ATTD 2017 (Advanced Technologies & Treatments for Diabetes)

February 15-18, 2017; Paris, France; Preview – Draft

Conference Website

Conference Agenda

View Abstracts in the Interactive Program (click on the orange box next to the oral session)

Industry Sponsored Agenda / Industry Programs

The tenth (!) International Conference on Advanced Technologies & Treatments for Diabetes (ATTD) will be held in Paris, France from February 15-18. Boy, are we excited for this year’s lineup, which shows very clearly how the field is maturing – giving dosing guidance to MDIs (three separate sessions), bringing CGM and pumps to type 2s, and a greater insulin-company-meets-technology presence than we’ve seen in the past. The full preview below shares commentary on each conference session, and we’ve highlighted sessions in yellow that we’re most excited for. Here’s a quick day-by-day summary of the highlights:

Wednesday Highlights – Abbott will share real-world data on FreeStyle Libre; Lilly will bring together David Panzirer, Chris Bergstrom, and Dr. Howard Wolpert for a panel on connected care; Roche will share an update on the Accu-Chek Insight CGM; and Dr. Eric Renard will give the opening keynote on “Moving to a Dynamic View of Diabetes.”

Thursday Highlights – The conference’s first oral session will start with a bang and include results from the long-awaited T1D Exchange REPLACE-BG study (insulin dosing off the Dexcom G4 without a confirmatory fingerstick), new type 2 data from Dexcom’s DIaMonD study, three studies of Libre, and an update on GlySens’ implantable CGM. The conference’s can’t-miss opening session will highlight automated clinical decision support systems with Drs. Aaron Kowalski, Bruce Bode, George Grunberger, and Moshe Phillip. On the corporate symposium front, Medtronic will share real-world experiences with the MiniMed 670G and give an update on the Sugar.IQ app with Watson, while Dexcom will share its own pipeline update and cover sensor-based algorithms for MDI decision support. And if that’s enough, we’ll also hear from Onduo (Sanofi/Verily) CEO Dr. Josh Riff for the first time at a diabetes conference, 670G data in another oral session, and Drs. John Pickup and Irl Hirsch on technology in type 2. Whoa!

Friday Highlights – A closing the loop session will share a progress update on The International Diabetes Closed-Loop (iDCL) Trial (Tandem/TypeZero’s NIH-funded pivotal), plus include new inpatient closed-loop data from the Cambridge team. We’ll see the first clinical data on Insulet’s OmniPod Horizon Automated Glucose Control system (Dr. Bruce Buckingham); hear the year in research in the lightning fast ATTD Yearbook; and learn even more about the 670G from Dr. Satish Garg. A strong session on Advisors will close out the day, including Glytec, TypeZero, and DreaMed.

Saturday Highlights – The third major session on insulin dosing support will bring together Sansum’s Dr. David Kerr, Diabeo’s Dr. Guillaume Charpentier, and DreaMed’s Dr. Moshe Philip. Meanwhile, Dr. Aaron Kowalski will moderate a rapid-fire session with startup company presentations (including a “bandage-like patch pump,” AI coaching, glucose-responsive insulin, and beyond). The annual dual-hormone pro/con session will continue, this year bringing Drs. Steve Russell, Stu Weinzimer, Remi Rabasa-Lhoret, and Mr. Ahmad Haidar together (great to see use of amylin gets a slot this time).

This is our view of some of the highlights, but it is certainly not everything at the meeting! Read on below for a more detailed breakdown of what we’ll see at ATTD 2017.

