Type 1 diabetes mellitus (T1DM) is a chronic disease that usually manifests at a younger age and is associated with higher morbidity and mortality compared to the general population. The objective of this study was to assess the blood pressure response to exercise in patients with T1DM with varying durations of diabetes and with respect to the determinants of systolic blood pressure (SBP) and diastolic blood pressure (DBP) during the exercise stress test. This cross-sectional exploratory study included 52 patients (35 with T1DM aged < 35 years and 17 aged > 35 years) and 25 control subjects. All participants were untrained and underwent a cardiopulmonary exercise stress test using a cycle ergometer and their BP was measured manually. Compared to control subjects, both younger and older patients with T1DM had higher SBP and DBP at submaximal exercise load 0,5 W/kg (SBP 124 ± 18; 142 ± 17; 146 ± 19 mmHg, p = 0.0004, respectively, and DBP 75 ± 10; 84 ± 7; 82 ± 7 mmHg, p = 0.0015, respectively), and at peak exercise (SBP 170 ± 24; 188 ± 26; 192 ± 23 mmHg, p = 0.0006, respectively. BP during exercise in T1DM patients in multivariate model was influenced by resting SBP, and diabetes duration. Patients with T1DM exhibited impaired BP control during exercise, which may serve as an early marker of heightened cardiovascular risk.

Objective: This study was designed to investigate the switch between the open-source automated insulin delivery (OS-AID) system AndroidAPS (AAPS) and commercially available AID systems Control-IQ (CIQ) and MiniMed 780G (780G) conducted in a new extended follow-up study. Research Design and Methods: In this prospective open-label single-arm clinical trial, 41 adults with type 1 diabetes (age 35 ± 11 years, glycated hemoglobin [HbA1c] 6.4 ± 2.8% [46 ± 6.8 mmol/mol]) who have voluntarily used AAPS entered a total of three study phases. In the first phase, participants continued with AAPS for 3 months. In the second 3-month study phase, all participants initiated CIQ (n = 25) or 780G (n = 16). Finally, participants were switched back to the AAPS for the last 3 months phase. Results of the treatment with commercially available AID systems were compared with both AAPS phases. Results: Commercially available systems were comparable to AAPS in achieving time in range (TIR) (84.2 ± 7.6 vs. 85 ± 6.9%; P = 0.31) and in HbA1c (6.4 ± 3 vs. 6.3 ± 2.7% [46 ± 8.8 vs. 45.7 ± 6.2 mmol/mol]; P = 0.68). In contrast, time in tight range (TITR) was significantly higher in AAPS (66.38 ± 11.84 vs. 63.4 ± 11.77, P = 0.035). However, the time in hypoglycemia <70 mg/dL [<3.9 mmol/L] was significantly lower with commercially available AID systems (2.2 ± 1.2 vs. 3.8 ± 1.9%; P < 0.001). These results were consistent after switching back to AAPS. Conclusion: The extension of the Comparison of Different Hybrid Closed-Loop Systems-AndroidAPS and Control-IQ-in adults with Type 1 Diabetes study is the only prospective study to investigate switching between OS and commercially available AID systems. The switch from AAPS to commercially available systems was not associated with a change in TIR. However, the use of AAPS was associated with a higher TITR, but also with a higher risk of hypoglycemia.

ABSTRACT Aim To determine whether people with type 1 diabetes (T1D) initiating glucose sensor monitoring experience greater improvements in HbA1c when provided with education on carbohydrate counting and flexible insulin dosing than those who do not receive nutrition education. Materials and Methods Our retrospective observational study included 329 people with T1D initiating glucose sensor monitoring between 2015 and 2021. The participants were divided into two groups: one group attended at least one structured educational session with a registered dietitian (n = 126), while the other group did not receive structured education (n = 203). After 12 months of glucose sensor initiation, we compared glycaemic outcomes and CGM metrics between the two groups. Results At glucose sensor initiation, both groups with and without education had similar HbA1c levels (7.64% [60.0 mmol/mol] vs. 7.66% [60.2 mmol/mol]). After twelve months, the education group demonstrated greater improvement in glycemic outcomes (HbA1c 7.17% [54.9mmol/mol] vs. 7.37% [57.1 mmol/mol], p < 0.05) and spent significantly more time in the target range than did the group without structured education (68.8% vs. 64.1%, p < 0.05). We observed an inverse correlation between the number of completed educational sessions and HbA1c after 12 months, as well as between the number of educational sessions and the change in HbA1c. Conclusions People with T1D who initiated glucose sensor monitoring alongside nutrition education showed greater improvements in HbA1c and increased time spent in the target glucose range compared to individuals who did not receive structured education. Trail Registration ClinicalTrials.gov identifier: NCT06264271

