Experts Discuss Advances in Diabetes Technology, Medications, Type 1 Prevention, and Telehealth
By Andrew Briskin
At the 16th annual Diabetes Forum, a panel discussion co-hosted by the diaTribe Foundation and Taking Control of Your Diabetes (TCOYD) at the American Diabetes Association 2022 Annual Conference, experts weigh in on changing standards of care, the latest in drug development, diabetes technology, and more.
The 16th annual Diabetes Forum, hosted by The diaTribe Foundation and Taking Control of Your Diabetes (TCOYD), brought together some of the world’s most esteemed experts in diabetes for a panel discussion on the latest updates in the field. Experts focused on some of the key topics discussed during the ADA conference, including a changing view on the treatment of type 2 diabetes, updates in continuous glucose monitoring (CGM) and automated insulin delivery (AID), the treatment and prevention of type 1 diabetes.
The panel, co-moderated by diaTribe founder Kelly Close and TCOYD founder Dr. Steve Edelman, included the following five speakers:
Dr. James Gavin – clinical professor of medicine at Emory University and Indiana University, CEO and chief medical officer of Healing Our Village, a corporation that specializes in targeted advocacy, training, education, disease management, and outreach for health care professionals and minority communities
Dr. Jeremy Pettus – endocrinologist and associate professor of medicine at the University of California San Diego - Pettus has type 1 diabetes himself and is well-known for his work on both adjunctive therapies as well as potential cures for T1D
Dr. Leslie Eiland – associate professor of medicine in the Division of Diabetes, Endocrinology & Metabolism at the University of Nebraska Medical Center and medical director of patient experience and telehealth at Nebraska Medicine
Dr. William Polonsky – associate clinical professor in Psychiatry at the University of California, San Diego, and president and co-founder of the Behavioral Diabetes Institute, the world's first organization wholly dedicated to studying and addressing the unmet psychological needs of people with diabetes
Dr. Carolyn Wysham – clinical endocrinologist and diabetologist at the Rockwood Clinic in Spokane, Washington and clinical professor of medicine at University of Washington; immediate past president, Endocrine Society
This exciting panel, which took place live in New Orleans on June 6, was broadcast in a separate virtual event on July 13.
*Note: You can watch the panel discussion and visit the Health Fair that took place through July 27 by registering here, and then logging in here, with the email address you used to register.
New medications and metabolic health in diabetes management
The panel began with a brief discussion on the shift toward personal treatment goals, or diabetes management goals specifically tailored for each individual. Gavin particularly focused on how people are assessed for diabetes-related complications like heart disease, liver disease, and chronic kidney disease (CKD), especially those with type 2 diabetes.
“We are now moving away from a glucose management-centric model, and the [ADA] guidelines reflect this,” asserted Gavin. “I prefer to think of it now as a model to assess overall metabolic health. Endocrinologists, cardiologists, and nephrologists (kidney specialists) are all using common tools to address chronic complications in our patients. I wonder if there is an opportunity to have a joint panel to develop guidelines across those disciplines.” Wysham added that the American College of Cardiology (ACC) has endorsed the ADA recommendations for managing people with heart disease, and it is working to include nephrology recommendations as well.
The panelists agreed on the importance of taking complications and the effects of excess weight and obesity into account when treating people with diabetes. In light of the extensive news at ADA on the recent FDA approved drug Mounjaro (tirzepatide), the discussion shifted toward the potential uses of diabetes drugs such as GLP-1 receptor agonists and SGLT-2 inhibitors, in people with type 1 or type 2. These drug classes have been shown to help people improve their overall metabolic health, lower glucose levels, help people lose weight, and protect against heart and kidney disease.
“Tirzepatide offers the opportunity for people to reach bariatric surgery-level weight loss, with over 50% of patients in trials able to lose at least 15% of their starting body weight,” said Wysham. “That’s the threshold at which type 2 diabetes, NASH, sleep apnea, and potentially CKD, can be impacted by weight loss alone.”
The conversation around these medications focused primarily on people with type 2, as most GLP-1 and SGLT-2 drugs are only approved for type 2. But Pettus, a type 1 expert, said that people with type 1 face many of the same issues and could benefit from access to these drugs.
