An Interview with Dr. Anne Peters (Continued)
Diabetes Technology and The Quest for the CURE
Joseph: What do you think about the prospects for new therapies for type 1 diabetes? How would you define a cure, and what is the path there?
Dr. Peters:I think that people with type 1 diabetes need an immunologic miracle. They need somebody to figure out how to turn off the immune system so their beta cells can come back, and they need better technology. If it were my world, I'd put a lot more money into devices and cures for type 1, because I believe it's possible. If you look at the autopsy specimens from people who have type 1 diabetes for years and years, you still see new beta cells forming. So maybe all you've got to do is shut off the immune system. But it needs lots of money, and it's not nearly as profitable because so few people have type 1 diabetes compared to type 2. Type 1 diabetes today is under-treated because of hypoglycemia, because of the complexities of the treatment, and because of the complexities of the care. The whole system of care for type 1 diabetes needs research, funding, and products.
I think we need a cure, and I think it's going to be immunologic. That to me is like discovering penicillin. I think it's going to take somebody in some lab that just figures it out, you know? You have to go through the research process until we get an answer.
I think the artificial pancreas will at best be a stepping stone, because artificial treatment has so many limitations. I don't care what the system is. All of my patients that are athletes, no matter what their pump settings are, do something different the day before their event. Or before they exercise. They do something different during exercise, and they do something the night after the exercise. None of that's programmed into anything. I think that would be hard to program into an entire artificial pancreas system.
Adam: As for today's diabetes technology, only roughly 30% of people with type 1 diabetes in the US are on insulin pumps, and around 5% are on CGM. What are the barriers? Do you think it's a reimbursement issue? Do you think it's psychological — as in people that think, "I don't want something attached to me?" Or are the devices not easy enough to use? Or are they simply not for everyone?
Dr. Peters: I have a preconception that if I had diabetes, I couldn't imagine not wearing a CGM sensor. But I have a lot of patients who don't want the sensor because it intrudes on their life or because it makes them too aware of their blood sugars or for some other reason. Similarly I have a lot of patients who don't want the pumps because they don't want the pieces attached.
Yet when I look at the A1Cs in my clinic, there's no difference between patients on pumps and patients giving themselves shots. It's not the device that makes the patients' blood sugars normal. It's the use of the technology — even including simple technologies like vials and syringes.
I have a patient who was treated by Elliot Joslin. He's had type 1 diabetes since the 1940s. He's done amazingly well. He's almost 90, and he walks four miles a day. He said that Elliot Joslin sat at his bedside after he had just woken up from his coma and said, "There are three things you have to do to live a long and healthy life with diabetes." He said, "Take your insulin every day; never miss a shot." The second was, "Always eat fresh fruits and vegetables every day for the rest of your life." Never forget your nutrition, basically. The third was, "Exercise every day for the rest of your life."
Dr. Joslin told him these three things, and this guy did it. Now, he has really good genes because he doesn't have dyslipidemia, and he doesn't have cardiovascular disease. But the point is, that's still the best advice. I don't care what these technologies are; it's only how you apply them. This patient will never go on a pump or a sensor. He doesn't have the capacity at this stage of his life. He barely ever does anything I tell him to, but you know what? God bless him, he's doing so well.
I think that's the advice for people with type 1 diabetes. I think these technologies can make it better, but it's got to be based on what the patient wants. I love pumps. They allow me to make adjustments that can have a meaningful impact. If patients use a bolus calculator and I can adjust it, that's really powerful. Pumps allow me to download data.
But pumps fail, infusion sets go bad, blood sugars go high for a day, I mean, all these things happen. The technology itself isn't good enough to make me say, "Everyone should be on this."
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As I mentioned in an earlier post, one of the benefits that made it cost-effective for me to go with the real healthcare (HSA) plan rather than the phony (HRA) plan is that my company is now covering "preventative" medicines at $0 copay. The formulary for these, as stated by CVS/Caremark (my pharmacy benefits provider), covers all test strips, lancets, and control solutions. I dutifully get my doctor to write up prescriptions for all of my testing needs, submit...