INTEGRATED-DIABETES-CARE

DIABETES

The Evolving Role of Treatment and Technology in Diabetes Care

Join Dr. Robert Rizzel as he navigates the transformative role of treatment and technology in diabetes care. This video provides a detailed overview of how these innovations are reshaping diabetes management, offering medical practitioners a deeper insight into contemporary diabetes care. Step into this enlightening journey to understand the future trajectory of diabetes treatment.

<h2>DKA IS A MEDICAL EMERGENCY ASSOCIATED WITH HIGH MORBIDITY3</h2>
Prevalence of DKA at diagnosis varies, but can be up to 70% across Europe and North America. DKA at diagnosis is often due to diagnostic error and treatment delay.3

DKA is responsible for approximately half of all hospitalisations in people with autoimmune T1D.29,30

DKA can have serious neurocognitive effects31; even a single severe episode has been shown to impair memory and IQ.*32

DKA is associated with a sustained negative effect on glycaemic control over time,†&nbsp;increasing morbidity and mortality.33

By approximately how much can screening and monitoring programmes reduce DKA rates?
DKA, diabetic ketoacidosis; FLUID, Fluid Therapies Under Investigation in Diabetic Ketoacidosis; IQ, intelligence quotient; PECARN, Pediatric Emergency Care Applied Research Network; T1D, type 1 diabetes. *In a prospective study including 758 children who presented with DKA in a randomised multisite clinical trial evaluating fluid protocols for DKA treatment (PECARN FLUID trial). DKA status was associated with lower scores in overall IQ, memory for item-colour associations and forward digit span recall.32†Independent of other variables.33

<h2>AVOIDING DKA AT DIAGNOSIS CAN IMPROVE HEALTH OUTCOMES1,41–44</h2>
Screening can facilitate prompt and effective glycaemic management, reducing the risk of severe macrovascular and microvascular complications.1,41–44
Avoiding DKA at diagnosis is associated with better long-term HbA1c levels.7,33

Preventing chronic hyperglycaemia can help reduce the risk of:

including stroke and cardiovascular disease

MACROVASCULAR COMPLICATIONS45

including eye, kidney and nervous system

MICROVASCULAR COMPLICATIONS45

An average of up to ~18 life-years lost in those diagnosed before age 10

A REDUCED LIFE EXPECTANCY*†46

Of ~40% of adults with autoimmune T1D initially misdiagnosed,&nbsp;77% were misdiagnosed with T2D‡; this can delay proper insulin replacement therapy, prolong hyperglycaemia and increase the risk of DKA.20
CI, confidence interval; DKA, diabetic ketoacidosis; HbA1c, haemoglobin A1c; T1D, type 1 diabetes; US, United States. *Compared to matched controls, according to a nationwide, register-based cohort study including 27,195 individuals with autoimmune T1D in Sweden, using data from the Swedish National Diabetes Register46&nbsp;†Men diagnosed with autoimmune T1D before 10 years of age lost a median of 14.2 life-years (95% CI 12.1, 18.2). Females diagnosed at the same age lost a median of 17.7 life-years (95% CI 14.5, 20.4). People diagnosed after 20 years of age lost approximately 10 life-years.46&nbsp;‡In a retrospective online survey of people with autoimmune T1D and caregivers of people with autoimmune T1D in the US, a diagnosis of autoimmune T1D was missed in 38.6% of those diagnosed at ≥18 years of age. Of those people, 76.8% were initially diagnosed with type 2 diabetes.20

References

The burden of Autoimmune T1D

TYPE-1-DIABETES

<h2>Beyond HbA1C, It is time to think Time-in-Range</h2>
Optimizing Time-in-range is fundamental to effective Diabetes management and to help reduce the risk of the negative consequences for your patients1-5

Each&nbsp;1‌0‌% drop in Time-in-Range (TIR)&nbsp;was associated with increased frequency of

<h4 style="text-align: center;">Retinopathy2*</h4>
<img alt="" src="/dam/jcr:b196a16d-2dec-4c07-a138-242cc1bf3cc0/encadres-1.png">

<h4 style="text-align: center;">Microalbuminuria2*</h4>
<h4><img alt="" src="/dam/jcr:6f5f7f10-64e8-48c5-aa14-2dd071b9d7fb/encadres-2.png"></h4>

<h4 style="text-align: center;">Neuropathy3†</h4>
<img alt="" src="/dam/jcr:72b8750b-f8cc-4d4f-b6a4-ad32a7c56277/encadres-3.png">

