Experts Discuss Developments in Diabetes Technology & Therapy and Effects of the COVID-19 Pandemic

Highlights from The diaTribe Foundation and TCOYD panel discussion at ADA 2020 

The diaTribe Foundation and TCOYD hosted the 14th Annual Diabetes Forum during ADA’s 2020 Scientific Sessions, gathering virtually over 1,800 people with diabetes, healthcare professionals, researchers, industry leaders, and advocates from all over the world. As is tradition, the  panel of experts shared their key takeaways and highlights from the ADA Scientific Sessions and discussed recent developments in diabetes therapy and technology. This year, panelists and attendees also reflected on the effects of COVID-19 on individual diabetes management and population health. 

Missed the event? Click here to watch a recording. 

The panel included: 

• Dr. Vanita Aroda (Harvard Medical School) 

• Dr. Will Cefalu (National Institute of Diabetes and Digestive and Kidney Diseases) 

• Dr. Irl Hirsch (University of Washington Medicine Diabetes Institute) 

• Dr. Jeremy Pettus (University of California, San Diego) 

• Dr. Eugene Wright (Duke Southern Regional AHEC, Fayetteville, North Carolina)

• Moderators Kelly Close (The diaTribe Foundation) and Dr. Steve Edelman (TCOYD) 

Main themes included: 

• The COVID-19 pandemic and telemedicine 

• Continuous glucose monitoring and automated insulin delivery 

• Clinical guidelines and expanding beyond glucose-centric care

• Heart, kidney, and liver health and the effects of SGLT-2 inhibitors and GLP-1 agonists

• Adjunctive therapies for type 1 diabetes

• Panelists’ hopes for the coming year

See below for our favorite quotable quotes of the night. 

On the COVID-19 pandemic and telemedicine: 

• “The past few months have brought forward huge challenges to the world – COVID-19 brought forward a virus along with a pandemic of loneliness, mental health, and unemployment. When it comes to diabetes, all of these challenges play a huge role: racism, COVID-19, mental health, and cost and access. There is a lot of pain in the world right now. We can’t talk about diabetes without talking about the many systems that affect it.” - Kelly Close 

• “Research around this country is not immune to the effects of COVID-19...Research, in general, has been affected, with many activities suspended...The problem is what happens when we come back and get to a new normal – will [people] be comfortable [participating in trials]?...[The pandemic] has affected research and every level of life. I hope that with testing, research will come back.” - Dr. Will Cefalu

• “The move to telemedicine that was supposed to take about two years, took about a week and a half. We learned how to do it from home despite a very steep learning curve...I think that telemedicine will stay with us although many issues need to be worked out...It’ll be important to figure out reimbursement.” - Dr. Irl Hirsch

• “I like that [telemedicine] is easy for patients, they don’t have to go through traffic. The downside is that it is an isolating way to practice medicine – it’s all virtual, via email. It puts a lot of pressure on the provider to be the central peg more than ever now.” - Dr. Jeremy Pettus 

•  “The other thing is it’s good to see [patients’] living environments. We want to talk about the social determinants of healthcare, and [with telemedicine,] we can see how they live. When they come to the office, we can’t see their house. I expect from the primary care perspective, we’ll have one face-to-face visit a year to do the head-to-toe. The virtual visits will become very much a part of primary care.” - Dr. Eugene Wright 

On continuous glucose monitoring (CGM) and automated insulin delivery (AID):

• “I think [CGM for type 2 diabetes] has great potential for patient engagement. It is an empowering tool. People can understand making changes in time in range easier than making changes in their A1C. Seeing their eyes light up when they see what it does, how it affects what they eat, it makes a big change.” - Dr. Eugene Wright 

• “Due to new regulations during the COVID-19 pandemic, it is easier to get CGM. I want to stress, if you’re on Medicare (or not!), talk to your doctor about CGM. Sometimes I think doctors don’t know how much CGM has improved, and for many doctors and patients alike, knowing about CGM is so valuable.” - Kelly Close 

• “[CGM use in type 2 diabetes] is going to be about cost. When it comes to insulin management, the quicker patients can be part of that loop with self-management, self-titration, – patients do it better than physicians. CGM is important to empower that knowledge of self-management.” - Dr. Vanita Aroda

• “[With AID] we’re getting the people at the highest risk and bringing them down to low. We see that over and over, and as AID evolves and gets better, it’s easier for patients and physicians. I think that [AID] over time will be shown to be extremely cost-effective because it’s a lot of hardware.” - Dr. Irl Hirsch

• “I’ve always pushed CGM, but I’ve never really pushed pumps until recently. With the development of AID, we have systems that can do what you couldn’t do before. I’ve been blown away by improvements in the clinic. It’s been fascinating to watch this development, and it’s been transformed into something that is moving people. [These systems] allow you to take control of your life. That’s a powerful message.” - Dr. Jeremy Pettus

• “[AID] systems can do a lot of the things that we've been pushing for with adjunctive therapies for type 1 diabetes. The smart pen is a great addition as well. We have to remember that worldwide, at least 75% of people with type 1 diabetes are on multiple daily injections. CGM and pump access is pretty low because of price and accessibility. Now that these algorithms can make decisions for us, it’s pretty impressive. Our patients aren’t even going to need us anymore.” - Dr. Steve Edelman

•  “We know diabetes is a chronic disease associated with a lot of stressors about self-managing. In terms of technology, it’s important to understand what it’s there for. If it’s there and it’s not being used, then that’s an added stressor. We can simplify one’s life and have dialogues with caretakers to try to reduce some of that stress.” - Dr. Vanita Aroda

