And really before I realise it, the conference has reached its last day. The last day of the EASD congress is only, in essence, a half day. There is plenty packed into the programme but the halls are noticeably quieter as delegates have already drifted home in order to get back for the weekend.
As I meander through the morning sunshine on my way to the centre, I reflect upon what I’ve been reporting on whilst here. On Day One, I covered beta cell dysfunction and stem cells. On Day Two, I reported back on hypoglycaemia, the results of the DECLARE-TIMI 58 and VERIFY trials and the molecule of the moment, GLP-1. And, on Day Three, it was the turn of diabetes and pregnancy, obesity and heart failure.
More personalised treatment
At the root of all of this research is the hope that clinicians will be able to offer more personalised treatment and care to their patients, taking on board their specific circumstances whether it’s pregnancy or cardiovascular disease, obesity or hypoglycaemia. By delving right down into the beta cell that is at the heart of this condition, I can see where all of this research is taking us.
Five subtypes of diabetes
And it is taking me straight to the first session of the day - Genetics and Precision Medicine.
Professor Jose Florez starts with a description of how many subtypes of diabetes we now know about – it’s not just type 1 diabetes and type 2 diabetes anymore! There are multiple genetic forms including maturity onset diabetes in the young and latent autoimmune diabetes in adults and many others in between.
This has led a team in Sweden and Finland to propose that adult-onset diabetes can be broken down into five reproducible clusters:
- Severe autoimmune diabetes (SAID)
- Severe insulin-deficient diabetes (SIDD)
- Severe insulin-resistant diabetes (SIRD)
- Mild obesity diabetes (MOD) and
- Mild age-related diabetes (MARD)
These five types have a very different escalation pattern for therapy and also display different rates for the onset of complications.
This analysis has several strengths including that it is an important first step in subtyping diabetes and the clusters make physiological sense and reflect, in part, clinical reality. But the study is not without its limitations because some of the variables used to subtype are not routinely measured in clinical practice and it has still not been convincingly demonstrated that a given individual can be confidently placed in a specific cluster.
Instead, Professor Florez argues that what is needed is an approach that driven by physiological data but that is not contingent on the time of measurement. It also needs to define clear disease subtypes and be of clinical consequence for prevention strategies, for treatment and for the development of complications.
One important take home message is that this original study was done in Caucasian, predominantly Nordic populations. So, does this subtyping hold true for other, non-European populations?
Many would argue that it does not.
This work has sparked controversy but it has the potential to make scientists and clinicians work translationally to redefine or to define more accurately the growing number of subtypes that all fall under the growing umbrella term of diabetes.
Personalised approaches to screening for diabetic retinopathy
I finish my stay here in Barcelona at another session on personalised medicine – this time about personalised approaches to screening for diabetic retinopathy.
Screening for diabetic retinopathy uses a process called fundus photography which is effective in limiting visual impairment from diabetic retinopathy. Guidelines across the world recommend regular screening and several countries have introduced screening programmes.
However, the design of screening programmes is often based on practicality rather than evidence and attempts are now being made to personalise screening schedules to allocate screening intervals efficiently to individual patients.
So what does that all mean?
Well, personalised schedules i.e. those just made for an individual do not provide clear advantages over stratified schedules i.e. assessing groups of patients who have similar disease progression. But what has been indicated is that screening intervals for patients with no prior diabetic retinopathy can be longer and those for patients with moderate disease should be shorted than in most current policies.
But the cost-effectiveness of personalised or stratified screening also needs to be considered. And this is a huge issue given that there are approximately 93 million people with diabetic retinopathy worldwide, 17 million of whom have proliferative retinopathy.
Clearly, having no diabetic eye screening will lead to blindness and opportunistic screening will miss many cases but then systematic screening, as is the current practice in the UK, is also suboptimal in terms of resource use and the number of sight years saved.
In Liverpool, one study to investigate personalised eye screening was conducted.
The control group received the usual screening at a 12 monthly interval whilst the intervention arm was split according to risk – the high-risk group received screening every 6 months, the medium risk group every 12 months and the low risk had a two-year screening interval.
The risk engine used to allocate people with diabetes to these intervals of screening was based on duration of diabetes, age, HbA1c, systolic blood pressure and total cholesterol.
Attendance rates in both the control and individualised screening arms were more than 80% and demonstrated no difference in quality of life between the two groups at the two-year time horizon.
From a cost viewpoint, there were significant savings to the NHS estimated to be in the region of £226,000 per year across the Liverpool region. By extrapolating this out to across England, such personalised screening intervals could potentially lead to savings of around £27.2 million in health service costs.
This led the researchers to conclude that cost saving could be used in future screening programmes to target hard to reach groups and those at high risk of visual impairment. Patients in low risk groups could then be spared the inconvenience and additional personal cost of attending superfluous screening appointments.
Brave new world not possible without research
So, the quest for personalised medicine continues apace – from genetics to epidemiology.
As I pack my bag and head for the airport, I, like so many of my colleagues here in Barcelona, am aware that this brave new world that we’re approaching and, indeed, some may argue already in, would never have been possible without research!