Wednesday, February 15

  • (2:30-4:00 PM, Blue Amphitheatre) Industry Workshop: Flash Glucose Monitoring: Real World Benefits Across the Clinical Spectrum (Supported by Abbott). In one of three parallel industry-sponsored sessions in this time slot, Drs. Eleanor Scott, (University of Leeds, UK), Elena Toschi (Joslin Diabetes Center, Boston, MA), and Ramzi Ajjan (University of Leeds, UK) will share real-world data and experiences with Abbott’s FreeStyle Libre. Dr. Scott will discuss the accuracy of Libre in pregnant women with diabetes, which we’d expect to be on par with accuracy in non-pregnant women (given previous sensor accuracy studies in pregnant women and similar data for adults vs. pediatric populations). Next, Dr. Toschi will give what is sure to be an interesting overview of behavior modification with Flash Glucose Monitoring – this is really the whole point of continuous glucose sensors – observe a real-time change in glucose, learn from it, and take a different action now or next time. What strategies does Dr. Toschi use with her patients to encourage behavioral change? Is behavior change similar between CGM with alarms vs. Libre? Since the Libre consumer version is not yet approved in the US (expected in 2H17), perhaps Dr. Toschi will discuss experiences with the blinded, 14-day Pro version (launched in 3Q16 in the US). Dr. Ajjan will wrap up with a talk entitled “Real World Benefits of Flash Glucose Monitoring in a Multinational Database” – this kind of data can be very compelling and we wonder if Abbott can use it effectively with payers.
  • (2:30-4:00 PM, Maillot Hall) Industry Workshop: The Value of Connected Care in Diabetes (Supported by Lilly). This impressive panel, consisting of Mr. David Panzirer (Helmsley Charitable Trust, New York, NY), Mr. Chris Bergstrom (Boston Consulting Group, Boston, MA), Lilly/Joslin’s Dr. Howard Wolpert, and moderator Schuyler Buck (Lilly) is another reminder that the insulin company is embracing digital health. The company already has several digital health investments/products, including one in Bluetooth-enabled smart pen developer Companion Medical (expected launch this year), one in Beta Bionics, and a just-cleared prescribed app for Humalog titration called GoDose (we’ll have more details on this soon). We assume there is a lot happening behind the scenes too – perhaps on connected patch devices and other apps to drive better use of medication or stronger education. We look forward to hearing from Mr. Panzirer, Mr. Bergstrom, and Dr. Wolpert about ways in which large insulin companies can and should get further involved in technology and connected care. Other large pharma players have also gotten into the digital health field, as Sanofi entered a ~$496 million joint venture with Verily (Onduo) last fall and Novo Nordisk has partnerships with Glooko (smart pen to pilot in Europe in 2017) and IBM Watson.
  • (2:30-4:00 PM, Room 252) MiniMed 640G With SmartGuard: How Best To Utilise The System To Improve Patient Outcomes (Supported by Medtronic). This session will focus on the MiniMed 640G (predictive low glucose management), which first launched two years ago at ATTD 2015. We saw real-world user evaluation data last year from Dr. Pratik Choudhary, and expect this session to cover similar ground. Drs. Kirsten Norgaard (Copenhagen University Hospital) and Ohad Cohen (Sheba Medical Center, Israel) will share case studies and best practices for using the system in different patient populations. As a reminder, Medtronic’s MiniMed 670G hybrid closed loop is expected to launch outside the US in May-September of this year (per JPM), so we’ll have to wait for ATTD 2018 for updates on that front.
  • (4:15-5:45 PM, Blue Amphitheatre) Industry Workshop: What Do We Need Beyond a Sensor to Make the Use of CGM Safe and Effective for Patients? (Supported by Roche Diabetes Care). Dr. Eric Renard (Montpellier University Hospital, France) and Dr. Rolf Hinzmann (Roche Diabetes Care, Germany) will chair this Roche-sponsored workshop. We are very eager to hear Dr. Raimund Weitgasser (Paracelsus Medical University, Salzburg, Austria) describe the “first patient experience” with the Accu-Chek Insight CGM, which was expected to roll out in a controlled fashion in the Netherlands, Sweden, Norway, and Denmark by the end of 2016 – we got a first in-person look at this device at EASD in September. It seems very accurate (MARD: 10.5%, two fingersticks per day, seven-day wear), but has a larger on-body footprint than other devices. UVA’s Dr. Marc Breton will follow with an intriguing talk questioning the current lack of quality standards for CGM – FDA guidance has been established for SMBG, but this is noticeably absent on the continuous monitoring side. Oh boy. Besides accuracy, what else should be included in such guidelines – Duration? Interfering substances? We will also get another look at the Accu-Chek SmartPix software – a platform to visualize and analyze Insight CGM data – which reps showed off at EASD in September, and a masterclass on training concepts for safe and effective use of CGM from Profil Institute’s Dr. Lutz Heinemann.
  • (4:15-5:45 PM, Maillot Room) Benefits Of Professional CGM Across A Wide Spectrum Of Patients With Diabetes: Customizing Treatments For Improved Outcomes (Supported by Medtronic). Drs. Hélène Hanaire (France) Medtronic’s Dr. Robert Vigersky will share the latest innovations in Medtronic’s professional CGM pipeline, which we expect to focus on the Pattern Snapshot report, iPro2, and the new Fitbit partnership for contextual data logging. We hope for an update on the single-use iPro3, which is expected to launch by April 2018 (per JPM).
  • (4:15-5:45 PM, Room 252) MiniMed 640G With SmartGuard: How Best To Utilise The System To Improve Patient Outcomes (Supported by Medtronic). This session will repeat the one listed above with Drs. Norgaard and Cohen.
  • (6:00-7:30 PM, Grand Amphitheatre) Opening Ceremony and Keynote. We last heard Dr. Eric Renard (Montpellier University Hospital, France) speak at ADA on the details of different closed-loop algorithms, but this keynote will be a much bigger picture: “Moving to a Dynamic View of Diabetes: A Cornerstone on the Road Toward Glucose Control.” We hope this touches on different care models as the field becomes more connected – instead of an in-person visit every 3-6 months, how about continuously monitored data (via algorithms) that alerts providers to patients in trouble?

