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Time in Range (TIR) Data Shows the Potential for Diabetes Technology in Children, Adults, and Seniors – ATTD 2021

Last updated: 6/14/21
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By Frida Velcani, Julia Kenney, Natalie Sainz, and Eliza Skoler

The latest innovations in diabetes technology have brought Time in Range (TIR) to the forefront of diabetes care. Read to learn about the most exciting TIR news from one of the biggest international diabetes conferences of the year, with a special focus on automated insulin delivery systems for kids, adults, and seniors.

Time in Range (TIR) came into the spotlight at the 14th annual 2021 Advanced Technologies and Treatments in Diabetes (ATTD) virtual conference. At diaTribe, we believe that the use of TIR in diabetes care can improve the lives of people with diabetes by providing them with actionable, real-time health data. As more people get access to diabetes technology, new studies are showing just how much continuous glucose monitoring (CGM) and automated insulin delivery (AID) systems can support diabetes management across age groups.

Here are the main TIR highlights from this year’s ATTD conference; to read more news from ATTD, check out our day one highlights and our extended coverage. To learn more about time in range, click here.

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Omnipod 5 increases Time in Range and reduces highs and lows 

The Omnipod 5 system is the first tubeless, patch-based automated insulin delivery (AID) system, and the first with full smartphone control. The system includes Insulet’s disposable Omnipod insulin patch pump, Dexcom’s G6 CGM, and the Omnipod 5 algorithm (built into the patch pump). Dr. Bruce Buckingham presented data from 241 people with type 1 diabetes (ages six to 70 years) who used Omnipod 5 for three months. Results showed:

  • TIR was significantly higher when Omnipod 5 was used in auto mode, compared to manual mode. In children, this difference in TIR was 68% compared to 55%, and in adults, 74% compared to 65%.

  • Higher TIR was primarily due to less time in hyperglycemia (glucose levels above 180 mg/dl).

  • Children had a low rate of hypoglycemia before the study (glucose levels below 70 mg/dl), though this significantly decreased in the transition from manual to automated mode (1.7% vs. 1.2%, respectively).

  • In adults, automated mode significantly lowered time in hypoglycemia (below 70 mg/dl; 2.0% in manual mode compared to 0.9% in auto mode).

  • Automated insulin delivery had a pronounced positive effect on TIR at night.

MiniMed 670G in children under the age of seven

Dr. Thekla von dem Berge and her team tested the MiniMed 670G with the Guardian Sensor 3 CGM in a small clinical trial of children with type 1 diabetes. Currently, this is the only AID system covered by public insurance in Germany and is only approved for people ages seven and up. The study included 37 participants across two age groups: ages seven to 14 and ages two to six. 

After eight weeks, results showed that the system was safe in children below the age of seven. Among young participants (ages 2-6) who started using auto mode:

  • TIR improved significantly from 68% to 74%.

  • Average glucose values decreased from 151 mg/dl to 144 mg/dl.

Among participants in the older group (ages 7-14):

  • TIR increased significantly from 54% to 71%

  • Time spent in hyperglycemia (glucose levels above 180 mg/dl) fell significantly

  • Average glucose values decreased from 176 mg/dl to 155 mg/dl

This research could be the first step toward approving a closed-loop system for young people.

Three-month MiniMed 780G data in children

Dr. Andrea Scaramuzza presented a small study of 25 children, adolescents, and young adults who used MiniMed 780G over three months. At the start of the trial, 19 participants were using MiniMed 670G, four were on multiple daily injections of insulin (MDI), and two were insulin pump users.

Compared to using MiniMed 780G in manual mode, the hybrid closed-loop system,  significantly improved TIR by 11% (69% to 82%) and decreased time spent in hyperglycemia.

Upgrading children to Control-IQ at a virtual educational camp

Dr. Valentino Cherubini explored the impact of upgrading 43 children and adolescents with type 1 diabetes from Basal-IQ to Control-IQ automated insulin delivery through a virtual educational camp.

