Journal of Diabetes News

Manu V. Venkat, Rajiv R. Narayan, and Kelly L. Close are of Close Concerns (http://www.closeconcerns.com), a healthcare information company focused exclusively on diabetes and obesity care. Close Concerns publishes Diabetes Close Up and Closer Look, periodicals that bring together news and insights in these areas. Each quarter, the Journal of Diabetes includes this News feature, in which Venkat, Narayan, and Close review the latest developments relevant to researchers and clinicians. Readers of Journal of Diabetes involved in the clinical care of patients with diabetes (including students and educators) may request a complimentary 1-year subscription to Close Concerns' monthly newsletter, Diabetes Close Up (kelly.close@closeconcerns.com). Although ostensibly “American”, the 73rd Scientific Sessions of the American Diabetes Association (ADA) in 2013 featured contingents from Brazil, Japan, India, China, and Canada (in decreasing order of attendance). A tremendous 17 890 attendees converged at the McCormick Convention Center in Chicago (IL, USA) to take on the global diabetes epidemic. Front and center among the hundreds of talks at ADA 2013 were those that showcased data from closed-loop outpatient trials, which are quickly becoming the norm in the development of the artificial pancreas (AP). Dr Revital Nimri (Schneider Children's Medical Center of Israel, Petach Tikvah, Israel) presented data from the DREAM 4 closed-loop trial, which compared overnight glycemic control with the MD-Logic AP (MDLAP) (Schneider Children's Medical Center, Petach Tikvah, Israel) system to that achieved using sensor-augmented pump control in patients' homes. Among the intent-to-treat study population (n = 44), MDLAP significantly decreased the time spent in hypoglycemia (blood glucose [BG] <70 mg/dL; 2.9% vs 5.6%; P = 0.02) and increased the time spent in range (BG 70–180 mg/dL; 81.5% vs 73.6%; P = 0.01). Even less complex closed-loop systems were shown to have a marked impact on patient outcomes. In what Dr Hans DeVries (University of Amsterdam, Amsterdam, The Netherlands) labeled “the most important study at this whole meeting”, Dr Trang Ly (Princess Margaret Hospital, Perth, WA, Australia) and her research group compared low glucose suspend (LGS) with the Paradigm Veo (Medtronic, Minneapolis, MN, USA) to pump-only therapy over a 6-month period in 95 patients with hypoglycemia unawareness. The LGS system eliminated severe hypoglycemia without any resulting increase in HbA1c in any of the 46 patients in the Veo group, a rather impressive result. Progress for diabetes drugs was somewhat modest compared with the leaps seen in diabetes devices, but there were still a number of newsworthy developments. Elcelyx presented promising data on its extended-release metformin formulation (NewMet), which has the potential to overcome renal and gastrointestinal limitations that currently available metformin formulations face.1 There was a more in-depth discussion of sodium-glucose cotransporter 2 (SGLT-2) inhibitors at ADA 2013 than in previous meetings, perhaps because their efficacy and safety profiles have been better established. Notably, we saw early (and promising) data on the use of dapagliflozin and empagliflozin in patients with type 1 diabetes. Regarding incretin therapies, widely publicized concerns from the past year regarding pancreatitis and pancreatic cancer loomed large throughout the meeting. However, the general appraisal among the endocrinologists we heard from was that the clinical data available do not support taking patients off these drugs. This assessment is in line with statements made in the past year by high-profile organizations, including the ADA, International Diabetes Federation (IDF), and European Association for the Study of Diabetes (EASD).2 We noticed more companies venturing beyond metformin combination therapy into the branded combination therapy realm; although concrete data on these therapies are still somewhat sparse, what we have seen so far is impressive. The results for IDegLira (insulin degludec and liraglutide co-therapy) were some of the most compelling we saw at the conference: Dr John Buse (University of North Carolina, Chapel Hill, NC, USA) presented data from IDegLira's DUAL-1 Phase 3 trial, in which over 80% of patients taking IDegLira achieved the HbA1c goal of 7.0% or below. IDegLira was better than insulin degludec alone in terms of hypoglycemia (one-third less than with degludec) and weight (slight weight loss, instead of the weight gain seen with insulin degludec). Turning to treatment algorithms and strategies, Dr Ralph DeFronzo (University of Texas Health Science Center at San Antonio, San Antonio, TX, USA) investigated whether initial triple therapy (metformin plus pioglitazone plus exenatide twice