Thursday, February 16

  • (8:30-10:00 AM, Grand Amphitheatre) Plenary session: Automated Clinical Decision Support Systems. The first plenary of ATTD is stacked with familiar and renowned faces: JDRF’s Chief Mission Officer and VP of Research Dr. Aaron Kowalski, Atlanta Diabetes Associates’ Dr. Bruce Bode, AACE Past President Dr. George Grunberger, and ATTD chairperson Dr. Moshe Phillip. They will discuss the promise of big data, personalized treatment using decision support tools, and the challenges of introducing new technologies into clinical practice. Automated systems are more scalable and faster than most humans’ eyes for picking trends out of glucose data or titrating insulin appropriately – they can supplement care, allowing providers to spend more time speaking with the patient about lifestyle and other concerns. (As Wired magazine founder Kevin Kelly says in Tim Ferriss’ new book, Tools of Titans, “Productivity is for robots. What humans are going to be really good at is asking questions, being creative, and experiences.” We agree – when something like IBM Watson can read 200 million pages of text in three seconds, and give an evidence-based treatment recommendation at the point of care, the role of humans in healthcare should change dramatically.) On the connected insulin pen and dose titration side alone, there are at least ten systems in development or already launched (see our 2016+2017 Reflections piece).
  • (10:30-12:00 PM, Grand Amphitheatre) Improving Patient Care With Continuous Glucose Monitoring: From Diagnosis To Artificial Intelligence (Supported by Medtronic). This is the Medtronic symposium we are most looking forward to ATTD, as it should give updates on both the MiniMed 670G and the Sugar.IQ with IBM Watson. On the former, IDC’s Dr. Rich Bergenstal will share “first experience” with the hybrid closed loop system, presumably covering the pivotal data (shown at ADA 2016 and again at EASD) and perhaps the extension data (n=99) included in the device’s FDA Summary of Safety and Effectiveness (see our coverage in highlight #5 here). As a reminder, a full US 670G launch is expected in May-October (customer training launch by April). An international launch is also expected in May-October, though the countries  have not been specified. Meanwhile, Medtronic’s very smart Huzefa Neemuchwala will discuss “CGM and Cognitive Computing: easing patient burden in daily diabetes management,” hopefully sharing new screenshots and an update on the Sugar.IQ app with Watson. As of JPM, this app’s launch was pushed back to May-October. We have been impressed with the potential so far and might expect a co-launch with the standalone Guardian Mobile CGM in the US. No international timing has ever been shared on this app. Medtronic’s Chief Medical Officer Dr. Fran Kaufman will chair this session, and will listen closely for major updates on the planned 670G outcomes study (~1,000 patients) and future closed-loop technologies.
  • (1:00-2:00 PM, Grand Amphitheatre) Parallel Session: Pregnancy and Technology. Dr. Helen Murphy (Norwich Medical School, University of East Anglia, UK) headlines this session with a talk on her impressive NEJM-published paper investigating the use of closed loop during pregnancy and labor. The study definitively showed a benefit: overnight time in a very tight target (63-140 mg/dl) was 75% during the four weeks of overnight closed-loop vs. 60% during the four weeks of sensor-augmented pump therapy (p=0.002), with a lower average glucose (119 vs. 133 mg/dl) and no significant difference in hypoglycemia or insulin dose. What’s more, out of the 16 participants, fourteen chose to continue with closed loop therapy well past the four-week study period. Also featured in the session is Dr. Yariv Yogev (Lis Maternity and Women’s Hospital, Tel Aviv, Israel), who will speak about the effect of maternal diabetes on future maternal fetal health. We hope the growing evidence around use of CGM and closed-loop in pregnancy expands access globally – any mother that wants these technologies should be able to access them without significant burden, at minimum during term and labor.
  • (1:00-2:00 PM, Blue Amphitheatre) Parallel Session: Closed Loop Algorithms: Benefits and Limitations of the Various Options. This unique session will feature the lead architects of various closed loop algorithms talking about the pros and cons of their approaches: Dr. Moshe Phillip on DREAM’s Fuzzy Logic, Dr. Roman Hovorka on Cambridge’s MPC algorithm, Dr. Claudio Cobelli on Padova’s MPC algorithm, and Dr. Garry Steil on the older PID approach. All these algorithms do well overnight, and we believe the key differentiators will come on user experience, daytime interaction burden, adaptability, and training burden.
  • (1:00-2:30 PM, Maillot Room) Industry Symposium (Supported by Dexcom). This session looks excellent and will include a pipeline update from Dexcom VP Jake Leach (“Introduction of the Next Novel Dexcom CGM Technology Platform” – presumably the new inserter/transmitter and G6 and perhaps the Verily products); cover CGM trials in MDI users in talk from OHSU’s Dr. Andrew Ahmann (e.g., DIaMonD and GOLD, both just published in JAMA); and close with Dr. Boris Kovatchev on “Sensor-Based Smart Algorithms for MDI Decision Support.” We love seeing this last session most of all and hope TypeZero can really drive change with its inControl Advice platform (shown at DTM). The technology exists to do this now, so it’s really a matter of regulatory clearance, business model, and commercialization. In our view, this remains one of the lowest hanging fruits in diabetes technology that could have a tremendous impact on clinical practice and patient outcomes.
