Mary Binsu Abraham

Introduction: With an increased use of diabetes technology in type 1 diabetes, there is noted variability in the glucose thresholds at which hypoglycaemia is treated. The study therefore investigated the thresholds for hypoglycaemia treatment on contemporary treatment to capture real-life practices and compared the relationship between glycaemia, hypoglycaemia awareness (HA), and fear of hypoglycaemia (FOH) with their chosen treatment threshold. Methods: Children with type 1 diabetes (parent if child < 12 years) responded to an online survey reporting their chosen glucose thresholds. Clinical and glycaemic data were retrieved from the Western Australian Children’s Diabetes Database. Participant groups were defined as treatment at, below, and above the recommended threshold (RT) of less than 3.9 mmol/L. Results: Of 271 respondents (median age: 13.4 years, 98% continuous glucose monitor [CGM]), 54% treated hypoglycaemia at RT, 25% treated above, and 21% treated below. This adoption of glucose thresholds was independent of mode of insulin delivery (p = 0.54). Participants also adjusted thresholds based on day/night (37.3%), presence of active insulin on board (56.1%), and exercise (83.8%), with 96.2% using CGM trend arrows to guide the need for treatment. There was no evidence of a difference in HbA1c, time in range, time below range (TBR), HA, and FOH scores between the three groups (p > 0.05). However, those treating above RT achieved target TBR <3.9 mmol/L (<4%) than other groups (p < 0.05). Three episodes of severe hypoglycaemia occurred: one in the below RT group and two in the RT group. Conclusion: Parents and children personalise the glucose thresholds for commencing hypoglycaemia treatment based on the clinical context. Although these thresholds did not increase the time in hypoglycaemia, further studies are needed to evaluate the safe adoption of this approach in clinical care.

Self‐monitoring of glycaemia is a cornerstone of diabetes management, particularly for people using insulin. Traditionally, glucose monitoring involved finger‐pricking and measuring capillary blood glucose concentration. Continuous glucose monitors (CGMs) have revolutionised self‐monitoring of glucose levels. These devices provide continuous interstitial fluid glucose measurements, including trend arrows and alarms to alert the person if glucose levels are outside predetermined ranges. The increased reliance on CGM metrics for clinical decisions to manage diabetes necessitates the consideration and implementation of minimum standards that device manufacturers should meet to demonstrate safety, precision and accuracy. This statement provides recommendations to ensure that CGM devices that are approved for the Australian and New Zealand markets meet/exceed these minimum standards of accuracy, to provide health professionals and people living with diabetes the confidence to manage their glucose levels effectively.

Objectives: To describe the birth prevalence and characterise the genotype, phenotype and management of children with congenital hyperinsulinism (CHI) in Western Australia (WA). Methods: A population-based retrospective study (2005–2024) of children with CHI was conducted at the tertiary paediatric centre in WA. Children with transient perinatal stress-induced HI and insulinoma were excluded. Data collection included clinical presentation, investigations and management. Results: The birth prevalence was 1 in 17,394 per 100,000 live births. Of 40 CHI cases, 65 % were neonatal presentations. 32.5 % were symptomatic with seizures in 15 % of presentations. An aetiology was identified in 80 % (n=32); 64.5 % (n=21) had identified pathogenic gene variants with K-ATP channel defects in 14 children [ABCC8 (n=11), KCNJ11 (n=3)], the remainder had syndromic HI (n=11). 80 % (n=32) responded to medical therapies; 78 % (n=25) had an identified etiology. A pathogenic variant was identified in six of the seven infants with CHI which resolved in six months. Of those children who were diazoxide unresponsive (n=10), two stabilised on octreotide while eight (20 %) required surgical management, which was curative in focal lesions (n=2). Secondary diabetes post pancreatectomy (n=6) occurred at a mean age of 5.25 years. The cohort had high continuous glucose monitoring uptake (92 %) for glucose monitoring following subsidy with nine commenced in the neonatal period. Conclusions: The prevalence of CHI in WA is higher than the reported European-ancestry population due to early genetic evaluation of newborns with CHI. Correlation between genotype and phenotype is consistent with literature and supports genetic investigation of infants with CHI to inform management.

Aim: School time represents a significant component of overall glycaemia for children with type 1 diabetes (T1D), and glucose levels during instructional time may be important for optimising academic progress. There is, however, limited literature regarding glycaemia during school hours. This study aimed to evaluate glucose levels during school in primary school‐aged children with T1D in Western Australia (WA) and to compare these with non‐school days. Methods: A 12‐week cross‐sectional cohort study was performed comprising a WA school term and subsequent school holidays, utilising demographic, clinical and continuous glucose monitor data from the WA Children's Diabetes Database for primary school children with > 1 year of diagnosis of T1D. Results: A total of 235 children, mean age 9.54 ± 1.67 years and duration of T1D of 4.08 ± 2.31 years met inclusion criteria. Children had higher mean ± standard deviation time in range (3.9–10.0 mmol/L) during school (58.0% ± 15.8%) than equivalent hours during school holidays (53.5% ± 18.8%, p < 0.001) and weekends (56.6% ± 17.3%, p = 0.006). Children had lower mean sensor glucose, SD sensor glucose and time above range (> 10.0 and > 13.9 mmol/L) during school compared to school holidays and weekends. Time below 3.9 mmol/L was higher during school time compared with weekdays during school holidays ( p = 0.024), but lower than on school term weekends ( p = 0.009), and < 4% in all periods. There was no significant difference in time below 3.0 mmol/L. Conclusions: Primary school‐aged children in WA had modestly improved glycaemia during school compared with weekends, with more pronounced improvements compared with school holidays.

OBJECTIVE: To investigate the change in prevalence of impaired awareness of hypoglycemia (IAH) and severe hypoglycemia (SH) across three cohorts (2002, 2015, and 2024) in youth with type 1 diabetes. RESEARCH DESIGN AND METHODS: Youth (12–18 years old) completed a Modified Clarke questionnaire to assess IAH. Prevalence of IAH and recent SH was compared across cohorts. Continuous glucose monitoring (CGM)-derived metrics were compared between those with and without IAH in 2024. RESULTS: IAH prevalence was 15.9% compared with 33.1% in 2002 (P < 0.001) and 21.4% in 2015 (P = 0.051). The 2024 SH rate was 0.92 per 100 patient-years, 3.5-fold lower (95% CI 1.2, 12.5) than in 2015 and 30-fold lower (12.7, 98.9) than in 2002 despite HbA1c reduction across cohorts (P < 0.001). Hypoglycemia exposure did not differ between IAH and non-IAH when analyzing CGM metrics (P > 0.05). CONCLUSIONS: IAH and SH have declined substantially over two decades, reflecting improved diabetes care. However, ongoing IAH signifies the need for routine screening.

Background: Automated insulin delivery (AID) improves glycemia in people with type 1 diabetes (T1D). However, concern remains about early worsening of diabetic retinopathy (EWDR) following rapid and large glycemic improvements. This study evaluated diabetic retinopathy (DR) outcomes in adolescents and young adults with T1D (aged 10-30 years) following AID initiation. Methods: This retrospective observational study included adolescents and young adults with T1D and hemoglobin A1c (HbA1c) ≥ 8.5% (69 mmol/mol) prior to AID initiation. Clinical data, continuous glucose monitoring (CGM) metrics, and retinopathy grading were collected from research and clinical databases before and after at least three months of AID initiation. Statistical analyses assessed outcomes. Results: A total of 95 adolescents/young adults (mean age 17.8 years, diabetes duration 9.7 years, 54.7% female) with a baseline HbA1c of 10.3% (89.5 mmol/mol) were included. Mean HbA1c improved by 2.1 percentage points (22.6 mmol/mol) following AID initiation. Retinopathy remained stable or improved in 72/95 (75.8%), while 23/95 (24.2%) experienced EWDR inclusive of diabetic macular edema (DME). While no one required treatment for DME, proliferative DR requiring treatment developed in three participants (3.2%); all had preexisting retinopathy and ≥1 additional diabetes-related complication/risk factor. Logistic regression identified age >18 years and preexisting retinopathy at AID initiation as the only significant risk factors for EWDR. Conclusions: Automated insulin delivery is associated with substantial glycemic improvement in adolescents and young adults with T1D. Despite these large glycemic improvements, diabetic retinal disease remains stable or improves in most cases. Risk factors for deterioration include age >18 years and preexisting DR.

Introduction: Mitochondrial diabetes is rare and typically treated with dietary intervention and oral hypoglycaemic agents. Most require insulin. Novel treatments are available but are not well characterised. Case Presentation: A 16-year-old adolescent girl with a genetically confirmed diagnosis of MELAS due to an m.3243A>G variant presented with clinical and biochemical features of diabetes. She was successfully transitioned from subcutaneous insulin therapy to weekly GLP-1RA monotherapy shortly after diagnosis of diabetes. Treatment with 0.25 mg semaglutide SC weekly led to a reduction in HbA1c from 13.7% (126 mmol/mol) to 5.6% (38 mmol/mol) over a 7-month period. Insulin was completely ceased within 5 days of starting semaglutide. CGM data from a 11 months follow-up period are presented, which demonstrate CGM data meeting glycaemic targets. Conclusion: Low-dose semaglutide 0.25 mg sc weekly was efficacious and well tolerated without lactic acidosis. Use of GLP-1RA could be considered a novel and effective treatment in the pharmacological management of paediatric mitochondrial diabetes.

Purpose: Octreotide is second-line treatment for patients with congenital hyperinsulinism (CHI) unresponsive to diazoxide. Short-acting octreotide is administered via subcutaneous (SC) injection or continuous infusion using a pump, but limited data exist on pump therapy. We present two cases of CHI managed with an octreotide infusion via pump with or without concurrent continuous glucose monitoring (CGM), providing practical guidance. Case presentation: Octreotide 500mcg/1ml ampoule was used. The starting dose was 5mcg/kg/day, with titration to optimize glycaemia, and delivered as a continuous basal rate using a pump. CGM was used by Patient 2. Patient 1: CHI due to a paternal ABCC8 mutation was detected at 16 weeks of age, with diffuse uptake on 18F-DOPA PET. Unresponsive to diazoxide, SC octreotide injections commenced, transitioning to an infusion (13mcg/kg/day) with good response, and complete cessation of therapy at four years. Patient 2: Neonate with CHI due to Beckwith Wiedemann Syndrome developed side-effects from diazoxide and was commenced on SC octreotide injections. Effective at 30mcg/kg/day, he transitioned to an infusion at 4.5 months followed by long-acting octreotide at 12 months. Both patients tolerated the infusion with no adverse effects. Conclusion: This report highlights the practical use of octreotide infusion via pump. When combined with CGM, it allows for tailored dosing to meet individual needs while enhancing patient convenience.