Adam Brown 2018 Transcript

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Adam Brown ADA 2018 Full Interview

Freed: This is Steve Freed. We’re here at the American Diabetes Association, 78th Scientific Sessions, and we have a special guest, Adam Brown. And maybe we can start off with, tell us a little bit about yourself and what you do.

Brown: Sure. So, I started at my job as a summer intern actually. I live with type 1. And started my job in 2010 as a summer intern at Close Concerns and diaTribe.org. And since then, I’ve joined full-time and have been there ever since, following diabetes technology, writing about it every single day. So, understanding what’s happening in CGM, and pumps, and mobile apps, and automated insulin delivery and software is what I do every single day. And we write for tens of thousands of leaders in diabetes at Close Concerns and then also over a 150,000 people over at diaTribe.org. And our mission is just to make people with diabetes happier, and healthier, and more hopeful, and we do that by curating all the great stuff happening and sharing it with people. And as I said, I lead technology at Close Concerns and I edit and write at diaTribe. And then, about a year ago I published a book, kind of sharing my own personal journey with diabetes and all of the tools I found the most helpful called Bright Spots and Landmines.

Freed: Just out curiosity, when was it published?

Brown: May 2017.

Freed: It’s outdated.

Brown: (Laughs) Not really because it’s focused on food, and mindset, exercise, and sleep, so it’s not actually about technology really, minus a little bit on CGM, which was something I kind of tried to hold myself to that bar; can we write something that will outlast some of the technology?

Freed: I’d be surprised if you’re not wearing a CGM.

Brown: I am wearing a CGM, yeah. I’m on the G6 actually, which has been fun to test.

Freed: Okay. So, you’re technology expert when it comes to diabetes and we know that in the field of diabetes forgetting about technology, just in treatments, that’s changed almost weekly. As far as technology goes I think there were three FDA approvals within the last couple of weeks.

Brown: Yeah, on Thursday actually. There were three.

Freed: And so, it’s changing very rapidly. How do you stay up-to-date with it? I find it kind of difficult, except for coming to obviously ADA but that’s once a year.

Brown: Yeah.

Freed: How do you stay current and learn about the newest and the best?

Brown: Well, it helps that it’s my full-time job and I have a team, two other people who help me on technology. So, I think that’s actually what it takes to follow. And I gave a talk on diabetes apps on Saturday and I commented to the audience, “I think most of this talk would not have existed a year ago.” I mean, that is how quickly it’s changing. And now we’re starting to see pharmaceutical companies like Lilly invest big in diabetes technology. They have their own pump, and hybrid closed loop, and a system for titrading insulin on a phone. So, it’s going to get even crazier in the next year, in two years, and three years. So, the ways we stay up-to-date are we just have as many inputs as possible. We get company press releases. We listen to earnings calls. We test out stuff that we hear about. I mean, literally every channel we can think of and then we try — I mean, the hard part is separating the signal from the noise. So, I always bring it back to like, “Would I use this? I mean, is this going to make my life better?” But I think it’s hard for the average person to keep up with that and so we try to share that kind of stuff in diaTribe.org just giving people a sense of what’s cool, and what’s new, and what’s next. But if people feel overwhelmed about technology, they should, because it’s overwhelming for even those of us who work on that full-time.

Freed: So, what was title of your presentation here?

Brown: “Can Diabetes Apps Make Our Lives Easier?”

Freed: And how was the response — I mean, how was the turnout?

Brown: Tremendous. Tremendous interest.

Freed: And so, maybe you can share with us some of the top [apps], because there are so many diabetes apps out there. It gets really confusing.

Brown: Yeah.

Freed: And a lot of them are very similar to each other.

Brown: Yeah.

Freed: So, as far as the top apps out there that you worked with, that you like, what would they be?

Brown: Yeah. So, just to take one step back I feel like — Can Apps Make Our Lives Easier? I try to look at what makes a useful app in general. We’re all used to like the diabetes apps where you just log stuff and log stuff and log stuff, and after 72 hours you’re like, “Yeah, this is not helping me.” So, that to me is not a useful app. Where we’re going in diabetes is two things; radically convenient tools, so things like Uber, and Lyft, and Amazon. Apps that literally make your life easier by saving time and money. And the second is decision support: tell me how much insulin to take. And so, the things I’m really excited about are those individually and in combination. So, the most popular apps that we see, that I shared were the Dexcom G5, and Dexcom CLARITY, and Dexcom Share, and CGM. We’re now seeing multiple blood glucose meters with Bluetooth in them, so Ascensia, CONTOUR NEXT, and Accu-Chek. One touch reveal, no need to plug in cables to download the meters. And then, a lot of data apps like mySugr, and One Drop, and Gluco are really popular. And so, that’s kind of the stuff people are using now but what I’m more excited about is the decision support stuff that’s coming.

