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      The role of continuous glucose monitoring in the care of children with type 1 diabetes

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          Abstract

          Continuous glucose monitoring (CGM), while a relatively new technology, has the potential to transform care for children with type 1 diabetes. Some, but not all studies, have shown that CGM can significantly improve hemoglobin A1c levels and reduce time spent in the hypoglycemic range in children, particularly when used as part of sensor-augmented pump (SAP) therapy. Despite the publication of recent clinical practice guidelines suggesting CGM be offered to all children 8 years of age or older who are likely to benefit, and studies showing that younger children can also benefit, this technology is not yet commonly used by children with type 1 diabetes. Effects of CGM are enhanced when used on a near-daily basis (a use-dependent effect) and with insulin pump therapy. Therefore, coordinated strategies are needed to help children and their families initiate and continue to use this resource for diabetes care. This review introduces CGM to pediatric endocrinologists who are not yet familiar with the finer details of this technology, summarizes current data showing the benefits and limitations of CGM use in children, reviews specific case examples demonstrating when CGM can be helpful, and shows the value of both retrospective and real-time CGM. It is hoped that this information leads to discussion of this technology in pediatric endocrinology clinics as an important next step in improving the care of children with type 1 diabetes.

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          The use and efficacy of continuous glucose monitoring in type 1 diabetes treated with insulin pump therapy: a randomised controlled trial

          T. Battelino, I Conget, BIRGITTE B. OLSEN … (2012)
          Aims/hypothesis The aim of this multicentre, randomised, controlled crossover study was to determine the efficacy of adding continuous glucose monitoring (CGM) to insulin pump therapy (CSII) in type 1 diabetes. Methods Children and adults (n = 153) on CSII with HbA1c 7.5–9.5% (58.5–80.3 mmol/mol) were randomised to (CGM) a Sensor On or Sensor Off arm for 6 months. After 4 months’ washout, participants crossed over to the other arm for 6 months. Paediatric and adult participants were separately electronically randomised through the case report form according to a predefined randomisation sequence in eight secondary and tertiary centres. The primary outcome was the difference in HbA1c levels between arms after 6 months. Results Seventy-seven participants were randomised to the On/Off sequence and 76 to the Off/On sequence; all were included in the primary analysis. The mean difference in HbA1c was –0.43% (–4.74 mmol/mol) in favour of the Sensor On arm (8.04% [64.34 mmol/mol] vs 8.47% [69.08 mmol/mol]; 95% CI −0.32%, −0.55% [−3.50, −6.01 mmol/mol]; p < 0.001). Following cessation of glucose sensing, HbA1c reverted to baseline levels. Less time was spent with sensor glucose <3.9 mmol/l during the Sensor On arm than in the Sensor Off arm (19 vs 31 min/day; p = 0.009). The mean number of daily boluses increased in the Sensor On arm (6.8 ± 2.5 vs 5.8 ± 1.9, p < 0.0001), together with the frequency of use of the temporary basal rate (0.75 ± 1.11 vs 0.26 ± 0.47, p < 0.0001) and manual insulin suspend (0.91 ± 1.25 vs 0.70 ± 0.75, p < 0.018) functions. Four vs two events of severe hypoglycaemia occurred in the Sensor On and Sensor Off arm, respectively (p = 0.40). Conclusions/interpretation Continuous glucose monitoring was associated with decreased HbA1c levels and time spent in hypoglycaemia in individuals with type 1 diabetes using CSII. More frequent self-adjustments of insulin therapy may have contributed to these effects. Trial registration ClinicalTrials.gov registration no. NCT00598663. Funding The study was funded by Medtronic International Trading Sarl Switzerland.
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            Continuous glucose monitoring: an Endocrine Society Clinical Practice Guideline.

