The challenges of achieving postprandial glucose control using closed‐loop systems in patients with type 1 diabetes. Issue 2 (10th August 2017)

• Record Type: Journal Article
• Authors: Gingras, Véronique; Taleb, Nadine; Roy‐Fleming, Amélie; Legault, Laurent; Rabasa‐Lhoret, Rémi
• Is Part Of: Diabetes, obesity & metabolism. Volume 20:Issue 2(2018)
• Page Start: 245
• Page End: 256
• Publication Date: 2017-08-10
• Subjects: artificial pancreas -- closed‐loop -- glycaemic control -- insulin delivery -- insulin therapy -- type 1 diabetes; Diabetes -- Periodicals; Obesity -- Periodicals; Metabolism -- Disorders -- Periodicals; Clinical pharmacology -- Periodicals; 616.462
• DOI: 10.1111/dom.13052
• Languages: English
• ISSNs: 1462-8902

Abstract

Abstract : For patients with type 1 diabetes, closed‐loop delivery systems (CLS) combining an insulin pump, a glucose sensor and a dosing algorithm allowing a dynamic hormonal infusion have been shown to improve glucose control when compared with conventional therapy. Yet, reducing glucose excursion and simplification of prandial insulin doses remain a challenge. The objective of this literature review is to examine current meal‐time strategies in the context of automated delivery systems in adults and children with type 1 diabetes. Current challenges and considerations for post‐meal glucose control will also be discussed. Despite promising results with meal detection, the fully automated CLS has yet failed to provide comparable glucose control to CLS with carbohydrate‐matched bolus in the post‐meal period. The latter strategy has been efficient in controlling post‐meal glucose using different algorithms and in various settings, but at the cost of a meal carbohydrate counting burden for patients. Further improvements in meal detection algorithms or simplified meal‐priming boluses may represent interesting avenues. The greatest challenges remain in regards to the pharmacokinetic and dynamic profiles of available rapid insulins as well as sensor accuracy and lag‐time. New and upcoming faster acting insulins could provide important benefits. Multi‐hormone CLS (eg, dual‐hormone combining insulin with glucagon or pramlintide) and adjunctive therapy (eg, GLP‐1 and SGLT2 inhibitors) also represent promising options. Meal glucose control with the artificial pancreas remains an important challenge for which the optimal strategy is still to be determined.