  • (1:00-2:30 PM, Room 252) Overcoming Insulin Refractoriness In Type 2 Patients With MiniMed 640G Insulin Pump (Supported by Medtronic). This session will cover Medtronic’s OpT2mise study and present case studies on pump therapy in type 2. We’ve seen similar sessions at the past couple of ATTDs following the trial’s publication in the Lancet in 2013.
  • (1:00-2:30 PM, Room 251) Oral Presentation Session #1. This major oral session is a can’t miss, headlined by results from the long-awaited T1D Exchange REPLACE-BG study (n=250), testing insulin dosing off the Dexcom G4 Platinum without a confirmatory fingerstick [abstract here]. Of course, Dexcom secured FDA approval for this indication in December and has had EU approval since 2015. We’ll also see the type 2 diabetes data from Dexcom’s DIaMonD study, augmenting the type 1 results shared at ADA 2016 and recently published in JAMA [abstract here]. Meanwhile, we’ll see plenty on Libre, including a study out of India testing Pro in type 2s; a subgroup analysis of type 1 MDI users in the IMPACT trial; and real-world data comparing Libre scans per day vs. outcomes. [Abstracts here, here, and here.] On the novel CGM front, we’ll also be excited for the latest clinical update on Glysens’ long-term implantable CGM [abstract here]. On a related note, a poster presentation will  separately share results of phase 2 of the DIaMonD study in which those using CGM were randomized to adding a pump vs continuing on MDI - these should be fascinating results (not yet posted in the abstract).
  • (2:05-2:30 PM, Grand Amphitheatre) Parallel Session: Insulin Pumps. Dr. Ralph Ziegler (Diabetes Clinic for Children and Adolescents, Münster, Germany) will compare the function and accuracy of various pump options. Dr. John Pickup summed this “controversial topic” up beautifully at DTM last fall – (i) pump accuracy and precision study results may be method dependent; (ii) accuracy varies between pumps, and results are good when manufacturers perform or sponsor studies, but there is little independent research in this area; and (iii) the clinical significance of varying pump accuracy is unclear (it might be important in children, insulin sensitive individuals, and with faster-acting insulin). Given how fragile the pump field is right now, we believe accuracy and precision of different pumps is low on the list of barriers to adoption.
  • (3:00-4:30 PM, Blue Amphitheatre) Industry Symposium: Connecting Therapeutics, Technology and Outcomes: A New Vision for Diabetes Care (Supported by Sanofi). The ~$496 million Sanofi-Verily joint venture, Onduo, has been quiet since it was announced in September. Impressive Onduo CEO Dr. Josh Riff will speak publicly at a major diabetes conference for the first time, and we eagerly await hearing more on the vision. How is the company thinking about care delivery? What is its business model? Who might it partner with? (Read our speculation and interview with him here.) UCSD’s Dr. Steve Edelman will also take to the podium for a talk on insulin titration and delivery, most likely highlighting MyStar Dose Coach and perhaps other products. Sanofi’s Dr. Ricardo Perfitti and Profil’s Dr. Lutz Heinemann will moderate.
  • (4:40-5:50 PM, Mailott Hall) Oral Presentation Session #2. This session will share four abstracts on the MiniMed 670G hybrid closed loop, including a three-month study in adolescents and young adults ranging from 14-21 years and three deep-dive data talks from the 670G US pivotal trial – one on change in A1c vs. baseline A1c and three showing how variability in insulin delivery increases overnight when on the 670G (a consistent finding in automated insulin delivery studies). Read these 670G abstracts here, here, here, and here. We’ll also see data from the DREAM5 study of the DreaMeD system over one weekend [abstract here], along with other more detailed closed-loop studies.
  • (4:40-6:00 PM, Grand Amphitheatre) Parallel Session: Type 2 Diabetes and Technology. The always-entertaining and insightful Dr. Irl Hirsch (University of Washington, Seattle, WA) – have you read his fifth annual rant on diabetes care yet? – will deliver a talk entitled “CGM in Type 2 Diabetes: Is it a Realistic Technology?” We expect Dr. Hirsch will express concerns about cost, the payer environment, and lack of clinical data (key barriers to CGM in type 2), but also share optimism about less expensive/more intuitive devices like FreeStyle Libre, Dexcom/Verily, and disposable professional CGM. We’ll be listening closely for his level of optimism. Dr. John Pickup (King’s College, London, UK), who gave a masterful overview of patch pumps at DTM 2016, will then examine the efficacy of pump therapy in type 2 diabetes in “An Individual Patient Data Meta-Analysis.”
  • (4:40-6:00 PM, Blue Amphitheatre) Parallel Session: Psychology and Diabetes Technology. The great Drs. Lori Laffel (Joslin Diabetes Center, Boston, MA) and Katharine Bernard (Bournemouth University, Poole, UK) are featured in this session – Dr. Laffel will focus on the type 1 pediatric population, while Dr. Bernard will speak more broadly on “making the most of diabetes technology.” We wonder if commentary will resemble that presented in the recently-published Diabetes Care paper from Dr. Korey Hood and colleagues: aside from cost/reimbursement, the hassle of wearing devices all the time, having devices on the body, and the look of devices on the body were the most commonly cited barriers to pump and CGM use. We’ll be interested to hear what solutions Drs. Laffel and Bernard offer. We also hope they touch on expectation management – the first iteration of a hybrid closed loop system, the MiniMed 670G, will hit the market in the coming months. Many expect this to make diabetes invisible, which is simply not possible with a basal-only modulation, 3-4 recommended fingerstick calibrations per day, and a first-gen system. How should the hype surrounding the impending launch be managed – sharing optimism but also a dose of reality?

