ATTD2021 Conference Report

Why have WE NOT Prevented/Cured Type 1 Diabetes?

1. Sub-optimal trial designs (dose/power/populations);
2. Treating too late / lack of stage specific interventions;
3. Treating “just” the immune response;
4. Failure to use drugs in combination;
5. Performance of trials with questionable rationale;
6. Lack of informative biomarkers;
7. Not knowing the role of environment in in T1D;
8. Failure to appreciate disease heterogeneity;
9. Failure to understand the disorder pathogenesis.

The role of Technology in Type 1 Diabetes Beyond the Pandemic @ChantalMathieu

1.    1. Insulin therapy remains challenging in people with Type 1 Diabetes;
2. Glucose variability, risk of hypoglycemia, weight gain and overall disease burden remain issues in those living with T1D;
3. Patient education and coaching, better insulins and novel technologies are helping people with T1D

Digital Diabetes Emergencies @IrlHirsch

·         Hypoglycaemia and DKA remain major emergencies in the treatment of T1D and current technology and forms of glucagon has not resulted in a reduction;
·         Sick-day management and home-treatment of DKA continues to require preparation, no matter if care is virtual or not;
·         Newer technologies such as CGM (Continuous Glucose Monitoring) and new apps to assist with vital signs may be helpful for the digital management of the acute hyperglycaemic crisis.

Using Digital Health Technology to prevent and treat Diabetes @NealDavidKaufman

·         High health literacy patients show higher levels of patient activation than those with low health literacy;
·         The effectiveness of social media-based Health literacy- sensitive diabetes self-management.
·         Thus social media-based self-management interventions accommodating low health literacy have the potential to help overcome disadvantages associated with low health literacy;
·         Interventions based on providing extra messages, even in context of clinical care, may not be able to change long-time habits and behaviors required to improve outcomes, as was found out on a study to enhance patient activation and self-management activities in patients with type 2 diabetes
·         Digital therapeutics deliver evidence based therapeutic interventions to patients that are driven by high quality software programs to prevent, manage or treat a medical disorder or disease.

Technology and Pregnancy

·         In pregnancy, Real-Time Continuous Glucose Monitoring (CGM) has been shown to improve neonatal outcomes.

·         CGM gives a detailed picture of maternal glycemic control throughout pregnancy. However, summary CGM measures do not capture daily glycemic excursions and patterns.

·         Regular CGM use is associated with improved metabolic control

Metformin in Pregnancy-Long term follow up:

·         Children exposed to metformin had more subcutaneous fat;

·         Children exposed to had slightly higher fasting glucose;

·         There was a possible trend towards higher systolic blood pressure and lower LDL cholesterol level;

·         Children exposed to metformin were heavier;

·         Metformin exposed children had higher BMI and increased prevalence of overweight/obesity;

·         At 9 years of age, metformin exposed children have higher readings for measures such as weight, arms and waist circumferences, BMI, triceps skinfold and abdominal fat volume.

Should all pregnant women with diabetes take metformin during pregnancy? @DeniceFeig

Metformin has beneficial effects in mothers and infants of women with diabetes.

·         Metformin improves maternal and neonatal outcomes in women with gestational diabetes and type 2 diabetes;

·         Metformin is associated with better patient satisfaction;

·         The preponderance of evidence suggests metformin is safe in the long-term;

·         Metformin should be offered to all women with diabetes.

Factors associated with stillbirth in women with diabetes:

What is modifiable?

• 1.    Deal with reversible risk factors:
• ·         Smoking;
• ·         Obesity/ overweight between pregnancies;
• ·         Ketosis (a serious diabetes complication where the body produces excess blood acids/ketones) in pregnancy;
• ·         Glycaemia

Diabetes and Sport

Monitoring the elite athlete with type 1 @MichaelRiddell

·         For almost 100 years, many people with Type 1 Diabetes have been pushing the boundaries of what is possible in sport;

·         Developments in technology have helped athletes to reach their sporting goals;

·         CGM and emerging AID systems appear to help with glucose control but sensor lag may be an issue;

·         Novel data displays are helping athletes to better understand the relationships between exercise and glycaemia.

Nocturnal Post-Exercise Strategies

1.    Adults with Type 1 Diabetes should perform a scan at least once intermittently scanned continuous glucose monitoring (isCGM) during the nocturnal period due to the increased risk of nocturnal hypoglycaemia;
2.    Family/friends can be alerted using the remote monitoring function, which can support to avoid (severe) nocturnal hypoglycaemia;
3.    Different types and intensities of exercise result in different glucose responses during and after exercise;
4.    Different groups of people with T1D require different glucose targets based on “exercise experience” and risk of hypoglycaemia (use assessment tool);
5.    Check glucose as often as possible during exercise (10 minutely);
6.    Using both, the actual sensor glucose level and accompanied trend arrow improves glycaemia around exercise;
7.    Defining individual carbohydrate intake at a glycaemic threshold based on trend arrows ameliorates glucose levels during exercise.

