Bridging the Gap: Innovative Solutions for Diabetes Care

Revolutionary weight loss drugs, over-the-counter continuous glucose monitors, and insulin pumps small enough to fit in a coin pocket are just a few examples of the incredible advancements seen in diabetes technology and treatments over the last few years. 

Not only are these advancements transforming diabetes management, but they are accelerating the development of even more innovative tools to optimize care. While the life-changing benefits of such devices and drug therapies is good news, the bad news is they frequently aren’t making it into the hands of people with diabetes. 

All this and more were hot discussion topics at a recent diaTribe Musings panel just before the 2024 ADA Scientific Sessions in Orlando, Florida. The panel, moderated by Dr. Alan Moses, board chair of The diaTribe Foundation and past chief medical officer at the Joslin Diabetes Center and Novo Nordisk, included the following diabetes experts: 

• Dr. Alice Cheng, endocrinologist at Trillium Health Partners and associate professor at the University of Toronto 
• Dr. Anila Bindal, associate medical director at Abbott’s diabetes care business and an endocrinologist
• Dr. Thomas Grace, head of advocacy and clinical outcomes at Dexcom and a diabetologist 
• Dr. Jennifer McVean, senior director of global medical affairs at Medtronic and a pediatric endocrinologist
• Dr. Laurel Messer, senior director of medical affairs at Tandem Diabetes Care and certified diabetes care and education specialist 

CGM: the gold standard for glucose monitoring 

The panel opened with a conversation about how continuous glucose monitoring (CGM) has radically changed care for both physicians and people with diabetes. 

In many studies, CGM has been shown to improve glucose management, reduce hypoglycemia (low blood sugar), and lower the risk of diabetes complications. And with each new model, CGMs continue to get more accurate. ​​Of course, technology alone is not enough as diabetes education – including how to gain the greatest benefit from new devices – is critical.

“I have 99.5% of the patients in my clinic using CGM. I don't know anything different and I couldn't imagine going the other way,” said Grace, who lives with type 1 diabetes. 

Not only are the people Grace sees learning much more about blood sugar (and the myriad of factors that affect it) with a CGM, but he said the technology also benefits clinicians, allowing them to individualize and better administer care.

“Every single one of us has fluctuating glucose every moment we're alive, and we need to have metrics that reflect these parameters,” Bindal said. “Using a CGM gives a more complete glycemic profile, which allows us to see where we can intervene and make more specific recommendations to really personalize care.”

“I couldn't in my heart pretend to adjust medications [without a CGM] knowing what I know now using CGM,” Grace added. “I don't know how the rest of practicing clinicians in the U.S. would dare adjust insulin without having this data.” 

Panelists also spoke about the wider adoption of CGM as the next big goal for improved diabetes management as these devices have huge potential (but unfortunately are vastly underused), especially in the type 2 community. 

The next frontier: ketone monitoring 

A key topic that surfaced in many ADA sessions was the potential of adjunctive therapies (meaning in addition to insulin) for type 1 diabetes. 

Right now, many people with type 1 diabetes take GLP-1 agonists or SGLT-2 inhibitors like Ozempic (semaglutide) and Farxiga (dapagliflozin) off-label to help with blood sugar, weight management, and possibly kidney and heart complications. 

Despite the potential benefits of adjunctive therapies, these drugs aren’t approved for the type 1 population because proper clinical trials have not yet been conducted to address safety concerns including hypoglycemia and diabetic ketoacidosis (DKA). This is where ketone monitoring may be helpful.

“Data now shows that ketone levels start to rise even before glucose levels do,” said Bindal. “If we can detect those ketone levels early, people can intervene earlier, potentially reducing the risk of DKA.”

Because ketone monitoring helps prevent DKA, it could be an immensely powerful tool to protect those using off-label medications while we wait for (hopefully) more clinical trials to test the safety and efficacy of these therapies in people with type 1. 

