Solvable Problems in Diabetes – From Low-Hanging Fruit to Moonshot Ideas

By Jeemin Kwon and Brian Levine

Insightful diabetes leaders discuss high-potential areas ranging from SGLT-2s in type 1 diabetes, personalized treatment plans, and the do-it-yourself Loop app

The diaTribe Foundation’s fifth annual “Solvable Problems in Diabetes” event convened over 100 attendees to explore the most promising breakthroughs and challenges to improving life with diabetes. The event was held at the 2018 European Association for the Study of Diabetes (EASD) meeting in Berlin, Germany. Attendees heard from an expert panel:

• Dr. Chantal Mathieu - Katholieke Universiteit Leuven

• Dr. Partha Kar – Portsmouth Hospital, NHS

• Moderated by Adam Brown – diaTribe Senior Editor

Adam framed the discussion by stating, “We can build new technology and tackle ‘moonshots,’ but we can also focus on low-hanging fruit that requires less investment. We could build the perfect glucose-responsive insulin that keeps people in range; that’s a moonshot. But we could also work on getting insulin and fingersticks to people who literally don’t have enough to live with diabetes each day.” With that in mind, topics spanned across continuous glucose monitoring (CGM), the prospect of using SGLT-2 inhibitor pills in type 1 diabetes, the need to consider patient circumstances and individualize care, and more. Below are some of our favorite quotable quotes from the evening:

On using SGLT-2 inhibitor pills in type 1 diabetes (for background reading, click here):

• “Patients love SGLT-1/2 or SGLT-2 inhibitors because the moment you swallow this pill, in the evening, you see your glucose curves [flatten]. You feel in control, happy, and your weight goes down. They love it. But things happen, despite education, despite a plastic card I give them telling them to check ketones if feeling nauseous, telling the ER doc it’s ketosis, etc. All adjunct (add-on) therapies in type 1 come with some risk of ketosis, because if you give a therapy to a person with type 1 that lowers glucose, you need to bring down insulin dose, and that means that levels of insulin drop…” – Dr. Mathieu

• “It’s not about, ‘Oh my god, we have a new drug in type 1 to use.’ If I were to spend my euros, would I put that on SGLT-2 inhibitors or on education? Or on non-invasive glucose monitoring? I think those [tough] questions will come through. We handpick patients [to use these drugs]. It does drop A1C and weight, but with risk of DKA and infection.” – Dr. Kar

On CGM in people with type 1 and type 2:

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  “I’m still surprised that many of our type 1s say, ‘I want nothing to do with [CGM], leave me alone with my multiple daily injections, I want no one to know I live with type 1.’ In Belgium, we have full reimbursement of CGM, and penetration of CGM is 80% in type 1s in my clinic… It’s free, and still 20% say, ‘No thanks.’… Let’s be honest, with pumps and CGM, the burden of diabetes is not decreased.” – Dr. Mathieu

• “Type 2 diabetes is so much more than just glucose… [CGM] is expensive, and I’d rather spend my euro on giving them all access to GLP-1 or SGLT-2 than on CGM.” – Dr. Mathieu

On the patient voice and celebrity power:

• “I’m a big believer in the power of the patients. In Belgium, everything is around cancer. We have a project called “Let’s Fight Cancer,” and they sell little plants, and they had the good fortune that the weather guy is their supporter, so every evening, when the guy says ‘it’ll rain tomorrow,’ he adds, ‘and do not forget, fight cancer.’ So it’s high on the agenda, so many expensive drugs, and when we come with something for diabetes, ‘oh, they need to discuss for 700 days.’ Patients are central, they need to voice why it’s important to have attention for non-sexy chronic diseases.” – Dr. Mathieu

• “One of the reasons we’ve had so much attention on diabetes is because our prime minister [Theresa May] has type 1. No one knew about metatarsal bones until David Beckham broke his foot. That’s the power of celebrity…We need somebody super special, loved by everyone, with type 1 or type 2 diabetes to come forward.” – Dr. Kar

On better treatment guidelines for healthcare providers:

• “I don’t know about the rest of the world, but in the UK, hypoglycemia admissions in frail elderly have now overtaken DKA admissions. That is just poor care. She is 94, just let her be, stop trying to get her A1C to 6%. It’s time to update the guidelines based on frailty, weight, and CV disease.” – Dr. Kar

• “If I may ask industry, we need trials in non-classical populations. Like frail elderly, for instance, there’s zero evidence [on what to do]. We were very frustrated in the EASD/ADA Consensus committee, we couldn’t say anything about the elderly, let alone the frail elderly. Yeah, we need some gutsy studies in people over 75 years old, demonstrating safety and efficacy of drugs (or not).” – Dr. Mathieu

On how some healthcare providers may view Loop (stay tuned for more on Loop user experience from diaTribe):

• “If something is happening that works, then my job is to find those people and learn about what they’re doing and encourage them. And I know there are concerns about safety and out-of-warranty pumps, but we need to be open and talking about these things. I heard about a doctor who had a patient on Loop and said, ‘I’m not going to see you.’ And we don’t want to do that. We want to provide cover so that doctors can say, ‘We’re not responsible for this but we’re going to support you.’” – Dr. Kar