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Continuous and Intermittent Glucose Monitoring in 2020

2021; Mary Ann Liebert, Inc.; Volume: 23; Issue: S2 Linguagem: Inglês

10.1089/dia.2021.2502

1557-8593

Bruce W. Bode, Tadej Battelino, Klemen Dovč,

Diabetes and associated disorders

Diabetes Technology & TherapeuticsVol. 23, No. S2 Original ArticlesFree AccessContinuous and Intermittent Glucose Monitoring in 2020Bruce W. Bode, Tadej Battelino, and Klemen DovcBruce W. BodeAtlanta Diabetes Associates and Emory University School of Medicine, Atlanta, GASearch for more papers by this author, Tadej BattelinoUMC-University Children's Hospital Ljubljana, Ljubljana, SloveniaFaculty of Medicine, University of Ljubljana, Ljubljana, SloveniaSearch for more papers by this author, and Klemen DovcUMC-University Children's Hospital Ljubljana, Ljubljana, SloveniaFaculty of Medicine, University of Ljubljana, Ljubljana, SloveniaSearch for more papers by this authorPublished Online:31 May 2021https://doi.org/10.1089/dia.2021.2502AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail IntroductionOld and sage people say every terrible thing also brings something positive. And as wretched as this may sound, the SARS-CoV-2 pandemic with all its terrible consequences boosted the adoption and use of continuous and intermittent glucose monitoring (CGM) with the possibility of remote data access to an unimaginable extent: the CGM was recommended for the management of glycemia in the hospitals and intensive care units (1) and was successfully used at homes in most societies during the lockdown of cities, regions, and entire countries (2–4). The international digital/virtual clinic consensus endorsed during the Madrid 2020 ATTD congress (5), which intended to modestly start this important informatization process, became the roadmap overnight for many centers all over the world with routine digital/virtual diabetes clinics, serving as the predominant way of delivering diabetes care. This silver lining brings some consolation to diabetes teams faced with increased morbidity and mortality of people with diabetes related to COVID-19 (6).Meanwhile, additional evidence for CGM use and particularly for the CGM-derived glycemic metrics such as time in range (TIR), time below range (TBR), and time above range (TAR) accumulated and demonstrated its superior usability in everyday diabetes care (7–9). There are some indications that advanced technology could incrementally increase TIR (Fig. 1) (10).FIG. 1. FIG. 1. Average time in range achieved in recent randomized controlled trials with various technology. CGM, continuous glucose monitoring; PLGS, predicted low glucose suspend; CL, closed loop. Adapted from (10.This year, our article focuses on clinical trials that extend existing knowledge particularly related to incremental benefits of diabetes technology and open new questions and challenges in the routine use of CGM. Importantly, evidence supporting CGM-derived metrics as the primary outcome in clinical trials is discussed.Key Articles Reviewed for the ArticleContinuous glucose monitoring in people with type 1 diabetes on multiple-dose injection therapy: the relationship between glycemic control and hypoglycemiaOliver N, Gimenez M, Calhoun P, Cohen N, Moscardo V, Hermanns N, Freckmann G, Reddy M, Heinemann LDiabetes Care 2020;43: 53–58Use of factory-calibrated real-time continuous glucose monitoring improves time in target and HbA1c in a multiethnic cohort of adolescents and young adults with type 1 diabetes: the MILLENNIALS studyThabit H, Prabhu JN, Mubita W, Fullwood C, Azmi S, Urwin A, Doughty I, Leelarathna LDiabetes Care 2020;43: 2537–2543Effect of continuous glucose monitoring on glycemic control in adolescents and young adults with type 1 diabetes: a randomized clinical trialLaffel LM, Kanapka LG, Beck RW, Bergamo