T1 Diabetes Hypoglycemia Prevention Pilot

This is a single center 12-week Pilot trial with one arm. Subjects will serve as their own controls. The study will include usual care patients on MDI (multiple daily injections) or CSII (continuous subcutaneous insulin infusion) with the additional use of the Vigilant ™ Diabetes Management System. There will be a 4-week baseline period prior to the 12-week intervention. Subject participation for the 4-week baseline period will last for 2-4 hours during two visits. Subjects participating in the intervention phase of 12 weeks will require one additional visit (2-3 hours) at 3 months, which is routine for this population. Participants will be provided with a wireless blood glucose meter for the duration of the study and will download the Vigilant mobile application to their mobile phone.

The Vigilant™ system stores blood glucose test results, pattern events, and user settings. In addition to receiving blood glucose measurements entered from the user, storing and displaying them, Vigilant™ provides the following features and tools for the user:

• Blood Glucose Reading review and editing: The user will be able to review data logs and manually edit blood glucose results.
• Pattern Messages: Alerts the user that one or more patterns were found in the results that were entered, including patterns that are indicative of risk of severe hypoglycemia in the next 24 hours.
• Long Term Control Summary: Identifies the current and retrospective blood glucose averages and variability.

The following blood glucose patterns will be identified by the Vigilant application:

• Weekly and monthly glucose averages overall and within daily time periods
• Daily periods of infrequent testing
• Daily periods of high, low or variable blood glucose ("Daily Pattern Messaging System")
• Patterns of blood glucose indicative of increased risk of low blood glucose levels in the next 24 hours ("Hypo Risk Indicator")
• Weekly and monthly blood glucose variability ("Average Daily Risk Range or ADDR")

Vigilant™ incorporates a "Tutorial Mode" which offers detailed feedback on the meaning of pattern analyses performed by the software. In addition, two separate training videos have been developed for patients and clinicians to initiate them on use and understanding of the device and its features.

Caregivers will have access to the information outlined above, as well as summary screens that highlight glycemic control metrics and patients and risk notifications for all of their patients on Vigilant, subject to patient approval.

Subjects will be recruited from one diabetes clinic. Patients with type I diabetes and a history of mild to moderate hypoglycemia will be assessed to see if they are eligible for the study. All those who are considered eligible will be approached to give their written, informed consent before attending a screening visit where the inclusion criteria will be checked.

At the Screening Visit the following procedures will be performed / criteria will be checked and documented:

• Signed and dated informed consent
• Assignment of subject number
• Inclusion and exclusion criteria
• Demographics (date of birth, gender, race and ethnicity)
• Diabetes history (subjects only)
• Professional history (diabetes clinicians only)
• SMBG training with study meter
• Use of study hypoglycemia diary
• Completion of study questionnaires

After consent, participants will participate in the 4-week run in/baseline period before the 12 week pilot intervention to collect baseline data on glycemic control and hypoglycemia and to assess adherence with testing criteria. All participants will be asked to conduct SMBG(self-monitoring of blood glucose) three or more times a day and asked to record the clinical details of any hypoglycemia events.

At the end of the 4-week baseline period, participants will return for a study visit where the investigator will complete the following:

• Download the SMBG and hypoglycemia diary and data
• Obtain A1C
• Affirmation of participant commitment to test and record

To continue in the study, subjects will need to have obtained at least three blood glucose values per day and have recorded hypoglycemia symptoms and episodes.

Prior to the 12-week intervention period, all study participants will complete validated study questionnaires (Hypoglycemia Fear, Diabetes Empowerment Survey etc.).

At visit 2, the subjects will complete training with the Vigilant™ program. They will watch a video demonstration on an iPhone , Android or iPod Touch that explains the use of the Vigilant™ device. Study participants will be provided a wireless blood glucose monitor and asked to follow their normal diabetes management program for the subsequent 12 weeks. They will be asked to use the Vigilant™ program at home in conjunction with the provided wireless meter for the subsequent 12 weeks, according to the following instructions:

The subject will follow their typical blood glucose-testing regimen, with the exception that they must perform an average of at least 3 fingerstick blood glucose measurements daily during that time.

• Subjects will be asked to keep a log of HRI (hypoglycemia risk indicator) pattern messages received, with any entered glucose reading if delivered at that time, and what diabetes management action they chose to perform when the message is received.
• Subjects will be asked to log 1) whether or not they understand the feedback given, and 2) what action is taken to address the pattern, if any.
• Subjects will not be required to perform any specific diabetes management action to address identified patterns. Worksheets will be provided to patients to facilitate record keeping for pattern message feedback.
• It is preferred that the subject use predominantly the study supplied meter during the course of the 12 weeks of home use (two glucometers maximum).
• Subjects will be instructed to change the date / time of their meter in the event of any changes for 1) daylight savings time, or 2) travel to different time zones, so that it matches the iPod touch or Phone clock time.
• S/he will be instructed on proper SMBG technique including using water and dry towel prior to testing, avoiding alternate site testing, and using the second hanging blood drop. The subject will be asked to demonstrate an SMBG test at the visit to document proper technique.

Participants will be followed up at three months during the 12-week intervention period. Subjects will also receive a telephone or email communication from the study manager within several days of the beginning of the home use portion of the study to ensure the patient understands the protocol and is entering data according to instructions. At this time they will also be asked to send several screen shots of their application with a log of their data and patterns that have been identified, to ensure the device is working according to the intended use and data is being entered. Another follow up will occur 4 weeks into the study where the patients will be asked the same questions and given the same instructions.

Subjects involved in this study should also allow their Vigilant-using clinician to see their Vigilant patterns, and also plan to see their Vigilant-using clinician at least once for a regular check up during their Vigilant use period (this can be done at Visit 3, if desired).

A follow-up and final visit (3) will occur at the three-month end of the 12 week intervention period, which is the typical routine schedule for usual care. Additional visits may be scheduled by provider as indicated for diabetes management. The following procedures will be performed in at the follow-up visit:

• Blood draw for HbA1c
• Download SMBG data
• Review of patient diaries and data
• Data collection of hypoglycemia and other events
• Review of Vigilant pattern messages and patient log
• Completion of study questionnaires and surveys