In this Exclusive Interview transcript, Kevin Sayer talks with Diabetes in Control Publisher Steve Freed about the Dexcom G6 CGM System and the future of CGMs changing diabetes management for type 1, type 2, and even prediabetes.
Steve Freed: This is Steve Freed and we’re here at the American Diabetes Association Seventy-eighth Scientific meeting. Today we have a special guest. who works at a company that has really changed diabetes per se, how we treat it, how we look at it, just about every aspect of diabetes: Kevin Sayer, who happens to be president and chief executive officer of Dexcom. Maybe you can start off with,tell us a little bit about who you are how you got involved with this.
Kevin Sayer: Thanks for having me on today and for the interview opportunity. I’ve been involved in diabetes for a long time; I actually started life as a CPA and did a lot of finance work, and I landed as the chief financial officer of MiniMed in 1994 as a very young guy working with Al Mann. and Terry Gregg, Dexcom’s former CEO and our chairman at Dexcom. And so I spent a lot of time in diabetes growing that company, from very small size to near 400 million dollars when Medtronic acquired it. And then I took some time away and did some other things after I left Medtronic, and in 2007 I had the opportunity to join the Dexcom board and get back into diabetes, and in 2011 — again Terry was our CEO and we’ve known each other forever — I had wrapped up my previous company and everybody looked to me and said you know there’s a wonderful opportunity at Dexcom in San Diego, why don’t you come and be the president. And I went home and talked with my wife about it and it took us all of about 10 seconds to decide this what we’re going to do. And we moved to San Diego, and I was involved in the approval of the first continuous glucose monitor. And in addition to being a finance guy I’m an I.T. and a gadget geek too, and I love numbers. It always made perfect sense to me that continuous glucose monitoring was the most important tool that somebody could have in managing diabetes, because without data as to how you’re doing, you’re just living in the dark, which is what a patient told me last week when I was sitting in the center. You’re just living in the dark and this is the light. And so coming to Dexcom and getting to realize all those things we thought about back in the 90s, it’s just been a fabulous journey. And so I’ve been at Dexcom since 2011, I became CEO and president three and a half years ago and we just have a wonderful culture. We’ve gone from three hundred to three thousand employees, and the company is just — we do a great thing for people and then. you know, you get rewarded for that. And it’s been very rewarding.
Steve Freed: Do you remember the GlucoWatch? I had one of those.
Kevin Sayer: I remember the GlucoWatch, I wore one and I may still have a mark!
Steve Freed: It burned me, it left a mark there for a long time.
Kevin Sayer: But you know what, everybody has tried to solve this problem for a very very long time. And I think our solutions now are so much better than what we’ve had before, as is evidenced by the launch of our new G6 product this month and at this show this year, at the ADA.
Steve Freed: How has the G6 been received by the medical community?
Kevin Sayer: Extremely well. The promise of the G6 sensor with the continuous communication to the mobile platforms and the sharing of data amongst caregivers, combined with a no calibration system, that is the most accurate system ever on the market. And you combine that with the mechanical features that we’ve spent years designing to where it’s very simple to put on your body. There really aren’t any threatening steps; it’s a button push after the tape is taken off and it’s put on your body, and most patients who do it respond they don’t feel it. And so the response has been just overwhelming.
Steve Freed: Have you seen patients that have not improved their diabetes by wearing it?
Kevin Sayer: With G6, since we’re just launched, I can’t answer that. I think with any diabetes therapy you have to use what you have. And there certainly are patients who go on CGM and don’t use the data as actively as they should to manage their condition, and their physicians who would tell you that. What we give you is an opportunity to manage your data and opportunities to avoid the danger spots with real time alerts and alarms within G6 system. For example, there’s what we call a predictive low alert; 20 minutes before you’re going to hit 55, we tell you, you might want to do something now, rather than wait 20 minutes till you hit 55 and get that dangerous alert. That’s been a big deal to our patients as we’ve launched this product, and we have many other predictive tools that we’re developing. You just can’t put them all into the first product offering. We need to see how this one will function. But patients have to use and engage with the technology for it to be valuable. Many of ours do, and many of ours do very well. There’s the occasional patient who doesn’t.
