Advanced hybrid artificial pancreas system improves on unannounced meal response - In silico comparison to currently available system.

BACKGROUND AND OBJECTIVE: Glycemic control, especially meal-related disturbance rejection, has proven to be a major challenge for people with type 1 diabetes. In this manuscript, we introduce a novel, personalized, advanced hybrid insulin infusion system (a.k.a. artificial pancreas) based on the Model Predictive Control (MPC) methodology to adjust insulin infusion while automatically rejecting uninformed meals. METHODS: The proposed advanced hybrid closed-loop system relies on the integration of three key elements: (i) an adaptive personalized MPC control law that modulates the control strength depending on recent past control actions, glucose measurements, and its derivative, (ii) an automatic Bolus Priming System (BPS) that commands additional insulin injections safely upon the detection of enabling metabolic conditions (e.g., an unacknowledged meal), and (iii) a new hyperglycemia mitigation system to avoid prevailing hyperglycemia. The benefits of the proposed system are demonstrated through simulations and tests using the most up-to-date Type 1 UVA/Padova simulator as preclinical stage prior to in vivo clinical tests. We used a legacy algorithm (USS Virginia), currently used in clinical care, as a benchmark controller. RESULTS: Overall, the proposed control strategy enhanced by an automatic BPS improves glycemic control when compared with an available system. When a large meal is not announced (80g CHO), the proposed controller outperformed the legacy controller in time-in-target-range TIR (postprandial and overnight) and time-in-tight-range TTR (overall, postprandial, and overnight). CONCLUSION: The integration of a novel BPS into an advanced control system allowed to automatically reject unannounced meals. Exhaustive simulation studies indicated the safety and feasibility of the proposed controller to be deployed in human clinical trials.

Continuous Glucose Monitoring and Insulin Informed Advisory System with Automated Titration and Dosing of Insulin Reduces Glucose Variability in Type 1 Diabetes Mellitus.

BACKGROUND: Glucose variability (GV) remains a key limiting factor in the success of diabetes management. While new technologies, for example, accurate continuous glucose monitoring (CGM) and connected insulin delivery devices, are now available, current treatment standards fail to leverage the wealth of information generated. Expert systems, from automated insulin delivery to advisory systems, are a key missing element to richer, more personalized, glucose management in diabetes. METHODS: Twenty four subjects with type 1 diabetes mellitus (T1DM), 15 women, 37 ± 11 years of age, hemoglobin A1c 7.2% ± 1%, total daily insulin (TDI) 46.7 ± 22.3 U, using either an insulin pump or multiple daily injections with carbohydrate counting, completed two randomized crossover 48-h visits at the University of Virginia, wearing Dexcom G4 CGM, and using either usual care or the UVA decision support system (DSS). DSS consisted of a combination of automated insulin titration, bolus calculation, and CHO treatment advice. During each admission, participants were exposed to a variety of meal sizes and contents and two 45-min bouts of exercise. GV and glucose control were assessed using CGM. RESULTS: The use of DSS significantly reduced GV (coefficient of variation: 0.36 ± 08. vs. 0.33 ± 0.06, P = 0.045) while maintaining glycemic control (average CGM: 155.2 ± 27.1 mg/dL vs. 155.2 ± 23.2 mg/dL), by reducing hypoglycemia exposure (%<70 mg/dL: 3.8% ± 4.6% vs. 1.8% ± 2%, P = 0.018), with nonsignificant trends toward reduction of significant hyperglycemia overnight (%>250 mg/dL: 5.3% ± 9.5% vs. 1.9% ± 4.6%) and at mealtime (11.3% ± 14.8% vs. 5.8% ± 9.1%). CONCLUSIONS: A CGM/insulin informed advisory system proved to be safe and feasible in a cohort of 24 T1DM subjects. Use of the system may result in reduced GV and improved protection against hypoglycemia.

The UVA/Padova Type 1 Diabetes Simulator Goes From Single Meal to Single Day.

BACKGROUND: A new version of the UVA/Padova Type 1 Diabetes (T1D) Simulator is presented which provides a more realistic testing scenario. The upgrades to the previous simulator, which was accepted by the Food and Drug Administration in 2013, are described. METHOD: Intraday variability of insulin sensitivity (SI) has been modeled, based on clinical T1D data, accounting for both intra- and intersubject variability of daily SI. Thus, time-varying distributions of both subject's basal insulin infusion and insulin-to-carbohydrate ratio were calculated and made available to the user. A model of "dawn" phenomenon based on clinical T1D data has been also included. Moreover, the model of subcutaneous insulin delivery has been updated with a recently developed model of commercially available fast-acting insulin analogs. Models of both intradermal and inhaled insulin pharmacokinetics have been included. Finally, new models of error affecting continuous glucose monitoring and self-monitoring of blood glucose devices have been added. RESULTS: One hundred in silico adults, adolescent, and children have been generated according to the above modifications. The new simulator reproduces the intraday glucose variability observed in clinical data, also describing the nocturnal glucose increase, and the simulated insulin profiles reflect real life data. CONCLUSIONS: The new modifications introduced in the T1D simulator allow to extend its domain of validity from "single-meal" to "single-day" scenarios, thus enabling a more realistic framework for in silico testing of advanced diabetes technologies including glucose sensors, new insulin molecules and artificial pancreas.

