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Sodium-glucose co-transporter 2 (SGLT2) inhibitors are a new class of diabetic medications indicated only for the treatment of type 2 diabetes. SGLT2 is a low-affinity, high capacity glucose transporter located in the proximal tubule in the kidneys. It is proposed that in prehistoric times, we developed an elegant system for maximizing energy conservation and storage, due to lack of consistent food supplies.
Now that the majority of our type 2 patients have an adequate or most likely an over-abundant supply of glucose from the foods we eat this system is no longer necessary for survival and in fact contributes to increased weight and diabetes risk. Vaginal yeast infections and urinary tract infections are the most common side effects associated with canagliflozin with the greatest risk being in female patients and those men who are uncircumcised. There is also an increased desire to urinate and the medication is not indicated in patients with type 1 diabetes, or patients with frequent ketones in their blood or urine, severe renal impairment, end stage renal disease or patients receiving dialysis. Last Friday, I had the pleasure of attending the 2013 DiabetesMine Innovation Summit, an annual conference that assembles a diverse set of players in the diabetes space to discuss technology and innovation in diabetes care.
This year, one of the primary topics was how healthcare affects access to diabetes care, both in terms of achieving the existing standard of care, and in terms of making the best-in-class technology options available.
I will leave it to others to discuss the ins and outs and rights and wrongs of the payer discussion.
I recognize that this is a heretical statement in the middle of Diabetes Awareness Month, and from amidst a community of online advocates. Instead of getting offended when people don’t care enough, perhaps we should consider what does make people care about type 1 diabetes. I admit I have a libertarian bent, and I cringe at bureaucracies and cultivate a healthy distrust for the government. Payers are therefore not beholden to type 1 diabetics, or any other patient population for that matter. Social scientists like us for our online communities, and for our willingness to persist through questionnaires. From the medical device angle, we are willing to stick ourselves, hang things on our belts, wear multiple devices simultaneously, manage different brands that don’t talk to each other, and pay recurring costs for supplies.
On the biological side, type 1 diabetes is one of the most approachable potential uses of stem cell therapies, which makes us a hot topic in the stem cell field. We’re a small population, which makes software, apps, and other one-time purchases an unattractive market for many.
Type 1 diabetes may be a small market, but type 2 diabetes affects close to 25 million people in the US, and that number is rapidly increasing. As the smaller of the two populations, we type 1 diabetics stand to gain a lot from this overlap.
Thus, every time I hear type 1 diabetics complain about the fact that the general populace doesn’t know the difference between type 1 and type 2 diabetes, I flinch a little. Not many people have type 1 diabetes, but it’s not a rare or orphaned disease either.
On top of the many who end up working in the diabetes space, some of the people with connections to diabetes become philanthropists, and fund incredible research, care, and tools for type 1 diabetics. In sum, instead of getting indignant that no one cares about our teeny market, let’s appreciate the people who care about us at all, and figure out how to work with them so that they can serve us better.
We do hope that the conversations we’re opening up with Decision Makers via the Summit will make waves enough to impact ALL people with diabetes for the better. Rarely does a mandate reduce costs, as you stated in the article, payers are in business to make money.
Payers have to factor in the mandated coverages,  in doing so, it inevitably ends up being passed to the customers in higher premiums & deductibles.
The Diabetes Media Foundation is a 501(c)(3) tax-exempt nonprofit media organization devoted to informing, educating, and generating community around living a healthy life with diabetes. These substances are AT1-receptor antagonists – that is, they block the activation of angiotensin II AT1 receptors.


