COMMENTARY

Irl Hirsch Reviews ADA Highlights With Anne Peters

Anne L. Peters, MD; Irl B. Hirsch, MD; Mark Harmel, MPH

Disclosures

July 01, 2020

This transcript has been edited for clarity.

Anne L. Peters, MD: I'm here with a dear friend of mine, Dr Irl Hirsch, at the end of the virtual American Diabetes Association (ADA) Scientific Sessions to discuss a few of the findings from the meeting, as well as how we feel about virtual meetings. Irl, could you tell us a bit about some of the newer insulins?

Irl B. Hirsch, MD: Yes, thank you. It's always good to be with you. There are, as usual, quite a few new insulins to think about and hope come to the market. One of those is the weekly long-acting basal insulin from Novo Nordisk. I did not know this was in development. What's interesting is that other companies are also working on a weekly basal insulin.

Upon my first glance at the data, I think this will work quite well in people with type 2 diabetes. We now have history of using a weekly medication in type 2 diabetes with our GLP-1 inhibitors.

But I am a bit concerned about using a weekly insulin because of the fact that the half-life of this insulin is 196 hours. That's incredible. Think about onboarding patients on the outpatient side, but even more so — and this has become a big interest of mine — what happens when somebody on a weekly basal insulin comes in to the hospital and that insulin is not in the hospital? How do you know how to switch them to and from glargine or NPH or anything else?

So, it was really fun for me, but I think we need to see more data and really figure out how we are going to make these changes when these patients come in to the hospital.

Peters: That makes a lot of sense and also applies if their circumstances change — they eat less or suddenly decide to go on a low-carb diet, or make any behavioral changes that can affect their sugars. But as you stated, I really like the idea that patients may be more adherent to a once-weekly medication, so I'm intrigued, as you are. It will be interesting to see their phase 3 trials.

Hirsch: Yes. I'll point out that the last patient I saw today was on a weekly GLP-1 inhibitor, and it was the first time I had seen him since we started it — a very nice man with type 2 diabetes. And he lost 12 pounds. That is another situation where you want to make a relatively quick change in the insulin, if you're starting to see a lot of nocturnal hypoglycemia. But when you have a half-life of 196 hours, there's nothing quick.

Peters: No. On the other hand — since you and I both love technology — hopefully by the time we have once-weekly insulin, everyone will be on continuous glucose monitoring (CGM), and then it'll be easier to monitor.

Approval of the Freestyle Libre 2

Peters: Now, with that in mind — and this wasn't part of the ADA meeting, per se, although there were a lot of data on CGM at the meeting — the Libre 2 has been approved. Could you discuss that a bit and tell us what you think of it?

Hirsch: Well, nobody is more excited about it than I am. Not only was this new sensor approved by the FDA, but there will be no change in cost. For a lot of our patients, cost is key. And especially for patients who need an alarm for hypoglycemia, which is most of my type 1 patients, I really need to have that low-glucose alarm. For those who do not have good coverage, the cost is so important. Now we actually have a low-cost sensor that can help us defend better against hypoglycemia.

More important than that, though, is the improved accuracy of this sensor compared with the previous one. Hopefully we will soon also have integration with pumps for automated insulin delivery with the sensor. We don't have that yet, but I think that's the goal. I'm quite excited that we now have another choice.

Peters: I am, too, and I love that it got the iCGM [integrated CGM] designation; it is now interconnectable with other systems. The more choices patients get, the better it is. There are a lot of patients who like the way this system feels. It suits some people; others prefer a different device, but now we have choice. I really love the idea of giving people choice for things they're going to be wearing on their body as they go through their lives. So I'm thrilled that we have it available. I've been waiting for this for a long time.

Virtual Conferences, the Good and Bad

Peters: That leads me to the question about virtual meetings. What did you think of them? How did you like them? What do you think the future holds for us in our field and in sharing information with colleagues?

Hirsch: I've been thinking about this, as we all have, and like anything, there's good and bad. I don't have to fly across the country and walk around the meeting jetlagged. But the reality is that I miss seeing my friends. I miss both the professional and the social interactions. I didn't realize how important it was to meet colleagues and have coffee — or to even run into somebody while walking across the street, like you and I did one year in San Diego — and it ends up in a research study or an editorial in a journal. A lot of what we do is based on our interaction.

But there are many other things. The fact that I can be watching a lecture and then move to another lecture in another room by clicking my mouse — that could never happen with the usual ADA meetings. And I really like being able to see questions and what other people are thinking in the chat rooms. The chat rooms were great.

I'd be very interested to see what the final attendance was. I could see people from all over the world who were attending in the middle of the morning or the middle of the night for them. From an international point of view, I would not be surprised if we actually had a higher attendance.

One of the disappointments for me was that there seemed to be very little poster traffic compared with usual in terms of the number of questions I would get or people wanting more information about the data on my posters. Sometimes the posters end up being as important as some of the oral presentations. I think that with the virtual meeting and having so much information on your computer, the posters may have been left out. There are other issues, but those are the main ones that come to the top of my mind.

Peters: Yes, I thought it was interesting. I liked the lectures more than I thought I would, because I was forced to really look at people. It was really nice seeing my very smart colleagues talk about things and feeling like I was right there with them. I liked that.

I think the point you made about the posters is right, because I used to make it an absolute self-mandate to see every poster and read them, and I really wanted to learn from the posters. I didn't have time with this meeting to do anything that was a poster. I just listened to lectures and felt like they were more accessible.

The chat function was nice. On the other hand, I did a technology interest group discussion, and the whole system kind of broke down. There were technical issues when they were trying to do it live, and it didn't work. Some of those glitches are obviously things that can be fixed.

What I worry about are our younger colleagues. We're a tight-knit family, so to speak. We all know each other — you know me, I know you, we know our buddies — but this is based on years of sharing time together, drinks together, and meetings together. We know each other no matter where we are, but I'm really worried that some of this is lost for the younger colleagues who I can't just drag over and say, "Here, meet Dr Hirsch. He's a legend." I can't do that.

And so I really hope that in the future we are able to do both, that we have virtual capacity. Maybe for people who might have to come from overseas it works better, but when you can meet together at least annually, I think there's something really good inherent in that.

I think it's the same for me with patients. I like doing telemedicine, but I still think I have to meet them physically, at least once a year, just to reconnect and look at their feet and their injection sites and everything else. I like the real touch, at least once a year. So, I think we'll come up with some way that is in between, once we're through with the COVID pandemic, whenever that might be.

Hirsch: I'll just add, who knows what the future is going to look like? Especially for next year, which to me is a really important ADA meeting, being the 100th anniversary of insulin. That's a big deal. My guess is that if we are able to meet in person, people will still have the option to do it virtually. And what that will mean from a logistical point of view is that taping our lectures 2 or 3 weeks before the actual presentation won't happen; everything will be live, which is not necessarily a good thing for some people and their schedules.

What I really liked about this meeting is that at the end of the day, there was always stuff that I missed. And I could go that night and listen to somebody's talk that I couldn't go to because I had another talk I wanted to see. I really, really enjoyed that.

Peters: Right. Me too. There's something good in all of this. Where is the ADA meeting next year, if it's held in a real place?

Hirsch: Washington, DC.

Peters: All right. Well, Irl, I hope to see you in Washington, DC, for a thousand reasons. But if not, I'll see you some way, somehow. I really appreciate your time today. Thank you.

Hirsch: Thanks, Anne. My pleasure.

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