Experts Discuss Diabetes Technology, Medications, and Time in Range at 15th Annual Diabetes Forum
By Andrew Briskin
Highlights from The diaTribe Foundation and TCOYD panel discussion at ADA 2021 include changing standards of care, continuous glucose monitoring, and the latest in diabetes drug development.
The 15th annual (and second virtual) Diabetes Forum, hosted by The diaTribe Foundation and Taking Control of Your Diabetes (TCOYD), brought together a superb group of panelists for a conversation on the latest updates in diabetes. Panelists discussed the most interesting findings from the 2021 ADA Scientific Sessions, focusing on diabetes and the COVID -19 pandemic, the expanding role of telehealth in diabetes care, changing standards of care, the latest in diabetes technology and therapies, and much more.
Dr. Daniel Drucker – University of Toronto, Mount Sinai Hospital, Lunenfeld-Tanenbaum Research Institute
Professor Rury Holman – Founder and Emeritus Director of Diabetes Trial Unit at Oxford
Dr. Sam Dagogo-Jack – University of Tennessee Health Science Center, Division of Endocrinology, Diabetes, and Metabolism
Davida Kruger – Nurse Practitioner at Henry Ford Health System in Detroit, Division of Endocrinology, Diabetes, and Bone Disorders
Dr. Jeremy Pettus – University of California San Diego, Associate Professor of Medicine
Moderators included Kelly Close, founder of The diaTribe Foundation and Close Concerns, and Dr. Steve Edelman, founder of TCOYD.
The panel began with a brief discussion on the impacts of COVID-19 on people with diabetes. Dr. Dagogo-Jack affirmed that type 2 diabetes is indeed a marker for worse health outcomes and mortality when it comes to COVID-19. However, the physiological mechanism for why this is the case is still not completely understood.
Dr. Pettus, an expert on type 1, challenged the misconception that people with type 1 are at a lower risk for severe COVID complications, emphasizing that people with type 1 are “far closer to the risk level of those with type 2” than people without diabetes.
The conversation shifted to the impact of the pandemic in general, especially regarding the expansion of telemedicine and its implications for people with diabetes. Kruger said, “We can access people and lab data very easily through telehealth. Some in-person examination is still necessary, but people are not necessarily coming back to the clinic as quickly. Telemedicine is expanding, and that is not a bad thing.”
Next, panelists discussed the latest in diabetes therapies, specifically the use of GLP-1 receptor agonists and SGLT-2 inhibitors as preventive measures (against things like cardiovascular disease and kidney disease) and for those with type 1 diabetes. Currently, these medications are only approved for people with type 2 diabetes, but they have shown remarkable results in combatting heart disease, lowering A1C, and increasing weight loss.
Dr. Drucker brought up the impressive effects of the new drug tirzepatide (a GIP/GLP-1 dual receptor agonist) in lowering A1C and weight loss, and he advocated for investigating the expanded use of these types of medications in the type 1 population with appropriate risk factors as well as for those with prediabetes. This was a point of contention, however, with Dr. Holman and Dr. Dagogo-Jack advising a more cautious rollout into these other populations.
The topic of prediabetes and the use of preventive measures to combat the progression to diabetes came up repeatedly. Dr. Dagogo-Jack said that “prediabetes is three times more prevalent than diagnosed diabetes in the US. It is smart medicine to intervene and possibly reverse the progression of diabetes through non-pharmacological methods [such as diet and exercise].”
Discussing the effectiveness of new drugs for prevention, Dr. Drucker admitted that “it is very hard to convince people to take a medication to prevent something that could develop 10 years down the road.”
The panelists emphasized that people and their healthcare professionals need to have honest conversations about medications and lifestyle modification programs (in person or virtual “digital health” programs) that have been effective in preventing diabetes and reducing risk factors for diabetes and its comorbid conditions (such as hypertension, dyslipidemia, sleep apnea, etc.
Finally, panelists discussed the latest in continuous glucose monitoring (CGM) technology and the quest to develop an artificial pancreas. Currently, AID systems and insulin pumps are hybrid closed loop, meaning that there are still some manual requirements such as meal-time bolusing or calibration requirements.
The best outcomes occur when people with diabetes become more knowledgeable and they become their own best advocates, panelists agreed. Kruger shared her optimism for the near future of CGM and AID systems. She advised, “If there’s nothing wrong with your pump now, wait. There will be an explosion of new closed loop systems and CGM in the next two years, and people with diabetes deserve to have access to the best, most updated technology.”
During the Q&A session, each panelist addressed their most notable takeaways from ADA and the most exciting findings that came out over the past year. The topics included:
An expanding focus on the intersection between heart disease and type 1 diabetes, as opposed to prior views which had a much narrower focus on type 2 diabetes only.
Exciting findings showing the success of new GLP-1 receptor agonists and SGLT-2 inhibitors, not only in people with type 2, but also proposals and growing support for investigation and safe use in those with type 1.
The impending FDA approval of tirzepatide for people with type 2 diabetes (and hopefully those with accompanying heart disease), which shows extremely successful trial results for both weight loss and A1C reduction.
Advancing technology in continuous glucose monitoring (CGM), Time in Range, automated insulin delivery (AID) systems, and advancement toward an artificial pancreas.
- “We are in a position to act more like oncologists rather than endocrinologists. We now have the power to put this disease into remission by using these powerful new tools. Problems of access and education are still there, but we should have an aggressive mindset toward using these new medications based on the evidence.” – Dr. Daniel Drucker
- “Why shouldn’t people with type 2 diabetes be on insulin pumps if they are taking multiple daily injections? I believe CGM is a right, not a privilege. Years ago, we held blood glucose monitoring close to our chests and gave access selectively, not giving it to enough people because we didn’t know enough about it and didn’t have the insurance coverage. We cannot do that with CGM. It helps patients manage and own their diabetes.” – Davida Kruger
- “With these new GLP-1 receptor agonist and SGLT-2 inhibitor drugs, we can make an impact on two of the most undiagnosed serious conditions in type 2 diabetes: chronic kidney disease and congestive heart failure, and how these confer over to people with type 1. We are now true partners with nephrologists, cardiologists, and primary care providers with these two drug classes that show benefits in people with and without type 2 diabetes. We need to increase awareness and access to these drugs and prevent morbidity and mortality. We need to work on adherence and persistence when it comes to these treatments, encourage people with diabetes to become knowledgeable about new treatments. If you are a person with diabetes and think there is something out there that can provide benefit to your care, it’s worth the conversation with your provider.” – Dr. Steve Edelman
- On using GLP-1 receptor agonists and SGLT-2 inhibitor drugs for patients with type 1 diabetes: “The risks of [diabetic ketoacidosis] are at a different level for these drugs. If you were to prescribe SGLT-2 inhibitor drugs routinely in primary care practice, you may run into some problems. I agree that the potential for people with type 1 is enormous, but we should tread a bit carefully to roll this out as a routine. If we could show this better in a study, then rollout could proceed much more quickly.” – Professor Rury Holman
- “End-stage kidney disease in America is an entitlement; you do not need to be insured to receive dialysis, placing the burden of costs up to $200,000 per person per year on the government. As an alternative, you can take an SGLT-2 inhibitor from the earliest point where you begin deviating from normal kidney function, and it could delay the need for dialysis by years, or even decades. It makes economic sense to increase access to these medications for people with diabetes who are at risk for kidney disease, and hopefully we will see graphs in the future demonstrating the plummeting number of people with diabetes on dialysis when given upfront protection.” – Dr. Sam Dagogo-Jack
To watch the entire panel discussion and view other resources from the event, click here.