COMMENTARY

Analysis: New ADA-EASD Guidelines for the Management of Type 2 Diabetes

Prof Simon Heller, BA, MB, Bchir, DM, FRCP

Disclosures

October 05, 2018

My name is Simon Heller. I am Professor of clinical diabetes at the University of Sheffield in the north of England and I'm delighted to talk about just a few of the highlights of the EASD meeting here in Berlin.

So on Friday, we've heard about the new ADA-EASD guidelines for the management of type 2 diabetes. And I think these are really important, particularly as they've really been revised at an important time for practitioners, physicians dealing with diabetes, especially primary care physicians.

And the reason I think it's so important is that over the last few years we've seen a proliferation of new treatments, particularly the SGLT2 inhibitors, which not only improve glucose control but help people to lose weight, and even more importantly, have been shown to reduce mortality, quite substantially, and quite quickly. And that is almost certainly because they're having effects on heart failure. So this is a new class of drugs that we're using.

We've also now got evidence that incretin therapies have benefit and a number of the GLP-1 analogues can also reduce mortality.

So what that means is that diabetes treatment is becoming much more complicated. And previous guidelines essentially laid out the medication and invited the practitioner to sort of make a choice. I don't regard those as guidelines. And what we've seen is that the new guidance, which has been published, are really much, much better because they are helping practitioners, depending upon the characteristics of the patient (for example, whether they're overweight, whether they have cardiovascular disease), to select the appropriate therapy.

Do I think it's individualisation of therapy? Not quite, but I do think we're coming close.

Another highlight was an oral session which I had the honour to chair[1], and this was looking at the new ultra-long acting insulin analogues Toujeo insulin glargine U-300 and insulin degludec Tresiba.

And we've seen trials of these products versus other medications, which suggests they do both have benefit, particularly in terms of reducing hypoglycaemia. And in the DEVOTE study[2] of insulin degludec, they actually showed a dramatic fall in severe hypoglycaemia.

But in this particular session, we heard about the BRIGHT study[3], which was a head-to-head comparison between the two, sponsored by Sanofi-Aventis. And the upshot was that this one-year study showed really no difference between the two. Both reduced hypoglycaemia and both improved HbA1c to the same extent.

I think that that is interesting and worthwhile. We do need more head-to-head studies.

We also had so-called real world studies shown, which suggested insulin degludec was more effective. But I suppose rightly raised in the discussion, real world studies are subject to confounders, and I think we can't be sure exactly how successful the product is. We really need more data.

The final highlight which I would just mention is a large European project called the Innovation Medicines Initiative, which is worth €26 million. And the reason that it's so exciting is that it's assembling academics, the insulin manufacturers, all three, and some continuous glucose companies who've all agreed to put all their clinical trial data into a single database.

And you might say, what is the advantage of that? But the advantage is that we can do very powerful statistical analysis and learn much more about hypoglycaemia. And what we hope, particularly using the new classifications[4], which have been agreed by the ADA and the EASD, is to begin to improve the evidence base and most important of all, allow us to compare new treatments, be they therapeutic, be they technological, or actually even educational. And if we can do these analyses, we hope to be able to really identify the ways in which we can reduce hypoglycaemia as a burden for patients with both type 2 and type 1 diabetes.

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