EASD: Precision in Diabetes Management and Impact of COVID-19

Miriam E. Tucker

September 23, 2021

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

The European Association for the Study of Diabetes (EASD) 2021 annual meeting will delve into individualized approaches in diabetes management, particularly with regard to tailoring drug therapy for type 2 diabetes and management of type 1 diabetes.  

The virtual meeting, taking place September 28 to October 1 in Central European Summer Time, will feature results from TriMASTER (a three-way cross-over trial of precision medicine strategy of second-/third-line therapy in type 2 diabetes), new subgroup analyses from the GRADE (Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness) study, the final version of a consensus statement on type 1 diabetes management, and new data on the dual incretin agonist tirzepatide, as well as much more.

"I'm a strong believer in personalization. I don't think the big blockbuster [drugs] will serve the entire community with diabetes. Even in type 1 diabetes, there's evidence of heterogeneity...We need a better way to identify individual needs. I think that's where we're going...It's one of the themes of the conference," EASD President Stefano Del Prato, MD, professor of endocrinology at the University of Pisa, Italy, told Medscape Medical News.

He noted that EASD and the American Diabetes Association (ADA) have recently teamed up with other organizations to form the Precision Medicine in Diabetes Initiative.

As would be expected, the meeting will also feature numerous presentations on the COVID-19 pandemic, including studies looking at how people with COVID-19 and diabetes have fared; how the pandemic has affected diabetes care; and the still unclear impact of SARS-CoV-2 on pancreatic beta-cells and whether, in some instances, it triggers new-onset diabetes.  

New Data From Previously Reported Trials

There will be new data from several previously reported trials focusing on specific groups of patients with type 2 diabetes. One is the EMPEROR-Preserved study of empagliflozin (Jardiance) in individuals with heart failure and preserved ejection fraction. Initially presented in August 2021 at the virtual annual congress of the European Society of Cardiology (ESC), the new data will focus on patient subpopulations, efficacy endpoints, and safety in patients with and without diabetes. A companion study, EMPEROR-Reduced, in those with heart failure and reduced ejection fraction, was presented at the ESC Congress in August 2020.

New findings will also be presented from the DAPA-CKD study of dapagliflozin (Farxiga) in patients with chronic kidney disease. The study was stopped early in March 2020 because of overwhelming efficacy of the drug in preventing CKD. Now, the data will be analyzed in terms of metabolic, nephrology, and cardiology parameters.

And from FIDELIO-DKD and FIGARO-DKD, trials of the nonsteroidal mineralocorticoid receptor antagonist finerenone (Kerendia), new data will also focus on a variety of subgroups of individuals with type 2 diabetes and chronic kidney disease.

"Our goal is to cover most aspects of what's happening in the type 2 diabetes field," EASD Honorary Secretary Mikael Rydén, MD, PhD, professor and senior consultant in endocrinology at the Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden, told Medscape Medical News.

Rydén, who chairs the meeting's scientific program committee, added: "We can only focus on so much every year but we try to be active and changing from year to year. I'm convinced that a clinician or translational researcher will definitely have a number of very interesting symposia to follow and learn new things. If you follow all of these things, you will know a lot about what's cooking in the diabetes world."

Consensus on Type 1 Diabetes Management: Special Considerations

Both Del Prato and Rydén cited presentation of the new type 1 diabetes ADA/EASD consensus report as among the most clinically important of the conference. Initially presented in draft form at the ADA Scientific Sessions in June 2021, the document aims to move away from routinely applying principles derived from studies of patients with type 2 diabetes to those with type 1 diabetes, an autoimmune disease with unique characteristics.

The final version of the document is expected to include information on goals of therapy, glycemic targets, prevention and management of hypoglycemia and diabetic ketoacidosis, psychosocial care, and special populations, among other issues. It is also expected to include a section dedicated to adjunctive treatments beyond insulin, including metformin, pramlintide, glucagonlike peptide-1 (GLP-1) agonists, and sodium-glucose cotransporter 2 (SGLT2) inhibitors for certain patients.  

Del Prato noted, "From a clinical point of view, this is quite an important step that two major organizations came together recommending some strategies for treating type 2 diabetes...It really deals with a big problem and tries to provide the tools for improving homogenization of the treatment of type 1 diabetes across the different health systems."

And Rydén commented, "I think it's really important to have, since there's been so much focus on type 2 diabetes for the last few years, and to have the ADA and EASD getting together and actually write this."

