Remote monitoring and treatment of children and adolescents with type 1 diabetes

RATIONALE: Continuous subcutaneous insulin infusion (CSII) is an effective method for optimizing glycemic control in children with type 1 diabetes mellitus (DM1). However, the use of CSII does not always result in adequate glycemic control. Telehealth can be applied as one of the methods to improve the effectiveness of treatment.

AIMS: To evaluate the use of remote medical support of children and adolescents with DM1 and its influence on glycemic control, quality of life, and incidence of acute complications of DM1.

MATERIALS AND METHODS: We conducted a 24-week multi-institutional prospective open-label controlled clinical trial. 180 children and adolescents were included in this study and divided into the following categories: 1) age 8–18 years; 2) DM1 at least 1 year; 3) pump insulin therapy Medtronic Paradigm (Medtronic MiniMed, USA) at least 6 months; 4) self-monitoring of glycemia at least 4 times a day and replacement of the insulin pump infusion system at least once every 3 days; 5) inadequate glycemic control of DM1: the level of glycated hemoglobin (HbA_1c) 7.5% or higher. Patients were assigned to a remote consultation group (RC; n=100) or a traditional control group (TC; n=80). All patients were trained on the basic principles of DM1 and CSII, and we measured initial HbA_1c, then after 12 and 24 weeks, also registered and analyzed glycemic indicators and daily doses of insulin, evaluated and corrected the treatment. Patients or their parents in the RC group sent pump data via the Internet to the pump insulin therapy center at least once every 2 weeks at home and received treatment recommendations in response.

RESULTS: The total number of patients included in the study in all institutions was 180 children at 8–18 years. Patients in both groups did not differ in age, gender, duration of DM1 and CSII, and HbA_1c level. The total amount of remote consultations for all institutions was 949. The decrease in the level of HbA_1c by the end of the study against the initial one was statistically significantly greater in the RC group: 1.17% compared to 0.59% in the TC group (p<0.05). The proportion of patients who reached the target level of HbA_1c (<7.5%) was significantly higher in the RC group (32%) compared to the TC group (12.5%, p<0.05). During the study, the incidence of DKA and severe hypoglycemia in the RC group was statistically significantly lower.

CONCLUSIONS: Remote monitoring in children with DM1 resulted in significant improvements in glycemic control (HbA_1c, glycemic variability, and hypoglycemic frequency). The accumulation of evidence on the effectiveness and safety of telehealth in DM should contribute to implementing this approach in practical health care.

1. Dedov II, Peterkova VA, Kuraeva TL, et al. Pompovaya insulinoterapiya sakharnogo diabeta u detei i podrostkov. Rossiiskii konsensus detskikh endokrinologov. Problemy endokrinologii. 2012;58(2-2):2−18. (In Russ.).

2. Dedov II, Peterkova VA, Kuraeva TL, Laptev DN. Insulinovaya pompa (pomoshch’ vrachu i patsientu dlya effektivnogo upravleniya diabetom). Moscow; 2014. 128 р. (In Russ.).

3. Emel’yanov AO, Kuraeva TL, Laptev DN, Peterkova VA. Prospective study of efficacy and safety of insulin pump therapy in children and adolescents. Diabetes mellitus. 2010;(3):143−146. (In Russ.). doi: 10.14341/2072-0351-5503.

4. Laptev DN. The advantages of insulin pump therapy and real time glucose monitoring systems as the tools for reducing the frequency of hypoglycemic episodes in the children and adolescents with type 1 diabetes mellitus. Problemy endokrinologii. 2014;60(2):24−30. (In Russ.). doi: 10.14341/probl201460224-30.

5. Laptev DN, Philippov YI, Emel’yanov AO, Kuraeva TL. Age-adjustment of insulin pump settings in children and adolescents with type 1 diabetes mellitus. Diabetes mellitus. 2013;(3):109−115. (In Russ.). doi: 10.14341/2072-0351-98.

6. Peterkova VA, Kuraeva TL, Emel’yanov AO, et al. Pompovaya insulinoterapiya sakharnogo diabeta u detei i podrostkov (metodicheskoe posobie dlya pediatrovendokrinologov). Moscow; 2011 – 48 p. (In Russ.).

7. Shestakova MV, Mayorov AY, Philippov YI, et al. Russian national guidelines on insulin pump therapy and continuous glucose monitoring for diabetes mellitus patients. Draft. Problemy endokrinologii. 2015;61(6):55−78. (In Russ.). doi: 10.14341/probl201561655-78.

8. Dedov II, Shestakova MV, Peterkova VA, et al. Diabetes mellitus in children and adolescents according to the federal diabetes registry in the Russian Federation: dynamics of major epidemiological characteristics for 2013−2016. Diabetes mellitus. 2017;20(6):392−402. (In Russ.). doi: 10.14341/DM9460.

9. Izquierdo R, Morin PC, Bratt K, et al. School-Centered telemedicine for children with Type 1 diabetes mellitus. J Pediatr. 2009;155(3):374−379. doi: 10.1016/j.jpeds.2009.03.014.

10. Nathan DM; DCCT/EDIC Research Group. The diabetes control and complications trial/epidemiology of diabetes interventions and complications study at 30 years: overview. Diabetes Care. 2014;37(1):9−16. doi: 10.2337/dc13-2112.

11. Carroll AE, DiMeglio LA, Stein S, Marrero DG. Contracting and monitoring relationships for adolescents with Type 1 diabetes: a pilot study. Diabetes Technol Ther. 2011;13(5):543−549. doi: 10.1089/dia.2010.0181.

12. Heidgerken AD, Adkins J, Storch EA, et al. Telehealth intervention for adolescents with type 1 diabetes. J Pediatr. 2006;148(5):707−708. doi: 10.1016/j.jpeds.2006.01.001.

13. Hirsch IB. Glycemic variability and diabetes complications: does it matter? Of course it does! Diabetes Care. 2015;38(8):1610−1614. doi: 10.2337/dc14-2898.

14. Peña NV, Torres M, Cardona JA, Iniesta R. Impact of telemedicine assessment on glycemic variability in children with Type 1 diabetes mellitus. Diabetes Technol Ther. 2013;15(2):136−142. doi: 10.1089/dia.2012.0243.

15. Farrell K, Holmes-Walker DJ. Mobile phone support is associated with reduced ketoacidosis in young adults. Diabet Med. 2011;28(8):1001−1004. doi: 10.1111/j.1464-5491.2011.03302.x.