K, Clements MA, Criego A, DeSalvo DJ, Goland R, Hood K, Liljenquist D, Messer LH, Monzavi R, Mouse TJ, Prahalad P, Sherr J, Simmons JH, Wadwa RP, Weinstock RS, Willi SM, Miller KM for the CGM Intervention in Teens and Young Adults with T1D (CITY) Study GroupJAMA 2020;323: 2388–2396Sustained intensive treatment and long-term effects on HbA1c reduction (SILVER Study) by CGM in people with type 1 diabetes treated with MDILind M, Olafsdottir AF, Hirsch IB, Bolinder J, Dahlqvist S, Pivodic A, Hellman J, Wijkman M, Schwarcz E, Albrektsson H, Heise T\, Polonsky W\Diabetes Care 2021;44: 141–149The relationship between CGM derived metrics, A1C, and risk of hypoglycemia in older adults with type 1 diabetesToschi E, Slyne C, Sifre K, O'Donnell R, Greenberg J, Atakov-Castillo A, Carl S, Munshi MDiabetes Care 2020;43: 2349–2354Improved time in range over 1 year is associated with reduced albuminuria in individuals with sensor-augmented insulin pump–treated type 1 diabetesRanjan AG, Rosenlund SV, Hansen TV, Rossing P, Andersen S, Nørgaard KDiabetes Care 2020;43: 2882–2885Effect of flash glucose monitoring on glycemic control, hypoglycemia, diabetes-related distress, and resource utilization in the Association of British Clinical Diabetologists (ABCD) nationwide auditDeshmukh H, Wilmot EG, Gregory R, Barnes D, Narendran P, Saunders S, Furlong N, Kamaruddin S, Banatwalla R, Herring R, Kilvert A, Patmore J, Walton C, Ryder REJ, Sathyapalan TDiabetes Care 2020;43: 2153–2160Quality of life and glucose control after 1 year of nationwide reimbursement of intermittently scanned continuous glucose monitoring in adults living with type 1 diabetes (FUTURE): a prospective observational real-world cohort studyCharleer S, De Block C, Van Huffel L, Broos B, Fieuws S, Nobels F, Mathieu C, Gillard PDiabetes Care 2020;43: 389–397Real-time CGM is superior to flash glucose monitoring for glucose control in type 1 diabetes: the CORRIDA randomized control trialHaskova A, Radovnicka L, Petruzelkova L, Parkin CG, Grunberger G, Horova E, Navratilova V, Kade O, Matoulek M, Prazny M, Soupal JDiabetes Care 2020;43: 2744–2750Effects of continuous glucose monitoring on metrics of glycemic control in diabetes: a systematic review with meta-analysis of randomized controlled trialsMaiorino MI, Signoriello S, Maio A, Chiodini P, Bellastella G, Scappaticcio L, Longo M, Giugliano D, Esposito KDiabetes Care 2020;43: 1146–1156Comparison of the FreeStyle Libre Pro Flash continuous glucose monitoring (CGM) system and point-of-care capillary glucose testing in hospitalized patients with type 2 diabetes treated with basal-bolus insulin regimenGalindo RJ, Migdal AL, Davis GM, Urrutia MA, Albury B, Zambrano C, Vellanki P, Pasquel FJ, Fayfman M, Peng L, Umpierrez GEDiabetes Care 2020;43: 2730–2735Time in range is associated with carotid intima-media thickness in type 2 diabetesLu J, Ma X, Shen Y, Wu Q, Wang R, Zhang L, Mo Y, Lu W, Zhu W, Bao Y, Vigersky RA, Jia W, Zhou J, MDDiabetes Technol Ther 2020;22: 72–78Time in range in relation to all-cause and cardiovascular mortality in patients with type 2 diabetes: a prospective cohort studyLu J, Wang C, Shen Y, Chen L, Zhang L, Cai J, Lu W, Zhu W, Hu G, Xia T, Zhou JDiabetes Care 2021;44: 549–555Glucose management for exercise using continuous glucose monitoring (CGM) and intermittently scanned CGM (isCGM) systems in type 1 diabetes: position statement of the European Association for the Study of Diabetes (EASD) and of the International Society for Pediatric and Adolescent Diabetes (ISPAD) endorsed by JDRF and supported by the American Diabetes Association (ADA)Moser O, Riddell MC, Eckstein ML, Adolfsson A, Rabasa-Lhoret R, van den Boom L, Gillard P, Nørgaard K, Oliver NS, Zaharieva DP, Battelino T, de Beaufort C, Bergenstal RM, Buckingham B, Cengiz E, Deeb A, Heise T, Heller S, Kowalski AJ, Leelarathna L, Mathieu