Journal of Diabetes <scp>NEWS</scp>

Nina A. Ran 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 Ran and Close review the latest developments relevant to researchers and clinicians. Readers of the 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 ([email protected]). The 2nd China Congress on Controversies to Consensus in Diabetes, Obesity, and Hypertension (CODHy China) took place in Shanghai from 9 to 11 May 2013 and attracted approximately 300 attendees, most of whom were international. Dr Ning Guang (Shanghai Institute of Endocrinology and Metabolic Disease, Shanghai, China) commenced the meeting with a warm welcome to all international attendees and emphasized the importance of a conference in China. Referring to the growing epidemic of non-communicable diseases, including China's 10% diabetes prevalence, Dr Ning remarked, “It's our responsibility to target these diseases and we need more communication with the rest of the world. This meeting is thus very important to us.” Throughout the conference, speakers outlined the burden of diabetes and its comorbidities in China. Dr Ning noted that Asia includes five of the top 10 countries with the greatest number of people with type 2 diabetes: China, India, Japan, Indonesia, and Bangladesh (the other five are the US, Russia, Brazil, Mexico, and Egypt). He highlighted that China specifically has a prevalence rate of 9.7% for both type 1 and type 2 diabetes, which to him suggests that the disease poses a significant danger. Dr Jie Hong (Shanghai Institute of Endocrine and Metabolic Disease, Shanghai, China) stated that although people tend to think of obesity as mainly an American epidemic, as of 2008, 1.46 billion adults (1 in 10 adults) were overweight globally. China has also experienced a rising disease prevalence: as of 2010, 33% of the Chinese population was overweight or obese, a significant increase from 15% in 1992. In describing the main weight loss strategies in China, Dr Hong cited diet modification, pharmacotherapy, traditional Chinese medications (e.g. acupuncture and massage), and bariatric surgery. His label of bariatric surgery as an “unconventional therapy” reflected the low prevalence of such surgeries in China. In a panel discussion on diabetes drug algorithms and target HbA1c levels, speakers illustrated the challenge of treating China's large population of diabetes patients. Dr Paolo Pozzilli (Campus Bio-Medico University of Rome, Rome, Italy) noted that Chinese doctors often see 100 patients a day, a comment that was confirmed by several other panelists. In general, the speakers remarked that the high volume of patients, along with low levels of patient education, made it harder to tailor the treatment algorithm to each person. In discussing future solutions, both Dr Kumar Ajay Kumar (Diabetes Care & Research Centre, Patna, India) and Dr Ning emphasized the importance of using other types of healthcare providers (dieticians, nurses, junior doctors, and social workers) to support doctors and patients. Dr Pozzilli stated that patient empowerment is as important as personalized medicine, noting that rather than press their views onto patients, physicians should give patients the tools to increase adherence and decide themselves how different medications fit their lifestyles. The panelists spoke favorably about using the position statement written jointly by the American Diabetes Association and the European Association for the Study of Diabetes (ADA/EASD).1 Dr Ning mentioned that the Chinese Endocrine Society follows the ADA/EASD guidelines quite carefully, and favors the consensus because it stratifies risk by HbA1c level. Other speakers, such as Dr Kumar, pointed out that the ADA/EASD guidelines omit certain medications that are popular in Asia, such as α-glucosidase inhibitors. He explained that although the ADA and EASD include various options, such as incretin therapies, 90% of his patients cannot afford a dipeptidyl peptidase-4 (DPP-4) inhibitor and 70% cannot pay for a glucagon-like peptide-1 (GLP-1) agonist, leaving him to prescribe sulfonylureas to most patients. Dr Pozzilli provided a European perspective for comparison, noting that patients in the UK and Italy are limited not just by the price of therapies, but by government policies: for example, physicians must demonstrate to the government that a patient is unable to achieve an HbA1c below 7.5% for 6 months while on metformin before they can prescribe a DPP-4 inhibitor. Several speakers highlighted the importance of specific therapies in China. Dr Linong Ji (Peking University, Beijing, China) asserted that short-term intensive insulin treatment could lead to remission and improved long-term glycemic control without medication in some type 2 diabetes patients. Although pumps are typically used to treat patients with type 1 diabetes and long-standing type 2 diabetes, Dr Ji posited that people with newly diagnosed type 2 diabetes could benefit from short-term insulin pump therapy. Dr Ji cited data from The Lancet showing that after 1 year of follow up, the remission rate was higher for insulin pumps (51%) compared with multiple daily injections (45%) and oral antidiabetic agents (27%).2 Dr Dajin Zou (Changhai Hospital of Shanghai, Shanghai, China) emphasized the growing importance of DPP-4 inhibitors in China, noting that the Chinese guidelines now officially recommend this drug class as second-line therapy after metformin. In arguably the most pointed recommendation of the conference, he championed the use of Novartis' Galvus (vildagliptin), which he favors because of its efficacy, low risk of hypoglycemia, weight neutrality, and cost-effectiveness. Dr Zou noted that the total average cost of vildagliptin/metformin dual therapy is CNY 124 892 (∼US$20 321), which, surprisingly, is on par with the cost of metformin/pioglitazone therapy (CNY 126 610 or ∼US$20 601) and metformin/glimepiride therapy (CNY 134 135 or ∼US$21 825).3 This stands in contrast with with the US, where both pioglitazone and glimepiride would be far less expensive than a DPP-4 inhibitor because they are generic. Dr Zou cited data from the UK Prospective Diabetes Study (UKPDS) outcomes model4 that showed that the combination of vildagliptin and metformin increases quality-adjusted life years (QALYs) for Chinese patients by 11.02 years; as a comparison, patients would experience an average increase in QALY of 10.96 years with metformin plus pioglitazone and of 10.90 years with metformin plus glimepiride. Dr Zou remarked that, compared with the other two combination therapies, the combination of vildagliptin/metformin will improve health outcomes and lead to cost savings in China in the long term. After opening his presentation in Chinese, which garnered a round of applause from the audience, Dr Bloomgarden (Mount Sinai School of Medicine, New York, NY, USA) discussed the new diabetes comprehensive treatment algorithm published by the American Association of Clinical Endocrinologists (AACE).5 The guidelines recommend metformin as the first-choice therapy, and then rank GLP-1 agonists, DPP-4 inhibitors, and α-glucosidase inhibitors as equal second-choice agents, standing above thiazolidinediones (TZDs) and sodium glucose transporter 2 (SGLT-2) inhibitors. Dr Bloomgarden cautioned against the use of sulfonylureas, pointing to their high risk of adverse events. His presentation centered on GLP-1 agonists, which in his view have come to the forefront of therapy. He highlighted that GLP-1 agonists improve β-cell function and insulin secretion, suppress glucagon secretion, and are very efficacious when combined with a basal insulin. Turning to safety concerns, he posited that diagnosis bias may explain why GLP-1 agonists have been associated with an increased risk of pancreatitis in only hospital patient studies, not epidemiological studies. The 2nd CODHy China featured valuable discussion on the state of diabetes in China and illustrated the importance of international collaboration in stemming the growing tide of diabetes worldwide. Greater understanding of the pathophysiology and treatment of diabetes in different countries will hopefully result in smarter, more individualized therapy and allow physicians to harness best practices from across the globe. If you are interested in receiving the full Close Concerns report on the 2nd China Congress on Controversies to Consensus in Diabetes, Obesity, and Hypertension, please email Kelly Close ([email protected]).

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