The Biggest News in Diabetes Technology: Opening Day at ATTD 2021
By Arvind SommiMatthew GarzaEliza SkolerFrida VelcaniJulia KenneyNatalie Sainz
The diaTribe team covers the latest in diabetes technology from the 14th annual ATTD 2021 international conference (set virtually this year). Here are our top highlights from day one – stay tuned for updates on the rest of the conference!
The 14th annual Advanced Technologies and Treatments in Diabetes (ATTD) virtual conference brought together great minds in diabetes from around the world. This conference focuses on the powerful momentum behind diabetes technology. Here are some key highlights from the first day of the event, including the latest data on automated insulin delivery systems. We’ll be back next week with more news from the conference!
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Automated insulin delivery: preferences, training, and personalization
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CGM shows positive results for people with type 2 diabetes on basal insulin
First MiniMed 780G Real-World Data
Dr. Ohad Cohen presented real-world data from MiniMed 780G users, following the automated insulin delivery (AID) system’s launch in Europe last fall. Results came from 4,120 of the first users of the MiniMed 780G system across eight countries (the UK, Italy, Belgium, the Netherlands, Qatar, South Africa, Sweden, and Switzerland), between August 2020 and March 2021.
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Time in Range (TIR) for MiniMed 780G users in the real-world was 76%.
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Hypoglycemia: Time below 70 mg/dl was just 2.5% and time below 54 mg/dl was only 0.5%.
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Hyperglycemia: Time above 180 mg/dl was 21% and time above 250 mg/dl was 4%.
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TIR was particularly high at night (from midnight to 6am), at 83%, compared to 74% during the day (between 6am and midnight).
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Mean glucose for users was 144 mg/dL, which corresponds to a glucose management indicator (GMI) of 6.8%. With 780G, a remarkable 79% of users had a GMI below 7%, and 77%, had a TIR above 70%. Nearly three out of four users met both GMI and TIR targets of less than 7% and more than 70%, respectively.
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On average, users spent 94% of time in Auto Mode and performed 3.4 fingersticks per day using the 780G system.
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In the real-world, users spent about half of the time with the glucose set point of 100 mg/dl. MiniMed 780G allows users to choose between four glucose targets for basal insulin rate modulation: 100, 110, 120, and 150 mg/dl.
In a separate analysis, Dr. Cohen presented results from 812 users who had at least ten days of data both before and after starting MiniMed 780G. The results showed the effects of switching to use the closed loop system:
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Mean TIR improved from 63% to 76% (that’s almost three more hours per day in range). This was mostly due to reductions in hyperglycemia: mean time above 180 mg/dL declined from 34% to 22% with Auto Mode.
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Auto Mode helped about twice as many users achieve a GMI below 7% and a TIR above 70%. At baseline, 38% of users had a GMI below 7%, compared to 75% of users after starting on closed loop. Similarly, the percentage of users meeting the 70% Time in Range target jumped from 35% to 75% after initiating Auto Mode.
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Auto Mode was associated with a 4.8 unit per day increase in total daily dose of insulin. As a reminder, MiniMed 780G not only includes basal rate automation, but can also deliver automatic correction boluses.
Finally, Professor Goran Petrovski presented additional results on the MiniMed 780G, this time from a study of children and adolescents who went straight from multiple daily injections of insulin (MDI) to the MiniMed 780G system. The trial included 34 children and adolescents with an average baseline A1C of 8.6%; more than half of the group had never used a CGM. After switching to the MiniMed 780G and using it for three months:
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Participants spent 8.8 hours more time in range each day (from 42% to 79%), driven primarily by much less time spent with glucose above 180 mg/dL (hyperglycemia dropped from 55% to 18%).
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A1C dropped by more than two percentage points.
The new technology was hugely helpful for both the children and their parents. The new data show the benefits of adopting AID technology in young people with diabetes, even if they haven’t previously used other forms of diabetes technology.
Automated insulin delivery: preferences, training, and personalization
During one of many sessions this week focused on innovation in automated insulin delivery (AID) systems, Dr. Lori Laffel explained that personal preference plays a key role in diabetes care choices. The biggest priority for people with diabetes and their family members is to reduce the burden of the condition, including the day-to-day stress that comes with managing diabetes. While technology can be hugely helpful in this area, cost considerations (such as those associated with supplies, devices, and insurance) are a major barrier to the broader adoption of diabetes technology.
Because diabetes technology is constantly changing and improving, it’s important for people with diabetes to get support starting – and continuing – with AID systems. Dr. Laurel Messer explained that healthcare professionals should plan to provide comprehensive training both before and after people initiate a new device to help ease the transition. Here are Dr. Messer’s best practices:
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Before starting AID:
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Training should build upon what people with diabetes already know about using their insulin pump or CGM.
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Healthcare professionals should help individuals choose the best system for their needs, considering lifestyle, education, familiarity with technology, support, and cost.
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After initiating AID:
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Healthcare professionals and industry professionals should acknowledge the steep learning curve that may come with using a new device. It’s important for people and their care teams to know that it takes time to adapt to new technology and get comfortable with it.
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Industry professionals should provide support for technical issues while healthcare professionals should focus on following-up with people for non-technical diabetes treatment issues.
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If you already use AID or want to start using it, talk with your healthcare team about how they can help you learn the technology.
Finally, Professor Francis Doyle III talked about personalizing AID for certain populations based on both age (children, young adults, and seniors) and specific needs (for example, pregnant women, shift-workers, and athletes). Over five years, 93.5% of studies have shown that AID can help different subgroups achieve their recommended Time in Range targets by adjusting insulin levels in response to factors such as physical activity, stress, and meals. Professor Doyle shared recent research showing that AID successfully helped manage glucose levels for people at home, regardless of food choice.
