Dr. Jamie Rosenzweig Discusses Key Insights from The American Diabetes Association’s 75th Scientific Sessions

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James Rosenzweig

Mark Morrison, Director of Business Development, and I attended the American Diabetes Association 2015 Scientific Sessions, which were held in Boston June 5-9.  This is the most important meeting of the year specifically devoted to diabetes, and it attracted approximately 18,000 attendees.  The presentations, symposia, and posters contained much new scientific information on causes, pathophysiology, and epidemiology of diabetes, and there was extensive discussion of all the new medications and forms of treatment. Below are some of my key insights from the meeting.

James Rosenzweig, MD
Senior Director, Clinical Consulting

Incidence of Type 2 Diabetes Plateauing in Developed Countries, Yet Rising in Developing Countries

An important theme was that although we have made significant progress in the treatment of diabetes and reducing its complications, type 2 diabetes (T2DM) as a public health problem continues to grow to epidemic proportions.  According to Dr. Venkat Narayan, the Kelly West Award lecturer, “We are winning the diabetes battle, but losing the war.”  Incidence of T2DM is increasing massively, especially in developing countries like India, and it appears that individuals from these countries are much more susceptible to developing diabetes at much lower levels of weight or body mass index (BMI).  It appears that T2DM tends to occur in two phenotypes, one with significant insulin resistance and adiposity called type 2a, while another type 2b, largely unrecognized and unstudied, is probably driven by decreased metabolic capacity and reduced insulin secretion.  The type 2a phenotype is the one more commonly seen in the United States and the type 2b is what you see in the Indian subcontinent and probably parts of Africa and East Asia.  These are places that are emerging from centuries of undernutrition and poor living conditions.

Although the prevalence of diabetes may be plateauing in the US and Europe, global trends show a continuing rise in diabetes and a worsening public health problem.  The only way to stem the tide of rising diabetes numbers globally will have to be by focusing on prevention with screening of high risk groups, lifestyle changes, and perhaps medications—all within the context of creating community infrastructures to accomplish these goals.

New Classes of Diabetes Medications

There were a number of newer classes of medications for the treatment of diabetes that were discussed intensively.  These include the DPP-4 antagonists and GLP-1 agonists, which increase insulin secretion, and the SGLT2 antagonists, which increase excretion of glucose from the urine.  All of these have become significant parts of caregivers’ armamentarium for T2DM treatment, which now involves the combination of multiple complementary agents for optimal therapy. 

Are Antidiabetic Medications Increasing the Risk of Cardiovascular Disease?

Another important issue has been the question of the risk of cardiovascular disease that might be caused by the newer antidiabetic medications.  This had been brought to focus with an older class, the thiazolidinediones (TZD’s) for which questions of increased cardiovascular risk were raised in the past.  The FDA now requires extensive analysis of this problem, both before and after release of new medications.  At the conference, the results of two large multicenter trials were reported.  The ELIXA trial showed no increased cardiovascular risk with lixisenatide, a GLP-1 agonist, while the TECOS trial showed no increased cardiovascular risk with sitagliptin, a DPP-4 antagonist, in line with previous studies of other medications in that class, the SAVOR-TIMI and EXAMINE trials.  A small risk of pancreatitis was detected in TECOS, but this is probably not significant for clinical use of the medication. 

Scientific Advances for Understanding and Treating Diabetes

For type 1 diabetes, significant progress has been made in the understanding of the genetics of the disease, and potential biomarkers to predict T2DM are being studied.  There has also been progress in the development of an artificial pancreas through closed loop systems, in which a continuous glucose monitors actually regulate the rate of infusion of insulin (or insulin and glucagon) in subcutaneous pumps.  A key problem has been the prevention of hypoglycemia (low blood glucose) which can be very dangerous to children and adults. 

Additional Brief Insights from ADA

  • There have been advances in islet cell transplantation, including results from a multicenter phase 3 trial.
  • A symposium discussed the possible relationship between diabetes and cancer.
  • In a discussion of the relationship of hemoglobin A1c (A1C) to average glucose levels, it appears that there are racial differences.  African Americans tend to have higher levels of A1C than whites given the same levels of average glucose.  Nevertheless, this does not affect the utility of the test in clinical practice.
  • New medications are under study for the treatment of elevated cholesterol in high-risk patients. 
  • The value of some of the new insulins were debated.  These include Afrezza, a recently released inhaled form of insulin, and degludec, a long acting analog currently under development.
  • Investigators have discovered new factors that play a role in the activation of brown and beige fat, highly metabolic forms of fat that can increase energy expenditure and cause weight loss. 
  • The largest-ever web-based genetics portal for type 2 diabetes made its debut at this meeting.  The new portal, type2diabetesgenetics.org, allows users to investigate relationships between, genetic variants, type 2 diabetes, and related traits and conditions.
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