EASD blog – Day 3 (22nd February 2020)
The last day of the ATTD conference in Madrid ended, for me, with three very different sessions − from liver disease and hypoglycaemia to metabolic surgery and stem cells.
The increasing burden of non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) is one being felt around the world. With figures ranging from a prevalence of just 13.5% in Africa to 31.8% in the Middle East, these levels increase in people with type 2 diabetes to 30.4% and 67.3% respectively. There is also a trend towards increasing NAFLD diagnosis among children, with a worldwide prevalence rate now between 7 and 10%. All of which corresponds to a disability-adjusted life-years figure of over 62 million – a worryingly high figure for a condition for which there are currently no approved drugs and for which diet and exercise remain the mainstay of treatment.
The next session focussed on the effects of hypoglycaemia on the brain. The absence of thalamic activation in those with impaired awareness may reflect a habituation response to the stress of hypoglycaemia. Moreover, altered responses in regions involved with executive function, motivation and memory may account for the different behavioural responses to hypoglycaemia in those with impaired awareness. It may be that these adaptations ultimately create barriers to effective behavioural changes that otherwise might reduce the risk of future episodes of hypoglycaemia.
From here, the focus switched to severe hypoglycaemia and the development of stable formulations of glucagon. The availability of liquid-stable formulations has broadened the use of glucagon in type 1 diabetes from an emergency rescue for severe hypoglycaemia to the treatment and prevention of mild hypoglycaemia. These liquid-stable formulations of glucagon will enable large-scale developments and commercialisation of bi-hormonal closed-loop systems and could also find novel non-diabetic uses for glucagon in conditions of hyperinsulinism.
The trial results from nasal glucagon were then presented. This needle-free, dry powder requires no reconstitution and is carried in a compact, portable, single-use unit that has a two-year expiry date and is stable at temperatures up to 30°C.
Tested in both adult and paediatric populations, nasal glucagon has also been trialled in a real-world study. During this period, a total of 157 hypoglycaemic events occurred, with 96% of them being resolved within 30 minutes of administration of nasal glucagon.
In five of the remaining six that did not resolve by 30 minutes, resolution was noted by 45 minutes. Ease of use was endorsed by most of the caregivers and no serious drug-related adverse effects were reported.
The penultimate talk of the conference was on metabolic surgery and Professor Walter Pories gave a thought-provoking talk on the safety of metabolic surgery as an effective treatment for type 2 diabetes, citing 90-day mortality rates in the US for bariatric surgery of just 0.2% − significantly less than the 2-4% quoted for coronary artery bypass graft surgery and just slightly higher than the 0.1% cited for uncomplicated childbirth.
His call for earlier referral as it leads to better outcomes was followed by a potential new avenue for research in the way that type 2 diabetes resolves so rapidly after surgery, proposing lactate levels as a novel way to stage the condition, which could lead to the development of better medications.
And so the conference ended really where it began, with Professor Jay Skyler giving a talk – not a retrospective look at how far the field has advanced since insulin’s discovery almost 100 years ago, as he did at the start of the congress, but rather a look forward. Recognising the prevention of immune destruction of beta cells, the preservation of beta cell mass and automated insulin delivery as key drivers in further research, he focussed on the replacement or regeneration of beta cells, touching on islet cell transplantation − which will be the focus of another new module coming soon to the EASD’s e-learning platform.
The session and, indeed, the conference, ended with another call for more research and ideas for where such research is required, particularly given the number of unlicensed stem cell clinics mushrooming in the US, offering largely untested therapies for a number of different conditions and illnesses. His message, one of hope not hype, was that a cure for type 1 diabetes will be found through research − a message which gave everyone in the audience food for thought and was a fitting end to the conference.
The opinions expressed in this article are those of Dr Eleanor D. Kennedy.
Want to know more about these topics?
NAFLD and NASH
NASH, the progressive form of NAFLD, is part of a multisystem disease leading to adverse clinical outcomes, both hepatic and non-hepatic in nature. Its management requires a dedicated multidisciplinary team. In recognition of this growing epidemic, the tremendous economic burden it entails and the poor patient-related outcomes, the EASD’s e-learning team is currently working with an expert in the field to bring you a new course on NAFLD and NASH, which will launch at this year’s EASD conference in Vienna. By clicking here to register on our site, when this exciting new course launches, you will be able to access it and test your knowledge in this increasingly important area of diabetes management.
In 2020, the EASD e-learning team will be producing a new course on the topic of hypoglycaemia, which will cover the role of glucagon as a recovery agent. By clicking here to register on our site, when this exciting new course launches, you will be able to access it and test your knowledge in this important area of diabetes management.
Recognising the enormous interest in the field of metabolic surgery, the EASD’s e-learning team is currently developing an ambitious seven-module course covering all aspects from the types of metabolic surgery to anti-diabetic medication and treatment and the management and prevention of nutritional complications following surgery. If you haven’t already done so, please click here to register on our site to learn more about this exciting field when our course launches later in 2020.