Diabetes Mellitus, Type 1
Conditions
Keywords
Diabetes Mellitus, Type 1, Continuous Glucose Monitor, Artificial Pancreas, Insulin Pump, Closed Loop control, Open Loop treatment
Brief summary
An unblinded, randomized, cross-over design with each patient participating in two 40-hour outpatient admissions: (a) Experimental involving automated Control-to-Range (CTR) and (b) Control using Continuous Glucose Monitor (CGM)- augmented insulin pump treatment outside of a hospital based clinical research center. The principal goal is to validate a smart phone-based control-to-range (CTR) system for ambulatory use and to estimate the effect of CTR vs. sensor-augmented pump therapy, thereby providing justification for further larger home-based trials of CTR.
Detailed description
The overall objective of this project is to sequentially test, validate, obtain regulatory approval for, and deploy at home, a closed-loop Control-to-Range (CTR) system for optimal blood glucose (BG) regulation in people with type 1 diabetes. The CTR system is comprised of two algorithmic layers: a Safety Supervision Module (SSM) and Insulin on Board Tracking and Safety Module (ITSM), and an automated Range Correction Module (RCM). Both modules will receive continuous glucose monitoring (CGM) and insulin delivery data. The SSM and ITSM will monitor the safety of the subject's continuous subcutaneous insulin infusion pump (CSII) to prevent hypoglycemia. The RCM will be responsible for optimizing BG control and mitigating postprandial hyperglycemic excursions through series of insulin boluses. To run CTR, we will use our wearable artificial pancreas platform, known as DiAs (Diabetes Assistant), which consists of a smart phone running CTR and connected to standard insulin delivery and CGM devices.
Interventions
A medical platform that uses a smart-phone to connect to a continuous glucose sensor to insulin pump and run closed-loop control. The cell phone runs the Control to Range and is connected to work with the insulin pump and continuous glucose monitor to help keep the blood sugar in a desired range (80-180 mg/dL during the day) and help avoid hypoglycemia during the night.
Sponsors
Juvenile Diabetes Research Foundation
Sansum Diabetes Research Institute
University of Padova
University Hospital, Montpellier
University of Virginia
Study design
Allocation
RANDOMIZED
Intervention model
CROSSOVER
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
21 Years to 64 Years
Healthy volunteers
No
Inclusion criteria
1. ≥21 and \<65 years old. 2. Clinical diagnosis of type 1 diabetes mellitus. For an individual to be enrolled at least one criterion from each list must be met. o Criteria for documented hyperglycemia (at least 1 must be met): i. Fasting glucose ≥126 mg/dL - confirmed ii. Two-hour Oral Glucose Tolerance Test (OGTT) glucose ≥200 mg/dL - confirmed iii. HbA1c ≥6.5% documented - confirmed iv. Random glucose ≥200 mg/dL with symptoms v. No data at diagnosis is available but the participant has a convincing history of hyperglycemia consistent with diabetes o Criteria for requiring insulin at diagnosis (1 must be met): i. Participant required insulin at diagnosis and continually thereafter ii. Participant did not start insulin at diagnosis but upon investigator review likely needed insulin (significant hyperglycemia that did not respond to oral agents) and did require insulin eventually and used continually iii. Participant did not start insulin at diagnosis but continued to be hyperglycemic, had positive islet cell antibodies - consistent with latent autoimmune diabetes in adults (LADA) and did require insulin eventually and used continually 3. Use of an insulin pump to treat his/her diabetes for at least 1 year. 4. Familiarity with a bolus calculator with the current insulin pump with pre-defined parameters for carbohydrate (CHO) ratio, insulin sensitivity factor (ISF), target glucose and active insulin. 5. HbA1c \<9% as measured with DCA2000 or equivalent device. 6. Not currently known to be pregnant, breast feeding, or intending to become pregnant (females). 7. Demonstration of proper mental status and cognition for the study. 8. Willingness to avoid consumption of acetaminophen-containing products during the study interventions involving CGM use. 9. If on antihypertensive, thyroid, anti-depressant or lipid lowering medication, have stability on the medication for at least 2 months prior to enrollment in the study.
