Improved Glycemic Control in Adult Subjects With Type 1 Diabetes on MDI Using Insulin Guidance Software
Condition: Diabetes
MeSH terms: Diabetes Mellitus; Diabetes Mellitus, Type 1
Study type: Observational

Summary: 
      140 subjects will be enrolled into the clinical study and randomized into the Control Group
      or the Experimental Group by block randomization. The subjects must meet all inclusion and
      none of the exclusion criteria. Each subject will have 7 clinic visits and 3 phone visits.
      The Baseline Visit will consist of a complete history, vitals, a physical examination and
      completion of the consent and screening process. All clinic visits, except for the Baseline
      Visit will include meter/PDA download. In addition, meter education will be provided to all
      subjects, and PDA education will be provided to the Experimental group at the Baseline Visit
      and 2-Week Visit as needed to ensure subject understanding. The phone visits will consist of
      a history including any changes in insulin dose, and any hypoglycemic events, hyperglycemic
      events, or other adverse events that have occurred since the last clinic visit.

      The primary endpoint in this study was to show a reduction in A1c of at least 0.4% or higher
      in the insulin guidance software group at 6 months and/or 1 year.
    

Detailed description: 
      Research Design and Methods A total of 123 adult subjects with type 1 diabetes with a
      baseline A1c of 7.5-11% were enrolled in the study at the Barbara Davis Center for Childhood
      Diabetes at the University of Colorado at Denver Health Sciences Center. Two patients screen
      failed (entry criteria not met) before randomization, leaving 60 subjects randomized to the
      control group and 61 subjects randomized to the experimental group (Advisor). Subjects were
      randomized based on lottery system using sealed envelopes. All patients had baseline blood
      work which included a complete blood count (CBC), complete metabolic panel (CMP), creatnine
      kinase (CK) and an A1c. The mean A1c at baseline was 8.54 ±0.11 in the control group and 8.42
      ±0.11 in the experimental group (p=0.4265).

      Subjects were randomized on a 1:1 basis to either the experimental or control group. All
      subjects in the experimental group received the same training for insulin guidance software
      program for personal data assistant (PDA). All subjects were given a glucose meter and an
      unlimited supply of test strips for self monitoring of blood glucose (SMBG). Women who were
      pregnant or planning to become pregnant were excluded from participation in the study as were
      patients on insulin pumps, those taking glucocorticoid therapy, and those diagnosed with
      cancer, liver disease, anemia or hepatitis. Patients who exercised more than five days a
      week, or often traveled internationally were also excluded.

      The protocol was approved by the Colorado Multiple Institutional Review Board (COMIRB). All
      subjects signed an informed consent form before being enrolled in the study.

      Visits All subjects were asked to attend 7 in clinic visits (baseline, 2 week, 6 week, 3
      month, 6 month, 9 month and 12 month) and participate in 3 telephone visits (4.5month,
      7.5month, 9.5 month) throughout the course of the study. Data for blood glucose values,
      testing frequency, hyperglycemic excursions, hypoglycemic events (all, nocturnal, and
      severe), insulin dose, weight and BMI, hospitalizations, emergency room visits and illnesses
      were recorded at each in clinic visit. All subjects completed a patient satisfaction
      questionnaire and the experimental group also completed an Advisor questionnaire.

      As part of their routine clinical care, any additional phone visits were equally encouraged
      in both groups.

      Advisor Insulin Guidance Software (Figure 1a) Subjects randomized to the experimental group
      received a PDA loaded with the insulin guidance software. At baseline (visit 1), a healthcare
      provider and/or certified diabetes educator (CDE) reviewed the features of the software on
      the PDA and loaded a subject specific insulin dosing algorithm into the software based on the
      physician's recommendations. The software program allowed the healthcare provider to enter
      demographic data such as age, height and weight which could potentially affect the insulin
      sensitivity factor already programmed into the device. The program advised basal, bolus and
      correction insulin dosages based on individual patients' prescriptions in addition to being
      alerted for SMBG testing. Subjects in the experimental group were also asked to input their
      blood glucose values into the PDA via the touch screen. Subjects then received a recommended
      insulin dose based on their prescription which was programmed by the healthcare provider. The
      patients were asked to either agree with the recommended insulin dose or disagree, and
      manually enter the insulin dose they took for a given event. All the data from the glucose
      meters and the PDAs were downloaded at every visit.

