News of the Center
News Archive — Fall 2021
Message from the Director
These have been difficult times for all, and although things are better we are certainly not done with COVID-19. I am seeing increasing numbers of vaccinated people with COVID but fortunately none are severely ill. However, those who are not vaccinated are doing much worse, particularly those with diabetes. Therefore, if you have yet to be vaccinated get vaccinated!!! You can visit https://myturn.ca.gov to find where to receive a safe, free and effective COVID-19 vaccine to protect you from the current and future variants of COVID-19.
We’ve been doing our best to take care of you through the pandemic and appreciate the extra effort required on your behalf to learn how to upload your devices and connect for telemedicine visits. As we move forward, we are offering both telemedicine and in-patient visits depending on your preference. I see patients in the office or over telemedicine on Mondays and Tuesday afternoons and Thursdays are telemedicine visits only.
The American Diabetes Association annual meetings were held virtually again this year and I learned more than usual because I had time to “attend” the lectures rather than be trapped in meetings. Among other things I reported on the meetings for the New England Journal of Medicine, which was both challenging and fun.
My headlines are:
1. A new drug called tirzepatide, which is a new class of treatment, shows tremendous promise both for glucose as well as weight reduction. Its effectiveness is greater than any other treatment on the market. But it is not yet FDA approved and we need to learn if it is as good for the heart and kidneys as other medications for type 2 diabetes seem to be.
2. Multiple sessions discussed health care inequalities and social determinants of health. Although these have always existed more attention is being focused in these areas. True solutions involve economic and political changes leading to better education healthcare and a reduction in rates of poverty and food insecurity. However, given the limits of what healthcare professionals can do it is clear that answers are local and providing culturally appropriate care through individuals who are part of the community is helpful.
3. My most important presentation was as the co-chair of the new ADA/EASD guidelines for the Management of Type 1 Diabetes in Adults. Look for the "Peters on Diabetes" video on Medscape about the guidelines and read the outline in this newsletter feature story. I was also involved in two other presentations at the meeting, one providing an Overview of the ADA/EASD Consensus Statement on Diabetes Apps, another was participating in a Debate—Digital Coaching Systems for Type 2 Diabetes—Are They Worth the Cost?
4. We also learned more about the STEP trials that led to the recent FDA approved weight-loss medication branded as Wegovy that is a higher dose injectable version of the GLP-1 semaglutide. This is the medication that has been used at a lower dose for the treatment of type 2 diabetes sold as Ozempic and the oral version Rybelsus. People with and without type 2 diabetes showed an impressive 15% to 18% weight-loss over 68 weeks. However, it is unclear if it will be covered by insurance.
5. COVID-19 and the roll out of vaccines has taken most of the medical attention for this year, but 2021 is also the 100th anniversary of the identification and development of insulin. A session highlighted the transition from turning type 1 diabetes from a uniformly fatal disease to a treatable condition. Although we have many forms of insulin available it is still not easy to treat insulin-requiring diabetes. A potential one weekly basal insulin is under development and we look forward to more responsive insulins that can improve the performance of hybrid-closed loop pumps.
Many of these are covered in videos created by Dr. Peters and in meeting coverage provided by Mark. These videos can be viewed on Medscape after a free registration.
We saw tremendous healthcare disparities during COVID—disparities which always existed but were amplified by the pandemic. I work in underserved East Los Angeles and the death and suffering I saw there is difficult to describe. In our own way my dear Westside patients were able to help—a portion of the donations we received during the past year were used to provide devices like continuous glucose monitors so our less affluent patients could monitor their blood sugars and participate in telemedicine visits. I also received grant funding from the Helmsley Charitable Trust and Insulin for Life to help our East LA patients as well as an incredibly generous grant from the Hankey Foundation to further our work on health care disparities.
We can use all donations - big and small to help fund our research, advocacy and outreach programs in East Los Angeles and to improve the lives of all people with diabetes.