<h4 style="text-align: center;">Mortality4☨</h4>
<img alt="" src="/dam/jcr:73077044-5ded-40bc-ac02-3cabb06f421a/encadres-4.png">

More TIR was associated with reduced&nbsp;risk of severe hypoglycemia, MACE and microvascular complications&nbsp;vs&nbsp;less TIR5#&nbsp;

In people with T2DM
Risk of a severe hypoglycemia event decreased by up to:

<div>
 <table border="1" cellpadding="1" cellspacing="1" style="width:100%;">
 <tbody>
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 <td style="text-align: center;">Time-in-range is an important physical and emotional measure of success for people with T1DM and T2DM6,7</td>
 </tr>
 </tbody>
 </table>
 Up to 5‌7‌% of people with T1‌DM and T2‌DM ranked TIR as the measurable therapy outcome that had the biggest impact on daily life with diabetes6†† Up to 5‌4‌% ranked TIR as the highest driver of a positive mindset6‡‡&nbsp;
</div>

<table border="1" cellpadding="1" cellspacing="1" style="width:100%;">
 <tbody>
 <tr>
 <td style="text-align: center;">ADA and the International Consensus on TIR&nbsp;recommend reducing glycemic variability and&nbsp;optimizing TIR&nbsp;as a key aspect of effective diabetes management in people with T1DM and T2DM&nbsp;8,9</td>
 </tr>
 </tbody>
</table>

<table border="1" cellpadding="1" cellspacing="1" style="width:100%;">
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 <td style="text-align: center;">Optimizing HbA1c to &lt;7‌.0‌%8,10&nbsp;and reducing glycemic variability: 
 TIR&gt;7‌0‌% and %CV≤3‌6‌%8,10&nbsp;helps achieve better patient outcomes2,4,5,7,8</td>
 </tr>
 </tbody>
</table>

*Post hoc analysis using the DCCT dataset to evaluate the association of TIR of 7‌0‌–1‌8‌0‌ mg/dL (3‌.9‌–1‌0‌ mmol/L) with the development or progression of retinopathy and microalbuminuria to validate TIR as a metric. Criteria for the retinopathy outcome were met by n=2‌7‌1‌/1‌,4‌4‌0‌ (1‌9‌%), and for the microalbuminuria outcome were met by n=1‌1‌6‌/1‌,2‌8‌3‌ (9‌%). Mean TIR for 7‌-point profiles for 1‌,4‌4‌0‌ people was 4‌1‌ ± 1‌6‌%. Adjusted HR (9‌5‌% CI) for retinopathy: 1‌.6‌4‌ (1‌.5‌1‌ to 1‌.7‌8‌); adjusted HR (9‌5‌% CI) for microalbuminuria: 1‌.4‌0‌ (1‌.2‌5‌ to 1‌.5‌6‌). From discrete Cox proportional hazards regression models using a time-dependent version of each glucose metric stratified by the ETDRS level of retinopathy at baseline and adjusted for the pre-DCCT glycemic exposure represented by the pre-existing duration of diabetes separately for the primary and secondary cohorts; p&lt;0‌.0‌0‌1‌.2

†&nbsp;Data from a prospective observational cohort study which evaluated the association of TIR of 7‌0‌–1‌8‌0‌ mg/dL (3‌.9‌–1‌0‌ mmol/L) with microvascular diabetes outcomes, including peripheral neuropathy; 6‌2‌ out of 1‌0‌5‌ participants with a total MNSI questionnaire score ≥2‌ were defined as having distal peripheral neuropathy, including 5‌1‌ with CKD and 1‌1‌ controls; CKD patients defined as having eGFR &lt;6‌0‌mL/min/1‌.7‌3‌m2. Odds ratio (9‌5‌% CI): 1‌.2‌5‌ (1‌.0‌2‌ to 1‌.5‌2‌). Adjusted for age, sex and race.3

‡&nbsp;A prospective cohort study (N=6‌,2‌2‌5‌) evaluating the link between TIR of 7‌0‌–1‌8‌0‌ mg/dL (3‌.9‌–1‌0‌ mmol/L) with all-cause and cardiovascular mortality, with the objective of validating TIR as surrogate marker of long-term adverse clinical outcomes. Adjusted HR (9‌5‌% CI) for all-cause mortality: 1‌.0‌8‌ (1‌.0‌5‌ to 1‌.1‌2‌); adjusted HR (9‌5‌% CI) for CV mortality: 1‌.0‌5‌ (1‌.0‌0‌ to 1‌.1‌1‌). From restricted cubic spline nested in time-dependent Cox model. Adjusted for age, sex, smoking, diabetes duration, BMI, systolic blood pressure, triglycerides, HDL cholesterol, LDL cholesterol, history of cancer, history of CVD, and using antihypertensive drugs, aspirin, and statins.4

