Incretins; Bionic Pancreas; Turf Wars: A Day at the ADA

June 16, 2014

The endocrinologist, the primary care physician, the nurse practitioner: who will do what in the coming days of diabetes care? Just one of the debates going on at the ADA conference.

There was a lot going on today at the ADA conference. Sunday is always an exciting day since it holds the president’s Lecture and the Awarding of the Banting Medal. Both lectures were wonderful.

The President of Medicine and Science clearly outlined the human need for greater research to be done to Stop Diabetes (a theme this year). She introduced a patient to put a human face on what could be seen as an esoteric problem. In recent years there has been a shrinking of federal research dollars available for diabetes researchers. This has resulted in a smaller pool of scientists who are nearly a decade older than in past decades when they receive their first federal (NIH) grant. Obviously, such a sluggish process results in some researchers perusing other paths.

The ADA has started an accelerated granting process that not only delivers grants to researchers of younger ages, but also stimulates a far more economic process from lab bench to publication. Each of you with an interest in diabetes can help by becoming a member of the ADA.

The Banting Award went to Dr. Dan Drucker, a noted researcher in incretin matters. His lecture reveals that this class of drugs offers promising new capabilities to improve glycemic control without hypoglycemia with the added benefit of weight reduction in some cases (GLP-1 RA’s). His lecture as well as the President’s can be seen on the ADA website.

In an interesting afternoon session on closed loop pumps, we learned that more rapid acting insulins may be needed to optimized closed loop pump systems. A variety of closed loop systems were examined. Dr Irl Hirsh pointed out that we have made great strides with closed loop pumps, but little progress with infusion sets, which are still subject to kinking or occlusion and can lead to scarring in areas chronically used for insulin delivery. Any of these problems can disrupt predictable insulin flow.

In an exciting oral presentation, Dr Russell presented information on a bionic pancreas that was applied to young volunteers. With the device, most had sugars that trended toward normal-a 60% reduction in low sugars and an 88% reduction in nocturnal hypoglycemia. An “at home study” starts Monday June 16 in the Boston area to validate the utility of this system that delivers insulin and glucagon as needed. Look for an “online ahead of print” article in the NEJM about this.

The end of the day for me was a session on “who will do what” in the coming days of diabetes care-essentially a debate between an endocrinologist, a primary care internist, and a nurse practitioner. The endo, Dr Steven Smith from Mayo, sees endocrinology as the caregivers for all but the most simple cases of type 2 and, more importantly, agents to set up a comprehensive strategy to deliver planned care (chronic care) to the population with diabetes. The internist, Dr John Anderson, former president of the ADA, stressed overall competence of primary care physicians to care for all but the most complex cases of diabetes. He felt this is actually a necessity due to the severely reduced numbers of endocrinologists, especially in under-served areas. The nurse practitioner, Davida Kruger who has been at the Henry Ford Hospital for 32 years, reviewed statistics on the success of advanced providers (NP’s and PA’s) in providing comprehensive diabetes care. With shrinking numbers of primary care physicians and expanding numbers of NP’s and PA’s, her statistics are compelling. We will need these advanced providers to help fill a critical gap in care.

After much post-presentation input from the audience it is clear that future successes will depend on building care teams that draw on the strengths of all providers. This will require top-flight education for all involved and likely some way to certify that education so properly prepared providers can be recognized and identified.

Tomorrow I hope to discuss some of the more interesting posters as well as the latest scientific breakthroughs. See you tomorrow.