You can make an on-line donation at:
www.keck.usc.edu/donatewcd
or send a check to:
USC Westside Center for Diabetes
9033 Wilshire Boulevard
Suite 406
Los Angeles, CA 90211
I wish you all a joyous and healthy next few months. I am optimistic that we will continue to win in the battle against COVID, although in slow steps. I encourage everyone to go in for all their missed routine visits, take care of yourself and hug the people you love.
Anne
Summer Research Updates
On the research front, we have results to report from two completed trials, we are continuing to recruit for two occupational therapy trials, and we are completing a study with the Omnipod 5 hybrid closed-loop system in people with type 2 diabetes.
Occupational Therapy Trials
We are continuing to recruit for two trials on type 1 diabetes that have made a successful transition to remote visits. These are studies where we partner with a USC occupational therapy research team lead by Beth Pyatak, PhD.
FEEL-T1D
Many of our patients with type 1 patients will qualify for the FEEL-T1D trial and this is a great introduction to clinical research. This is a two-week observational study for adults aged 18-75 with T1D where the purpose is to improve the understanding of the connection between blood glucose, well-being, and functioning to help improve future diabetes treatments.
If you participate in the trial, we will ship you a blinded continuous glucose monitor (you may also continue wearing your own CGM), accelerometer and a smart phone. Six times a day, participants will also be asked brief questions and perform visual tests on the study phone.
If you are interested contact: Mark Harmel, MPH, CDCES
REAL-T
We are also recruiting for a study of young adults with type 1 diabetes between the ages of 18-30 with an A1C of 7.5% or higher. This is a 12-month telehealth behavioral intervention that will be performed by USC occupational therapists to test a program designed to help young adults with type 1 diabetes deal with the everyday hassles and problems they experience in managing their diabetes.
All the meetings will take place online and an A1C test kit will be mailed. Participants will be compensated for these visits.
Half of the people in the study will be chosen at random to meet with an occupational therapist (OT) over 6 months using telehealth. What is an OT? Think of them like a diabetes coach, who helps young adults manage diabetes and deal with everyday hassles related to having diabetes. You will connect through videoconferencing to talk through your challenges and goals related to your diabetes care. The other participants will be followed over time to see how they do without the intervention.
You can visit chan.usc.edu/real to learn more and sign up, or you can contact Mark Harmel.
OmniPod 5 in People With Type 2 Diabetes
We were excited to get our hands on the new Omnipod 5, the new tubeless hybrid closed-loop pump system that is expected to be available within the next 6 to 12 months. In this trial we used the pump in a set of patients with type 2 diabetes who were either using basal insulin alone or a mix of basal and mealtime insulin. We again have a mix of participants from the West and East Los Angeles and we have completed the initial three-month phase and have moved into a six-month extension with most of the participants. There are no results to share from the trial yet, but we have become experts in the use of the Omnipod 5 system which should help once it is approved by the FDA. The current projections are that it will be available through a limited launch in the last quarter of 2021 and more generally available in 2022.
MOBILE CGM Study in People with Type 2 Diabetes published in the Journal of the American Medical Association (JAMA)
This study was designed to determine if a Dexcom 6 CGM would provide benefits in either glucose control or quality of life for participants with type 2 diabetes who are using long-acting, but not mealtime insulin. This was a multicenter trial but our part of the study was performed at our East Los Angeles location which allowed us to recruit from a study population that is representative of many people with type 2 diabetes who often don't have access to the latest diabetes technology. The result after 8-months in the full study population was an A1c reduction from a starting 9.1% to 8% at the end in those who used CGM. The control group who used a blood glucose meter started at the same A1c of 9.1% and ended with an A1c of 8.4%. The difference was significant between the two groups.
Patients came from the offices of primary care providers and you may have noticed that the control group improved as well as those on the CGM. This because both groups benefited from diabetes and nutrition education, which they had never had before. The patients probably would have gotten even better, but Dr. Peters was not allowed to adjust the medication doses, just the patient’s primary care doctor. She gave them suggestions, but they were not always followed. This shows how important it is to teach primary care doctors about using continuous glucose monitors.
