Hybrid Closed-Loop Insulin Pump Improves Type 1 Diabetes Control

Source: Farhat I, Drishti S, Bochner R, et al. Do hybrid closed loop insulin pump systems improve glycemic control and reduce hospitalizations in poorly controlled type 1 diabetes? J Pediatr Endocrinol Metab. 2024;37(12):1028-1035; doi: 10.1515/jpem-2024-0312.Investigators from the New York City Health and Hospitals (NYCHHC) System and St. George’s University, St. George, Grenada, conducted a retrospective study to evaluate the effectiveness of hybrid closed-loop (HCL) systems for treatment of youths with poorly controlled type 1 diabetes (T1D). HCL systems integrate a continuous glucose monitor (CGM) and insulin pump for continuous subcutaneous insulin infusion via an algorithm to determine dosing. Study participants were youths and young adults 3–24 years old with T1D and a baseline hemoglobin A1c (HbA1c) level >9% who were prescribed an HCL system. These patients were identified by reviewing medical records of patients in the NYCHHC system who were prescribed HCL systems between 2021 and 2023. Data collected on study participants included demographics, type of insurance (public or private), HbA1c levels, hospitalizations, and use of CGM or insulin pump in the baseline period (prior to HCL). The primary study outcomes were change in HbA1c levels and diabetes hospitalizations after prescription of HCL, compared to the baseline period. For change in HbA1c, values in each period (baseline and follow-up) in each study patient were averaged. Signed rank tests were used to determine if there was a statistically significant change in these outcomes. In an additional analysis, logistic regression was used to identify predictors of achieving a HbA1c <9% after prescription of HCL.Data on 47 youths with T1D who were prescribed HCL systems were analyzed. The mean age of study patients was 16.0 ±3.6 years; 82.2% were on public insurance. The mean baseline HbA1c was 10.6%. During the baseline period, 31 (66.0%) patients were using CGM, and 19 (40.4%) had an insulin pump. The median times assessed during the baseline and follow-up periods were 19 and 7 months, respectively. Following prescription of HCL, there was a significant decrease in HbA1c levels in study patients, with a median HbA1c of 9.3% during the follow-up period (P <0.05 compared to baseline levels). Similarly, the median number of diabetes hospitalizations decreased from 1.0 prior to use of HCL to 0 in the follow-up period (P <0.05). There were 18 (41.8%) study participants who achieved a HBA1c <9% after prescription of HCL. In the logistic model, patients with lower baseline HbA1c levels were significantly more likely to meet this goal than those with higher levels at baseline. Use of a pump at baseline was associated with a significantly lower chance of achievement of a HbA1c level <9% after HCL.The authors conclude HCL therapy was associated with improved glycemic control in youths with poorly controlled T1D.Dr Fechner has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.Diabetes technology has continued to advance and improve glycemic control in children with type 1 diabetes. A 2019 study demonstrated that insulin pump therapy was superior to multiple daily injections (See AAP Grand Rounds. 2019:42[1]:4.)1 A subsequent 2020 study documented longer periods of in target glucose levels in those randomized to an HCL system than in those using a sensor-augmented pump (See AAP Grand Rounds. 2020;44[6]:69.)2 A randomized crossover study in children 1–7 years also demonstrated improved diabetes management when using an HCL system compared to sensor-augmented pump therapy (See AAP Grand Rounds. 2022;47[5]:53.)3 However, these studies occurred in carefully controlled study environments with participants who were fairly well controlled, which may not mimic the real world that does not offer the same medical support.The strength of the current study is that the researchers analyzed real-world data by using a retrospective chart review of patients with poorly controlled type 1 diabetes who received standard care from their providers in the NYCHHC system. HCL therapy in this setting was associated with a decrease in HgbA1c levels. There was a greater decrease in HgbA1c in those who started with a HgbA1c closer to 9%, but even those who had a median HgbA1c of 11.2% were able to decrease their HgbA1c after an average of 7 months. Also, for the brief period studied, there were no hospitalizations for diabetes-related issues. The current study, however, has several weaknesses which include the small number of participants and the limited time for follow-up after switching to HCL therapy. A longer period of follow-up may have provided more meaningful conclusions.Hybrid closed-loop insulin therapy in children and young adults with poorly controlled type 1 diabetes has the potential to significantly improve long-term outcomes through improved glycemic control.