Classifications

• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61M—DEVICES FOR INTRODUCING MEDIA INTO, OR ONTO, THE BODY; DEVICES FOR TRANSDUCING BODY MEDIA OR FOR TAKING MEDIA FROM THE BODY; DEVICES FOR PRODUCING OR ENDING SLEEP OR STUPOR
  • A61M5/00—Devices for bringing media into the body in a subcutaneous, intra-vascular or intramuscular way; Accessories therefor, e.g. filling or cleaning devices, arm-rests
  • A61M5/14—Infusion devices, e.g. infusing by gravity; Blood infusion; Accessories therefor
  • A61M5/168—Means for controlling media flow to the body or for metering media to the body, e.g. drip meters, counters ; Monitoring media flow to the body
  • A61M5/172—Means for controlling media flow to the body or for metering media to the body, e.g. drip meters, counters ; Monitoring media flow to the body electrical or electronic
  • A61M5/1723—Means for controlling media flow to the body or for metering media to the body, e.g. drip meters, counters ; Monitoring media flow to the body electrical or electronic using feedback of body parameters, e.g. blood-sugar, pressure
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61F—FILTERS IMPLANTABLE INTO BLOOD VESSELS; PROSTHESES; DEVICES PROVIDING PATENCY TO, OR PREVENTING COLLAPSING OF, TUBULAR STRUCTURES OF THE BODY, e.g. STENTS; ORTHOPAEDIC, NURSING OR CONTRACEPTIVE DEVICES; FOMENTATION; TREATMENT OR PROTECTION OF EYES OR EARS; BANDAGES, DRESSINGS OR ABSORBENT PADS; FIRST-AID KITS
  • A61F2/00—Filters implantable into blood vessels; Prostheses, i.e. artificial substitutes or replacements for parts of the body; Appliances for connecting them with the body; Devices providing patency to, or preventing collapsing of, tubular structures of the body, e.g. stents
  • A61F2/02—Prostheses implantable into the body
  • A61F2/022—Artificial gland structures using bioreactors
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61M—DEVICES FOR INTRODUCING MEDIA INTO, OR ONTO, THE BODY; DEVICES FOR TRANSDUCING BODY MEDIA OR FOR TAKING MEDIA FROM THE BODY; DEVICES FOR PRODUCING OR ENDING SLEEP OR STUPOR
  • A61M5/00—Devices for bringing media into the body in a subcutaneous, intra-vascular or intramuscular way; Accessories therefor, e.g. filling or cleaning devices, arm-rests
  • A61M5/14—Infusion devices, e.g. infusing by gravity; Blood infusion; Accessories therefor
  • A61M5/168—Means for controlling media flow to the body or for metering media to the body, e.g. drip meters, counters ; Monitoring media flow to the body
  • A61M5/172—Means for controlling media flow to the body or for metering media to the body, e.g. drip meters, counters ; Monitoring media flow to the body electrical or electronic
  • A61M5/1723—Means for controlling media flow to the body or for metering media to the body, e.g. drip meters, counters ; Monitoring media flow to the body electrical or electronic using feedback of body parameters, e.g. blood-sugar, pressure
  • A61M2005/1726—Means for controlling media flow to the body or for metering media to the body, e.g. drip meters, counters ; Monitoring media flow to the body electrical or electronic using feedback of body parameters, e.g. blood-sugar, pressure the body parameters being measured at, or proximate to, the infusion site
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61M—DEVICES FOR INTRODUCING MEDIA INTO, OR ONTO, THE BODY; DEVICES FOR TRANSDUCING BODY MEDIA OR FOR TAKING MEDIA FROM THE BODY; DEVICES FOR PRODUCING OR ENDING SLEEP OR STUPOR
  • A61M2205/00—General characteristics of the apparatus
  • A61M2205/50—General characteristics of the apparatus with microprocessors or computers
  • A61M2205/52—General characteristics of the apparatus with microprocessors or computers with memories providing a history of measured variating parameters of apparatus or patient

Definitions

• hypoglycemia defined as having a blood glucose concentration greater than 180mg/dl [2]), leading to diabetic ketoacidosis and long-term complications such as cardiovascular disease, kidney failure, blindness, and death [3].
• Manual administration of exogenous insulin to treat T1DM requires multiple exacting calculations of blood glucose concentrations and carbohydrate ingestion daily, as even a slight overdose may cause immediate life-threatening consequences of low blood glucose concentrations (called “hypoglycemia” and generally defined as having a blood glucose concentration lower than 70mg/dl [2]), including trembling, weakness, difficulty speaking, convulsion, unconsciousness, and death [3]. Due to these and other complications, the average life expectancy of individuals with type 1 diabetes continues to lag at least a decade behind that of the overall population [4].
• a closed-loop system combines a subcutaneous continuous glucose monitor (CGM) and continuous subcutaneous insulin injections (CSII) pump to deliver insulin.
• CGM subcutaneous continuous glucose monitor
• CSII continuous subcutaneous insulin injections
• [14] can be used to design a controller based on linear models.
• a subject's basal insulin injection characteristic is incorporated in addition to the total daily insulin (TDI) clinical parameter used by Van Heusden et al. to further attune the controller action in cases of model and patient mismatch.
• TDI total daily insulin
• the disclosed controller also incorporates an insulin feedback scheme (IFB) which accelerates the apparent insulin pharmacokinetic profile.
• IFB insulin feedback scheme
• PID controllers that incorporate this scheme can exhibit improved performance, as shown in both model simulations [15] and a clinical trial [16].
• the key component in a successful artificial pancreas system designed to maintain the blood glucose concentrations of people with type I diabetes mellitus within the euglycemic zone (80- 140mg/dl) is the control algorithm, which automatically directs the delivery of insulin to be administered to a subject with type 1 diabetes.
• the controller must meet a variety of challenges, such as the inherent long time delays between subcutaneous sensing, subcutaneous pump action, and the body's insulin-blood glucose dynamics, among others.
• the performance of any algorithm is limited by the development of a reliable model from which to base the controller design - controllers based on irrelevant models may not deal with the particular control challenges inherent in the artificial pancreas applications successfully, inducing hypoglycemic risk within the subjects.
• the invention combines an internal model control based design of a proportional-integral-derivative controller with individual gain personalization based on each subject's clinical characteristics.
• the invention uses a discrete model with a priori subject information; in particular embodiments the personalized controller is based on a lower order model, such as a 3 rd order model, but 1 st , 2 nd , 4 th , 5 th or other lower order model may be used, and preferred lower dimensional models are 5 th order or lower.
• the subject's basal insulin is incorporated into the lower order model to further personalize the controller's aggressiveness and take into account the wide variations in insulin sensitivity throughout the population.
• This personalization allows the controller to be appropriately aggressive in cases where the subject is insensitive to insulin and requires a large basal amount to maintain euglycemia, while preventing hypoglycemic risk by bringing down the controller's aggressiveness in cases where the subject requires a low basal amount to maintain normal blood glucose levels.
• the invention provides an internal model-based proportional-integral- derivative (IMC-PID) controller with an insulin feedback (IFB) scheme personalized based on a priori subject characteristics and comprising a lower order control-relevant model to obtain PID controller parameters through an IMC based approach adapted for artificial pancreas (AP) applications.
• IMC-PID insulin feedback
• IFB insulin feedback
• the invention provides an internal model-based proportional- integral-derivative (IMC-PID) controller adapted for an artificial pancreas (AP) system which controller requires only a single tuning parameter to modify controller performance and comprises a discrete lower order model with a priori subject information as design criteria, wherein a subject's basal insulin injection characteristic is incorporated, in addition to the total daily insulin (TDI) clinical parameter to further attune the controller's action in cases of model and patient mismatch, and an insulin feedback scheme (IFB), which accelerates the apparent insulin pharmacokinetic profile.
• IMC-PID internal model-based proportional- integral-derivative
• AP artificial pancreas
• the invention provides a controller for an artificial pancreas (AP) system adapted to maintain blood glucose concentrations of people with type I diabetes mellitus within the euglycemic zone (80-140mg/dl) comprising a control algorithm, and which automatically directs the delivery of insulin to be administered to a subject with type 1 diabetes, comprising an internal model control (IMC) based design of a proportional-integral- derivative (PID) controller with individual gain personalization based on each subject's clinical characteristics, using a lower order discrete model with a priori subject information, wherein the subject's basal insulin is incorporated into the lower order model to further personalize the controller's aggressiveness and take into account variations in insulin sensitivity, wherein the personalization allows the controller to be aggressive in cases where the subject is insensitive to insulin and requires a large basal amount to maintain euglycemia, while preventing hypoglycemic risk by reducing the controller's aggressiveness in cases where the subject requires a low basal amount
• the invention also provides corresponding algorithms for programming the subject controllers to effectively implement the disclosed control steps.
• the invention also provides an artificial pancreas system or subsystem comprising a subject controller, which may comprise for example, the controller and a pump.
• a subject controller which may comprise for example, the controller and a pump.
• the invention also provides a model-based personalization scheme of an artificial pancreas (AP) for Type I diabetes applications comprising a control algorithm which controls a subject controller.
• AP artificial pancreas
• the invention also provides a method comprising directing insulin delivery using a subject controller, and optionally delivering the insulin.
• the invention includes controllers, algorithms and insulin directing systems essentially as described herein, and includes all combinations of the recited particular embodiments. All publications and patent applications cited in this specification are herein incorporated by reference as if each individual publication or patent application were specifically and individually indicated to be incorporated by reference.
• Controllers are assessed as a part of an AP system that utilizes noise-free and noise- included blood glucose measurements and continuous subcutaneous insulin injections.
• the system is incorporated as a part of a ten subject study using the Food and Drug
• a controller that is implemented in this manner must meet a variety of challenges.
• K can be personalized using a priori subject parameters as
• Kj is an individualized gain based on the correction factor calculated as
• TDI represents the subject's total daily insulin requirement, an easily available clinical parameter for any subject with a history of type 1 diabetes, c is a factor to maintain consistency in units as
• SFb is a scaling factor based on the actual value of the subject's basal profile, another easily available clinical parameter, versus what is recommended as the standard starting basal quantity calculated from their TDI prior to further adjustments, as follows
• b is the subject's actual nominal basal in U/h
• b ca i c is the recommended calculation for a subject with TlDM's initial basal rate prior to fine-tuning, with the factor in the formula for the calculation varying between 0.4 and 0.6 depending on the subject's fitness, age, and other characteristics.
• Basal insulin profile of a subject with T1DM is a standard part of the subject's daily injection regimen, and is designed to maintain the subject at euglycemia absent meal disturbances [18].
• this unitless scaling factor can attenuate the control signal based on how much more or less insulin the subject actually requires to maintain open-loop glucose concentration compared to the standard as calculated by the subject TDI, thus providing a measure of insulin sensitivity greater or less than standard.
• the discrete model as shown in (1) can be transformed to continuous domain using a bilinear transform approximation as The discrete model as shown in (1) can be transformed to continuous domain using a bilinear transform approximation as
• T s is the sampling time of the discretized model at 5 minutes.
• the IMC method for PID controller tuning relations calls for a low pass filter with a gain of 1 and a tuning parameter x c , leading to the calculations of the three PID controller parameters K c , 3 ⁇ 4 ⁇ and 3 ⁇ 4> as [23]
• the control signal as a result of the application of these parameters in the standard parallel form of the PID controller is added on the subject's basal to signal the final suggested insulin delivery IDPID to the insulin pump.
• This insulin signal can then be further attenuated by the use of IFB [15], which takes into account the amount of insulin previously delivered, accelerating the apparent insulin pharmacokinetics as
• n denotes the most recent time value
• ID(n) is the final insulin delivery profile
• Ip(n) is a real time estimate of insulin concentration.
• Kj, K 2 , and ⁇ are constants each reported as 1.966308, 0.966584, and 0.5, with K 0 given as
• the performance of the designed PID controller is tested in silico within the FDA accepted UVA/Padova metabolic simulator [17].
• the simulator contains ten subject models with various time-invariant clinical characteristics that have a large intersubject variability.
• the simulator also has the capability of providing an optimal bolus injection when given the meal size for each subject based on the subject's basal rate and insulin to carbohydrate ratio (I:C), a clinical parameter that signifies how many grams of carbohydrates are compensated for that specific patient for a unit of insulin.
• I:C insulin to carbohydrate ratio
• Optimal regulation in the context of the disclosed AP, is defined providing the perfect basal rate for each subject that would, given no disturbances, maintain blood glucose concentration at the 1 lOmg/dl target (average of the euglycemic zone). Further, a perfect bolus should also be provided at the beginning of each meal that does not over or under- compensate for the glucose content of the meal, thus both avoiding late postprandial hypoglycemia and minimizing hyperglycemia prior to returning to the target. On the other hand, the minimum amount of regulation would feasibly still provide the same basal rate but eschew meal disturbance rejection, and thus will be prone to long episodes of hyperglycemia.
• each controller is measured using a medically inspired metric that takes into account the three objectives outlined in the control specifications, scored in a linearly scaled approach with the perfect basal-only control scheme serving as the baseline ("0") and the perfect basal-bolus scheme serving as the top performer (“1") ⁇
• the specific metrics are:
• any controller that causes a subject to experience hypoglycemia b virtue of blood glucose concentrations below 70mg/dl is discarded.
• the controller is turned on after an initialization period of 20 minutes from the beginning of the simulation. A 50g meal is given at 7 hours after the beginning of the simulation. Each subject's blood glucose profile is recorded for 24 hours after the meal disturbance, with total simulation duration of 31 hours. The controller is activated every 5 minutes, and actual insulin delivery is discretized to the nearest 0.05U to simulate the limits on current generation subcutaneous insulin pumps [24].
• r c is varied as the only tuning parameter from 60 to 300 minutes, in 60 minute intervals. As can be seen in the scaled performance scores in Table II, a Tc of 120 minutes gives the best response among the tested settings while still avoiding any instances of hypoglycemia. The controller setting with r c of lh was discarded due to the presence of hypoglycemia. [078] After the optimal IMC PID controller is found through this method under noise-free conditions, the controller is then detuned accordingly within noisy conditions to test for robustness. r c is varied from 2 to 6 hours in 30 minute intervals. r c settings of 4 hours or less induced hypoglycemia. Fig.
• Fig. 2 shows the average glucose and insulin profiles of controllers that does not express hypoglycemia under noisy conditions.
• r c setting of 4.5h achieves the closest performance to the optimal basal-bolus profile while still avoiding hypoglycemia, with an average postprandial (post meal) peak of 183mg/dl and over 95 percent of time spent within the safe zone of 70mg/dl to 180mg/dl within 24 hours of the meal disturbance.
• Fig. 3 shows the average, minimum, and maximum values for each step for this setting and is compared with the optimal basal-bolus control scheme.
• the disclosed controller has a slightly higher prandial peak, it still maintains all subject glucose profiles within the target zone for an extreme majority of the simulations and avoids any instances of hypoglycemia.
• This disclosure demonstrates the value of an IMC -based design method with a personalization scheme to calculate PID controller parameters and combine it with IFB for AP applications.
• the subject controller with subject specific personalization of the controller's aggressiveness and inclusion of IFB give good control results based on a set of metrics designed to quantify each controller's adherence to medically inspired objectives. Selection of correct personalization methods and an optimal TC value gives a resulting average subject glucose profile that can closely match the optimal basal-bolus scheme, while avoiding hypoglycemia for all 10 tested subjects.
• a 3rd order control-relevant model was used to obtain PID controller parameters through an IMC based approach for AP applications.
• the resulting PID controller with accompanying IFB scheme was personalized based on a priori subject characteristics and tested on ten simulated subjects under the UVA/Padova metabolic simulator.
• Optimal controller settings were determined through a set of controller performance metrics, and the PID controller based on the resulting choice in personalization rule parameters and TC was able to achieve comparable performance to the optimal basal-bolus scheme.
• the average post prandial peak was maintained below 185mg/dl, and 97% of the combined total simulation time for all subjects was maintained within the target safe blood glucose zone of 70-180mg/dl with 80% of the time remaining within the euglycemic zone of 80-140mg/dl - all without inducing instances of hypoglycemia.
• the controller can achieve this performance without a time-consuming model identification step, and thus will have greater utility in practical applications.
• UVA/Padova metabolic simulator to a 50g meal disturbance applied to the IMC PID controller as described in the text, with setpoint at 1 lOmg/dl, T c at 3h, and various combinations of personalization rule settings as in table I.
• Solid continuous line represents controller 1 (optimal basal-bolus scheme)
• thin continuous line represents controller 2 (optimal basal scheme)
• thick dashed line represents controller 3 (1600 correction factor and 0.4 basal factor)
• thin dashed line represents controller 4 (1600 correction factor and 0.6 basal factor)
• thick dash dotted line represents controller 5 (2400 correction factor and 0.6 basal factor)
• thin dash dotted line represents controller 10 (PID without personalization but with insulin feedback)
• thick dotted line represents controller 11 (PID without personalization and without insulin feedback).
• FIG. 1 Comparison of various T c settings with noise. Average blood glucose profiles and insulin delivery for 10 in silico subjects simulated in the UVA/Padova metabolic simulator to a 50g meal disturbance applied to the IMC PID controller as described in the text, with setpoint at 1 lOmg/dl, correction factor rule chosen as 1600, basal calculation factor chosen as 0.4, and t c varied from 2h to 6h in 30 minute intervals. Controller with T c of 4h or less were discarded due to presence of hypoglycemia.
• Solid continuous line represents controller 1 (optimal basal-bolus scheme), thin continuous line represents controller 2 (optimal basal scheme), thick dashed line represents controller 17 ( ⁇ 0 of 4.5h), thin dashed line represents controller 18 ( ⁇ 0 of 5h), and thick dash dotted line represents controller 19 ( ⁇ 0 of 5.5h) and thin dash dotted line represents controller 20 (T c of 6h).
• FIG. 3 Comparison of the best PID controller with noise and the optimal basal bolus scheme. Average, minimum, and maximum blood glucose profiles and average insulin delivery for 10 in silico subjects simulated in the UVA/Padova metabolic simulator to a 50g meal disturbance applied to the IMC PID controller as described in the text, with setpoint at 1 lOmg/dl, correction factor rule chosen as 1600, basal calculation factor chosen as 0.4, and T C chosen as 4.5h. Dashed lines represent the controller's average, minimum, and maximum values at each time point and controller insulin delivery profiles. Solid lines represent the same characteristics of the basal bolus scheme.
• Tamborlane "Fully automated closed-loop insulin delivery versus semiautomated hybrid control in pediatric patients with type 1 diabetes using an artificial pancreas," Diabetes Care, vol. 31, pp. 934-9, May 2008.

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