ESPE 2018 SATELLITE SYMPOSIUM MEETING REPORT

6 MEETING REPORT – ESPE 2018 SATELLITE SYMPOSIUM Insulin Treatment & Advanced Technology in the Management of Children with Diabetes THE LATEST TECHNOLOGIES FOR TYPE 1 DIABETES Battelino opened his presentation by highlighting a “crucial paper”, recently published in The Lancet , 2 showing reduced survival in patients with type 1 diabetes – by an average of 17 years in patients diagnosed within the first 10 years of life. The paper also showed a particularly high cardiovascular mortality risk in females with diabetes, mostly strikingly for myocardial infarction, and in line with other findings. “And my first message for today: we need to understand why”, said Battelino. However, he highlighted a “window of opportunity”, stressing that the increased mortality risk for patients with diabetes affects only those with poor glycaemic control. And he raised the issue of poor glucose control during puberty, saying: “We actually just accept this […] I don’t believe this should be accepted so easily.” As Chiarelli did, Battelino noted the evidence that brain damage in children with diabetes is related not, as previously believed, to severe hypoglycaemia, but rather to glucose variability and to hyperglycaemia. These day-to-day fluctuations in glucose levels are not reflected in patients’ glycated haemoglobin (HbA1c) levels, however. So while HbA1c is very useful as benchmark of glycaemic control across centres and countries, Battelino believes it is no longer a helpful indicator in clinical practice. For example, a study published in The BMJ showed virtually identical average HbA1c levels between insulin pump users and patients on multiple daily injections, yet mortality was significantly lower in the pump users . 3 A separate study showed significantly reduced rates of microvascular complications in pump user s 4 and a JAMA paper reported reduced rates of hypoglycaemia, diabetic ketoacidosis and severe diabetic ketoacidosis, despite only a very small difference in HbA1c relative to injection users . 5 “So please be aware that having A1c as the major or primary outcome is probably not the best idea”, said Battelino, because of the “considerably larger” benefits that may be overlooked when relying on a marker of average glucose levels to gauge the effectiveness of a treatment. Battelino’s group recently showed that poor glycaemic control in children with type 1 diabetes is associated with significant shortening of telomeres, the protective caps at the end of the chromosomes – a phenomenon more usually associated with ageing . 6 The increasing importance of glucose variability highlights the value of continuous glucose monitoring (CGM), which reveals the day-to-day fluctuations that are concealed by HbA1c, allowing patients to target them. As a consequence of reducing hypoglycaemia, CGM also demonstrably increases the time patients spend within an optimal blood glucose range. An extract from Dr. Battelino ‘s presentation is available here