But Rydén also pointed out that outcomes data are much more conclusive for drugs in type 2 diabetes to inform international guidelines, whereas "this is much more difficult to demonstrate with type 1 diabetes. With a new pump or [continuous glucose monitor (CGM)] you might show a reduction in A1c of X percent or X mmol/mol or hypoglycemia events, but it's much harder to show improvements in hard outcomes like deaths and cardiovascular events. I'm really looking forward to having this presented."

Diabetes in 2021: It's Personal

Several meeting sessions will specifically address precision medicine approaches, including the TriMASTER study, which aims to identify subgroups of patients with type 2 diabetes who respond well or poorly to particular drugs based on clinical characteristics so that treatments can be better targeted to individuals. In total, 600 patients with type 2 diabetes and suboptimal glycemic control with metformin were randomized to a dipeptidyl peptidase-4 (DPP-4) inhibitor, an SGLT2 inhibitor, or thiazolidinedione (TZD).

According to Rydén, "The TriMASTER final results will be interesting. TZDs still have a place...You can't give them to people with heart failure, but I think like a carpenter you have to have many tools in your toolbox. And I still think that there are some individuals who respond well to pioglitazone. [The study findings] could be influential, depending on the results."

An EASD/ADA symposium entitled "Optimizing diabetes diagnosis, prevention and care: Is precision medicine the answer?" will offer three distinct perspectives, with one speaker arguing it's the future of diabetes medicine, another that it isn't, and a third explaining that "the devil is in the details."

The Diabetologia symposium will focus on a related concept: the use of artificial intelligence in diabetes research and care, with particular application to glucose control, neuropathy, and wound healing.

And during the 36th Camillo Golgi Lecture, kidney disease expert H.J. Lambers Heerspink, PhD, of the University of Groningen, the Netherlands, will speak about personalizing treatment for patients with type 2 diabetes, arguing that "the mean is meaningless."

Next-Generation Incretin Therapy: Is Weight Loss the Treatment?

New data will continue the buzz from the ADA meeting surrounding tirzepatide, the dual GLP-1 receptor agonist and glucose-dependent insulinotropic polypeptide agent.

A session will add new data from SURPASS-3 CGM, looking at the effect of the drug captured by CGM in patients with type 2 diabetes; SURPASS-3 MRI, examining the effect of the drug on liver fat content and abdominal adipose tissue; and SURPASS-4, investigating the efficacy and safety of tirzepatide once weekly versus insulin glargine in patients with type 2 diabetes and increased cardiovascular risk.

The drug is notable for its dramatic reductions in both A1c and weight, although questions remain about the incidence of gastrointestinal side effects and effects on long-term cardiovascular and renal outcomes.

Rydén commented, "Given its effects on A1c and body weight, we would expect a positive result, but one never knows. It's at least safe, that's for sure. I think this mode of action is extremely interesting."

Del Prato noted that tirzepatide could also "open up a new area of intervention for type 1 diabetes. The initial data were promising...It's worth keeping an eye on."

A related symposium will address the future of incretin-based treatments overall, while the EASD-Lancet symposium will examine whether the treatment of obesity is the "future" of diabetes treatment.

COVID-19, Hypoglycemia, Bone, and Much More

As always, there's much more on the agenda. Other noteworthy sessions include those addressing hypoglycemia management; a joint EASD/European Society of Endocrinology session on diabetes and bone; a debate about whether women with diabetes are at higher cardiovascular risk than men; and in-hospital management of hyperglycemia. 

A new feature of the meeting will be a roundup/wrap-up, where members of the program committee and speakers will summarize the day's highlights. And another feature, "EASD e-Learning," has been expanded to include more clinical topics on insulin use, nonalcoholic fatty liver disease, obesity, and neuropathy. 

Overall, Del Prato said, "It's a very populated program, with more than 700 presenters,162 invited symposia speakers, and 53 chairs. It's covering widely different areas from basic to clinical research...It's a lot of stuff going on."

Both Rydén and Del Prato have disclosures with multiple manufacturers of diabetes-related products.

Miriam E. Tucker is a freelance journalist based in the Washington, DC, area. She is a regular contributor to Medscape, with other work appearing in The Washington Post, NPR's Shots blog, and Diabetes Forecast magazine. She is on Twitter @MiriamETucker.

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