Twelve-Week 24/7 Ambulatory Artificial Pancreas With Weekly Adaptation of Insulin Delivery Settings: Effect on Hemoglobin A1c and Hypoglycemia.

OBJECTIVE: Artificial pancreas (AP) systems are best positioned for optimal treatment of type 1 diabetes (T1D) and are currently being tested in outpatient clinical trials. Our consortium developed and tested a novel adaptive AP in an outpatient, single-arm, uncontrolled multicenter clinical trial lasting 12 weeks. RESEARCH DESIGN AND METHODS: Thirty adults with T1D completed a continuous glucose monitor (CGM)-augmented 1-week sensor-augmented pump (SAP) period. After the AP was started, basal insulin delivery settings used by the AP for initialization were adapted weekly, and carbohydrate ratios were adapted every 4 weeks by an algorithm running on a cloud-based server, with automatic data upload from devices. Adaptations were reviewed by expert study clinicians and patients. The primary end point was change in hemoglobin A1c (HbA1c). Outcomes are reported adhering to consensus recommendations on reporting of AP trials. RESULTS: Twenty-nine patients completed the trial. HbA1c, 7.0 ± 0.8% at the start of AP use, improved to 6.7 ± 0.6% after 12 weeks (-0.3, 95% CI -0.5 to -0.2, P < 0.001). Compared with the SAP run-in, CGM time spent in the hypoglycemic range improved during the day from 5.0 to 1.9% (-3.1, 95% CI -4.1 to -2.1, P < 0.001) and overnight from 4.1 to 1.1% (-3.1, 95% CI -4.2 to -1.9, P < 0.001). Whereas carbohydrate ratios were adapted to a larger extent initially with minimal changes thereafter, basal insulin was adapted throughout. Approximately 10% of adaptation recommendations were manually overridden. There were no protocol-related serious adverse events. CONCLUSIONS: Use of our novel adaptive AP yielded significant reductions in HbA1c and hypoglycemia.

Adjustment of Open-Loop Settings to Improve Closed-Loop Results in Type 1 Diabetes: A Multicenter Randomized Trial.

CONTEXT: Closed-loop control (CLC) relies on an individual's open-loop insulin pump settings to initialize the system. Optimizing open-loop settings before using CLC usually requires significant time and effort. OBJECTIVE: The objective was to investigate the effects of a one-time algorithmic adjustment of basal rate and insulin to carbohydrate ratio open-loop settings on the performance of CLC. DESIGN: This study reports a multicenter, outpatient, randomized, crossover clinical trial. PATIENTS: Thirty-seven adults with type 1 diabetes were enrolled at three clinical sites. INTERVENTIONS: Each subject's insulin pump settings were subject to a one-time algorithmic adjustment based on 1 week of open-loop (i.e., home care) data collection. Subjects then underwent two 27-hour periods of CLC in random order with either unchanged (control) or algorithmic adjusted basal rate and carbohydrate ratio settings (adjusted) used to initialize the zone-model predictive control artificial pancreas controller. Subject's followed their usual meal-plan and had an unannounced exercise session. MAIN OUTCOMES AND MEASURES: Time in the glucose range was 80-140 mg/dL, compared between both arms. RESULTS: Thirty-two subjects completed the protocol. Median time in CLC was 25.3 hours. The median time in the 80-140 mg/dl range was similar in both groups (39.7% control, 44.2% adjusted). Subjects in both arms of CLC showed minimal time spent less than 70 mg/dl (median 1.34% and 1.37%, respectively). There were no significant differences more than 140 mg/dL. CONCLUSIONS: A one-time algorithmic adjustment of open-loop settings did not alter glucose control in a relatively short duration outpatient closed-loop study. The CLC system proved very robust and adaptable, with minimal (<2%) time spent in the hypoglycemic range in either arm.

Pharmacokinetic Model of the Transport of Fast-Acting Insulin From the Subcutaneous and Intradermal Spaces to Blood.

