New diabetes technology and other innovations have revolutionized type 2 diabetes control. Here are highlights of some noteworthy breakthroughs

In a few short decades, type 2 diabetes research and technological breakthroughs have brought about significant advancements in how the condition is treated and managed. Here are some of the top innovations that are helping people with type 2 diabetes better manage the condition today.

1. Insulin Pumps The first insulin pump came on the market in 1974. Previously, insulin pumps were only approved for use in those with type 1 diabetes. But if you have type 2 diabetes and have to inject insulin multiple times a day, a pump is an alternative to self-injection. “An insulin pump is a medical device that delivers insulin into the tissue just underneath the skin,” says Megan Porter, RD, CDCES, a certified diabetes educator in Portland, Oregon.

This computerized device, which is about the size of a deck of cards, can be worn around your waist, put in a pocket, secured with an armband, or attached to a belt or bra. “Some pumps deliver the insulin continuously, and others only deliver the insulin at meals or large snacks,” adds Porter. An insulin pump can also be more convenient if you’re out or at work, because all you may need to do is push a button to deliver the insulin instead of giving yourself a shot.

2. Continuous Glucose Monitors (CGMs) These devices have a tiny sensor that is placed below the surface of the skin to measure the amount of glucose in the fluid between cells every few minutes and transmit the data wirelessly to a device or your smartphone. 

CGMs are a game-changer: Unlike glucose meters that require a drop of blood to check what your blood glucose levels are at that moment, CGMs monitor your levels at set times throughout the day, such as every five minutes. This can help you and your doctor identify patterns and trends that may be helpful in fine-tuning your type 2 diabetes treatment plan to optimize management, according to the American Diabetes Association (ADA). These devices can also alert you when your glucose level is too low or too high.

The first CGM, which involved wearing a device provided by the doctor for two weeks or less and then returning it to the clinic or hospital, was approved by the U.S. Food and Drug Administration (FDA) in 1999. Since then, CGMs have become increasingly accurate and much more widely available for home use. In the past five years, there have been even more advances in CGM therapy. In 2018, the FDA approved the first implantable CGM device, which can be worn up to three months without changing the sensor, for people with type 1 or 2 diabetes. 

“The benefit of using a CGM is that it can be worn for seven or more days, which means one poke to insert the monitor [during that time frame] replaces checking blood sugars via a finger poke three or more times per day,” Porter notes. CGMs make it easier to check your blood sugar before and after meals, and they can help you understand how your diet, activity, and lifestyle affect your blood sugar levels.

3. Connected CGM-Insulin Pumps Another option available is a combination CGM-insulin pump, which enables the pump to use the data from the CGM to suggest changes in medication dosing or make necessary adjustments on its own. In 2020, the FDA approved an integrated CGM, which allows it to be connected to other diabetes management devices, such as insulin pumps and blood glucose monitors.

This integration of devices can help improve type 2 diabetes management by quickly reducing blood sugar and minimizing the amount of time you experience unsafe and unhealthy blood sugar levels.

4. Diabetes Medications Although insulin has been used in the United States since the 1920s, according to the FDA, today’s medications can be far more targeted for specific diabetes issues. 

Metformin, which belongs to a class of medications called biguanides, is often the first medication prescribed for type 2 diabetes. “Metformin decreases glucose absorption from food and decreases liver production of insulin,” says Porter. Other options, including oral medications and noninsulin injectables: 

• Sodium-glucose cotransporter-2 (SGLT2) inhibitors are oral medications that lower blood sugar levels by preventing the kidneys from absorbing glucose.
• Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are injectable medications that help you control appetite and blood sugar levels. 
• DPP-4 inhibitors, also called gliptins, are oral medications that help manage diabetes in several ways, such as by enhancing insulin secretion, slowing down digestion, and decreasing appetite, which can help with weight loss. 
• Thiazolidinediones, also called glitazones, are oral medications that help make your body’s tissues more sensitive to insulin.
• Sulfonylureas are oral medications that increase the release of insulin from your pancreas.
• Meglitinides are oral medications that help your body make more insulin around mealtimes.
• Alpha-glucosidase inhibitors are oral medications that help your body digest sugar more slowly.
• Combination therapies join multiple drug classes in a single medication. They may be injected or taken orally.

“And, of course, insulin is still used as a replacement when a person’s body does not create enough insulin on its own,” Porter adds.

5. Insulin Innovations Insulin has come a long way since it was first discovered. It now comes in a variety of forms, including rapid-acting, long-lasting, and premixed formulas, and can be delivered via a number of methods, such as syringes, pumps, and pens. And innovations are still coming. For instance, there are now insulin pen devices that can remember the last dose and the time that it was given, which is especially helpful if you’re busy or tend to forget to take it. Smart insulin pens have many of the features of insulin pumps but cost less and don’t have to be attached to your body. 

