When people with diabetes (PwD) are introduced to real-time continuous glucose monitoring (rtCGM), they may still struggle to meet glycemic targets, as highlighted by the T1D Exchange. We assessed missed bolus doses (MBD) in relation to psychosocial factors and rtCGM use in PwD using insulin. This 12-week, single-arm, observational study enrolled PwD who reported A1C ≥8% and taking ≥3 insulin boluses/day. We administered the Adult Low Blood Sugar Survey short form (ALBSS), which evaluates hypoglycemic fear at baseline. Data from a connected insulin pen and CGM (1st 6 weeks blinded, 2nd 6 weeks rtCGM) were used to calculate MBD as defined by an 80 mg/dL glucose increase over ≤2 hours not preceded within 1 hour by an insulin dose. A mixed-effect model for repeated measures tested the association of MBD with ALBSS. Logistic regression assessed the relationship of MBD change (blinded to rtCGM) with ALBSS. Covariates in both models were baseline A1C (≤ or >9%), diabetes type and duration, sex, ethnicity, age, and BMI. Participants (N=68), mean age 48 (range 22-65 years), were 44% female, 18% Hispanic, 59% T1D. The mean ALBSS score was 13.7 (range 0-34). In the blinded period, a mean of 0.94±0.39 MBD/day were calculated, which reduced in rtCGM (0.85±0.37 MBD/day, p=0.05). For blinded and rtCGM, more frequent MBD were independently associated with greater hypoglycemic fear (ALBSS, p=0.04) and higher baseline A1C (p=0.001). Participants with greater hypoglycemic fear were more likely to miss more bolus doses even after switching to rtCGM (odds ratio 1.1, p=0.045). MBD were relatively common in PwD using multiple daily injections who had not achieved adequate glycemic control. Hypoglycemic fear was associated with more MBD, even following the introduction of rtCGM. Therefore, when managing PwD using bolus insulin, clinicians should address fear of hypoglycemia as a potential barrier to appropriate dosing. As shown in this exploratory study, without attention to psychosocial factors, technology may not contribute to improved self-care.


S.S. Edwards: Employee; Self; Eli Lilly and Company. J. Johnson: Employee; Self; Eli Lilly and Company. Stock/Shareholder; Self; Eli Lilly and Company. H. Wolpert: Employee; Self; Eli Lilly and Company. X. He: Employee; Self; Eli Lilly and Company. C.Y. Kao: None. E. Meadows: Employee; Self; Eli Lilly and Company. Stock/Shareholder; Self; Eli Lilly and Company. J. Poon: Employee; Self; Eli Lilly and Company. D.A. Price: Employee; Self; Dexcom, Inc. Stock/Shareholder; Self; Johnson & Johnson. W. Polonsky: Consultant; Self; Abbott, Bigfoot Biomedical, Dexcom, Inc., Eli Lilly and Company, Insulet Corporation, Johnson & Johnson Diabetes Institute, Merck & Co., Inc., Novo Nordisk Inc., Sanofi, Servier.

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