Friday, February 17

  • (8:00-8:50 AM, Maillot Room) Industry Symposium: Simple Insulin Infusion for People with Type 2 Diabetes: When Daily Insulin Injections Fail…It’s Not the Insulin, It’s the Delivery (Supported by CeQur). This cleverly titled symposium will kick off with a talk from King’s College’s Dr. John Pickup on pump therapy in type 2 diabetes – we expect that he’ll share some of his DTM talk on patch pumps. Dr. Julia Mader (Assistant Professor, Medical University of Graz, Austria) will follow with a “Demonstration of PAQ Clinical Performance Including CGM and PROs.” Lower-cost basal-bolus patch delivery devices  hold great promise for type 2 especially, but the big question is commercialization and manufacturing scale. Can CeQur make it happen? We reported last April that PAQ was slated for a 2017 US launch, though Senior VP Mr. Jay Warner confirmed in late September that the company had not yet filed with the FDA (it was CE marked in 2012). Perhaps we’ll hear a filing update in this session.
  • (9:00-10:00 AM, Grand Amphitheatre) Parallel Session: Closing the Loop. UVA’s Dr. Boris Kovatchev will lead with a progress report on The International Diabetes Closed-Loop (iDCL) Trial. We learned in November that iDCL will serve as a pivotal study for the Tandem t:slim X2 with Dexcom G6 and TypeZero inControl algorithm, very positive news for the company. The initial phase of the study, a “Research Site Training Protocol” (n=20), which will use a smartphone running the TypeZero inControl algorithm, a Tandem pump, and Dexcom’s G5, has an estimated completion date of February 2017. We expect this talk will cover that phase of the trial. The “Main Protocol” (n=120), now up on Clinicaltrials.gov, will use the upgraded hardware and a fully-integrated system. The site indicates a January 2017 start date and a primary completion date of January 2018. (This timing will be tight to hit Tandem’s goal of a 2018 launch!) Following Dr. Kovatchev, the esteemed Dr. Roman Hovorka will share inpatient closed loop data out of Cambridge – we were blown away by the team’s inpatient data shared at ADA 2016.
  • (9:00-10:00 AM, Blue Amphitheatre) Oral Presentation Session #3. We’ll get a look at clinical data in adults from Insulet’s first study of its OmniPod Horizon Automated Glucose Control system [abstract here, presented by the great Dr. Bruce Buckingham]. This session also includes back-to-back talks on the Cellnovo-partnered Diabeloop closed-loop algorithm – a group we have not heard a lot from, but have been working at this for a while [abstracts here and here].  
  • (9:00-10:00 AM, Maillot Room) Oral Presentation Session #4. Highlights include a talk from Medtronic on the “Hypo-Triad,” a new composite metric for hypoglycemia [abstract here]; an interesting health economic analysis of the 640G with PLGM vs. pump therapy alone in Swedish type 1s  [abstract here]; and Canary Health CMO Dr. Neal Kaufman on keys to scaling and sustaining digitally-delivered diabetes programs [abstract here]. We’ll also hear glycemic control data on the OneTouch Verio BGM [abstract here] and accuracy data on the novel PixoTest smartphone-coupled BGM [abstract here].
  • (9:00-10:00 AM, Room 252) Improving patients’ experience with insulin infusion and injection port solutions: a hands-on session to discover the use of MiniMed Mio 30 & i-Port Advance to benefit your patients.  (Supported by Medtronic). This infusion-set focused workshops will share case studies on the angled all-in-one Mio30 and the i-Port Advance injection port for MDIs. Based on the title, it appears that the BD/Medtronic MiniMed Pro-set with FlowSmart will not be discussed.
  • (10:30-12:00 PM, Grand Amphitheatre) Plenary Industry Symposium: New Technologies Supporting Personalized Diabetes Management (Supported by Roche Diabetes Care). In this plenary symposium, Roche will detail the four main divisions of its Diabetes Care business: Dr. Guido Freckmann (AG Diabetes & Technologie, Ulm, Germany) will explain the Accu-Chek Insight CGM (which was expected to roll out in a controlled fashion in select European markets by then end of 2016; Dr. Ralph Ziegler will speak again on the accuracy of various pump options – notably, Roche recently halted sales of new pumps in the US, though it will continue internationally; and Roche’s Ms. Amy Day will talk about the next-gen Accu-Chek Guide BGM System, which is already in Denmark, Switzerland, and Australia and expected to launch in the US in 2017.
