The Future of the Type 1 Diabetes Field – what challenges and promises lie ahead? Our interview with David Panzirer and Dana Ball.

by Adam Brown, Hannah Deming, Nancy Liu, and Kelly Close

twitter summary: What are the most promising and most challenging parts of working in t1d? Find out more from the experts in our HCT interview.

short summary: We had a wide-ranging interview with two of the pioneers of the Helmsley Charitable Trust’s (HCT) Type 1 Diabetes (T1D) program (which gives $50 million a year to type 1 research, treatment, and services): HCT trustee David Panzirer, and patient advocate Dana Ball. In part two of our interview, David and Dana share incredible insights on what they view as the biggest challenges and promises in the type 1 diabetes field. What do they think is the most important advance? How would they define a cure? And what type 2 drugs can be used for type 1? Read on for more and stay tuned for further installments in our five-part series:

Part 1. How The Helmsley Charitable Trust became one of the most important players in diabetes, and the funding needs and challenges in type 1

Part 2. The Future of the Type 1 Diabetes Field – what challenges and promises lie ahead?

Part 3. Controversies in Diabetes: Technology, Debates, and the “Cure”

Part 4. The T1D Exchange: A story of David and Dana’s drive to accelerate innovative type 1 diabetes research.

Part 5. What can diabetes advocates learn from successes of the HIV/AIDs movement?

ADVANCES IN TYPE 1 DIABETES

KELLY CLOSE: What do you think will be the most important advance in type 1 diabetes in the next five years? The next 10 years?

DAVID PANZIRER: I think the most important advance in the next five years will be a CGM that will be accurate enough to begin to automate some insulin delivery. I have always said if we can automate basal rates overnight and keep people in control, that this would have a dramatic impact on those living with type 1 diabetes. I would hope that in the next ten years, we would move closer towards automation of insulin delivery, but I don’t believe you will ever have a device that you put on people and say, ‘Go live your life like you don’t have diabetes.” I do think we can have dramatic improvement from where we are today, but I think type 1 diabetes is way too complex to fully automate.  

DANA BALL: In the next five years, incredibly accurate, easy to wear, connected sensors. I believe the future of personalized care for patients with diabetes is in sensor use and adoption. I hope to see progress towards automating insulin delivery and reducing the burden on patients through technology – low glucose suspend and treat to range systems; testing and greater awareness of type 2 drugs for type 1 diabetes; and standardization of device data. I hope we also see patients come to understand that they are the missing piece and they need to take action, whether that’s getting involved in a study, donating blood, or becoming part of our type 1 diabetes army.

ADAM BROWN: How would each of you define a cure for type 1 diabetes? Would putting a pump on every three days count as a cure, if insulin delivery could be largely automated?

DAVID: I define a cure as though you live your life like you never had the disease.

DANA: I think an automated insulin delivery system is in the cure family. I think it cures the burden. HIV patients that were once dying can now take three pills at bedtime. They understand intellectually that the disease is not gone, but they are not the same as they were before. I don’t define a cure as permanently reversing type 1 diabetes with no management required, whether it’s a medication or whether it’s a device. I think a “cure” is anything that relieves an individual from the burden of managing type 1 diabetes and controlling blood glucose. Diabetes is time, it’s stress, it’s money, it’s worry, and it’s the damage of not having your blood glucose under control.

HANNAH: What is the biggest thing the type 1 diabetes field is missing?

DAVID: I think that the groups working in type 1 diabetes are very separated; they don’t always work together and I think a huge reason for this is the competition for fundraising dollars. We have started and continue to help to build bridges and work together with all entities that have an interest in improving the lives of patients with diabetes.

DANA: I agree – too many competing interests and most people want to operate independently.

KELLY: Advocates should all think about that a little more. Switching gears a bit, can we talk about what you see the top areas of unmet need in type 1 diabetes globally?

DAVID: The fact that in some places in the world type 1 diabetes is a death sentence is horrible. We need to get people access to the tools required to stay alive. A stabilized insulin that isn’t affected by heat or cold would be awesome.

DANA: Agreed – we definitely need far better global care and access to insulin. In my view, the other major areas of unmet need include funding and expertise for translation studies; funding for phase 2 studies; data and care standards; new endpoints for studies (e.g., time-in-range); quality of life; and improving reimbursement and the financial burden of managing type 1 diabetes both in the US and around the world.

