Precision medicine: “If not now, then when?”
Healthcare providers need tools to help personalise care for people living with diabetes, so they can achieve better outcomes and quality of life. But as attendees at this year’s Precision Medicine Diabetes Conference heard, patients themselves aren’t waiting; they can’t afford to.
Each of the three days of this year’s Precision Medicine Diabetes Conference (a joint ADA/EASD initiative) opened with a keynote talk from a person with diabetes, who shared their perspective on the real-life needs of people with diabetes and why precision medicine matters to them. Dana Lewis, who opened the first day, has lived with type 1 diabetes for over 18 years. She highlighted that the one-size-fits-all approach for diabetes treatment following diagnosis is not appropriate nor effective, and the current standard of care is ‘imprecision medicine’. Many patients are constantly learning how to improve their quality of life: they find themselves creating tools, collecting and calculating data, setting alarms for medications, taking action to suit them and doing precision medicine themselves when left with few options. The hallmark of precision medicine is doing the right thing at the right time for someone with diabetes, she said; it is time to bring new tools to people with diabetes.
To realise the potential of precision medicine, there are varying degrees and subtypes of diabetes and a key aim is to find and understand the subtypes to improve the diagnosis and classification of disease. William Cefalu shared a study by Thomas Peterson et al. published Diabetes Care in April 2021 in which monitoring of treatment strategies aided finding unique treatments for patients. The authors were tracking patients who changed therapy patterns from their initial suggested therapy and found that tracking the first four medication changes in 97,231 patients with type 2 diabetes identified 12,134 unique clinical treatments. Characteristics of diabetes subtypes may be classified into variables to help define therapy earlier on to mitigate complications. Cefalu also referred to the Rare and Atypical DIabetes NeTwork (RADIANT), which is a programme that aims to identify the patients and families with rare, novel and atypical forms of diabetes and characterise the underlying molecular mechanisms. The hope for the programme is that it will allow further understanding of disease subtypes and impact greatly on subtype classification.
In his talk on the vision and future direction of the initiative, Paul Franks explained how the Precision Medicine in Diabetes initiative, described in the first consensus statement from the ADA and the EASD in 2020, was directed. Different areas within precision medicine were mapped out starting with precision diagnostics, describing the process one would go through to achieve a precision diagnosis. This was followed by precision therapeutics, prevention, treatment, monitoring and prognostics. Paraphrasing Rabbi Hiell, who in circa 50 BC said, “If not now, then when? If not us, then who?” Franks reflected on comments that suggest it is too early to be asking about precision medicine; if we wait, he retorted, it will simply be too late.
In the final talk of the series, Marten Ridderstråle called for aligned expectations and competencies between all stakeholders, including people with diabetes, to allow for optimal performance where there is a common goal. Focusing on value-adding activities, typically time with healthcare providers, saves time, energy, effort and resources. In clinical practice, bringing diabetes precision medicine together requires a number of parameters that can be combined for a heterogenous disease. Methods should include using a validated response biomarker and a decision framework to identify the smartest design in the smallest group of people for the shortest period of time. To facilitate precision diabetes medicine on a larger scale, Ridderstråle believes in the ‘power of one’: one set of profiling prognostic and predictive parameters, one recommendation to patients and providers of diabetes type and best-fit treatment and one open-access database for research and development.
For more on this topic, see our course Phenotypic variability.
The joint ADA-EASD consensus report on precision diabetes medicine were published in Diabetes Care, April 2020. https://care.diabetesjournals.org/content/43/7/1617
The views expressed in this article are those of the author, Dr Eleanor D Kennedy.