#Post hoc study using data from the devote&nbsp;study from 5‌,6‌4‌4‌ people with T2‌DM who had an 8‌-point glucose profile. Individual TIR was derived as the proportion of the 8‌-point glucose profile within range (derived TIR). A Cox model was used to estimate the association between derived TIR and time to first MACE, severe hypoglycaemic episode and microvascular event (retinopathy and CKD). HRs (9‌5‌% CI) for MACE: 0‌.6‌9‌ (0‌.5‌2‌ to 0‌.9‌1‌) for TIR&gt;7‌0‌% vs TIR ≤5‌0‌%; 0‌.9‌1‌ (0‌.6‌6‌ to 1‌.2‌4‌) for TIR &gt;7‌0‌% vs TIR &gt;5‌0‌–≤7‌0‌% (overall association p&lt;0‌.0‌1‌). HR (9‌5‌% CI) for microvascular event: 0‌.6‌0‌ (0‌.4‌3‌ to 0‌.8‌5‌) for TIR&gt;7‌0‌% vs TIR ≤5‌0‌%; 0‌.7‌3‌ (0‌.4‌9‌ to 1‌.0‌9‌) for TIR &gt;7‌0‌% vs TIR &gt;5‌0‌–≤7‌0‌% (overall association p&lt;0‌.0‌1‌9‌). Hazard ratios were consistent when analyses were adjusted for baseline characteristics.5

**TIR &gt;7‌0‌% vs ≤5‌0‌%. HR (9‌5‌% CI) vs TIR ≤5‌0‌% for time to first severe hypoglycemia: 0‌.5‌4‌ (0‌.4‌0‌ to 0‌.7‌3‌).5

††Online survey of 3‌,4‌6‌1‌ people with T1‌DM (n=1‌,0‌2‌6‌) or T2‌DM (n=1‌,1‌5‌4‌ on insulin; n=1‌,2‌8‌1‌ not on insulin). The survey presented respondents with 2‌5‌ questions investigating patients’ perceptions of the success of current diabetes drugs and devices; which factors have the biggest impact on patients’ daily lives and which changes would have the biggest positive impact on diabetes management and mindset; and mental well-being, QoL, desired improvements for future therapies, relationships with health care providers, and the concerns of loved ones. The survey was conducted from 1‌7‌–2‌2‌ August.6

‡‡Food choices were rated by all groups (range 6‌3‌% to 6‌7‌% of the groups) as the greatest factor having an impact on daily life with diabetes, but TIR emerged as the measurable therapy outcome that had the biggest impact on daily life with diabetes for all groups of respondents (range 4‌1‌% to 5‌7‌%).6

##Including intra-day mean glucose, glycemic variability, and glucose levels after meals and overnight. Based on a multicentre, randomised, crossover trial in adults with T1‌DM (n=8‌2‌) and T2‌DM (n=3‌0‌6‌). Participants received basal-bolus regimen of insulin glargine plus premeal insulin glulisine (n=1‌9‌2‌) or premix analogue insulin (n=1‌9‌6‌). Participants were then crossed over to the other treatment at 1‌2‌ weeks and continued for another 1‌2‌ weeks.7

Abbreviations

Impact of Time-In-Range on Diabetes Management

Real-World Study on Effectiveness of InsulinGlargine U300 After Oral Antidiabetic Drug Failure in Patients with Type 2 Diabetes in the Gulf Region

<h2>Introduction</h2>
Recent updates from the American Diabetes Association (ADA 2022) guidelines recommend basal insulin with OAD treatment for individuals with T2D post-oral therapy failure
The ATOS study, a global observational, real-world study, aimed to evaluate the effectiveness and safety of Gla-300 in Asia, the Middle East, North Africa, Latin America, and Eastern Europe
This chapter presents data from Gulf countries - Kuwait, Saudi Arabia, and the UAE - aiming to analyze regional variations in diabetes management. The focus on the Gulf region enhances the significance of the findings, considering differences in healthcare systems and patient support resources

<h2>Objective</h2>
To evaluate the real-world effectiveness and safety of Gla-300 in participants with T2D after OAD drug failure in people with T2D in the gulf region

<h2>Study Design</h2>
412 individuals with T2D from 3 countries&nbsp;

