Diabetes devices not enough to achieve HbA1c goals in kids, teens

Despite the high uptake of diabetes-related technologies, glucose control seems to remain suboptimal in young people with type 1 diabetes, with more than 60 percent failing to reach the target glycated haemoglobin (HbA1c) level, according to a recent Norway study.

Some devices work better than others, the researchers pointed out. “The overall use of continuous subcutaneous insulin infusion (CSII) was not associated with a higher proportion of children and adolescents with HbA1c <7.5 percent or lower mean HbA1c. The use of continuous glucose monitoring (CGM), however, was associated with a 0.15-percentage point (pp) lower HbA1c.”

The nationwide cross-sectional study included 2,623 paediatric patients with type 1 diabetes (mean age 12.6±3.8 years) whose data were retrieved from the 2017 Norwegian Childhood Diabetes Registry. CSIIs were the most common device type, used by 74.7 percent (n=1,918) of participants. CGMs were used by 52.6 percent (n=1,321) while 25.3 percent (n=651) were on multiple daily injections (MDI). [Diabetes Ther 2021;12:2571-2583]

Data on the primary outcome of HbA1c were available for 2,555 patients, in whom the mean level was 7.83 percent (62 mmol/mol). Only 39.5 percent of these patients were able to achieve the target of <7.50 percent, as set by the International Society for Paediatric and Adolescent Diabetes (ISPAD). Only 20 percent had HbA1c <7.00 percent.

Comparing across device use groups showed that CSII users had significantly higher HbA1c levels than MDI comparators (B, 0.14 pp; 95 percent confidence interval [CI], 0.04–0.24; p=0.008); fewer CSII users likewise achieved HbA1c <7.5 percent (38.3 percent vs 41.6 percent).

On the other hand, linear mixed-effects (LME) models showed that CGM use led to significant reductions in HbA1c relative to nonuse (B, –0.18 pp; 95 percent CI, –0.27 to –0.09; p<0.001) and a higher percentage of patients achieving HbA1c <7.5 percent (40.5 percent vs 38.0 percent).

Diabetic ketoacidosis (DKA), another study outcome, had an annual occurrence of 67 incidence, corresponding to 2.6 percent of the overall study sample. Logistic regression analysis showed no significant difference in the odds of DKA between the CGM and CSII groups. The same was true for severe incidence hypoglycaemia, which occurred in 90 participants overall (3.5 percent).

“Most children and adolescents with type 1 diabetes in our 2017 cohort did not achieve ISPAD’s HbA1c goal, irrespective of whether they were using a CSII, a CGM, or neither,” the researchers said. “Both longitudinal and cross-sectional studies have limitations due to confounding factors, which makes the evaluation of the long-term effects of technical devices in diabetes treatment difficult.”

“Expectations for the use of technical devices, at least those prevalent in 2017, should be modest. Insulin pumps and CGM systems that are more user-friendly and more sophisticated, especially newer closed-loop systems, might lead to better metabolic control than the devices used in our 2017 cohort,” they added.