Steve Freed: I would think that someone who’s obsessive compulsive and checks 10 times a day would be a great candidate. But then. with all that information that could drive them crazy, and they over treat themselves.
Kevin Sayer: And that happens and there is a stereotype to that even amongst the providers of those patients, I don’t know that they can handle all this information. So it is important that we learn to simplify the information and when to use and to act on it. You know a perfect example is when somebody eats and they take a bolus but they see them going out for the meal and keep going up up up because they see the data. They might overreact and want to stack another bolus on top of it, and then you can end up in a dangerous low with that. Over the future, in future years, as we integrate our system with insulin delivery systems, with pens that will have automated or manual insulin delivery, with pumps that are going to do that and also with connected pens, we believe we can add tools to the app that will help patients, and decision support software where we can say, hey, look we noticed it’s noontime and you ate, your glucose is going up and we also noticed you didn’t take a bolus; should you do something? And as we can take this technology with all the information we’re gathering and learn and make it that simple for patients, it’ll even become more useful. But making it real complicated isn’t the answer either. We’ve got to find the right balance between utility and adherence and the science. The science is really fun and easy and we all head down science fast sometimes and we’ve got to make sure we head down a path people will use.
Steve Freed: So I’m always thinking that if you have a CGM, and you put it on a type 2 who’s not on insulin, that they can take that information and change their diet, because most people with type 2 diabetes not on insulin, they really don’t change their diet. They don’t understand what a carbohydrate is. But if they can see what corn does or watermelon does, they may not eat that anymore and they may change their diet. So when do you think, and will it happen, that I can go to the Walgreens and pick up a CGM?
Kevin Sayer: It’s going to happen. We are running studies in type 2 patients now trying to decide what exactly that model is for a non insulin using person who’s dealing with diabetes, maybe even prediabetes. How many sensors a year does a patient wear? What do you diagnose when you put them on it? So we are working, we have a program with UnitedHealthcare where we’re providing sensors and they’re accumulating data and learning. We have a joint venture with Verily, Google’s healthcare arm, where they’re developing type 2 programs and we’re looking at data from these patients. And your posture is absolutely correct: “Wow. I did not know that Starbucks thing I get at 10 o’clock every morning is driving me to 400.” But there’s another ramification of the sensor with type 2 patients that’s very important as well. As we’ve got into this market and as we’ve looked at these patients, they’re expensive to the healthcare system also. And the compounds that these patients take, particularly these new advanced ones, they’re not cheap. There’s not a better way to evaluate the effectiveness of an SGLT2 than to put a sensor on a patient and make sure that the highs are not happening.
And so you can evaluate the effectiveness of a drug without waiting six months or 12 months for another A1c test; put it on somebody for two weeks and let’s see what happens. The educational tool, it’s not only just the nutrition that you learn, so you learn about the effectiveness of the compounds the patient takes. You can also learn a little bit about their activity rate. And we have programs where we’re combining activity data from a Fitbit type device with CGM data to see what type of difference a walk can make after a meal. So I think there are some great things that can happen in type 2 diabetes with this. G6, this launch of this product with no calibration and easier insertion and the better form factor, was the the platform we needed to start. We needed to make it easier for patients to use and we’ve really successfully achieved that we think. So more on type 2, hopefully in two years we can sit and have a whole type 2 interview, how’s that?
Steve Freed: That would be great. You know you’re actually responsible for the death of a billion dollar industry, that’s blood glucose monitors. I can’t imagine why anybody would want to stick their finger five times a day when they can just put a patch on that’s pretty painless and get more information. I mean why would anybody spend that kind of money for something that’s outdated? It’s like where can I buy the model T Ford?
Kevin Sayer: I think I’ll take you with me to my next meeting with an insurance company! We can get you in front of them. I agree. And I think again I’ll go back to what we’ve launched here at this meeting with the no calibration, continuous data feed, the alerts and the alarms. This is what we promised CGM would be when I started this journey over 20 years ago. It’s here now. And so now where we go from here is just going to be exponentially more amazing than what we’ve done before, because we can take this to a number of markets. We can broaden the use case of it because again, it’s simpler. And I think I think great things are going to happen here. We couldn’t be more excited.