According to the ADA, smart insulin pens can connect to your smartphone or watch and link to diabetes data-tracking platforms to help you accurately calculate each dose based on factors such as your blood sugar level, carb amounts, meal size, and other parameters prescribed by your doctor. These devices can also remind you to take your dose, keep track of the amount of each dose, and tell you when your insulin has expired.

6. Easier-to-Use Glucagon Glucagon is used in emergencies to treat very low blood sugar, or hypoglycemia, a dangerous condition that can lead to confusion, loss of consciousness, seizures, and even death, according to the National Institute of Diabetes and Digestive and Kidney Diseases.

Glucagon injections have been available for more than 20 years, but in the past few years, devices such as injectable pens and glucagon that can be inhaled have made it much easier for you — or your family or friends — to administer glucagon in the event of an emergency.

7. Better Support for People With Diabetes In the past, many people with type 2 diabetes were treated by their primary care physician — rather than an endocrinologist, who is trained to treat diabetes — who may not have had any special training in the complexities of type 2 diabetes management. Today, there are many specialists who can help. Since the 1980s, certified diabetes educators have transformed diabetes management, according to the ADA. These professionals, who are now called certified diabetes care and education specialists (CDCES), take a comprehensive approach to teaching diabetes management and specialize in educating and supporting those with diabetes to optimize their health.

Diabetes educators can also connect you to dietitians, physical therapists, and mental health experts trained to help with the condition. “Hopefully, over time, more people with chronic conditions, such as diabetes, will be referred out to other healthcare professionals who can help them manage their condition physically and mentally,” Porter says.

8. Diabetes Smartphone Apps Yes, there’s an app for that — many of them, in fact. Nowadays, diabetes apps can track your blood sugar levels and show trends; monitor your diet and suggest recipes; log your exercise; and provide support from other people with diabetes. “Coaching apps can also give you access to highly trained diabetes educators and fitness coaches,” Porter says.

But it’s important to check with your doctor, CDCES, or other trusted diabetes health professional before you choose an app. An article in the journal Diabetes Care noted that there isn’t sufficient evidence to back up the effectiveness, accuracy, and safety of many apps, and many are plagued by technical problems. The authors noted that regulatory agencies and app companies urgently need to work with diabetes health professionals and researchers to ensure the safety and effectiveness of diabetes apps.

9. Meal Delivery Services While they weren’t developed specifically for diabetes, meal delivery companies that offer healthy foods and recipes have become very popular over the past several years. Now, many companies provide diabetes-friendly meal kits if you want to eat healthy but don’t want to do a lot of food shopping and planning.

Details of the Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Outcome Results—A Long Term Evaluation (LEADER) trial of the glucose-lowering drug liraglutide (Victoza, Novo Nordisk), showing that it significantly reduced the rates of major adverse cardiovascular events in type 2 diabetes patients at elevated cardiovascular risk, were reported today.

The study is the second such mandated FDA cardiovascular safety study for a diabetes drug to show cardiovascular benefit, rather than just lack of harm, on top of standard therapy in type 2 diabetes patients at high cardiovascular risk after the EMPA-REG trial, and the first with an agent from the glucagonlike peptide 1 (GLP-1) receptor agonist class. Results of a previous trial with another GLP-1 agonist, ELIXA, were neutral.

Experts here said that LEADER and EMPA-REG may now begin to change the landscape of diabetes therapy, giving doctors a somewhat clearer choice when deciding which drug to use second line after metformin in type 2 diabetes.

The results from the multicenter, international study were presented June 13, 2016 here at the American Diabetes Association (ADA) 2016 Scientific Sessions and were published online simultaneously in the New England Journal of Medicine, by Steven P Marso, MD, of University of Texas Southwestern Medical Center, Dallas, and colleagues.

LEADER began in 2010 and followed 9340 high-risk adults with type 2 diabetes for 3.5 to 5 years, who were randomly assigned to receive either a subcutaneous injection of liraglutide 1.8 mg once daily (or the maximum tolerated dose) or placebo along with standard treatment.

The primary end point was the first occurrence of the three-point major adverse cardiac event (MACE) components: cardiovascular death, nonfatal myocardial infarction (MI), or nonfatal stroke.

The degree of risk reduction for MACE was 13% (occurring in 608 of 4668 patients taking liraglutide) vs 14.9% (in 694 of 4672 taking placebo) (P = .01 for superiority), including a 22% lower rate of cardiovascular death (4.7 vs 6.0%, P = .007), Dr Marso reported in a press briefing held at the ADA meeting in advance of a special 2-hour symposium devoted to the findings.