Insulin-naïve ≥18 years old participants included were:
Having uncontrolled HbA1c
<ul>
 <li>HbA1c &gt;7% and ≤11% on ≥1 OAD</li>
 <li>in whom the treating physicians had decided, in accordance with the local guidelines, to add Gla-300 to the treatment</li>
</ul>

<table align="center" border="1" cellpadding="1" cellspacing="1" style="width:500px;">
 <tbody>
 <tr>
 <td style="text-align: center; background-color: rgb(122, 0, 230); border-color: rgb(122, 0, 230);">Gla-300 once daily (N = 412)</td>
 </tr>
 </tbody>
</table>

<ul>
 <li>The Mean ± SD at baseline for age was 52.2 ± 11.1, for duration of T2DM was 10.7 ± 6.8 years, and for HbA1c % it was 9.2 ± 1.1</li>
 <li>Around 50% of participants were on a non-T2D medication (n=208); ([CV conditions (n=197) and blood-related conditions (n=51)])</li>
</ul>

<h2>Study Endpoints</h2>
<h3>Primary Endpoint</h3>

Percentage of participants achieving predefined individualized HbA1c goal at Month 6

Change from baseline in HbA1c, FPG, SMPG, and body weight at Month 6 and 12

Percentage of participants achieving their pre-defined individualized HbA1c&nbsp;target at Month 3 and 12

Hypoglycemic events reported during the study

DTSQs Score, EQ-5D VAS score, EQ-5D TTO score, and perceived frequency of hypo and hyperglycemia

<h2>Efficacy Outcomes</h2>
<ul>
 <li>The proportion of participants achieving HbA1c target increased over the study duration, with over 75% of participants reaching HbA1c &lt;8% at the end of the study</li>
 <li>The drop HbA1c from baseline to each of the data points (month 3, 6 and 12) was consistent and significant with tight 95% CI</li>
</ul>

<div>
 <table align="center" border="1" cellpadding="1" cellspacing="1" style="width:500px;">
 <tbody>
 <tr>
 <td style="text-align: center; background-color: rgb(122, 0, 230); border-color: rgb(122, 0, 230);">Proportion of participants achieving HbA1c target achievement</td>
 </tr>
 </tbody>
 </table>
</div>

<div>
 <table align="center" border="1" cellpadding="1" cellspacing="1" style="width:500px;">
 <tbody>
 <tr>
 <td style="text-align: center; background-color: rgb(122, 0, 230); border-color: rgb(122, 0, 230);">Levels of HbA1c in participants from Month 3 to 12</td>
 </tr>
 </tbody>
 </table>
</div>

The primary endpoint of achieving individually set HbA1c target (average of 6.9% ± 0.4%) by Month 6 of treatment with Gla-300 was achieved in 57 participants [13.8% with 95% CI (10.6; 17.6)]
At month 6, the individualized HbA1ctargets showed correlation with geographical location of participants i.e., participants from rural area had lower odds of meeting the target compared to urban dwellers (suburban: OR = 0.492; 95% CI [0.063; 3.864] Vs rural areas: OR = 0.656; 95% CI [0.192; 2.240])
In comparison to baseline HbA1c of 7–8% the baseline HbA1c ≥10% was associated with a lower likelihood of achieving HbA1c target at Month 6.&nbsp;i.e., baseline HbA1c 8–9%: [OR = 0.839; 95% CI (0.352; 1.995)], baseline HbA1c 9–10%: [OR = 0.665; 95% CI (0.272; 1.625)], baseline HbA1c ≥10%: [OR = 0.523; 95% CI (0.205; 1.336)]
A greater number of co-morbid conditions reduced the likelihood of achieving the HbA1c target by half [OR = 0.508; 95% CI 0.111; 2.332)]. Moreover, age beyond 75 years was associated with approximately 49% lower likelihood of achieving the primary endpoint (P = 0.138) (may be due to the small group size).
Other parameters analysed, including BMI, comorbidities, prior OAD use, and health insurance status, showed trends in impacting HbA1c target achievement, however these trends were not statistically significant
<h2>Other parameters analyzed</h2>
<ul>
 <li>Employment status of individuals significantly modified likelihood of HbA1c target achievement at Month 6 (P = 0.021)</li>
 <li>Compared to full-time employees or students, retired individuals (n = 35) were 2.893 times more likely to achieve HbA1c target(P = 0.016)</li>
 <li>Individuals with unknown occupation status (n = 21) had 3.857-fold higher odds of achieving the primary endpoint of the study (P = 0.007)</li>
</ul>
<h2>Safety Outcomes</h2>
<table border="1" cellpadding="1" cellspacing="1" style="width:100%;">
 <tbody>
 <tr>
 <td style="background-color: rgb(122, 0, 230);">Adverse Events</td>
 <td style="text-align: center; background-color: rgb(122, 0, 230);">GLA 300 
 (N = 412)</td>
 </tr>
 <tr>
 <td>Any AE over 6 months&nbsp;&nbsp; &nbsp;</td>
 <td style="text-align: center;">4 (1%)</td>
 </tr>
 <tr>
 <td>Any AE over 12 months</td>
 <td style="text-align: center;">4 (1%)</td>
 </tr>
 <tr>
 <td>Any SAE</td>
 <td style="text-align: center;">(0.2%)</td>
 </tr>
 <tr>
 <td>Any TEAE</td>
 <td style="text-align: center;">(1.0%)</td>
 </tr>
 <tr>
 <td>Any hypoglycemia, without instances of severe hypoglycemia&nbsp;&nbsp; &nbsp;</td>
 <td style="text-align: center;">3 (0.7)</td>
 </tr>
 <tr>
 <td>Any TEAE leading to treatment discontinuation&nbsp;&nbsp; &nbsp;</td>
 <td style="text-align: center;">(0.5%)</td>
 </tr>
 <tr>
 <td>Any TEAE leading to death</td>
 <td style="text-align: center;">0</td>
 </tr>
 </tbody>
</table>