Steve Freed: You know one of the areas that you’re not looking at which you might consider down the road, that’s prediabetes. You know the major problem is we have 100 million people with prediabetes. We only have 30 million with diabetes, and 10 percent of those with type 1. But that’s a 360 billion dollar industry. And when those other 100 million become diabetic, or the other 70 million, it’s going to be in the trillions of dollars. So if we can get. the physicians to put a CGM on every patient, just for a week, OK?
Kevin Sayer: I hear you completely and I think it is a wonderful opportunity. We do look at this. We haven’t had the efforts in this that we’ve had in type 2 and in type 1 diabetes but we are considering it. And as you look at our future generation products, as the CGM become smaller and smaller and requires even less patient interaction, having this great glucose measurement tool, it becomes literally a discussion of how do you display it and how does the patient interact with it. And where do they interact with it and what learnings do you want to offer somebody with prediabetes. But the other piece of that again, in the healthcare system today. if you can diagnose prediabetes that’s getting more severe through a sensor wear, then a physician or the insurance company can intervene and say we need to do more for you. Preventative medicine will save a lot of money, and we think that as a diagnostic tool CGM could be very valuable.
Steve Freed: Because right now you know most of the people that have prediabetes don’t know it. So they are going to become diabetic in the long run because they’re doing all the wrong things and no one told them why they shouldn’t be doing it. So if people knew they had a disease called prediabetes, my experience in working with people just in general, I call it, A1c test, I call it the quality of life test. That number represents when you’re going to live or die. And I can take a whole audience and tell them how important that test is. Their doctor is not going to do it. He’s going to do a fasting blood sugar, because when you go in for a physical and he wants to get your triglycerides, tell you not to eat, he’ll miss diabetes by 25 percent. So the A1c also tells you when you’re going to live or die. It tells you if you have a higher risk for cancer, Alzheimer’s, dry skin, athlete’s foot. It affects every cell in your body. And when I tell people that, and I give them the A1 test, now they’re motivated to increase their physical activity, be more careful with what they eat, and they can actually prevent from getting diabetes.
Kevin Sayer: Well I was going to say we can take it a step further, because as you know a patient with an A1c can have glucose values that go up and down like this but they can have a flatline like this. There are patients for example that we have seen in our type 2 studies who have very consistent glucose values during the day, whose values go up at night while they sleep because everything finally shuts down and then that glucose hits the body; they produce too much insulin. And insulin goes on all day and then at nighttime the pancreas says oh I finally get a break, and all that glucose is still in the body. Well that’s a condition that’s a precursor to type 2 diabetes. And I guess my guess is that as you’ve been in diabetes forever, type 1 and type 2 are such different conditions it’s almost not fair to call them both diabetes; they’re just different. And so there is an opportunity here across the board and that’s why we’ve stayed doing what we do. This is all we make. We make continuous glucose monitors and over time what we’ll do is derive this into several different products based on the core technology that addresses many of these medical needs that we can get out to patients to better their lives and also better, literally the economic environment for payers too, because we know, we’re not going to go in and say hey we’re going to charge you X thousand dollars more a year for each of these type 2 patients. You can’t do that. You’ve got to deliver outcomes that reduce costs to provide more information that helps us do better therapy, and that’s for prediabetes and for type 2, but we believe this is very doable.
Steve Freed: You know one of the problems I see, not really a major problem but what I see is that when it comes to the education, okay I can have all this great information. I can see my blood sugars going up to 275 after eating a corn on the cob. I won’t do anything because nobody told me what to do. So the education plays a major role in taking that information and doing something with it, because if you don’t do anything with it it’s useless.
Kevin Sayer: Yeah there has to be an education element. And. one of the things we are we are working on and experimenting with in some of these studies, is how much of that is human education, interaction; what can we put in software, what can we put in chat bots, what can we put in instant messages. How do we interact with the patient to best get that education to where by those points are made in the most effective manner for the patient and also the cost effective manner for all the constituents involved in the treatment.
Steve Freed: I can really see you take a photograph of the food you’re about the and the voice come out, “You don’t want to eat that.”.
Kevin Sayer: Or you walk into the restaurant where your blood sugar went up over 400 two weeks ago and your phone starts going, “Leave, leave, leave, don’t go here.”
