ATTD 2024 brought together the brightest minds in diabetes care, showcasing groundbreaking advancements across four key areas: diabetes technology, glucose measurement techniques, novel drug therapies, and Type 1 diabetes (T1D) prevention strategies. Importantly, there was a fantastic session on how to look after skin in the era of devices. So, I have gone to town on that one. Let’s unwrap the insights and innovations presented.
1. Diabetes Technology
- Accu-Chek SmartGuide CGM by Roche: Roche’s Accu-Chek SmartGuide CGM for adults requires only a one-hour warmup and a one-time calibration. With a MARD of 9.2%, this system, presented by Professor Julia Mader, integrates AI to customize glucose predictions and prevention recommendations over two hours during the day, and up to seven hours overnight. We await the accuracy and usability studies to assess potential clinical impact.
- Neural-Net AID Algorithm by Dr. Boris Kovatchev: A revolution in diabetes management has been tested in a randomised control trial. This fully-closed loop system achieved comprable Time in Range (TIR) without needing meal announcements to AID systems but needed six time less processing power. It promises to significantly ease the burden of diabetes management through black box artificial intelligence that learns, rather than just adapting! There were more presentations on a Neural-Net approach, it seems a true black box learning (not adapting) algorithm might be the future?
- Advancements in Pediatric Diabetes Care: Dr. David Maahs reviewed key developments in diabetes technology for children, highlighting studies from the CLVer trial on the effects of Automated Insulin Delivery (AID) systems and verapamil in preserving beta-cell function in newly diagnosed paediatric T1D. In short, AID from diagnosis does not preserve c-peptide, but, Verapamil does! Verapamil may be an adjunct to insulin from diagnosis in the not to distant future.
2. Glucose Measurements: HbA1c and Time in Ranges
- Rethinking Glycemic Control with Dr. Rich Bergenstal: Proposing a shift in managing glycemic variability, Dr. Bergenstal suggested lowering the coefficient of variation (CV) target from 36% to 32% to improve TIR without increasing hypoglycemia risk, highlighting the importance of both average glucose and CV in achieving consensus targets. Key point, if one is to push toward 50% or more time in tight range (TITR, 3.9-7.8 mmol/L), CV must be 32% or below, otherwise, hypo city!
- The Synergy of A1c and CGM: Drs. Irl Hirsch and Gregg Simonson emphasized the need for a dual approach, combining A1c with CGM data for a comprehensive diabetes management strategy. They explored A1c discordance and its implications for uncovering microvascular complications. The posted had a key takeaway, if the GMI is 5 mmol/mol (0.5%) lower than actual HbA1c over 90-days, this likely signifies a person at higher risk of complications as they may be fast glycators. There is going to be a lot published on this over the next year. Here’s a teaser. People of black ethnic origin seem more prone to fast glycation. Therefore, it is likely half of the 7 mmol/mol difference in HbA1c between white and Black children and young people in England is due to glucose-independent factors impacting HbA1c – something to ponder! Important note, HbA1c is not going anywhere as it predicts future complications better than CGM metrics!
- Emotional Impacts of TIR Metrics: Dr. Molly Tanenbaum discussed the emotional responses to CGM-based metrics, highlighting how TIR and TITR are perceived and the need for careful framing and additional support to avoid discouraging patients. For the moment 70% TIR is good enough and only suggest 50% TITR is CV is less than 32% and its not going to cause undue stress!
3. Drugs
- Lyumjev with Control-IQ 1.5: Dr. Carol Levy’s trial findings showed improved patient satisfaction and very modest (2%) TIR increases with Lyumjev used alongside Tandem’s Control-IQ 1.5 technology, underscoring the nuanced benefits of ultra-rapid insulins in AID systems. This is a shame, it would have been interesting to see if TITR showed a bigger drop
- Verapamil in Preserving Beta-Cell Function: Prof. Desmond Schatz highlighted the CLVer trial findings that verapamil partially preserved beta-cell function in children and adolescents with T1D, indicating a potential low-cost intervention. Again, this could be coming sooner than you think.
- Incretin-Based Therapies and GLP-1 RAs: Prof. Satish Garg discussed the progress in incretin-based therapies, including promising results from Lilly’s retatrutide and semaglutide in inducing significant weight loss and improving glucose control in people with T1D. This could be the future for T1D and obesity and getting 50% or more TITR.
4. Type 1 Diabetes Prevention
- Immune Interventions and Restorative Therapies: Prof. Desmond Schatz reviewed clinical studies on immune interventions in T1D, including findings on abatacept and the TEDDY study’s insights into the genetic and family history factors influencing T1D progression. The immune modulating therapies are going to come thick and fast and Teplizumab will be in the UK within 12 months or so.
- Treating Obesity in T1D: Drs. Satish Garg, Jeremy Pettus, Kirsten Nørgaard, and Victor Gerdes delved into the challenges of managing obesity in T1D, exploring the interplay between weight management, insulin resistance, and diabetes care. GLP-1 RA’s are likely to be the future for T1D weight management.
Skin Care in the era of devices
This comprehensive article outlines the prevalence and management of skin injuries related to medical adhesive use, emphasising the need for greater clinical awareness and the adoption of best practices for prevention and treatment. Key points and clinical actions include:
1. Prevalence and Impact: Medical adhesive-related skin injuries (MARSI) are widespread across all age groups and care settings, affecting patient safety and increasing healthcare costs. They result from improper use of adhesives, causing skin integrity loss, pain, infection risk, and delayed healing.
2. Consensus and Research: A consensus panel of experts convened to define best practices for the assessment, prevention, and treatment of MARSI, highlighting the lack of guidance in literature and identifying research priorities for developing new adhesive technologies and skin protection protocols.
3. Prevention Strategies: Recommendations for preventing MARSI include avoiding alcohol-based preps, applying lipid lotion after adhesive use, and employing gentle removal techniques, such as using removal sprays. Barrier products, steroid creams, and silicone-based adhesives are advised for skin protection, with caution advised for the potential atrophy with steroid use.
4. Clinical Actions:
• Educate healthcare providers on the risks and prevention of MARSI.
• Assess patients’ skin daily or with each adhesive change, especially those at high risk for adhesive-related injuries.
• Use adhesives appropriately, considering the patient’s skin condition and the specific application area. Do not use alcohol-based wipes, they dry out the skin.
• Implement gentle removal techniques and consider medical adhesive removers to minimize skin damage. Get some prescribed from the start
• Apply evidence-based wound care principles for MARSI treatment and consult specialists for non-responsive or worsening injuries.
5. Future Research: There is a need for further study on adhesive performance, injury mechanisms, prevention methods, assessment tools, and effective treatments for MARSI.
Exercise and type 1 Diabetes.
There was an excellent session on how to go from general principles to individualised plans. This was very similar to what was delivered at EXTOD in 2023. Simple principles for pump and MDI of 50/50/20 and for hybrid closed loops T25/T25. If you want to know more, check out the EXTOD 2023 review. Watch out for the EASD position statement led by Othmar Moser and Dessi Zaharieva in 2024. I have managed, somehow, to be a co-author, so I will update on this publication.
ATTD 2024 offered an update on all things Tech and drugs, with some practical gems. Most importantly, it offered a chance to Network, party and for me, become part of the EXTOD faculty!
Hope you enjoyed this breif review.
John