The clinical trial took place across 19 centers in Italy and recruited participants between the ages of six to 18 who had spent at least three months using the Basal-IQ predictive low glucose system. A three-day virtual educational camp was organized for children and their families and included sessions on aerobic exercise, nutrition, diabetes management, and emotions around diabetes, technology, and therapy. Twelve weeks after attending the virtual camp:

  • Median TIR was 76%.

  • TIR improved by 11% from baseline (data collected for 12 weeks before upgrading to Control-IQ at camp). Most of this improvement was due to a reduction in time spent in hyperglycemia (glucose levels above 180 mg/dl).

  • Average A1C went down by 0.5 percentage points.

  • More than 75% of participants reached and maintained a TIR goal above 70% for 12 weeks.

Dr. Marco Marigliano reviewed the early effects of switching to Control-IQ among participants in this trial. TIR significantly improved from 67% to 75% after the first week on Control-IQ, and it stayed steady for three weeks after. This showed that a significant increase in TIR is evident even after one week using the Control-IQ system.

Transition from Dexcom G5 to G6 improves TIR and reduces variability

Dr. Joost Van Der Linden presented data on the transition from Dexcom’s G5 CGM to the newer G6 (which has strong accuracy without fingerstick calibrations and a longer wear time). More than 31,000 individuals participated in the study; their glycemic outcomes were tracked pre-switch, post-switch, and after one and two years. The study found:

  • Most people continued to use G6 long after their transition: 90% of people still used the device after a year and 86% of people used it after two years.

  • TIR improved significantly – by almost an hour per day – from 57% at the start of the trial to 61% at two years. 

  • People saw a small but significant 12 minute per day reduction in time in hypoglycemia (glucose levels below 70 mg/dl), at two years. 

  • Time in hyperglycemia (glucose levels above 180 mg/dl) was reduced by 32 minutes per day by year two.

CGM for seniors with diabetes

Joslin Diabetes Center’s Dr. Elena Toschi presented on the benefits of CGM for treating seniors with diabetes who use multiple daily injections of insulin (MDI). Elderly people with diabetes are at an increased risk for hypoglycemia and related health complications. The use of CGM in this population has been shown to improve glycemic management and decrease levels of hypoglycemia. Overall, Dr. Toschi argued that in elderly people with diabetes on MDI, CGM can add valuable information to A1C to help “set individualized glycemic goals and personalize insulin regimens.”  

To learn more about diabetes management for seniors, read Dr. Medha Munshi’s “Dare to Disrupt Diabetes as You Age.”

TIR versus A1C in predicting pregnancy outcomes in type 1 diabetes

Dr. Claire Meek shared her team’s original analysis of the CONCEPTT trial, which showed the effectiveness of CGM use in pregnant women with type 1 diabetes. In the trial, CGM data and blood glucose values were collected at weeks 12, 24, and 34. Dr. Meek compared CGM and A1C results to assess which marker of diabetes management best predicted adverse outcomes during pregnancy.

  • Preterm birth:

    • CGM metrics (mean glucose, TIR, and time above range, TAR) predicted preterm birth as early as 12 weeks and remained significant at 24 weeks.

    • A1C was only significantly associated with preterm birth at 24 weeks.

  • Large for gestational age (LGA):

    • A1C, TIR, and TAR were predictive at 12 weeks and remained predictive throughout pregnancy.

    • CGM metrics (mean glucose, TIR, and TAR) were strongly correlated with LGA at 34 weeks.

  • Neonatal intensive care unit (NICU) admission:

    • CGM metrics (mean glucose, TIR, and TAR) and A1C were all predictive at 24 weeks.

  • Neonatal hypoglycemia:

    • CGM metrics (mean glucose, TIR, and TAR) and A1C were all predictive at 24 weeks.

Dr. Meek concluded that A1C and TIR both predict pregnancy outcomes at various time points. In particular, TIR predicted preterm birth, LGA, NICU admission, and neonatal hypoglycemia as early as 12 weeks. This holds massive potential for improving health outcomes for mother and child in the future.

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