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Expert commentary

by Guy Todd Alonso, MD

Most youth with type 1 diabetes (T1D) do not meet glycemic targets, which has big implications for long-term complication risks. There is some evidence that tighter targets are associated with lower HbA1c, and that tighter blood sugar management early after diagnosis may affect long term glycemic trajectory.1,2 Together, there may to be an opportunity to improve outcomes by setting and achieving tighter targets soon after diagnosis. To better understand this, the Stanford Medicine group undertook this study, which included early continuous glucose monitoring (CGM) initiation, clear and tight blood sugar targets, and frequent and targeted remote patient monitoring.3

There were three groups in this study: a historical cohort (n=272), the Pilot 4T group (n=135), and the 4T Study 1 group (n=133). The Pilot group had roughly a 0.5% lower HbA1c at 6, 9, and 12 months after diagnosis when compared to the historical cohort. This is encouraging, but not surprising, because CGM uptake was both much earlier (median start 7 versus 221 days), and much higher (100% versus 56%).

But the remote patient monitoring system used in the Pilot and Study 1 groups was a real novelty that makes this study quite interesting. The Timely Interventions in Diabetes Excellence (TIDE) Tool is an electronic dashboard that allows diabetes educators to prioritize patients who may benefit from a targeted outreach.4,5 Thus, the TIDE tool allowed the team to invest valuable diabetes educator hours in patients who would benefit the most. No diabetes educator team could possibly have the capacity to reach out to all CGM users in their clinic cohort with any regularity, but this smart prioritization dashboard helped identify patients with key needs, such as those with worsening blood sugar trends – or even those who had stopped using CGM.

In the Study 1 group, blood sugar targets were tighter, in line with the ADA’s 2020 HbA1c target of <7%.6 Compared to the pilot, the Study 1 group had 3–6% greater time in range, lower HbA1c, and higher percent of patients reaching HbA1c targets, while not creating an increase in hypoglycemia. Indeed, in Study 1, two-thirds of patients achieved HbA1c <7%, up from 50% in the Pilot and 28% in the historical group! This is much better than what we would expect in a US pediatric T1D cohort.

I look forward to seeing more results from this study and their subsequent phases, including the exercise substudy, identification of optimal remote monitoring cadence, the inclusion Spanish speaking patients, and the outcomes when even tighter glycemic targets are recommended. It will be interesting to see how this type of intervention could work for patients with established diabetes and those using hybrid closed loop systems.

In conclusion, this is exciting evidence. It may not be enough just to prescribe CGM. Intentionally initiating CGM soon after diagnosis, employing targeted remote monitoring, and emphasizing realistic and achievable glycemic goals appear to drive improved outcomes in pediatric diabetes.

 

References

  1. Cameron FJ, de Beaufort C, Aanstoot HJ, et al. Lessons from the Hvidoere International Study Group on childhood diabetes: be dogmatic about outcome and flexible in approach. Pediatr Diabetes 2013;14(7):473–80.
  2. Van Loocke M, Battelino T, Tittel SR, et al. Lower HbA1c targets are associated with better metabolic control. Eur J Pediatr 2021;180(5):1513–20. https://pubmed.ncbi.nlm.nih.gov/33415466/
  3. Prahalad P, Ding VY, Zaharieva DP, et al. Teamwork, Targets, Technology, and Tight Control in Newly Diagnosed Type 1 Diabetes: the Pilot 4T Study. J Clin Endocrinol Metab 2022;107(4):998–1008.
  4. Scheinker D, Gu A, Grossman J, et al. Algorithm-Enabled, Personalized Glucose Management for Type 1 Diabetes at the Population Scale: Prospective Evaluation in Clinical Practice. JMIR Diabetes 2022;7(2):e27284.
  5. Ferstad JO, Vallon JJ, Jun D, et al. Population-level management of type 1 diabetes via continuous glucose monitoring and algorithm-enabled patient prioritization: Precision health meets population health. Pediatr Diabetes 2021;22(7):982–91.
  6. American Diabetes Association. 13. Children and Adolescents: Standards of Medical Care in Diabetes−2020. Diabetes Care 2020;43(Supplement 1):S163–82.
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