C, Stettler C, Tauschmann M, Thabit H, Wilmot EG, Sourij H, Smart CE, Jacobs PG, Bracken RM, Mader JKPediatr Diabetes 2020;21: 1375–1393Continuous glucose monitoring in people with type 1 diabetes on multiple-dose injection therapy: the relationship between glycemic control and hypoglycemiaOliver N1, Gimenez M2, Calhoun P3, Cohen N3, Moscardo V4, Hermanns N5,6, Freckmann G7, Reddy M1, Heinemann L81Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK; 2Diabetes Unit, Endocrinology and Nutrition, Institut d'Investigacions Biomèdiques August Pi i Sunyer, CIBERDEM, Hospital Clínic, Barcelona, Spain; 3Jaeb Center for Health Research, Tampa, FL; 4Instituto Universitario de Automática e Informática Industrial, Universitat Politècnica de València, Valencia, Spain; 5Research Institute of the Diabetes Academy Mergentheim, Bad Mergentheim, Germany; 6Department of Clinical Psychology and Psychotherapy, University of Bamberg, Bamberg, Germany; 7Institut für Diabetes-Technologie, Forschungsund Entwicklungsgesellschaft GmbH an der Universität Ulm, Ulm, Germany; 8Science Consulting in Diabetes GmbH, Neuss, GermanyDiabetes Care 2020;43: 53–58AimsReal-time continuous glucose monitoring (rtCGM) weakens the inverse relationship between overall glucose control and hypoglycemia risk. This study evaluates the correlation between glucose control and hypoglycemia in people with type 1 diabetes (T1D) using multiple-dose injection (MDI) regimens, including those at highest risk of hypoglycemia.MethodsThis study looked at data from the Multiple Daily Injections and Continuous Glucose Monitoring in Diabetes (DIAMOND) and HypoDE studies. CGM data from the intervention (rtCGM) and control (self-monitored blood glucose [SMBG]) phases were analyzed. The authors assessed the relationship between glucose control (HbA1c and mean rtCGM glucose levels) and percentage time spent in hypoglycemia for thresholds of 3.9 mmol/L (70 mg/dL) and 3.0 mmol/L (54 mg/dL), and they performed ANOVA across the range of HbA1c and mean glucose.ResultsThe authors identified a nonlinear relationship between mean glucose and hypoglycemia at baseline, with the steepest association at lower values of mean glucose. The use of rtCGM decreases the exposure to hypoglycemia at all thresholds and flattens the correlation between overall glucose and hypoglycemia, with the most marked impact at lower values of mean glucose and HbA1c. Across the range of overall glucose at baseline, exposure to hypoglycemia varied at all thresholds—in the SMBG group and with rtCGM—but the correlations were weaker in the rtCGM group.ConclusionsThe relationship between overall glucose control and hypoglycemia can be weakened with rtCGM, while rtCGM exerts its greatest impact at lower values of HbA1c and mean glucose in T1D patients using MDI regimens and at highest risk of hypoglycemia.CommentVery few publications so far credibly reverted the sacrosanct dogma of the Diabetes Control and Complication Trial (DCCT) related to higher hypoglycemia at lower HbA1c. This analysis of data from two randomized clinical trials clearly demonstrates that, with CGM usage, the rate of hypoglycemia at lower HbA1c or lower mean glucose does not increase. One cannot overemphasize the importance of this fact: hypoglycemia became an institutionalized reason for allowing higher HbA1c levels and ultimately for the recent increase in chronic complications of diabetes (11), and we desperately needed evidence to stop this dangerous leniency toward hyperglycemia. Despite the robustness of this analysis and its results, the message does not seem to be entering our daily practices: Is it too difficult for diabetes teams to alienate from the idle haven of hyperglycemia despite its devastating consequences? What evidence should clinical science generate to persuade clinicians that TIR really matters with TBR being