Which Treatment Modalities Are Being Used by Italian Children and Adolescents with Type 1 Diabetes?

To the Editor,

Successful treatment of type 1 diabetes requires both a precise insulin delivery system and reliable glucose monitoring. Different technologies meeting these aims have their own benefits in terms of glycemic control. ^1,2 However, the prevalence of use of different diabetes treatment modalities is unknown, especially at the population level.

We, therefore, conducted a web-based survey of all Italian Society for Paediatric Endocrinology and Diabetes centers, of which 98.3% (58/59), including all the tertiary referral centers, participated. Each center was asked what percentage of their patients aged 17 years and below used one of seven diabetes management modalities: (1) multiple daily injections with glucose self-monitoring or with (2) continuous or intermittently scanned glucose monitoring, (3) sensor-augmented pump therapy, (4) predictive low-glucose suspend management, (5) hybrid closed-loop systems (e.g., MiniMed 670G or Tandem t:slim X2 with the Basal-IQ algorithm), (6) advanced hybrid closed-loop systems (e.g., MiniMed 780G, Tandem t:slim X2 with the Control-IQ algorithm, or Ypsopump with the Cam APS Fx algorithm, or (7) open-source automated insulin delivery.

The questionnaire captured data on 14,961 children and adolescents, representing nearly all the pediatric diabetes population in Italy (one small center of ∼40 patients could not return data). The proportions of patients using each treatment modality expressed as absolute number (percentage, median, and interquartile range) were 778 [2.1% (0.8; 6.5)] taking multiple daily injections with glucose self-monitoring; 7158 [45.4% (30.6; 60.8)] taking multiple daily injections with continuous or flash glucose monitoring; 1565 [8.4% (3.1; 13.7)] on sensor-augmented pumps; 274 [0.02% (0; 1.8)] with predictive low-glucose management; 439 [0.2% (0; 2.5)] on hybrid closed-loop systems; 4691 [32.5% (20.5; 51.3)] on advanced hybrid closed-loop systems; and 56 [0.004% (0; 0.3)] equipped with open-source automated insulin delivery.

Figure 1 shows the overall data and according to geographic region of Italy (north, center, south, or the islands) or center size (less or more than 150 patients).

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FIG. 1.

(A) Treatment modalities used by 14,961 pediatric patients with type 1 diabetes attending 55 of 58 pediatric diabetes centers. Data were collected from each center by retrieving information from the electronic health record system and were subsequently validated by telephone. Multiple comparison test P < 0.01. (B) Treatment modalities according to center size (less or more than 150 patients). (C) Treatment modalities according to geographic region in Italy.

This representative national sample suggests that nearly all (98%, IQR 94–99.5%) children in Italy use a sensor (either continuous or intermittently scanned), making this standard of care for our pediatric patients. About half (45%, IQR 34.5–70%) use an insulin pump, most with advanced automated features.

According to our survey, 47.7% of patients still use multiple daily injections, 2% with self-monitoring, raising the question of why these less efficacious approaches are still being used. ^3,4 Is it through patient choice, physician choice, or is it an economic or resourcing issue? Clues from the better control in pediatric and adolescent diabeteS Working to creatE cEnTers (SWEET) consortium suggest that, overall, ∼34% of children and adolescents with diabetes use multiple daily injections with a sensor (continuous or intermittently scanned), ⁵ and the T1D Exchange reports similar data. This continued use of multiple daily injections needs assessing in a larger context to better understand the reasons why children and adolescents with type 1 diabetes are resistant to or cannot access newer technologies.

It is surprising that 10% of patients use multiple daily injections with self-monitoring in southern centers, whereas advanced hybrid closed loop systems seem to be used more frequently in the north and center of Italy than in the south (P < 0.01) and in smaller centers (<150 patients) (P < 0.01). Although the reasons for the geographic differences are unclear, it is likely that the regionalization of health care reimbursement may create access inequality or different practitioners have different treatment preferences.

With respect to center size, a favorable ratio between the diabetes team (pediatric diabetologist, nurse, dietitian, psychologist) and patients in smaller centers might encourage uptake of more advanced and demanding therapies, and they also probably have more time to spend on each patient. Few pediatric patients use an open-source automated insulin delivery system, which we hypothesize is due to concerns about the unregulated nature of these systems. ⁶

It will now be important to understand the reasons behind the different choices made about diabetes management to better allocate financial resources and define specific educational paths so that all patients have access to the best therapeutic option.