SimpliciT1 Study
In the last newsletter we reported the results of a phase 2B trial of the new medication that targets the liver known as TTP399. In this 12-week study of participants with Type 1 diabetes the result was an A1C reduction of 0.7% with a 40% less hypoglycemia compared to placebo. The results were promising enough to continue to a larger phase 3 trial in the near future and we will let qualified participants know if we are selected as a trial site. In this study we also used the InPen in our participants who were using injection to monitor their mealtime dosing and proved to be a popular option and we are now prescribing this smart pen for our patients.
Hopefully you have noticed from either our Twitter feed or Facebook page that Dr. Peters and Mark Harmel were covering the virtual ADA meetings. Multiple Medscape videos have been posted (all shot or directed by Mark) and you have the option of watching the video or reading the transcript on Medscape after completing a free one-time registration to create an account.
In addition to the recent ADA news there are also many other videos that have posted since the Winter newsletter that may interest you. These earlier videos can be found after the meeting news.
Videos Previews or News Related to the 81st ADA Scientific Sessions by Dr. Peters:
CGM in Type 2 Diabetes: What I Learned From the MOBILE Study
Anne Peters discusses the benefit of CGM in patients with type 2 diabetes on basal insulin, adding that there is much to be done in educating both patients and healthcare professionals about CGM.
Medscape Diabetes & Endocrinology, Jun 30, 2021
New Guidelines for Type 1 Diabetes in Adults: An Overview
Dr Anne Peters summarizes and gives highlights from the new ADA/EASD draft guidelines for the management of type 1 diabetes in adults.
Medscape Diabetes & Endocrinology, Jun 28, 2021
All About Wegovy for Weight Loss
Anne Peters talks about the newly approved semaglutide (Wegovy) for weight loss -- the various trials, indications and warnings, dosing, and expectations.
Medscape Diabetes & Endocrinology, Jun 21, 2021
Peters on Tirzepatide: 'Impressive, but We Need to Know More'
Dr Anne Peters discusses tirzepatide and the topline results from the SURPASS trials.
Medscape Diabetes & Endocrinology, Jun 18, 2021
Videos Reports from the 81st ADA Scientific Sessions by Mark Harmel, MPH:
After Metformin, Which Drug Makes the GRADE?
Which medication should be added after metformin? The GRADE study attempts to fill the evidence gap.
Perspectives, Jul 9, 2021
CGM in Hospitals as Standard of Care: What Have We Learned?
Isn't glucose yet another vital sign? Dr Athena Philis-Tsimikas argues that CGM as standard of care in the hospital allows for better management of patients with diabetes.
Perspectives, Jul 22, 2021
New FDA Guidance on T2D Trial Design Provides Flexibility
The FDA released new draft guidance for the evaluation of type 2 diabetes drugs. Dr John Buse discusses the impact this could have on clinical trials and the medications we might see from the changes.
Perspectives, Jul 20, 2021
With Tirzepatide, a 'Great Future' for Patients With T2D
Dr Juan Frias discusses results from the SURPASS trials and how tirzepatide might eventually be used in the clinical setting.
Perspectives, Jul 15, 2021
Agents of Change: 4 Ways to Battle Social Determinants of Health
How do we help patients navigate social determinants of health? Dr Shivani Agarwal outlines four simple actions that can lead to big outcomes.Perspectives, Jun 29, 2021
The Best Way to Prevent Type 2 Diabetes? Change Our Target
Type 2 diabetes prevention strategies need to be focused on environmental changes more than individual changes in order to be effective, argues Dr Hertzel Gerstein.
Perspectives, Jul 7, 2021
Understanding COVID and Diabetes: Ominous Findings, Next Steps
What do we know about the epidemiology of diabetes and COVID? Dr Edward Gregg discusses learnings from the past year, and the steps needed to reduce morbidity and mortality in the diabetes population.
