Optimizing Closed-Loop Control of Type 1 Diabetes Mellitus in Adolescents

The purpose of this study is to use a closed-loop Control-to-Range (CTR) system in adolescents with type 1 diabetes in an outpatient setting, and to evaluate the CTR system's ability to significantly improve blood glucose levels when an insulin bolus is omitted for a 30 gram carbohydrate snack and when insulin bolus is insufficient for the amount of carbohydrates consumed for a meal. The primary objective of this study is to use a closed-loop Control-to-Range (CTR) system to significantly reduce the post-prandial blood glucose excursion in adolescents with type 1 diabetes who omit and/or under-bolus insulin for either snacks or meals. Up to 20 subjects aged ≥13 and ≤18 years old will be tested.

Study Overview

• Status: Completed
• Conditions: Diabetes Mellitus, Type 1
• Intervention / Treatment: Device: Diabetes Assistant (DiAs)

Detailed Description

The purpose of this study is to use a closed-loop Control-to-Range (CTR) system in adolescents with type 1 diabetes in an outpatient setting, and to evaluate the CTR system's ability to significantly improve blood glucose levels when an insulin bolus is omitted for a 30 gram carbohydrate snack and when insulin bolus is insufficient for the amount of carbohydrates consumed for a meal. The CTR system is comprised of two algorithmic layers: (i) A Safety Supervision Module (SSM) which contains a predictive insulin request dampener (or brakes); (ii) a Range Correction Module (RCM), consisting in (a) a Hyperglycemia Mitigation System, and (b) Insulin on Board controller. Both modules will receive continuous glucose monitoring (CGM) and historical insulin delivery data. The SSM will monitor the safety of the subject's continuous subcutaneous insulin infusion pump (CSII) to prevent hypoglycemia. The RCM will be responsible for optimizing blood glucose (BG) control and mitigating postprandial hyperglycemic excursions through a mix of increased basal rate and, potentially, isolated 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.

• Study Type: Interventional
• Enrollment (Actual): 17
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • Virginia
    • Charlottesville, Virginia, United States, 22904
      • University of Virginia Center for Diabetes Technology

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 13 years to 18 years (Child, Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

1. ≥13 and ≤18 years old

2. Clinical diagnosis of type 1 diabetes mellitus for at least 2 years as noted by the following:

   Criteria for documented hyperglycemia (at least 1 criterion must be met):

   • Fasting glucose ≥126 mg/dL - confirmed
   • Two-hour Oral Glucose Tolerance Test (OGTT) ≥200 mg/dL - confirmed
   • Hemoglobin A1c (HbA1c) ≥6.5% documented by history - confirmed
   • Random glucose ≥200 mg/dL with symptoms
   • No data at diagnosis is available but the participant has a convincing history of hyperglycemia consistent with diabetes

   Criteria for requiring insulin at diagnosis (at least 1 criterion must be met):

   • Participant required insulin at diagnosis and continually thereafter
   • 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
   • 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 6 months
4. Actively using a carbohydrate (CHO) /insulin ratio for insulin bolus adjustments in order to keep blood glucose in a predefined range
5. Tanner stage II or greater based on physician exam
6. HbA1c between <10.5% as measured with DCA2000 or equivalent device
7. Not currently known to be pregnant, breast feeding, or intending to become pregnant (females)
8. Demonstration of proper mental status and cognition for the study
9. Willingness to avoid consumption of acetaminophen-containing products during the study visits involving DexCom use
10. Self-reported behavior of snacking without insulin coverage or under bolus for meals
11. Willingness to consume a 30 grams snack without insulin coverage and willingness to bolus 75 % of usual treatment for an 80 grams lunch during both admissions
12. Willingness to remove home CGM for admissions if the subject typically wears a CGM
13. Medication stability in the preceding two months if taking antihypertensive, thyroid, anti-depressant or lipid lowering medication
14. Reported history of missed or inaccurate bolus treatments at meal time

Exclusion Criteria:

1. Diabetic ketoacidosis (DKA) within the 6 months prior to enrollment
2. In adherence with the One Touch Ultra 2 User Guide, subjects with hematocrit levels below 30% or above 55% will be excluded. Severe hypoglycemia resulting in seizure or loss of consciousness in the 12 months prior to enrollment
3. Pregnancy; breast feeding, or intention of becoming pregnant
4. Uncontrolled arterial hypertension (based on resting blood pressure > 95 percentile as listed according to age and height percentile in the Harriet Lane Handbook of Pediatrics)
5. Conditions which may increase the risk of hypoglycemia such as 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 electrocardiogram (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
6. History of a systemic or deep tissue infection with methicillin-resistant staph aureus or Candida albicans
7. History of arrythmia
8. Use of a device that may pose electromagnetic compatibility issues and/or radiofrequency interference with the DexCom CGM (implantable cardioverter-defibrillator, electronic pacemaker, neurostimulator, intrathecal pump, and cochlear implants)
9. Anticoagulant therapy other than aspirin
10. Oral steroids
11. Medical condition requiring use of an acetaminophen-containing medication that cannot be withheld for for 24 hours before CGM insertions until the end of each the study admissions.
12. Psychiatric disorders that would interfere with study tasks (e.g. inpatient psychiatric treatment within 6 months prior to enrollment)
13. Mental incapacity, unwillingness or language barriers precluding adequate understanding or cooperation
14. Known current or recent alcohol or drug abuse
15. Medical conditions that would make operating a CGM, the DiAs cell phone, or insulin pump difficult (e.g. blindness, severe arthritis, immobility)
16. 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)
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 (other than diabetic non-proliferative retinopathy), such as history of laser coagulation, proliferative diabetic retinopathy, known diabetic nephropathy (other than microalbuminuria with normal creatinine) or neuropathy requiring treatment
20. Active gastroparesis requiring current medical therapy
21. Uncontrolled thyroid disease
22. Known bleeding diathesis or dyscrasia
23. Known allergy to medical adhesives, components of the insulin pump insertion set or continuous glucose monitor sensor
24. Active enrollment in another clinical trial
25. Use of anti-diabetic agents other than continuous subcutaneous insulin infusion (CSII) including long-acting insulin, intermediate-acting insulin, metformin, sulfonylureas, meglitinides, thiazolidinediones, dipeptidyl peptidase 4 (DPP-4) inhibitors, glucagon-like peptide 1 agonists and alpha-glucosidase inhibitors
26. Subjects with basal rates less than 0.01 units/hour

RESTRICTIONS ON USE OF OTHER DRUGS OR TREATMENTS

1. Use of anti-diabetic agents other than CSII including long-acting insulin, intermediate-acting insulin, metformin, sulfonylureas, meglitinides, thiazolidinediones, DPP-4, inhibitors, glucagon-like peptide 1 agonists, and alpha-glucosidase inhibitors.
2. Acetaminophen will be restricted 24 hours before the insertion of not be allowed while the continuous glucose monitor is in use.
3. Medications that block symptoms of hypoglycemia, including but not limited to beta blockers.
4. Subjects on amylin analogs will be asked to withhold the medication during the outpatient admissions.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Crossover Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: DiAs-closed-loop system; eight hours using Closed Loop Control (DiAs) under both, miss insulin bolus for 30 grams of carbohydrates snack or under bolus for an 80 grams of carbohydrates lunch	Device: Diabetes Assistant (DiAs); Diabetes Assistance (DiAs) is a software residing in a Smartphone that contains the algorithms to regulate and control insulin deliveries (insulin bolus for: Basal rate, meal insulin and correction bolus) with inputs glucose values from a CGM and outputs insulin infusion by an insulin pump; Other Names: Closed-Loop system
No Intervention: Sensor Augmented Pump; 8 hours observational under both, missed insulin bolus for 30 gr carbohydrates snack and under bolus for an 80 gr carbohydrates lunch. Sensor augmented pump used the patients own insulin settings (basal rate, meal boluses and correction boluses) and a CGM provided by the study team to be used during admission. No DiAs use during this admission.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Percent of Time Spent Near Normoglycemia	Percentage of time that blood glucose (BG) values (measured with both finger-stick and CGM) were near normoglycemia (70-180 mg/dL).	8 hours

Collaborators and Investigators

• Sponsor: University of Virginia
• Investigators: Principal Investigator: Daniel R. Chernavvsky, MD, CRC, University of Virginia; Principal Investigator: Mark DeBoer, MD, University of Virginia

Publications and helpful links

General Publications

• Chernavvsky DR, DeBoer MD, Keith-Hynes P, Mize B, McElwee M, Demartini S, Dunsmore SF, Wakeman C, Kovatchev BP, Breton MD. Use of an artificial pancreas among adolescents for a missed snack bolus and an underestimated meal bolus. Pediatr Diabetes. 2016 Feb;17(1):28-35. doi: 10.1111/pedi.12230. Epub 2014 Oct 27.

Study record dates

Study Major Dates

• Study Start: August 1, 2013
• Primary Completion (Actual): February 1, 2014
• Study Completion (Actual): February 1, 2014

Study Registration Dates

• First Submitted: June 27, 2013
• First Submitted That Met QC Criteria: June 27, 2013
• First Posted (Estimate): July 2, 2013

Study Record Updates

• Last Update Posted (Actual): September 13, 2022
• Last Update Submitted That Met QC Criteria: August 23, 2022
• Last Verified: August 1, 2022

More Information

Terms related to this study

• Keywords: Continuous Glucose Monitor (CGM); Closed Loop Control (CLC); Type 1 Diabetes Mellitus (T1DM); Diabetes Assistant (DiAs)
• Additional Relevant MeSH Terms: Glucose Metabolism Disorders; Metabolic Diseases; Immune System Diseases; Autoimmune Diseases; Endocrine System Diseases; Diabetes Mellitus; Diabetes Mellitus, Type 1
• Other Study ID Numbers: 16890

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: We will make de-identified individual participant data (IPD) collected in this study available to other researchers at the end of the study. Paper published in Pediatric Diabetes