Dr Louise Johnson gives us a brief overview of what was presented at the European Association of the Study of Diabetes (EASD) Annual Meeting 2018.
From fear to hope
The meeting started with a lecture titled From fear to hope. The lecture was about Dr Banting who discovered the first insulin and moved through the history of insulin up until till where we are now with the second-generation basal (long- acting) insulin. Both insulin glargine U300 (Toujeo) and degludec insulin (Tresiba) are available in South Africa.
The new direction in diabetes with insulin is not only the HbA1c (average three-month blood glucose value) but also glucose variability. Glucose variability is the time spent within target range. This is established with the help of a continuous glucose monitor (CGM) sensor that measure blood glucose every five minutes and displays it on a screen or a cell phone app. Currently, there are five different CGM monitors available in South Africa.
The target range would be a variation of blood glucose between 5 and 10 mmol/L in a 24-hour period. The more time spent within this range, the less likely the appearance of complications.
The lecturer, Dr Rosenstock, showed data from Diabetes Care (2017, 40 :554) that correlates the time in range and the presence of retinopathy complications.
The BRIGHT study
The results of The BRIGHT study – the first head-to-head randomised clinical trial comparing the two new basal insulins: Toujeo and Tresiba – were released.
The results showed no difference in HbA1c over a 12-week period. The glucose variability between the two groups were the same.
It is important to remember with these second-generation basal insulins to only adjust the insulin dosage once every week, due to the long-onset of action. Toujeo is 32-hours and Tresiba is 42-hours. This gives the advantage of flexibility and less hypoglycaemia, especially at night time.
Diabetes – a diverse and heterogeneous disease
Another highlight was a talk, by Dr James Gavin III, titled Diabetes – a diverse and heterogeneous disease. The core message was that our current diagnosis of Type 1 and Type 2 are not correct anymore since there are a lot of overlapping. The importance of a diagnosis is to be able to predict, prevent complications, and plan correctly.
The new diagnoses are in clusters:
- Cluster 1 – Severe autoimmune diabetes (previously most of Type 1 diabetes). This has early onset of disease at a young age, relatively low BMI, poor metabolic control, insulin deficiency and the presence of auto-antibodies (GAD antibodies).
- Cluster 2 – Severe insulin deficient diabetes. This is early onset of diabetes with a relatively low BMI and poor metabolic control. There is low secretion of insulin but the auto-antibodies are negative.
- Cluster 3 – Severe insulin resistant diabetes (most of Type 2 diabetes fit in here). These patients have high insulin levels and a high BMI.
- Cluster 4 – Mild obesity-related diabetes. These patients are obese but not insulin resistant.
- Cluster 5 – Mild age-related diabetes. These are older patients that are not insulin resistant
The importance of the new diagnosis classification is to not only focus on blood glucose control but also on disease modification. It was also stressed to get blood glucose to target early in the disease and this will prompt the legacy effect. The body will remember the good control for years afterwards and prevent complications.
What is new on the drug scene?
The new wonder drug in the Type 2 diabetes arena is the class of drugs called sodium glucose co-transporter 2 inhibitor (SGLT2). This class works on the proximal (first) part of the kidney tubule and blocks the absorption of glucose back into the body. The result of this is glucose in the urine. But there is more:
- Three to six kg weight loss.
- Blood pressure reduction.
- Better blood glucose control.
- Most important is reduction in the mortality of heart attack and heart failure.
In South Africa, we have dapagliflozin (Forxiga) and empagliflozin (Jardiance).
There is a new drug in this class that is now being tested in Type 1 diabetes. It is called sotagliflozin and works mostly on the gut. It prevents absorption of sugar from the gut and improve glucose in Type 1 diabetes, especially after meals. This drug is still under investigation and is not available yet anywhere in the world. The preliminary data shows the same reduction in mortality.
Can Type1 diabetes use the SGLT2 class?
The two SGLT2 inhibitors, Forxiga and Jardiance, currently available in South Africa are not registered for Type 1 use. The reason is the increase in diabetic ketoacidosis(DKA).
DKA can be fatal if not picked up early and it’s not suggested for Type 1 diabetes. Rather wait for the appearance of sotagliflozin that works mainly on the gut.
Focus on other targets
During the meeting, it was reiterated that diabetic patients should not only focus on glucose control but also blood pressure target below 130/80mmHg, LDL cholesterol below 1,8 mmol\L and not smoke at all. Regular, light exercise was also emphasised. It was shown that if more of these goals are met, the cognitive improvement, especially in older individuals, is achieved.
Does pneumopathy exist?
The last day ask the question Does pneumopathy exist? Pneumopathy is the presence of lung disease without other factors, such as smoking or lung infection being present.
There are only 64 papers worldwide but there is enough evidence to show that a restrictive lung function pattern does exist in long-standing diabetes. The data showed an incidence of 25%. The best predictor for lung disease is the presence of kidney disease. The treatment currently seems to be good control and regular exercise to improve lung function.
The microbiota in diabetes
The final but most riveting session was: The microbiota in diabetes. The microbiota is the normal microorganisms that stay in the gut in the faeces (stool). It was shown how the organisms differ between disease states.
The current thought process is that the microbiome first change to that of Type 2 diabetes and only later does the blood glucose rise. This is a fascinating area since correct diets could have the potential to prevent diabetes. This is unfortunately still early days but keep your eyes peeled.
Healthy diet, especially if you or your loved ones do not have diabetes yet, is important. Plus, low blood pressure, low cholesterol, low blood glucose and regular exercise are important.
Talk to your healthcare provider about the new drugs and monitors.Remember that the scientists are working diligently around the clock to find to a cure!
MEET OUR EXPERT
Dr Louise Johnson is a specialist physician passionate about diabetes and endocrinology. She enjoys helping people with diabetes live a full life with optimal quality. She is based in Pretoria in private practice.