Tyler Wins!!!!

“rtCGM was superior to SMBG in reducing A1C, hypoglycemia, and other end points in individuals with T1D regardless of their insulin delivery method. rtCGM+MDI can be considered an equivalent but lower-cost alternative to sensor-augmented insulin pump therapy and superior to treatment with SMBG+MDI or SMBG+CSII therapy.”

This is the conclusion from a study published in the latest issue of Diabetes Care. The study called Glycemic Outcomes in Adults With T1D Are Impacted More by Continuous Glucose Monitoring Than by Insulin Delivery Method: 3 Years of Follow-Up From the COMISAIR Study involved 94 adults with type 1 diabetes. All participants were at least 18 years old, had diagnosed type 1 diabetes for a minimum of two years, and had A1c levels between 7% and 10% at the beginning of the study.

The research subjects were assigned to one of four different treatment groups:

• CGM + MDI (multiple daily injections)

• CGM + insulin pump

• SMBG (self-monitoring of blood glucose) + MDI

• SMBG + insulin pump

Now we have long known that CGM is superior to SMBG but what really caught our eye was “rtCGM+MDI can be considered an equivalent but lower-cost alternative to sensor-augmented insulin pump therapy”. Something we have been stating consistently and the reason why Tyler is a serious threat to future growth in the insulin pump market. While we didn’t need a study to validate what we have long known but it sure drives this point home. It also provides the cover payors need to design reimbursement policies which favor Tyler over more expensive sensor augmented insulin pumps.

Although we are not attending EASD this year it is clear by the news flow that this show is all about Tyler. A system every insulin company has to have and a system which will drive even greater CGM usage. As we have noted all the insulin pump companies yes all of them better get their head out of the sand and develop a Tyler of their own.

About the only insulin pump company who isn’t in desperate need of a Tyler is Insulet who thanks to their move into the pharmacy may be the only insulin pump company somewhat immune to Tyler’s impact. It will be interesting to see whether this immunity is strengthened when the Horizon system arrives. Tyler will still be cheaper than the Horizon however an argument can be made that it is more patient friendly than a Tyler.

Given the coming of the Control IQ from Tandem we see Medtronic in more desperate need of a Tyler than Tandem as the Control IQ is going to eat the 670G for lunch in terms of performance. Should Tandem find a way to break through with payors and get to a level playing field with Medtronic it’s game over for the Evil Empire.

This study although not directed at Livongo or OneDrop is just further confirmation that these so-called way cool whiz bang systems aren’t so why cool or whiz bang given they are using old outdated technology which is according to the study delivers inferior outcomes. As the study concludes “rtCGM+MDI can be considered an equivalent but lower-cost alternative to sensor-augmented insulin pump therapy and superior to treatment with SMBG+MDI or SMBG+CSII therapy.” Or put simply Tyler wins in terms of delivering the most cost-effective outcomes.

The bottom line here is just that the bottom line as this study along with others have basically concluded how the insulin is delivered is irrelevant, what’s more important is an accurate, reliable CGM, which when you think about it rules out Medtronic completely and just strengthens the hands being played by Dexcom and Abbott.

The real scary part here is the study DID NOT look at a real Tyler, for a real Tyler includes an insulin dosing algorithm. It’s reasonable to conclude that when an algorithm is added to the mix the results seen for patients using a CGM/Connected Pen/Insulin Dosing Algorithm a real Tyler will be superior to CGM + MDI. Not like payors will need more reasons to favor the lower cost Tyler over sensor augmented pumps.

While we continue to believe the insulin companies will own the Tyler market it is also reasonable to conclude that a company like Dexcom could come out with a Tyler of their own using a biosimilar short-acting insulin making money on the continual sale of sensors and basically breaking even on the continual sale of insulin and the one-time sale of the connected pen or pens.

It also makes one wonder why Abbott did their deal with Sanofi when their partner Bigfoot supposedly has a Tyler ready to go. Just as Dexcom could develop their own Tyler with a biosimilar short-acting so too could Abbott as like Dexcom all they really care about is the continual sale of sensors.

This is what will make the Tyler market so interesting for as we noted the other day right now everyone is playing nicely in the sandbox. The insulin companies want to sell more insulin, the sensor companies want to sell more sensors. However history tells us this peaceful coexistence will not last forever especially with biosimilar short-acting on its way. At some point one of the kids is going to kick sand in the face of another and what was a peaceful coexistence will become every man for himself.

Ultimately the real winners here are Abbott and Dexcom as they are only sensor companies who can produce accurate reliable sensors on a massive scale. As good as things are now for both the coming of Tyler will only throw gas on an already raging fire. Let the good times roll.