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Real‐time continuous glucose monitors using subcutaneous needle‐type sensors continue to develop. The limitations of currently available systems, however, include time lag behind changes in blood glucose, the invasive nature of such systems, and in some cases, their accuracy. Non‐invasive techniques have been developed, but, to date, no commercial device has been successful. A key research priority for people with Type 1 diabetes identified by the James Lind Alliance was to identify ways of monitoring blood glucose constantly and accurately using a discrete device, invasive or non‐invasive. Integration of such a sensor is important in the development of a closed‐loop system and the technology must be rapid, selective and acceptable for continuous use by individuals. The present review provides an update on existing continuous glucose‐sensing technologies, and an overview of emergent techniques, including their accuracy and limitations. What's new?: One of 10 key research priorities identified by the James Lind Alliance Type 1 diabetes Priority Setting Partnership was to investigate whether it is possible to monitor blood sugar levels constantly and accurately with a discrete device (non‐invasive or invasive).This paper provides an overview of the latest glucose‐sensing techniques, currently marketed products and their accuracy.To date, no device based on a non‐invasive technique has successfully reached the commercial market. We review the technological challenges faced, clinical impact and future directions in continuous glucose monitoring. [ABSTRACT FROM AUTHOR]

Abstract: Background: Permanent neonatal diabetes caused by mutations in the KCNJ11 gene may be managed with high‐dose sulfonylureas. Complete transfer to sulfonylureas is not successful in all cases and can result in insulin monotherapy. In such cases, the outcomes of combining sulfonylureas with insulin have not been fully explored. We present the case of a woman with diabetes due to a KCNJ11 mutation, in whom combination therapy led to clinically meaningful improvements. Case: A 22‐year‐old woman was found to have a KCNJ11 mutation (G334V) following diagnosis with diabetes at 3 weeks. She was treated with insulin‐pump therapy, had hypoglycaemia unawareness and suboptimal glycaemic control. We assessed the in vitro response of the mutant channel to tolbutamide in Xenopus oocytes and undertook sulfonylurea dose‐titration with C‐peptide assessment and continuous glucose monitoring. In vitro studies predicted the G334V mutation would be sensitive to sulfonylurea therapy [91 ± 2% block (n = 6) with 0.5 mM tolbutamide]. C‐peptide increased following a glibenclamide test dose (from 5 to 410 pmol/l). Glibenclamide dose‐titration was undertaken: a lower glibenclamide dose did not reduce blood glucose levels sustainably, but at 1.2 mg/kg/day insulin delivery was reduced to 0.1 units/h. However, when insulin was stopped, hyperglycaemia ensued. Glibenclamide was further increased (2 mg/kg/day), but once‐daily long‐acting insulin was still required to maintain glycaemia. This resulted in improved HbA1c of 52 mmol/mol (6.9%), restoration of hypoglycaemia awareness and reduced glycaemic variability. Conclusion: In people with KCNJ11 mutations causing permanent neonatal diabetes, and where complete transfer is not possible, consideration should be given to dual insulin and sulfonylurea therapy. [ABSTRACT FROM AUTHOR]

Abstract: Aim: Hypoglycaemia in Type 1 diabetes is associated with mortality and morbidity, especially where awareness of hypoglycaemia is impaired. Clinical pathways for access to continuous glucose monitoring (CGM) and flash glucose monitoring technologies are unclear. We assessed the impact of CGM and flash glucose monitoring in a high‐risk group of people with Type 1 diabetes. Methods: A randomized, non‐masked parallel group study was undertaken. Adults with Type 1 diabetes using a multiple‐dose insulin‐injection regimen with a Gold score of ≥ 4 or recent severe hypoglycaemia were recruited. Following 2 weeks of blinded CGM, they were randomly assigned to CGM (Dexcom G5) or flash glucose monitoring (Abbott Freestyle Libre) for 8 weeks. The primary outcome was the difference in time spent in hypoglycaemia (below 3.3 mmol/l) from baseline to endpoint with CGM versus flash glucose monitoring. Results: Some 40 participants were randomized to CGM (n = 20) or flash glucose monitoring (n = 20). The participants (24 men, 16 women) had a median (IQR) age of 49.6 (37.5–63.5) years, duration of diabetes of 30.0 (21.0–36.5) years and HbA1c of 56 (48–63) mmol/mol [7.3 (6.5–7.8)%]. The baseline median percentage time < 3.3 mmol/l was 4.5% in the CGM group and 6.7% in the flash glucose monitoring. At the end‐point the percentage time < 3.3 mmol/l was 2.4%, and 6.8% respectively (median between group difference −4.3%, P = 0.006). Time spent in hypoglycaemia at all thresholds, and hypoglycaemia fear, were different between groups, favouring CGM. Conclusion: CGM more effectively reduces time spent in hypoglycaemia in people with Type 1 diabetes and impaired awareness of hypoglycaemia compared with flash glucose monitoring. (Clinical Trial Registry No: NCT03028220) [ABSTRACT FROM AUTHOR]

An introduction to articles published within the issue is presented, including one which reviews evidence on the association of glucose variability with the development of complications in type 1 diabetes, another which reviews the impact of insulin analogue development and whether clinical outcomes have improved with newer insulins, and another which examines whether lifestyle changes are adjuncts or alternatives to diabetes medications.

What's new?: Chronic sleep disturbance is common for people with Type 1 diabetes.Fear of nocturnal hypoglycaemia is causing frequent nocturnal blood glucose testing causing impaired sleep.New strategies for the prevention of nocturnal hypoglycaemia need to be devised and tested.The consequences of chronic sleep disturbance for people living with diabetes and their families needs to be appreciated by their clinical advisors. [ABSTRACT FROM AUTHOR]

The article discusses a study focusing on the access to and reimbursement for continuous glucose monitoring systems (CGM) for Type 1 diabetes patients in England. Topics discussed include the clinical guidelines published by the National Institute for Health and Care Excellence (NICE) in 2015; the Clinical Commissioning Groups (CCGs) in England, which provide funding for real-time CGM; and the discrepancies in policy regarding cost-effective use of routinely commissioned CGM.