On clinical guidelines and expanding beyond glucose-centric care:

• “When you put the patient in the center, you can’t just focus on glucose alone.” - Dr. Vanita Aroda

• “The [ADA] Standards of Care are still very glucose-centered. We push people to move when A1C is not at goal. But from this meeting, we see that A1c is not the only target. We need to be thinking more comprehensively about the cardio-renal-metabolic systems and not just the A1C.” - Dr. Eugene Wright 

• “Where I live in the Pacific Northwest, the payers are glucose-centric. We have the CVOTs and the labeling, but payers see this as based on glucose, while the rest of the diabetes world is moving onto cardiovascular and renal.” - Dr. Irl Hirsch

• “The reason [guidelines and payers are] glucose-centric is because we’ve been using the same biomarker (A1C) to classify diabetes for 70 years.” - Dr. Will Cefalu 

On heart, kidney, and liver health and the effects of SGLT-2 inhibitors and GLP-1 agonists:

• “It’s amazing that [endocrinologists, cardiologists, and nephrologists] are all brethren now taking care of our diabetes patients...I think with cardiologists and nephrologists pushing these meds, it’s opened the door, especially when they think it’s going to prevent future problems [based on the cardio-renal data].” - Dr. Steve Edelman

• “By putting people in the middle and all of the data around, you can match a drug to a patient. You can smartly pick the agents that would best match their condition, and GLP-1s have a lot going for them with cardiovascular protection, kidneys, glucose-lowering (even more than insulin), and weight loss.” - Dr. Vanita Aroda 

• (On NASH/NAFLD) “Now that we’re learning more about [liver disease in diabetes], there are more targeted interventions, and we are seeing positive data with GLP-1s and SGLT-2s suggesting improvements in NASH/NAFLD. It’s something to keep an eye out for because obesity is a big driver of liver disease and NAFLD. One of the speakers said in the next 15 years, the occurrence of that is going to more than double because of obesity.” - Dr. Vanita Aroda 

• “There are lots of studies and new agents that are being explored for NASH. To Dr. Aroda’s point, if we can attack obesity and weight loss, that’ll be key. It’s key to the metabolic syndrome.” - Dr. Will Cefalu 

• “The patient should ask for the assessment of cardiovascular, glycemia, and comorbidities at the top. All of these are individualized and go into therapy. Patients need to be educated to ask because these are the questions required at the first visit to make decisions about medicine and therapy.” - Dr. Will Cefalu 

On adjunctive therapies for type 1 diabetes: 

• “For me, adjunctive therapy is going to do something that insulin cannot do, or solve an issue that insulin creates. [With just insulin,] I’m still left with the risk of cardiovascular disease, obesity, etc...so I would like to see us adopt more of a type 2 diabetes paradigm...We need a realization that in adjunctive therapy, there are still issues in well-defined metabolic pathways, and if we target them, we can improve clinical outcomes.” - Dr. Jeremy Pettus

• “What would happen if we had a GLP-1 receptor agonist that had an indication for diabetes-related kidney disease in type 1 diabetes?...GLP-1s are a much safer drug, and I don’t think we’ve given it enough attention in terms of [diabetes] complications.” - Dr. Irl Hirsch

• “I think this is where we can learn from the [type 2 diabetes trials] – can all these mechanisms: blood pressure, weight, glucose have an effect? Two hundred thousand trial participants later, we don't have a single study looking at the same outcomes in type 1 diabetes. This is a huge gap.” - Dr. Vanita Aroda 

On what the panelists are most hopeful for in the coming year: 

• “I’m most hopeful about the importance of lifestyle change. We’re just starting to recognize what role that plays. We’re talking about socio-economic status, social determinants of health, having safe places to walk, and access to healthy foods. We need to think about society for health, disease, and diagnosis as well.” - Dr. Vanita Aroda 

• “I’m most hopeful for next year to take advantage of this virtual environment and take advantage of diabetes educators. In primary care, we’ve dropped the ball – if nothing else with this new platform, we can now take advantage of this valuable resource.” - Dr. Eugene Wright

• “I’ve been concerned about access to insulin for everyone. We’re getting there. Some of this was pushed forward by COVID-19, and I’m now not having insulin access issues with struggling patients. I hope that continues, and I want to be able to look back on the history of this that it used to be a problem but not anymore.” - Dr. Irl Hirsch

• “I just hope we get past COVID-19. If you look at some of the data in NEJM from England on the rates of mortality in people with types 1 and 2, I’m going to be hopeful we can address this and figure the issues with COVID-19.” - Dr. Will Cefalu

• “I really hope that we see the ADA and the world of diabetes land on their feet and fulfill a really important role in research and advocacy. I’m hopeful that next year [ADA’s Scientific Sessions] is an in-person meeting and that we can resume research enterprises that are so vital to diabetes.” - Dr. Jeremy Pettus

• “I think we all want COVID to go away, so I’m hopeful we can return to normal soon. I hope there's a silver lining to being quarantined and having virtual meetings – being able to reach more people. I’m hopeful for more [people with type 1 diabetes] to have access to CGM. I’m hoping for [people with type 2 diabetes] to connect more with their doctors and understand why we prescribe them these important meds.” - Dr. Steve Edelman

• “[My fellow panelists] have made me hopeful for all of us to get in the best time ranges – locally, in our neighborhoods, in our cities, but also nationally and globally. We have learned so much more about data and technology, and everyone needs to have access to the exciting new developments – it helps people access the right food and the right lifestyle. Having access to data and technology is just the best preparedness.” - Kelly Close