“Because we see the incredible data in the type 2 diabetes space and all of the fantastic organ protection that these therapies offer, there's no reason why someone living with type 1 would not benefit,” Cheng said. “Having a continuous ketone monitor, I think, changes that entire narrative.”

If you’re new to ketone testing, you can easily order or pick up an at-home ketone urine or blood test. Bindal said Abbott is currently developing a CGM that also can test for both glucose and ketones. 

“We really believe this is the next big advancement in diabetes technology and can be a breakthrough for people living with type 1,” Bindal said.

Talking about time in range

While A1C was once the gold standard for diabetes care, time in range – the percentage of time spent between 70-180 mg/dL – is quickly taking over as an increasingly important parameter for glucose management. People with diabetes and clinicians use time in range to guide healthcare decision-making because it is actionable and empowering. 

“I think regulatory bodies are becoming more in tune with the concept and are starting to accept time in range as an outcome, not just A1C,” Cheng said.

Because time in range offers a more complete glycemic profile compared to A1C, it enables physicians to make specific (and personalized) recommendations for diabetes care. For people with diabetes, using time in range provides more detailed information, which can make them feel more confident.

The value of time in range for people with diabetes was a major impetus for the formation of the Time In Range Coalition (TIRC). Convened by diaTribe, the TIRC has made significant progress in establishing time in range as an essential part of care and making the metric accessible to all people with diabetes.

With regard to achieving glycemic ranges like those of a person without diabetes, McVean said, “we never used to be able to do that in the past, but now with the advancements in technology and automated insulin delivery systems, we are able to push the needle even further.” 

“As an educator, I think the most important part of time in range is that there's something intuitively understandable by the person living with diabetes. Now we need to get policy and regulators to really understand it as well.” Messer added.

In her experience as a clinician, Cheng also discussed the potential benefits of the relatively new metric of time in tight range (70–140 mg/dL) for diabetes management.

“I think time in tight range is sort of that next frontier,” Cheng said. “Because it's cumulative glycemic exposure, the higher time in range we can achieve without the time below range, the better off someone’s going to be. So we can take that concept and run with it.”

Automated insulin delivery: revolutionizing diabetes care 

Of course, insulin therapy is critical to diabetes management. With the advent of automated insulin delivery (AID) systems, people with diabetes have experienced something they may never have had before: streamlined insulin dosing.

“Living with type 1 diabetes in the 1980s and being in the nurse's office all the time or waking up in the middle of the night with low blood sugar…when I think about where we are now with automated insulin delivery and how a person with diabetes can live a pretty normal life, it's just amazing,” said McVean.

AID systems have proven to be life-changing for people with diabetes and companies like Medtronic and Tandem are finding solutions to many of the ongoing challenges of diabetes management. One is the continued burden around meals and the goal of fully automated meal handling, where McVean said Medtronic has made significant strides with their Meal Detection technology. Meal handling could be further improved with faster-acting insulins, she added. 

Another advancement has been extending the life of infusion sets, which allows longer wear time between set changes and helps reduce insulin waste. Right now, most infusion sets need to be changed every 2-3 days. Newer insulin pump systems are addressing this, like the MiniMed 780G system, which is unique in offering extended infusion sets that last up to a week – one of the first major innovations in infusion sets in over two decades.

“For AID systems at Medtronic, we really look at it far, far upstream with the goal of minimizing the number of needed interactions to help improve quality of life while keeping a keen focus on clinical outcomes,” said McVean. “When you think about the MiniMed 780G system, the engineering team focused on making the device very easy for the person with diabetes and the physician to use.”

Diabetes management is, of course, not one size fits all.  

“Some people are very self-conscious about wearing insulin pump systems,” Messer said. “I think one way we can increase the prevalence of AID system use is by offering people choices.” 

Messer referenced the new Tandem Mobi (currently the smallest durable insulin pump on the market), which allows people to use AID much more discreetly.

