The American Diabetes Association's Postgraduate Sessions are annual educational sessions and research updates for the community of doctors and nurses that care for people with diabetes. We attended the 2007 ADA Postgrad, as it's known, in New York – we find them particularly useful because in addition to some excellent lectures, we love catching up with all the clinicians who tend to be in very active practices (this meeting is very well attended) and discussing further how diabetes has changed in the last year. We came away this time with excitement about how certain classes of therapies are evolving. Here are some of the highlights:
We love hearing positivity toward new treatments. It reminds us that therapy for people with diabetes continues to get better and better. With new drugs, there are always – and should be – concerns about safety; many just haven't been around long enough to accumulate long term data. However, reports of satisfaction, better glucose control, and improved tolerability compared to older anti-diabetes medications are inspiring – and these are what we heard in New York.
Doctors and certified diabetes educators (CDEs) reported satisfaction with Byetta, the first of a new class called incretin mimetics, which improve mealtime insulin release, after-meal glucose scores, and reduces appetite ("increases satiety" in medical language!) in people with type 2 diabetes. Byetta's twice-daily injection seems to be worth it for many patients, due to the impressive weight loss that some patients are experiencing with it (while about 15-20% see no change, about 25% lose a substantial amount, upwards of 40 pounds or more). With the entry of Januvia, the first of a new class called DPP-4 inhibitors, which are oral drugs that also help lower post-meal BG (though don't cause weight loss), some have thought Byetta usage might decline. However, it seems overall that more people with diabetes are just taking drugs earlier because they are easier and better. On this front, it might now be an easier time to try a sample, because many doctors say they have both Januvia and Byetta samples (they said their fridges were filled with Byetta samples, though we also mentioned that Byetta can now be kept at room temperature – a recent, welcome change approved by the FDA.) At this meeting, all the doctors seem at least to have heard of Byetta, which was a change from last year, when many clinicians still hadn't heard about the drug. Not everyone had heard of Januvia – and of course, new treatments aren't right for everyone, so please ask your diabetes team if they make sense for you to consider.
It was suggested that both incretin mimetics and DPP-4 inhibitors should be tested for use in prediabetes. One hurdle for this is long-term safety – we should really see how these new drugs behave over the long term. Right now, there is safety data for Byetta for three years and Januvia for two years. The safety "hurdle" is especially high for preventive drugs, which makes sense given how many people might take them (there were over 50 million people in the U.S. estimated to have pre-diabetes at last count. We also note that testing Byetta for prediabetes probably won't come until there is a long-release formula requiring only one injection per week rather than two-per-day. This is expected to be approved in 2009.
Symlin is a drug that is difficult to use, but we heard that those who stick with it seem to love it. It is an injectable analog of amylin, a hormone generally secreted with insulin but which is also lacking in people with diabetes. Symlin smoothes out post-meal rises in blood glucose. If you'd like to learn more about Symlin, please see our free newsletter diaTribe and the March/April 2007 cover story.
Meanwhile, older drugs like TZDs (Actos and Avandia) were criticized for their poor side effect profiles. Unfortunately, there are not yet cleaner alternatives to these well-worn insulin sensitizers. Insulin resistance is a huge problem in type 2 patients and contributes to the difficulty of getting them to A1c goal, sometimes even after they are on insulin therapy. But TZDs are getting a rap for the weight gain and fluid retention that they cause, as well as associations with higher rates of bone fractures and heart failure. We got the sense that DPP-4 inhibitors like Januvia are definitely an easier alternative compared to sulfonylureas (which cause insulin secretion) – we still need to find out about safer. We do think we need both easier and safer alternatives to TZDs and research on this is ongoing. A new class called PTP1b may be this alternative – possible insulin sensitizing without weight gain – but more research is happening on this front that we will be monitoring, as it is still very early in the research cycle.
Despite all the bad news on the diabetes complications front, this is an extremely dynamic time for diabetes treatment, from global recognition by the UN, to more popular advertising by diabetes therapy makers, to increased awareness and treatment of obesity and pre-diabetes, and finally to all these promising new therapies now catching on or in the works. And we're very excited about it.
Kelly Close is Editor-in-Chief of diaTribe, an electronic newsletter that helps people learn about new ways to manage diabetes better. diaTribe focuses on new drugs, devices and research. diaTribe is free and available online at www.diatribe.us.
NOTE: The information is not intended to be a replacement or substitute for consultation with a qualified medical professional or for professional medical advice related to diabetes or another medical condition. Please contact your physician or medical professional with any questions and concerns about your medical condition.
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