Chronic kidney disease (CKD) affects approximately 13% of people globally, including 20%-48% with type 2 diabetes (T2D), resulting in significant morbidity, mortality, and healthcare costs. There is an urgent need to increase early screening and intervention for CKD. We are experts in diabetology and nephrology in Central Europe and Israel. Herein, we review evidence supporting the use of sodium-glucose cotransporter-2 (SGLT2) inhibitors for kidney protection and discuss barriers to early CKD diagnosis and treatment, including in our respective countries. SGLT2 inhibitors exert cardiorenal protective effects, demonstrated in the renal outcomes trials (EMPA-KIDNEY, DAPA-CKD, CREDENCE) of empagliflozin, dapagliflozin, and canagliflozin in patients with CKD. EMPA-KIDNEY demonstrated cardiorenal efficacy across the broadest renal range, regardless of T2D status. Renoprotective evidence also comes from large real-world studies. International guidelines recommend first-line SGLT2 inhibitors for patients with T2D and estimated glomerular filtration rate (eGFR) ≥20 mL/min/1.73 m2, and that glucagon-like peptide-1 receptor agonists may also be administered if required for additional glucose control. Although these guidelines recommend at least annual eGFR and urine albumin-to-creatinine ratio screening for patients with T2D, observational studies suggest that only half are screened. Diagnosis is hampered by asymptomatic early CKD and under-recognition among patients with T2D and clinicians, including limited knowledge/use of guidelines and resources. Based on our experience and on the literature, we recommend robust screening programmes, potentially with albuminuria self-testing, and SGLT2 inhibitor reimbursement at general practitioner (GP) and specialist levels. High-tech tools (artificial intelligence, smartphone apps, etc.) are providing exciting opportunities to identify high-risk individuals, self-screen, detect abnormalities in images, and assist with prescribing and treatment adherence. Better education is also needed, alongside provision of concise guidelines, enabling GPs to identify who would benefit from early initiation of renoprotective therapy; although, regardless of current renal function, cardiorenal protection is provided by SGLT2 inhibitor therapy.

V populaci diabetiků 2. typu je častěji než v běžné populaci diagnostikováno jak srdeční selhání, tak i chronické onemocnění ledvin (CKD). Screening CKD musí směřovat k časnému záchytu onemocnění s cílem zvrátit, nebo alespoň významně zpomalit jeho průběh a oddálit přechod do selhání ledvin s nutností chronické dialyzační anebo transplantační léčby. Finerenon je nesteroidní, selektivní antagonista mineralokortikoidního receptoru. Efekty finerenonu u nemocných s diabetem 2. typu byly zkoumány ve velkých registračních klinických studiích fáze III FIDELIO-DKD, FIGARO-DKD a následně v jejich sdružené analýze FIDELITY. Na základě výsledků publikovaných prospektivních randomizovaných kontrolovaných studií s finerenonem je jeho použití u pacientů s CKD a diabetem 2. typu zmíněno v několika recentních doporučeních. Zástupci expertního panelu zahrnujícího Českou nefrologickou společnost, Českou diabetologickou společnost ČLS JEP, Českou internistickou společnost ČLS JEP a Českou kardiologickou společnost v souladu s recentními mezinárodními doporučeními považují finerenon za jeden z pilířů léčby pacientů s chronickým onemocněním ledvin a diabetem 2. typu pro jeho nefroprotektivní a kardioprotektivní účinky.

Microvascular diabetes complications are linked to inadequate long-term diabetes control, as indicated by glycated haemoglobin (HbA1c) levels. Fluctuations in glucose levels are connected to oxidative stress, endothelial dysfunction, and inflammation, all of which are traditionally linked to the development of vascular damage. While some studies have linked glucose variability to macrovascular disease, its association with microvascular disease is still debated. The major question is whether short-term glucose variability should be regarded as an independent risk factor for microvascular complications in diabetes. This summary reviews research on glucose variability and its potential connections to diabetic retinopathy, nephropathy, and neuropathy. Current data indicate the need for further research into the parameters of both short-term and long-term glucose variability. These variability parameters may be important for selecting optimal treatment strategies and for estimating the risk of chronic diabetic complications.

