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European Association for the Study of Diabetes 2009 Annual Meeting (Vienna, Austria, September 28-October 2, 2009)

by jessica swienckowski

Recently, the diaTribe team journeyed to Vienna, Austria for the 45th Annual Meeting of the European Association for the Study of Diabetes (EASD). This is one of our favorite meetings, as it is essentially the European counterpart to the American Diabetes Association Scientific Sessions in the US and is truly a global gathering of the most accomplished minds in diabetes. The meeting attracted over 18,000 attendees (beating out last year’s ADA attendance by 3,000!). We wanted to take some time to reflect on this conference and are now bringing you what we feel are both key take-home messages and also a good review of diabetes happenings in 2009.

a focus on new and innovative therapies for type 2 diabetes

As was the case at ADA, incretins (DPP-4 inhibitors and GLP-1 agonists, such as Januvia and Byetta, respectively) were a major focus. Incretins are a group of hormones believed to increase insulin levels after eating - they are only active when blood glucose levels are elevated, thus minimizing the risk of hypoglycemia. At the meeting, Novo Nordisk launched (for Europe, where it was approved last July) its new once-daily GLP-1 analog Victoza (liraglutide), which was approved by the FDA on January 25, 2010 and is now commercially available in the US. We also heard about long-acting incretins on the horizon: there is a once-weekly version of Byetta by Amylin and Eli Lilly (a “new drug application” or “NDA” was filed in the US last year and the FDA is expected to make a decision any day), and similar long-acting GLP-1s albiglutide by GlaxoSmithKline, taspoglutide by Roche, among others, prepared for later release in the next years.

Beyond incretins, we started to learn more about a very new class of drugs called SGLT2 inhibitors. These drugs take advantage of the kidney’s natural function to clear glucose from the body, encouraging the excess glucose to be secreted in the urine instead of reabsorbed into the blood stream – very clever! While these drugs are primarily being explored for type 2 diabetes at this time (for more information and a chance to participate in an ongoing trial, see Trial Watch from this issue), there seems to be strong interest in exploring its use in type 1 diabetes as well, which would be exciting given that the last new drug for type 1 before Symlin was insulin itself! Several companies are working on this new class of drugs, the furthest along in development being AstraZeneca/Bristol-Myers Squibb with dapagliflozin (currently in phase 3 in the US; the drug should file for approval in the EU sometime this year).

Moving beyond pharmaceutical choices, we listened to an interesting discussion on bariatric surgery to treat type 2 diabetes. While plenty of questions exist on how bariatric surgery relieves diabetes and other cardiovascular risk factors, it will be equally important – going forward – to better understand which individuals are most appropriate for the treatment (only the obese, or perhaps even people with prediabetes and lower body weight?). We think this is an exciting area of treatment with huge potential for growth, but clearly, figuring out the right patients to receive bariatric surgery is very important.

to help without harm – diabetes therapies scrutinized for unintended side-effects

There was extensive discussion concerning the link between diabetes therapies and cancer risk, a recent topic of interest in the media after a few articles were published in the scientific journal Diabetologia evaluating the association between cancer risk and sanofi-aventis’ Lantus (insulin glargine). Dr. Jay Skyler (University of Miami) presented evidence disputing the German study that sparked the controversy (the analysis of 127,000 insulin-treated patients in a German insurance database suggested a 9-31% increased risk of cancer malignancy with glargine compared to human insulin). He also criticized the media for over-extrapolating the results and presented multiple other analyses that have not shown increased risk of malignancy for glargine compared to other insulins. Interestingly, epidemiologic studies have shown an association between decreased cancer risk and metformin (see Learning Curve from this issue) – we must remember such associations cannot be taken as a cause-and-effect relationship, but they are nonetheless interesting in the new hypotheses they help formulate. More work is needed in this field, but the clinical takeaways were that physicians and patients should be aware of the increased risk of malignancy in diabetes patients in general, metformin and insulin should continue to be first and second line therapies for type 2 diabetes, and evidence-based use of insulin analogs should be continued.

In the diabetes world, we continue to see substantial interest from diabetes researchers in cardio-protection - i.e., drugs that could benefit the hearts of people with diabetes. Going forward, any drug that can be shown to reduce heart attacks and strokes in the long-term will grab the attention of physicians and patients alike, as cardiovascular risk reduction is a large part of the management of type 2 diabetes. We are seeing far more drug manufacturers pay attention to the cardiovascular implications of their drugs (looking at the effects of the drug on cholesterol levels, blood pressure, etc.) and to the weight-loss profiles of their drugs (most new diabetes drugs are designed to be weight-neutral, unless they offer other benefits that make weight gain an acceptable trade-off).