            David Klonoff, William Tamborlane, Robert Vigersky … (2011)
            The aim was to formulate practice guidelines for determining settings where patients are most likely to benefit from the use of continuous glucose monitoring (CGM). The Endocrine Society appointed a Task Force of experts, a methodologist, and a medical writer. This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe both the strength of recommendations and the quality of evidence. One group meeting, several conference calls, and e-mail communications enabled consensus. Committees and members of The Endocrine Society, the Diabetes Technology Society, and the European Society of Endocrinology reviewed and commented on preliminary drafts of these guidelines. The Task Force evaluated three potential uses of CGM: 1) real-time CGM in adult hospital settings; 2) real-time CGM in children and adolescent outpatients; and 3) real-time CGM in adult outpatients. The Task Force used the best available data to develop evidence-based recommendations about where CGM can be beneficial in maintaining target levels of glycemia and limiting the risk of hypoglycemia. Both strength of recommendations and quality of evidence were accounted for in the guidelines.
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              Sensor-augmented insulin pump therapy: results of the first randomized treat-to-target study.

              I Hirsch, Howard A. Wolpert, Helge B. Bode … (2008)
              The objective of the study was to evaluate the clinical effectiveness and safety of a device that combines an insulin pump with real-time continuous glucose monitoring (CGM), compared to using an insulin pump with standard blood glucose monitoring systems. This 6-month, randomized, multicenter, treat-to-target study enrolled 146 subjects treated with continuous subcutaneous insulin infusion between the ages of 12 and 72 years with type 1 diabetes and initial A1C levels of >or=7.5%. Subjects were randomized to pump therapy with real-time CGM (sensor group [SG]) or to pump therapy and self-monitoring of blood glucose only (control group [CG]). Clinical effectiveness and safety were evaluated. A1C levels decreased (P<0.001) from baseline (8.44+/-0.70%) in both groups (SG, -0.71+/-0.71%; CG, -0.56+/-0.072%); however, between-group differences did not achieve significance. SG subjects showed no change in mean hypoglycemia area under the curve (AUC), whereas CG subjects showed an increase (P=0.001) in hypoglycemia AUC during the blinded periods of the study. The between-group difference in hypoglycemia AUC was significant (P<0.0002). Greater than 60% sensor utilization was associated with A1C reduction (P=0.0456). Fourteen severe hypoglycemic events occurred (11 in the SG group and three in the CG group, P=0.04). A1C reduction was no different between the two groups. Subjects in the CG group had increased hypoglycemia AUC and number of events during blinded CGM use; however, there was no increase in hypoglycemia AUC or number of events in the SG group. Subjects with greater sensor utilization showed a greater improvement in A1C levels.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Int J Pediatr Endocrinol
                Journal ID (iso-abbrev): Int J Pediatr Endocrinol
                Title: International Journal of Pediatric Endocrinology
                Publisher: BioMed Central
                ISSN (Print): 1687-9848
                ISSN (Electronic): 1687-9856
                Publication date (Print): 2013
                Publication date (Electronic): 26 March 2013
                Volume: 2013
                Issue: 1
                Page: 8
                Affiliations
                [1 ]Department of Pediatrics, Division of Pediatric Endocrinology, Tripler Army Medical Center, 1 Jarrett White Road, Honolulu, HI, 96859, USA
                Article
                Publisher ID: 1687-9856-2013-8
                DOI: 10.1186/1687-9856-2013-8
                PMC ID: 3630059
                PubMed ID: 23531400
                SO-VID: 3e9301f6-03a2-4cbc-9b75-6aafa50d8c35
                Copyright © Copyright ©2013 Larson and Pinsker; licensee BioMed Central Ltd.
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 15 March 2013
                Date accepted : 20 March 2013
                Categories
                Subject: Review

                ScienceOpen disciplines: Pediatrics
                Keywords: adolescents,children,continuous glucose monitoring,diabetes,type 1 diabetes
                Data availability:
                ScienceOpen disciplines: Pediatrics
                Keywords: adolescents, children, continuous glucose monitoring, diabetes, type 1 diabetes

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