  • (1:00-1:30 PM, Grand Amphitheatre) Plenary Session: ATTD 2016 Yearbook. This lightning-fast year-in-review session (six minutes per talk!) is always a terrific way to stay on top of the past year’s research. Most of the micro-talks will be delivered by the same experts who gave them last year for a very objective look at how far we’ve come in the past year!
    • Drs. Satish Garg and Irl Hirsch on SMBG. As noted in our 2016+2017 Reflections piece, growing signs of connectivity, partnership, and novel players were bright spots in an otherwise tough financial year for the big BGM companies.
    • Drs. Bruce Bode and Dr. Tadej Battelino on CGM. It was a huge year for CGM, with the Dexcom G5 obtaining a non-adjunctive (insulin-dosing) label claim and a benefit category under DME (not to mention impressive G6 pre-pivotal data and pictures of the next-gen sensors with Verily), Abbott’s FreeStyle Libre going “gangbusters” in Europe with more than 200,000 users, the first implantable (Senseonics Eversense) hitting the market, and Roche entering the field with the Accu-Chek Insight. We also saw a slew of major studies in publications and growing clinical acceptance of the field. Read a broader take in our year-end Reflections.
    • Dr. John Pickup on Insulin Pumps. With tremendous competition, a word we have been using to describe the insulin pump market is “fragile” – does Dr. Pickup have hope for the future, particularly with automation?
    • Drs. Eyal Dassau and Revital Nimri on Closing the Loop. 2016 was a pivotal year for automated insulin delivery (AID), headlined by earlier-than-expected FDA approval of Medtronic’s MiniMed 670G hybrid closed loop and Guardian Sensor 3. The pivotal was presented at ADA and subsequently published in JAMA as a research letter. Plus, there are at least five players vying for second-to-market status, as noted here.
    • Drs. Jan Bolinder, Thomas Danne, and Lutz Heinemann on New Insulins, Biosimilars, and Insulin Therapy. We’ll be interested to hear their thoughts on gaps in research and optimism for the future of insulin therapy – is it more about molecular advancements, or simply using the insulins that we have better?
    • Dr. Neal Kaufman on Using Digital Health Technology to Prevent and Treat Diabetes. Our favorite recent comment on the state of digital health came at CES earlier this month: “We’re at the bottom of the hockey stick and the peak of the hype cycle.” In other words, a lot of groundwork has been laid that poises the field to accelerate exponentially, but hype for the field is at an all-time high right now. We expect Dr. Kaufman to put this in perspective, but also share optimism as the field matures.
    • Drs. Moshe Hod and Helen Murphy on Technology and Pregnancy. Dr. Murphy et al. showed that closed loop is beneficial in pregnancy (and labor) last year, and we look forward to hearing what else she and Dr. Hod can squeeze into their six minutes.
    • Drs. Desmond Schatz and Natasa Bratina on Immune Intervention for Type 1 Diabetes. Where should the field invest in the coming years?
    • Dr. Michael C. Riddell on “Advances in Exercise, Physical Activity and Diabetes Mellitus.” He will most certainly discuss the just-published Lancet consensus statement on Type 1 Diabetes and Exercise.  
    • Drs. Shlomit Shalitin and David Maahs on Diabetes Technology and Therapy in the Pediatric Age Group. CGM uptake in very young age groups has been excellent – particularly with remote monitoring – but what can be done about adolescents?
    • Dr. Alon Liberman on Diabetes Technology and the Human Factor. Passive data collection, small on-body footprint, and consumer-grade user experiences are key in our view.
    • Dr. Satish Garg on New Medications for the Treatment of Diabetes. Dr. Garg will presumably focus on metformin, SGLT-1/2 inhibitors, and GLP-1s.
