Bridging the Gap for T1D Management

Opinion
Video

Expert endocrinologists provide final thoughts on addressing unmet needs and improving the management of T1D.

Steve Edelman, MD: What can we do with our patients to bridge the gap until we have a more solid cure? I think I can start off, and then Linda can jump in, or anybody. Are these hybrid closed-loop systems? We have 4 different ones on the market. I think you all would agree with automatic insulin delivery, modulating basal rate, alerts, and alarms that you could set individually that, for adults with type 1, my clinic has gotten so boring. Patients come in, their [hemoglobin A1C (HbA1C)] is good, time below range is really low, glycemic variability—and it’s not like you slapped [it] on, they have perfect control. You do some adjustments, a patient gets engaged in their care.

Linda A. DiMeglio, MD: We are still struggling on the pediatric side with some of the closed-loop technologies. We have some families that plug it in, go chug, and then we’re just tweaking little things, but kids’ insulin continues to change throughout childhood because of adolescent behaviors that lead to that. We had that nice type 1 diabetes exchange graph with peak [HbA1C] in there with 9.2%, same as before [the] DCCT [trial] across the population. So at least in our clinics, I’m still having kids [on Control-IQs walk in with HbA1Cs] of 10. And then, I got to go back, and it’s usually bolus, bolus, bolus, but don’t bolus after you’ve eaten because the system has already given you insulin; that’s why you’re going low. Avoiding the next bolus is not going to help you here. On the flip side, when we can manage them or when they manage well themselves—having just come off diabetes camp earlier this month, I have never seen so many blood sugars of 120, 130 in the morning. Still, the days are a little bit unpredictable. I don’t think we did much ketone testing at all in the morning. I’ve been doing camp for 25 years. It never looked that way before.

Steve Edelman, MD: That’s a third of the day.

Linda A. DiMeglio, MD: I was up more of the night with the alerts and alarms from the CGMs [continuous glucose monitors] with the staff trying to figure out what to do with them. I think it’s [promising], and access is important. We know that underrepresented populations are still much less likely to be using those devices. We’re doing well in kids right now with CGM incorporation across our clinics, but we need people to be insured, [and for] the underinsured to get them and to have access. As pediatric endocrinologists, getting that stuff down to the little kids is also going to be important, and there have been huge advances there.

Steve Edelman, MD: I’m going to take that as your final point. Egils, do you want to end our program with some final thoughts?

Egils K. Bogdanovics, MD: Well, we just celebrated the centenary of the discovery of insulin. I have a [Toronto, Ontario, Canada] newspaper that says, “Diabetes cured” that I show my patients; so, 101 years later and even though overnights are great with AID [automatic insulin delivery], insulin is still a pretty poor hormone replacement. I look forward to the day that we’re using teplizumab to prevent progression of diabetes.

Steve Edelman, MD: Well said. I think you emphasized, Linda, that although we do have these hybrid closed-loop, automatic insulin delivery systems, we have a long way to go, even for people who have access to them. Justin, my good friend, any final thoughts before we end the program officially?

Justin M. Gregory, MD, MSC: I just feel so fortunate to get to work in a field where we can have these discussions. About just a few years ago, we [had] been trying immunotherapy right and left. We’ve been doing antigen therapy right and left and disappointment after disappointment. Now we’re talking about how to implement immunotherapy in the way that we treat type 1 diabetes. I think of it as we’re at the dawn of the immunotherapy era. As endocrinologists, we don’t usually use immunotherapy drugs, unlike some of our other subspecialist colleagues. It’s an exciting era, but we’ve talked a lot about some of the challenges that we’re just starting to get our arms around as we enter that era. I look forward to getting to do it with people like you.

Steve Edelman, MD: Well, thank you for that. Very exciting time as well. Schafer, you get the final word on that.

Schafer Boeder, MD: Well, I would just say I learned a lot today. Thank you for all that expert knowledge, that was fantastic. I’m going to echo a little bit what was just said to some degree that it does feel sort of a dawn of a new era. Thank God for insulin, but it has been limited, and despite all these great technologies and CGM and closed-loop, the picture is not quite as rosy as Steve painted it in his clinic, where everything’s great. We see people come into the hospital, wearing their pump, but they’re in full-blown DKA [diabetic ketoacidosis]. There are a lot of problems still that we haven’t been able to solve even with great insulin therapies, new and faster insulins, and longer-acting insulins. There are still issues with increased cardiovascular disease, with the majority of patients not meeting glycemic goals, and issues with DKA. There’s a lot of work to do, but it’s such an exciting time to have some therapies, that we’re not just trying to play catch-up and treat by giving more insulin and figuring out different ways to use insulin, but to actually be able to get ahead of the curve a little bit is just very exciting and optimistic.

Steve Edelman, MD: Well, thank you, Schafer, Linda, Justin, and Egils, I learned a lot myself. It’s been a pleasure working with all of you, and I wanted to thank everyone for viewing and watching this Peer Exchange program. Don’t forget, they have an e-newsletter, where you can look at prior programs and future programs on different topics. Thank you very much for watching.

Transcript edited for clarity

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