Frequent scanning of FreeStyle Libre (FSL) flash glucose monitoring sensors is known to be important whilst wearing an active sensor, but adherence to sensor reapplication is also critical to effective glucose monitoring. We report novel measures of adherence for users of the FSL system and their association with improvements in metrics of glucose control. Anonymous data were extracted for 1600 FSL users in the Czech Republic with ≥ 36 completed sensors from October 22, 2018 to December 31, 2021. “Experience” was defined by the number of sensors used (1–36 sensors). “Adherence” was defined by time between the end of one sensor and the start of the next (gap time). User adherence was analyzed for four experience levels after initiating FLASH; Start (sensors 1–3); Early (sensors 4–6); Middle (sensors 19–21); End (sensors 34–36). Users were split into two adherence levels based on mean gap time during Start period, “low” (> 24 h, n = 723) and “high” (≤ 8 h, n = 877). Low-adherence users reduced their sensor gap times significantly: 38.5

The number of patients using open-source automated insulin delivery systems (OS-AID) is increasing. Although there is a lack of evidence, some people believe OS-AID provides better results than commercially available AID systems. We, therefore, compared an open-source AndroidAPS (AAPS) and commercially available Control-IQ (CIQ) in a prospective open-label single-arm clinical trial. Adults with T1D who had been using AAPS by their own decision were switched to the CIQ for 3 months. Results of this treatment were compared with those after 3-month phase on AAPS. The primary outcome was %TIR (70-180 mg/dL). Twenty-five patients participated in this study. CIQ was non-inferior to AAPS in achieving TIR (Figure). Similarly, there were no differences in %TAR (> 180 and > 250 mg/dL), in mean sensor glucose (130.3 ± 13.9 vs. 128.3 ± 16.9 mg/dL; p=0.21) and in A1C (6.3 ± 2.1% vs. 6.4 ± 3.1%; p=0.59). Importantly, %TBR (< 70 and < 54 mg/dL) were significantly lower when using CIQ than with AAPS. Even though participants were mostly satisfied with CIQ (63.6% mostly agree, 9.1% strongly agree) they do not plan to switch to CIQ. CIQ and AAPS were non-inferior in TIR. Hypoglycemia was significantly lower with CIQ. The CODIAC study is the first prospective study comparing OS-AID and commercially available AID system. These findings provide further guidance for clinicians and patients when discussing treatment options. Disclosure Q.Do: None. A.Hásková: None. L.Radovnická: None. J.Konecna: None. E.Horova: None. G.Grunberger: Advisory Panel; CeQur SA, Nevro Corp., LifeScan Diabetes Institute, Speaker's Bureau; Eli Lilly and Company, Novo Nordisk. C.Parkin: Consultant; Abbott Diabetes, Dexcom, Inc., CeQur SA, Tandem Diabetes Care, Inc., Roche Diabetes Care, Provention Bio, Inc., Lifecare, Inc., Insulet Corporation, Becton, Dickinson and Company. M.Prazny: Speaker's Bureau; Abbott, Boehringer Ingelheim Inc., AstraZeneca, Bayer Inc., Eli Lilly and Company, Merck Sharp & Dohme Corp., Novo Nordisk, Medtronic, Sanofi. J.Soupal: Speaker's Bureau; Dexcom, Inc. Funding Czech Ministry of Health (00064165); General University Hospital in Prague

AIM:To compare open-source AndroidAPS (AAPS) and commercially available Control-IQ (CIQ) automated insulin delivery (AID) systems in a prospective, open-label, single-arm clinical trial. METHODS:Adults with type 1 diabetes who had been using AAPS by their own decision entered the first 3-month AAPS phase then were switched to CIQ for 3 months. The results of this treatment were compared with those after the 3-month AAPS phase. The primary endpoint was the change in time in range (% TIR; 70-80 mg/dL). RESULTS:Twenty-five people with diabetes (mean age 34.32 ± 11.07 years; HbA1c 6.4% ± 3%) participated in this study. CIQ was comparable with AAPS in achieving TIR (85.72% ± 7.64% vs. 84.24% ± 8.46%; P = .12). Similarly, there were no differences in percentage time above range (> 180 and > 250 mg/dL), mean sensor glucose (130.3 ± 13.9 vs. 128.3 ± 16.9 mg/dL; P = .21) or HbA1c (6.3% ± 2.1% vs. 6.4% ± 3.1%; P = .59). Percentage time below range (< 70 and < 54 mg/dL) was significantly lower using CIQ than AAPS. Even although participants were mostly satisfied with CIQ (63.6% mostly agreed, 9.1% strongly agreed), they did not plan to switch to CIQ. CONCLUSIONS:The CODIAC study is the first prospective study investigating the switch between open-source and commercially available AID systems. CIQ and AAPS were comparable in achieving TIR. However, hypoglycaemia was significantly lower with CIQ.