largely sorted out?Use of factory-calibrated real-time continuous glucose monitoring improves time in target and HbA1c in a multiethnic cohort of adolescents and young adults with type 1 diabetes: the MILLENNIALS studyThabit H1,2, Prabhu JN1, Mubita W1, Fullwood C3, Azmi S1, Urwin A1, Doughty I4, Leelarathna L1,21Manchester Diabetes Centre, Manchester Royal Infirmary, Manchester, UK; 2Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; 3Research and Innovation, Manchester Royal Infirmary, Manchester, UK; 4Royal Manchester Children's Hospital, Manchester Royal Infirmary, Manchester, UKDiabetes Care 2020;43: 2537–2543AimsInternational T1D registries demonstrate that HbA1c levels are highest in young people with T1D. Because improving glycemic control in young people remains such a challenge, the authors of this study propose the use of the factory-calibrated Dexcom G6CGM system.MethodsThis is a randomized crossover trial including young people 16 to 24 years old with T1D. During two 8-week study periods, participants were randomly assigned to the interventions comparing the Dexcom G6 CGM system and self-monitoring of blood glucose (SMBG). During SMBG, each participant wore blinded CGM for 10 days at the start, week 4, and week 7 of the control period. HbA1c measurements were drawn after enrollment and before and after each treatment period. The primary outcome was time in range 70–180 mg/dL.ResultsTime in range was significantly higher during CGM compared with control (35.7±13.5% vs 24.6±9.3%; mean difference 11.1% [95% CI 7.0–15.2]; P<0.001). CGM use reduced mean sensor glucose (219.7±37.6 mg/dL vs 251.9±36.3 mg/dL; mean difference −32.2 mg/dL [95% CI −44.5 to −20.0]; P<0.001) and time above range (61.7±15.1% vs 73.6±10.4%; mean difference 11.9% [95% CI −16.4 to −7.4]; P<0.001). HbA1c level was reduced by 0.76% (95% CI −1.1 to −0.4) (28.5 mmol/mol [95% CI −12.4 to −4.6]; P<0.001). Times spent below range (<70 mg/dL and <54 mg/dL) were low and comparable during both study periods. During the CGM period, sensor wear was 84%.ConclusionsYoung people with T1D can obtain better time in target and HbA1c levels using CGM compared with SMBG.CommentThis small randomized controlled trial (RCT) of only 8-weeks' duration conveys a very important message from an environment traditionally opposed to innovations in diabetology: CGM works in the age group usually encountering most challenges with routine diabetes management—adolescents and young adults. Not only has the HbA1c decreased by 0.76% during this short time period, which is comparable to or better than several adult studies (12), the primary outcome TIR has improved for 11.1%, which is double the amount considered clinically meaningful (13). TBR was low and remained unchanged. This important data additionally communicate a nonapparent message, potentially the most important of them all: it does matter how we introduce CGM to this vulnerable population and how we instruct them on its usage. This has not been formally studied so far, yet the vast differences in RCT outcomes in adolescents and young adults clearly indicate this fact, with the bottom line that CGM can also work efficiently in this age group. One important question remains: how close to the recommended target can TIR increase in this population with the long-term use of CGM?Effect of continuous glucose monitoring on glycemic control in adolescents and young adults with type 1 diabetes: a randomized clinical trialLaffel LM1, Kanapka LG2, Beck RW2, Bergamo K3, Clements MA4, Criego A5, DeSalvo DJ6, Goland R7, Hood K8, Liljenquist D9, Messer LH10, Monzavi R11, Mouse TJ2, Prahalad P8, Sherr J12, Simmons JH13, Wadwa RP10, Weinstock RS14, Willi SM15, Miller KM2 for the CGM Intervention in Teens and Young Adults with T1D (CITY) Study Group1Joslin Diabetes Center, Harvard Medical School, Boston, MA; 2Jaeb