<h2>Conclusion</h2>
In real-life setting in Gulf region, initiation of Gla-300 in insulin-naïve people with T2D uncontrolled on OADs resulted in improved glycaemic control with low rates of reported and perceived hypoglycemia and increasingly improved PROs throughout the study duration; reflecting treatment satisfaction and better health status
<h3>Abbreviations</h3>
AE, adverse event;BMI, body mass index; CI, confidence interval; CV, cardiovascular; DTSQ, diabetes treatment satisfaction questionnaire; EQ-5D VAS, EuroQol 5-dimension scale visual analogue scale; EQ-5D TTO, EuroQol 5-dimension scale time trade-off; FPG, fasting plasma glucose; GI, gastrointestinal; Gla-300, insulin glargine 300 U/mL; HbA1c, glycated haemoglobin; OAD, oral antidiabetic drug; OR, odds ratio; PROs, patients reported outcomes; SD, standard deviation; SMBG, self-monitored blood glucose; SAE, serious adverse events; T2D, type 2 diabetes TEAEs, treatment-emergent AEs.

Reference

The ATOS Study: Real-World Study on Effectiveness of Insulin Glargine U300 in the Gulf Region.

TYPE-2-DIABETES

SoliD: Redefine Treatment Paradigm Post-OAD

Get a sneak peek into the groundbreaking clinical data on iGlarLixi, unveiled at the American Diabetes Association’s 84th Scientific Sessions. This teaser video introduces a 24-week randomized controlled trial that explores the effectiveness of iGlarLixi in managing Type 2 diabetes. Without revealing too much, we can promise interesting findings on blood glucose control and hypoglycemia risk. Stay tuned for a deep dive into the trial’s results and their implications for diabetes treatment. Don’t miss out on this exciting revelation in the world of diabetes research.

SoliCGM Synergy: Soliqua’s Synchronized Impact on T2DM CGM Dynamics Therapy

Join Dr. Viral Shah as he explores the use of CGM metrics to assess clinical outcomes in Type 2 Diabetes patients receiving Iglarlixi. This insightful discussion sheds light on the transformative role of Soliqua in diabetes management, providing valuable perspectives for healthcare professionals. Enhance your knowledge and improve patient care with this engaging talk.

Adults with Type 2 diabetes on OADs often struggle to achieve adequate fasting and postprandial glucose control without increasing their treatment burden:
Can a change in current practice help smooth their journey post-OAD?

They may face additional treatment burdens with their first injectable therapy

†Basal bolus, premix.

