Anne L. Peters, MD, CDE; Julio Rosenstock, MD


August 24, 2011

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Anne L. Peters, MD, CDE: Hi. I'm Dr. Anne Peters, Director of the Clinical Diabetes Program at the University of Southern California. I am joined today by Dr. Julio Rosenstock, Director, Dallas Diabetes and Endocrine Center and Clinical Professor of Medicine, University of Texas Southwestern Medical Center. We are here at the American Diabetes Association (ADA) meeting in San Diego, California, and I would like to ask Julio about some of the highlights from the meeting.

Julio, we were working on the clinical therapeutics committee together. What do you think is interesting here?

Julio Rosenstock, MD: I think this is a great meeting. We have been coming to the ADA meeting for more than 25 years, and this is the top scientific meeting for diabetes in the world. Every year we learn something else. This year is particularly important because several symposia were very interesting, where we discussed hot topics of interest to the clinician. There are different, new drugs for the armamentarium in diabetes, especially in type 2 diabetes.

Dr. Peters: What are the drugs that are going to be the most important to a clinician in the next couple of years?

Dr. Rosenstock: The incretin-related therapies are available and are widely used. Two dipeptidyl peptidase-4 (DPP-4) inhibitors are on the market, and just recently linagliptin became available. We have the opportunity to look at all the data for these agents. Linagliptin is a DPP-4 inhibitor that is given once a day and doesn't need any adjustments; it can be given to people with renal insufficiency. That's an interesting new drug.

We have a lot of data on the glucagon-like polypeptide-1 (GLP-1) receptor analogs that are available. Exenatide and liraglutide are available -- once a day liraglutide, twice-a-day exenatide, and once-a-week exenatide (which is very interesting). In combination with insulin, the GLP-1 analogs are another new way of treating type 2 diabetes. They are going to find a very important place.

Dr. Peters: I heard that a once-a-month GLP-1 analog is coming out. What about that?

Dr. Rosenstock: We will see. We need to go slowly. Going from twice a day to once a day is good. There will be patients who will like once a day. Once a week -- I like it. To have something on board for once a month, however, we will see. We are going to need a lot of research about it, but I like the concept of once a week to improve compliance. The data showing that the combination of GLP-1 receptor analogs and basal insulin works very well are interesting. For years we have been saying, "Is it basal insulin or is it GLP-1?" I think it is the combination that is going to work very well.

Dr. Peters: I find that a very exciting idea, and we will see that borne out with some of the data at the meetings. What about this new class of drugs that involves the kidney? Can you explain sodium glucose co-transporter-2 (SGLT-2) inhibitors?

Dr. Rosenstock: This is a very interesting class. We have glucose transporters in the kidney and so the kidney is very good at reabsorbing glucose. We filter glucose and we reabsorb it. We have been taught that in hyperglycemia, when you have high blood sugar, you spill a lot of sugar and then you have glycosuria. These drugs produce glycosuria. You spill glucose in the urine, and by doing so you can lose 60 or 80 grams of glucose. You lower the blood sugar, and people can actually lose weight because they lose calories. It's exciting. One drug has been submitted to the US Food and Drug Administration and they will be reviewing it very shortly, and 2 other drugs are in development. There will be a lot of data on this.

It is interesting because this drug has a mechanism that is insulin-independent; so in theory, it can be used in combination with any drug for type 2 diabetes.

Dr. Peters: As a clinician, I have always been a little wary of this whole concept of worsening glycosuria. What about bladder infections and vaginal infections -- that kind of thing? What about side effects?

Dr. Rosenstock: You are absolutely correct. In this era, what is critical is safety and adverse events. We have a lot of drugs out there. The issue is how to use them right and combine them. You have increased glycosuria. You would think that you would have a little increased urinary tract infection. It doesn't appear to be the case, but certainly vulvovaginitis is an issue for women and balanitis is for men. In general, what we have seen from all the different trials is that approximately 6%-9% of the people are affected, but that is an issue.

These are mild [adverse effects], and we know that women can deal with these infections with over-the-counter products, but this is something that needs to be watched very closely. Obviously there will be issues of compliance and adherence that we need to monitor.

Dr. Peters: We will look to see the risks and benefits. This is going to be a very interesting meeting and we will all learn a lot. Thank you very much for coming and talking with us.

Dr. Rosenstock: My pleasure.


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