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Anne Peters, MD:
ADA 2021 was host to many exciting developments in the management of diabetes. In this commentary, I review a few of what I consider the key highlights.
Joint ADA and EASD Guidelines in Type 1 Diabetes
At ADA 2021, the ADA and European Association for the Study of Diabetes (EASD) presented a draft consensus report on the management of type 1 diabetes in adults, marking the first time these organizations have released such guidance. I was honored to serve as a co-chair for the committee, which consisted of 14 diabetologists from Europe and the United States.
Among the most useful and interesting outcomes of this consensus report is a guide to diagnosing type 1 diabetes in adults. A key message from the committee is that healthcare professionals should suspect type 1 diabetes in individuals with new onset diabetes without a family history of type 2 diabetes. The first step is to measure anti‑GAD antibodies. A positive result is defined as type 1 diabetes; a negative result is less conclusive. Depending on the population, 5% to 10% of people with type 1 diabetes will test negative for anti-GAD. To further delineate a diagnosis, we look at age. For individuals older than age 35, it can be challenging to discern a diagnosis of type 1 vs type 2 diabetes and we recommend treating them based on clinical characteristics. After 3 years of treatment, we discuss measuring C‑peptide levels to determine if they are still making insulin or not. For those younger than age 35, it is important to determine whether the individual has monogenic diabetes, that is, a genetic form of type 2 diabetes. The consensus report provides details on the characteristics of and screening for monogenic diabetes. Ruling out monogenic diabetes, we must then ask whether the individual has features of type 2 diabetes; those who do not are identified as having type 1 diabetes (anti-GAD negative).
Regarding treatment, one of the most basic recommendations is that all people with type 1 diabetes should have access to continuous glucose monitoring (CGM). The data are clear that CGM benefits the user. In addition, the report reviews a variety of insulin regimens, including hybrid closed loop systems and analogue insulins, which are the preferred insulin in type 1 diabetes. However, access and cost are important considerations, so alternative options are also discussed.
Patient preference is a major focus of the guideline. Type 1 diabetes is such a personal disease that is difficult to treat, so we must consider the psychology of patients living with this condition. We must provide education and support for our patients, including referral to a mental health specialist when needed. The guideline also provides a paradigm for what should happen at various visits, including a schedule of care. Finally, there is some discussion of emerging therapies, such as stem cells and islet cell transplants, which may someday be part of the guideline.
Overall, I hope our colleagues will find this an interesting document that can help the general practitioner understand how to identify and treat patients with type 1 diabetes.
As healthcare professionals, it can be challenging to know how patients are managing multiple daily insulin injections. The advent of smart pens, which integrate with a smartphone app to manage insulin dosing along with CGM, has the potential to remove some uncertainty.
At ADA 2021, we saw results from a real‑world study of persons with poorly controlled diabetes who were initiating smart pen use. Among 423 patients with a baseline glucose management indicator >8.0%, the time in range increased within 90 days of initiating the smart pen. Moreover, those with the poorest glycemic control experienced the greatest improvement. These data were retrospective, but I suspect that if they had surveyed the patients, they would have seen additional benefits in terms of patient preferences.
I like this abstract because it shows, in a relatively large population, that people were in fact using the smart pen to dose their insulin and they were benefitting. It is a small change that patients can make to have better glycemic control. I think smart pens are useful tools moving forward, and they will continue to improve. For example, I look forward to smart pens that will tell us basal insulin dosing vs just premeal insulin.
Social Determinants of Health
The COVID-19 pandemic has raised broad awareness of social determinants of health and racial disparities in health outcomes. Although these differences have always existed, more investigators are beginning to look at how to make a change. At ADA 2021, an abstract that best exemplifies this kind of research was presented by Agarwal and colleagues, who examined racial and ethnic disparities in the use of diabetes technology among young adults with type 1 diabetes.
People of color, including Black and Hispanic youth, with type 1 diabetes are less likely to use technology than their White counterparts, even when insurance helps cover the cost. In this study, the investigators conducted interactive virtual focus groups across 11 states to gain perspectives on the barriers to diabetes technology uptake. Among their primary findings was that many of the participants were never offered the technology. So, first, healthcare professionals need to offer technology. Even if there are technology options that a provider is less familiar with, there are trainers and other options available to help patients.
Even among participants who were offered technology, multiple barriers were identified, including:
In their assessment, the authors identified 4 areas of need:
I think these data underscore the importance of local, community‑based solutions. Support from peers is especially helpful because I think it is easier to see somebody like you who is using technology and who can say, “This worked in my life.” Moreover, these findings are true for any medical technology and for medications with a high cost that are harder to access. We need to help people navigate within their world and try to incorporate strategies and resources to help them get better.