“Type 1s have been completely left out of this conversation about new medications like GLP-1s, SGLT-2s, and tirzepatide,” said Pettus. “We should think about these therapies in T1D as a way to address the things that insulin cannot. For example, people with type 1, across the board, have insulin resistance, the idea being that resistance is built up in response to taking high insulin doses each day. There is an opportunity to reduce insulin resistance and prevent [heart disease] with these drugs. Weight gain and hypoglycemia are also huge problems faced by people with T1D, which cannot be treated by insulin. We’re still left with the problem of cardiometabolic health, which we only really talk about for type 2s.”
CGM and automated insulin delivery
In light of the advances in CGM technology in 2022, such as the FDA clearance of the Freestyle Libre 3, Eversense E3 180-day sensor, and the much-anticipated Dexcom G7, panelists discussed how these devices have benefitted people not just physically, but behaviorally.
“We see CGM as a behavioral and motivational tool that has changed everything, and not just for type 1s or people on insulin,” emphasized Polonsky. “The biggest impact has been on helping people feel less concerned about hypoglycemia and more confident in their safety.”
Adding on to the discussion about the key features of these new CGMs, Eiland highlighted the impact of automated insulin delivery (AID) and 2022 advancements, such as the rollout of Omnipod 5 and new features of Tandem’s Control IQ and Medtronic’s MiniMed 770G.
Eiland shared that her patients on AID no longer have to worry as much about constant, small adjustments to insulin therapy. “People have been doing really well with these systems,” she said. “The conversations at my visits have changed; we’re talking now about the advanced features of the systems, exercise mode, sleep mode, and how to optimize use.”
“We’re now also starting to get quality of life data for these systems,” continued Polonsky. “These systems are not just helping people have better glucose control, it’s actually changing people’s lives, making them feel safer, freer: our patients are telling us that.”
Type 1 delay and type 2 remission
With new medications and tools to address weight management, complications, and the progression of type 1 and type 2 diabetes, the panelists discussed the potential to delay a diagnosis of diabetes in people at high risk for developing the condition.
Pettus discussed teplizumab, a drug nearing FDA approval for delaying type 1 diabetes in those most at-risk. “The clinical data is showing that a 14-day course of [teplizumab] can prevent the onset of type 1 diabetes, on average, by two years,” he said. “We’ve been treating the symptoms of type 1 for decades. CGM, insulin, and medications are all great things, but they don’t change the disease itself. Here we are reminded that this is an autoimmune disease, and for the first time we have a therapy that can actually do something about that.”
On the possibilities for people with type 2, Gavin discussed type 2 diabetes remission, a term with a range of definitions, all of which involve maintaining an A1C of 6.5% or lower while discontinuing most or all diabetes medications. “It’s not a cure, and not reversal of diabetes either,” said Gavin. “It’s really a ‘pause’ of the condition for an indeterminate amount of time.”
Addressing excess weight, particularly in those newly diagnosed with type 2, is one of the necessary components to achieve remission. “As clinicians, we need to be able to refer our patients with newly diagnosed type 2 diabetes to programs offering low-calorie diets or meal replacement,” said Wysham. “That threshold of 15% weight loss is where we saw the vast majority of patients achieve remission.” Drugs that have been shown to have weight loss properties, such as tirzepatide and other GLP-1 drugs, can also make it easier for people to achieve this weight loss threshold.
Diabetes Disparities and Access to Treatment
Panelists also discussed the cost and access barriers that prevent many people with diabetes from reaping the benefits of these new treatments.
Eiland shared her perspectives on other elements that improve care for people with diabetes and what she’s observed since the start of the COVID-19 pandemic regarding telehealth and access to care, from her experience caring for people in rural Nebraska and Iowa.
“[Telehealth and home visits] are a great way to receive care, but for people who are already plugged-in and receiving care,” she said. “I think we underestimate how poor broadband internet and digital literacy is in this country; people need high-speed internet with the capability for video conferencing, and must know how to use it, to have an effective and productive visit. I worry that the people who need care are still not able to access home visits, and we should be careful going forward to not widen existing disparities.”
The panel concluded by addressing further social and economic barriers to diabetes care, a key topic throughout the conference that has expanded as ADA has made health equity a signature issue.
“The wealth gap drives the health gap,” stressed Gavin. “Social determinants of health account for 50 to 60% of health outcomes. When we talk about these issues, we’re talking about poor healthcare access, housing and food insecurity, all of which have an effect on someone’s response to health interventions. All of these new drugs and technologies still don’t address this elephant in the room. It’s not quick and it’s not easy, but we need to tackle these issues one step at a time, making products and medications more available to marginalized groups.”
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