Exclusion criteria
1. Severe hypoglycemia resulting in seizure, loss of consciousness, or diabetic ketoacidosis within the 12 months prior to enrollment. 2. Pregnancy; breast feeding, or intention of becoming pregnant. 3. Uncontrolled arterial hypertension (Resting diastolic blood pressure \>90 mmHg and/or systolic blood pressure \>160 mmHg). 4. Conditions which may increase the risks associated with possible hypoglycemia, such as any active cardiac disorder/arrhythmia, uncontrolled coronary artery disease during the previous year (e.g. history of myocardial infarction, acute coronary syndrome, therapeutic coronary intervention, coronary bypass or stenting procedure, stable or unstable angina, episode of chest pain of cardiac etiology with documented EKG changes, or positive stress test or catheterization with coronary blockages \>50%), congestive heart failure, history of cerebrovascular event, seizure disorder, syncope, adrenal insufficiency, neurologic disease or atrial fibrillation. 5. Self-reported hypoglycemia unawareness. 6. History of a systemic or deep tissue infection with methicillin-resistant staph aureus or Candida albicans. 7. Use of a device that may pose electromagnetic compatibility issues and/or radiofrequency interference with the CGM (implantable cardioverter-defibrillator, electronic pacemaker, neurostimulator, intrathecal pump, and cochlear implants). 8. Anticoagulant therapy other than aspirin. 9. Oral steroids. 10. Medical condition requiring use of an acetaminophen-containing medication that cannot be withheld for the study admissions. 11. Psychiatric disorders that would interfere with study tasks (e.g. inpatient psychiatric treatment within 6 months prior to enrollment). 12. Mental incapacity, unwillingness or language barriers precluding adequate understanding or cooperation. 13. Known current or recent alcohol or drug abuse. 14. Medical conditions that would make operating a CGM, the DiAs cell phone or insulin pump difficult (e.g. blindness, severe arthritis, immobility). 15. Any skin condition that prevents sensor or pump placement on the abdomen or arm (e.g. bad sunburn, pre-existing dermatitis, intertrigo, psoriasis, extensive scarring, cellulitis). 16. In adherence with the One Touch Ultra 2 User Guide, subjects with hematocrit levels less than 30% and above 55% will be excluded. 17. Impaired hepatic function measured as alanine aminotransferase or aspartate aminotransferase ≥three times the upper reference limit. 18. Impaired renal function measured as creatinine \>1.2 times above the upper limit of normal. 19. Uncontrolled microvascular (diabetic) complications, such as current proliferative diabetic retinopathy or macular edema, known diabetic nephropathy (other than microalbuminuria with normal creatinine) or neuropathy requiring treatment. 20. Active gastroparesis requiring current medical therapy. 21. If on antihypertensive, thyroid, anti-depressant or lipid lowering medication, lack of stability on the medication for the past 2 months prior to enrollment in the study. 22. Uncontrolled thyroid disease. 23. Known bleeding diathesis or dyscrasia. 24. Known allergy to medical adhesives, components of the insulin pump insertion set or continuous glucose monitor sensor. 25. Active enrollment in another clinical trial. 26. Use of anti-diabetic agents other than continuous subcutaneous insulin infusion (CSII) including long-acting insulin, intermediate-acting insulin, metformin, sulfonylureas, meglitinides, thiazolidinediones, DPP-IV inhibitors, glucagon-like peptide 1 agonists, and alpha-glucosidase inhibitors 27. Subjects with basal rates less than 0.01U/hr.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Safety, Low Blood Glucose Index (LBGI) | 40 hours (x2 admissions) | The LBGI reflects the frequency and extent of hypoglycemic episodes and presents the results in risk space. Thus the LBGI is a weighted average of the number of hypoglycemic readings, with progressively increasing weights as BG levels go down. The increase of the weights follows a risk function; thus the LBGI has been associated with risk for hypoglycemia and prediction of severe hypoglycemic episodes. LBGI \< 2.5 is associated with low risk of hypoglycemia, 2.5 \< LBGI \< 5 is associated with a moderate risk of hypoglycemia and LBGI \> 5 is associated with a high risk of hypoglycemia. |
| Safety, Frequency of Hypoglycemia | 40 hours (x 2 admissions) | Hypoglycemic episodes are defined as BG \< 3.9mmol/L |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Efficacy, Time Spent in Target Range | 40 hours (x2 admissions) | Percentage of time in the target range of 3.9-10 mmol/L (70-180 mg/dL). |
Countries
United States
Participant flow
Participants by arm
| Arm | Count |
|---|---|
| Open and Closed Loop Control Closed-Loop: Insulin delivery will be controlled by the Diabetes Assistant (DiAs) system running in Control to Range (CTR) or in Safety Only mode. The subject will interact with the system through its Graphic User Interface (GUI). Subjects will not be allowed to administer correction boluses between meals and snacks as the DiAs will automatically be adjusting insulin to correct for hyperglycemia.
