Pediatric Endocrinologist Dr. Jennifer Sherr on Managing Diabetes
By Divya Gopisetty and Emily Fitts
From clinical expertise and personal experience as a type 1, Dr. Sherr shares valuable (and exciting) perspectives on diabetes treatments
Sanofi and Lexicon recently gathered experts together in diabetes in Washington D.C., hoping to define diabetes management success Beyond A1C, to figure out how people with diabetes can improve glucose control and time in range and help people to have productive conversations with their healthcare providers in the midst of rapidly changing medicines and technologies. In line with these goals, Yale University’s Dr. Jennifer Sherr kicked off the meeting with her best practices and wishes as a pediatric endocrinologist.
In three words, Dr. Sherr looks forward to “making management easier.” More specifically, Dr. Sherr said she was excited about:
1. SGLT-2 Inhibitors for Type 1s
SGLT-2 inhibitors are a class of medications approved for type 2 diabetes – there has been growing interest in using them in type 1s, due to the increased time-in-range, weight loss, need for less insulin, and A1C reduction benefits. In a recent Yale study, Dr. Sherr’s team was researching the major obstacle SGLT inhibitor use by people with type 1 diabetes: a complication called euglycemic diabetic ketoacidosis (DKA), which can be self-treated but often results in hospitalization and can even be life-threatening. Euglycemic DKA has similar symptoms to the typical form of DKA (vomiting, nausea, fatigue, stomach pain, shortness of breath, dry mouth) that is associated with high blood glucose, but it occurs at “normal” (below 225 mg/dl) levels. The hope is that people with type 1 diabetes will be able to safely take advantage of this new drug class – (see more background here) – which would be the first pill for type 1 diabetes.
Dr. Sherr discussed how many companies are looking at ready-to-use glucagon products, ranging from nasal glucagon (manufactured by Lilly, currently awaiting approval by the FDA and EMA) to stable, liquid glucagon preparations (also under development by Xeris and Zealand) which would act as a rescue treatment for emergency hypo situations. Liquid glucagon could eventually become a part of automated insulin delivery systems, the game changers for glucose control we discussed in our article earlier this year.
3. More Continuous Glucose Monitoring (CGM)
To encourage more CGM use, Dr. Sherr encouraged CGM manufacturers to tackle the limitations with accuracy, frequent alarms, size of devices, problems with insertion, data overload, and lost signals. She emphasized that the benefits of wearing a CGM – less glucose variability, less hypoglycemia, fewer fingersticks, etc. – are worth the hassle, particularly given the improvements in accuracy, longer duration of wear, easier insertion, ability to use sensors without fingersticks, and remote monitoring. She urged manufacturers to think about how to continue to develop sensors with longer duration of wear and smaller physical footprints. Recognizing that CGM is out of reach to many with diabetes due to cost, Dr. Sherr also asked how we can expand insurance coverage for these devices.
4. Insulin and Pramlintide Taken Together
Pramlintide (Symlin) is a synthetic form of amylin, which is a hormone secreted by the pancreas which helps to reduce post-meal blood sugar spikes by making you feel full more quickly and slowing the digestion. It’s approved for type 1 and type 2 and also leads to weight loss in some people. Dr. Sherr discussed a study that taking insulin and pramlintide together led to an 11% increase in time-in-range (70-180 mg/dl), which is nearly three more hours a day. Pramlintide use is limited today because it means an extra injection prior to meals and it is harder to dose. The ultimate goal would be to make a mixture of the two hormones.
5. Better Mealtime Insulins
Dr. Sherr is excited to see the development and use of faster acting insulins that behaves more like insulin naturally produced in the body. She added that smart pens – insulin pens that digitally track usage – will be an amazing option for individuals who don’t necessarily want devices but can still benefit from data to more easily track doses.
6. Time-in-Range as a Critical Outcome
Dr. Sherr summarized why time in range is better than A1C for measuring how patients are doing. For example, using a three-month average does not differentiate someone with very little glucose variation from someone with great variation (click here for background on the Beyond A1C movement). As researchers are beginning to find that increased time-in-range is an indicator for decreased risk in diabetes complications, she expressed her hope that a focus on time-in-range and glucose variation can help address unmet needs and that healthcare providers can collaborate with people with diabetes to individualize goals for diabetes management.
Dr. Sherr quoted Dr. William Tamborlane, referring to type 1 diabetes as “doing the same thing over again and always getting a different result.” diaTribe Senior Editor Adam Brown’s piece on 42 factors that affect blood glucose could not better describe what Dr. Sherr means by this quote. With the chaotic rollercoaster that is oftentimes diabetes, Dr. Sherr encouraged the community to remember that the enormity of the challenges should not get in the way of us continuing to move forward.