Steve Freed: So if CGM can actually predict before we eat the food what our blood sugars would be, that would even be better.
Kevin Sayer: And so here’s the issue that is a balance, and having been around diabetes so long you understand this. How much information does somebody really want to digest, to deal with this? How much do you put in front of them to whereby it becomes overload? And so we take this very seriously and we look at all these technical options, and then we’ll go through a process over time. And I think what we’re going to be doing is giving patients menus. One of the things that we’ve done as a company for example is we have an open API architecture with our data. So if a patient’s on a Dexcom CGM, and a company who makes software outside of diabetes has signed an arrangement with us, we will give them access to your retrospective CGM data. So if you have a nutrition app, and you do chart everything on the nutrition app, if the nutrition app enters into our API program, the CGM data can be downloaded to nutrition app and you can match, and they can offer insights. We think that can be a remarkable tool because the other thing, with a problem this big and this costly and with so many people trying to address it, we know we can’t solve everything. We can make the best tool we can make for what we do and what we’re good at. We’re going to need to work with others to do some of these things better than we can.
Steve Freed: So how does diabetes patient care evolve with a CGM like the G6?
Kevin Sayer: With the G6 — and again we’re only a month into it but I can tell you what’s going to happen, we have a pretty good idea so far. The ease of use of this system, the concerns patients had before with calibrating it twice a day, and before that before we got the noninjective claim with having to take a finger stick to validate the CGM data — you can now put this thing on and replace finger sticks in your life. With that data going straight to a mobile device, with that data being able to be shared with a caregiver or others. I think the biggest evolutions that we’ve made in diabetes care at Dexcom, you can go through the list of what’s happened in CGM. We were the first seven day sensor, we were the first one to really have I think accuracy good enough to change people’s lives, we’re the first one to openly connect to other companies’ insulin pumps, we’re the first one to go to a mobile platform. Now we’re the first continuous monitor with real time signals going to a mobile device all the time and providing alerts and alarms. And now it’s simpler to use with no calibrations. I think you’re going to see another group of patients who wouldn’t take advantage of this technology before take advantage of it now with intensive therapy.
We’ve seen another great advance in the past several months: Medicare gave us approval in 2017 early and it took us over a year really to work through the paperwork maze. But we’re now seeing a great number of Medicare patients adopt this technology as well, and you think about somebody on insulin who’s a senior, having the ability now we just got through the CMS people, the ability for these senior patients to use the phone app and share the data. Now you’re going to see I think great use in that population as well. So we’re expanding very rapidly in the intensive managed market. And then over the next five to 10 years you’ll see us address many of those questions you asked me earlier and those are our new markets.
Steve Freed: So now, patient gets diagnosed, they have an elevated A1c of 10, 11, 12, and the doctor starts them on insulin immediately. Is he going to recommend the blood glucose monitor or a CGM? The philosophy I mean in today’s market.
Kevin Sayer: It varies physician to physician. There are many who start patients on CGM early and one of our taglines, a CGM first, it’s the most important tool to give a patient. I think the experience from getting a CGM early, I don’t think there’s anything to replicate it. Many physicians talk about the honeymoon period where you’re not taking that much insulin and your pancreas still works a bit, but as far as educating a person as to what they’re in for for the rest of their life, there’s not a better tool. So our hope is they’ll put patients on CGM early, and many of them do and I think the practices have evolved a lot over the past several years. There’s still more to go.
Steve Freed: Do you wear a CGM?
Kevin Sayer: I wear CGMs all the time. A lot of the stuff I wear, I have to confess, is from the R&D lab to see how it works, so I wore Gen6 dancers very frequently before this product got approved, to see how it worked. I don’t have one on currently that we can look at my data on. But yeah I wear them a lot.
Steve Freed: You have diabetes in your family?
Kevin Sayer: My mother has type 2 diabetes and her father did. And I would tell you she’s not had great care and — well I’ll rephrase that. She’s had fine care but you can see the telltale signs of many years affecting her overall health. I haven’t got her CGM yet because I don’t have a prescription for her but one of these days I will. And we’ll see how her blood sugars are doing.
