1. Updates in Insulin Therapy
Terrence Swade, MD

2. Objectives
Review general diabetes management and non-insulin therapies
Review newer insulin molecules
Review general concepts of using insulin therapy in diabetics

3. AACE Comprehensive Care Plan
Disease management from a multidisciplinary team
Antihyperglycemic pharmacotherapy
Comprehensive diabetes self-education for the patient
Therapeutic lifestyle change
Handelsman YH, et al. Endocr Pract. 2015;21(suppl 1):1-87.

4. Noninsulin Agents Available for T2D
Class
Primary Mechanism of Action
Agent(s)
Available as
-Glucosidase inhibitors
Delay carbohydrate absorption from intestine
Acarbose
Miglitol
Precose or generic
Glyset
Amylin analogue
Decrease glucagon secretion
Slow gastric emptying
Increase satiety
Pramlintide
Symlin
Biguanide
Decrease HGP
Increase glucose uptake in muscle
Metformin
Glucophage or generic
Bile acid sequestrant
Decrease HGP?
Increase incretin levels?
Colesevelam
WelChol
DPP-4 inhibitors
Increase glucose-dependent insulin secretion
Alogliptin
Linagliptin
Saxagliptin
Sitagliptin
Nesina
Tradjenta
Onglyza
Januvia
Dopamine-2 agonist
Activates dopaminergic receptors
Bromocriptine
Cycloset
Glinides
Increase insulin secretion
Nateglinide
Repaglinide
Starlix or generic
Prandin
DPP-4, dipeptidyl peptidase; HGP, hepatic glucose production.
Garber AJ, et al. Endocr Pract. 2016;22: Inzucchi SE, et al. Diabetes Care. 2015;38:
Continued on next slide

5. Noninsulin Agents Available for T2D
Class
Primary Mechanism of Action
Agent(s)
Available as
GLP-1 receptor agonists
Increase glucose-dependent insulin secretion
Decrease glucagon secretion
Slow gastric emptying
Increase satiety
Albiglutide
Dulaglutide
Exenatide
Exenatide XR
Liraglutide
Tanzeum
Trulicity
Byetta
Bydureon
Victoza
SGLT2 inhibitors
Increase urinary excretion of glucose
Canagliflozin
Dapagliflozin
Empagliflozin
Invokana
Farxiga
Jardiance
Sulfonylureas
Increase insulin secretion
Glimepiride
Glipizide
Glyburide
Amaryl or generic
Glucotrol or generic
Diaeta, Glynase, Micronase, or generic
Thiazolidinediones
Increase glucose uptake in muscle and fat
Decrease HGP
Pioglitazone
Rosiglitazone
Actos
Avandia
GLP-1, glucagon-like peptide; HGP, hepatic glucose production; SGLT2, sodium glucose cotransporter 2.
Garber AJ, et al. Endocr Pract. 2016;22: Inzucchi SE, et al. Diabetes Care. 2015;38:
Continued from previous slide

6. Monotherapy, Dual Therapy, and Triple Therapy for T2D
Metformin (or other first-line agent) plus
Triple therapy*
First- and second-line agent plus
Metformin
GLP1RA
SGLT2I
DPP4I
TZD†
Basal insulin†
AGI
Colesevelam
SU/glinide†
BCR-QR
AGI = -glucosidase inhibitors; BCR-QR = bromocriptine quick release; Coles = colesevelam; DPP4I = dipeptidyl peptidase 4 inhibitors; GLP1RA = glucagon-like peptide 1 receptor agonists; Met = metformin; SGLT2I = sodium-glucose cotransporter 2 inhibitors; SU = sulfonylureas; TZD = thiazolidinediones.
*Intensify therapy whenever A1C exceeds individualized target. Boldface denotes little or no risk of hypoglycemia or weight gain, few adverse events, and/or the possibility of benefits beyond glucose-lowering.
† Use with caution.
Handelsman YH, et al. Endocr Pract. 2015;21(suppl 1):1-87.

9. Current Insulin Options
Type
Basal Insulins
Prandial Insulins
Premixed Insulins
Human
U-100 NPH
U-100 regular human insulin
U-500 regular human insulin
Technosphere inhaled insulin
U /30 RHI
Analog
U-100 glargine
U-100 glargine equivalent*
U-100 detemir
U-100 degludec
U-200 degludec
U-300 glargine
U-100 lispro
U-100 aspart
U-100 glulisine
U-200 lispro
U /50 lispro
U /30 aspart
U /25 lispro
U /30 degludec/aspart
Analogue insulins are associated with less hypoglycemia than human insulins, although these differences are not always statistically significant
*In the US, U-100 glargine equivalent is not approved as a biosimilar product.
Singh SR, et al. CMAJ. 2009;180: FDA.

