RESPONSE TO COMMENT ON LITTLE ET AL. Recovery of Hypoglycemia Awareness in Long-standing Type 1 Diabetes: A Multicenter 2 3 2 Factorial Randomized Controlled Trial Comparing Insulin Pump With Multiple Daily Injections and Continuous With Conventional Glucose Self-monitoring (HypoCOMPaSS). Diabetes Care 2014;37:2114–2122 Diabetes Care 2014;37:e272–e273 | DOI: 10.2337/dc14-1947 We agree with Edelman (1) that the HypoCOMPaSS protocol (2) does not re- flect current routine clinical practice. It was not our intention to replicate existing suboptimal clinical practice with regard to conventional multiple daily injection (MDI) therapy and self-monitoring of blood glucose (SMBG). Rather, the prem- ise of our study focused on achievability within routine care. We do not agree that education, weekly telephone con- tact, and monthly visits (as part of a tar- geted 6-month intervention for those with impaired awareness of hypogly- cemia [IAH]) should be dismissed as unachievable. We have shown the po- tential for a .10-fold reduction in severe hypoglycemia (SH)dincluding in those patients not receiving more costly tech- nological interventions (2). Moreover, given increasing availability of bolus cal- culators on both handheld glucometers and cell phone apps, there is no reason why access should be limited to those using continuous subcutaneous insulin infusion (CSII) or real-time continuous glucose monitoring (RT-CGM). Edelman highlights our intent to pro- vide comparable education and support, but emphasizes that “device and glu- cose management education should dif- fer for different devices” (1). This was indeed the case, as detailed in our initial protocol publication (3). Participants randomized to CSII or RT-CGM attended specific training sessions tailored to safe and effective use, while those random- ized to MDI or SMBG attended compa- rable but distinct sessions also focused on optimized use. All participants were provided with clear and specific insulin titration protocols, previously reported in detail (3). We question the assertion that there was “lack of glycemic benefit observed in the subjects who used pumps and CGM” (1), as our goal was active insulin titration to avoid biochemical hypogly- cemia without worsening overall glyce- mic control. This was rapidly achieved in all groups within the first 4 weeks and maintained throughout the randomized controlled trial (2). We accept that “consistency of use of the CGM device is a known key determi- nant for clinical benefit” (1) but do not agree that there was lack of clinical ben- efit in our study. RT-CGM was successful in improving IAH and preventing SH, and we observed that comparable benefits could be accrued from optimized SMBG. Of particular interest, although those using RT-CGM for .50% of the time ap- peared more successful in avoiding bio- chemical hypoglycemia and achieving best overall glycemic control, this did not translate to greater improvement in IAH and SH in this very high-risk group. 1 Institute of Cellular Medicine, Newcastle University, Newcastle, U.K. 2 Wellcome Trust-MRC Institute of Metabolic Science Metabolic Research Laboratories, University of Cambridge, Cambridge, U.K. 3 School of Medicine and Biomedical Sciences, Sheffield University, Sheffield, U.K. 4 Peninsula College of Medicine and Dentistry, Plymouth, U.K. 5 Bournemouth Diabetes and Endocrine Centre, Royal Bournemouth Hospital, Bournemouth, U.K. 6 Newcastle Clinical Trials Unit, Institute of Health and Society, Newcastle University, Newcastle, U.K. 7 AHP Research, Hornchurch, U.K. 8 The Australian Centre for Behavioural Research in Diabetes, Diabetes AustraliadVic, Melbourne, Australia 9 Centre for Mental Health and Wellbeing Research, School of Psychology, Deakin University, Burwood, Australia 10 Centre for Postgraduate Medical Research and Education, Bournemouth University, Bournemouth, U.K. Corresponding author: James A.M. Shaw, jim.shaw@ncl.ac.uk. © 2014 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. Stuart A. Little, 1 Lalantha Leelarathna, 2 Emma Walkinshaw, 3 Horng Kai Tan, 4 Olivia Chapple, 5 Alexandra Lubina-Solomon, 3 Thomas J. Chadwick, 6 Shalleen Barendse, 7 Deborah D. Stocken, 6 Catherine Brennand, 6 Sally M. Marshall, 1 Ruth Wood, 6 Jane Speight, 7,8,9 David Kerr, 10 Daniel Flanagan, 4 Simon R. Heller, 3 Mark L. Evans, 2 and James A.M. Shaw 1 e272 Diabetes Care Volume 37, December 2014 e-LETTERS – COMMENTS AND RESPONSES