Center for Health Research, Tampa, FL; 3University of North Carolina Diabetes Care Center, Chapel Hill, NC; 4Children's Mercy Hospital, Kansas City, MO; 5Health Partners Institute, International Diabetes Center, St Louis Park, MN; 6Baylor College of Medicine, Houston, TX; 7Naomi Berrie Diabetes Center, Columbia University, New York, NY; 8Stanford University, Palo Alto, CA; 9Rocky Mountain Diabetes & Osteoporosis Center, Idaho Falls, ID; 10Barbara Davis Center for Childhood Diabetes, Aurora, CO; 11Children's Hospital Los Angeles, Los Angeles, CA; 12Yale Children's Diabetes Program, New Haven, CT; 13Vanderbilt University Medical Center, Nashville, TN; 14SUNY Upstate Medical University, Syracuse, NY; 15Childrens Hospital of Philadelphia, Philadelphia, PAJAMA 2020;323: 2388–2396AimsAmong individuals with T1D, adolescents and young adults demonstrate the worst glycemic control across the lifespan. The aim of this study was to evaluate the effect of CGM on glycemic control in this particular cohort.MethodsFrom January 2018 to May 2019, this randomized clinical trial took place at 14 endocrinology practices in the United States. Participants included 153 T1D patients aged 14 to 24 years with screening hemoglobin A1c (HbA1c) between 7.5% and 10.9%. They were randomized 1:1 to undergo CGM (CGM group; n=74) or usual care using a blood glucose meter (blood glucose monitoring [BGM] group; n=79) for glucose monitoring. The primary outcome was change in HbA1c from baseline to 26 weeks. There were also 20 secondary outcomes, including additional HbA1c outcomes, CGM glucose metrics, and patient-reported outcomes with adjustment for multiple comparisons to control for the false discovery rate.ResultsA total of 142 (93%) out of 153 participants completed the study (mean [SD] age, 17 [3] years; 76 [50%] were female; mean [SD] diabetes duration, 9 [5] years). In the CGM group, 68% of participants used CGM at least 5 days per week in month 6, and mean HbA1c was 8.9% at baseline and 8.5% at 26 weeks. In the BGM group, mean HbA1c was 8.9% at both baseline and 26 weeks (adjusted between-group difference, −0.37% [95%CI, −0.66% to −0.08%]; P=0.01). In a per-protocol analysis, the 26-week adjusted between-group difference for the CGM versus BGM group was −0.69% (95% CI, −1.01% to −0.36%; P<0.001). The mean percentage of time in target glucose range of 70 to 180 mg/dL was 37% (9.0 h/d) at baseline and 43% (10.3 h/d) during follow-up in the CGM group and 36% (8.7 h/d) at baseline and 35% (8.3 h/d) during follow-up in the BGM group (adjusted between-group difference, 6.9% [1.7 h/d] [95% CI, 3.1%–10.7%]; P<0.001). Mean time in hypoglycemia (glucose 5 days per week near the end of the trial. Yet, the TAR (180) remained at 54±18% at the end of the trial; with the accumulating evidence of acute (14) and chronic (15) glucose toxicity to the brain, these results emphasize the dismay most pediatric diabetologists feel when confronted with such outcomes. There are considerable regional differences in metabolic control of adolescents and young adults with T1D: a recent survey of the SWEET centers (16) included data of 35,483 pediatric individuals with T1D from 53 centers around the globe and clearly demonstrated that lower glycemic targets associate with better metabolic outcomes. The pediatric members of the American Diabetes Association (ADA) recently reviewed the history of glycemic target setting by the ADA for pediatric populations (17); however, a strong commitment toward considerably more stringent glycemic targets remains elusive. Perhaps early involvement of adolescents in the process of decision-making related to the CGM initiation and use can augment the long-term success in this vulnerable age group (18).Sustained intensive treatment and long-term effects on HbA1c reduction (SILVER Study) by CGM in people with type 1 diabetes