Building Competency in Diabetes Education THE ESSENTIALS

BASAL-BOLUS INSULIN THERAPY | 12-49 and self-monitoring of blood glucose (104). The 15% increase in TIR compared to manual insulin dosing translates into 3.6 additional hours per day in target for the HCL users. A decrease in glycemic variability both in the higher than target and lower than target range contributed to the increase in the TIR. McAuley also reported an increase in diabetes-specific well being and quality of life in the HCL cohort (104). Specific features such as higher targets for exercise, additional night-time tighter target and customizable glucose target range are available on some systems (112). The HCL is yet a stepping stone to the development of a complete closed loop system where both the basal and bolus insulin can be managed automatically. Termed the ‘artificial pancreas” this system would allow the patient freedom from manual insulin delivery with their insulin requirements being monitored and met by the integration of the rtCGM and pump. Several models of CL have been developed and trialed with very promising results. Repeatedly the CL studies have shown superiority of the artificial pancreas as compared to CSII or SAP in regard to TIR, A1C reduction, hypoglycemia reduction and patient useability(113-119). A recent meta-analysis concluded that CL systems ranked best out of all type 1 diabetes management technologies for TIR (117). In their systematic review and meta-analysis of randomized controlled trials Weisman et al compared artificial pancreas systems (insulin only or insulin plus glucagon) with conventional pump therapy (continuous subcutaneous insulin infusion [CSII] with blinded continuous glucose monitoring [CGM] or unblinded sensor-augmented pump [SAP] therapy) in adults and children with type 1 diabetes(115). They determined that TIR 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%). They also found that Dual-hormone artificial pancreas systems using insulin and glucagon, were associated with a greater improvement in time in target range compared with single-hormone. (115) Although not available yet on the Canadian market these research results show a promising future for the closed loop system. A lay group known as Do It Yourself(DIY) -Artificial Pancreas Systems - for closed looped pumping has been active in the past several years with the focus to move the development of CL at a faster rate( 118). With an international reach this group shares personal algorithms and information as to how to connect to various devices to develop their own CL system. Although not authorized by any specific company and not supported by any clinical trials, patients and their families using DIY have reported improved A1C and increased satisfaction with their diabetes management. (118)