*The CNHSS project was initiated by the Chinese Diabetes Society and conducted in mainland China from April to June 2013 . The CNHSS was established to monitor glycemic control in adults with T2DM. A total of 24,266 adult T2DM patients were included, and they were divided into pure fasting hyperglycemia group (IFH, n=2674, 19.7%), pure postprandial hyperglycemia group (IPH, n=6462, 47.6%) and combined hyperglycemia group (CH, n=4444, 32.7%) according to phenotype. Accordingly, the calculated proportion of patients who were having fasting hyperglycemia is 52.4% (19.7% IFH + 32.7% CH) and who were having postprandial hyperglycemia is 80.3% (47.6% IPH + 32.7% CH). The main outcomes were diabetic retinopathy, diabetic nephropathy, and diabetic retinopathy combined with nephropathy, aiming to study the correlation between abnormal blood glucose phenotypes and microvascular complications in patients with type 2 diabetes.1 tBasal bolus, premix. The IDMPS is the largest ongoing global, cross-sectional observational study describing real-world data on patient profiles, disease management and patterns of care in people with diabetes across 27 countries across Africa, Eurasia, the Middle East and South Asia.' A retrospective cohort study i nvestigated whether clinical inertia, the failu re to intensify treatment when required, exists in Japanese clinical practice, usi ng the CoDiC® database.'*Study Design: Randomized, open-label, 48-week study compared two algorithms. Up to three injections of insu lin lispro mix 25 and/or insu lin lispro mix 50 (premix; premixed insulin lispro) or basal insulin glargine plus up to three injections of insulin lispro (basal+; glargine + insu lin lispro) were used in type 2 diabetic patients uncontrolled with oral antihyperglycemic medication and consuming&lt;15% daily calories at breakfast. The primary objective was to test the non-inferiority in glycemic contrai with premix versus basal plus regimen based on the HbA1c at week 48.4
Abbreviations: 
 HbA1c: Hemoglobin A," iDegAsp: insulin degludec/insulin aspart, iGlar: lnsulin glargine, T2D: Type 2 diabetes
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Need to redefine the treatment paradigm Post OAD

The 17th International Conference on Advanced Technologies and Treatments for Diabetes (ATTD) concluded on March 9, 2024.
The congress was a resounding success, drawing more than 5000 participants from 96 countries around the world. Attendees had the opportunity to engage with leading experts, researchers, and industry professionals to discuss advancements in diabetes care, including new technologies, treatment modalities, and research findings.
The conference covered a broad spectrum of topics such as CGM, insulin delivery systems, digital health solutions, and emerging therapies. We are delighted to present some notable highlights distilled from all four days of ATTD 2024, with a particular emphasis on T2D.

<h2>The art of perspective: advancing type 2 diabetes care with treatment intensification and technology</h2>
Session chair: Tadej Battelino
Speakers: Alexandria Ratzki-Leewing, Riccardo Candido, Francesco Giorgino, Robert Ritzel, Partha Kar, and Julia K. Mader
<ul>
 <li>Managing hypoglycemia is crucial for optimal insulin use in PwT2D, requiring a balance between glycemic control benefits and hypoglycemia risks.</li>
 <li>Timely intensification of treatment with BI, preferably second-generation analogs, is important for those with sub-optimally controlled T2D on GLP-1 RAs for effective diabetes management.</li>
 <li>Once-daily FRCs offer a simple alternative to complex insulin regimens for PwT2D in need of further therapeutic advancement.</li>
 <li>Patient barriers to BI therapy intensification include regimen complexity, fear of hypoglycemia, weight gain, and misconceptions about insulin use. In addition to holistic diabetes management, incorporating CGM metrics is important to promote effective communication and provide transparency with easy integration of BI.</li>
 <li>CGM plays a vital role in simplifying diabetes self-management, promoting effective communication, and facilitating collaborative decision-making between HCPs and PwT2D. More evidence is needed, especially among PwT2D. Global barriers to CGM integration include accessibility and affordability issues.</li>
 <li>Appropriate language use is essential in fostering a positive HCP-patient relationship and optimal clinical outcomes. Various factors can influence adherence to insulin therapy, potentially leading to suboptimal concordance. Leveraging digital platforms for diabetes management offers avenues to enhance support for PwD by addressing obstacles to self-management.</li>
 <li>Smart connected insulin pens and digital solutions, integrated into a cloud-based ecosystem, enhance clinical conversations and satisfaction levels among PwD, caregivers, and HCPs, leading to individualized and person-centric diabetes care and optimal health outcomes.</li>
</ul>

<h2>CGM diabetes quality measures</h2>
Session chairs: Guillermo Arreaza-Rubin and Revital Nimri
Speakers: Elisabeth Selvin and Gregg Simonson
<h3>Should HbA1c still be a diagnostic criterion for diabetes in 2024?</h3>
<ul>
 <li>Although various factors interfere with the assays used to measure HbA1c, data show that there is a robust association between HbA1c level and long-term microvascular complications. Due to the lack of standardized CGM metrics for diabetes diagnosis, using and educating patients about using laboratory HbA1c along with CGM mean glucose.</li>
</ul>
<h3>CGM (GMI/TIR) as diabetes quality metrics</h3>
<ul>
 <li>While HbA1c possesses characteristics of a good quality measure, it may be impacted by various factors and does not reflect hypoglycemia or variability. Similarly, GMI and average glucose levels may serve as good glycemic metrics; however, there is a need to go beyond these measures. TIR/TBR data could be an excellent diabetes management metric and evolving quality measure.</li>
</ul>

