My thoughts on the American Diabetes Association’s 78th Scientific Sessions
As usual, this year’s American Diabetes Association Scientific Sessions didn’t place much emphasis on a healthy lifestyle. There was food everywhere, and trust me, we’re not talking fruits & veggies. And given the oppressive Orlando, FL summer climate, the only running we did was to get a seat near the a/c.
But there was a great deal of research presented on diabetes medications and devices.
Here’s a quick summary:
- Enough is enough! There were dozens of oral presentations and research posters on the subtle differences between the multitude of long-acting insulins, SGLT-2 inhibitors (oral meds that facilitate the loss of glucose through the urine), and GLP-1 agonists (injectables that slow digestion, invigorate functioning beta cells, and blunt both appetite and glucagon secretion). To me, this is much more a quest for profit than meaningful clinical outcomes and improving patients’ quality of life. Let’s move on.
- Finally, the pharmaceutical industry is paying some attention to the needs of the type-1 community. Results of a one-year randomized study showed that liraglutide (a GLP-1 agonist) produced significant reductions in A1c, average blood glucose, blood pressure and weight – all without any increase in hypoglycemia. Data was also presented on use of sotagliflozin, an SGLT-1 and 2 inhibitor, in people with type-1. SGLT-1 inhibitors blunt the absorption of glucose through the upper-GI tract, thus delaying the glucose rise after meals; SGLT-2 inhibitors block the reabsorption of glucose by the kidneys, thus leading to excretion of glucose in the urine. The two together seem to have a synergistic effect, producing a significant reduction in A1c, post-meal glucose peaks, weight, and bolus insulin requirements. Users saw their “time in-range” (as measured by CGM) increase from 56% to 68%. Sanofi submitted sotagliflozin to the FDA for a type-1 indication in May, and hope to have approval some time in 2019.
- For the first time ever, there were more companies promoting CGM systems than traditional glucose meters. Senseonics’ Eversense implanted sensor received a great deal of attention, as it appears to produce accuracy close to that of the Dexcom, and the sensor implantation process is a lot less invasive than everyone imagined. Abbott was busy selling the merits of its Libre system as a replacement for fingersticks, particularly for the type-2 market. And Dexcom proudly showed off its new calibration-free G6 system with one-button sensor insertion. Even Medtronic got into the act with its new Guardian Connect freestanding CGM system, preferring to place greater emphasis on its pattern-detection software than on the sensor itself.
- Insulin pump therapy was completely overshadowed by hybrid closed loop (hcl) technology. The only real innovation with the pumps themselves involved Insulet’s recently-approved Dash programmer, a cell-phone-like device that will replace the bulky, old-school PDM for controlling the OmniPods. But there was greater excitement over data on Insulet’s Horizon hcl system. Safety and performance data on the system’s personalized, model-predictive control algorithm showed an increase in time spent in-range (from 64% to 74%), a reduction in time spent in a hypoglycemic range both overall (from 5% to 2%) and overnight (from 6% to less than 1%). Tandem presented data on its recently-approved predictive low glucose suspend feature, which suspends basal insulin delivery any time glucose levels are projected to dip below 80 mg/dl within the next 30 minutes. Basal delivery resumes as soon as glucose levels rise at all. The feature runs in the background – it does not disturb the user and turns basal insulin off/on automatically. While reducing the incidence of hypoglycemia by 31%, it was not associated with any increase in average glucose.
- The whole “To Carb or Not to Carb” debate rages on. An Australian study comparing the effects of a low-carb (and low saturated-fat) diet to a traditional high-carb diet in people with type-2 diabetes showed the following:
- No difference in weight loss
- No difference in A1c
- No difference in blood pressure
- No difference in renal (kidney) function
- No difference in cognitive (brain) function
- No difference in LDL cholesterol
- Less glycemic variability (lower post-meal peaks) with the low-carb diet
- Lower insulin and medication requirements with the low-carb diet
- Better HDL levels with the high-carb diet
Although the low carb approach doesn’t seem to do any real harm (and may help in a few areas) for those with type-2 diabetes, the same cannot be said for low-carb diets in children. Data revealed that kids following low-carb diets are more prone to stunted growth, family emotional conflicts, iron deficiency, high cholesterol, eating disorders, hypoglycemia, and a diminished response to hypoglycemia.
A few other “fun facts” obtained at the conference:
- In the US, there is 1 diabetes educator for every 367 people with diabetes, and one diabetes-focused psychologist for every 3,367.
- People with diabetes who analyze their own data for patterns experience far less hypoglycemia than those who do not.
Experiments in Exercise:
- People with alzheimers and diabetes may be able to improve their memory by performing regular cardiovascular exercise; enhanced insulin sensitivity is believed to be involved.
- For those who experience elevated blood sugars after high-intensity exercise, normal correction doses of insulin (rather than decreased doses) appear to work fine.
- Individual responses to exercise vary, but early morning (fasting) high-intensity exercise produces an average blood sugar rise of approximately 70 mg/dl (4 mmol/l).
- The risk of hypoglycemia during and immediately after moderate-intensity cardio workouts can be reduced by approximately one-third by plugging intermittent sprints (4 seconds every 2 minutes, or 10 seconds every 20 minutes) into the workout.
- People with diabetes who download their devices and analyze their own data for patterns experience far less hypoglycemia than those who do not.
- Users of the Freestyle Libre glucose monitor saw improvements in overall glucose control as the number of daily “scans” (data reads) increased, with the best control at 9-12 “scans” per day.
- Multiple-port infusion sets produce wider and more even distribution of insulin in the subcutaneous space.
- By combining Humalog (lispro) insulin with Biochaperone (hyalaronidase), the insulin starts working an average of eight minutes earlier, peaks 10 minutes earlier, and stops working 22 minutes earlier than ordinary lispro. It also shows greater action one hour after injection and a shorter duration of action compared to Fiasp (utra-rapid) insulin.
- Use of the type-2 diabetes drug metformin during pre-pregnancy may help reduce weight gain during pregnancy in overweight women.
- Women with diabetes who have multiple unsuccessful pregnancies are at an increased risk of health problems and death than women who have successful pregnancies.
- Sleep apnea is common during pregnancy, and correlates with increased blood sugar levels during the third trimester.
- A hybrid closed loop system developed by the University of Cambridge did a great job of managing blood sugars in type-1 women during and after labor; could have implications for using other closed-loop systems.
And in conclusion…
Apparently, praying to the “Ice Gods” at the Orlando Ice Bar, even with the combined efforts of myself and JDRF President Aaron Kowalski, does not guarantee a speedy cure for diabetes. (see image below).