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VOLUME 9 NUMBER 2 • JUNE 2012
75
SA JOURNAL OF DIABETES & VASCULAR DISEASE
CONFERENCE REPORT
I
was recently privileged to attend the
Diabetes Expert Forum in Marseilles on
11 and 12 May 2012. This was a two-day
conference with world-class international
speakers, sponsored by Lilly.
Initiation and use of insulin in type
2 diabetes
The first speaker was Prof Dario Giugliano,
from Naples University, Italy. He discussed
when and how to initiate insulin in type 2
diabetes. Data show that 26% of diabetics
in the USA are on insulin and about 30%
of those in Italy. He also presented data
suggesting about 40% of type 2 diabetes
patients can reach target on basal insulin,
according to a recent meta-analysis. However,
if the HbA
1c
level is more than 9%, it is unlikely
that HbA
1c
control will be achieved with basal
insulin alone.
He gave a few pointers as to which
patients should be started on insulin,
including patients who fail to control their
diabetes on two drugs, those who are more
than 1% above target on two drugs, and
symptomatic patients. He also discussed
the new idea of a patient-centred approach
for diabetes care and said the 4-S principle
was important: Safe, Successful, Simple and
Sensible initiation of insulin and basal insulin.
He also mentioned new GLP-1 analogues,
including dulaglutide, which will be available
in the future.
GLP-1 receptor agonists in type 2
diabetes
Dr Guillaume Charpentier from Paris gave a
talk on the use of GLP-1 receptor agonists
in type 2 diabetes. According to studies,
about 45–50% of patients can reach target
on GLP-1 analogues, which is comparable to
basal insulin use. These drugs are clearlymore
potent than DPP-4 inhibitors, and liraglutide
has been shown to be more effective than
exenatide (bd) in general control and weight
loss. However, extended-release exenatide
has been shown to be superior to liraglutide
in terms of glucose control, although the
difference is quite small. Currently in South
Africa, only liraglutide (Victoza) and twice-
daily exenatide (Byetta) are available.
It is difficult to predict a response to
GLP-1 analogues. Recent data showed that
Diabetes Expert Forum
Perspectives on diabetes management in 2012
people with longstanding diabetes often
responded well to GLP-1 analogues and
this should not be an exclusion criterion.
It has also been shown that exenatide can
be combined with insulin glargine as a very
effective combination.
Dr Charpentier also discussed a recent
article by Zinman in
Diabetes, Obesity and
Metabolism
(2012), which gives criteria for
good diabetes care. These criteria combined
a goal of HbA
1c
level less than 7%, no weight
gain and no hypoglycaemia. Liraglutide use
could achieve this goal in up to 40% of
cases, while exenatide (bd) could achieve
this in 25% of cases. Both are more effective
than any other diabetic agents available.
Treatment of the elderly diabetic
An interesting talk by Prof Isabelle Bourdel-
Marchasson, from Bordeaux University in
France,was givenon treatment considerations
in the elderly diabetic patient. She discussed
the definition of frail patients and what
constitutes frailty; and concluded that gait
speed is a good measure. Many patients
older than 75 years are diabetics. There is a
clearly documented increased mortality rate
in diabetics and one must specifically try to
avoid hypoglycaemia, more often seen in
elderly patients with dementia, which can
lead to other complications.
The relative risk of dementia in diabetes
is increased 2.3-fold. Risk of vascular
dementia increases as much as three-fold in
diabetic patients on treatment. These very
frail patients are also more likely to develop
hyperosmolar comas. Different goals must
be set for these frail patients, who should
have an HbA
1c
target level of 7.5–8%.
In patients who are dependent, the goal
should be 7.5–8.5% HbA
1c
.
Specific preference must be given to
medicine that does not cause hypoglycaemia;
metformin and DPP-4 inhibitors are the first
choices, after which other options need
consideration. Only low-risk sulfonylureas
should be considered and renal function
should always be kept in mind.
Safety considerations and drug
interactions of new diabetes agents
Prof Andre Scheen from Belgium gave a
talk on safety considerations and drug
interactions of new diabetic drug classes.
Common drugs such as purbac, flagyl and
fluconazole all have a potentiating effect on
sulfonylureas. This should be kept in mind,
because combined use will increase the risk
of hypoglycaemia.
In terms of DPP-4 inhibitors, he discussed
the fact that they showed very low side-effect
profiles in all the studies. Nasal congestion
was seen initially but not confirmed in meta-
analyses. Infections due to defects in T cells
were seen initially but also not confirmed
by follow-up meta-analyses. The risk of
pancreatitis is still being investigated and
currently there are only case reports. The
increased risk of pancreatitis and pancreatic
cancer will be closely watched in the future.
There is also the suggestion that these drugs
might have cardiovascular benefits. On-going
outcome trials are already in progress.
The new SGLT-2 inhibitor dapagliflozin
and others of this class were also discussed.
These agents are not yet registered in this
country and will take quite a while to reach
our shores. Increased glucosuria, caused by
SGLT-2 inhibitors, tends to cause weight loss,
but also an increase in genital and urinary
tract infections. The response of these
drugs is independent of the duration of
diabetes and will give a predictable result in
longstanding diabetics. The mode of action
is not dependant on beta-cell function.
Diabetes and cancer
Prof Martin Buysschaert from Belgium
discussed diabetes and cancer, showing data
on the increased risk of cancer in diabetes,
particularly cancers of the liver, biliary tract,
pancreas, colon, kidneys and breast. The
mechanisms of oncogenesis were discussed,
including hyperglycaemia. The higher the
HbA
1c
level, the greater the risk was for
cancer. With an HbA
1c
level of 6%, no clear
increased risk could be shown, whereas
an HbA
1c
of 10% represented a two-fold
increased risk of cancer.
Other mechanisms of oncogenesis
included hyperinsulinaemia and increased
IGF-1 levels. He also discussed the possibility
of so-called ‘intruders’, among which were
many of the drugs used by diabetics that
might increase the risk of cancer, including the
new DPP-4 inhibitors and GLP-1 analogues.