetes Management and Out- comes From the T1D Exchange in 2016–2018. Diabetes Technol Ther 2019 Jan 18;[EPub Ahead of Print], NC Foster, RW Beck, KM Miller, et al. www.practiceupdate.com/c/79012 improved overall metabolic control, our next hope is that integrated, automatic, or semi- automatic artificial pancreas systems that link pumps and sensors will be able to move HbA1c levels downward. "

COMMENT By William V. Tamborlane MD and Michelle A. Van Name MD

I n 2015, the Type 1 Diabetes (T1D) Exchange published its first report of the state of type 1 diabetes treatment in the US between 2010 and 2012. That study included >25,000 T1D patients across all age groups at leading diabe- tes treatment centers who were enrolled in the T1D Exchange Registry. 1 The current report compares data in the first study with new data collected by the Regis- try between 2016 and 2018 in >22,000 patients. To paraphrase Dickens, the current report indicates that it is the best of times and still the worst of times for patients with T1D in the US. The good news is that more patients are using advanced dia- betes technologies, with more than 60% on insulin pump therapy and a dramatic increase in use of continuous glucose monitoring (CGM) from 7% to 30%, most markedly in youth under 12 years of age. Moreover, HbA1c levels were as low in CGM users using injection therapy as CGM users on insulin pumps (7.3% and 7.4%, respectively) in adults aged 26 years and older. The bad news is that minority patients still lagged well behind non-Hispanic whites in the use of pumps and sensors, and, across all age groups, there was little or no improvement in overall metabolic

control. Indeed, HbA1c levels actually increased in adolescents between 15 and 18 years of age. It is noteworthy, how- ever, that the majority of adolescents in the 2016–2018 cohort were also preteens who were enrolled in the 2010–2012 cohort. Consequently, increases in HbA1c in this group over time can be amplified by physiologic changes including dimin- ished endogenous insulin secretion and increases in insulin resistance that nor- mally accompany puberty. Because increases in insulin pump and CGM use individually have not improved overall metabolic control, our next hope is that integrated, automatic, or semi- automatic artificial pancreas systems that link pumps and sensors will be able to move HbA1c levels downward. Outcomes beyond glycemic control related to technology use should also be considered. Reference 1. Miller KM, Foster NC, Beck RW, et al. Current state of type 1 diabetes treatment in the US: Updated data from the T1D Exchange clinic registry. Diabetes Care 2015;38(6):971-978. Dr. Tamborlane is Professor and Chief of Pediatric Endocrinology at Yale School of Medicine in New Haven, Connecticut. Dr. Van Name is Assistant Professor of Pediatric Endocrinology at Yale School of Medicine in New Haven, Connecticut.

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