daily) provided superior glycemic control to the conventional step-wise add-on method used by most providers and endorsed by the ADA–EASD joint position statement.3 Dr DeFronzo's study showed compelling results for the triple therapy approach (an average HbA1c of 6.0% after 24 months vs 6.6% in the conventional therapy arm from a baseline HbA1c of 8.6%; P < 0.001) and corroborated the advantages of addressing the pathophysiological defects underlying diabetes along with hyperglycemia. The study also raised several questions beyond the glycemic efficacy of these two treatment approaches, namely: (i) how relevant are the results now that prescriptions for pioglitazone and exenatide twice daily appear to be decreasing; and (ii) how can the results of the trial be replicated in a real-world setting? We were heartened to see that diabetes care in Asia received a good deal of attention during the conference. The China Medical Tribune hosted a full symposium on Chinese diabetes research, which featured Dr Zhao Liebin (Shanghai Jiao Tong University School of Medicine, Shanghai, China) and Dr Jin Li (Guangdong Diabetes Center, Guangzhou, China). To help determine a way to provide care in the face of a Chinese primary care system challenged by tremendous demand, Dr Liebin presented a study on collaborative, community-based care for patients with type 2 diabetes versus the usual care found in either the community or hospital. The 415 type 2 patients (60–80 years old; baseline HbA1c ∼7.0%) randomized to the collaborative care group were provided several forms of diabetes support, including guideline-based training, once-monthly telemedicine guidance, and a free blood glucose measurement at the clinic every month (this was their only blood glucose assessment because patients did not test at home). Those in the collaborative group exhibited lower HbA1c and blood pressure levels at 1 year compared with patients in the standard community programs, and also demonstrated improvements in blood glucose monitoring, healthy eating, foot care, and diabetes knowledge. Next in the symposium, Dr Jin Li reviewed preliminary results from a multicenter registration study characterizing the current status of type 1 diabetes in the Guangdong province of China. A low percentage (13.4%) of patients used insulin pumps, because most were on multiple daily injections (MDI) of insulin (50%) or took three or fewer injections per day (36.2%). Only 9% of patients achieved blood glucose, blood pressure, and lipid targets. We hope that this and other such registry studies can better characterize the Chinese type 1 diabetes population and ultimately improve patients' access to the tools they need to manage their diabetes. We were intrigued by a presentation by Dr Ronald Ma (Hong Kong Institute of Diabetes and Obesity, Hong Kong, China), who showed through a prospective 8-year cohort of 5264 Chinese patients with type 2 diabetes and no history of coronary heart disease (CHD) at baseline that the novel type 2 diabetes genetic variant 7q32 predicted new onset CHD. Patients with the 7q32 variant demonstrated an elevated risk of CHD (hazard ratio [HR] = 1.43 and 1.56 under the additive and recessive models, respectively). Given that the cardiovascular risks associated with type 2 diabetes and diabetes therapies is such an important topic, we would be very interested to see whether the 7q32 variant could predict the progression of CHD in other populations. Turning towards the Asian population living in the US, we were very pleased to hear Dr William Hsu (Joslin Diabetes Center, Boston, MA, USA) call for greater cultural inclusion and sensitivity in diabetes care. He hypothesized that the primary reason for the accelerated diabetes epidemic in many Asian populations is that they have greater amounts of visceral adiposity.4 Given this difference, providers may consider re-evaluating medications, diet, and exercise recommendations. Dr Hsu also cautioned against considering Asian Americans in aggregate, as doing so masks the unique challenges facing the many subpopulations of Asia. Although there was so much to learn from ADA 2013, we wish there were more substantive sessions on diabetes and obesity prevention, an enormously important issue in America, Asia, and elsewhere. We were also somewhat disappointed that many of the type 1 diabetes cure immunomodulatory therapies discussed at ADA 2013 failed to meet their primary outcomes. Nonetheless, we found ADA 2013 to be incredibly informative, and are already anticipating the 74th Scientific Sessions in San Francisco (CA, USA) next year. If you are interested in receiving the full Close Concerns report on the ADA's 73rd Scientific Sessions, please email Kelly Close (kelly.close@closeconcerns.com).

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