COMMENTARY

Top Trials, Governance, and Guidelines: EASD President Prof David Matthews

Prof David Matthews

Disclosures

September 20, 2019

Professor David Matthews, emeritus professor of diabetes at the University of Oxford, and the current president of the European Association for the Study of Diabetes (EASD) talks to Medscape UK about the 2019 Annual Meeting in Barcelona, his time in office, and the changes he's made to the organisation.

When we spoke to Prof Matthews last year at the congress in Berlin, he had just been named president-elect and spoke about the 'pandemic of diabetes'.

This transcript has been edited for clarity.

In terms of the pandemic of diabetes, I'm afraid we've still got a pandemic of diabetes, and it's still going up. However, the good news is that people are now concentrating on ways in which we can actually reverse this. And so there's a lot of activity in preventive medicine, people are beginning to understand the absolute need for trying to address the pandemic of diabetes. And the precursor to that is obesity. But you'll have seen that even on the BBC News, and in the newspapers in the UK, that one fifth of the entire NHS (National Health Service) budget goes towards diabetes. 

And of course, that's not just buying a few tablets. That's because people get heart attacks, they get renal failure, they need laser therapy, and so on. So the complications are what really cut into your budget. I think this is a way of focusing people's attention, saying, you can either spend one fifth of your entire eye-watering healthcare budget on diabetes, or you could really think about doing something to prevent the epidemic.

What were your conference highlights?

I think the conference has shown a variety of interesting things. First of all, there's interest in in semaglutide (Ozempic, Novo Nordisk), this is an oral GLP-1 agonist (glucagon-like peptide-1) with very good effects. Previously, you had to inject a GLP-1 agonist and semaglutide now is coming in an oral form. There's really good data coming out of that. 

There's good data now coming out at this Congress here about combination therapy rather than metformin mono-therapy at the onset of diabetes. After diet and exercise, the usual way of treating this has been to say, go on to mono-therapy, and when that fails, we'll put another agent in. 

Nobody had ever bothered to test that. And so this has now been tested with a DPP4 inhibitor to say, would it help to go onto combined therapy at the beginning? Or should we go on to metformin, and then combined therapy? You've got then two arms, which just test that hypothesis. And it turns out, for three reasons, that you do better to be on the combination therapy from the outset than you do just to add it on. 

But the most telling reason is that actually, over a 5 year study, you were 26% less likely to go on to insulin if you'd started on the combination therapy at the beginning, than if you'd started on metformin, and then had the other agent added in as needed. So that's exciting. 

We've got new data coming out about precision medicine as well. People are focusing now very much on the idea of thinking it's no good just treating everybody the same. 

And so the data from the CREDENCE trial, for instance, now showing that even people with well-established kidney disease, their outcomes are so much better if you're using an SGLT-2 inhibitor.

So we've got new information about GLP-1 agonists in terms of oral agents, we've got new information coming out about the SGLT-2 inhibitors with the CREDENCE trial, and the good outcomes from that.

And we've got new information about the DPP-4 inhibitors with the VERIFY trial. That's really exciting stuff.

There's been a lot of crossover with cardiology at this year's congress. Did recent cardiology conferences steal EASD's thunder?

Interestingly, we have a slightly different angle on things from the cardiologists and the European Society for Cardiology (ESC) produced their guidelines, and they asked us to contribute towards those and we were moving towards having a combined statement about those.

We differed significantly over some of the areas where the recommendations weren't wrong, but they looked as though they might be a bit too early. What was said to me is that they're moving into an 'evidence-free' area.

So we pulled back rather, and said we won't sign off on these as being joint guidelines, you can say that we had people on the committee which they duly did, and said they were in association with the EASD.

I'm all in favour of guidelines, and I'm all in favour of guidelines that say get on and treat people, right? But we really, really do have to have the evidence base for doing this. And the evidence base, you have to think about. It's not just that we've done a trial that shows a good outcome, it's that we've done a trial on the appropriate group of people that shows a good outcome. So if you take people who've had 10 years of diabetes, then we've got some good evidence about what you should be doing 10 years on in diabetes, OK? You can't just paste that forward and say, on day 2, we know what you're going to need to do with people with diabetes, because we don't know that. 