Another problem discussed is improving the accessibility of CGM and AID systems for people with vision or hearing loss. People in these communities are often left out of clinical research testing these devices and say they should be part of the development process from the beginning to ensure the technology also works for them. 

During her time at Tandem, Messer shared her experience working with the Accessible Insulin Pump Task Force, an advocacy group fighting for better care for people with diabetes who are blind or have low vision which, she said, is informing their design processes.

Access to care: an ongoing challenge 

While there are so many great options today to tailor therapy for people living with diabetes, a huge problem is access. 

“If people don't have access to the technology, then what good is the technology?” McVean said.

The first issue is that CGMs and AID systems are only available in certain countries. If you can get your hands on one, another issue can be cost. In the U.S. it’s especially tricky as each state and insurance company has its own, sometimes wildly differing, rules and regulations on CGM coverage. As the head of advocacy at Dexcom, Grace said equitable access to diabetes technology has been, and unfortunately continues to be, a major challenge.

“They hired me to help break down some of these barriers,” Grace said. “As a clinician with no real background in how the spider web of the insurance world works, going in, I thought I was going to kick down all these doors and everyone on Medicaid was going to have a CGM tomorrow. It's been frustrating.” 

The good news is that many U.S. insurance plans cover CGMs and AID systems. For individuals who don’t have health insurance, the companies that develop these devices often have discount access programs or coupons that can help cut costs. 

If cost, insurance, or geography aren’t issues, another big barrier to accessing diabetes technology is actually getting your doctor to prescribe it. Many physicians aren’t well-versed in CGMs or AID systems, and therefore might not feel confident recommending them. The lack of endocrinologists or diabetes specialists in the U.S. doesn’t help this issue, which is why it’s crucial that primary care physicians, nurse practitioners, and physician assistants are properly educated and trained on these devices so they can prescribe them. 

“I lead our clinical education, and we have live programs, webinars, and on-demand learning,” McVean said. “We are doing everything that we can to educate healthcare providers and teams so that more people have access to automated insulin delivery.”

Of course, educating people with diabetes is equally important. Studies have found that diabetes self-management education plays a huge role in helping people manage their diabetes and improve health outcomes. For people who have access to CGM or AID systems, understanding how to use these devices and interpret the data is crucial to how beneficial these devices will be for their diabetes care.

Another step forward for access is over-the-counter CGMs such as Dexcom’s Stelo and Abbott’s Lingo (for general consumers) and Libre Rio (for people with type 2 diabetes). The benefit of over-the-counter CGMs is that you don’t need a prescription from a healthcare provider to get one.

“Innovation without access is truly meaningless,” Bindal said.

Looking forward

Experts agree that access to cutting-edge diabetes technology and medications continue to be a major issue, but expressed what an exciting time it is to be working in the field of diabetes care – and how that holds promise for the future. 

As an endocrinologist and a person living with diabetes, McVean said she’s most excited about the decreased burden these advancements offer.

“I'm approaching four decades of living with type 1 diabetes. I think about how hard I had to work back then and with outcomes that weren't nearly as good as they are now,” she said.

On top of improved health outcomes, Messer said that this technology and new drug therapies might even mean “we have a day where complications are a thing of the past.”

From his perspective as a doctor and person with type 1 diabetes, Grace added: “Looking back to where we were, we've moved mountains. We still have a few more mountains to move and I'm hopeful that we're getting closer and closer every day.” 

‘What I’m most excited about is the ability to use CGM technology to reach more people with diabetes, specifically focusing on personalized medicine for people with type 2 diabetes who do not use insulin,” said Bindal.

To close the panel discussion, Cheng looked to a future where misconceptions and stigma around diabetes no longer make the challenges of living with the disease even greater than they are.

“I'm excited about a future where diabetes stigma is not as rampant as it is now, and looking at  the companies that are up here, I think all of us in this room have a very critical role in allowing that to happen,” she said.