Blood Glucose Target Before and During Exercise in Adults With Type 1 Diabetes Using an Artificial Pancreas

Study Overview
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Brief Summary
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Despite major technological advances in type 1 diabetes (artificial pancreas), the management of hypoglycemia remains a major challenge, especially during and after physical activity. The primary outcome is to determine the temporary blood glucose (BG) target to be set 60 minutes before aerobic exercise in people with type 1 diabetes (PWT1D) using do-it-yourself automated insulin delivery (DIY-AID) systems. Three glycemic thresholds to be applied 60 minutes before physical activity will be tested in 32 people on AID-DIY: 8.3 (current target for commercial AID systems), 8.8, and 9.3 mmol/L. Each participant will perform 3 sessions of moderate aerobic physical activity (ergocycle) at 60% of vo2peak with a different glycemic target each time (random order). Plasma glucose will be measured every 20 minutes before and during physical activity, and blood glucose measured by continuous glucose reading (DEXCOM) for 24 hours post-intervention. Once the best glycemic target is selected, participants could come to the research center for 1 or 2 more voluntary interventions to test the threshold during 1) fasting exercise and 2) late luteal phase of the menstrual cycle.

Detailed Description
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This study follows a randomized, cross-over design and aims to test tree temporary BG targets (8.3, 8.8 and 9.3 mmol/L), resulting in 3 intervention visits per participants. A total of 32 participants will be recruited and randomized for this study. Intervention visit: Participants will be admitted at the research center (IRCM; Montréal or Alberta) at 15:30. A venous catheter will be installed for plasma glucose and insulin measurements. At 16:00, the temporary BG target will be set in the DIY-AID system and blood sampling will begin. At 16:40, if glucose is < 5.5 mmol/L, 16g carbohydrate (CHO; 4 Dex4®) will be provided. At 16:55, a smaller sample will be taken only to verify glucose level. If glucose is < 5.5 mmol/L, 16g CHO (4 Dex4®) will be provided and exercise start will be postponed by at least 15 minutes or until glucose level is > 5.5 mmol/L. If more than three CHO intake are needed, the test will be canceled and rescheduled. At 17:00, exercise will be started if glucose is > 5.5 mmol/L. The exercise will consist of 60 minutes on the ergocycle at 60% of pre-determined VO2peak (moderate intensity). At 18:00, exercise and temporary BG target will be stopped. Blood sampling will continue for 1-hr during recovery. At 19:00, participant will be discharged. If glucose level is below 5.0 mmol/L, a snack of 16g CHO (4 Dex4®) will be offered. Participants will have the option to bring their dinner and eat it at the research facility before leaving if they prefer.

Official Title
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Evaluating the Appropriate Blood Glucose Target Before and During Moderate Intensity Aerobic Exercise in Adults With Type 1 Diabetes Using Do-it-yourself Automated Insulin Delivery (AID) Systems (the GUARDIA [GlUcose tARget DIY-AID] Trial)

Conditions
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Type 1 Diabetes

Intervention / Treatment
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* Other: Physical activity trial intervention


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Males and females aged between 18 and 65 years old. Clinical diagnosis of type 1 diabetes for 1 year. (Note: The diagnosis of type 1 diabetes is based on the investigator's judgment; C peptide level and antibody determinations are not needed.) Treatment using DIY-AID system for 3 months. Own a smartphone or tablet to use the mobile application: Keenoa, Fitbit App Using Dexcom G6 and willing to share CGM data with the research team. Using rapid- (e.g., Aspart, Lispro or Glulisine) or ultra-rapid (e.g., FiAsp) acting insulin analogs. HbA1c < 8.5%. Exclusion Criteria: Major complication within the previous 3 months (e.g., severe hypoglycemia requiring assistance, diabetic ketoacidosis, or cardiovascular event). Restriction in PA due to significant diabetes complications (e.g., severe peripheral neuropathy, active proliferative retinopathy, etc.) or other type of limitations (e.g., orthopedic, severe arthritis, etc.). Uncontrolled hypertension (e.g., blood pressure > 150 mmHg systolic or > 95 mmHg diastolic). Ongoing pregnancy or breastfeeding. Inability to give consent.