Steve Freed: You know what your A1c is?
Kevin Sayer: My A1c I think is five and a half. But I given the predisposition of my genetics, I look at the CGM data pretty frequently when I wear one and see what I can learn about my own self. And I’ve had many learnings.
Steve Freed: Now that you’ve got approval from Medicare, how do you think that will have an effect on older people that have type 2 diabetes using insulin? Hypoglycemia is a real concern for older people. A lot of times physicians will say you know their A1C is eight and a half, I’m not going to push it, concern about older patients having hypoglycemia.
Kevin Sayer: Goes back to my earlier comment: they’ll be going from the darkness to the light. With a CGM they’ll be able to to really focus in on that. But not only the patients themselves, their caregivers, their infrastructure. You know there’s people around them, there’s people around everybody who cares about your health. And as you get to be a senior and have type 2 diabetes, you’re using insulin all the time, there’s a lot of people who want to make sure that you’re safe and you’re healthy and that you’re around. I think again, I think now with the ability to share and the easier ability to use the G6 system, we’ll see even more Medicare acceptance of what we have.
Steve Freed: Well I certainly want to find out what’s in your pipeline because with your technology and your knowledge I could see some unbelievable things I know. Once it was part of my program I had a slide that showed Ford on the dashboard, you know with the blood glucose monitor it could show you your blood while you’re driving. I figured you guys must have something like that coming up.
Kevin Sayer: You know our recent approval of G6 is called ICGM; the FDA created a new class which means interconnected and interoperable continuous glucose monitoring. So fundamentally at our core we will connect to a number of devices. We connect to IOs phones, we connect to Android phones, we connect certainly to the Dexcom receiver, we talk to other insulin pumps. So one of the questions we ask ourselves is what do we connect to to make it worthwhile for our patients? And where do you see that signal? I mean do we someday, and we haven’t done this yet, do we someday connect to Alexa and you walk in your house and [hear] “Your blood sugar is X Y and Z,” you know, some type of function like that. In our pipeline we focus on interconnectability as a major feature, but we focus really on four things: we focus on making the product accurate and perform well every time; the technology has to be good enough for people to trust and rely on or it’s not going to be in our portfolio. The second thing is convenience for patients and making their lives easier. Some examples are making it smaller, making it connect to the phone directly, making it no calibration so they don’t have to stick their fingers. We have initiatives that are focused on different sized platforms, disposable platforms that you can peel off and throw away, so you don’t have to keep track of the transmitter, and other software applications that might enable them to make better decisions as far as bolus calculations and the meals. The third thing we focus on is cost. We know this is expensive therapy still. And we’d like that cost to come down. So as we make new products one of our other mantras is you’ve got to drive the cost down. The final one is outcomes. If we don’t deliver better healthcare outcomes for everybody else in the system it’s not worth doing. Those are the four things we focus on over and over again. We have more sensors in the pipeline. We have new electronics in the pipeline. We have new insertion systems in the pipeline. Across the board there’s new stuff going on. Again this is what we do.
Steve Freed: So my last question is, a patient comes into the physician’s office and they’re on insulin. They’re using a blood glucose monitor, not doing great. The doctor says I want you to use the CGM. What should the doctor be telling their patient when he initially puts that patient on a CGM ,because there’s going to be more questions obviously. What do I do when my blood sugar goes up or goes down, for the person that’s not a type one?
Kevin Sayer: So I can’t practice for the doctors but I think the first thing I hear from many of them as I ride along is when you first put it on, put it on and wear it and don’t do anything. Put it on and learn for a week. Put it on and learn what is going on with your body. Then let’s address those questions that you have before you start doing things like, I’m gonna take a bunch more insulin because I see I’m going to high. Or what happens when I exercise — learn what happens when you exercise. For me for example when I exercise I get a great big spike of glucose, my body goes Hallelujah, the guy’s finally moving, and my blood sugars go up. but then I have a drop for the rest of the day by about 10 points, so I’m much healthier when I exercise by about 10 percent for the whole day, but I get a big blip in the morning. Well if I had diabetes and saw that, I might take more insulin, not knowing. So I think you know often that the guidance is let’s take a little bit of time and learn, and then let’s see what makes you better.