<h2>Hypoglycemia - any progress?</h2>
Session chairs: Stephanie A. Amiel and Fernando Gomez-Peralta
Speakers: Stephanie A. Amiel and Simon Heller
<h3>CGM detection of hypoglycemia in diabetes management</h3>
<ul>
 <li>CGM has played an important role in increasing the recognition of hypoglycemia events. Data from HypoMETRICS study showed that hypoglycemia, whether symptomatic or asymptomatic, may have a negative impact on daily functioning. Additionally, CGM alerts for non-harmful events could be detrimental and requires further personalization.</li>
</ul>
<h3>Should the classification of hypoglycemia be updated?</h3>
<ul>
 <li>Hypo-RESOLVE project investigates patient engagement and interactions via 8 work packages. The association between hypoglycemic events and T1D or T2D varies, and there is an increased risk of adverse events as blood glucose falls to lower levels during hypoglycemic events.</li>
</ul>

<h2>Effect of iGlarLixi on continuous glucose monitoring-measured time in range in insulin-naive adults with suboptimally controlled type 2 diabetes (HbA1c ≥11.7–18.1 mmol/l/ 9–13%)</h2>
Presenter: Juan P. Frias
<ul>
 <li>In PwT2D suboptimally controlled on BI, treatment with iGlarLixi significantly improved glycemic control. TIR increased by 26.2%, while TBR remained within the recommended targets. The coefficient of variation (%) also remained below the recommended target of 36%.</li>
 <li>iGlarLixi was well tolerated with no increased risk of hypoglycemia, as evidenced by CGM data.</li>
</ul>

<h2>Decision support and automated insulin delivery for the management of type 2 diabetes</h2>
Session chair: Lia Bally
Presenter: Lia Bally
<h3>Virtual clinic for insulin therapy in type 2 diabetes</h3>
<ul>
 <li>Adopting a virtual clinic approach envisions a future characterized by scalable, accessible, and adaptive insulin treatment for T2D through connected devices and smart insulin dosing algorithms.</li>
 <li>Nevertheless, a significant barrier exists in the form of a lack of interoperability, necessitating collaboration with primary care providers. The successful implementation of this approach, especially with fully automated insulin dosing technologies, mandates additional engagement with individual patients.</li>
</ul>

<h2>Advances in treating diabetes</h2>
Session chairs: Peter Adolfsson
Presenter: Peter Adolfsson, Fernando Gomez-Peralta, Christophe De Block, Andrea Facchinetti, and Neal Kaufman
<ul>
 <li>Connected pens and caps and smart MDI system offer potential benefits, such as keeping track of injection times, and doses and integrating the data to a care platform. Smart digital solutions may empower PwD to better optimize BI dose and manage their diabetes, enabling an individualized approach for achieving glycemic targets.</li>
 <li>Recently published expert recommendations by the Spanish Endocrinology and Nutrition Society suggest providing guidance on the possible usage of technology for individual user and families, diabetes team, institutional user, and usage in clinical research.</li>
 <li>The continuous ketone monitoring may aid in the early detection of diabetes ketoacidosis. The current continuous ketone monitoring systems are less effective and require novel algorithms based on ketone data with ketone specific alarms for high ketone levels, potentially enhancing QoL in PwD. Additionally, the continuous ketone monitoring sensor are more accurate than ketone strips used for ketone monitoring in PwT1D.</li>
 <li>The digital twin technologies provide personalized and tailored treatment for PwD. The digital twin technology is expected to offer real-time, robust, precise, and effective medical services in diagnosis, treatment, monitoring, trauma management, and drug development of diabetes. The ReplayBG, a digital twin tool, can be used for optimizing and personalizing T1D therapy.</li>
</ul>

Inside Diabetes: ATTD Edition | Type 2 Diabetes

The 17th International Conference on Advanced Technologies and Treatments for Diabetes (ATTD) concluded on March 9, 2024. The congress was a resounding success, drawing more than 5000 participants from 96 countries around the world.
Attendees had the opportunity to engage with leading experts, researchers, and industry professionals to discuss advancements in diabetes care, including new technologies, treatment modalities, and research findings. The conference covered a broad spectrum of topics such as CGM, insulin delivery systems, digital health solutions, and emerging therapies.
We are delighted to present some notable highlights distilled from all four days of ATTD 2024, with a particular emphasis on T1D.