The number of patients who would be needed to treat to prevent one event in 3 years was 66 for the MACE composite and 98 for death from any cause.

Liraglutide also reduced HbA1c, body weight, and hypoglycemia, and its safety profile was similar to what has been seen in previous trials, with gastrointestinal adverse events and increases in heart rate being the most common.

New Trials Inform Clinical Choice of Second Drug for Type 2 Diabetes

Coming on the heels of the cardiovascular benefit seen for the sodium glucose cotransporter-2 (SGLT-2) inhibitor empagliflozin (Jardiance, Boehringer Ingelheim/Lilly) in the EMPA-REG trial, the LEADER findings have experts talking about a “new era” in the management of type 2 diabetes.
While most agree that metformin remains the first-line drug of choice, these new landmark study data are starting to better inform the clinical choice of second drug based on characteristics beyond their glucose-lowering capacity, speakers said during the press briefing.

“In type 2 diabetes, most of us agree that under most circumstances metformin is the drug of choice,” briefing moderator Robert H Eckel, MD, of the University of Colorado, Denver, said, noting that additional potential cardiovascular and also anticancer benefits have been seen with that drug as well.

However, he said, “It’s interesting, with LEADER the benefit for cardiovascular death is very similar to what statins do. I think with validation, it could potentially change practice….I’d like to see second and third trials for both [liraglutide and empagliflozin]. Keep in mind there are 25 or 30 trials for statins showing benefit,” said Dr Eckel, who was not involved in LEADER or EMPA-REG.

Senior investigator of LEADER, John Buse, MD, of the University of North Carolina, Chapel Hill, added: “I think this changes the conversation with patients. Now, instead of just saying we’re giving you this drug to manage your hyperglycemia in diabetes, [we can say] this drug also has the potential to modify your risk for cardiovascular disease and death.

“It was beyond our expectations that we would be able to demonstrate cardiovascular efficacy,” he told the press briefing.

Asked to comment, Simon Heller, MD, professor of clinical diabetes, University of Sheffield, United Kingdom, toldMedscape Medical News, “I think we are in a different era now. People die from hypoglycemia, whether by insulin or sulfonylureas. We shouldn’t forget that.

“These drugs [liraglutide and empagliflozin] don’t cause hypoglycemia and have other effects that may be beneficial. I agree absolutely we need to confirm with other studies, but I think we’re definitely going to see a shift toward modern therapies.”

Benefits Seen for Multiple Cardiovascular End Points

The LEADER trial included patients with type 2 diabetes who had HbA_1c levels of 7.0% or higher. Entry criteria were either age 50 and above with established cardiovascular disease or chronic renal failure or age 60 and older with CVD risk factors.

Dr Robert H Eckel on podium; left to right, Drs Simon Heller, John Buse, Steven P Marso, and Bernard Zinman

Patients could be drug-naive or taking oral agents or basal insulin but not other GLP-1 agonists or DPP-4 inhibitors, pramlintide, or rapid-acting insulin. In both treatment and placebo groups, current standards of care were targeted for HbA_1c, blood pressure, lipids, and antiplatelet therapy.

Subjects had a mean baseline age of 64 years, diabetes duration 13 years, and HbA_1c 8.7%.

At 36 months’ postrandomization, HbA_1c levels were 0.40 percentage points lower in the liraglutide group, a significant difference (P < .001). Body weight also dropped significantly, by 2.3 kg (P < .001).

Overall, results for each of the components of the composite primary MACE outcome were in favor of liraglutide, with a 22% reduction in cardiovascular death (4.7% vs 6.0%, P = .007), which was significant, and a nonsignificant 12% reduction in nonfatal MI (6.0% vs 6.8%, P = .11) and an 11% lower rate of nonfatal stroke (3.4% vs 3.8%, P = .30).

Also significant were a 15% reduction in all-cause death (8.2% vs 9.6%, P = .02) and an expanded composite CV outcome that included coronary revascularization, unstable angina, or hospitalization for heart failure (20.3% vs 22.7%, P = .005).

Hospitalization for heart failure itself was 13% less frequent in the liraglutide group (4.7% vs 5.3%, P = .14). Although not statistically significant in terms of benefit, the lack of any signal for concern with regard to heart failure is noteworthy, Dr Marso said. “There has been a lot of discussion in the incretin space about whether agents such as SGLT2 inhibitors, DPP-4 inhibitors, or GLP-1 receptor agonists are neutral, hazardous, or beneficial for heart failure.”

He added: “What’s striking is the consistency in the relative risk reduction in all of the major cardiovascular end points that we measured in LEADER.”