DRWF Research Manager Dr Eleanor Kennedy blogs from the second day of the EASD conference.

The second day of the EASD conference is a busy one and I am facing some serious decisions. Do I attend the session on the treatment of diabetes with SGLT-2 inhibitors or the one on new insights into early onset type 2 diabetes? Or do I walk through the conference centre to hear more about diabetes-related complications like retinopathy and neuropathy?

Lower rates of hypoglycaemia in older people with type 2 diabetes

Instead, I opt for Reducing hypoglycaemia in patients treated with insulin. The familiar face of Professor Brian Frier kicks off proceedings at just after 8.30am and he reminds the early risers in the lecture hall that hypoglycaemia is not just an issue from those with type 1 diabetes.

In a study from Scotland, he demonstrates that, overall, whilst hypoglycaemic episodes (low blood sugar) are about three times more frequent in those with type 1 diabetes than in those with insulin-treated type 2 diabetes, hypoglycaemia in this latter group is still a problem.

Similarly, severe episodes are also about three times more common in those with type 1 diabetes but they are also reported in those with insulin-treated type 2 diabetes.

However, one issue that Professor Frier highlights is that the frequency of hypoglycaemia is older patients – most of whom have type 2 diabetes - is underreported and there have been very few systematic studies performed in people with diabetes over the age of 70 years old.

So why is this?

Well, there is often no enquiry made about hypoglycaemia at routine medical consultations and patients do not volunteer this information. Often, recall of non-severe hypoglycaemic events is poor with amnesia playing a part in this.

Treatment of severe hypoglycaemia by the emergency medical services is seldom reported to the patient’s clinician and many patients with type 2 diabetes and their relatives have limited knowledge of hypoglycaemia and its treatment and symptoms are age-specific and manifestations of hypoglycaemia may be attributed to other medical disorders.

In the knowledge that there is clearly still much research to be done in this area, I move to the results of two clinical trials – DECLARE-TIMI 58 and VERIFY.

The former investigated dapagliflozin, one of the impressive class of gliflozin drugs, and renal outcomes. Before this trial, we knew that dapagliflozin reduced major adverse cardiovascular events like stroke and myocardial infarction in people with type 2 diabetes as well as reduce heart failure in patients with atherosclerotic cardiovascular disease.

Jelly babies.

Clinical guidelines should be updated in line with latest research discoveries

However, this study, conducted in more than 17,000 patients with type 2 diabetes and established cardiovascular disease or multiple other risk factors, demonstrated not just reduced cardiovascular disease or hospitalisation for heart failure, it also improved renal outcomes in a broad population including in the elderly. The session ended with a call for existing clinical guidelines to be updated to include these new findings.

The Vildagliptin Efficacy in Combination with Metformin For Early Treatment of Type 2 Diabetes Study, thankfully shortened to the VERIFY Study, asked three pertinent questions:

  • Do those with type 2 diabetes benefit from having combined therapy at the beginning of their pharmacological treatment?
  • Do those with type 2 diabetes benefit more from having combined therapy at the beginning of their pharmacological treatment compared to a sequential additive strategy? and
  • Does it matter?

The primary outcome of early combination therapy for type 2 diabetes management in this study tells us that it can ensure earlier and better glycaemic control that may be more durable.

With the added benefits of a low risk of hypoglycaemia and with no increase in body weight the is the added possibility of improving patient adherence to treatment and of reducing clinical inertia and ultimately, therefore, of offering more opportunity to address individual patient needs.

The flip side of these results was that the assessment was only of one treatment option – metformin and vildagliptin - so, again, I see that, even from large clinical trials, the results always open up more questions that need to be addressed.

Ground-breaking research helping people with diabetes manage it more effectively

From there, I walk through this enormous conference centre to hear another of EASD’s prize lectures. This year’s EASD-Novo Nordisk Foundation Diabetes Prize for Excellence has been awarded to Professor Dan Drucker from the University of Toronto.

Professor Drucker’s work on gut hormones, in particular on GLP-1, has been ground-breaking and he leads us through a wide-ranging exploration of this molecule which has been one of those in the diabetes world that has made it from bench to bedside and is now an established part of the diabetes armamentarium.

It began decades ago with the discovery of GLP-1 but it progressed through basic research and into the clinic ultimately helping thousands of people living with the condition to manage it more effectively.

However, it is how Professor Drucker ends his talk that strikes me the most. “Look how far we have all come in the treatment of type 2 diabetes,” he says and he reminds us about an important anniversary.

Banting and Best

100 years since the discovery of insulin

Next year, it will be 100 years since the discovery of insulin – coincidentally also in Toronto, Canada.

Professor Drucker concluded: “This was the fundamental, seminal discovery that changed our concepts of clinical medicine in the 20th century.”

And he’s right. It is still the bedrock of diabetes treatment but there is now so much more that can be offered to patients.

Yes, there are still gaps in our knowledge, but it is privilege and an honour to be sitting here amongst those who are working tirelessly to fill in those pieces of this particularly complex jigsaw.

Read the report from Day One of EASD 2019 here
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