  • (3:00-4:30 PM, Blue Amphitheatre) Industry Symposium: Approaching Physiology with Ultra-Fast Insulins (Supported by Novo Nordisk). Dr. Eric Zijlstra (Profil Institute for Clinical Research, Neuss, Germany) will reflect on the clinical pharmacology of ultra-fast insulin in pumps – this has definite upside and should allow systems to better control meals and be more aggressive with dosing. Dr. Vincent Woo (University of Manitoba, Canada) and Dr. Helena W. Rodbard (Endocrine and Metabolic Consultants, Rockville, MD) will then share results from the Onset Program, a phase 3 clinical program with faster-acting insulin aspart consisting of four trials – results from Onset 1 and 2 were presented at ADA 2016, but we wonder if there will be additional data shared here (two orals later at ATTD will share postprandial data). Some thought leaders have characterized FIasp’s postprandial improvements as “incremental” rather than “very life-changing,” but often, incremental gains are needed to get to the latter (case in point: CGM). Stanford’s Dr. Bruce Buckingham will give his own talk on advances in diabetes management – these are always a highlight and must-attend, particularly his wish lists.
  • (4:40-6:00 PM, Grand Amphitheatre) Parallel Session: Moving Forward with Technology. By ATTD, some patients will have been using the MiniMed 670G hybrid closed loop system for over 18 months – Dr. Satish Garg (Barbara Davis Center, Aurora, CO) will share data from a 99-person cohort. Topline data from the pivotal trial (presented at ADA 2016) was very impressive, and the FDA summary released upon the 670G’s approval included reassuring safety data from those who continued past the trial’s completion date. We wonder if additional data will be shared here. Other closed loop luminaries Dr. Eyal Dassau (Harvard University, Cambridge, MA), Dr. David Maahs (Barbara Davis Center, Aurora, CO), and Dr. Francis Doyle III (Harvard University, Cambridge, MA) will follow with discussions on the benefits and challenges of implantable artificial pancreas, the necessity of a pre-meal bolus in MMPC (multiple model probabilistic predictive control) algorithms, and multi-week outpatient studies with adaptation, respectively. This is sure to be a data-heavy and person-packed session!
  • (4:40-6:00 PM, Blue Amphitheatre) Parallel Session: Novel Insulin Analogues and Add-On Therapies in T1D. The most intriguing aspect of this session will be reflections from Dr. Bruce Bode and Dr. Thomas Danne on the use of SGLT-1/2 and SGLT-2 inhibitors in type 1 diabetes. Lexicon’s inTandem clinical trial program has showed encouraging data thus far (placebo-adjusted A1c reductions of 0.36% and 0.35%), and we’ll be listening closely to see how these benefits are characterized – of course, a therapy that shaves off highs and lows may not change the average (A1c) much, but still have a huge impact on patients. Dr. Danne will explore SGLT-2 inhibitors in pediatrics specifically – we wonder if there may be more concern over DKA risk in this population.
  • (4:40-6:00 PM, Maillot Room) Parallel Session: Advisors. Dr. Bruce Bode will present another Glytec Glucommander Outpatient study (n=38), following up impressive data from Glytec’s ADA poster (2.7% A1c drop at three months). UVA’s Dr. Marc Breton will give a talk on data from a TypeZero trial (n=35; see clinicaltrials.gov) testing mobile decision support software for titrating insulin (the trial is in pumpers, though TypeZero also has an MDI version). Dr. Revital Nimri closes out the session with a talk on the DreaMed Advisor, which automates insulin pump settings adjustments using glucose data from Glooko. Glooko CEO Mr. Rick Altinger said at DTM 2016 in November that a multi-site clinical trial will launch “in just a few months” – this appears to now be posted on ClinicalTrials.gov as the Advice4U Pro Study (n=112), which is slated to begin this month and wrap up in one year (not yet recruiting).
  • (4:40-6:00 PM, Room 252) Industry Symposium: CGM or SMBG? Interactions and Implications (Supported by Ascensia). Dr. Marc Breton (University of Virginia, Charlottesville, VA) headlines with a talk on the interaction between BGM accuracy and CGM performance. There is so much talk on MARD, but, with current options requiring calibrations, real-world CGM accuracy is only as good as the fingerstick measurements used for calibration. Adam recently switched to a more accurate meter and has noticed a significant difference in his CGM accuracy; we wonder if this will become a bigger topic for the BGM companies. The symposium will close with a panel discussion between Profil’s Dr. Lutz Heinemann and Ascensia CEO Dr. Michael Kloss.

