INSULIN INSIGHTS

New Research Findings: A Look Into ATTD 2021

By Mamie Lausch, MS, RN, RDN, CDCES
Clinical Territory Manager/ Rochester, MN

The 14th International Conference on Advanced Technologies & Treatments for Diabetes (ATTD 2021) took place last month with all sessions presented virtually. Registration is still being accepted to view recorded sessions until September 5, 2021 via https://attd.kenes.com/. This is a premier conference to showcase diabetes technology!

The MOBILE Study (Continuous Glucose MOnitoring in T2D Basal InsuLin UsErs) was presented at ATTD by Dr. Thomas Martens.1 This multi-center randomized controlled trial (RCT) enrolled adults ages 30+ years with type 2 diabetes who have their diabetes managed by primary care providers (n=175). Study inclusion criteria included basal-only insulin use for at least 6 months, an A1C of 7.8-11.5% and completing blood glucose meter (BGM) checks at least 3 times per week. Participants were randomized in 2:1 ratio to either continuous glucose monitoring (CGM) or BGM (daily fasting and post-prandial checks) for the duration of the 8-month study. Participants in the CGM group were able to use BGM to verify CGM readings as needed.

Both study groups had the same number of follow-up research visits and primary care visits. At the end of the MOBILE study, participants in the CGM group (n=116) achieved an A1C reduction of 0.4% more than the BGM group (n=59) (p<0.001). The CGM group achieved 59% Time-in-Range (TIR) of 70-180 mg/dL compared to BGM group TIR of 43% (blinded CGM assessment) (p<0.001). Improvement in A1C and TIR in the CGM group was present across all different demographics such as age groups, baseline A1C and education levels. The study population was racially and socioeconomically diverse. There was one participant in each study group who experienced a severe hypoglycemic event and one participant in the CGM group who experienced diabetic ketoacidosis.

Prior to the MOBILE study, there was less research evidence regarding the benefits of CGM use in people living with type 2 diabetes compared to its use among those living with type 1 diabetes.2 Since type 2 diabetes is much more common than type 1 (n=>34 million type 2 in US) and considering the overall trends for glucose control are getting worse in the US,3 now is the time to talk with patients living with type 2 diabetes about the benefits of CGM if you haven’t already.

The Guardian™ Connect system by Medtronic is a CGM that requires a prescription and is indicated for continuous or periodic monitoring of glucose levels in the interstitial fluid under the skin, in patients 14 to 75 years of age with diabetes mellitus. The system is intended to complement, not replace, information obtained from standard blood glucose monitoring devices, and is not recommended for people who are unwilling or unable to perform a minimum of two meter blood glucose tests per day, or for people who are unable or unwilling to maintain contact with their healthcare professional. The system requires a functioning mobile electronic device with correct settings. If the mobile device is not set up or used correctly, you may not receive sensor glucose information or alerts. For complete details of the system and its components, including warnings, contraindications, and precautions, please consult the user guide at http://www.medtronicdiabetes.com/support/download-library/user-guides and important safety information. Contact your local Medtronic Diabetes representative for more information including how to have a patient evaluate this system free-of-charge for 30 days!

New Clinical Guidelines from AACE

Clinical guidelines were recently completed by researchers on behalf of the American Association of Clinical Endocrinologists (AACE) regarding the use of advanced diabetes technologies.4 These guidelines are intended to assist medical decision-making by health professionals who work with people who live with diabetes mellitus. When following these guidelines, practitioners are also encouraged to use their best clinical judgement while considering individual patient situations.

A total of 357 references were included as a part of these guidelines. Research papers identified through literature review were systematically graded A (strongest), B, C, or D according to various measures such as study design and analysis of data. Recommendations were made based on the strength of evidence.  The advanced technologies included were continuous glucose monitoring (CGM), insulin pumps and smart insulin pens. Blood glucose meters and conventional insulin pens were not included.

Examples of the strongest evidence and recommendation include:

  • “CGM is strongly recommended for all persons with diabetes treated with intensive insulin therapy, defined as 3 or more injections of insulin per day or the use of an insulin pump.”
  • “Insulin pump with CGM or SAP (sensor-augmented insulin pumps) is recommended to manage all persons with diabetes treated with intensive insulin management who prefer not to use automated insulin suspension/dosing systems or have no access to them.”
  • “AID (automated insulin dosing) systems are strongly recommended for all persons with T1D, since their use has been shown to increase TIR (Time in Range), especially in the overnight period, without causing an increased risk of hypoglycemia. Given the improvement in TIR and the reduction in hyperglycemia with AID, this method of insulin delivery is preferred above other modalities. For persons with diabetes with suboptimal glycemia, significant glycemic variability, impaired hypoglycemia awareness, or who allow for permissive hyperglycemia due to the fear of hypoglycemia, such AID systems should be considered.”
  • “All persons with diabetes using an insulin delivery technology should receive comprehensive training in its proper use and care.”