So, there are four FDA cleared apps for titrating basal insulin. So, a health care provider would prescribe an app, let’s say Voluntis, Insulia, or the Gluco Mobile Insulin Dosing System. They’d prescribe this app. They’d set up the titration plan. Patient gets the app, and they enter their fasting glucose information, and they get updated doses based on their patterns. And it just tightens the feedback loop which we’re so slow on in diabetes, helping people with that. And then there’s a slew of bolus calculator apps. There’s a few that are approved. MySugr has one in Europe. Accu-Chek Connect has one in the US. Companion Medical has a smart pen with a Bolus Calculator. So, helping people know not just how much basal to take but how much Bolus. And then, Medtronic has just launched the Sugar.IQ which is an artificial intelligence powered app that watches your CGM trends and would give you insights. Like, it’s Saturday morning, you get an insight that says, “Hey, Adam. You actually tend to go low on Saturdays between 12:00 and 3:00.” And I get that on Saturday morning, which is to me really helpful decision support. And then where this is all going is titrating people’s basal and bolus insulin from a smart phone app based on all their glucose trends, so Lilly is working on that, Bigfoot is working on that.

And then for pumpers, being able to dose from your phone and have a hybrid closed loop is actually not that far away. So, there’s one smart phone controlled pump outside the US made by a company called SOOIL. And then Medtronic, [Insula, Bigfoot, Lilly, they’re all working on being able to do that. So, it does sound like a lot. I actually covered 40 examples in this talk of things that I think make life easier. But we’re in the early stages of diabetes apps, so if people feel like they prescribe apps or they recommend apps and people don’t use them, I think it’s because they’re just not useful enough yet. But we shouldn’t forget that when CGM came out, what was it the Gluco Watch? You know, the Dexcom STS. And look at where we are now. We have two factory calibrated continuous glucose monitors and four systems where you can use your smart phone to view your CGM data. You don’t even need a receiver. And four great systems approved in the US. So, I think we just have to be patient. And the other thing people forget is people’s expectations are super high. Like, when you use something and it doesn’t work, you’re just like, “Ah! Forget it.” You kind of get one shot deal. And so, I think we should also keep that in mind.

Freed: Well, you took half of my questions. (Laughs)

Brown: (Laughs)

Freed: Your thoughts on CGM? Do you think it’s going to basically take the blood glucose monitors off the shelf eventually? Because why would you want to stick yourself five times a day when you don’t have to.

Brown: Well, I think the operative word in your question is eventually. And everyone’s wondering when will that be and what will it look like in what populations. So, I think in type 1 diabetes, not having a CGM is dangerous. I mean, every single person with type 1 diabetes should have CGM.

Freed: How about everybody using insulin?

Brown: Yeah. And everyone using insulin, for sure, or certainly people on multiple daily injections with type 2 diabetes. What will — I think a couple of things are gating the field right now. So, one, is still reimbursement. Actually a lot of people are paying out of pocket for CGM even if they have coverage. Maybe they pay 20% or 30% or 40% of the CGM, but that can actually really add up and especially if you’re having trouble paying for your insulin. But what’s good is companies get it. They are making affordable systems. So, Libre came out in the US, much more affordable, sold in the pharmacy, less hassle hopefully for providers to prescribe. Dexcom just came out with G6 which is 10-day wear instead of seven. And they’re moving quickly to get to a disposable system that’s even less expensive. So, I think we’re going to see it — most people would say about 20% to 30% of type 1s in the US right now wear CGMs, so it’s still pretty early in type 1. And we’re going to see that explode with two factory calibrated systems now. I mean, I think that’s really going to open up the field.

And then in type 2, there’s just not a lot of studies showing the benefit, so that’s going to gate the coverage until we get more studies. And the other thing is often these things are tested like a drug; give one group the CGM, give one group finger-sticks, follow them over time, see how they do. CGM is a tool. It’s not a therapy, so you have to do something with the data. And so, the other thing people are working on is building education around the CGM. So, imagine if you took pictures of your meals, those pictures were overlaid on the CGM data, and then you would actually be prompted to say, “Here are the 10 meals that keep your blood sugar in range and here are the 10 that are challenging,” that is decision support and that will enhance the efficacy of CGM, but that stuff is still kind of early. The Sugar.IQ from Medtronic is kind of one of the first really cool pattern recognitions, I think, we’ve seen and we’ll see much, much more of that. And then the big question for kind of the world is, what about people with type 2 not on insulin? What about them? What about people with prediabetes, I mean would they ever wear CGM? And I hope so. People like Anne Peters, prescribes CGM to everyone she can get it for, people with prediabetes even. And so, I hope someone does those studies to prove it but it’s going to take time. Especially in developing countries, we’re going to need much less expensive systems. But I am a huge CGM advocate. I think everyone who we can get it for should be on it.