Open-Loop: Insulin delivery will be controlled by the DiAs system running in open-loop mode. The subject will interact with the system through its GUI. Subjects will be permitted to administer correction boluses at any time during the Control Admission, whether or not they are eating a scheduled meal or snack. DiAs will be initialized with the subject's typical insulin pump settings. | 20 |
| Total | 20 |
Baseline characteristics
| Characteristic | Open and Closed Loop Control |
|---|---|
| Age, Categorical <=18 years | 0 Participants |
| Age, Categorical >=65 years | 0 Participants |
| Age, Categorical Between 18 and 65 years | 20 Participants |
| Sex: Female, Male Female | 5 Participants |
| Sex: Female, Male Male | 15 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | — / — | — / — |
| other Total, other adverse events | 5 / 19 | 1 / 20 |
| serious Total, serious adverse events | 0 / 19 | 0 / 20 |
Outcome results
Primary
Safety, Frequency of Hypoglycemia
Hypoglycemic episodes are defined as BG \< 3.9mmol/L
Time frame: 40 hours (x 2 admissions)
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Closed-loop Control to Range | Safety, Frequency of Hypoglycemia | 1.22 hypoglycemic episodes/participant | Standard Deviation 0.4 |
| Open-Loop CGM-Augmented Insulin Pump Therapy | Safety, Frequency of Hypoglycemia | 2.39 hypoglycemic episodes/participant | Standard Deviation 0.6 |
p-value: 0.02Wilcoxon (Mann-Whitney)
Primary
Safety, Low Blood Glucose Index (LBGI)
The LBGI reflects the frequency and extent of hypoglycemic episodes and presents the results in risk space. Thus the LBGI is a weighted average of the number of hypoglycemic readings, with progressively increasing weights as BG levels go down. The increase of the weights follows a risk function; thus the LBGI has been associated with risk for hypoglycemia and prediction of severe hypoglycemic episodes. LBGI \< 2.5 is associated with low risk of hypoglycemia, 2.5 \< LBGI \< 5 is associated with a moderate risk of hypoglycemia and LBGI \> 5 is associated with a high risk of hypoglycemia.
Time frame: 40 hours (x2 admissions)
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Closed-loop Control to Range | Safety, Low Blood Glucose Index (LBGI) | 0.64 index score | Standard Deviation 0.72 |
| Open-Loop CGM-Augmented Insulin Pump Therapy | Safety, Low Blood Glucose Index (LBGI) | 1.12 index score | Standard Deviation 0.77 |
p-value: 0.003t-test, 1 sided
Secondary
Efficacy, Time Spent in Target Range
Percentage of time in the target range of 3.9-10 mmol/L (70-180 mg/dL).
Time frame: 40 hours (x2 admissions)
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Closed-loop Control to Range | Efficacy, Time Spent in Target Range | 66.1 percentage of time spent in range | Standard Deviation 18.6 |
| Open-Loop CGM-Augmented Insulin Pump Therapy | Efficacy, Time Spent in Target Range | 70.7 percentage of time spent in range | Standard Deviation 21.7 |
p-value: >0.1t-test, 1 sided