The European Society of Cardiology may be right in saying get in there and get on with some treatment and so on. But our position is to say, look, I like the idea of getting on and treating things and I like the idea of preventive medicine and don't let's have people with heart attacks. But do let's get the evidence, please. Please, please, let's not start having advice in evidence-free areas.

What priorities do you have for the rest of your time in office?

I've taken a very close interest in the way that the EASD is governed. I think that governance has been at the top of my list of priorities for this year. What we've recognised is that the EASD needs to have very open access in terms of saying who is on the committee for a start? We needed a proper nomination process. And we ran that through the Electoral Reform Society services in London and did that entirely so that it's all anonymous; we know nothing about those nominations, and we can't interfere with the nominations.

Secondly, once you've got those people nominated, then you have an election. It's a single transferable vote. You can then say A would be better than C and E goes to the bottom of my pile, and I'll mark those off in order of preference. 

The single transferable vote system is run entirely by the Electoral Reform Society. 

We then see that these are the top ranked people and we do those in two categories. We do those for pure science and for clinicians. 

Again, it's absolutely transparent that the committee is made up in that way. 

Then, we needed to expand the committee in order to allow enough conversation in the committee. I recognised that in the committee we've got people metaphorically wearing stethoscopes and people with Eppendorfs. In other words, we've got clinicians and scientists, but where are the financiers, and where's the legal advice? We can't run a board without finance and legal advice and so we needed to co-opt people. We found two brilliant people that we've appointed to the board with full voting rights and we've expanded the board slightly to allow those people on the board.

It was previously called the executive committee. It wasn't an executive committee. The executive is a wonderful organisation running out of Dusseldorf, headed up by Monika Grüsser. We're not the executive. We are the governing body, we are the board. So we've changed that. 

We've changed the articles of association, we've changed the way that we nominate for the board, we've changed the way that we elect for the board, we've put people on the board with the necessary experiences.

Then we've been working hard at setting up the European Diabetes Forum (EUDF), which is our forum. Again, articles of association going through the lawyers, and iteration 22 now is going through lawyers to be signed off.

So it's been hard work for all of those reasons. But now we have organisations that in my belief are fit for purpose for the 21st century. 

Why did we get to a position where we needed a new think about governance? And the answer is very simple, because you start off with a small organisation, and say we'll have a general assembly, and everyone puts their hand up and says yes, we can do that rather like a, you know, a small village community with a village hall and you just turn up and vote.

But by the time that you've got 4000 members, and you've got a meeting that's pushing up towards 15,000 attendees, then you've got to take something that says, just putting up your hand, at some general assembly is not enough. We need to be communicating with our members much better. 

I think the communication with the membership is better than it was, and I've written various letters saying this is where we're at, this is what we're doing.

The EASD is a charity. Yes, we do make a bit of profit, but all of that profit, apart from a small reserve in case we have a catastrophe, goes off to the European Foundation for the Study of Diabetes (EFSD), and I'm pleased to say that over 20 years the EFSD has given out altogether in excess of 100,000 euros in grants to researchers. 

That includes money that has come in from the meetings but the vast majority of that is coming from industry and our partners, who we are truly grateful [to] in their support of the enterprise. 

The other extraordinary thing that's happened over the last few years is the Novo Nordisk Foundation, independent from the pharmaceutical company, which is now giving out a prize on an annual basis at the EASD conference of nearly 700,000 euros to one person - a bigger prize than the Nobel Prize. 

That is mainly for their research purposes, so they have to be an active researcher, and part of it is an honorarium to themselves in order to run their lab in the way that they want to. 

So these are really, really significant things. We're truly grateful to the Foundation for putting that amount of money into diabetes. So we have wonderful partnerships with industry, with pharma, with many other partners that we're truly grateful for. And I think that all of those partnerships are the basis of a really improving future, both for people with diabetes and indeed for people who potentially would have got diabetes and now won't.

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