Dr. Halis Akturk, MD, had the pleasure of attending the 79th Scientific Sessions of the American Diabetes Association (ADA) in San Francisco, CA, on June 7-11, 2019. Dr. Akturk is Assistant Professor of Pediatrics and Medicine - Adult Clinic at the Barbara Davis Center for Diabetes at the University of Colorado. He was awarded the Young Investigator Travel Grant Award for his poster, “Immune Checkpoint Inhibitor Therapy Precipitates the Rapid Development of Type 1 Diabetes.” Dr. Akturk also co-authored three other posters at ADA on research on the hybrid closed loop (HCL) system for glycemic control, as well as cannabis use in Type 1 Diabetes.
Doximity: Thank you for speaking with me today on your pioneering work in diabetes. What do you think are the most pressing issues right now in diabetes?
Dr. Halis Akturk, MD: Thank you for your interest in my work. New technologies like HCL and continuous glucose monitoring (CGM) systems, and also the results of studies of the cardiovascular outcomes of new medications, the announcement of which is highly anticipated at this meeting.
Dox: What is a HCL system insulin pump?
HA: They have bluetooth-enabled CGM. They are powered by an algorithm that adjusts insulin delivery based on the patient’s blood sugar results which is known through CGM. The features of suspending or decreasing insulin delivery can prevent hypoglycemia. Medtronic’s MiniMed 670G system is the only FDA approved HCL system in the U.S. The most patients in the country (and world, since it is only made in the U.S. right now) use it where I work at the Barbara Davis Center, over 1,000 patients. It is the world’s first “artificial pancreas,” but we avoid using that term with patients since it can give false expectations. It is like smartphones, obviously the newer generation phones are better than the older ones, but this HCL system is like the first smartphone, it is opening a new era in diabetes management.
Dox: What is most important for clinicians to know when using the HCL system with patients living with Type 1 Diabetes?
HA: The most important things to consider when initiating the HCL system with a patient is explaining how the system works, and setting expectations and making adjustments based on the patient’s lifestyle. At my center we have a very close follow-up system with the >1,000 patients with these new generation pumps. We do a training on the pump and check in every few weeks and months to decrease any dissatisfaction with the pump and address any issues.
There are limitations, however, and patient selection is key. There is no one-size-fits-all. The people who can get the most benefit from this system are people with Type 1 Diabetes who experience a lot of uncontrolled hypoglycemia, especially at night. It improves glycemic control by providing full coverage no matter the activity or food level. But this all depends on patients doing the calibrations and inputting finger sticks. If directions aren’t followed, the HCL system has limited benefit.
Dox: What are the greatest barriers to adherence with the HCL system?
HA: Cost is huge. It is very expensive and only commercial insurances are paying for it. Unfortunately it is not covered for patients with Medicare or Medicaid. And it is not only a one-time purchase. Patients need to get new sensors every 10 days and there’s also a transmitter cost. However, the data can be uploaded to a cloud system which can be accessed from anywhere by the patient and clinician. There’s a lot of maintenance which can be challenging for patients who are not as technologically savvy.
Dox: Your research also shows improvement in Time-in-Range (TIR) with the HCL system. Can you please expand on that?
HA: Yes, Time-in-Range (TIR) is how long the patient is in the normal range of blood sugars which we have set as 70-180. Less than 70% of time spent in that range is called time below range. It measures how long a patient spends in a hypoglycemic state. We followed and compared patients using a different pump before transitioning to the Medtronic 670G, then used it for three months and six months. After three months hypoglycemia was decreased by 20% and 30% after six months. TIR was also higher at three and six months by 18%. There was also lower HgA1c and no weight gain for these patients. Using the pump’s automatic (vs. manual) mode (by inputting calibrations) was found to increase these positive outcomes in patients. Women seem to do better than men in maintaining auto mode.
Dox: Thank you. And what should clinicians know about your research on immune checkpoint inhibitor therapy?
HA: Immune checkpoint inhibitors are revolutionary cancer treatments. They activate one’s immune system to fight cancer cells in the body. They are highly effective and decrease mortality in advanced cancers. Developing Type 1 diabetes is a rare side effect of these medications. We did a literature review up to 2018 of all cases in which patients developed Type 1 diabetes to better understand why they developed it and what are associated risk factors. We found that 72% of patients developed Type 1 diabetes within 3 months of being on immune checkpoint inhibitor therapy. Serious side effects like DKA need to be monitored in this population especially since they tend to be older and already have advanced cancer. Why do some develop this irreversible diabetes within days and some within months? There may be a link between the presence of certain antibodies and the development and severity of the diabetes.
Dox: And for your final poster abstract, what do clinicians and endocrinologists need to know about cannabis use and Type 1 Diabetes?
HA: This is a nationwide follow-up to a prior study conducted in Colorado. Where I practice in Colorado many patients use cannabis either for medical purposes or recreationally because it is legal. In this study, 30% of T1D patients who presented to ER in 1 year self-reported that they use cannabis. DKA risk is 2x higher compared to those not using cannabis. We believe these people may have “cannabis hyperemesis syndrome,” possibly making them more prone to developing DKA and losing electrolytes. There may be metabolic reasons regarding gut motility and cannabis hyperemesis syndrome. Precautions should be taken for people living with T1D and using cannabis.
Dox: Thank you, Dr. Akturk for taking the time to share clinical insights from your research.
This interview was conducted by Angelica Recierdo, MS, Op-Med Editor.
Illustration by Jennifer Bogartz