Utility of Technology in the Treatment of Type 1 Diabetes: Current State of the Art and Precision Evidence

The greatest change in the treatment of people living with type 1 diabetes in the last decade has been the explosion of technology assisting in all aspects of diabetes therapy, from glucose monitoring to insulin delivery and decision making. Through screening of 835 peer-reviewed articles followed by systematic review of 70 of them (focusing on randomized trials and extension studies with ≥50 participants from the past 10 years), we conclude that novel technologies, ranging from continuous glucose monitoring systems, insulin pumps and decision support tools to the most advanced hybrid closed loop systems, improve important measures like HbA1c, time in range, and glycemic variability, while reducing hypoglycemia risk. Several studies included person-reported outcomes, allowing assessment of the burden or benefit of the technology in the lives of those with type 1 diabetes, demonstrating positive results or, at a minimum, no increase in self-care burden compared with standard care. Important limitations of the trials to date are their small size, the scarcity of pre-planned or powered analyses in sub-populations such as children, racial/ethnic minorities, people with advanced complications, and variations in baseline glycemic levels. In addition, confounders including education with device initiation, concomitant behavioral modifications, and frequent contact with the healthcare team are rarely described in enough detail to assess their impact. Our review highlights the potential of technology in the treatment of people living with type 1 diabetes and provides suggestions for optimization of outcomes and areas of further study for precision medicine-directed technology use in type 1 diabetes. Preface (Lay Abstract) We reviewed literature of the last decade to evaluate the impact of technology on the treatment of people living with type 1 diabetes. Screening of 835 articles and in-depth review of 70 showed that novel technologies, ranging from continuous glucose monitoring systems, insulin pumps and decision support tools to the most advanced hybrid closed loop systems, improve important measures like HbA1c and time in range, while reducing hypoglycemia risk. Of importance, several studies showed a positive impact on person-reported outcomes, like quality of life or, at a minimum, no increase in self-care burden compared with standard care. ### Competing Interest Statement JLS serves or has served on advisory panels for Bigfoot Biomedical, Cecelia Health, Insulet Corporation, Medtronic Diabetes, StartUp Health Diabetes Moonshot, and Vertex. JLS has served as a consultant to Abbott Diabetes, Bigfoot Biomedical, Insulet, Medtronic Diabetes, and Zealand. Yale School of Medicine has received research support for JLS from Abbott Diabetes, JAEB Center for Health Research, JDRF, Insulet, Medtronic, NIH, and Provention Bio. KKH received consulting fees from Cecelia Health. PG serves, or has served, on the advisory panel for Novo Nordisk, Sanofi-Aventis, Boehringer-Ingelheim, Janssen Pharmaceuticals, Roche, Medtronic, Abbott, Ypsomed and Bayer. PG serves, or has served, on the speakers bureau for Merck Sharp and Dohme, Boehringer-Ingelheim, Bayer, Medtronic, Insulet, Novo Nordisk, Abbott, Roche, VitalAire, and Dexcom. Financial compensation for these activities has been received by KU Leuven. KU Leuven received non-financial support for PG for travel from Sanofi-Aventis, A Menarini Diagnostics, Novo Nordisk, Medtronic, and Roche. All disclosures are unrelated to the present work. IBH has received research funding from Insulet and Dexcom and is a consultant for Abbott, embecta, Lifescan, Hagar. REP reports consulting fees from Bayer AG, Corcept Therapeutics Incorporated, Dexcom, Hanmi Pharmaceutical Co., Merck, Novo Nordisk, Pfizer, Sanofi, Scohia Pharma Inc., and Sun Pharmaceutical Industries, and grants/research support from Hanmi Pharmaceutical Co., Janssen, Metavention, Novo Nordisk, Poxel SA, and Sanofi. All funds are paid directly to REPs employer, AdventHealth, a nonprofit organisation that supports education and research. LL serves as a consultant for Boehringer Ingelheim, Eli Lilly, NovoNordisk, Janssen, Dexcom, Insulet, Roche, Medtronic, Dompe, Provention Bio, and Vertex. CM serves or has served on the advisory panel for Novo Nordisk, Sanofi, Merck Sharp and Dohme Ltd., Eli Lilly and Company, Novartis, AstraZeneca, Boehringer Ingelheim, Roche, Medtronic, ActoBio Therapeutics, Pfizer, Imcyse, Insulet, Zealand Pharma, Avotres and Vertex. Financial compensation for these activities has been received by KU Leuven; KU Leuven has received research support for CM from Medtronic, Imcyse, Novo Nordisk, Sanofi and ActoBio Therapeutics. LMJ, EC, AC, SP, MH, SC, MU, SA, MT, MJR, PAG, JJW, and LL report no dualities of interest. ### Funding Statement This study did not receive any funding. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data in the present study is from published peer-reviewed manuscripts (systematic review).