Insulin Therapy and the Future of Type 2 Diabetes Care

Jennifer B. Green, MD: We can’t forget about insulin therapy. Insulin is a very effective tool. I talk about insulin as though it’s 1 thing, but there are many types of insulin being developed. One area that has seen a tremendous amount of evolution in recent years is the development of artificial pancreas systems. We have devices available that include both an insulin delivery component and a glucose sensor, or CGM [continuous glucose monitoring], component that are at least partially linked. The insulin delivery in at least some respect is directly affected by the ambient glucose level that the sensor detects.

We have a couple of devices that alter basal insulin delivery based on what the glucose level is, and that represents an exciting step forward. A true artificial pancreas—there are many such systems in development—would be completely hands-free or at least come very close. There are also a number of systems in development that include an algorithm or very sophisticated algorithms that alter insulin adjustment—not just for basal insulin delivery but for correction insulin or, to some extent, mealtime insulin in response to the individual’s activity and blood glucose level that will come a little closer. None of those hands-free systems are in development, but they’re getting closer.

We’ve seen published data, particularly in the pediatrics population, that look incredibly promising. Consistently, almost all the trials I’ve reviewed suggest that these kinds of systems reduce the risk of hypoglycemia compared with the traditionally available semi-integrated systems. The challenges we’ll see moving forward will be how these systems can be designed to account for meal intake, how to customize or appropriately deliver insulin in response to what the person is eating, and how the system reacts to hypoglycemia, should it occur.

Some of these systems are dual-hormonal systems that infuse not just insulin but also glucagon. Although none of these appear extremely close to becoming available, within the next 5 years, we’ll probably have multiple systems on the market that I hope will make life much easier for individuals who require these sophisticated insulin delivery systems. They’re not just for people with type 1 diabetes. These systems hold great potential for people with type 2 diabetes who need this intensive and complex treatment as well.

Dennis Bruemmer, MD, PhD: Technology has certainly taken off. We have penny-size sensors for continuous glucose monitoring. We have subcutaneously implanted sensors. We get a lot of questions from patients who might not necessarily benefit from sensors. They may be cardiovascular patients or any patient with diabetes who says, “I’m on 2 medications. I’m on metformin, and my hemoglobin A1C [glycated hemoglobin] is 6.8%. Should I wear a sensor?” That’s probably not helpful. These are meant more for patients on complex insulin regimens or multiple daily injections, combined with insulin pumps and an algorithm used to semiautomate—at least for now—the basal rates.

If you look at the requirements from the FDA for diabetes medications, they’re very stringent on outcome trials. For durable medical equipment, we’ve never had an outcome trial, other than looking at time in euglycemia or hemoglobin A1C. We don’t know well whether using a pump vs multiple daily injections would reduce microvascular or macrovascular complications. I alway s thought that would be a very interesting area to explore. But much of this has to do with quality of life in addition to quality of care. More time spent in euglycemia, safer insulin use, shut-off algorithms—basal insulin in the middle of the night—etc. These are the main advantages of pumps and continuous glucose monitoring. It’s available with phone data, so it becomes much more user friendly. If you look at pictures of how the first pump, the backpack pump, was developed to now automated algorithms, it’s really taken off. Diabetes care will become much easier, much safer, and outcomes will become much better in the future.

Some of the most encouraging data for us endocrinologists and cardiologists have been from a large Swedish cohort that looked at mortality data in patients with diabetes, emphasizing the comprehensive care model. I keep citing the Steno-2 trial in every presentation because it sends the message of comprehensive care, where if patients are treated with their hemoglobin A1C and albuminuria protected, and smoking, LDL cholesterol, and blood pressure all under control—all 5 of those factors were under control in this large Swedish cohort—there was no significant excess mortality across every age group. This is really encouraging. We have all the tools available to do that. The challenge will be to bring this to the wider population and to fill a lot of the gaps that we’re dealing with.

Jennifer B. Green, MD: I completely agree. I briefly mentioned the GRADE study. We have just a few moments left, but some of the information that trial will ultimately provide will be a bit of insight into personal phenotypes and drug choices that may be particularly effective and tolerable for individual patients. I’m interested to hear more from that study about personal phenotypes, individual predictors of accomplishment of good glycemic control, and even benefits from a microvascular or macrovascular perspective within the various classes of drugs that were studied in that trial.

Thank you, Dr Bruemmer. I’d like to thank everyone for watching this HCPLive® Peers & Perspectives®. If you enjoyed the content, please subscribe to the e-newsletters to receive upcoming Peers & Perspectives® and other great content right in your in-box. Thank you very much.

Transcript edited for clarity.