Having connections in the diabetes world is great.
It is with great pleasure that we have a special opportunity to post Dr. Steve Edelman & Dr. Jeremy Pettus’s ADA recap from the recent ADA Scientific Sessions in Boston. These gentlemen are well known and well-loved Endos in Southern California. They run TCOYD as well as We Are One Nation (an online collaborative center for diabetes professionals who are living with type 1 diabetes) – it’s wonderful to have their feedback on upcoming advances that will help our management.
We wanted to send a blurb as promised about what stuck out in the world of type 1 diabetes from the recent ADA conference. Heeeerrrrrre goes!
ARTIFICIAL PANCREAS – So we would say the coolest thing about the AP is that it really has transitioned completely from an “IF” to a “WHEN”.
This ADA stood out to us in that there are a lot of people with stake in this AP game. Multiple research groups and multiple companies racing towards the finish line, which is really great for type 1 peeps. Most us have heard about Ed Damiano and Steve Russel’s Bionic Pancreas out in Boston that uses both insulin and glucagon, but a ton of other research is going into insulin only products. FY there is a controversy of whether to use glucagon in addition to insulin for AP systems because of the risk for hypoglycemia if glucagon is needed and there is an issue with the infusion system. We were impressed with the pipeline that Medtronic has coming out. Let’s be honest, Medtronic has struggled with their sensor technology for awhile but they are now on their enlite 3 version with an army of in-house researcher working on their AP system. They have been in this business for a long time and are dedicated to improving their technology so we really have to hand it to them for that. Their next steps will be a PREDICTIVE low glucose feature that stops insulin secretion if you are within 30 minutes of getting to your low glucose limit (640G now available in Australia). This is a step up from the currently available 530G model that only shuts off when you are actually low. So the idea here is to prevent a low entirely rather than help you recover from one. The data from Bruce Buckingham’s group at Stanford with the 640G was
impressive in that the subjects had not only fewer lows but also fewer highs. The 640G will be followed by the 670G (hybrid-closed-loop with predictive low AND high glucose features.) This pump goes one step further and will start cranking up the insulin when you are high to try to keep you in range. Neither of these are available in the US yet but will likely be in the next year or so. They also have a new design of their pump (finally!) so it looks less like the first pager ever made and more like something you might actually see at best buy or something. So the point really is that there are researchers and pump companies working actively on closing the loop between CGM and insulin pumps and it is happening sooner than later. As the AP hasn’t made endocrinologists obsolete just yet, I haven’t started looking for a new career, but I have started honing my balloon animal making skills in case this AP thing eventually puts me outta work! Best way to lose your job ever – So
until we have the AP we still need to work on our pump technology.
One thing that people were buzzing over is the very soon to be released new Omnipod controller that was on display at their booth. So we both love patch pumps but the current Omnipod PDM is just big and lame. It’s a real pocket buster too, and as a guy who doesn’t carry around a purse or murse (man purse), it just makes things difficult. People would be like “Here comes old bulgy pocket McGillicutty”. Thankfully they have redesigned this to be a touchscreen/slicker device. They ended up keeping it as a functional glucose meter as well which adds to the size of it but handy to use for calibration. I imagine, however, that not a ton of people still rely on the meter function as more and more folks migrate over to CGM. With that in mind, it would be pretty sweet to have a second controller that fit on your key chain and was only for giving a bolus and temporary basal rates. The meter function will become obsolete as soon as Dexcom receives FDA approval for the replacement claim not requiring patients to confirm their BG level with a finger stick (does anybody still do that all the time anyways?). Anyways, just glad to see the one patch pump on the market getting a makeover.
Tandem (makers of T:slim) just starting shipping their larger 480u cartridges for their “T:Flex” pump for folks that require more insulin which is actually a needed advance and opens up pump therapy to more folks including our type 2 blood brothers. They also are still working on integrating the CGM onto the pump screen but that has really been slow to get here, and we actually don’t think that just displaying your CGM info on the pump is THAT big of an advance. The Animas pump already does this but without some sort of integration it just doesn’t get me that revved up. We both personally don’t mind taking out our CGMs to look at it, and sometimes it’s easier to do this than get out your pump (especially for you ladies that wear it attached to your bra etc). We love the Tandem pump, and actually think it’s one of the best traditional pumps on the market, but these days, if you don’t have a clear path forward toward the artificial pancreas, you might be left behind. The people at Tandem are also working on a patch pump which I think is awesome but I have no idea about the timeframe, and with the technology market moving so fast, simply making another pump doesn’t make a lot of sense unless it has some sort of AP technology. CeQur has a patch pump that has excellent features but they are not approved yet by the FDA and looking for a partner. Lastly, BD announced that they formed a partnership with Medtronic to be the distributor of their new and markedly improved infusion line. I have always said that a pump is only as good as the infusion line!