Freed: When are you going to use the Eversense?

Brown: (Laughs) Well, I’ve been a Dexcom user for a long time. I’m very happy with it. The other thing I’ll say is I’ve been using one of these do-it-yourself closed loop systems that some really smart patients hacked together, so I actually can dose insulin from my phone and I have a hybrid closed loop on that. Right now it only works with the Dexcom, so I’ll probably stick with the Dexcom until I get to survey kind of everything and see what I like. And so, we’ll see. I think Eversense is really exciting because it’s a new form factor for CGM. So, there are people who say, “I just can’t deal with the adhesive of CGM,” or, “I don’t like plunging a needle through my skin once a week.” And so, for that group Eversense will be really exciting. And then once they can get to 180 days and even 360 days, I think they’ll see hopefully more uptake too. But it’s still really early for Eversense.

Freed: I had a chance to talk to one of the reps just 10 minutes ago.

Brown: Yeah.

Freed: And asked him how much and he said, “It’ll be equal to what’s out there.”

Brown: Yeah.

Freed: And I said to him, “Well, the people that wear the Dexcom, to try to save money they may wear it one week a month, but you’re saying it’s going to cost like four weeks of — or it’s going to cost three months for sensors, that’s going to be kind of expensive because you can’t take it out. You’d have to use it.” And so, he came up with around five grand a year, which is almost the price of a pump.

Brown: Yeah, that sounds a little expensive. I think they said $10 a day on their earnings call, so that’s about $3,600 a year. I mean, an advantage they have is no receiver — so, with the Dexcom you have to buy the receiver when you get it. With Eversense there’s — and you can use an app for the Dexcom, but you have to buy the receiver. With Eversense, there’s no approved receiver, so the only way to use it is phone. So, that does pull out one piece of the cost. And as I said since it’s only one sensor instead of — if you’re using the Dexcom that’s 36 sensors a year, right, 10 days a sensor. If you’re using Eversense that’s four sensors a year. And when they get to 180 that’s two sensors a year. And when they get to a year, that’s one sensor. And so, they can spread out the pricing over fewer items and I think hopefully that will help them drive it down.

Freed: Well, they should have the six months sensor very soon because it’s available in Europe. It’s not like they have to reinvent the wheel.

Brown: Let’s hope not.

Freed: So, what’s the most exciting thing that you’ve seen here that you feel is going to have a great future?

Brown: Couple of things. One is just closed loop systems, I think where there’s one on the market, the Medtronix 670G. A lot of people like it. Some people, it’s not a fit for them. And we’re seeing a slew of commercial products starting to make it close to pivotal studies or getting into pivotal studies. Insulet presented exciting data here on their OmniPod Horizon which looks really great. And I think we’re just going to see more and more of – Tandem got approval for their Basal-IQ on Thursday which is a predictive low glucose suspend system and they actually got it with the Dexcom G6. So, FDA made a really — even though it started with G5, FDA said, “You know what, it’s similar to G6. We’ll approve it with G6.” And so, now we’re not going to see this annoy lag time between the sensors. So, I think closed loop is going to be really exciting for people who are able to access it and willing to do that. And then, just seeing CGM continue to get better and better in terms of the — not only the hardware that you wear on your body but actually the software around it, and the prompts, and the analysis, and also getting it to providers. So, one of the things we saw approved earlier this week was the DreaMed Gluco Advisor Pro. You come in as a person with diabetes. You’re wearing a pump and a CGM. The software crunches all your data, gives the provider recommendations on how to change the pump’s settings to optimize your basal carb ratio, insulin sensitivity factor, and then the providers sends it to the patient’s mobile app, and that’s it. And so, I think for people about five, ten minutes with a patient, being able to get that kind of decision support, it’s going to be awesome.

Freed: What was the name of that?

Brown: That’s the DreaMed Gluco Advisor Pro.

Freed: And that’s from who?

Brown: It’s made — the algorithm is from DreaMed, Gluco is commercializing it.

Freed: Oh, Gluco.

Brown: Yeah, yeah, yeah. And it was cleared on Monday, so they’re going to start rolling it out, I think, later this summer.

Freed: So, CGM has basically changed the world of diabetes. And you had mentioned, which I think is kind of curious, using a CGM for prediabetes. And it only makes sense that if a person was to wear it with prediabetes, they would change their eating habits. I mean, without a doubt — because most people would think that corn is a vegetable and it’s good for you. (Laughs)

Brown: Totally. Orange juice, it’s fruit, right? (Laughs)

Freed: People need a better understanding because when it comes to Diabetes in Control it’s all about knowledge and education.

Brown: Totally.

Freed: So, where you get cancer, hopefully you get a good oncologist and you can cure it. With diabetes, there’s no medicine in the world that’s going to take care of your blood sugars and you can eat whatever you want.

Brown: Exactly.