Saturday morning’s ADA Diabetes Care Symposium, Diabetes Care and Research through the Ages, explored changes in diabetes treatment over the years with an eye toward improving care in the future.
Matthew C. Riddle, MD, Professor of Medicine at Oregon Health & Science University, discussed how past cardiovascular outcomes trials shape ongoing efforts to reduce complications. Dr. Riddle referenced results from trials dating back to the 1990s that he said offer valuable lessons for today’s clinicians and researchers.
Dr. Riddle also cited more recent research indicating that glucose-lowering agents that have effects other than glucose lowering may reduce cardiovascular events by non-glycemic mechanisms.
“For clinical practice, I think it enhances the need for us to do a better job in treating the ordinary patients we see everyday, a high proportion of whom have relatively short-duration diabetes,” he said. “It also means that we need to do a better job in other areas. We should be screening to make earlier diagnoses in patients with diabetes—systematically screening so that patients don’t go five or seven years before treatment is instituted so there will be a favorable legacy effect 10 and 20 years down the road.”
Bernard Zinman, CM, MD, FRCPC, FACP, Director of the Leadership Sinai Centre for Diabetes at Mount Sinai Hospital, examined the current treatment paradigms for type 2 diabetes and ways to improve them. He promoted starting combination therapy earlier.
Current guidelines follow a stepped, menu approach starting with monotherapy—usually metformin—then accelerating dual therapy, and triple therapy if warranted. Metformin is a “wonderful drug,” Dr. Zinman said, but clinical inertia leaves too many patients on monotherapy for too long.
“This is a complex disease with various abnormalities contributing to hyperglycemia,” he said. “There may be different components in different patients. Can we expect a single agent to have a robust, durable impact? Given that understanding of diabetes, why do we expect a single agent to do this?”
Jay S. Skyler, MD, MACP, from the University of Miami Miller School of Medicine, opened the session with a look back to the origins of diabetes knowledge, starting with the earliest mention of the disease around 1,500 B.C. and the introduction of the term “diabetes” by the Greeks in 250 B.C. He also discussed developments in the late 20th century and the introduction of metformin in the United States in 1995.
Dr. Skyler said the story of insulin offers translational lessons worth remembering. He recounted how a team of researchers from the University of Toronto that included Frederick Banting, John J.R. Macleod, Charles H. Best, and James B. Collip, along with help from George H.A. Clowes of Eli Lilly and Co., led the way to mass-produced insulin.
“One of the things that we see so much of at this meeting is that everybody has their great, new, bench-top way to approach diabetes,” Dr. Skyler said. “They forget that to be successful, a product will need to be made and manufactured at commercial scale so it can be used. Many of the great ideas never come to fruition because it’s not possible to convert them from the tabletop to reality.”
Ele Ferrannini, MD, from CNR Institute of Clinical Physiology at the University of Pisa in Italy, concluded the symposium with a wide-ranging look ahead at areas such as genomics, environmental factors, pharmacology, and information technology. Information technology has shown great promise for precision and personalized medicine, he said, but the world of big data could lead to care becoming more impersonal, he warned.
Today, a patient visits the doctor, who gives feedback about treatment. Dr. Ferrannini discussed a future where the patient instead gives data that goes to an app, and the app provides the feedback. He then described a potential next step that involved greater anonymity.
“I think we will slightly slide into a replacement of the physical doctors that we have today with apps, and a sliding from a physical patient that we look at every day to ID numbers, eventually, to feed this black hole of big data,” he said.