<h2>JDRF - international consensus monitoring guidance for presymptomatic (early stage) type 1 diabetes</h2>
Session chair: Anastasia Albanese-O'Neill
Speakers: Moshe Phillip, Linda DiMeglio, Kirstine Bell, Emanuele Bosi
<ul>
 <li>It is important to monitor people with stage 1 and 2 T1D to prevent DKA and initiate immunomodulation therapy. The consensus guidance advocates community partnership, emphasizing the importance of viable monitoring modalities.</li>
 <li>The primary goal of education is to prevent DKA, emergency visits for intensive care and to improve risk perception with understanding of outcomes and interventions. This assists individuals and families in managing psychosocial impacts.</li>
 <li>The ‘D1CE SCREEN’ is a planned pilot study that will be conducted in ~5000 children who will be screened for T1D and celiac disease by their family pediatricians in Italy. The aim is to prevent DKA and identify early T1D, while also assessing feasibility and acceptability of universal screening in general population.</li>
</ul>

<h2>ATTD in partnership with The diaTribe Foundation: Is it time for time in tight range?</h2>
Moderators: Tadej Battelino, Natalie Bellini, Natasa Bratina, Chiara Fabris, and Helena Rodbard
<ul>
 <li>Raising the bar for TITR may be associated with a loss of trust among PwD, highlighting the need for caution when setting TITR targets. Despite recognizing the beneficial effects of higher TITR in euglycemic conditions, it is crucial to adopt a more open-ended approach in target setting.</li>
 <li>Technological and therapeutic advancements offer an opportunity to consider TITR as a valuable glycemic metric alongside TIR in clinical trials.</li>
 <li>Aligning treatment goals with PwD and their family members requires a comprehensive understanding of developments in diabetes technology and treatment. All family members must share the same goal and belief in order to ensure successful alignment.</li>
 <li>Glycemic targets need to be tailored and personalized for each individual. It is crucial to educate the HCP on effectively collaborating with PwT1D and gaining their trust. Additionally, PwD should be made aware of new target ranges and understand TITR as the new goal for optimizing treatment together as a team.</li>
</ul>

<h2>Time-in-range vs. time-in-tighter-range: parent and teen experiences with CGM metrics for pediatric T1D management</h2>
Presenter: Molly Tanenbaum
<ul>
 <li>This study conducted in PwT1D, exploring their perception and navigation of CGM metrics, particularly focusing on TIR and TITR using qualitative methods.</li>
 <li>Study results revealed diverse perspectives and psychological impacts among participants, with some favoring narrow ranges for safety, while others expressed concerns about stress and lifestyle constraints.</li>
 <li>Participants expressed the need for greater support and guidance from HCPs to effectively manage their diabetes. It was underscored that involving input from parents and caregivers is crucial when making adjustments to TIR and TITR goals. This highlights the importance of a collaborative approach for improved T1D management and overall patient satisfaction.</li>
</ul>

<h2>Screening, intervention and prevention of type 1 diabetes</h2>
Session chair: Linda DiMeglio
Presenter: Emanuele Bosi, Laura Jacobsen, Jennifer L. Sherr, Raffaella Buzzetti
<ul>
 <li>The Teplizumab prevention trial demonstrated that teplizumab treatment prolonged the pre-symptomatic phase and led to a delay in the median time to clinical T1D diagnosis. The UNISCREEN study investigated the potential of capillary blood screening in the general population for early T1D detection, offering advantages like acceptability, feasibility, and reliable autoantibody assays.</li>
 <li>Identifying DMT responders is crucial to maximize benefits and minimize unnecessary exposure. Disease pathophysiology varies based on age of diagnosis, emphasizing the need for adaptive clinical trials with precise participant enrollment using biomarkers. The proinsulin-C-peptide ratio has emerged as a potential marker for β-cell stress.</li>
 <li>In PROTECT trial, teplizumab preserved C-peptide in people with new-onset T1D, delaying stage 3 diagnosis significantly. Real-world data emphasized the need for screening and consistent protocols, informing potential label expansion based on PROTECT study outcomes.</li>
 <li>Underreported T1D cases in adults, with varying β-cell destruction rates, pose challenges in diagnosis of T1D. GADA is the most prevalent autoantibody. Age and antibody status impact insulin requirements, emphasizing personalized approaches to preserve β-cell function and minimize complications.</li>
</ul>

Abbreviation

Inside Diabetes: ATTD Edition | Type 1 Diabetes

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