Updates by Dr. Jothydev Kesavadev
Dr. Jothydev Kesavadev provides comprehensive updates on advancements in diabetes management at a conference, focusing on both type 1 and type 2 diabetes.
It is important to address obesity alongside diabetes, for prevention of complications and improvement of quality of life as primary objectives. There is a need for a multifaceted approach, incorporating lifestyle modifications, medications, and potentially surgical interventions to achieve optimal outcomes.
The Effect of Weight Loss on Co-morbidities
Dr. Jothydev Kesavadev emphasizes Lifestyle Modification and Medications plays a major role along with Diet.
But there are subgroup of individuals opting for interventions like gastric bypass or banding.
Melanie Davis addresses the need to fill the gap before such interventions, focusing on newer options like combination pharmacotherapy, particularly GLP-1 medications. GLP-1 drugs, originally approved for diabetes and related conditions, are now also approved for managing obesity, offering a heterogeneous range of treatment options.
A new era is on the horizon for type 2 diabetes treatment.
Dr. Jothydev Kesavadev explains how Automated Insulin Delivery (AID) is now integral to the clinical practice of Type 1 diabetes (T1D) with emergence of a Neural-Net Artificial Pancreas (NAP), encoding AID algorithm into a neural network that approximates its action.
In a study, the UVA model-predictive control (UMPC) algorithm was converted into a NAP, which was then compared with UMPC in a randomized crossover trial involving 17 T1DM patients, aged 22-68, with baseline HbA1c ranging from 5.4% to 8.1%.
Results showed that the neural network implementation of UMPC demonstrated comparable performance to traditional UMPC but required significantly fewer computational resources. This process, known as NAPing, allows for the replication of insulin dosing rules using neural networks.
Furthermore, NAP calculations were approximately six times faster than UMPC, showcasing the efficiency and potential of neural network-based AID algorithms in diabetes management.
Updates by Dr. Purvi Chawla
Dr. Purvi Chawla highlights that Glucagon like peptide-1 receptor agonists (GLP-1 RAs) are recommended as the first injectable therapy for type 2 diabetes mellitus (T2DM). However, despite this recommendation, basal insulin remains widely preferred due to factors such as cost, reimbursement issues, and prescribing habits.
Clinical trials like DURATION-7, AWARD-9, SUSTAIN-5, and PIONEER-8 have indeed demonstrated significant reductions in HbA1c levels when combining GLP-1 receptor agonists with basal insulin. The reduction in HbA1c ranged from 1% to 1.8%, with the highest reduction achieved by Semaglutide.
Additionally, across these same trials, there has been a significant reduction in body weight ranging from 1 kg to 6.4 kg. The highest weight reduction was observed with Semaglutide 1 mg administered once weekly.
Dr. Purvi Chawla discusses the ADA 2024 recommendations on advancing basal insulin emphasize the importance of optimizing therapy for patients with diabetes. Despite the challenges in initiating insulin therapy, it is crucial to address poor glycemic control, which affects nearly 50% of patients.
a. According to the ADA, patients may already be on a background of metformin with or without SGLT2 inhibitors when considering initiating basal insulin.
b. If patients fail to achieve fasting plasma glucose targets with basal insulin or if the basal insulin dose exceeds 0.5 units per kg per day without achieving control, therapy needs to be intensified.
c. The ADA does not recommend switching to pre-mixed insulins but suggests several options for intensification:
Dr. Purvi Chawla summarizes the SURPASS-6 Trial. SURPASS-6 Trial compared patients with T2DM who were uncontrolled on baseline oral hypoglycemic agents (OHAs) plus basal insulin.
They were randomized to receive either Tirzepatide at three doses (5, 10, or 15 milligrams once weekly) or a complete basal-bolus regimen with insulin lispro, while continuing oral agents and basal insulin.
In Conclusion:
Dr. Purvi Chawla explain how the present analysis demonstrates that the plasma glucose levels associated with the best individual combination of insulin sensitivity and glucose sensitivity that are substantially lower than the conventional thresholds for FPG and 2-hG and that subjects with non-Opt glycemias are at increased risk of progressing to diabetes.
The IDF's approach involves a mathematical solution utilizing a constraint optimization algorithm to identify minimal glucose levels associated with optimal combinations of insulin sensitivity and beta cell function. The optimized fasting glucose levels suggested are <87 mg/dL for women and <89 mg/dL for men under 45 years of age, with slightly higher thresholds for older individuals. Additionally, the optimized 2-hour glycemia levels are found to be lower than conventional diagnostic thresholds. Individuals with non-optimized glycemia are deemed to be at increased risk of progressing to diabetes.
Studies, such as the San Antonio Heart Study and meta-analyses, have demonstrated that a one-hour post-load glucose level of at least 155 mg/dL predicts the risk of diabetes more sensitively than other measures such as fasting or two-hour post-load glucose levels or HbA1c. The proposed use of one-hour post-load glucose levels for identifying high-risk individuals before the onset of conventionally defined pre-diabetes could enable more proactive lifestyle interventions to prevent the progression to diabetes.
