AADE Day One - High level themes
We're in LA! Excellent. Here are some quick initial themes from day one
#1 - LOTS MORE SYMLIN DISCUSSION: So for the first theme, this is sort of interesting - it's Symlin! This drug is definitely taking off a bit more - maybe due to the Byetta shortage, which we've been thinking is going to end soon (thankfully!) We've heard more people talking about Symlin - it also makes sense since more educators that we saw/spoke to today see intensively managed patients - but we also heard a lot about Symlin and pumping - we heard it at the Medtronic session that started off the day, where Dr. Fran Kaufman was extremely engaged as always; we heard it at one of the DPP4 sessions, and then we heard it tonight at Dex Com, which took place at the spectacular Disney Hall.
This sort of surprised us. For a long time, we've been calling Symlin a sleeper drug, so from it to move from "sleeper" or just "small drug, right now" status to a drug where everyone is singing its praises and discussing how fabulous this alternative new delivery form is ... wow. Of course we personally concur with how excellent pumping Symlin is. Everyone was saying how practical that wasn't, but I think eventually there will be a way. Symlin is also probably getting more discussion points here because with the emergence of continuous monitoring, there's now an easier way to figure out the titration. Most of all, we’re impressed with the reimbursement strategy for Symlin. Would that reimbursement could be as easy for CGM…they are both such high potential tools.
#2: BYETTA IS BIG HERE TOO: CDEs we've spoken to so far don't seem to be concerned about pancreatitis. There is also a lot of excitement about LAR. Davida Kruger, who is part of the LAR trial, characterized the results as “amazing,” with more weight loss, better glucose control, and the same or less nausea than Byetta.
#3: PFIZER IS THE LATEST NEWEST BIG ADVOCATE OF POST-PRANDIAL TESTING TO IMPROVE ABILITY TO GET A1C UNDER 7. Complications from type 2 start long before diagnosis. “We treat too late” is a becoming a flatter and flatter statement every year - the consequences of a younger population of type 2s living with complications much longer is a daunting prospect. Monnier showed us that controlling PPG gave the best bang for the buck in lowering A1cs compared to FBG for most, except those with very unacceptably high A1Cs. Also, powerhouse educator Catherine Gray (Diabetes Network, Inc. Albuquerque, NM) believes that PPG testing offers more encouragement to her patients – she believes they are more motivated, creative, and successful in their self management if they are on the PPG bandwagon. Very intriguingly - if the reimbursement piece works (and it does in her NM community) she believes in aggressively treating pre-diabetics. Blonde also speculated that early insulin therapy may reduce atheroschlerotic processes and macrovascular complications and help preserve beta cells. He mentioned the NAVIGATOR trial, which is investigating whether insulin for pre-diabetics and early diabetics reduces progression.
#4: CONTINUOUS GLUCOSE MONITORING IS CHANGING THE PARADIGM OF SELF-MANAGEMENT. There is increasing evidence that glycemic variability contributes to morbidity and mortality, but A1Cs do not reflect this glycemic variability and fingersticks alone are not catching it. Thus, Dr. Francine Kaufman of Children’s LA feels that CMG is “the next big breakthrough” because it is proactive rather than reactive. Kaufman and her team have jumped on the CMG bandwagon as fast as possible, even prescribing it off-label in their pediatric patients. CMG lowers the risk of hypoglycemia (due to alarms) and the discovery of blood glucose trends allows clinicians to correct easily correctable factors in insulin regimens. The most corrected factor in patients who have used CGM is an increase in meal boluses and the second is a decrease in basal insulin. A close third is a change the method of counting carbs—big changes!
#5: WE WERE REMINDED YET AGAIN OF THE FABULOUS VALUE AND LEARNING THAT COME FROM THE PHARMACIST RELATIONSHIPS in "Treatment of Type 2 Diabetes: Controversies, Challenges, and Opportunities." Curtis Triplitt, PharmD CDE, Texas Diabetes Institute, Clinical Assistant Professor of Medicine/Diabetes, University of Texas Health Science Center at San Antonio took the lead on this one and had some interesting thoughts:
On the DREAM trial. He expects the study results to be positive and that a shift in how TZDs are used will follow. We'll be watching in mid-September ...
On Byetta use in his clinic. His group is having lots of pre-authorization issues with respect to reimbursement. Some of his patients with nausea can't get past it no matter what they try with dosing, etc. Some people lose weight, some people don't.
On DPP4s. He likes that they are well tolerated but expects ongoing controversy around their long term impact on the immune system.
On Exubera. There was audible paper rustling when he turned started talking about Exubera. He expects some confusion as to where it "fits". Right, us too, since people who take inhaled insulin probably won't get it reimbursed initially. As for the pulmonary function topic, he believes the work to date and ongoing work on collecting safety data will dampen the concerns over time.
#6: ON BALANCE, WE BELIEVE THERE IS AN INCREASINGLY COMPLICATED LANDSCAPE FOR THE DIABETES EDUCATOR AS NEW THERAPIES AND TECHNOLOGIES EMERGE. The CDEs will be the frontline and charged with knowing about everything that's happening – and often in more depth than the doctors. This speaks to fantastic opportunity, but also to our ongoing concern that the field hasn't created enough incentives for educators and thank heavens for their hearts – they are sadly in dire need of reimbursement funds for all the life-changing and life savings education they do.
#7: EMPOWERING PATIENTS AND INDIVIDUALIZING THERAPY are emerging themes, with caregivers talking less about what patients HAVE to do and more about figuring out what patients CAN do. Educators can only advise patients, they can’t set their goals. As star educator Davida Kruger put it when talking about the ACCORD trial, “There is no right way – it all depends on the patient.” Caregivers must listen to patients and tailor therapy to how they behave. Karmeen Kulkarni also emphasized the need for clinicians to integrate their therapies because patients rarely have diabetes alone – they also have hypertension, dyslipidemia, etc.