Effect of a Hybrid Closed-Loop System on Glycemic and Psychosocial Outcomes in Children and Adolescents With Type 1 Diabetes
Authors: Mary B. Abraham, Martin de Bock, Grant J. Smith, Julie Dart, Janice M. Fairchild, Bruce R. King, Geoffrey R. Ambler, Fergus J. Cameron, Sybil A. McAuley, Anthony C. Keech, Alicia Jenkins, Elizabeth A. Davis, David N. O’Neal, Timothy W. Jones, Ace Choo, Jennifer Nicholas, Leah Laurenson, Alison Roberts, Keely Bebbingtom, Julie Klimek, Kristine Heels, Rebecca Gebert, Shaun Johnson, Stephanie Oats, Jordan Rafferty, Anthony Pease, Sophia Zoungas, Melissa H Lee, Barbora Paldus, Catriona M Sims, Richard J MacIssac, Glenn M Ward, Peter G Colman, Neale D Cohen, Leon Bach, Kavita Kumareswaran, Stephen N Stranks, Morton G Burt, Jane D Holmes-Walker, Roland W McCallum, Joey Kaye, Jane Speight, Christel Hendreickx, Andrzej Januszewski, Adreinne Kirby, Sara Vogrin
Journal: JAMA Pediatrics (2021)

<h3>Importance</h3> Hybrid closed-loop (HCL) therapy has improved glycemic control in children and adolescents with type 1 diabetes; however, the efficacy of HCL on glycemic and psychosocial outcomes has not yet been established in a long-term randomized clinical trial. <h3>Objective</h3> To determine the percentage of time spent in the target glucose range using HCL vs current conventional therapies of continuous subcutaneous insulin infusion or multiple daily insulin injections with or without continuous glucose monitoring (CGM). <h3>Design, Setting, and Participants</h3> This 6-month, multicenter, randomized clinical trial included 172 children and adolescents with type 1 diabetes; patients were recruited between April 18, 2017, and October 4, 2019, in Australia. Data were analyzed from July 25, 2020, to February 26, 2021. <h3>Interventions</h3> Eligible participants were randomly assigned to either the control group for conventional therapy (continuous subcutaneous insulin infusion or multiple daily insulin injections with or without CGM) or the intervention group for HCL therapy. <h3>Main Outcomes and Measures</h3> The primary outcome was the percentage of time in range (TIR) within a glucose range of 70 to 180 mg/dL, measured by 3-week masked CGM collected at the end of the study in both groups. Secondary outcomes included CGM metrics for hypoglycemia, hyperglycemia, and glycemic variability and psychosocial measures collected by validated questionnaires. <h3>Results</h3> A total of 135 patients (mean [SD] age, 15.3 [3.1] years; 76 girls [56%]) were included, with 68 randomized to the control group and 67 to the HCL group. Patients had a mean (SD) diabetes duration of 7.7 (4.3) years and mean hemoglobin A<sub>1c</sub>of 64 (11) mmol/mol, with 110 participants (81%) receiving continuous subcutaneous insulin infusion and 72 (53%) receiving CGM. In the intention-to-treat analyses, TIR increased from a mean (SD) of 53.1% (13.0%) at baseline to 62.5% (12.0%) at the end of the study in the HCL group and from 54.6% (12.5%) to 56.1% (12.2%) in the control group, with a mean adjusted difference between the 2 groups of 6.7% (95% CI, 2.7%-10.8%;<i>P</i> = .002). Hybrid closed-loop therapy also reduced the time that patients spent in a hypoglycemic (&lt;70 mg/dL) range (difference, −1.9%; 95% CI, −2.5% to −1.3%) and improved glycemic variability (coefficient of variation difference, −5.7%; 95% CI, −10.2% to −0.9%). Hybrid closed-loop therapy was associated with improved diabetes-specific quality of life (difference, 4.4 points; 95% CI, 0.4-8.4 points), with no change in diabetes distress. There were no episodes of severe hypoglycemia or diabetic ketoacidosis in either group. <h3>Conclusions and Relevance</h3> In this randomized clinical trial, 6 months of HCL therapy significantly improved glycemic control and quality of life compared with conventional therapy in children and adolescents with type 1 diabetes. <h3>Trial Registration</h3> ANZCTR identifier:ACTRN12616000753459