Chronic kidney disease (CKD) affects 10% of the population of developed countries and significantly affects the population health. In addition to the well-known renoprotection tools slowing down the progression of CKD, SGLT2 inhibitors have been newly introduced into clinical practice based on the results of extensive studies, both in diabetics and non-diabetics. This expert opinion discusses the classification of CKD, current renoprotection options, and the recent role of SGLT2 inhibitors in the care of patients with CKD.

a Kardiovaskulární centrum, Nemocnice Na Homolce, Praha b I. interní klinika – kardiologická, Lékařská fakulta Univerzity Palackého v Olomouci a Fakultní nemocnice Olomouc, Olomouc c II. interní klinika kardiologie a angiologie, 1. lékařská fakulta Univerzity Karlovy a Všeobecná fakultní nemocnice, Praha d III. interní klinika – klinika endokrinologie a metabolismu, 1. lékařská fakulta Univerzity Karlovy a Všeobecná fakultní nemocnice, Praha e Centrum kardiovaskulární prevence, 1. lékařská fakulta Univerzity Karlovy a Fakultní Thomayerova nemocnice, Praha f Centrum pro závislé na tabáku, III. interní klinika – klinika endokrinologie a metabolismu, 1. lékařská fakulta Univerzity Karlovy a Všeobecná fakultní nemocnice, Praha g Ústav hygieny a epidemiologie, 1. lékařská fakulta Univerzity Karlovy a Všeobecná fakultní nemocnice, Praha h Pracoviště preventivní kardiologie, Institut klinické a experimentální medicíny, Praha ch Kardiomed s.r.o., Praha

Given the progressive nature of type 2 diabetes (T2D), most individuals with the disease will ultimately undergo treatment intensification. This usually involves the stepwise addition of a new glucose-lowering agent or switching to a more complex insulin regimen. However, complex treatment regimens can result in an increased risk of hypoglycaemia and high treatment burden, which may impact negatively on both therapeutic adherence and overall quality of life. Individuals with good glycaemic control may also be overtreated with unnecessarily complex regimens. Treatment simplification aims to reduce individual treatment burden, without compromising therapeutic effectiveness or safety. Despite data showing that simplifying therapy can achieve good glycaemic control without negatively impacting on treatment efficacy or safety, it is not always implemented in clinical practice. Current clinical guidelines focus on treatment intensification, rather than simplification. Where simplification is recommended, clear guidance is lacking and mostly focused on treatment of the elderly. An expert, multidisciplinary panel evaluated the current treatment landscape with respect to guidance, published evidence, recommendations and approaches regarding simplification of complex insulin regimens. This article outlines the benefits of treatment simplification and provides practical recommendations on simplifying complex insulin treatment strategies in people with T2D using illustrative cases.

Cardiovascular diseases are still the most common cause of mortality in patients with type 2 diabetes. Studies on the cardiovascular safety of new antidiabetic treatments, that have significantly expanded the treatment options for type 2 diabetes over the last 20 years, have provided evidence not only for the cardiovascular safety of SGLT-2 inhibitors (SGLT-2i, gliflozins), but also unexpectedly showed a significant effect on the reduction of cardiovascular risk, incidence and progress of heart failure and nephroprotectivity. For the first time, a reduction in cardiovascular and overall mortality was demonstrated for empagliflozin in 2015 in patients at very high cardiovascular risk. Further studies with gliflozins in patients with diabetes, but also in non-diabetic individuals, show that gliflozins have more pharmacological similarities than differences, especially in terms of protection against the development and progression of heart failure and maintenance of glomerular filtration rate. The revolutionary contribution of SGLT-2i is therefore perceived today not only by diabetologists, but also by cardiologists and nephrologists. In ESC guidelines, SGLT-2i are recommended as a first-line antidiabetic treatment for patients with diabetes at high cardiovascular risk, attacking the hitherto unshakable position of metformin at this pole position, and their indications should be considered in patients with type 2 diabetes with atherosclerosis, heart and renal failure regardless of the level of diabetes control (values of HbA1c). In the treatment of heart failure with reduced ejection fraction (with or without diabetes), dapagliflozin and empagliflozin have been recommended by cardiologists since 2021 to prevent hospitalizations for heart failure and to reduce mortality with the strongest class and level of evidence.