Advanced Therapeutic Approaches in Type 2 Diabetes

Diabetes Outcome Trials: Current Status @Jay.S.Skyler,MD,MACP

1.    Dapagliflozin Indications:

·         In patients with type 2 Diabetes, to improve glycaemic control;
·         In patients with T2D with either eCVD or multiple CV risk factors, to reduce the risk of hospitalisation for heart failure;
·         In patients with heart failure with reduced ejection fraction, to reduce the risk of CV death and hospitalisation for heart failure;
·         In patients with CKD at risk of progression, to reduce the risk of sustained eGFR decline, ESKD, CV death, and hospitalisation for heart failure.

2.    Dulaglutide Indications:

·         In patients with T2D, to improve glycaemic control;
·         In adult with type 2 diabetes mellitus who have established cardiovascular disease or multiple cardiovascular risk factors, to reduce the risk of major adverse cardiovascular events (cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke) 

3.    Semaglutide Indications:

·         In patients with T2D, to improve glycaemic control;
·         In adult with type 2 diabetes mellitus and established cardiovascular disease, to reduce the risk of major adverse cardiovascular events.

4.    Liraglutide Indications:

·         In patients with T2D, to improve glycaemic control;
·         In adult with type 2 diabetes mellitus and established cardiovascular disease, to reduce the risk of major adverse cardiovascular events.

5.    Empagliflozin Indications:

·         In patients with T2D, to improve glycaemic control;
·         In adult with type 2 diabetes mellitus and established cardiovascular disease, to reduce the risk of cardiovascular death.

Terzepetide: Comparison to an Ideal Drug to Treat Type 2 Diabetes Mellitus @StevenMissen

·         High efficacy at lowering HbA1c;
·         Low incidence of hypoglycaemia;
·         Weight loss, not weight gain;
·         Good tolerability;
·         Convenience of administration;
·         Benefits on important endpoints such as cardiovascular morbidity/mortality

New Insulins, Biosimilars and Insulin Therapy:

1.    Studies with novel supra-long-acting Insulin show that this has similar glucose-lowering effectiveness and comparable rates of hypoglycaemia versus glargine U100 in insulin-naïve adults with type 2 diabetes
2.    The main findings of the two (glargine U300 & degludec) randomised controlled head-to-head trials, the clinical effectiveness and safety of glargine U300 and degludec in adults with T2D appear to be largely equivalent

Smart Insulins: A lot of smoke with a little fire @LutzHeinemann

Smart microneedles with porous polymer layer for glucose- responsive insulin delivery
3.    Ultra rapid lispro (URLi) lowers postprandial glucose and more closely matches normal physiological glucose response compared to other rapid Insulin analogues
4.    Biosimilar Insulin are a potential to reduce healthcare costs, especially in view of the high insulin prices across the world.

Decision Support systems and closed-loop @BorisKovatchev

5.    Fully closed-loop Insulin delivery using either faster or standard Insulin Aspart is safe and efficient in achieving near-normal glucose concentrations outside postprandial periods. The closed-loop algorithm was better adjusted to the standard Insulin Aspart.

Impact of COVID-19 Pandemic on Diabetes:

1.    COVID-19 mortality is higher with diabetes and there may be associations with gender;
2.    The data are mixed with the association between outpatient glycaemic control and mortality in Type 2 diabetes;
3.    The totality of evidence suggests that RAAS (Renin-Angiotensin-Aldosterone System) inhibitors either have no effect or may be beneficial to COVID-19 outcomes;
4.    Data for COVID-19 infection use of metformin is mixed but does not appear to be harmful. Beneficial effects may be related to gender and other clinical confounders;
5.    The interesting theoretical reasons dipeptidyl peptidase (DPP)-4 inhibitors may improve outcome and as now they appear to be safe and may be beneficial;
6.    It does not appear Sodium-glucose Cotransporter-2 (SGLT2) inhibitors will be effective for the treatment of COVID-19;
7.    Telemedicine has come a long way in the past 15 months, but there still challenges that are needed to be addressed.

Covid-19 And Management of Patients with Diabetes: How to implement Scientific Knowledge to Clinical Practice?