10. Pharmacokinetics of Available Insulins
Agent
Onset (h)
Peak (h)
Duration (h)
Considerations
Basal
NPH
2-4
4-10
10-16
Greater risk of nocturnal hypoglycemia compared to insulin analogs
Glargine
Detemir
Degludec
~1-4
No pronounced peak*
Up to 24†
Less nocturnal hypoglycemia compared to NPH
Basal-Prandial
Regular U-500
≤0.5
~2-3
12-24
Inject 30 min before a meal
Indicated for highly insulin resistant individuals
Use caution when measuring dosage to avoid inadvertent overdose
Prandial
Regular
~0.5-1
Up to 8
Must be injected min before a meal
Injection with or after a meal could increase risk for hypoglycemia
Aspart
Glulisine
Lispro
Inhaled insulin
<0.5 ~
~3-5
Can be administered 0-15 min before a meal
Less risk of postprandial hypoglycemia compared to regular insulin 
* Exhibits a peak at higher dosages.
† Dose-dependent.
NPH, Neutral Protamine Hagedorn.
Moghissi E et al. Endocr Pract. 2013;19: Humulin R U-500 (concentrated) insulin prescribing information. Indianapolis: Lilly USA, LLC.

11. Pharmacokinetic Profiles of Insulins
Rapid (lispro, aspart, glulisine, inhaled)
Insulin Level
Short (regular)
Intermediate (NPH)
Long (glargine, degludec)
Long (detemir)
Hours
Adapted from Hirsch I. N Engl J Med. 2005;352:

12. Insulin Concentrations
Units/mL
Units/vial
Units/pen
U-100
100
1000
(10 units per vial)
300
(3 mL/pen)
U-200
200
Not available in vials
600
U-300
450
(1.5 mL/pen)
U-500
500
10,000
(20 units/vial)
1500
erry Drake
Insulin pens significantly reduce the risk of dosing errors and hypoglycemic events
Pens completely eliminate the need for converting doses based on the volume of insulin injected
Dosing errors with U-500 insulin vials are common and dangerous but can be avoided with newly available pens
5-fold higher insulin dose relative to the same volume of a U-100 insulin
Newton C, et al. AACE Annual Meeting [abstract 271]. Segal AR, et al. Am J Health Syst Pharm. 2010;67:

14. Common Principles in AACE/ACE and ADA/EASD T2D Treatment Algorithms
Individualize glycemic goals based on patient characteristics
Promptly intensify antihyperglycemic therapy to maintain blood glucose at individual targets
Combination therapy necessary for most patients
Base choice of agent(s) on individual patient medical history, behaviors and risk factors, ethno-cultural background, and environment
Insulin eventually necessary for many patients
SMBG vital for day-to-day management of blood sugar
All patients using insulin
Many patients not using insulin
Garber AJ, et al. Endocr Pract. 2016;22: Inzucchi SE, et al. Diabetes Care. 2015;38:

15. ADA/EASD T2D Treatment Algorithm
Inzucchi SE, et al. Diabetes Care. 2015;38:
Inzucchi SE, et al. Diabetes Care. 2012;35:

16. ADA/EASD T2D Treatment Algorithm: Sequential Insulin Strategies
Inzucchi SE, et al. Diabetes Care. 2015;38:

17. Efficacy and Safety of U-100 Glargine Equivalent
Patients With T2D*
(N=756)
Overall
(BG <70 mg/dL or S/S)
Nocturnal
(between bedtime and waking)
Severe
(Requiring assistance) † †
Episodes per patient-year
Episodes per patient-year
No. events
A1C
Insulin Dose
Weight † †
BL =
U/kg/day
 A1C (%)
 Weight (kg) †
*Mean age = 59 y; duration of diabetes = y; baseline BMI = 32 kg/m2. †Not significant vs glargine.
BMI = body mass index; Glar-Eq = glargine equivalent (n=376); Glar = insulin glargine (n=380); S/S = signs and symptoms; T2D = type 2 diabetes.
Rosenstock J, et al. Diabetes Obes Metab. 2015;17:

18. Glycemic Management in Type 2 Diabetes: Efficacy and Safety of Modern Antihyperglycemic Therapies
Glargine U-300

19. Efficacy and Safety of Glargine U-300
Insulin-Naive T2D Patients*
(N=878)
Overall
(BG <70 mg/dL)
Nocturnal
(between midnight and 6:00 am)
Severe
(Requiring assistance) †
P<0.05 †
Patients (%)
Patients (%)
Patients (%)
A1C
Insulin Dose
Weight † †
BL =
U/kg/day
 A1C (%)
 Weight (kg) †
*Mean age = 58 y; duration of diabetes = 9.8 y; baseline BMI = 33 kg/m2. †Not significant vs glargine U-100.
BMI = body mass index; NS = not significant; T2D = type 2 diabetes.
Bolli GB, et al. Diabetes Obes Metab. 2015;17:

20. Glucose Control With Glargine U-300
Add-on to OA, Insulin-Naive
6 Months1
Add-on to OA, Basal Insulin Users
6 Months2
Basal-Bolus Insulin Regimen
6 Months3 N
878
811
807
Treatment
Gla 100
Gla 300
Baseline A1C (%)
8.6
8.5
8.2
8.3
 A1C (%)
1. Bolli GB, et al. Diabetes Obes Metab. 2015;17: Yki-Järvinen H, et al. Diabetes Care. 2014;37: Riddle MC, et al. Diabetes Care. 2014;37:

21. Risk of Hypoglycemia With Glargine U-300
Pooled Analysis of Phase III Trials
(N=2496)
Favors Glargine 300
Favors Glargine 100
Hypoglycemia any time of day
Relative risk (95% CI)
Confirmed (≤70 mg/dL) or severe
0.91 ( )
Documented symptomatic (≤70 mg/dL)
0.88 ( )
Nocturnal hypoglycemia
0.75 ( )
0.75 ( )
Ritzel R, et al. Diabetes Obes Metab Apr 30. doi: /dom [Epub ahead of print].

22. Glycemic Management in Type 2 Diabetes: Efficacy and Safety of Modern Antihyperglycemic Therapies
Degludec

23. Efficacy and Safety of Degludec and Glargine U-100
Insulin-Naive T2D Patients*
(N=1030)
Overall
(BG <70 mg/dL or S/S)
Nocturnal
(between bedtime and waking)
Severe
(Requiring assistance) †
P=0.038
Episodes per patient-year
Episodes per patient-year
Episodes per patient-year
P=0.017
A1C
Insulin Dose
Weight † †
BL =
U/kg/day
 A1C (%)
 Weight (kg) †
*Mean age = 59 y; duration of diabetes = 9 y; baseline BMI = kg/m2; degludec (n=773); glargine (n=257). †Not significant vs glargine.
BMI = body mass index; Deg = degludec; Glar = glargine; NS = not significant; T2D = type 2 diabetes.
Zinman B, et al. Diabetes Care. 2012;35:

24. Glucose Control With Degludec
Add-on to OA, Insulin-Naive
52 Weeks1
Add-on to OA, Basal Insulin Users or Insulin-Naive
26 Weeks2
Basal-Bolus Insulin Regimen
52 Weeks3 N
1030
687
744
Treatment
Deg
Glar
Deg OD
Deg OD Flex
Baseline A1C (%)
8.2
8.4
8.5
8.3
 A1C (%)
Deg = degludec; Flex = prespecified rotating morning and evening dosing schedule with 8- to 40-h intervals between doses; Glar = glargine; OD = once daily.
1. Zinman B, et al. Diabetes Care. 2012;35: Meneghini L, et al. Diabetes Care. 2013;36: Garber AJ, et al. Lancet Endocrinol. 2012;379:

25. Hypoglycemia With Degludec
Add-on to OA, Insulin-Naive
52 Weeks1
Add-on to OA, Basal Insulin Users or Insulin-Naive
26 Weeks2
Basal-Bolus Insulin Regimen
52 Weeks3 N
1030
687
744
Treatment
Deg
Glar
Deg OD
Deg OD Flex
Overall*
Nocturnal*
Severe*
2 events † † † †
*Events per patient-year. †P<0.05 vs glargine. Deg = degludec; Flex = prespecified rotating morning and evening dosing schedule with 8- to 40-h intervals between doses; Glar = glargine; OD = once daily.
1. Zinman B, et al. Diabetes Care. 2012;35: Meneghini L, et al. Diabetes Care. 2013;36: Garber AJ, et al. Lancet Endocrinol. 2012;379:

26. Inhaled Insulin Inhaled administration Rapid-acting insulin
Peak levels achieved in ~15 minutes
Rave K, et al. J Diabetes Sci Technol. 2008;2:

27. Glucose Control with Inhaled Insulin
Add-on to Metformin and/or Other OAs
24 Weeks
Placebo
Inhaled insulin N
353
Baseline A1C (%)
8.3
 A1C (%) * *
*Difference from placebo (95% CI): -0.40% (-0.57% to -0.23%).
Afrezza (insulin human) inhalation powder prescribing information. Danbury, CT: MannKind Corporation; 2014.

28. Inhaled Insulin: Adverse Events
Patients (%)
Inhaled insulin
(n=1991)
Placebo
(n=290)
Active comparators
(n=1363)
Cough
25.6
19.7
5.4
Throat pain or irritation
4.4
3.8
0.9
Headache
3.1
2.8
1.8
Diarrhea
2.7
1.4
2.2
Productive cough
1.0
Fatigue
2.0
0.7
0.6
Nausea
0.3
*Adverse events of interest occurring in ≥2% of patients receiving inhaled insulin.
Afrezza (insulin human) inhalation powder prescribing information. Danbury, CT: MannKind Corporation; 2014.

29. Safety Considerations with Inhaled Insulin
Lung disease
Contraindicated in asthma, COPD, and other chronic lung diseases
Perform spirometry to assess lung function before initiating inhaled insulin, after 6 months of therapy, and annually thereafter, even in the absence of pulmonary symptoms
Do not use in patients with active lung cancer and use with caution in patients with a history of lung cancer or those at risk for lung cancer
Heart failure
Observe for signs and symptoms of fluid retention or heart failure, especially when used with TZDs
Hypoglycemia
Increase frequency of glucose monitoring
Afrezza (insulin human) inhalation powder prescribing information. Danbury, CT: MannKind Corporation; 2014.

30. Management of Hyperglycemia in the Noncritical Care Setting

31. Glycemic Targets in Noncritical Care Setting
Maintain fasting and preprandial BG <140 mg/dL
Modify therapy when BG <100 mg/dL to avoid risk of hypoglycemia
Maintain random BG <180 mg/dL
More stringent targets may be appropriate in stable patients with previous tight glycemic control
Less stringent targets may be appropriate in terminally ill patients or in patients with severe comorbidities
Moghissi ES, et al. Endocrine Pract. 2009;15:
Umpierrez GE, et al. J Clin Endocrinol Metab. 2012;97:16-38.

32. Pharmacological Treatment of Hyperglycemia in Non-ICU Setting
Antihyperglycemic Therapy
Continuous IV Infusion Selected medical-surgical patients
SC Insulin
Recommended for most medical-surgical patients
OADs Not generally recommended
Moghissi ES, et al. Endocrine Pract. 2009;15:
Umpierrez GE, et al. J Clin Endocrinol Metab. 2012;97:16-38.
Smiley D, et al. J Hosp Med. 2010;5:

33. Noninsulin Therapies in the Hospital
Time-action profiles of oral agents can result in delayed achievement of target glucose ranges in hospitalized patients
Sulfonylureas are a major cause of prolonged hypoglycemia
Metformin is contraindicated in patients with decreased renal function, use of iodinated contrast dye, and any state associated with poor tissue perfusion (CHF, sepsis)
Thiazolidinediones are associated with edema and CHF
α-Glucosidase inhibitors are weak glucose-lowering agents
Pramlintide and GLP-1 receptor agonists can cause nausea and exert a greater effect on postprandial glucose
DPP4 inhibitors may provide safe and effective blood glucose control when used alone or in combination with basal insulin
Insulin therapy is the preferred approach

34. Glycemic Management Strategies in Noncritically Ill Patients
Insulin therapy preferred regardless of type of diabetes
Discontinue noninsulin agents at hospital admission of most patients with type 2 diabetes with acute illness
Use scheduled SC insulin with basal, nutritional, and correction components
Modify insulin dose in patients treated with insulin before admission to reduce risk for hypoglycemia and hyperglycemia
Avoid prolonged therapy with “sliding scale” insulin alone
Umpierrez GE, et al. J Clin Endocrinol Metab. 2012;97:16-38.

