Clinical Diabetes Technology Meeting 2007
The third annual Clinical Diabetes Technology Meeting was held in San Diego on April 20th and 21st, 2007. In attendance were hundreds of clinicians, scientists, and engineers from government, industry, academia, and clinical practice. During the two days of sessions, speakers shared information on a variety of topics, including many aspects of continuous glucose monitoring, the growing appreciation for the importance of minimizing glycemic variability, new drug therapies (GLP-1 agonists and DPP-4 inhibitors), the challenge of reimbursement, the importance of glucose control in the hospital setting, and MDI vs. pump therapy, just to name a few. Here is a summary of some of the sessions:
- Christopher Saudek, MD, presented The Impact of Self Monitoring of Blood Glucose on Glycemic Control. While self monitoring is a given for anyone with type 1 diabetes, there remains a debate in the medical and scientific community about the benefit of self monitoring by patients with type 2 diabetes. Given the enormous cost associated with self monitoring -- Medicare Part B spent $460 million on test strips in 2002 -- many payers are asking for data to support monitoring by patients with type 2 diabetes. Dr. Saudek presented data from several studies that showed reductions in HbA1c of as much as 0.4% in people with type 2 who are treated with only oral medications. Other studies hinted at benefits only in patients treated with insulin.
- Bruce Buckingham, MD, presented Continuous Glucose Monitoring Overview. Families who have attended a CWD conference have heard Dr. Buckingham present this excellent talk, which illustrated very well the benefit of continuous glucose sensing. One particularly important point that he made was that 75% of seizures in kids with type 1 diabetes happen at night, which argues very strongly for the importance of nighttime monitoring.
- William Clarke, MD, spoke about Glycemic Variability, a topic of considerable and growing interest among scientists and clinicians. Dr. Clarke noted the growing understanding of the potential role of high glycemic variability in the risk for complications. Dr. Clarke then examined several statistical ways to examine and report on glycemic variability from blood glucose data in an effort to make variability easier to discuss among clinicians and with patients. After reviewing several well known topics, Dr. Clarke focused on new statistical ways to quantify the concept of risk, both the risk for impending severe low blood sugar and the risk from glycemic variability.
- Howard Wolpert, MD, in a talk entitled Establishing a CGM Program, offered several excellent tips on how to teach patients to use continuous glucose monitors safely and effectively. Dr. Wolpert showed, for example, that relying only on sensor data can result in overtreating lows due to the physiological lag between finger stick data from blood and continuous sensor data from the interstitial space. He also cautioned about the potential for increased lows due to excessive correctly for elevated blood sugar and the importance of teaching insulin action to patients. He also offered advice on adjusting pre-meal insulin based on rate of change data from continuous sensors.
- Three speakers participated in a panel discussion about Reimbursement of CGM: Panel Discussion. Much of the presentation was somewhat technical, focusing on procedure codes and CMS. However, the take away for CWD families is that we should always submit claims for reimbursement for continuous glucose sensors to insurance companies to make sure that they are aware of the growing demand for the technology. Families should always appeal any denials also, which again demonstrates a growing demand for continuous sensing.
- David Sacks, MD, in a talk entitled Hemoglobin A1c and Mean Blood Glucose (MBG) To Diagnose and Manage Diabetes, taught about the history of the use of glycated hemoglobin as a tool in managing diabetes. For many years there was a wide variety in assays and as a consequence enormous variability from one lab to another, making direct comparisons of HbA1c in patients nearly impossible. With the National Glycohemoglobin Standardization Program (NGSP), that has almost entirely changed, much for the better. Now, for almost all patients (99%), the HbA1c value that they receive from their diabetes team can be directly related to other HbA1c data, most importantly the HbA1c data from the DCCT.
- Michael Goldberg, MD, and Jeffrey Joseph, DO, each spoke about managing patients in the hospital setting. Drs. Goldberg and Joseph, both anaesthesiologists, stressed the growing awareness of the importance of tight glucose control in patients who are undergoing surgery. Controlling blood sugar levels in surgical patients has been shown to reduce complications such as post-operative infections and to reduce hosptial stays. While all of the data presented was based on adults, and much of it in adults with type 2 diabetes, parents of children with type 1 diabetes we face surgery should be sure that their child's diabetes is discussed and that they are confident that the entire surgical team will work to control blood sugar levels.
- In Insulin Pump Therapy: Case Studies, Stephen Gitelman, MD, and Howard Wolpert, MD, took turns presenting real clinical data from their patients -- Dr. Gitelman children and Dr. Wolpert adults. Based on a growing body of data from continuous sensing, it's clear that insulin analogs, while fast, are not fast enough and that bolusing before meals is an important strategy to prevent large post-meal glucose excursions. Dr. Wolpert presented a fascinating example of the impact of fat in a meal from an adult patient who ate pizza late at night. While the patient used the correct dosing strategy for pizza (about 70% up front with a two hour extended bolus), the fat in the meal caused insulin resistance overnight, resulting in a high morning blood sugar. The take away for pump users is to check often after high fat meals and to be prepared to increase basal rates temporarily if you experience this effect.
- Anne Peters, MD, spoke about GLP-1 Agonists, focusing on extenetide, known as Byetta. Dr. Peters eloquently explained how Byetta differs from other treatment options for diabetes, and why it is such an important new option for treating adults with type 2 and even type 1 diabetes in some cases. With science learning more about these gut hormones, treatment options are likely to include more than just insulin in type 1 diabetes and traditional oral medications in type 2 diabetes. Patients taking Byetta experience both reduced blood sugar levels but also lose weight -- sometimes significant amounts of weight.
- As part of a group of talks about managing obesity, Erik Dutson, MD, a bariatric surgeon, spoke about the dramatic improvements in type 2 diabetes seen in patients who undergo bariatric surgery. Dr. Dutson explained several different kinds of surgery for weight loss and noted that bariatric surgery is the only weight loss strategy that offers long term success. He also noted that the majority of his patients with type 2 diabetes who undergo bariatric surgery experience an almost immediate resolution of their diabetes and can stop taking their oral medications. He stressed that the reason for this is unknown.
Dr. David Klonoff opened the third annual Clinical Diabetes Technology Meeting
Dr. Bruce Buckingham answers a question from the audience after his presentation about continuous glucose monitoring
Dr. Howard Wolpert offered his experiences in using continuous glucose sensing
The final session of the first day was a panel of four adults who use continuous glucose sensors
Dr. Anne Peters explained the importance of GLP-1 agonists