1.    Optimal control of blood sugar and blood pressure. Strive to continue oral antidiabetic and antihypertensive medication (DPP4 inhibitors and metformin possibly protective);
2.    Insulinisation if the course of disease is severe;
3.    Intensive blood sugar monitoring in patients with Dexamethasone (also Budenoside);
4.    Follow-up monitoring after COVID-19 infection: metabolism, neurostatus, foot findings, vascular status, heart, kidneys, lungs.

How to manage Type 2 Diabetes and obesity during the COVID-19 pandemic @Prof_Cerrillo

1.    Hyperglycaemia admission and during hospital stay are independent risk factors for mortality in high risk cardiac patients admitted to an intensive cardiac care unit;
2.    Higher glycaemic variability within the first day of ICU admission is associated with increased 30-day mortality in ICU patients with sepsis (recent publication on Glycaemic variability);
3.    Obesity is a key risk factor for a very bad prognosis for COVID-19;
4.    Type 2 Diabetes is associated with higher death rate, but type 2 diabetes persons with better controlled blood glucose die at a lower rate than those with poorly controlled blood glucose;

Glycaemic variability is an integral component of glucose homoeostasis. Although it is not definitely confirmed as an independent risk factor for diabetes complications, GV can represent the presence of excess glycaemic excursions and, consequently, the risk of hyperglycaemia or hypoglycaemia. GV is currently defined by large and increasing number of metrics, representing either short-term (within-day and between-day variability) or long-term GV, which is usually based on serial measurements of HbA1c or other measures of glycaemia examining the association between GV and diabetes-related complications, as well as non-pharmacological and pharmacological strategies currently available to address this challenging aspect of diabetes management. 

Practical Implementation of Diabetes Technologies overcoming barriers in the Real-World

·         Improving payer coverage is essential to “level the playing field”
·         Not sufficient to address: implicit provider biases; and access to specialty care.
·         Glucose monitoring technologies may be a key: Quicker diffusion across Socioeconomic status (SESL levels; and Impact on outcomes, both glycaemic & economic.
·         Essential to continue work to equalise opportunities for people with diabetes (policy, organisational, community, personal level).

Primary Care and Diabetes Technologies and Treatments @Gregg.D.Simonson

·         Patients treated with Metformin and Sulphonylureas (SU) have higher risk of major adverse cardiovascular events (MACE), severe hypoglycaemia and all-cause mortality;
·         SU should not be 2^nd line therapy for most patients with type 2 diabetes mellitus;
·         GLP-1 receptor agonists and SGLT2 inhibitors should be considered 2^nd line therapy.
·         Consider adding GLP-1 receptor agonists for patients on basal insulin, especially those with severe hypoglycaemia.

Updates on NAFLD/NASH And Diabetes:

1.    NAFLD is “prevalent” in Type 1 Diabetes, but numbers are depending on:
·         Screening methodology (5-8% using MRI- 22-27% using US)
·         Referral bias
2.    Need for an accurate diagnostic algorithm;
3.    Visceral fat accumulation and insulin resistance are strongly associated with NAFLD in Type 1 Diabetes;
4.    Type 1 Diabetes patients with NAFLD have a higher incidence of:
·         Cardiovascular disease
·         Microvascular complications

NAFLD/NASH in metabolic syndrome and early type 2 diabetes @ChrisByrne

·         Non-Alcoholic Fatty Liver Disease (NAFLD) is a multi-system disease with implications beyond the liver;
·         NAFLD represents a wide spectrum of liver diseases that is strongly associated with Metabolic Syndrome (MetS) that increases risk of Type 2 Diabetes Mellitus, Cardiovascular disease, Chronic Kidney Disease (CKD) and certain cancers;
·         The aetiology of increased risk of CVD is complex but the atherogenic dyslipidaemia is important;
·         Treatment with pioglitazone and/ or Glucagon-like peptide-1 (GLP-1) receptor agonists is effective in patients with early T2DM and NAFLD

Psycho-educational interventions to improve glycaemic control in adults with type 2diabetes @SimonHeller

1.    Many (most) individuals currently struggle to implement and sustain effective diabetes self-management;
2.    Altering lifestyle and self-managing type 2 diabetes successfully requires major changes in behaviour and acquisition of skills;
3.    Structured education/training:
·         is more effective than unstructured and adhoc education and produces small but clinically relevant improvements in HbA1c;
·         is undertaken by a small fraction of those with diabetes in the UK;
·         probably needs underpinning by structured support, technology and addressing key self-management behaviours.
4.    The major need is to ensure that structured education is not only offered but undertaken.