SGLT2 inhibitors block the reabsorption of glucose in the kidney, increase glucose excretion, and lower blood glucose levels. This system included reducing the activity of our neurological endocrine system to slow metabolism and conserve the stored energy in our bodies, as well as a method to increase reabsorption of excess glucose that was removed by the kidneys. The first of the defects was addressed in May of 2009 when Cycloset (bromocriptine mesylate rapid release) was approved by the FDA and now with the approval of Invokana (canagliflozin), Jardiance (empagliflozin), and Farxiga (dapagliflozin), we have medications to address the second half of this problem. At this time canagliflozin is the only drug in this class approved by the FDA for the treatment of type 2 diabetes. Patients should be advised to expect glucose to be in the urine and if they are using urine glucose strips that they will have a positive reading most of the time. This was my second year attending, and both times I have enjoyed the event, as DiabetesMine does an excellent job of bringing together thought leaders in the diabetes space to discuss the now and the next.
But, at the end of the day, I’m a pragmatist, and I was not offended by the conservative and self-interested stances of the payers. But there are certain things that the government is crucial for, and one of those is preventing the tyranny of the majority. Part of their warrant to sell health insurance is to offer coverage to sick people under certain conditions. Their goal is spend the minimum amount in order to provide the amount of care that balances my needs now with the potential costs they are obligated to in the future if my care is inadequate. Because the burden of the disease is high and constant, we are willing to spend money on devices that might be too cumbersome or inconvenient for many other people. In immunology, we represent an example of a complex autoimmune disorder with a relatively well-mapped genetic background, lots of biomarkers, an established animal model, and patients available for short- or long-term study. So if we want the field of type 1 diabetes science to progress, we have to ensure the research funding pipeline stays open, from non-profits like the American Diabetes Association and the JDRF as well as from the largest funder — the National Institutes of Health (NIH). But if you’re selling, for example, an insulin pump that costs several grand up front, and then generates recurring revenue of thousands of dollars a year, three million people is enough to be interesting.
Though the underlying causes of type 2 diabetes differ from those of type 1 diabetes, many of the symptoms overlap, and therefore companies and products that address one market often hope to work in both. A lot of great technology and choice comes to us from that overlap, and it helps keep us from becoming an obscure autoimmune disorder. We are three million strong, and we tend to be very engaged in our care and very vocal about our needs. Don’t begrudge payers their money, but convince them they can make more by giving us more tools.
It shows the problems associated with T1D (on both sides of the financial coin, payer & patient). I also think it’s great that the payers showed up at the summit, because I think they probably learned a lot from speaking with people who actually have the disease. Blockade of AT1 receptors directly causes vasodilation, reduces secretion of vasopressin, reduces production and secretion of aldosterone, amongst other actions – the combined effect of which is reduction of blood pressure.
They have been studied alone and with other medications including metformin, sulfonylureas, pioglitazone, and insulin….
Inhibition of SGLT2 leads to the decrease in blood glucose due to the increase in renal glucose excretion. The payers showed up for this conference, there are a number of successful companies serving primarily type 1 diabetics, and there is an entire research community around type 1 diabetes. Yes, we are a very small type 1 diabetic minority, but the government still has an obligation to ensure our rights as Americans.
Until recently, the conditions under which they covered type 1 diabetes were more limited, but, with the recent Affordable Care Act, the government has expanded the payers’ obligations to people with illnesses like type 1 diabetes. They are not evil or blind to the health needs of humans, but they can’t run their companies by catering to every demand for increased care. Type 1 diabetics tend to be very engaged in their disease by necessity, and we have a disease that generates tons of data.


This means manufacturers can design new instruments with new algorithms or interfaces, with multiple parts and needles, and we are happy to try them if they can give us better results.
That makes it both interesting and possible to build an entire research community around type 1 diabetes, and to attract new researchers into the field. Further, we need to stop complaining about how many times mice have been cured of diabetes. Case in point — there are a great number of companies trying to market new insulin pumps, and one of them, Tandem Diabetes, just raised $120 million in an IPO. By definition, diabetes is a condition in which blood sugars are elevated, and though there are many causes for that elevation, the fact that we all share that high blood sugar means we can benefit from some of the treatments designed for subsets of the whole group. Further, we have parents who are heroically dedicated to getting the best care for their type 1 children, and the daily burden of the disease means patients and parents together move mountains to get the care they need. As many words as I have, I don’t have any way to adequately thank the people who have given so much to cure a disease that affects so relatively few. Although the Affordable Health care Law (AHL) was supposed to reduce costs, it will only increase patient cost.
The mechanism of action of this new class of drugs also offers further glucose control by allowing increased insulin sensitivity and uptake of glucose in the muscle cells, decreased gluconeogenesis and improved first phase insulin release from the beta cells. Payers must serve their own self-interests and the interests of investors in order to survive. I am not a profit center for my health insurance company, but in order to gain the right to charge profitable patients, insurers have to take me along for the ride.
These qualities make us attractive to researchers, who are always hungry for people willing to participate in trials, or diseases with data to analyze.
That is part of science, and part of learning about each separate part of the complex puzzle that makes up diabetes. It is impressive how many of the people building new diabetes technologies or developing new treatments have a personal connection to type 1 diabetes. Be willing to pay for choice and options in our small market, and embrace the similarities between the flavors of diabetes that allow us to benefit from the type 2 market.
Similarly, I am not offended or surprised that medical device companies attempt to shield their data with proprietary formats. So instead of demanding care because we are owed it, or because it’s the human thing to do, we as type 1 diabetics need to work on the arguments that a better continuous glucose monitor now will save the payer some number of kidney transplants in the future. We should embrace the researchers who are interested in solving our problem, and accept that curiosity is a powerful driver. Finally, befriend all the payers and device manufacturers you can find, so that at the end of the day, they will think of type 1 diabetes not as just a small market, but as a burdensome disease with a face that looks like yours. As a relatively small market, we can’t expect the disinterested businessperson to care about us.
They have to cover us, and luckily our interests are arguably aligned– we both want to minimize adverse health effects. In that way, they will be more equipped and willing to put more time, energy, and people into research that benefits a measly 1% of the American population, and we will be the winners in the end. We gain leverage if we start from there instead of a point of expectation that they care about us as type 1 diabetics. We type 1s will use them, but the money that made that research possible comes from the promise of the type 2 market.
Even ignoring the fact that no one would expect 100% market penetration, that’s peanuts to the innovators and investors in the tech world.



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