Saturday, February 18

  • (9:00-10:20 AM, Blue Amphitheatre) Parallel Session: Sports and Diabetes. Dr. Michael Riddell (York University, Toronto, Canada) leads off with a talk on physiology and drug development for the prevention of exercise-related hypoglycemia. We last heard from Dr. Riddell at ENDO 2016 where he expressed dismay at the incredibly low adherence to exercise recommendations in patients with type 1 diabetes as well as strategies for diabetes management with intense physical activity. As noted above, we expect he will mention the just-published Lancet consensus statement on Type 1 Diabetes and Exercise. Other talks in the session fall in the “non-traditional” and “awesome” bins: “Continuous and Flash Glucose Monitoring in Youth with Type 1 Diabetes Hiking Gorges in Greece” and “CSII, CGM, and Scuba Diving in Pediatrics.”   
  • (9:00-10:20 AM, Maillot Room) Parallel Session: Connected Tools: How Can They Help Patient Decisions on Insulin Therapy? This is the third major session of the meeting focused on decision support systems. Dr. David Kerr (William Sansum Diabetes Center, Santa Barbara, CA) will speak about a unified platform for diabetes management, Dr. Guillaume Charpentier (Sud-Francilien Hospital, France) will discuss the Diabeo Platform (a CE-marked basal-bolus titration software), Dr. Marc Breton will discuss open loop algorithm development for glucose data collected from CGM, and Dr. Moshe Phillip will discuss open loop algorithm development for glucose data collected from SMBG.
  • (9:00-10:20 AM, Room 252) Presentations of Start-Up Companies. JDRF’s Dr. Aaron Kowalski will chair this session, which includes presentations from many companies we have not previously heard from: Cam Med (bandage-like patch pump); DiaTrends Biotech (AI coaching and Big Data); Sensulin (glucose responsive insulin); Biomicro (implantable CGM); Jupiter Devices (non-invasive glucose detection); Thera Nova (an intraperitoneal artificial pancreas); Ilya Pharma (wound healing); Hci (smart insoles); UND Life Sciences (diabetic retinopathy); and Predictive Autoimmune Biomarkers.
  • (9:00-10:20 AM, Room 251) Oral Presentation Session #5. This session will cover a wide array of topics in pump therapy, including two studies on pumps in type 2 [abstracts here and here]; an interesting survey from the dQ&A patient panel on choice of insulin therapy in type 2 diabetes [abstract here]; the impact of non-severe hypoglycemia on quality of life, sleep, and work productivity [abstract here]; a multi-center study on the MiniMed 640G’s impact on hypoglycemia fear and quality of life [abstract here].
  • (10:50-12:10 PM, Blue Amphitheatre) Parallel Session: Cybersecurity of Medical Devices. Mr. Jay Radcliffe (Senior Security Consultant, Rapid7, Boise, Idaho), recently known for exposing a cybersecurity vulnerability in the OneTouch Ping pump, will deliver an ominously titled talk: “Are we going too fast? The dangers of connected diabetic devices.” Mr. Radcliffe has previously said that removing an insulin pump from a diabetic over this risk is similar to never taking an airplane because it might crash.” We think that is a sound assessment, though we still expect him to be fairly negative on the security of connected devices. This issue receives far more attention and negative press than the real-world dangers presented to people with diabetes; we hope it is interpreted in a proper light. Other industries have solved security challenges and there is no reason why diabetes cannot do the same. Harvard’s very smart Dr. Eyal Dassau will also be featured in this session.
  • (10:50-12:10 PM, Maillot Room) Parallel Session: Dual-Hormone Closed-Loop: Issues and Expected Benefits. MGH’s Dr. Steve Russell will lead off with a description of the Bionic Pancreas insulin+glucagon approach, while Montreal’s Dr. Ahmad Haidar will follow and share their group’s approach. Next, Yale’s Dr. Stuart Weinzimer will delve into his group’s studies of using amylin plus insulin, and Dr. Remi Rabasa-Lhoret (Montreal Diabetes Research Center, Canada) will close with a talk on issues related to infusion of glucagon or amylin. With the kinetics of currently available insulins, adding glucagon and/or amylin should allow for tighter control, possibly less risk of hypoglycemia, and a better user experience (particularly around mealtime and exercise; see Dr. Russell’s 2016 NIH AP Workshop for limitations with insulin-only systems). Of course, many would note the tradeoffs – higher cost and additional on-body size and infusion sites. Ultimately, we support many lines of research inquiry, particularly those that are bold and ambitious. As XPrize Founder Peter Diamandis has said, “The day before something is truly a breakthrough, it's a crazy idea.”
  • (10:50-12:10 PM, Room 252) Oral Presentation Session #6. Highlights from this oral session include an impressive four-year pump study in type 2 diabetes [abstract here]; postprandial data from Novo Nordisk’s Onset 1 and 2 studies of faster-acting aspart [abstracts here and here; main data presented at ADA 2016]; and a Sanofi-sponsored Tresiba vs. Toujeo PK/PD study in type 1 diabetes [abstract here].
  • (10:50-12:10 PM, Room 251) Oral Presentation Session #7. Highlights include a compelling RCT testing CGM in pre-term infants [abstract here]; and an RCT comparing one week of a low-carbohydrate vs. higher-carbohydrate diet on glycemic control and daily insulin doses [abstract here; we’re very glad to see this type of study at ATTD and wish it had allowed more time for participants to adapt to the ultra low-carb, ketogenic diet, which typically takes 2-6 weeks].
  • (12:15-1:45 PM, Blue Amphitheatre) Plenary Session: The Evolving Face of Immunotherapy of T1D. Chairman Dr. Jay Skyler (University of Miami, Florida) will give a ten-minute introduction to the state of immunotherapy for type 1 diabetes treatment. We last heard him speak on this topic at Keystone 2016, where he argued that the key to effective treatment is a combination of immune therapies, all operating via different mechanisms. On that note, the DIPIT (Diabetes Islet Preservation Immune Treatment) trial will use a blend of simultaneous immunotherapies aimed at restoring insulin secretion in early onset type 1 patients after one year. The study is expected to complete in January 2021. ADA President of Medicine and Science Dr. Desmond Schatz (University of Florida, Gainesville, FL) will follow with a lecture entitled “Type One Diabetes Heterogeneity: Why Does It Matter?” He also spoke on this topic at Keystone 2016, commenting that recognizing heterogeneity would improve the way we understand, prevent, and treat type 1 diabetes, pushing us toward personalized medicine. Dr. Schatz warned that, while big data may lead us to the “coalescence of factors” that cause type 1 diabetes, healthcare providers must continue to approach each patient as a unique case in order to achieve the best possible outcomes in diabetes care. 

-- by Sarah Ferguson, Brian Levine, Adam Brown, and Kelly Close