Perspectives, Jul 1, 2021
Earlier Videos of Interest to Patients by Dr. Peters:
Updates on Semaglutide for Weight Loss, From ENDO 2021
Dr Anne Peters discusses updates from the STEP trials that were presented at ENDO 2021.
Medscape Diabetes & Endocrinology, April 20, 2021
The Omnipod 5 System: Trial Results From ENDO 2021
Find out why Dr Anne Peters was 'incredibly excited' to see data presented from the Omnipod 5 clinical trials.
Medscape Diabetes & Endocrinology, April 02, 2021
SGLT2 Inhibitors in T1D: 'People Are Using Them Now'
Dr Anne Peters talks about what you need to know regarding off-label use of SGLT2 inhibitors in type 1 diabetes.
Medscape Diabetes & Endocrinology, March 30, 2021
Managing Pregnancy in T1D: 'One of the Hardest Things We Do'
Dr Anne Peters discusses blood glucose targets and continuous glucose monitoring in pregnant patients with type 1 diabetes.
Medscape Diabetes & Endocrinology, March 11, 2021
"Heart" of the New ADA Guidelines: Pharmacologic Approaches
Dr Anne Peters continues her overview of the ADA 2021 Standards of Care, focusing on the updates to pharmacologic management of glycemia.
Medscape Diabetes & Endocrinology, January 07, 2021
Key Changes to the 2021 ADA Standards of Care
Dr Anne Peters provides an overview of important changes to the first half of the ADA 2021 Standards of Care.
Medscape Diabetes & Endocrinology, January 04, 2021
Preparation for Drought, Wildfires and Other Natural Disasters
There is a historic drought impacting much of the Western half of the United States and conditions are especially bad in California which means people with diabetes need to be prepared for an active wildfire season this year. These fires and the subsequent mudslides can both prompt split-second evacuations. And of course, there is also the ever-present danger of a wide-spread major earthquake that can impact California or your local neighborhood.
Whatever the cause, you need to have your emergency kit ready because there isn't always time to prepare your diabetes survival kit. This is especially important for seniors and people who are using insulin. We know from published studies on the impact of hurricanes Katrina and Rita that more seniors died in the first month after the storms and the impact from the storms lasted a year or more. The impact could be localized to a specific area or very widespread if a major earthquake impacts your region.
This is what a basic (not refrigerated) diabetes survival kit, ideally kept in a small backpack that is easily accessible, should contain:
1. A small supply of all your prescription medications and nonprescription medications (like Tylenol/Advil/Benadryl—anything you might routinely take)
2. A list of your medications
3. A list of your medical conditions
4. A copy of your health insurance card and driver’s license.
5. A paper list of contact information for critical family members/friends/doctors (in case cell phone dies)
6. A glucose meter, test strips, lancing device, and lancets if testing your blood sugar (this is true for patients on continuous glucose monitors as well, to have as a back-up).
7. An extra pair of glasses (if needed)
8. Drinking water (available in emergency pouches) at least enough for 3 days.
9. Food bars/other easily carried nonperishable snacks
10. Glucose tablets or gels (if on insulin or other medication that can cause low blood sugars)
11. Insulin pump/sensor supplies if needed.
12. A change of underwear and socks.
13. Chargers for your devices, particularly your cell phone
14. Cash
For patients taking insulin, a small insulated bag (like a child’s lunch bag) should be kept in the refrigerator. I suggest a bit of redundancy with the backpack above. For insulin requiring patients the insulin kit is life sustaining and if only one is grabbed it must be this one. This should contain:
1. Unopened Insulin pens/vials for all types of insulin taken. For those on pumps this must include long acting insulin such as Lantus with instructions on what dose to take
2. Syringes/pen needles
3. Glucagon
4. Glucose tablets/gel
5. A food bar or two
6. A few pouches of water
7. Meter without battery in it/strips/lancing device/lancets (put here rather than in backpack if packing both—this way it always comes with the insulin)
8. An extra battery for your meter should be taped to outside of refrigerator in can the one in your meter develops condensation. Be sure to grab it when you leave.
Make sure your refrigerator is strapped to the wall so if it falls over your supplies won’t be trapped inside. Otherwise put the insulin bag in a small refrigerator that you can easily pick up.
If, in an emergency, only regular and NPH insulin are available, reduce the doses by 20% compared to your usual doses of insulin. NPH (intermediate acting insulin—peaks in 6 – 10 hours; it is cloudy) and regular insulin (short acting) are available at Walmart as the ReliOn brand insulin. You can get them without a prescription for $25 apiece. Be sure to get syringes as well. This guide can help you determine the new dose.
With many patients reading their glucose information on a smart phone it is also helpful to a backup battery charger or a portable solar charger panel and power bank. These are readily available at REI or other outdoor camping stores or online through Amazon and other retailers.
Diabetes Preparation Resources:
1. The American Diabetes Association has a great preparation website, and if you or a loved one is impacted by an emergency disaster event you can call 1-800-DIABETES (800-342-2383) Monday - Friday from 9am to 5pm Eastern time.
2. The Diabetes Disaster Relief Coalition (DDRC), was founded by multiple diabetes organization to provide support for people with diabetes affected by recent natural disasters. They have a diabetes specific preparation checklist, advice on how to obtain emergency prescription refills,
When emergencies occur in other areas, patients often ask how they can donate their insulin and other diabetes supplies. We recommend the Insulin For Life USA group and you can also check your favorite social network source to explore ways to share supplies within patient network groups.
General Earthquake and Fire Preparation Resources:
The Los Angeles Times just completed a six-part earthquake preparation series called Unshaken. The full series is available on their website or you can sign-up for the newsletter version. If you prefer to learn through a podcast, the public radio station KPCC created a ten-episode podcast called The Big One: Your Survival Guide. If you live in a high-risk fire area you can visit the CalFire website to develop an action plan and follow active fires and sign-up for text messages for updates on local wildfires.
Stay safe and take the time to be prepared.
The Hankey Grant
Over the past 20 plus years our diabetes group has made many contributions to the care and treatment of people with diabetes. We are not a large team compared to most diabetes center around the country but we have managed to create a national and international presence in the field. Much of the reason for this is due to your support, without which we could never have been so successful.
Recently we received a generous donation from the Hankey Foundation which will make a huge difference in terms of what we can do moving forward. While pharmaceutical and devices companies have funded studies in drug and device use it is foundations, individual donors and the NIH who have allowed our most meaningful research to occur. These projects involve being allowed to ask and answer questions that directly impact the lives of people with diabetes, from the impact of lifestyle changes as a treatment for type 2 diabetes to how to best educate our underserved patients with type 1 diabetes.
The Hankey grant will go towards trying to find a better way to treat our underserved patients with both type 1 and type 2 diabetes. Prior efforts to improve their outcomes have not been successful. But those approaches all used the “traditional” model for healthcare, meaning that patients interact with their providers either at routinely scheduled appointments or for emergency care in between. Healthcare itself doesn’t come to the patient when the patient needs it. However, through use of continuous glucose monitors that stream data back to a clinic dashboard we can watch over our patients remotely and identify those who need help. Our team can outreach to those individuals via telemedicine, at times that suit the patient, such as in the evenings or weekends. We don’t want patients to have to miss work to take three buses to come to a clinic appointment.
This is a different model for medicine in which providers are paid to see patients at appointments, not for remote monitoring. But increasingly we can do this sort of follow up whether it is for cardiac disease or diabetes. If it works better than what we have done it the past it could be a way to reduce healthcare disparities—everyone can be remotely monitored if needed, based on their clinical needs and situation. And it may not be the answer for everyone, but if it can help us guide therapeutic dose adjustments to improve glucose control it will be a big step forward. And it may help change the model for healthcare delivery in people with diabetes.