35. Subcutaneous Insulin Options
Basal insulin
Controls blood glucose in the fasting state
Detemir (Levemir), glargine (Lantus), NPH
Nutritional (prandial) insulin
Blunts the rise in blood glucose following nutritional intake (meals, IV dextrose, enteral/parenteral nutrition)
Rapid-acting: aspart (NovoLog), glulisine (Apidra), lispro (Humalog)
Short-acting: regular (Humulin, Novolin)
Correction insulin
Corrects hyperglycemia due to mismatch of nutritional intake and/or illness-related factors and scheduled insulin administration

36. Initiating Insulin Therapy in the Hospital
Obtain patient weight in kg
Calculate total daily dose (TDD) as units per kg/day
Choose the dosing schedule
Give 50%-60% of TDD as basal insulin
Give 40%-50% of TDD as nutritional insulin
Use correction insulin for BG above goal range
Adjust according to results of bedside glucose monitoring Adjust dose for NPO status or changes in clinical status

37. Insulin Therapy in Patients With Type 2 Diabetes
Discontinue noninsulin agents on admission
Insulin naïve: starting total daily dose (TDD):
0.3 U/kg to 0.5 U/kg
Lower doses in the elderly and patients with renal insufficiency
Previous insulin therapy: reduce outpatient insulin dose by 20%-25%
Half of TDD as basal insulin given at the same time of day and half as rapid-acting insulin in equally divided doses (AC)
Umpierrez GE, et al. Diabetes Care. 2007;30: 37

38. Basal-Bolus Insulin Therapy in Inpatients With Type 2 Diabetes (RABBIT 2 Trial)
130 nonsurgical insulin-naïve patients age with known type 2 diabetes admitted to noncritical care unit
Randomly assigned to sliding scale insulin (SSI) or a basal-bolus regimen with glargine and glulisine
0.4 units per kg/day for BG
0.5 units per kg /day for BG >200
50% given as glargine and 50% as glulisine
Oral antidiabetic drugs discontinued
2 hypoglycemic events (BG <60 mg/dL) in each group
Umpierrez GE, et al. Diabetes Care. 2007;30:

39. Rabbit 2 Trial: SSI Resulted in Uncontrolled Hyperglycemia in Some Patients
300
Sliding-scale
Basal-bolus
Hypoglycemia Rate
280
260
240
Basal Bolus Group:
BG <60 mg/dL: 3%
BG <40 mg/dL: none
SSRI:
220
BG, mg/dL
200
180
160
140
120
100
Admit 1 2 3 4 1 2 3 4 5 6 7
Days of Therapy
Persistent hyperglycemia (BG >240 mg/dL) is common (15%) with SSI therapy
Umpierrez GE, et al. Diabetes Care. 2007;30:

40. Basal-Bolus Insulin Therapy in Inpatients With Type 2 Diabetes (RABBIT 2 Trial)
Adjusting scheduled insulin regimen
If fasting and premeal BG >140 mg/dL, dose of glargine increased by 20%
For BG <70 mg/dL, glargine reduced by 20%
Umpierrez GE, et al. Diabetes Care. 2007;30:

41. Treatment of Type 1 Diabetes

42. Goals of T1D Management
Utilize intensive therapy aimed at near-normal BG and A1C levels
Prevent diabetic ketoacidosis and severe hypoglycemia
Achieve the highest quality of life compatible with the daily demands of diabetes management
In children, achieve normal growth and physical development and psychological maturation
Establish realistic goals adapted to each individual’s circumstances
T1D, type 1 diabetes.
Handelsman YH, et al. Endocr Pract. 2015;21(suppl 1):1-87.

43. ADA A1C Goals: Patients with Type 1 Diabetes
Age Group
A1C Goal*
Youth (<18 years)
<7.5%
Adults
<7.0%
Older adults
Healthy†
Complex/intermediate health
<8.0%
Very complex/poor health
<8.5%
*Individualize goal based on patient’s circumstances:
<6.5% may be appropriate for select patients if achievable without significant hypoglycemia
<8.5% may be appropriate for patients with history of severe hypoglycemia, hypoglycemia unawareness, limited life expectancy, advanced complications, or extensive comorbidities
†No comorbidities, long life expectancy.
T1D, type 1 diabetes.
Chiang JL, et al. Diabetes Care. 2014;37:

44. Effect of Intensive Treatment on Retinopathy in T1D
DCCT
(N=1441)
DCCT, Diabetes Control and Complications Trial; T1D, type 1 diabetes..
DCCT. N Engl J Med. 1993;329:

45. Sustained Effect of Intensive Treatment on Nephropathy in T1D
DCCT-EDIC
(N=1349)
Annual Prevalence
Cumulative Incidence
DCCT, Diabetes Control and Complications Trial; EDIC, Epidemiology of Diabetes Interventions and Complications; T1D, type 1 diabetes.
DCCT EDIC. JAMA. 2003;290:

46. Advances in the Care of Persons With Type 1 Diabetes
Development of insulin analogues
Insulin pump therapy
Home glucose monitoring
Advent of continuous glucose monitoring (CGM)

47. Principles of Insulin Therapy in Type 1 Diabetes
Starting dose based on weight
Range: units/kg per day
Daily dosing
Basal
40% to 50% TDI
Given as single injection of basal analog or 2 injections of NPH per day
Prandial
50% to 60% of TDI in divided doses given 15 min before each meal
Each dose determined by estimating carbohydrate content of meal
Higher TDI needed for obese patients, those with sedentary lifestyles, and during puberty
TDD, total daily dose.
Handelsman YH, et al. Endocr Pract. 2015;21(suppl 1):1-87.

48. Continuous Subcutaneous Insulin Infusion
Treatment of Type 1 Diabetes
Continuous Subcutaneous Insulin Infusion

49. Normal Insulin Secretion
Meal
Bolus (meal)
insulin needs 60 50 40
Serum insulin (µU/mL) 30 20
Basal (background) insulin needs 10 2 4 6 8 10 12 14 16 18 20 22 24
Time

50. CSII With Rapid-Acting Analog
Morning
Afternoon
Evening
Night
Bolus
Bolus
Bolus
Insulin effect
Basal Infusion
Breakfast
Lunch
Dinner
Bedtime
CSII, continuous subcutaneous insulin infusion.

51. Features of Modern Insulin Pumps Not Shared by MDI
Variable basal and prandial infusion rates
Meal profiles (eg, normal and advanced bolus), pre-set basal rate changes, temporary basal rates, etc
On-board calculators for meal insulin boluses
Alarms/reminders (eg, missed bolus)
Ability to download pump data to computer
Integration with CGM for automatic feedback control and threshold suspend automation (“semi-closed loop”)
CGM, continuous glucose monitoring; MDI, multiple daily injections.

52. Improved Glucose Control with CSII* *
A1C (%) *
Age group
*P<0.02 vs baseline.
CSII, continuous subcutaneous insulin infusion.
Ahern JA, et al. Pediatr Diabetes. 2002;3:10-15.

53. Efficacy of CSII Switching to CSII results in Lower A1C, by ~0.5%-0.6%
Mean A1C ~7.5%-7.6%
Less hypoglycemia
Less glucose variability
No excessive weight gain
Greater patient satisfaction and quality of life
CSII, continuous subcutaneous insulin infusion.
Tamborlane WV, et al. Rev Endo Metab Disorders. 2006;7:

54. Not All Patients Have Good Control on CSII
Patients with T1D Switched from MDI to Pump Therapy
(N=104)
Patients on CSII (%)
A1C on CSII significantly correlated with prior A1C on MDI
(r=0.66; P<0.001)
CSII, continuous subcutaneous insulin infusion; T1D, type 1 diabetes.
Nixon R, Pickup JC. Diabetes Technol Ther. 2011;13:93-98.

55. Continuous Glucose Monitoring
Treatment of Type 1 Diabetes
Continuous Glucose Monitoring

56. Continuous Glucose Monitoring in Type 1 Diabetes
JDRF Sensor Trial
Patients
Baseline A1C >7.0%
Age cohorts
8-14 years (n=114)
15-24 years (n=110)
≥25 years (n=98)
Improvement sustained for 12 months in patients aged ≥25 years
No significant difference between CGM and control group among patients <25 years of age
Patients ≥25 Years of Age
P<0.001
 A1C (%)
JDRF, Juvenile Diabetes Research Foundation.
JDRF CGM Study Group. New Engl J Med. 2008;359:

57. Change in A1C Over Time JDRF Sensor Trial (N=322)
Patients ≥25 Years of Age
CGM, continuous glucose monitoring; JDRF, Juvenile Diabetes Research Foundation.
JDRF CGM Study Group. New Engl J Med. 2008;359: