Diabetes Update 2005

Better Blood Sugar Balance

Diabetes Update 2005

WebMD Live Events Transcript

The American Diabetes Association has held its 65th Annual Scientific Sessions, where researchers and clinicians from around the world gathered to share information. Cleveland Clinic endocrinologist S. Sethu K. Reddy, MD, joined us on June 15, 2005 to share the latest news from this important conference and answer your questions.

The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

MODERATOR:
Welcome to WebMD Live Dr. Reddy. Thank you for joining us today.

REDDY:
Good morning and good afternoon to everyone. I look forward to your questions.

MODERATOR:
Let's start by discussing the highlights of the just concluded American Diabetes Association (ADA) Scientific Sessions.

REDDY:
I think the ADA concluded its meeting June 14 in San Diego and there were several highlights, including new therapies for diabetes .

Within the last three months we've had approved two new injectible therapies, which are going to start a new class of medications for diabetes. One is called Symilin, which is an analog of a hormone that is made by beta cells, the same cells that make insulin. It has been found that this hormone reduces your appetite, slows down the rise in sugar levels after eating, so in general causes weight loss along with improvement in diabetes control. The other injectible agent that has been approved is called exendin and the trade name is Byetta. This is a hormone that actually is derived from the venom of a giant lizard in the southwestern U.S.. It's called the Gila monster.

"We don't accept a high blood pressure reading once a person has been diagnosed with hypertension. Likewise, with diabetes, as we get better and safer therapies, we naturally want the sugars to be in the normal range, which means to aim for a more normal A1c."

This is a fascinating hormone that appears to improve insulin secretion, preserve beta cell life, and also result in some weight loss. These new therapies do not cause low blood sugars by themselves, and also the dosage does not have to be adjusted from day to day. They are available in a pen form so that it's convenient for patients to take it and both would improve postprandial or after-eating blood sugar levels and cause weight loss. So for many of our patients, this addresses one concern, in terms of many are worried about weight gain when they improve their diabetes. These agents actually cause weight loss. They are injectibles right now and that may be a barrier for some of our patients. As many of our readers or listeners know, you can bring your blood sugars down fairly well by targeting the fasting blood sugars, but to get the blood sugars in a better or perfect range one has to target postprandial blood sugars. These new therapies certainly fit a niche in that particular area.

The other highlight from the meeting would be changing attitudes towards the targets for control. More and more, endocrinologists would like the hemoglobin A1c to be 6.5% or lower compared to the current value of 7%. The Europeans, Japanese, and American college of Endocrinology have already said to go below 6.5%. Cholesterol levels are also being targeted. Some scientists feel that if you have diabetes your LDL cholesterol should be less than 80. There were several symposia on cardiovascular risk in diabetes, and the theme was early aggressive therapy to lower the cholesterol. Recent clinical trials were highlighted which suggest that if one has diabetes, one should almost automatically be on a lipid-lowering agent.

MEMBER QUESTION:
Why the changes in target levels?

REDDY:
We already know the normal range for hemoglobin A1c in nondiabetic individuals is 4%-6%, so in the past when we're aiming for 7%, we thought that was practical, but we knew that was not quite normal. If you look at other conditions like blood pressure or leukemia, we always try to get the patient back to normal. We don't accept a high blood pressure reading once a person has been diagnosed with hypertension. Likewise, with diabetes, as we get better and safer therapies, we naturally want the sugars to be in the normal range, which means to aim for a more normal A1c.

There is some feeling that even hemoglobin A1c of 5.5% might put those people at a higher cardiac risk. We have information that so-called nondiabetics with A1c of 5.5% or 6% have a higher risk of heart disease. So maybe in 10 years' time we would actually like people's A1c to be less than 6%. The biggest barrier to getting to these low targets is low blood sugars. Obviously, we don't want to put anyone at risk of severe hypoglycemia. So the challenge will be to find, again, safer therapies in the future, which don't cause hypoglycemia.

MEMBER QUESTION:
How soon will the new therapies you described be available?

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Type 2 Diabetes Diagnosis, Treatment, Medication

REDDY:
The two injectible therapies are already available.

MODERATOR:
What were some of the other highlights of the conference?

REDDY:
There is tremendous interest in gastric bypass surgery for managing severe obesity. There have been some very good outcomes from this type of procedure published. There is some early information that bypass surgery in those with diabetes may actually appear to cure diabetes, especially if the surgery is performed when the patient is only on oral agents or has had diabetes for a short time.

Currently national guidelines recommend gastric bypass surgery for those with diabetes if they have a body mass index of 35 or over. There is currently a debate about perhaps trying to perform the surgery with a body mass index of 30 or over.

The data show that if the surgery is performed later in diabetes, chances are less for reversal of the diabetes. So the debate is whether to offer this relatively expensive surgical procedure in early diabetes and obesity.

"This is some exciting development in the field of medical management. It's a new medication from Europe from the company Sanofi-Aventis, which promises to reduce appetite and cause weight loss."

MEMBER QUESTION:
How about inhaled insulin?

REDDY:
There's still a great interest in inhaled insulin. The one product that's being researched by Aventis and Pfizer has been well received in studies by patients. However the FDA is still looking for longer-term lung safety data.

People in the audience may know that one needs to take about 10 times the insulin by the inhaler to get the same response as a subcutaneous dose. Also, inhaled insulin works very well for mealtime coverage, but is not the answer for basal insulin.

In the future, people may be taking a basal insulin injection and inhaled insulin for mealtime coverage. But right now, there is no inhaled insulin that will be FDA approved this year.

MODERATOR:
Tell us about the news regarding Rimonabant.

REDDY:
This is some exciting development in the field of medical management. It's a new medication from Europe from the company Sanofi-Aventis, which promises to reduce appetite and cause weight loss. This works through the dopamine pathway in the brain and does not have any cardiac or pulmonary side effects.

What is interesting is this may also be useful in other addictive behaviors, such as smoking, so this medication may also be useful in smoking cessation. There are promises that it will arrive next year on the U.S. market; it has already been released in Europe.

Over the course of a year, it can cause between 10 to 30 pounds of weight loss depending on the person's baseline weight.

MODERATOR:
There was discussion about a new potential oral drug for type 2 diabetes.

REDDY:
There is a lot of research happening with medications that are related to TZDs, such as Actos or Avandia -- called PPAR-gamma receptor drugs. There is some interest in having these types of agents that not only work on PPAR-gamma, but also a PPAR-alpha. There are several companies that are investigating these so-called dual agonists. The hope is that these agents will not only improve blood sugar levels, but will have a dramatic impact on lipids as well as vascular function. There is some early evidence that TZDs may benefit the endothelium in blood vessels and may protect the blood vessels from atherosclerosis. These new drugs will also hopefully have even better vascular effects. In the future, one may see these medications being targeted for those with heart disease and not necessarily those with diabetes only.

MEMBER QUESTION:
I have diabetes type 2, I am age 25, and I am now expecting my first child (18 weeks, 6 days.) My sugars are always under 125 after one hour meal plan and fasting is always under 85. Is this good control and will my baby have any problems if once in a while my sugar goes up to 160? I am controlling by dieting only; I haven't started insulin yet.

REDDY:
I think this would be gestational diabetes and your sugars appear to be in good control.

An occasional blood sugar going to 160 should not harm the baby. The main concern in gestational diabetes is the size of the baby. One does not expect any congenital problems with the baby. However, during the last part of the pregnancy -- the last four months or so -- if the blood sugars are elevated, the baby makes more insulin in response to the higher sugar. And insulin leads to more fat storage in the baby. So the baby may become larger and one may have to have a C-section at the time of delivery.

In general, I am sure that you're in good hands with your obstetrician, since they're following you with the baby's growth rate, ultrasound, as well as following your metabolic profile.

"Women who come from a high risk ethnic group, such as Hispanic, African-American or recent immigrant groups to the U.S. or those who are older, overweight or following sedentary lifestyles, are also at greater risk of developing diabetes during pregnancy."

MEMBER:
I was diagnosed with diabetes type 2 three years ago.

REDDY:
If a woman has type 2 diabetes before getting pregnant, then there is a higher risk to the infant since many of the baby's organs are fully formed by the end of the third month of pregnancy. So we always advise good blood sugar control prior to conception, as this will minimize any congenital problems in the future. Ideally, we like to get the hemoglobin A1c as close as possible to 6.5% or lower prior to the pregnancy.

MODERATOR:
There was a presentation about gestational diabetes at the conference.

REDDY:
A few additional facts about gestational diabetes: Women who come from a high risk ethnic group, such as Hispanic, African-American or recent immigrant groups to the U.S. or those who are older, overweight or following sedentary lifestyles, are also at greater risk of developing diabetes during pregnancy.

The definition of gestational DM is that the diabetes disappears following the delivery. This is good news, but we also consider this as a yellow flag. Over the next five to ten years, following the pregnancy, the mother is at higher risk of developing type 2 diabetes. Some of this information was confirmed by the Nurses' Health Study from Boston, which was also presented at the ADA meeting.

MODERATOR:
There was a great deal of discussion about the relationship between inflammation, diabetes and heart disease.

REDDY:
Over the last two or three years, there's been a lot of interest in inflammation and heart disease. Many have read TIME and Newsweek about PRP levels to be checked as a risk marker. There is some data suggesting that C-reactive protein levels may be more predictive of diabetes than LDL cholesterol. This was a real surprise for many physicians. PRP is a marker of inflammation and we think these blood tests are reflecting inflammation in the blood vessels. We know that with atherosclerosis, hardening of the arteries, there is inflammation seen in the blood vessels. We also know that with diabetes, there is a higher risk of heart disease and we generally find higher levels of these inflammatory markers in diabetes.

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Currently, there are no bona fide anti-inflammatory therapies for heart disease. We do know that the TZDs (Actos and Avandia) do lower these inflammatory markers. We also know that improved blood sugar control can reduce inflammatory markers. The other point to remember is if a diabetic has high levels of these markers, we need to be even more aggressive about lowering blood pressure and lowering cholesterol levels.

MODERATOR:
There was a report about palm pricks instead of finger pricks.

REDDY:
There is a lot of interest in doing the capillary glucose checks from sites other than the fingers. Some groups suggest one can check the palm, others suggest one can check the forearm.

In general, the finger pricks correlate best with actual blood sugars taken from the arm at your hospital laboratory or doctor's office. The sticks that one does in the forearm may not reflect the low blood sugar as quickly as a finger prick would. Palm pricks probably would be very close to the finger pricks and may not be as much of a problem.

In the near future we should have some implantable glucose centers which would be good for six months to one year and if this technology becomes available, then one would not have to prick their fingers or palms or forearm.

"Treating blood pressure is perhaps the single most cost effective way to reduce risk of chronic kidney disease and heart disease in diabetes."

MEMBER QUESTION:
Is a CRP of 4.9 (confirmed with two blood tests) really bad?

REDDY:
When it comes to CRP levels, remember that if we have a sore throat, infection or flu, you can get extremely high CRP levels. So when that happens it's not a risk of heart disease we're concerned about.

The CRP level that we are testing for heart disease is actually called hsCRP and it's just highly sensitive CRP. So these levels are measured when the patient is otherwise well, and you're looking for very small changes in the CRP levels in the so-called low end range. Like any test, this test does not tell you that you have heart disease, but you may be at a higher risk.

So getting back to our people with diabetes, if you are a good patient and you have a good doctor, you are probably already aggressively treating your cholesterol and blood pressure and eating a heart-healthy diet. In this situation, a high CRP level would not change your management because you are already doing all the right things to reduce the risk of heart disease.

MODERATOR:
Two reports from the CDC reflected both good news and bad. The bad news: They reported the incidence of diabetes rose almost 41% from 1997 to 2003. This is just new cases per year. The good news: Kidney disease in people with diabetes has declined 40% in the years from 1990-2002.

REDDY:
There were some striking observations at the ADA from the CDC showing a marked prevalence of diabetes in the country, but at the same time, a striking reduction in kidney disease in diabetics. I think these generally reflect improved surveillance and screening for diabetes and improved treatment of hypertension in the diabetes. Treating blood pressure is perhaps the single most cost effective way to reduce risk of chronic kidney disease and heart disease in diabetes. Some of the increased prevalence of diabetes might also reflect the increasing incidence in teenagers of high-risk communities.

MODERATOR:
There was a great deal of news about new therapies and advanced research. However I found it very interesting that a rather simple community-based program led to a 70% reduction in amputations. The program was focused on getting patients to do regular foot checks.

REDDY:
It's clear that we already know what to do to prevent many complications. The problem is for us to develop health care systems that can implement this knowledge with good outcomes. We have many financial as well as social barriers to achieving this.

It's great to see that a simple intervention, such as an energetic community-awareness program targeting foot care, can reduce foot-amputation rate by 70%.

It's also important to note that we need to have patients do more self-management with their diabetes and to be advocates for their care so that they themselves can push the health care system to provide better care.

"The Holy Grail for diabetes right now is the promise of stem cells that could behave as beta cells and that would be widely available and well tolerated by people with diabetes."

MEMBER QUESTION:
Are we close to any cures?

REDDY:
There is no cure yet for type 2 diabetes, although we know that increased exercise and reducing body weight will reduce the risk of developing type 2 diabetes by about 50% to 60% over a five- to six-year period. So there is a treatment or a way to prevent diabetes, but it's a lot of hard work.

As yet, there is no magic pill that will prevent diabetes outright. We also have a way to go before a cure for type 1 diabetes is found. The Holy Grail for diabetes right now is the promise of stem cells that could behave as beta cells and that would be widely available and well tolerated by people with diabetes.

MODERATOR:
Our thanks to Sethu Reddy, MD, for joining us today. For more information, please visit the Cleveland Clinic web site (www.ccf.org) as well as the American Diabetes Association web site (www.diabetes.org).



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Reviewed on 6/27/2005 7:26:01 PM

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