Should Youth With Type 1 Diabetes Use Closed-Loop Systems?

MONTPELLIER, France — Would closed-loop systems be a good option for young patients with type 1 diabetes?

International and French recommendations on closed-loop systems state that the use of an "artificial pancreas" should be reserved for adults who are fully engaged with their treatment. This means that young patients, especially adolescents, who are less likely to comply with treatment and are more likely to experience suboptimal blood glucose control, are often excluded from the use of such systems for managing their diabetes.

Several recent studies seem to call this approach into question.

One such study, which was presented at a Francophone Diabetes Society conference and was published in Nature Communications, showed that adolescents with poorly controlled diabetes who were equipped with closed-loop systems gained IQ points and reasoning capacity and experienced a reduction in edematous tissue in the brain cortex. Furthermore, with the closed-loop system, patients spent 13% more time in a target range, and there was a significant reduction in time spent in hyperglycemia.

In the same vein, a small prospective study published in Diabetes Care on January 23 showed that the closed-loop system with the Minimed 780G pump improved glycemic control for 20 young patients with type 1 diabetes aged 13 to 25 years whose diabetes was poorly controlled (A1c ≥ 8.5%). At the end of the 3-month study period, the average A1c had decreased from 10.5% (±2.1%) to 7.6% (±1.1%), an average decrease of 2.9%. The time spent in target A1c, which was set from 0.70 to 1.80 g/L, was increased by almost 40%.

With respect to very young children, a study published in The New England Journal of Medicine on March 15 also showed a favorable risk–benefit ratio for closed-loop systems. The trial, which enrolled 102 children aged 2 years to less than 6 years who had type 1 diabetes, showed that the amount of time that the glucose level was within the target range during the 13-week study period was higher (+3 hours) for those who had been randomly assigned to receive the hybrid closed-loop system (n = 68) than for those who had received the standard treatment (n = 34), either with an insulin pump or multiple daily injections or a Dexcom G6 continuous glucose monitoring device.

A previous study carried out by the Paris Public Hospital System had already shown that the French Diabeloop system could reduce episodes of hypoglycemia and achieve good glycemic control for prepubescent children (n = 21; age 6 to 12 years) with type 1 diabetes in real-life conditions.

Medscape French Edition questioned endocrinologist and diabetes specialist and conference chair Eric Renard, MD, PhD, head of the Department of Endocrinology and Diabetes at Lapeyronie Hospital in Montpellier, about these results, especially those from adolescents with poorly controlled diabetes. The expert was not surprised at the findings from the study.

"We have already seen studies in which those patients who had the most poorly controlled diabetes at the start were the ones who improved the most with the closed-loop system, by at least 20% in terms of time in target. These findings resonate with what I see in my clinic," said Renard.

"In my experience, these young adolescents, who neglected their diabetes when they had no devices to help control it, when they had to inject themselves, et cetera... well, they're just not the same people when they're put on a closed-loop system," he added. "They rise to the challenge, and for the first time, they succeed without making a huge effort, since the algorithm does what they weren't doing. It's astonishing to see near-total engagement in these young people when explaining the technology to them and saying, 'Let's give it a go.' These are the very same youngsters who didn't want to hear about their diabetes in the past. They are delighted and once again involved in managing their condition."

That's why Renard recommends keeping an open mind when considering treatment options for young patients with poorly controlled type 1 diabetes.

"When young people have very poorly controlled diabetes, they risk having cardiovascular complications and damaging their retinas and kidneys," he said. "If we can get them from 25% to 45% time in target, even if that hasn't been easy to achieve, this will help save their blood vessels! The only thing we have to be careful of is that we don't set up a closed-loop system in someone who doesn't want one. But, if it can manage to spark the interest of a young patient, in most cases, it's beneficial."

This article was translated from the Medscape French edition.

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Cite this: Should Youth With Type 1 Diabetes Use Closed-Loop Systems? - Medscape - Apr 25, 2023.