While insulin pumps and CGM have been available for several years and a wide array of evidence exists for their use, smart pens are new to this technology world. Less evidence exists, however in the few short years they have been available, this recommendation has been made by AACE:

  • “Connected pens may be recommended for all persons with diabetes who are treated with intensive insulin management, with 3 or more injections per day and who are not on insulin pump therapy, in whom an assessment of insulin dosing may help the person with diabetes and the clinician to further optimize the insulin regimen and avoid the stacking of rapid-acting insulin doses that could lead to hypoglycemia.”

The goal at Medtronic Diabetes is to help reduce the burden of living with diabetes by offering innovative technology that can help address a full array of needs. Our family of solutions includes:

  • i-Port Advance™ Injection Port
  • Guardian™ Connect CGM indicated for type 1 and type 2 diabetes
  • InPen™ Smart Insulin Pen for mealtime insulin users
  • Low Glucose Suspend insulin pump indicated for type 1 and type 2 diabetes: MiniMed™ 630G System
  • AID pump system indicated for type 1 diabetes: the MiniMed ™770G System
  • Various no-charge comprehensive training opportunities available to patients who purchase products and to the healthcare providers who manage their care!

Contact your local Medtronic Diabetes representative for more information!

Solutions offered by Medtronic.

*Refers to SmartGuardTM Auto Mode. Some user interaction required. Individual results may vary.
** Injection port lets you take your medication without having to puncture your skin for each shot.
◊ Smart insulin pens connect to a mobile app to provide dosing calculations, reminders and CGM system integration.
***The MiniMedTM 770G system is enabled for future software upgrades, when such software upgrades are available. Customers will be offered a software upgrade at no charge through December 2021.* *Program eligibility requirements and terms and conditions apply. Subject to change.
1. Riley D, Raup G. Impact of a subcutaneous injection device on improving patient care. Nurs Manage. 2010;41(6):49-54
2. Battelino T, Conget I, Olsen B, et al. The use and efficacy of continuous glucose monitoring in type 1 diabetes treated with insulin pump therapy: a randomized controlled trial. Diabetologia. 2012;55:3155–3162
3. Reznik Y, Cohen O, Aronson R, et al, Insulin pump treatment compared with multiple daily injections for treatment of type 2 diabetes (OpT2mise): a randomized open-label controlled trial. The Lancet. 2014; 2014;384:1265-1272.
4. Effect of intensive diabetes treatment on carotid artery wall thickness in the epidemiology of diabetes interventions and complications. Epidemiology of Diabetes Interventions and Complications (EDIC) Research Group. Diabetes. 1999;48(2):383-390. doi:10.2337/diabetes.48.2.383

1

Martens, T., Beck, R. W., Bailey, R., et al. Effect of Continuous Glucose Monitoring on Glycemic Control in Patients with Type 2 Diabetes Treated with Basal Insulin A Randomized Clinical Trial. JAMA. doi:10.1001/jama.2021.7444. Published online June 2, 2021. Accessed online 6/11/2021 at https://jamanetwork.com/journals/jama/article-abstract/2780593.

2

Lin R, Brown F, James S, Jones J, Ekinci E. Continuous glucose monitoring: A review of the evidence in type 1 and 2 diabetes mellitus. Diabet Med. 2021 May;38(5):e14528. doi: 10.1111/dme.14528. Epub 2021 Mar 6. PMID: 33496979.

3

Fang, M., Wang, D., Coresh, J., Selvin, E. Trends in Diabetes Treatment and Control in U.S. Adults, 1999–2018. N Engl J Med 2021; 384:2219-2228. DOI: 10.1056/NEJMsa2032271.

4

Grunberger, G., Sherr, J., Allende, M., et al. American Association of Clinical Endocrinology Clinical Practice Guideline: The Use of Advanced Technology in the Management of Persons with Diabetes Mellitus. Endocrine Practice 27 (2021) 505-537. Accessed online 6/11/21 at www.endocrinepractice.org.