Pharmacokinetic (PK) models describing the transport of insulin from the injection site to blood assist clinical decision making and are part of in silico platforms for developing and testing of insulin delivery strategies for treatment of patients with diabetes. The ability of these models to accurately describe all facets of the in vivo insulin transport is therefore critical for their application. Here, we propose a new model of fast-acting insulin analogs transport from the subcutaneous and intradermal spaces to blood that can accommodate clinically observed biphasic appearance and delayed clearance of injected insulin, 2 phenomena that are not captured by existing PK models. To develop the model we compare 9 insulin transport PK models which describe hypothetical insulin delivery pathways potentially capable of approximating biphasic appearance of exogenous insulin. The models are tested with respect to their ability to describe clinical data from 10 healthy volunteers which received 1 subcutaneous and 2 intradermal insulin injections on 3 different occasions. The optimal model, selected based on information and posterior identifiability criteria, assumes that insulin is delivered at the administrative site and is then transported to the bloodstream via 2 independent routes (1) diffusion-like process to the blood and (2) combination of diffusion-like processes followed by an additional compartment before entering the blood. This optimal model accounts for biphasic appearance and delayed clearance of exogenous insulin. It agrees better with the clinical data as compared to commonly used models and is expected to improve the in silico development and testing of insulin treatment strategies, including artificial pancreas systems.

The UVA/PADOVA Type 1 Diabetes Simulator: New Features.

Recent studies have provided new insights into nonlinearities of insulin action in the hypoglycemic range and into glucagon kinetics as it relates to response to hypoglycemia. Based on these data, we developed a new version of the UVA/PADOVA Type 1 Diabetes Simulator, which was submitted to FDA in 2013 (S2013). The model of glucose kinetics in hypoglycemia has been improved, implementing the notion that insulin-dependent utilization increases nonlinearly when glucose decreases below a certain threshold. In addition, glucagon kinetics and secretion and action models have been incorporated into the simulator: glucagon kinetics is a single compartment; glucagon secretion is controlled by plasma insulin, plasma glucose below a certain threshold, and glucose rate of change; and plasma glucagon stimulates with some delay endogenous glucose production. A refined statistical strategy for virtual patient generation has been adopted as well. Finally, new rules for determining insulin to carbs ratio (CR) and correction factor (CF) of the virtual patients have been implemented to better comply with clinical definitions. S2013 shows a better performance in describing hypoglycemic events. In addition, the new virtual subjects span well the real type 1 diabetes mellitus population as demonstrated by good agreement between real and simulated distribution of patient-specific parameters, such as CR and CF. S2013 provides a more reliable framework for in silico trials, for testing glucose sensors and insulin augmented pump prediction methods, and for closed-loop single/dual hormone controller design, testing, and validation.

Pharmacokinetics modeling of exogenous glucagon in type 1 diabetes mellitus patients.

BACKGROUND: Insulin-induced hypoglycemia is as a critical barrier in the treatment of type 1 diabetes mellitus patients and may lead to unconsciousness, brain damage, or even death. Clinically, glucagon is used as a rescue drug to treat severe hypoglycemic episodes. More recently, in a bihormonal closed-loop glucose control, glucagon has been used subcutaneously along with insulin for protection against hypoglycemia. In this context, small doses of glucagon are frequently administered. The efficacy and safety of such systems, however, require precise information on the pharmacokinetics of the glucagon transport from the administrative site to the circulation, which is currently lacking. The goal of this work is to address this need by developing and validating a mathematical model of exogenous glucagon transport to the plasma. MATERIALS AND METHODS: Eight pharmacokinetic models with various levels of complexity were fitted to nine clinical datasets. An optimal model was chosen in two consecutive steps. At Step 1, all models were screened for parameter identifiability (discarding the unidentifiable candidates). At Step 2, the remaining models are compared based on Bayesian information criterion. RESULTS: At Step 1, two models were removed for higher parameter fractional SDs. Another three were discarded for location of their optimal parameters on the parameter search boundaries. At Step 2, an optimal model was selected based on the Bayesian information criterion. It has a simple linear structure, assuming that glucagon is injected into one compartment, from where it enters a pool for a slower release into a third, plasma compartment. In the first and third compartments, glucagon is cleared at a rate proportional to its concentration. CONCLUSIONS: A linear kinetic model of glucagon intervention has been developed and validated. It is expected to provide guidance for glucagon delivery and the construction of preclinical simulation testing platforms.

Pancreas modelling by a deterministic optimisation method.

Diabetes mellitus is a disease characterised by abnormally high glucose concentration, insulin dysfunction and resistance which may lead to health problems such as cardiovascular disease. This paper presents a mechanistic pancreas model of insulin dynamics which incorporates experimental physiological data. This model will provide an efficient and accurate way to determine the specifics of a metabolic problem in the pancreas. We use Intravenous Glucose Tolerance Test (IVGTT) data from the literature to identify the model parameters by implementing a deterministic optimisation method called DIRECT (Dividing RECTangles). Different data sets are used for optimisation and validation.