Outpatient Reduction of Nocturnal Hypoglycemia by Using Predictive Algorithms and Pump Suspension in Children
Condition: Type 1 Diabetes
MeSH terms: Diabetes Mellitus, Type 1; Hypoglycemia
Study type: Interventional
Phase: Phase 2

Summary: 
      The purpose of this study is to see whether low blood sugar at night can be reduced by using
      a system that turns off the insulin pump automatically. The study system includes a
      continuous glucose monitor (CGM) and an insulin pump. The CGM and pump work with a regular
      laptop computer. A The system works by (1) measuring the glucose levels under the skin with
      the CGM, (2) using a computer program on the laptop to predict whether a low blood sugar is
      likely to occur, and (3) turning off the insulin pump when the computer program predicts that
      a low blood sugar will occur.

      We have tested the system in the home environment in individuals with type 1 diabetes age 15
      years and older. We have found an indication that the system can decrease the frequency of
      hypoglycemia. We have not had any serious cases of high blood sugars or other problems. We
      are now ready to further test the system in the home environment in a younger age group to
      learn more about its ability to reduce overnight low blood sugar risk.

      This study has several phases and will take about 3 months for a patient to complete.

        -  First, the patient will use the CGM and pump at home for up to 15 days with the help of
           a parent/guardian. This is done to determine if the patient meets our study criteria to
           proceed with the next phase of the study.

        -  If the patient is eligible to continue in the study, the patient will need to use the
           full study system for at least 5 nights at home with the help of a parent/guardian. This
           is done to make sure the patient and parent/guardian are able to use the system
           correctly. The patient may participate in starting and stopping the system at home, but
           the parent/guardian is responsible for making sure it is used as instructed.

        -  After that, the patient will be asked to use the study system each night for an
           additional 6 to 8 weeks. The parent/guardian will remain responsible for making sure the
           system is used as instructed.

      The study will include about 90 individuals with type 1 diabetes at 3 clinical centers in the
      United States and Canada. First a study of children 8 to less than 15 years old will be done.
      Then, a study of children 3 to less than 8 years old will be conducted.
    

Detailed description: 
      Patients who are eligible for the clinical trial initially will use a Veo insulin pump and
      Enlite sensor at home to verify that the patient is able to use the continuous glucose
      monitor (CGM) and insert sensors and is eligible to continue in the study. A parent or
      guardian of the child subject will oversee the actions of the subject and be responsible for
      the patient's overall participation during the proposed study, including operation of the
      investigational device system.

      The first 10 patients 8 to <15 years of age will participate in an Algorithm Assessment Phase
      of approximately 10 nights of active system use each (for a nominal total of 100 nights of
      use) to determine if any adjustments to the algorithm parameters are needed and if it is safe
      to advance to a randomized clinical trial phase with these subjects. If adjustments are
      needed, the Algorithm Assessment Phase will be repeated, using the same 10 patients if
      possible. Once the randomized clinical trial phase begins for patients 8 to <15 years of age,
      approximately 200 nights of randomized system use will be collected and assessed for safety
      before any patients 3 to <8 years of age may be enrolled in the study. When enrollment does
      begin for patients 3 to <8 years of age, a second Algorithm Assessment Phase will be
      conducted with the first 10 patients in that younger age group using the same approach
      described above for the older subjects. Once the randomized clinical trial phase begins for
      patients 3 to <8 years of age, a final Data Safety Monitoring Board safety assessment will be
      performed after approximately the first 200 nights of randomized system use.

      Patients who enroll in the study after the completion of the Algorithm Assessment Phase for
      their age group will use the closed-loop system at home for at least 5 days to demonstrate
      their ability to use the system and submit study data to the Coordinating Center.

      Patients who successfully demonstrate their ability to use the system at home as described
      above will be eligible for the randomized trial phase. This phase consists of use of the full
      system as an outpatient for approximately 42 nights:

        -  Each night the blood glucose (BG) level will be checked with the BG meter and used to
           perform a calibration of the CGM. This calibration must occur no more than 90 minutes
           prior to activation of the system. NOTE: Subjects will be instructed to calibrate the
           CGM per manufacturer guidelines.

        -  Then the system will be activated, linking the CGM and insulin pump to the computer at
           the bedside.

        -  A randomization schedule on the laptop will be used to determine whether the 'pump shut
           off' application will be active that night or not.

        -  Patients will be blinded as to whether the pump shut off is active when a session is
           initiated each night.

        -  There will not be an alarm if the pump shuts off. The CGM alarm will be set to 60 mg/dL
           (3.3 mmol/L). When a CGM alarm occurs, the subject will be asked to measure the blood
           glucose with a BG meter, if he/she is aware of the alarm.

        -  Patients will be asked to check blood ketones with the study ketone meter if the subject
           has a fingerstick BG ≥250 mg/dL (13.9 mmol/L).

        -  Patients will be asked to check blood glucose with the study BG meter, blood ketones
           with the study ketone meter, and urine ketones with a ketone strip each morning prior to
           breakfast and enter the results using the controller software interface. The patient
           will be instructed to contact the study physician if the blood glucose or ketone
           readings are out of an expected range.

        -  Patients will be asked to record all overnight carbohydrate intake using the controller
           software interface.

        -  Patients will be asked to perform periodic CGM data uploads using the controller
           software interface.

      Upon completion of the study, patients as well as study clinicians will be asked to complete
      a human factors usability questionnaire regarding use of the study system.
    

Intervention name(s): Pump suspension algorithm
Intervention type(s): Device
Intervention description(s): The study laptop will communicate to the pump causing a suspension based on output from the algorithm which predicts hypoglycemia.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Prevention
Keywords: Type 1 Diabetes; Hypoglycemia; Continuous Glucose Monitoring; Pump Suspension