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 65 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Prevention
Allocation: Randomized
Intervention Model: Crossover Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Temporary target of 8.3 mmol/L<br>Current commercial artificial pancreas thresholds. Temporary target set 60 minutes before the intervention. | Other: Physical activity trial intervention<br>* 60 minutes aerobic ergocyle exercice at 60% VO2 Peak<br>|
| Experimental: Temporary target of 8.8 mmol/L<br>Temporary target set 60 minutes before the intervention | Other: Physical activity trial intervention<br>* 60 minutes aerobic ergocyle exercice at 60% VO2 Peak<br>|
| Experimental: Temporary target of 9.3 mmol/L<br>Temporary target set 60 minutes before the intervention | Other: Physical activity trial intervention<br>* 60 minutes aerobic ergocyle exercice at 60% VO2 Peak<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in plasma glucose during exercise | To determine the temporary blood glucose (BG) target to be set 60 minutes before aerobic exercise in PWT1D using DIY-AID systems which will be associated with the smallest change in glucose during exercise by testing the targets of 8.3 (current target for commercial AID systems), 8.8, and 9.3 mmol/L. | 60 minutes (during exercice) | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Time in range during exercice: menstrual cycle phases | Volunteer participants will return in the luteal phase of the menstrual cycle to repeat the intervention at the glycemic threshold targeted during the primary outcome. | 60 minutes (during exercice) | 
| Time in range (during fasting exercice) | The intervention will be repeated at the glycemic threshold targeted during the primary outcome | 60 minutes (during exercice) | 
| Number of hypoglycemic episodes | number of hypoglycemic episodes (plasma glucose < 4.0 mmol/L) during exercise. | 60 minutes (during exercice) | 
| Number of participants who required oral treatment during exercise | Number of participants who required oral treatment during exercise for: a) plasma glucose value < 4.5 mmol/L and b) plasma glucose value < 4.0 mmol/L. | 60 minutes (during exercice) | 
| Lowest plasma glucose | Lowest plasma glucose level during exercise | 60 minutes (during exercice) | 
| Plasma glucose at 60 minutes | plasma glucose level at the end of exercise | 60 minutes | 
| Carbohydrate consumption (g) | amount of carbohydrate (CHO) needed to increase glucose value | 60 minutes (during exercice) | 
| Insulin on board (units) | Insulin on board or active insulin at exercise onset (Units will be collected on insulin pump) from start to finish | 60 minutes (during exercice) | 
| Plasma insulin | plasma insulin changes from exercise start to finish (uU/mL) | 60 minutes (during exercice) | 
| Percent time in range, in hypoglycemia and in hyperglycemia | Percentage of time < 3.0 mmol/L, between 3.0-3.9 mmol/L, between 3.9-10.0 mmol/L, between 10.1-13.9 mmol/L, and > 13.9 mmol/L post-exercice until 6 am | 6 hours post-exercice | 
| Percent time in range, in hypoglycemia and in hyperglycemia | Percentage of time < 3.0 mmol/L, between 3.0-3.9 mmol/L, between 3.9-10.0 mmol/L, between 10.1-13.9 mmol/L, and > 13.9 mmol/L post-exercice until 6 am | midnight to 6 am | 
| Mean CGM glucose | post-exercice until 6 am | 24 hours post-exercice | 
| Glucose variability | post-exercice until 6 am; assessed by the CGM standard deviation | midnight to 6 am | 
| Coefficient of variation | post-exercice until 6 am; assessed by the coefficient of variation | midnight to 6 am | 
| Coefficient of variation | post-exercice until 6 am; assessed by the coefficient of variation | 24 hours post-exercice | 
| Glucose variability | post-exercice until 6 am; assessed by the CGM standard deviation | 24 hours post-exercice | 
| Number of participants requiring an oral treatment for hypoglycemia | Number of participants requiring an oral treatment for hypoglycemia (< 3.9 mmol/L) until 6 am. | midnight to 6 am | 
| Number of participants requiring an oral treatment for hypoglycemia | Number of participants requiring an oral treatment for hypoglycemia (< 3.9 mmol/L) until 6 am. | 24 hours post-exercice | 
| Hypoglycemia with treatment | Total number of hypoglycemia episodes requiring treatment | 24 hours post-exercice | 
| Hypoglycemia with treatment | Total number of hypoglycemia episodes requiring treatment | midnight to 6 am | 
| Carbohydrate needed (g) | total amount of carbohydrate (CHO) needed to treat hypoglycemic events. | midnight to 6 am | 
| Carbohydrate needed (g) | total amount of carbohydrate (CHO) needed to treat hypoglycemic events. | 24 hours post-exercice | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Artificial pancreas, Exercice, Hypoglycemia