So by this we mean stuff other than insulin to help glucose control. I have to start this one with an anecdote. Steve and I attended an advisory board before the conference in which we went over a lot of the data to be presented at the conference. When we started talking about SGLT-2 meds for type 1s, a very well-known diabetes doc made a statement somewhere along the lines of “type 1s don’t need any tricks to get their sugars down. They need insulin and only insulin. Giving them something else is wrong.”
Well I beg to differ. Recent data still shows that despite our best efforts, type 1s treated in the best clinics in the country are able to get their A1c down to < 7% about 30% of the time. That means that 70% or more of type 1s are not reaching their goal. Is it because we are all dumb and lazy? NO! Part of it is because we are stuck delivering insulin in the subcutaneous tissue that is not physiologic. The insulins aren’t fast enough, lead to delayed hypoglycemia, and the list goes on. So I’m ALL FOR exploring other options IN ADDITION to insulin to help us out. I mean with this kind of logic we might as well just put all type 2s on insulin also and not try any other meds at all. So I’ve gone over and over in my head what I should have said during this meeting. I piped up for sure but in my day dreams I say some way more heroic stuff with like Aerosmith playing in the background while utilizing a wind machine. Anyways, this meeting was great for increasing this specific conversation.
I think folks are FINALLY coming around to the idea that we might actually be able to use other meds for type 1s. Soon when you see your endo you will go over your insulin ratios like normal but then a whole part of the visit could be dedicated to other medications. The SGLT-2 meds do work and seem to help type 1s stay in range a greater percentage of the time…more forgiving with BG swings. There is really no doubt in my mind personally about this. However, as we already sent out an email about, there are some safety concerns of euglycemic DKA. We are actively studying all these meds and should have some answers in the next year or so in terms of whether they can safely be used in type 1s. I think it will happen, but likely at lower doses used in type 2s. I was actually surprised by some data released showing that the GLP-1 agonist, Victoza was able to help type 1s lower their insulin dose and lose weight but did not help with glucose variability or A1c reduction.
Other studies have shown more time in range but we do need a large well controlled study in type 1s.
Some work is being done into both better basal and Uber rapid acting insulin. The most data was presented on Lilly’s new basal insulin called BIL that is a SUPER flat insulin that actually seems to be superior to Lantus in terms of A1c reduction (which is hard to do), has less nighttime hypoglycemia, and less weight gain. All sounds awesome. However, it has more DAYTIME hypoglycemia and has had some issues with liver function elevations and liver fat accumulation. So before this insulin hits the market, some more studies are needed to figure out that mechanism and insure its safety. Along those same lines, NOVO has their insulin Degludec that is available in Europe but is undergoing safety trials as well. It also appears super flat and long acting so both of these MIGHT have some advantages over lantus for all you needle lovers out there.
In the world of rapid acting insulins, I have to say that Afrezza hasn’t really gotten much love. It is a new concept and although the smallest dose unit is 4 units, it seems like much less because it gets out of your system quickly. Uptake has been slow but the label does not state the true benefits and one must get incentive spirometry done first which may be an impediment as this device isn’t generally lying around in an endo office. We like the idea of a rapid acting insulin, but we need a traditional/injectable form that has the same rapid on and rapid off qualities as Afrezza. Novo is working on a faster acting aspart that looks promising as is a company called Biodel. Man do we need this though. I’m tired of blousing like 30 minutes before a meal, or correcting a high blood sugar when I’m 280mg/dl and just staring at my CGM and not seeing it come down. Then I usually get impatient and take half a bazillion units and then get low! I do think these insulins will make it to market but still going to be a little bit of time. So there was definitely some other stuff, but we gotta get back to work.
Let’s continue this conversation online at WeAreOneDiabetes. See you there!