DRWF Research Manager Dr Eleanor Kennedy reports from the American Diabetes Association 79th Scientific Sessions in San Francisco, USA.
The second day of the congress dawns bright and, well, very early thanks to jet-lag!
However, knowing that there will be yet more excellent sessions on at the ADA conference buoys me as I stroll down Stockton Street and across Market Street which rattles to the sound of the city’s iconic trolley cars, on my way to the congress centre.
This year’s organising committee has chosen well and, like yesterday, they are focussing on debates between titans in their respective fields. And first up is a debate entitled “Challenging the importance of hypoglycaemia in type 2 diabetes – Serious or just hype”.
The chairwoman for the session introduces the two speakers as if introducing a boxing match. In the blue corner, weighing in is Professor Brian Frier, from the University of Edinburgh, whose soft Scottish lilt I have often heard as he is a veteran speaker on the diabetes circuit. And, weighing in in the red corner, is the equally eminent American expert in hypoglycaemia, Professor Philip Cryer.
The main issue, as Professor Frier delineates, is that hypoglycaemia in type 2 diabetes is frequently under-estimated and often under-reported thanks, in part, to the fact that no enquiry is made about hypoglycaemia at routine medical consultations and patients do not volunteer the information.
Poor recall of non-severe events muddies the water still further and, because symptoms are age-specific, manifestations of hypoglycaemia may be attributed to other medical disorders. But, that said, a large study, called a meta-analysis, of 46 real-word studies has shown that an individual with type 2 diabetes experiences, on average, one severe episode of hypoglycaemia per year i.e. an episode that requires external assistance.
Professor Cryer counters that hypoglycaemia is really only a complication of type 1 diabetes but, for Professor Frier, this does not necessarily hold true. Although only found in people with type 2 diabetes who are treated with insulin – or, to a lesser extent, sulphonylureas – this actually represents a much larger percentage of the diabetes population globally and so should be considered as a very real and serious problem.
The next session I attend is another debate involving arguably one of the best known names in the diabetes world, Professor David Nathan. Professor Nathan is the man most readily identifiable for his seminal work on the landmark Diabetes Control and Complications Trial.
This was, at the time, one of the largest trials of its day and the one that showed that intensive treatment of type 1 diabetes over the course of several years significantly reduces a person’s risk of the long-term complications of the condition and it was a trial that, to this day, is routinely quoted as being one of a handful of studies that have radically altered the way that healthcare professionals treat and manage their patients with type 1 diabetes.
Unfortunately, for Professor Nathan, he is up against the charismatic Professor Bruce Perkins.
The debate centres on the newest class of drug to enter the diabetes armamentarium – the SGLT-2 inhibitors. They are known for having quite spectacular effects in people with type 2 diabetes on glucose control as well as having cardiovascular and renal benefits. But should they be used in people with type 1 diabetes – “SGLT-2 inhibitor adjunctive therapy in type 1 diabetes mellitus – Is it worth it?”
Now, research studies have shown a number of side effects of these drugs in people with type 2 diabetes – urinary tract and genital infections are not uncommon and, with some members of the class, there is a signal for amputation. However, the biggest concern is the very real increased risk of diabetic ketoacidosis (DKA).
Professor Nathan argues his case well – he has a full house here and he argues the side effects very well. But Professor Perkins has an ace up his sleeve. He has type 1 diabetes. He knows what it is like to live almost his entire life with a condition that really only insulin is used to treat. As he thanks Banting and Best repeatedly for their discovery of insulin which has kept him alive, he argues passionately that people with type 1 diabetes need more than just insulin.
Using statins as a precedent, he explains that drugs that come from the type 2 diabetes world should be made available to people with type 1 diabetes where appropriate education can also be offered. The proven cardio-renal protection and metabolic benefits of this class of drug far outweigh the side effects and he says that patients and healthcare professionals can mitigate the risk of DKA and, more importantly, that people with type 1 diabetes want to have the choice of adjunct therapies and should not be denied them.
It is a funny, clever and informative debate and I have just watched two heavyweights slug it out over one of the most hotly contested topics in the world of diabetes at the moment. I know who won the debate. However, we will need to await the real world evidence before we know for certain if SGLT-2 inhibitors can be used safely and effectively in people with type 1 diabetes.
I finish the day at another debate. “Indications for Pancreas Transplant in the Era of Glucose Sensors and Insulin Pumps”.
Attending these kinds of conferences is always a privilege not least because we are often given access to people from very different worlds. Enter stage left a transplant surgeon who argues that pancreas transplant is a viable option for people with diabetes. Dr Silke Niederhaus speaks eloquently about how beneficial it is for people with diabetes to have a pancreas transplant – it allows people to feel that they “no longer have diabetes”.
But what she doesn’t realise is the tsunami of people with diabetes in the world! This is a very limited resource that requires a waiting list and, in addition to the obvious risk of surgery, there are significant cost implications.
Dr Jessica Castle, instead, offers an alternative solution – the artificial pancreas – arguing that this technology is not dependent on a scarce resource and does not require immunosuppression. She focusses on three groups in which the closed loop system has been trialled – young children and adolescents, hospitalised patients and pregnant women – and the results are impressive particularly in preventing nocturnal hypoglycaemia.
But, as with all debates, we are left with more questions than answers. Should hypoglycaemia in type 2 diabetes be more recognised? Should people with type 1 diabetes be offered SGLT-2 inhibitors as an adjunct therapy? Is the artificial pancreas a viable alternative to whole pancreas transplant?
I’m sure that the bars and restaurants of San Francisco will be alive tonight with people continuing these debates!