CGM shows positive results for people with type 2 diabetes on basal insulin
Dr. Tom Martens presented exciting results from the MOBILE study which looked at the effects of continuous glucose monitoring (CGM) in adults with type 2 diabetes on basal insulin. At the start of the trial, the 175 participants had an average A1C of 9.1%, were being treated mainly in a primary care setting, took one to two injections of basal insulin per day, and had never used a CGM before. Participants were randomly assigned to use either a Dexcom G6 CGM or a One Touch Verio Flex blood glucose meter (BGM) for eight months, meeting with healthcare professionals throughout this period both in person and virtually.
After eight months, those using the CGM:
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Spent on average 3.8 more hours per day in range, compared to those using the BGM (59% versus 43% TIR, respectively).
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Spent on average 3.6 fewer hours per day with glucose values above 250 mg/dL (11% compared to 27% in the BGM group).
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Reduced A1C by 1.1% on average, compared to a 0.6% reduction in the BGM group.
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Used the CGM frequently over the eight-month period and reported high satisfaction with the system.
One of the most exciting aspects of this trial, beyond the positive improvements in TIR and A1C, was the extremely diverse study population. Only 47% of the participants identified as non-Hispanic white and the study included even proportions of men and women. The majority of the participants did not have a college degree or private health insurance. Given the common disparities in diabetes prevalence and outcomes between races and socioeconomic classes, especially among people with type 2 diabetes, a trial with both promising results and such a diverse population is encouraging.
"All in all, this represents a huge step forward and the entire group of investigators and staff should be commended. In my mind CGM is a must for all people on insulin, from basal insulin through MDI and insulin pumps, for people with type 1 and type 2 diabetes. Now we have to figure out how to use CGM even more effectively. And make sure all our patients with diabetes have access to the resources they need," said Dr. Anne Peters, Director of the USC Clinical Diabetes Programs.
Pregnancy, diabetes, metformin, and technology
Experts in diabetes and pregnancy discussed the benefits and drawbacks of using metformin during pregnancy and the importance of CGM use.
The presenters debated whether women with diabetes should take metformin during pregnancy. Dr. Denice Feig presented data suggesting that metformin improves maternal and neonatal outcomes in women with gestational diabetes and type 2 diabetes. She argued that metformin is shown to be safe both during pregnancy and in the long run; research shows that metformin results in less weight gain for the mother, fewer pregnancy complications, reduced insulin dosages, and increased satisfaction for the mothers (compared to other diabetes therapies).
Dr. Yariv Yogev presented an opposing viewpoint, that metformin should not be a first-line treatment for pregnant women with diabetes due to several unresolved issues. Some research shows that metformin does not always lead to glycemic improvements, it creates an increased risk for preterm birth, and could lead to an increased risk of babies who are small for their gestational age (SGA) – a condition associated with worse short and long-term outcomes for the child. He argued that more research is needed to understand the effects of metformin in pregnant women with diabetes.
Several experts advocated for greater use of continuous glucose monitoring (CGM) technology among pregnant women:
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Dr. Helen Murphy highlighted the importance of using CGM during pregnancy to help women with type 1 diabetes manage glucose levels.
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Dr. Robert Lindsay described how Time in Range (TIR) data from CGM can bring diabetes management into much sharper focus than A1C measurements alone. CGM monitoring enables women to better manage their TIR during pregnancy, which leads to better health outcomes for mother and child.
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Dr. Eleanor Scott presented clinical research on glycemic management during pregnancy:
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There seems to be a correlation between lower TIR and babies who are large for their gestational age (LGA).
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Reaching tight glucose targets by ten weeks into the pregnancy is crucial to support regular fetal development and reduce complications for the baby related to fetal hyperinsulinism (when there is too much insulin circulating in the blood relative to how much glucose there is).
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The CONCEPTT trial showed that the use of CGM technology improves maternal glucose management, reduces rates of LGA, and improves neonatal outcomes. However, even while using CGM, rates of LGA remain quite high in women with type 1 diabetes, indicating a need for more advanced technology solutions, such as closed loop insulin delivery.
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We look forward to learning more about diabetes care during pregnancy, and how to best support mothers and babies during this time.
What we’ve learned on COVID-19, diabetes, and obesity
Last year’s conference was held in February 2020 – right before much of the world shut down to international travel due to the COVID-19 pandemic. Dr. Irl Hirsch and Professor Antonio Ceriello kicked off this year’s virtual conference by reflecting on several lessons learned in diabetes and obesity care during the pandemic.
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Diabetes and obesity increase a person’s risk of severe COVID-19. Evidence shows that COVID-19 mortality is higher among people with diabetes and obesity, though data on the relationship between a person’s glucose levels and COVID-19 mortality varies.
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Certain diabetes therapies may help protect against severe COVID-19 – but more research is needed. The research shows that ACE Inhibitors, statins, and DPP-4 inhibitors could be beneficial in preventing severe COVID-19 complications. In addition, metformin use before COVID-19 infection does not appear to be harmful and was associated with lower rates of mortality among people with diabetes in several studies. SGLT-2 inhibitors, however, do not appear to be beneficial in treating COVID-19.
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Telemedicine has emerged as a valuable tool in diabetes and obesity care during the pandemic. Dr. Hirsch pointed to the value of remote diabetes care, including the increase in efficiency during appointments, ease of access, and a greater reliance on glucose data. He called for improvements in health data sharing between patients, caregivers, and healthcare teams and provider reimbursement systems to make telemedicine a sustainable and valuable health practice beyond the pandemic.
In addition, Dr. William Cefalu of the National Institute of Health (NIH) shared that diabetes and obesity are among the top priorities in NIH research on COVID-19 comorbidities. We are eager to monitor and share these insights on COVID-19 and diabetes as they come to light.