ADAM: Big picture, what do you each see as the biggest challenge or threat the field of type 1 diabetes faces in the next five or ten years? 

DAVID: As far as within industry, we need to try and increase the number of people using technologies to manage type 1 diabetes – the companies need to see that the numbers are increasing and there is money to be made in type 1 diabetes technology products. If industry cannot see a way to make a profit in the space, the innovations will continue to be very slow.

DANA: Tailored therapies will create subsets of patients to market therapies. How will we incentivize financial investment and industry engagement? How do we prepare for success and accumulate the evidence to address a stressful reimbursement environment? Will patients show up and embrace changing care and treatment options? Who will care for the population with type 1 diabetes?

TYPE 2 DRUGS FOR TYPE 1 DIABETES

KELLY: That sets up our next question really well. Please talk to us a little more about how you are thinking about type 2 diabetes drugs for type 1 diabetes?

DANA: I think there’s a lot of promise. It’s not going to be an insulin-only world. In terms of moving forward, I think the trick is looking at what’s already been learned from some of these studies, and then creating partnerships with the companies that have the drugs. We can run some very smart clinical trials to figure out who’s going to respond to these drugs and why. 

Throughout my career for 13 years, I never said “type 1 or type 2.” I always thought, “It can’t be right.” So many in the type 1 field were saying, “Well, this drug isn’t important. This is for the type 2 overweight population. It’s never going to help type 1. Why would we invest in this?” And I kept saying, “We don’t know that.” Glycemic variability! It’s glucose, and there’s a connection here – I think in many ways we’ve done a disservice. Now the world thinks in black and white, type 1 and type 2, and here we are. Now 13 years later, I’m glad I never said a word, because now I’m knocking on all the companies’ doors and saying, “We want to design a study because your drug may be able to help people with type 1.”

KELLY: When you think about type 2 drugs for type 1 diabetes, what drug classes intrigue you the most?

DANA: Metformin is the low-hanging fruit, because it’s so safe and it’s safe for kids. If we talk about changing the perception that type 1 diabetes is an insulin-only system, metformin is so important. The world has also changed and type 1 isn’t a thin person disease anymore; there are plenty of people with an increased BMI that are going to benefit from metformin. [Editor’s Note: Courtesy of a $2.8 million JDRF grant, the T1D Exchange is studying the use of metformin in overweight adolescents with type 1 diabetes].

Right now, we’re focused on DPP-4 inhibitors, GLP-1 agonists, SGLT-1 and SGLT-2 inhibitors. This is going to take time and we need to figure out the right patients for these different classes of drugs. We need to escalate the conversation.

CHANGES IN HEALTH CARE INNOVATION

KELLY: When you look at the future of type 1 diabetes, do you think a lot of healthcare delivery innovation needs to happen? Or is it an exception to this growing theme?

DANA: I don’t worry about it as much for type 1 diabetes, because the average type 1 adult sees their physician twice a year for 20 minutes. So that’s 40 minutes out of the year that a physician is involved with a patient’s care. Type 1 is a primarily patient- or family-driven disease on a day-to-day, hour-to-hour basis. I think we need to improve the technology to relieve the burden. 

DAVID: Type 1 diabetes is the only disease I know of that patients and their caregivers are making dosing decisions of a drug that if you get it really wrong, could kill you – and they are making these decisions 24/7/365. Type 1 diabetes is a relentless grind that never pauses. Ultimately patients and their caregivers become the lead in managing their disease if they are going to maintain good glycemic control. We strive to get technology to market that can ease the burden of managing this disease.

KELLY: Then it’s also about influencing the decision makers on reimbursement. More investment in health care provider’s time now could reap great rewards later.

DAVID: I think automated insulin delivery has the potential to revolutionize care of people living with type 1 diabetes. We know from data in the T1D Exchange that the large majority of people are failing to meet their A1c goals. In most cases it isn’t for lack of trying. People with type 1 must become a part-time pancreas, a job that is exquisitely done by the body in people that don’t have diabetes.

[Editor's note: Disclosure: diaTribe is supported in part by a generous grant from the Helmsley Charitable Trust.]

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