treated with MDILind M1,2, Olafsdottir AF1,2, Hirsch IB3, Bolinder J4, Dahlqvist S1, Pivodic A5,6, Hellman J7, Wijkman M8, Schwarcz E9, Albrektsson H5, Heise T10, Polonsky W11,121Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden; 2Department of Medicine, NU-Hospital Group, Uddevalla, Sweden; 3University of Washington School of Medicine, Seattle, WA; 4Department of Medicine, Karolinska University Hospital Huddinge, Karolinska Institutet, Stockholm, Sweden; 5Statistiska Konsultgruppen, Gothenburg, Sweden; 6Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; 7Department of Medical Sciences, Uppsala University, Uppsala, Sweden; 8Department of Internal Medicine and Department of Health, Medicine and Caring Sciences, Linkoping University, Norrkoping, Sweden; 9Department of Internal Medicine, Faculty of Medicine and Health, Orebro University, Orebro, Sweden; 10Profil, Neuss, Germany; 11Department of Medicine, University of California, San Diego, La Jolla, CA; 12Behavioral Diabetes Institute, San Diego, CADiabetes Care 2021;44: 141–149AimsWhen evaluated over shorter timeframes, CGM decreases HbA1c and time spent in hypoglycemia in people with T1D treated with MDIs. However, it is not clear yet to what extent CGM improves and helps maintain glucose control, treatment satisfaction, diabetes distress, hypoglycemic concerns, and overall well-being over longer periods of time.MethodsA randomized crossover trial called the GOLD trial took place over a span of 16 months and consisted of CGM treatment for people with T1D treated with MDI. Participants who completed the GOLD trial (n=141) were asked to participate in the SILVER extension study, where 107 patients continued CGM treatment over 1 year and incorporated the support of a diabetes nurse every 3 months.ResultsThe primary endpoint of the change in HbA1c over 1.0–1.5 years of CGM use compared with previous self-monitoring of blood glucose during GOLD showed a decrease in HbA1c of 0.35% (95% CI 0.19–0.50, P<0.001). Time spent in hypoglycemia <3.0 mmol/L (54 mg/dL) and <4.0 mmol/L (72 mg/dL) decreased from 2.1% to 0.6% (P<0.001) and from 5.4% to 2.9% (P<0.001), respectively. Overall well-being (World Health Organization 5-item well-being index, P=0.009), treatment satisfaction (Diabetes Treatment Satisfaction Questionnaire, P<0.001), and hypoglycemic confidence (P<0.001) increased, while hypoglycemic fear (Hypoglycemia Fear Survey–Worry, P=0.016) decreased and diabetes distress tended to decrease (Problem Areas in Diabetes Scale, P=0.06). From randomization and screening in GOLD, HbA1c was lowered by 0.45% (P<0.001) and 0.68% (P<0.001) after 2.3 and 2.5 years, respectively.ConclusionsIn patients with T1D managed by MDI, the SILVER study supports beneficial long-term effects from CGM on HbA1c, hypoglycemia, treatment satisfaction, well-being, and hypoglycemic confidence.CommentThe GOLD-4 trial (19) calculations demonstrated that time spent in hypoglycemia <3.9 mmol/L (70 mg/dL) and <3.0 mmol/L (54 mg/dL) increased significantly with lower mean glucose levels or HbA1c during both CGM and SMBG use in individuals on MDI therapy. Individuals with HbA1c of 7.0% (52 mmol/mol) TBR <3.9 mmol/L (70 mg/dL) were 5.4% at the end of CGM use compared with 9.2% with SMBG therapy. TBR at glucose values <3.0 mmol/L (54 mg/dL) were 1.5% and 3.5% for CGM and SMBG, respectively. Similarly, TBR (both <3.9 mmol/L [70 mg/dL] and <3.0 mmol/L [54 mg/dL]) increased with more TIR. With a TIR of 60%, the mean TBR <3.9 mmol/L (70 mg/dL) was 4.2%, and TBR <3.0 mmol/L (54 mg/dL) was 1.1% during CGM, compared to 7.7% and 2.8%, respectively, during SMBG. This data differ from a similar European analysis of the CGM effect on hypoglycemia at different HbA1c levels, where TBR 65 years) with T1D wore a CGM device in this single-center study. The CV (%) and GMI were determined, and A1c and