Type 1 diabetes

ADC 2021 keynote: Yes to new insulins – but health disparities matter


Prof Satish Garg

Insulin has come a long way in 100 years but the promise of ultra-rapid and ultra-long-acting analogues and smart delivery devices is an empty one when too many patients are missing out, an international expert says.

Speaking in the Opening Plenary at the Australasian Diabetes Congress 2021, Professor Satish Garg said worldwide diabetes mortality data published recently in the NEJM clearly showed that many people in many countries cannot afford insulin therapy.

“Even in the developed world like the US, Canada and Western Europe, it is important to note that insulin therapies are widely available but pretty expensive. We need to make these therapies more easy [sic] for patients.”

Professor Garg, from the Barbara Davis Centre for Diabetes at the University of Colorado, and Editor-in-Chief of Diabetes Technology & Therapeutics, said the lifetime economic burden of about 1.5 million people with type 1 diabetes in the US was about $1 trillion.

Yet the majority of patients in the US were not doing well.

He said data from the T1D Exchange registry showed that only about one in four US adults and youth with type 1 diabetes were achieving ADA goals for HbA1c despite advances in technology and care.

“Somehow or another we all need to do a better job … so there are less disparities across the globe and everybody is able to get decent care for their diabetes.”

He noted that people with diabetes from communities of colour and those with low socioeconomic status were bearing the brunt of huge disparities in care.

As well, it was unfortunate to note that many patients with type 1 diabetes were becoming overweight or obese.

“Nowadays, two-thirds of patients have what we call double diabetes – diabetes which requires insulin therapy and insulin resistance from obesity,” he said.

Digital health can breaks down barriers

Professor Garg said possibly 150 million people required insulin therapy worldwide.

“If we want to reduce overall health care costs, we have to look at barriers so every patient is treated equally and glucose control is optimised in the majority of patients.”

“And maybe we are learning a lot from the COVID-19 pandemic … how digitisation of diabetes care might allow us to break down these barriers and have many more patients seen electronically or through telehealth and managed more effectively.”

Professor Garg said the pandemic’s mitigation efforts, especially social distancing, had led to an unprecedented surge in technology growth across all industries including health.

Digital medicine and telehealth – like virtual medical congresses – were here to stay, he said.

“Real-time CGM has really revolutionised care. It has proven its value across various environments during lockdown in the telehealth environment, remote monitoring and inside the hospital.”

Regarding CGMs, he said almost all sensors now have mean absolute relative difference (MARD) <10%.

“We also hope there will be a continuous ketone measurement made available.”

He said the CGM marketplace was about $6-7 billion and was going to exponentially increase to more than $15-20 billion in the next five years.

Professor Garg said some of the barriers to achieving glycaemic goals with insulin included non-physiologic pharmacokinetic profiles, non-adherence to MDI, erratic drug absorption due to lipohypertrophy, complex regimens and human error when calculating doses, the inability to adjust basal insulin once given, and weight gain with therapy.

As a consequence, insulins which could be given less frequently or delivered differently were in the spotlight.

Experimental approaches – some of which had come and gone – included:

  • The addition of hyaluronidase to rapid acting insulin to improve tissue permeability
  • The addition of EDTA to improve speed of action
  • Inhaled insulins e.g. Exubera and Afrezza
  • Warming the skin to speed infusion e.g. InsuPad
  • Microneedles into the intradermal space
  • Intraperitoneal delivery eg. Diaport
  • Smart pens e.g. InPen approved in the US
  • Aquasomes, biodegradable nanoparticles, injectable microgels & microspheres.

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