      Glucose Target Ranges Glucose values were captured in one of the following categories to
      assess target glycemia and pie charts were created. Within Target Range (WTR) glucose values
      were those between 70-150mg/dL (3.89 to 8.33 mmol/L) (20). Below Target Range (BTR) glucose
      values were defined as ≤ 69mg/dL (3.83 mmol/L) and Above Target Range (ATR) glucose values
      were those values above 150mg/dL (8.33 mmol/L). These glucose levels were chosen based on our
      previous research on SMBG downloads (20).

      Hypoglycemia Hypoglycemia was defined as glucose values ≤ 59mg/dL (3.27mmol/L). Severe
      hypoglycemia was defined as subjects needing assistance as previously described by DCCT
      Research Group (1).

      A1c and Other Lab Measurement

      The A1c values were measured by the DCA 2000® Analyzer, distributed by Bayer Corporation
      (Elkhart, IN). The DCA 2000® A1c assay gives accurate and precise results over a range of
      total hemoglobin from 7 to 24 g/dL. All subjects had hemoglobin concentrations well within
      these values. Normal A1c values are 3.4 to 6.2 % (18). The CBC (Beckman Coulter LH750,
      Beckman Coulter, Hialeah, FL), CMP (AU-5200 Olympus Japan Co Ltd, Tokyo) and CK (Olympus
      AU-800; Olympus, Tokyo, Japan) were performed by Quest Diagnostics, Denver, Colorado.

      Statistical Analysis Wilcoxon Rank Sum and Chi Square tests of independence were used to
      compare continuous and categorical variables, respectively, at baseline. Chi Square test of
      independence was used to compare the number of discontinued subjects between the two groups.
      Mixed model repeated measures analysis with an unstructured covariance structure and
      pre-planned contrasts were used to compare the experimental and control groups on A1c,
      percent of glucose readings within, above, and below target, percent of total hypoglycemic
      events, basal insulin dose, weight, and BMI. Paired t-tests were used to test the within
      group change in weight from baseline to 12 months among those who completed all 12 months.
      Fisher's Exact test was used to compare the number of patients achieving target values
      between groups at each time point. Poisson regression was used to compare the frequency of
      severe hypoglycemic events between the two groups. Data are presented as least squares mean ±
      SE unless otherwise noted. All analyses were performed using SAS 9.1. Results were considered
      significant at p < 0.05 using a two-sided alpha.
    

Intervention name(s): Insulin Guidance Software
Intervention type(s): Device
Intervention description(s): At baseline a healthcare provider reviewed the features of the software on the PDA and loaded a subject specific insulin dosing algorithm into the software based on the physician's recommendations. The program advised basal, bolus and correction insulin dosages based on individual patients' prescriptions in addition to being alerted for SMBG testing. Subjects in the experimental group were also asked to input their blood glucose values into the PDA via the touch screen. Subjects then received a recommended insulin dose based on their prescription which was programmed by the healthcare provider. The patients were asked to either agree with the recommended insulin dose or disagree, and manually enter the insulin dose they took for a given event.
Other intervention name(s): Accu-Chek Insulin Guidance Software
Intervention MeSH terms: Insulin; Insulin, Globin Zinc
Time perspective: Prospective
Sampling method: Non-Probability Sample
Study population: 
        123 adult subjects ages 18-60 with type 1 diabetes on mulitiple daily injections
      
Keywords: Type 1 diabetes; Improved glycemic control; Glucose excursions; Target range glucose levels; Insulin guidance software; Advisor