Social Media: In the Sea of Voices- Where Is the Lighthouse?

Harnessing the Power of Social Media and Peer Support @KellyClose

·         The jury is now on the impact of social media on patient outcomes- it provides helpful peer support and engagement.
·         There are concerns with social media for companies, HCPs, and patients. But there are also lots of best practices and guidelines made by experienced groups.
·         Patients trust their HCPs far more than the information they find online, and even so- HCPs will still find themselves in the position of being asked to curate the information patients find.
·         The DOC is not tightly regulated-positives and negatives to this. It allows for flexibility and autonomy and opportunity like insulin 100 from University of Toronto, like patients supporting each other, like reducing stigma. While it also brings up privacy concerns and the potential for misinformation, this is a solvable problem- or at least an addressable one!

Using Social Media to bridge the Social Distance in a Pandemic @DrRoseStewart

1.    Using agile and accessible communications platforms to convey messages from credible sources can help contain anxiety during emergency situations;
2.    Providing mass education via social media is a significant paradigm shift and may help make education more accessible;
3.    Delivering an equivalent level of support long-term will require funding.

What should we be saying to people with T2 who want to use social media?

·         Find a site that’s right for you
·         Watch and wait
·         No-one’s diabetes is the same
·         Don’t believe everything you read
·         Only share things you’d share with a stranger you’d just met
·         Try to be polite and helpful- if you’ve nothing good to say, don’t say it
·         If you are feeling bullied- block or report people
·         If using social media isn’t helping you with your diabetes, but is making you more stressed or upset- STOP.

Improvements in Time-In-Range and other Diabetes Related Health Metrics @PratikChoudhary

1.    Flash glucose monitoring has been a game changer just like SMBG was 40 years ago
2.    For people with diabetes, it has:
·         Improved quality of life
·         Given them freedom
·         Improved diabetes control
3.    For HCP and health care system:
·         Reduced admissions / Emergency call outs
·         Over time- reduced admissions
·         Facilitated remote care and telemedicine

Optimising HbA1c levels & Glycaemic control with Flash Glucose Monitoring @Monika Kellerer

·         Many T2D patients do not achieve their glycemic goals;
·         Flash Continuous Glucose Monitoring replace SMBG and results in significant and persistent HbA1c- Reduction, less hypoglycemia, more Time-In-Range (TIR) and higher treatment satisfaction in T2D with and without insulin;
·         More TIR correlates with less all cause and cardiovascular mortality in T2D’
·         CGM may also serve as modification tool for healthier behavior;
·         Flash CGM is associated with significantly less acute diabetes events and hospitalisation in T2D;
·         Continuous Glucose monitoring will be increasingly used in T2D who do not reach their targets.
·         Hachioji suggested “Observe due measure, for moderation in all things”. Recognition that there was a lower limit to normality.

Heart failure in Type 2 Diabetes- early identification and interventions for improving patient outcome

HF in T2D: perspectives from a diabetologist and a cardiologist @AntonioCeriello

Why and how to screen for heart failure in diabetes?

·         Heart failure is a very frequent complication of diabetes and is asymptomatic for a long time. Heart failure exposes people with diabetes to serious fatal cardiovascular events.

·         Screening for heart failure in people with diabetes is today mandatory because we now have very good tools to prevent worsening of the situation.

Major causes of Heart failure in patients with diabetes:

·         Coronary artery disease;
·         Hypertension;
·         Chronic kidney disease;
·         Lower extremity atherosclerotic disease;
·         Long duration of diabetes;
·         Aging;
·         Increased body mass index (BMI)

NB. LV (Left ventricular) dysfunction is frequent in both pre-diabetes and overt diabetes, and severity correlates with insulin resistance and the degree of glucose dysregulation.

Time to act- SGLT2 inhibitors in HF @MarkPetrie

·         SGLT2 (Sodium-glucose transport protein 2) inhibitors prevent HF hospitalisations in patients with diabetes and CVD or multiple risk factors;
·         SGLT2 inhibitors reduce HF hospitalisations and CV death in patients with Heart Failure with Reduced Ejection Fraction (HFrEF) with and without diabetes;
·         SGLT2 inhibitors reduce HF hospitalisations in patients with CKD with and without diabetes.  

HF in T2D: perspectives from a diabetologist and a cardiologist @ShelleyZieroth

·         T2D and HF are directly linked;
·         There is an urgent to diagnose and intervene to reduce risk in both T2D and HF;
·         Educate and empower and our colleagues and patients to prevent and treat heart failure;
·         Collaborations across disciplines will improve patient outcomes.

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