- The centennial annual meeting of the Endocrine Society (ENDO 2018) will take place March 16-20 in Chicago. We’ll be touching down a few days earlier to attend the Endo Fellow Series (March 13-15) chaired by dream team Dr. Irl Hirsch (University of Washington) and Ms. Linda Siminerio (University of Pittsburgh). This full conference preview covers some of the sessions across both meetings (and preconference events) that we’re most excited about. If you’d like to peruse the full agenda, which is jam-packed with learning, you can find it online here.
- In drugs, AZ’s DERIVE trial of SGLT-2 Farxiga (dapagliflozin) in type 2 diabetes/moderate CKD will report on Monday morning (March 19). This study could be the first of many highlighting SGLT-2 efficacy in patients with renal impairment, and we’ll be in the front row for these highly-anticipated results. During Endo Fellows, Dr. Irl Hirsch will discuss insulin options, and we’re excited for his commentary on next-gen basals, faster-acting prandials, and biosimilars. Above all, we look forward to what Dr. Hirsch has to say about the rising cost of insulin and what needs to be done about it. Dr. Guillermo Umpierrez will give a talk on strategies for DKA management during Endo Fellows, a topic that’s increasingly relevant as oral adjuncts for type 1 are submitted to FDA and EMA (AZ’s dapagliflozin, Sanofi/Lexicon’s sotagliflozin). The agenda promises lots of learning on CV risk reduction, through product theaters on Lilly/BI’s SGLT-2 Jardiance and Novo Nordisk’s LEADER trial for GLP-1 Victoza, a meet-the-professor session with Denmark’s Dr. Peter Gaede, and Dr. Robert Eckel’s Endo Fellows talk on macrovascular disease in type 1.
- In tech, Joslin’s Dr. Lori Laffel will discuss the optimal use of new technology childhood through the transition to adulthood. We’ll also hear from a star-studded panel including IDC’s Dr. Rich Bergenstal, SUNY’s Dr. Ruth Weinstock, and Northwestern’s Dr. Grazia Aleppo on the theory and implementation of CGM, telemedicine, and remote monitoring of insulin pump therapy. Other exciting presentations include ENDO Fellows appearances from greats Drs. Irl Hirsch (on CGM practical tips and data management) and Roy Beck (on interpreting study findings).
- We’re also excited by many of the big picture sessions featured on this year’s agenda. Of particular note is a presentation featuring NIDDK Director Dr. Judith Fradkin and FDA’s Dr. Christine Lee addressing outpatient hypoglycemia as an emerging national priority – we’re hoping for a fruitful discussion getting at the validity of CGM, which seems to be CDERs big elephant in the room whenever hypoglycemia comes up. We’re also intrigued by a symposium on global diabetes healthcare costs and disparities to be discussed by Drs. Edward Gregg (CDC), William Herman (University of Michigan), and Mohammed Ali (Emory University).
Our team is headed to the windy city for the centennial annual meeting of the Endocrine Society (ENDO 2018) and its associated preconference events, including the Endo Fellows Series focused on type 1, led by the amazing Dr. Irl Hirsch and Ms. Linda Siminiero. Read on for our detailed preview of all the not-to-miss sessions at what is sure to be an incredible meeting(s). Let us know if we should keep an eye out for you in Chicago!
Endocrine Fellow Series: Type 1 Diabetes Care and Management
Tuesday, March 13
- (7:00-7:45 PM) Keynote Address: Cheating Destiny. Renowned author and journalist Mr. Jim Hirsch will kick things off at Endo Fellows will a keynote on his experience living with type 1 diabetes and as a father of someone with type 1 diabetes. His book of the same name, “Cheating Destiny,” was published in 2006. Mr. Hirsch delivered the keynote address to open Endo Fellows 2017 as well, highlighting the psychology of this chronic disease: He described how most successes in diabetes are private (no one celebrates an AM blood sugar of 104 mg/dl), while the failures are public, and he spoke to the dangers of stigmatizing language like “normal” vs. “abnormal” or even “healthy” vs. “unhealthy” instead of blood glucose that is “in range” vs. “out of range.” We couldn’t imagine a better way to start this meeting, by sharing with endocrinology fellows the experience of living with diabetes and also having a child with diabetes. We’re certain Mr. Hirsch’s talk this year will be just as inspiring.
Wednesday, March 14
- (9:00-9:40 AM) Natural History and Pathogenesis of T1D. TrialNet chair Dr. Carla Greenbaum (Benaroya Research Institute, Seattle, WA) will address the etiology of type 1 diabetes. As we learned from Dr. Greenbaum at Levine-Riggs 2018, conceptions of type 1 development and pathogenesis are actually undergoing an evolution as researchers learn more about the different forms (“endotypes”) of type 1 and how they can be more specifically targeted. We’re interested in hearing more about how these emerging endotypes might enable precision medicine in type 1 diabetes.
- (9:40-10:20 AM) Emerging Strategies and Targets for Prevention and Preservation of Beta Cells. The legendary Dr. Carla Greenbaum will continue the Endo Fellows agenda with a review of the latest prevention efforts in type 1 diabetes. Our ears will be peeled for any mention of the phase 2 POInT trial, a project of GPPAD (Global Platform for the Prevention of Autoimmune Diabetes) recently funded by the Helmsley Charitable Trust. POInT will screen >300,000 newborns and will enroll infants with high genetic risk for type 1 diabetes, investigating the preventative potential of high-dose oral insulin. Suffice it to say, we’re intrigued by this study, and we’re curious for Dr. Greenbaum’s take given her expertise in this area.
- (11:00-11:45 AM) Hypoglycemia in T1D: Understanding Risks and Putting Prevention Strategies into Practice. Dr. Elizabeth Seaquist (University of Minnesota, Minneapolis, MN) – who has helped developed Lilly’s nasal glucagon and is part of the International Hypoglycemia Study Group – will offer strategies for avoiding hypoglycemia. This promises to be a practical, informative workshop. We hope to hear Dr. Seaquist’s opinion on the role that next-generation basal insulins (Novo Nordisk’s Tresiba, Sanofi’s Toujeo) should play, especially since Tresiba showed a statistically significant hypoglycemia benefit vs. Sanofi’s Lantus in DEVOTE; Sanofi recently reported real-world findings showing a hypo benefit to Toujeo vs. Lantus or Novo Nordisk’s Levemir as well (the LIGHTNING study). Similarly, we wonder if Dr. Seaquist will mention next-gen prandial insulin (Novo Nordisk’s Fiasp) as a method to reduce hypoglycemia risk, or at least fear of hypoglycemia in patients. We definitely expect some emphasis on technology, and how CGM, PLGS (predictive low glucose suspend), and closed loop address hypoglycemia.
- (1:20-1:50 PM) T1D Management in the Hospital: A Guide for Inpatient Care and Using Diabetes Technology. Emory’s highly regardedDr. Guillermo Umpierrez will provide case scenarios of patients in the ER to illustrate proper inpatient management of diabetes. We wonder if he’ll also discuss the recently FDA cleared OptiScanner 5000, the first inline CGM intended for bedside use in the surgical intensive care unit (SICU). We hope very much that he mentions euglycemic DKA since it is not intuitive without training the processes to follow for this dangerous and manageable emergency.
- (1:50-2:30 PM) Current Strategies for DKA Management. This presentation from Dr. Guillermo Umpierrez (Emory University, Atlanta, GA) could hardly be more timely: AZ just submitted SGLT-2 inhibitor Farxiga (dapagliflozin) for type 1 diabetes to EMA, and Sanofi/Lexicon’s filing of SGLT-1/2 dual inhibitor sotagliflozin is right around the corner (FDA and EMA submissions expected in 1Q18). With these new oral adjunct therapies for type 1 diabetes, the safety question on everyone’s mind is DKA – we believe this risk can be managed in the real world, but do not believe the current education on this topic is sufficient. Can it get there? Of course, and the risks, if handled properly, don’t outweigh the major benefits that these drugs could bring to people with type 1 - but that said, the field needs more consensus and then awareness building and education and action on best practice DKA management. We’re eager for leaders to discuss this. How well do patients know how to manage DKA now? How do hospitals treat DKA and euglycemic DKA currently? Logistically, how are hospital protocols distributed and are they followed? Treatment, especially of euglycemic DKA, is not intuitive; while we absolutely want these agents to be available to people with type 1 diabetes, we also want to see a comprehensive, smart, largescale effort to make them as safe as possible. Said Dr. John Buse about this recently: “SGLT2i’s definitely have a role in type 1 diabetes management … The issues around screening for and treating DKA in this setting are complex, requires effective patient education, and most importantly requires great vigilance on the part of the patient and expert 24x7 back-up by physicians expert in its management. Even then some ER docs will not follow specific expert guidance to treat a patient who is vomiting with DKA and a glucose of 120 with an insulin drip and IV D10.”
- (2:30-3:00 PM) Case Scenarios in Small Group Discussions. Drs. Umpierrez and Amisha Wallia (Northwestern University, Chicago, IL) will lead small group discussions on caring for sick patients at home and in emergency situations. We hope there is more discussion here of value on euglycemic DKA.
- (3:15-3:55 PM) Old, New, and Emerging Insulins. Dr. Irl Hirsch (University of Washington, Seattle, WA) will present on advances in insulin therapy, from almost 100 years ago to now. This is going to be epic! We expect a focus on “older” insulins and how to use them to next-generation basals and their benefits to glycemic outcomes beyond A1c (less hypoglycemia, more time-in-range). We hope Dr. Hirsh touches on ultra-rapid-acting insulins as well: Novo Nordisk’s Fiasp (faster-acting insulin aspart) was launched recently in US pharmacies, while MannKind’s inhaled insulin Afrezza had a particularly strong 4Q17, relatively speaking. A few potentially exciting insulins are also coming up the pipeline, including late-stage candidates from Lilly, Sanofi, and Adocia. By now, Dr. Hirsh is known for his rants on skyrocketing insulin prices, so we can easily confirm that cost will come up during this session – in preparation, read Dr. Hirsh’s 2018 rant in DT&T, and our coverage of his rant at ATTD 2018. To this end, we also hope for some commentary on biosimilar insulins (Lilly/BI’s Basaglar, Sanofi’s recently-approved Admelog); are the discounts promised on these products showing up for patients at the pharmacy counter?
- (4:00-4:40 PM) Breakout Sessions – Insulin Delivery. Attendees can participate in one of two simultaneous breakout sessions: (i) Multiple Daily Injection (MDI) Basics and Cases led by John Muir Health’s Dr. Luisa Duran; or (ii) Continuous Subcutaneous Insulin Infusion (CSII) Insights led by Wash U’s Dr. Janet McGill. We’re going to be looking out for the attendance split – which are young fellows more interested in or feel they need to learn more about? While insulin pumps may be a hotter topic at this time due to AID, a majority of patients are still on MDI, and the advent of automated dosing guidance may add a new dimension to providing care for them.
- (7:30-8:00 PM) Patient Engagement. In this not-to-miss session moderated by UW’s Dr. Irl Hirsch, Dr. Robert Eckel and his wife Margaret Eckel will share personal stories and insights on how type 1 diabetes has affected their lives and their family. This panel offered some of the best learning at Endo Fellows 2017 (see the highlight here, and a full transcript here) and the Eckel family is among the most inspiring families we have ever met – weare staying very tuned on this.
Thursday, March 15
- (8:00-8:40 AM) Depression and T1D. This practical session led by the brilliant Dr. Jill Weissberg-Benchell (Northwestern University, Evanston, IL) will use case scenarios to demonstrate the causes and signs of depression. People with diabetes are at significantly higher risk for depression, and many experience diabetes distress. We’ve noticed an increasing focus on psychological care for people with diabetes, and we’re glad to see this topic well-represented on the Endo Fellows agenda once again. We’d also like to see not just fellows focusing on it, but far more focus from a systems perspective.
- (8:45-9:15 AM) Developing Strategies in Small Group Discussions. Following the presentation of case scenarios on recognizing the signs and causes of depression (see above), attendees and faculty will break into small groups to review cases and to practice developing a strategy for psychosocial care. We recently heard Stanford’s Dr. Korey Hood advocate for routine psychosocial assessments as part of a patient’s ongoing diabetes care, and we expect to hear many in agreement at this Endo Fellows gathering. Given that one out of every four people with diabetes will experience depression, we’re pleased this topic is receiving attention early on in endocrinologists’ training – and again we’d like to see more resources put in place for depression for anyone with diabetes.
- (9:20-10:00 AM) T1D and the Prevention and Treatment of Macrovascular Disease. With two diabetes drugs in two different classes (Lilly/BI’s SGLT-2 inhibitor Jardiance and Novo Nordisk’s GLP-1 agonist Victoza) now indicated for cardioprotection, we’ve witnessed an explosion in commentary on minimizing CV risk in people with type 2 diabetes – and where does type 1 diabetes fit in? We’ve heard CV risk factors characterized as neglected in favor of glycemic control for patients with type 1, and in this session, Dr. Robert Eckel (University of Colorado, Aurora, CO) will emphasize the importance of macrovascular risk reduction and proper treatment of macrovascular disease once it appears. We’re interested to hear how he balances the priorities of glycemic control and mitigating CV risk factors. We also expect some mention of SGLT inhibitors for type 1, since AZ’s Farxiga (dapagliflozin) and Sanofi/Lexicon’s sotagliflozin will both be filed with FDA this year. What does Dr. Eckel think about the possibility for SGLT-2s to be cardioprotective for type 1 patients? What does he think about GLP-1 use in type 1s?
- (10:00-10:40 AM) The Endocrinologist’s Role in Screening/Managing Microvascular Disease. The highly respected Dr. Janet McGill (Washington University, St. Louis, MO) will address retinopathy, nephropathy, and neuropathy screening and management. Our sense is that microvascular complications are sometimes under-addressed in both type 1 and type 2 diabetes: Foot exams should be more common and comprehensive, and many patients don’t see an ophthalmologist as often as is recommended. How can the endocrinologist (to say nothing of PCPs, even though they are not the focus of this gathering) help fill these gaps and improve secondary prevention? What are the best options for treatment when it comes to microvascular disease in diabetes? How could complications be caught earlier? When might we see machine learning algorithms widely put to use in diagnostics, particularly in retinopathy? We’re eager for Dr. McGill’s insights on these important topics in diabetes care.
- (11:10 AM-12:00 PM) Practical Considerations and Approaches to Data Management. University of Washington’s Dr. Irl Hirsch headlines a session on the practical use of CGM with a deep dive into data management. In a recent talk, he was very enthusiastic regarding CGM uptake, sharing that ~60% of his type 1 diabetes patients are using some form of CGM – very impressive, particularly since the Pacific Northwest is a challenging payer environment. He specifically noted acceleration in uptake since the introduction of Abbott’s FreeStyle Libre. With regards to practical considerations for CGM use, Dr. Hirsch was adamant that robust education, training, and support is necessary for optimal CGM implementation, and we suspect he’ll be driving this point home especially hard when speaking to the next generation of endocrinologists. At last year’s ENDO meeting, Dr. Hirsch stressed the utmost importance of downloading patient data (despite the perceived time and cost) and developing infrastructure to ensure a smooth clinic workflow. We’re confident that he will touch on the standardized, one-page Ambulatory Glucose Profile (AGP) report, and wonder if he’ll discuss decision support tools such as the CE-marked and FDA-submitted DreaMed Advisor Pro. The great news is that at least some of this data is now easier to get …
- (1:00-1:40 PM) What I Wish I Was Told When I Left My Fellowship. Practicing endocrinologist Dr. Luisa Duran (John Muir Health, San Ramon, CA) will talk about what she didn’t know or expect in entering the field. With such a serious shortage of endocrinologists in the US and worldwide, we’re eager to hear why young doctors choose (or don’t) to enter endocrinology and to figure out what might encourage more entry. So far, we know that those who enter do so because they have a personal connection … or they are returning to a geography where it is not so poorly paid.
- (1:45-3:10 PM) Breakout Sessions – Insulin Delivery. Simultaneously, University of Washington’s Ms. Alison Evert will lead a session on implementing realistic nutrition strategies in type 1, while Seattle Children’s Hospital’s Dr. Craig Taplin will discuss strategies for type 1 diabetes management with intense physical activity. Dosing insulin for meals is a perennial bugaboo, since carb counting is not easy for anyone and there are multiple other factors relating to meals that affect blood glucose according to Adam Brown who has learned from the experts over the years! That said, “kids will be kids” rings especially true when it comes to diet, so we’re curious to hear Ms. Evert’s take on what she considers “realistic.” On exercising with type 1 (another bugaboo), Dr. Michael Riddell et al.’s ATTD Yearbook chapter highlighted one study finding high-intensity interval training (HIIT) to reduce hypoglycemia awareness in type 1 diabetes patients, and another that found circuit training to be less risky than continuous exercise. We’re curious to hear Dr. Taplin and others’ take on strategies in this area and wonder if anyone will bring up exercise and closed loop systems – still a major hurdle for developers. These sessions will repeat after a short break, allowing attendees to go to both.
- (3:30-4:15 PM) Principles and Practical Guides for Transitions of Care. Conference co-chair Dr. Linda Siminerio (University of Pittsburgh, PA) will review case scenarios of challenging care transitions. Dr. Siminerio has impressive experience in Diabetes Self-Management Education (DSME), so we’re sure she will offer valuable insight on how to best move patients between care settings, with tips directed toward the patient, caregiver, and HCP.
- (4:30-5:30 PM) Interpreting Study Findings: Moving Toward a Better Understanding of Today’s Literature. Jaeb Center Director Dr. Roy Beck will close out the meeting in perhaps one of the most relevant sessions for up-and-coming endocrinologists. Physicians are inundated with studies touting the latest great therapy or device – but how to make sense of them all (apart from a Closer Look subscription)? As his talk is part of a session on managing type 1 diabetes through the lifespan, he will likely focus on literature examining transitions of care. We’re looking forward to what we’re sure will be an incredibly actionable and informative lecture from Dr. Beck.
Friday, March 16
- (8:00 AM-5:20 PM) Managing Cardiometabolic Risk: Practical Considerations and Emerging Approaches. This star-studded, day-long preconference session (additional registration required) is chaired by Drs. Robert Eckel (University of Colorado, Aurora, CO) and Samuel Dagogo-Jack (University of Tennessee, Memphis, TN). In the morning, Yale’s Dr. Silvio Inzucchi will cover oral therapies for diabetes, likely focusing on the advanced class of SGLT-2 inhibitors. Then, he’ll debate Dr. Carol Wysham (University of Washington, Spokane, WA) on stepwise vs. sequential approaches to treatment – this is sure to be a fantastic discussion, and since we believe for the most part that combination therapy is under-utilized in type 2 diabetes management, we’re always looking for learning relevant to the patient perspective, HCP perspective, and payer perspective. For your tech fix, Dr. Bruce Bode (Atlanta Diabetes Association, GA) will review strategies on how to incorporate the latest diabetes devices into clinical practice. Moving into the afternoon, Dr. Caroline Apovian (Boston Medical Center, MA) will provide a comprehensive overview of obesity pharmacotherapy – what are the available products, and what are the major barriers to prescribing them (for HCPs) and taking them (for patients)? To close out the day, four experts will lead four “master clinical sessions” – UW’s Dr. Irl Hirsch on type 1 diabetes, Tulane’s Dr. Vivian Fonseca on type 2 diabetes, Dr. Apovian on obesity, and Cleveland Clinic’s Dr. Steven Nissen on lipids. Other speakers on this outstanding lineup include University of Colorado’s Dr. Robert Eckel (on metabolic syndrome as a paradigm of insulin resistance), UW’s Dr. Michael Schwartz (on regulation of energy balance in obesity; read our 2016 interview with him on his lab’s cutting-edge work in diabetes/obesity research), and Johns Hopkins cardiologist Dr. Michael Blaha (on imaging and CV outcomes).
Saturday, March 17
- (11:30 AM-12:30 PM) ENDOExpo Theater: Jardiance Tablets: Evolving Clinical Development. Dr. Helena Rodbard (Endo Metabolic Associates, Potomac, MD) will lead this product theater, and we hope for an update on Lilly/BI’s planned trial of SGLT-2 inhibitor Jardiance (empagliflozin) in patients with CKD (with or without diabetes), which is supposed to initiate sometime in 2018. The session title certainly suggests some interesting updates on the Jardiance clinical program. We’d also love to hear more about the EMPEROR trials in heart failure, as well as the just-announced EMPERIAL studies evaluating exercise capacity with Jardiance vs. placebo in chronic heart failure patients. Readouts from the phase 3 EASE program in type 1 diabetes are also expected later this year, and we’re eager for a hint as to how Lilly is thinking about this potential indication. Perhaps this will depend on how regulators respond to AZ’s application for SGLT-2 Farxiga (dapagliflozin) in type 1 and to Sanofi/Lexicon’s application for SGLT-1/2 dual inhibitor sotagliflozin in type 1.
- (12:30-1:30 PM) Diabetes and Pregnancy. University of Virginia’s Dr. Susan Kirk will focus on steps patients and providers can take prior to conception to improve maternal and fetal outcomes of pregnancies complicated by diabetes. She’ll also detail general management goals for pregnant women with diabetes, and we’re hoping she discusses the CONCEPTT trial demonstrating CGM use in pregnant women to result in positive neonatal outcomes, if not also maternal glycemia. Given that 1 in 6 births globally (21.3 million) were affected by hyperglycemia in 2017, we would love to see a moonshot of fitting every pregnant woman with CGM, at least for a short time when hyperglycemia is most likely to develop.
- (1:00-2:00 PM) ENDOExpo Theater: Introducing a New Option for Your Patients with T2D. In this Novo Nordisk-sponsored product theater, we expect to get our first glimpse at how the company is promoting once-weekly GLP-1 agonist Ozempic (semaglutide), just launched in US pharmacies in February. We think it’s clear that Ozempic offers a new level of efficacy compared to the rest of the GLP-1 agonist class (although more options are better for patient choice and personalization, and in general, we anticipate that semaglutide will grow the market rather than steal share). We’re looking forward to seeing how HCPs are viewing this new drug. Dr. Carol Wysham (University of Washington, Spokane, WA) will present.
- (1:00-3:00 PM) Randomized Controlled Trial for Assessment of Internet of Things System to Guide Intensive Glucose Control in Diabetes Outpatients: Nagoya Health Navigator Study. Results from the Nagoya Health Navigator Study will be presented as a poster at ENDOExpo, Hall F. In this multicenter RCT (see the protocol paper here), outpatients with type 2 diabetes were given connected devices to track activity, body weight, and blood pressure for six months. The experimental group received feedback according to the aggregated data, while a control group did not. The primary outcome of the study is change in A1c at six months. While “intensive [HCP] feedback” may have led to decreased A1c in this study, we have to question how it impacted the providers in the experimental vs. the control group. Did it increase their workload meaningfully? Is the risk of provider burnout and exhaustion worth what may have been an incremental A1c drop? Ideally, there would’ve been a third arm to the study with automated guidance. In this study design, we’d almost consider it a bigger win if the groups saw equal A1c drops; provider time is at a premium as it is, and spending more time analyzing data and giving advice, which a computer could easily do, might decrease the quality of care elsewhere.
- (2:00-2:45 PM) Childhood Obesity. Dr. Ellen Lancon Connor (University of Wisconsin, Madison, WI) will be featured in this meet-the-professor session on childhood obesity. We’re glad to see this session included on the ENDO agenda, which has no shortage of obesity content overall, though an emphasis on youth in particular is very important. The most recent NHANES data from 2015-2016 reveal a 19% rate of obesity among children in the US, and we know that childhood obesity often leads to adult obesity and type 2 diabetes. That said, addressing obesity in children presents unique challenges, both medically and psychosocially (person-first, non-stigmatizing language is especially key), and we’re excited to learn more on the topic.
- (2:00-2:45 PM) Obesity Management: Effective Use of Pharmacotherapy and Bariatric Surgery. Dr. Lisa Neff (Northwestern University, Evanston, IL) will talk obesity drugs and bariatric surgery, and how to use these different tools most effectively. We’re curious for her insights on how to individualize goals and treatment plans for patients with obesity; how can HCPs identify ideal candidates for pharmacotherapy (and specific agents) vs. bariatric surgery? At Obesity Week 2017, the esteemed Dr. Louis Aronne advocated for combining obesity therapies, as well as for their concurrent use with devices, also noting that pharmacotherapy can be used before and after bariatric surgery. We’ll be listening closely for Dr. Neff’s opinion on combination approaches to obesity treatment as well.
- (2:00-2:45 PM; 3:00-3:45 PM) Optimal Use of New Diabetes Technologies: From Kids Through Transition and Into Adulthood. Joslin's Dr. Lori Laffel will run this very important session, touching on “new” technologies – predominantly CGM and AID, we imagine. In 2016-2017, CGM use in the T1D Exchange hit 24% (45% in kids <6 years old). As those children get older, they will in all likelihood remain on CGM, meaning providers will have to familiarize themselves with best practices, and fast. We also recently saw compelling data from a four-year observational study at ATTD showing that initiating pump therapy at diagnosis resulted in 1.1% lower A1cs as compared to those who waited one year (of course, this could be merely an artifact of engagement – which type of patient with what type of support is likely to start pumping at diagnosis?). As some of the top barriers to CGM and pump adoption (cost, hassle, devices on body) begin to decline, optimizing use in pediatrics and the infamous adolescent A1c “hump” could represent great opportunity.
- (4:15-5:15 PM) Debate: The LDL Limbo: How Low Should You Go? We’ve heard suggestions that there should be no lower limit to LDL cholesterol levels, especially after the FOURIER trial for Amgen’s PCSK9 inhibitor Repatha (evolocumab) found CV benefit even for those with baseline LDL <80 mg/dl (so <70 mg/dl is perhaps too high as a target). Dr. Steven Nissen (Cleveland Clinic, OH) will take this position in a debate with Dr. Harry Ginsberg (Columbia University, New York, NY). This is an emerging area of discussion, and we’ll be paying close attention to both arguments, with particular interest in any commentary on LDL goal-setting in diabetes care.
- (4:15-5:45 PM) Innovations in Diabetes Translational Research: Working Toward Eliminating Health Disparities in T2DM. Panelists Drs. Deb Burnet, Arshiya Baig, and Monica Peek (all from the University of Chicago) will discuss the very important topic of access in type 2 diabetes. Technology uptake in the type 2 population is still quite low in the US, despite demonstrated benefits. The most advanced/safest therapy classes – GLP-1 agonists and SGLT-2 inhibitors – are only prescribed as second-line treatment to ~14% of adult type 2s in the US, according to a Diabetes Care article published last year. Sulfonylureas account for 46% of second-line prescriptions, despite their known association with hypoglycemia, weight gain, and beta cell burnout (plus possible CV harm). But alas, they are generic, and therefore more affordable. Dr. Irl Hirsch attributed this trend to high cost and poor reimbursement surround GLP-1s and SGLT-2s: “Between an increasing uninsured population, unaffordable co-pays, high-deductible plans, and the donut hole, we can't practice the evidenced-based medicine the RCTs tell us we should.” We’re eager to hear from these panelists on cost/reimbursement hurdles that stand in the way of best practice diabetes care, both on the tech side and the drug side. And of course, we’d love suggestions on how to jump these hurdles.
- (4:15-5:30 PM) Reducing Outpatient Hypoglycemia – An Emerging National Priority. A can’t-miss session including NIDDK Director Dr. Judith Fradkin and FDA’s Dr. Christine Lee, this session reflects the growing movement around Outcomes Beyond A1c and the ever-increasing recognition of the negative physiological, psychosocial, and economic impact of hypoglycemia. There have been great strides in just the past year in arriving at consensus definitions of hypoglycemia, but this is just the first step. CGM must be used to quantify hypoglycemia in different groups of people using different therapies, the field must arrive at guidelines for how much time <70 mg/dl is “acceptable” (any time <54 mg/dl is to be avoided at all costs, as that is where cognitive dysfunction sets in), and then we must figure out how to help patients meet those guidelines. A major barrier to pushing forward with this agenda is that, as we understand it, FDA’s CDER doesn’t currently accept CGM-based metrics. This session, with two federal government stakeholders, could be an opportunity to stress the importance and validity of CGM moving forward – we hope for a lively dialogue on this front.
- (6:00-9:00 PM) Adjusting for CGM Trend Arrows Across the Lifespan: A New Opportunity to Improve Glycemia. In this not-to-miss educational session sponsored by Dexcom, Joslin’s Dr. Lori Laffel and Northwestern’s Dr. Grazia Aleppo will take a deep dive into understanding and using Dexcom G5 trend arrows (recommendations recently published by the Endocrine Society). Dr. Laffel will also provide a brief overview of the clinical benefits of trend arrows in CGM, and Dr. Aleppo will supplement the discussion with case examples and patient perspectives. Perhaps most importantly, Dr. Laffel will provide advice on how to implement a simplified approach to using trend arrows into daily practice. We’ve seen a number of different approaches to arrow interpretation, from Gary Scheiner, Steve Edelman/Jeremy Pettus, and DirecNet.
- (6:00-9:00 PM) Improving Obesity Care: A Practical Guide to Engaging and Treating Patients. This evening symposium, sponsored by Novo Nordisk, will feature Northwestern’s Dr. Robert Kushner, George Washington University’s Dr. Scott Kahan, Pennington Biomedical’s Dr. Donna Ryan, and University of Alabama’s Dr. Timothy Garvey. The experts will present on an array of topics related to obesity care, reflecting the myriad of options now available. Dr. Kahan will provide tips on broaching the topic of obesity with patients (likely evoking the person-first language movement), while Dr. Ryan will discuss lifestyle interventions. Given her impassioned presentation at Obesity Week, in which she advocated to “stop messing around with lifestyle counseling and up our game,” we have a feeling Dr. Ryan won’t be positioning lifestyle interventions center stage, but as a supplement to pharmacotherapy, devices, and possibly surgery. To this end, Dr. Garvey will discuss proper timing and consideration of pharmacotherapy, with a particular focus on shared decision-making. Dr. Kushner will wrap up the night with a fresh look forward toward a new paradigm of multimodal, multidisciplinary, and long-term obesity care. We loved his idea of asking patients to chart a “life events-weight graph,” which he presented at Obesity Week.
Sunday, March 18
- (5:30-7:45 AM) The Future of Cholesterol Management: Application of PCSK9 Inhibitors in Practice. This Amgen-sponsored breakfast symposium will review the biology and genetics of hyperlipidemia and the PCSK9 receptor, followed by a discussion of the need to raise awareness about the class and who could benefit (presentation by University of Colorado’s Dr. Robert Eckel). In the final presentation, Dr. Henry Ginsberg (Columbia University, New York, NY) will cover when and how to treat cholesterol in patients with diabetes. At AHA 2017, we heard an eloquent argument from Dr. Michael Farkouh on why people with diabetes are good candidates for PCSK9 inhibitor therapy, and we’ll be listening for additional insights and nuance from Dr. Ginsberg at ENDO. Given the residual CV risk that comes with type 2 diabetes, effective lipid-lowering is critical, and no drugs are quite as strong in this department as the PCSK9 class (Amgen’s Repatha and Sanofi/Regeneron’s Praluent). Moreover, Amgen’s Repatha was granted a CV indication by FDA at the end of 2017 based on positive results from the FOURIER CVOT. We expect this to feature heavily throughout the symposium, and we’ll be looking for comments on how the new indication fits into the puzzle – how might it expand the body of patients who can access Repatha?
- (8:00-9:30 AM) Metabolism, Diabetes, and Bone. UCSF’s Dr. Ann Schwartz will review how different diabetes drug classes affect the bones; we anticipate a focus on SGLT-2 inhibitors and TZDs, given some past concerns about bone fracture risk, though we believe these have largely been put to bed among thought leaders.
- (11:30 AM-12:30 PM) ENDOExpo Theater: Targeting the Brain to Address Insulin Resistance: A Unique Approach in Type 2 Diabetes. The always-outstanding Dr. James Gavin (Emory University, Atlanta, GA) will lead this session on the fascinating link between diabetes and neurodegeneration. It’s not clear from the agenda exactly what he’ll discuss, but we wonder if he’ll detail the latest research suggesting an association between diabetes and Alzheimer’s disease, a topic that’s quickly gaining attention. At EASD, we learned that insulin expression in the brain is lower in people with Alzheimer’s and insulin receptors are downregulated; accordingly, Alzheimer’s increases the risk of type 2 diabetes and vice versa. We’re very intrigued by the possibility that GLP-1 agonists or combination drugs of gut peptides (e.g. GLP-1/GIP, GLP-1/GIP/glucagon) might have applications in Alzheimer’s treatment, and we’d love Dr. Gavin’s perspective on this.
- (1:00-2:00 PM) ENDOExpo Theater: Advancements in the Management of Patients with Type 2 Diabetes: Results from a Large Cardiovascular Outcomes Trial. We’re used to hearing about LEADER (CVOT for GLP-1 agonist Victoza) during this Novo Nordisk-sponsored session, but we’re curious to see how the discussion will expand to include Ozempic (semaglutide). While SUSTAIN 6 found semaglutide to be cardioprotective, it was a smaller, shorter trial than what’s needed to support a new CV indication and had notably wide confidence intervals. As such, Novo Nordisk will launch the SOUL CVOT (n=~13,000) this year to support a possible CV indication on the Ozempic label, and we hope Dr. Cres Miranda (Nevada Heart and Vascular Center, Las Vegas, NV) comments.
- (1:45-2:30 PM) Endocrine Educator Session: Make the Healthy Choice the Easy Choice – Insights from Behavioral Economics. Wharton’s Dr. David Asch will discuss how to leverage behavioral economics to help people improve their lifestyle. Behavioral science is having a major moment in public health, and rightly so. At The diaTribe Foundation’s fourth annual Solvable Problems in Diabetes gathering at EASD, Dr. Daniel Drucker (University of Toronto, Canada) was particularly passionate about behavior change, claiming that if he were beginning his career today, he might choose behavioral science over basic science (“that’s where I think we can make a big difference”). At Obesity Week, we heard Director of Nutrition Policy at the Center for Science in the Public Interest Dr. Margo Wootan describe how food company marketing can unconsciously influence our eating habits. We can’t wait for this talk, to learn what new insights Dr. Asch has on behavioral economics and its applications in diabetes/obesity.
- (1:45-2:30 PM) Hypoglycemia in Diabetes. In this meet-the-professor session, University of Minnesota’s Dr. Elizabeth Seaquist will review how to recognize and manage hypoglycemia in patients with diabetes. For both recognition and management, a top answer might be CGM – CGM is obviously the best way to detect asymptomatic hypoglycemia, and studies have shown repeatedly that it also reduces time in hypoglycemia (even for those who are hypo unaware; see HypoDE and iHART CGM). We also expect that Dr. Seaquist will touch on drugs that carry lower risk of hypoglycemia, such as Novo Nordisk’s Tresiba (see DEVOTE) or glycemic-dependent GLP-1 agonists and SGLT-2 inhibitors. Lastly, we expect she will detail novel hypoglycemia treatment agents such as Lilly’s phase 3 nasal glucagon, which she presented on at ADA 2017.
- (1:45-2:30 PM) Meet the Program Directors of the NIDDK. Program Directors from the National Institute of Diabetes & Digestive and Kidney Diseases (NIDDK) Drs. Corinne Silva and Saul Malozowski will present and answer questions – this is a not-to-miss opportunity. They will share details about research programs and funding opportunities, and we’re eager for the latest updates on what this division of the NIH is excited about. We hope to get a word in about one of the clinical trials on our dream list of studies to be done in diabetes… The NIDDK only recently published a slew of Special Diabetes Program-enabled funding opportunities for type 1.
- (4:00-5:30 PM) Metformin: New Twists on an Old Drug. While we’ve heard lots of commentary lately on the problematic over-reliance on metformin for type 2 diabetes (reflecting clinical inertia to advance patients to second-line therapy), this session will explore different pathologies that might be aided with the old standby. We’ll first hear from London’s Dr. Marta Korbonits about the mechanistic relevance of metformin for glucose-lowering and cancer metabolism. Next, Columbia University’s Dr. Jose Luchsinger will discuss the effects of chronic metformin use on cognition. Other presentations will address contraindications and precautions, as well as remaining questions on metformin’s CV effects.
Monday, March 19
- (8:00-9:30 AM) Diabetes and Technology: Is Big Brother Watching? In what is sure to be a fascinating session chaired by Mayo Clinic’s Dr. Yogish Kudva, Drs. Rich Bergenstal (International Diabetes Center), Ruth Weinstock (SUNY Upstate Medical University), and Grazia Aleppo (Northwestern University) will discuss the theory and implementation of technology in diabetes management. Dr. Bergenstal will tackle CGM, while Dr. Weinstock will detail the role of telemedicine and Dr. Aleppo will present on remote monitoring of insulin pump therapy. We don’t get the feeling that many patients are bothered by their data being available to caregivers and providers – the benefits of on-demand HCP virtual visits, smart guidance around data, and a safety net for erratic blood sugars surely outweigh the cons. We’re particularly interested in Dr. Weinstock’s take on telemedicine, which seems to be gaining recognition as a possible driver of positive outcomes. Most recently, American Well, which already has partnerships with Samsung, Medtronic, Phillips, Apple (the Apple Heart Study), Anthem, UnitedHealth, Cleveland Clinic, Onduo, etc., announced a collaboration with Joslin.
- (9:45-10:30 AM) Inpatient Diabetes Management Goals, Challenges, and Implications. Emory’s Dr. Guillermo Umpierrez will discuss how best to reduce hyperglycemia in the hospital setting. Not only is hyperglycemia in hospitalized patients a common and costly healthcare problem, it is also associated with poor outcomes, including prolonged hospital stay, infection, disability after discharge, and death. This meet-the-professor session will review (i) initiating insulin therapy to manage inpatient hyperglycemia and diabetes, (ii) advances in insulin and non-insulin therapies to manage hyperglycemia in the hospital setting, and (iii) strategies to tailor transition of care from hospital to home. Dr. Umpierrez is a well-spoken expert on this topic (see our coverage of his talk from Keystone 2017 as just one example), and we look forward to his insights.
- (11:15 AM-12:45 PM) Advances in the Management of Type 1 Diabetes. This session features several exciting oral presentations. We’re particularly interested in a post-hoc analysis of the OpT2mise randomized controlled trial, investigating whether C-peptide status impacts the benefits of pump therapy on A1c in type 2 patients. The outcomes of this study are incredibly meaningful, as fasting C-peptide levels have been used to differentiate between type 1 and type 2 diabetes and then used to deny insulin pump coverage for type 2 patients. Another study out of the Washington University School of Medicine in St. Louis describes how late onset type 1 diabetes predicts the risk of additional autoimmune disease. We’ll also hear how meal intake is suppressive of ketogenesis in patients with type 1 diabetes (an important finding given the possible availability of SGLT-2 inhibitors as adjuncts in type 1), and we’ll learn about the success and challenges of implementing precision medicine in diabetes from the US Monogenic Diabetes registry.
- (11:15-11:30 AM) Efficacy and Safety of Dapagliflozin in Patients with Type 2 Diabetes and Moderate Renal Impairment (Chronic Kidney Disease Stage 3A): The DERIVE Study. We’re extremely excited to see the first results from the DERIVE trial (n=323) of AZ’s SGLT-2 inhibitor Farxiga (dapagliflozin) in patients with type 2 diabetes and stage 3A CKD (eGFR 45-60 ml/min). This data was read out internally at AZ in 4Q17, and management shared that Farxiga was both safe and efficacious in participants (presumably on the primary endpoint of change in A1c over 24 weeks). That said, we’re looking forward to more granularity. Secondary outcomes in DERIVE, according to ClinicalTrials.gov, include weight loss, fasting plasma glucose, and seated systolic blood pressure at baseline vs. week 24. Farxiga is currently not recommended for people with eGFR between 30-60 mL/min/1.73 m2, and it’s contraindicated for eGFR <30 mL/min/1.73 m2, similar to other SGLT-2s. It’s important to keep in mind however that these designations are due to a presumed loss of efficacy given a mechanism of action that relies on kidney function – they’re not meant to imply any specific or major safety concerns. Dr. David Fitchett emphasized this point at ESC 2017, and he suggested that upcoming clinical trials (like DERIVE) could change product labels if SGLT-2s show distinct benefits in patients with impaired kidney function. In fact, he went so far as to imply that patients with kidney impairment could benefit the most from SGLT-2 inhibitors in terms of CV and renal benefits. We’re so intrigued by all of this (especially because treating nephropathy remains a particular challenge in the context of diabetes care), and we note that DERIVE is the first of many important studies on SGLT-2s in kidney disease coming up. AZ’s larger Dapa-CKD trial (n=4,000) is investigating Farxiga in people with CKD with or without diabetes; that study is expected to complete in November 2020. J&J’s CREDENCE study of Invokana (canagliflozin) in DKD will wrap up sooner, in June 2019, while Lilly/BI will launch a new trial of Jardiance (empagliflozin) in CKD sometime this year. We’ll be curious to see if AZ pursues a label update for Farxiga related to eGFR ahead of Dapa-CKD.
- (11:30-11:45 AM) Effect of Empagliflozin on Liver Fat in Patients with Type 2 Diabetes and NASH: A Randomized Controlled Trial (E-LIFT Trial). The E-LIFT trial (n=100), conducted in India, investigated the impact of empagliflozin (Lilly/BI’s SGLT-2 inhibitor Jardiance) on liver, pancreatic, visceral, and subcutaneous fat over three months. We haven’t heard anything explicitly indicating a link between SGLT-2 inhibitors and improvement in organ fattiness, and it seems unlikely that the level of weight loss afforded by SGLT-2s would significantly improve these outcomes, but we’ll keep our eyes and ears peeled for interesting results.
- (11:30 AM-12:30 PM) ENDOExpo Theater: CGM, Reinvented. Introducing the NEW FreeStyle Libre. Dr. Ernest Asamoah (Diabetes & Endocrinology Consultants) will present Abbott’s FreeStyle Libre, approved in the US by the FDA in September and reimbursed by Medicare as of January. However unlikely, we’re hoping to get an update on a possible FDA pediatric indication – Abbott is currently conducting two US FreeStyle Libre trials in peds (a 12-month post-approval safety trial and a six-month efficacy and adverse events trial). Also uncertain is the US status of FreeStyle LibreLink and LinkUp, which allow users to swipe over the device with their phones and share data with caregivers and providers, respectively. In Abbott’s 4Q17 call, CEO Mr. Miles White foreshadowed a “series of enhancement and approvals” – when will we see them start to benefit US users?
- (1:15-1:55 PM) Transitioning from Volume to Value Under the Quality Payment Program. Ms. Erika Miller, a lawyer who specializes in physician organizations and reimbursement, will talk about the transition from fee-for-service toward value-based care, especially with Medicare Part B’s new Quality Payment Program. Understandably, the transition to value is not an easy one, as evidenced by a recent letter from a number of ACOs petitioning for more time before taking on risk. Joslin’s Dr. Robert Gabbay tackled this topic in an excellent presentation at AADE 2017, and we’re looking forward to hearing more about how this paradigm shift will impact endocrinologists specifically.
- (2:00-2:45 PM) Cardiovascular Risk Reduction in Diabetes. Diabetes care is undergoing an important transition, moving toward outcomes-based medicine, and within this paradigm, CV risk reduction is key. We’ve heard many thought leaders encourage HCPs to make cardioprotection a central goal in any diabetes management plan (Dr. Wendy Lane had a particularly memorable bullseye metaphor at CMHC 2017), and Dr. Peter Gaede (Slagelse Hospital, Denmark) will take his turn at ENDO. Dr. Gaede will lead this meet-the-professor session, and we’ll be looking for his insight on practical ways to reduce CV risk, as well as his broader thoughts on the emerging role of SGLT-2 inhibitors and GLP-1 agonists in preventing adverse CV outcomes.
- (2:00-2:45 PM) Diabetes in the Athlete. USC’s Dr. Anne Peters will discuss diabetes management before, during, and after exercise. Attendees will have the opportunity to hear from a real patient, who will discuss his own approaches to exercise, particularly around his preparation for competing in a marathon. Xeris is developing a mini-dose glucagon that could be used to treat exercise-induced hypoglycemia, and we’re curious for Dr. Peters’ perspective on this. For an in-depth perspective on exercise in diabetes, check out the ATTD yearbook chapter here and our coverage here.
Tuesday, March 20
- (8:00-9:30 AM) Diabetes, Dollars, and Disparities: A Global Perspective. In this bound-to-be fascinating session chaired by Johns Hopkins’ Dr. Sherita Golden, Drs. Edward Gregg (CDC, Atlanta, GA), William Herman (University of Michigan, Ann Arbor, MI), and Mohammed Ali (Emory University, Atlanta, GA) will discuss the massive number of healthcare dollars spent on diabetes worldwide. The latest edition of the IDF Atlas reported that one in eight global healthcare dollars ($727 billion) goes toward diabetes, and this only accounts for direct costs. The US is responsible for 48% of this ($348 million), despite containing only ~7% of the global population with diabetes (30 million out of 425 million). We hope all three experts will weigh in on this disparity. Dr. Gregg will take the podium first to review epidemiology and trends in diabetes-related spending. Then, Dr. Herman will position diabetes as a disaster for the global economy. Finally, Dr. Ali will present on different systems of care in different countries, and we’ll have our ears peeled for cost-effectiveness comparisons. It’ll be worth sticking around Chicago through Tuesday for this symposium!
- (8:00-9:30 AM) Novel Techniques in the Management of Obesity. Dr. Tricia Tran (Imperial College London, UK) will deliver a presentation on multi-agonist gut peptide drugs, likely touching on GLP-1, GIP, and PYY. She’ll discuss how these peptides are elevated post-bariatric surgery, and how this knowledge can be leveraged to produce more effective obesity drugs. Notably, the obesity drug competitive landscape includes many candidates in this realm: Sanofi will launch phase 3 trials of its GLP-1/glucagon dual agonist in obesity sometime this year. OPKO Health has a GLP-1/glucagon dual agonist in phase 2. Novo Nordisk has a GLP-1/glucagon dual agonist, a GLP-1/GIP/glucagon tri-agonist, and a PYY agonist all in phase 1 (we’re watching closely to see which early-stage obesity candidate Novo Nordisk advances next). We’d love a review of this landscape from Dr. Tran, in addition to a mechanistic explanation of how these gut peptides stimulate weight loss. Brigham and Women’s Dr. Christopher Thompson will also present during this session, on endoscopic approaches to obesity, while Mayo Clinic’s Dr. Michael Camilleri will elaborate on ways to individualize obesity treatment with incretin therapies, namely GLP-1 agonists. There’s a lot of buzz around Novo Nordisk’s Saxenda (liraglutide 3.0 mg) as well as semaglutide for obesity, and we’re definitely intrigued by the weight loss efficacy of GLP-1s as a class.
- (10:45-11:30 AM) Debate: Energy Intake and Dietary Adherence are the Most Important Factors in Weight Loss. In this debate, Dr. Kevin Hall (NIDDK, Bethesda, MD) will take the affirmative, while Dr. Daniel Holland Bessesen (University of Colorado, Aurora, CO) will disagree. We expect Dr. Bessesen to focus on genetics and epigenetics, as well as the pathophysiological mechanisms that defend higher body weight. While providers struggle to treat obesity, sessions like this are an important reminder that the field has yet to reach full consensus on the cause of the disease itself, making it that much harder to fight.
-- by Ann Carracher, Maeve Serino, Payal Marathe, Brian Levine, and Kelly Close