Advanced glycation accelerated by chronic hyperglycaemia contributes to the development of diabetic vascular complications throughout several mechanisms. One of these mechanisms is supposed to be impaired microvascular reactivity, that precedes significant vascular changes. The aim of this study was to find an association between advanced glycation, the soluble receptor for AGEs (sRAGE), and microvascular reactivity (MVR) in diabetes. Skin autofluorescence (SAF), which reflects advanced glycation, was assessed by AGE-Reader, MVR was measured by laser Doppler fluxmetry and evaluated together with sRAGE in 43 patients with diabetes (25 Type 1 and 18 Type 2) and 26 healthy controls of comparable age. SAF was significantly higher in patients with diabetes compared to controls (2.4 & PLUSMN; 0.5 vs. 2.0 & PLUSMN; 0.5 AU; p < 0.01). Patients with diabetes with SAF > 2.3 AU presented significantly worse MVR in both post-occlusive reactive hyperaemia (PORH) on the finger and forearm, and thermal hyperaemia (TH), compared to patients with SAF < 2.3 AU. SAF was age dependent in both diabetes (r = 0.41, p < 0.01) and controls (r = 0.45, p < 0.05). There was no association between SAF and diabetes control expressed by glycated haemoglobin. A significant relationship was observed between SAF and sRAGE in diabetes (r = 0.56, p < 0.001), but not in controls. A significant inverse association was found between SAF and MVR on the forearm in diabetes (PORH: r = -0.42, p < 0.01; TH: r = -0.46, p < 0.005). Both advanced glycation expressed by higher SAF or sRAGE and impaired MVR are involved in the pathogenesis of vascular complications in diabetes, and we confirm a strong interplay of these processes in this scenario.

Background Guidelines from 2016 onwards recommend early use of SGLT2i or GLP-1 RA for patients with type 2 diabetes (T2D) and cardiovascular disease (CVD), to reduce CV events and mortality. Many eligible patients are not treated accordingly, although data are lacking for Central and Eastern Europe (CEE). Methods The CORDIALLY non-interventional study evaluated the real-world characteristics, modern antidiabetic treatment patterns, and the prevalence of CVD and chronic kidney disease (CKD) in adults with T2D at nonhospital-based practices in CEE. Data were retrospectively collated by medical chart review for patients initiating empagliflozin, another SGLT2i, DPP4i, or GLP-1 RA in autumn 2018. All data were analysed cross-sectionally, except for discontinuations assessed 1 year ± 2 months after initiation. Results Patients (N = 4055) were enrolled by diabetologists (56.7%), endocrinologists (40.7%), or cardiologists (2.5%). Empagliflozin (48.5%) was the most prescribed medication among SGLT2i, DPP4i, and GLP-1 RA; > 3 times more patients were prescribed empagliflozin than other SGLT2i (10 times more by cardiologists). Overall, 36.6% of patients had diagnosed CVD. Despite guidelines recommending SGLT2i or GLP-1 RA, 26.8% of patients with CVD received DPP4i. Patients initiating DPP4i were older (mean 66.4 years) than with SGLT2i (62.4 years) or GLP-1 RA (58.3 years). CKD prevalence differed by physician assessment (14.5%) or based on eGFR and UACR (27.9%). Many patients with CKD (≥ 41%) received DPP4i, despite guidelines recommending SGLT2is owing to their renal benefits. 1 year ± 2-months after initiation, 10.0% (7.9–12.3%) of patients had discontinued study medication: 23.7–45.0% due to ‘financial burden of co-payment’, 0–1.9% due to adverse events (no patients discontinued DPP4i due to adverse events). Treatment guidelines were ‘highly relevant’ for a greater proportion of cardiologists (79.4%) and endocrinologists (72.9%) than diabetologists (56.9%), and ≤ 20% of physicians consulted other physicians when choosing and discontinuing treatments. Conclusions In CORDIALLY, significant proportions of patients with T2D and CVD/CKD who initiated modern antidiabetic medication in CEE in autumn 2018 were not treated with cardioprotective T2D medications. Use of DPP4i instead of SGLT2i or GLP-1 RA may be related to lack of affordable access, the perceived safety of these medications, lack of adherence to the latest treatment guidelines, and lack of collaboration between physicians. Thus, many patients with T2D and comorbidities may develop preventable complications or die prematurely. Trial registration NCT03807440.