clinical and demographic information were gathered.ResultsThe authors assessed 130 older adults (age 71±5 years), of whom 55% were women and 97% were white, diabetes duration was 39±17 years, and A1c was 7.3±0.6% (56±15 mmol/mol). They were stratified by high CV (>36%; n=77) and low CV (<36%; n=53). There was no difference in A1c levels between the groups with high and low CV (7.3% [56 mmol/mol] vs 7.3% [53 mmol/mol], P=0.4), but the high CV group spent more time in hypoglycemia (<70 mg/dL and <54 mg/dL) compared with the low CV group (median 31 vs 84 min/day, P<0.0001; 8 vs 46 min/day, P 0.5% was observed. Also, a higher duration of hypoglycemia was observed (P=0.02) when the A1c was higher than the GMI by >0.5%.ConclusionsThe use of CGM-derived CV and GMI can better identify those at higher risk for hypoglycemia compared with A1c alone. In older adults with T1D, these measures should be combined with A1c for better diabetes management.CommentThis well-designed study confirms the strong correlation between glucose variability (CV) and the time below range in a prospective setting with a population older than 65 years. Already calculated from available RCT data for the international consensus on TIR targets (13) where experts decided to simplify the targets by omitting CV from the main focus as it is well-represented by TBR, glucose variability remains to be a concern. Two other independent studies confirmed the very strong correlation between CV and TBR: in the first, receiver operating characteristic (ROC) curve analysis demonstrated that CV of 34 had the strongest correlation with TBR targets (21); in the second, CV of 34 closely corresponded to TBR (70) of 4% (22), the proposed upper limit in the consensus. As diabetes teams now routinely discuss the CGM-derived glucose metrics with individuals with diabetes, straightforwardness matters. The intuitive intelligibility of the TIR and TBR concept with its “more green–less red” mantra that can be followed prospectively throughout the days, weeks, months, and years with diabetes seems to more acceptable to individuals with diabetes than the retrospective A1c. Toschi and coauthors propose CGM-derived metrics to be used as an adjunct to the HbA1c; we believe CGM-derived metrics simply are a better management tool (7). Reducing glucose variability of course remains an important therapeutic target (23): as now suggested by several independent analyses, by reaching the TIR and TBR targets the CV goes below the current target of 36. And by consistently reducing day-to-day glucose variability, hopefully long-term stability of glycemia is also achieved (24).Improved time in range over 1 year is associated with reduced albuminuria in individuals with sensor-augmented insulin pump–treated type 1 diabetesRanjan AG1,2, Rosenlund SV1, Hansen TV1, Rossing P1,3, Andersen S1, Nørgaard K11Steno Diabetes Center Copenhagen, Gentofte, Denmark; 2Danish Diabetes Academy, Odense, Denmark; 3Department of Clinical Medicine, University of Copenhagen, Copenhagen, DenmarkDiabetes Care 2020;43: 2882–2885AimsThis study aimed to evaluate the correlation among treatment-induced change in CGM time in range (TIR) and albuminuria in T1D patients treated with sensor-augmented insulin pumps (SAP).MethodsIn total, 26 out of 55 patients with albuminuria and multiple daily injection therapy (25% females; median 51 [interquartile range 46–63] years of age; glycated hemoglobin A1c (HbA1c) 75 [68–88] mmol/mol [9.0% (8.4–10.4%)]; and urinary albumin-to-creatinine ratio [UACR] 89 [37–250] mg/g) participated in a randomized controlled trial of SAP therapy for 1 year. Every 3 months, anthropometrics, CGM data, and blood and urine samples were gathered.ResultsMean change (95% CI) in percentage of TIR (%TIR) was 13.2% (6.2; 20.2), in HbA1c was −14.4 (−17.4; −10.5) mmol/mol (−1.3% [−1.6; − 1.0]), and i