Adolescents: A challenging age group
Children with type 1 diabetes have to manage their condition through multiple stages of physical and emotional development. To accompany our Hot Topic Review, we talk to pediatric diabetes specialist Professor Moshe Phillip (Schneider Children's Medical Center of Israel and Sackler Faculty of Medicine, Tel-Aviv University, Israel) about why artificial pancreas systems may prove of particular benefit for children and adolescents.
Phillip is an enthusiastic advocate of artificial pancreas systems, being intimately involved in the development of the MD-Logic algorithm, which, when teamed with a continuous glucose monitoring sensor and an insulin pump, uses the principles of fuzzy logic theory to mimic the way diabetes patients treat themselves, with a basal–bolus insulin regimen.
“This is, to the best of my knowledge, the only algorithm right now that also injects boluses, so the entire idea behind our algorithm and our closed-loop system is that it is based on the same way that the pediatric patients, but also adult patients, are treating themselves, meaning the basal–bolus approach,” he says.
Phillip and his colleagues have focused their testing of this system on children and adolescents. “We took the most challenging age group to try and achieve the maximum benefit for the patients,” he says.
Data from the T1D Exchange Registry illustrate a close association between age and glycemic control, with patients’ glycated hemoglobin levels rising steeply from the age of about 10 years, peaking at more than 9% at around 19 years, and then falling steeply until the age of about 30 years, after which they plateau.
Phillip gives two reasons for this, the first being that children and adolescents often forget to inject preprandial insulin boluses, and to correct if they underdose. “Children do not like to be involved with their diabetes,” he says. “If they choose they would prefer that it go away, disappear – vanish if possible.”
And the second reason is that children’s blood glucose is often insufficiently controlled by parents, out of fear of hypoglycemia.
Both of these issues can be addressed by a genuine artificial pancreas system – one that can act to both increase and decrease insulin delivery according to the patient’s current blood glucose levels and can, when necessary, compensate for their dosing errors and omissions.
Phillip stresses that patients should still ideally administer insulin boluses before meals, because of the delay before insulin reaches peak plasma concentrations. Nevertheless, a system controlled by the MD-Logic algorithm will react to a missed bolus, “which is much better than without the artificial pancreas.”
A number of rapid- and ultra-rapid-acting insulins are now either approved or are undergoing testing, including in children, and may further enhance the performance of a system that can compensate for missed boluses.
Although his research has focused mostly on adolescents, Phillip also sees benefits for younger children. Pumps are simple to remove while children take part in vigorous or water-based activities, and the technology can allow parents to monitor their children’s blood glucose even if not actually physically present, allowing greater freedom for children.
A further benefit – and not just for pediatric and adolescent patients – is that the artificial pancreas, if accessible to all patients, is potentially a great leveler.
“I think diabetes is not fair,” says Phillip. “There is no justice in diabetes because it affects everyone – poor and rich, talented and less talented children, and they all have to cope with diabetes.”
As he notes, “if you are so talented and able and devoted and engaged, you don’t need any help from automatic systems.” Whereas patients who are less well educated, or simply less engaged, stand to make the greatest gains from a system that can take much of the day-to-day diabetes management out of their hands.
Of course, much of this is still far removed – the MiniMed 670G device approved by the FDA can adjust the user’s basal insulin delivery in response to falling and rising blood glucose levels, but the user must enter information about mealtime carbohydrates for the device to deliver an insulin bolus.
Nevertheless, the continual advances in technology, such as insulin pumps and continuous glucose monitoring devices, already offer improvements in glycemic control and quality of life for patients who can access them.
“So we will always use what is best at a certain moment for our patients, knowing that the future will improve,” says Phillip.
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