Drs. Jeremy Pettus and Schafer Boeder led our Type 1 Spotlight Series in San Diego recently, and they covered trending topics in type 1 from new oral meds to groundbreaking glucagon spray. Here’s a recap of the night:
The Newest Fast-Acting Insulin: Fiasp
Fiasp is one of the newest fast-acting insulins on the market. It’s very similar to Novolog (aspart), but slightly faster at both onset and offset of action (and those are important for different reasons). Fiasp starts to work in about 15-20 minutes, peaks at around 40-50 minutes, and stays in your system for about 2-4 hours. It tends to handle glucose spikes better than aspart in a faster amount of time and it starts to wear off a little sooner, but after a few hours they both end up in the same place. According to the package insert, you can take Fiasp right at the start of your meal or even within the first 20 minutes, but we still recommend you take it beforehand to give it a head start. There have been mixed reviews from people saying there’s not a significant enough difference from aspart, but the good news about that is you don’t have to change the way you bolus if you want to try it. Fiasp may not be the best option for people with gastroparesis because it may work too fast for them and potentially put them at risk for post-meal hypoglycemia.
The Not-So-New (but Still Newish) Inhaled Insulin: Afrezza
There are pros and cons to inhaled insulin, but it definitely has some cool advantages. First of all, it works really quickly and wears off quickly, so this is an insulin you really can take when you start eating (or even 10-15 minutes after you start eating) because it works so fast. It’s gone in about 90 minutes, so if you’re eating a meal with a lot of fat or protein, you may need to take another dose.
Cartridges come in 4-unit increments, but 4 units of Afrezza is about 2.5 units of Humalog or Novalog so you almost have to take twice as many units to get the same effect. If you’re interested in using it, we recommend you stay on what you’re on now, get a prescription and just try it. If your blood sugars are high, try a 4 unit dose and see how many points it brings you down, and if you like it you can use it more frequently. We find it’s extremely useful for two things: 1) correcting a blood sugar really quickly without the delayed lows and 2) eating a crap load of carbs. Having a CGM is extremely helpful when using inhaled insulin. If you’re not on a CGM, you need to test frequently to learn what it feels like and how it affects you. The makers of Afrezza (MannKind) have a new device called BluHale that tracks dose delivery and helps you learn how to use the inhaler correctly.
Oral Meds Coming Soon
Two new T1D oral medications being considered for FDA approval are sotagliflozin (trade name is Zynquista) and dapagliflozin (trade name is Farxiga). These once-daily pills, that are typically used for type 2 diabetes, are designed to work alongside insulin, and we think this is something sorely needed. Both medications have been shown to decrease insulin use, lower body weight, and lower A1c without increasing the rates of hypoglycemia. More importantly, they increase the time in range which means they reduce the variability of glucose values, so there are less ups and downs. In one study, the folks who were on sotagliflozin were in range (70 to 180mg/dl) almost 3 more hours a day compared to the group who were just on insulin alone. These oral medications also reduce the risk of cardiac disease and renal disease progression in type 2 diabetes, and we think similar results may occur in type 1 diabetes, although this hasn’t been tested yet.
These drugs may be available as early as next year and we think they will be safe and effective medications for type 1, but you need to understand the risks. The main risk of these medications is that they increase the rate of DKA (diabetic ketoacidosis) slightly. The issue is that patients can start to produce ketones even if their blood sugars aren’t that high, so having a home ketone meter and knowing how and when to use it is a must. If you feel sick you definitely need to check your ketones, and if they’re high, you’ll need more insulin and may possibly need to seek medical care if you are really feeling badly.
In a nutshell, these new medications help get your A1c down (~0.4% on avg.), you may lose a little weight (3-5lbs), they may keep you in range a little better, and they may make diabetes management a little easier overall.
Hybrid Artificial Pancreas Systems
Our first step toward an artificial pancreas was the 670G from Medtronic.
It changes your basal rate based on what your blood sugar is doing, so if your blood sugar is creeping up it can give you more basal insulin, and if it’s going down it can give you a little less. You still have to bolus for all of your meals and do multiple finger sticks to calibrate, but the system does very well at controlling your blood sugars overnight when you’re sleeping.
Another hybrid system currently available is a DIY system that’s not produced by a major pharmaceutical company or FDA approved. It’s a system called LOOP and it’s made up of three components: an older Medtronic pump, an iPhone, a CGM such as Dexcom and a device called a RileyLink.
The RileyLink communicates with the pump to tell it how much insulin to deliver. (You also need a Mac computer for set up because you have to install the loop app on your computer first and then upload it to your iPhone).
With this system you never have to touch your pump – you control it all from the app. Like the 670G, you still have to bolus for meals, and the real benefit of this system is controlling your blood sugars overnight. For more info on loop, click here.
Even as we move into the next phase of advancement with the artificial pancreas, CGMs will continue to be important because you can’t have a good closed loop system without a good CGM.
The new Dexcom G6 has a lot of great advances including a smaller transmitter, no finger stick calibrations, a one-handed inserter device, an increased 10-day wear time for the sensor, built in predictive low alerts, and no acetaminophen interference.
Senseonics is a company that just came out with an implantable CGM called the Eversense.
A small sensor is placed under the skin in a short office procedure and stays there for 90 days. You wear a small transmitter over the inserted sensor and that sends the glucose values to a smart phone. It is a traditional CGM in that it has alerts and alarms and can send glucose values to your friends and family.
There’s a relatively new CGM on the market called the Freestyle Libre.
It’s a patch sensor you put on the back of your arm that measures blood glucose every minute. You wave a little device like a small cell phone over the patch and it tells you what your blood sugar is, as well as what it has been over the last 8 hours.
While the Freestyle Libre is a good device, we worry about type 1s using it (or even type 2s who are on multiple daily injections who are at risk for hypoglycemia) because there’s no continuous communication with the reader. There aren’t any alarms or alerts, so if you’re sleeping and your blood sugar drops to a dangerous level, you’re not going to know it. Also there’s no share feature so you can’t send data to your friends and family.
New Glucagon Options
Glucagon raises your blood sugars fast if you’re having a severe low. Our current glucagon rescue kit comes in a little powder, and you have to take out a syringe, inject it into the vile, shake it up, draw it back out and then inject it. It can be really confusing to administer, especially for a loved one of a type 1 who isn’t familiar with diabetes supplies or giving shots. But new options will be available soon and are going to be much easier to use:
1) The G-Pen: The G-Pen, made by Xeris, will auto inject like an EpiPen, so all you have to do is take the cap off and push it into someone having a severe low. You never see a needle and no mixing is required.
2) Nasal Spray: Glucagon nasal spray, made by Lilly, will come pre-packaged and you simply spray it into someone’s nose.
3) Mini-Dose Glucagon: Small doses of glucagon are being developed so you can treat a low without having to eat or drink. This can be particularly helpful if you get low during a workout.
Part of the reason it’s so hard to control type 1 diabetes is because we don’t have all of the tools we need. It’s not because we’re not trying hard, we don’t care, or we don’t have the right doctor. The good news is there are a lot of innovative advances right around the corner, and we’re looking forward to new medications and devices that will make all of our lives a little easier!