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Diabetes Update Matt Bouchonville, MD Endocrinology Division University of New Mexico ACP New Mexico Chapter Scientific Meeting November 7, 2014 mbouchonville@salud.unm.edu Slide 2 Diabetes Update 1.The stats revisited 2.Bariatric surgery long-term effects on DM 3.Newer drugs for diabetes 4.Technology update 5.A cure for type 1 diabetes? 6.Endo ECHO: Meeting the needs of underserved communities Slide 3 Diabetes: Current rates and projections CDC Press Release 2010: 1 in 3 adults with DM by 2050CDC Press Release 2010: 1 in 3 adults with DM by 2050 JAMA 2014;311(17):1778.: Increase in prevalence in youth between 2001 and 2009 of T1D (20%) and T2D (30%)JAMA 2014;311(17):1778.: Increase in prevalence in youth between 2001 and 2009 of T1D (20%) and T2D (30%) ADA Report: health care costs for DM increased by 40% to $245 billion between 2007 and 2012ADA Report: health care costs for DM increased by 40% to $245 billion between 2007 and 2012 Slide 4 Diabetes prevalence in the US leveling off? Slide 5 Lower rates of diabetes- related complications in the US Slide 6 Diabetes Update 1.The stats revisited 2.Bariatric surgery long-term effects on DM 3.Newer drugs for diabetes 4.Technology update 5.A cure for type 1 diabetes? 6.Endo ECHO: Meeting the needs of underserved communities Slide 7 Surgery group >6Xs more likely to be in remission of T2D at 15 yrs Slide 8 Remission less likely with longer duration of diabetes Slide 9 Surgery associated with >50% reduction in microvascular complications Slide 10 Surgery associated with 30% reduction in macrovascular complications Slide 11 Impact of bariatric surgery on diabetes- related complications attenuated by longer duration of diabetes Slide 12 Conclusions Compared to usual care, bariatric surgery was associated with : Higher diabetic remission rates Fewer diabetic complications Bariatric surgery may have less influence on diabetic remission and complication rates in patients with longer duration of disease Slide 13 Diabetes Update 1.The stats revisited 2.Bariatric surgery long-term effects on DM 3.Newer drugs for diabetes 4.Technology update 5.A cure for type 1 diabetes? 6.Endo ECHO: Meeting the needs of underserved communities Slide 14 SGLT2- inhibitors Slide 15 Slide 16 Slide 17 Similar A1c reduction (-0.52%) by end of study Slide 18 Weight loss (-3.22 kg) vs gain (+1.44 kg) with SGLT2I versus SU treatment Slide 19 Less hypoglycemia with SGLT2I vs SU treatment Slide 20 FDA Approval March 2013 Canagliflozin (Invokana) January 2014 Dapagliflozin (Farxiga) August 2014 Empagliflozin (Jardiance) Contraindications: Severe renal impairment Adverse effects: Hypotension/dehydration, genital mycotic infections Slide 21 Inhaled insulin Slide 22 Afrezza (Technosphere insulin) Technosphere insulin particles made up of diketopiperazine derivatives and insulin, which self-organize into a lattice array, and form particles of 24 m diameter. Slide 23 Rapid absorption of Technosphere insulin Slide 24 Modest A1c reduction at 12 weeks Cough ~30%Cough ~30% No clinically meaningful changes in PFTs (short-term)No clinically meaningful changes in PFTs (short-term) Slide 25 Affrezza: FDA Approval June 2014 Prandial insulin in T1D or T2D Baseline PFTs required Post-market studies in progress: Subjects with baseline lung disease Lung cancer risk? Slide 26 U-300 Insulin glargine (Lantus) Slide 27 Similar reduction in A1c compared to U-100 glargine Slide 28 Similar reduction in FPG compared to U-100 glargine Slide 29 Similar doses of basal and mealtime insulin Slide 30 Less nocturnal hypoglycemia with U-300 glargine Slide 31 Similar glycemic control and dosing with U- 300 glargine insulin but less nocturnal hypoglycemia Slide 32 Insulin peglispro (LY2605541) Slide 33 Insulin PEG (20 kDa) Slide 34 Insulin peglispro (LY2605541) Patent application US 12/481,111, 2009. Slide 35 Insulin peglispro (LY2605541) Compared to insulin glargine: Less glycemic variability Less hypoglycemia No weight gain Preferential hepatic (vs peripheral action) Diabetes Care 2014;37:659-665. Diabetes Care 2014;37:2609-2615. Diabetes 2014;63:390-392. Slide 36 Glimins Slide 37 Imeglimin Targets mitochondria (oxidative phosphorylation blocker) = decreased hepatic gluconeogenesis Increases skeletal muscle glucose uptake Enhanced insulin secretion in response to glucose Slide 38 A1c reduction of 0.7% compared to addition of placebo Slide 39 Diabetes Update 1.The stats revisited 2.Bariatric surgery long-term effects on DM 3.Newer drugs for diabetes 4.Technology update 5.A cure for type 1 diabetes? 6.Endo ECHO: Meeting the needs of underserved communities Slide 40 Continuous subcutaneous insulin infusion (CSII) Slide 41 CSII allows for delivery of variable rates of basal insulin infusion throughout the day Basal insulin rates Slide 42 Does insulin pump therapy eradicate the dawn phenomenon? Diabetes 2014;63:Supplement 1 A212-A343. Slide 43 Slide 44 Unpredictability of the dawn phenomenon Roughly a 50% chance of the dawn phenomenon occurring on any given night Slide 45 No impact on frequency of the dawn phenomenon (A) but increased hypoglycemia (B) in dawn programmers vs non-programmers *, P = 0.47 compared with dawn programmers. , P = 0.001 compared with dawn programmers Slide 46 Conclusions The dawn phenomenon does not occur predictably in patients with type 1 diabetes CSII programming for a fixed increase in early morning insulin to counteract the dawn phenomenon was associated with: No effect on the occurrence of the dawn phenomenon Increased rates of hypoglycemia The prevailing strategy for countering the dawn phenomenon is not effective and may be hazardous to the patient Slide 47 FDA Approves Threshold Suspend Feature Slide 48 Mean glucose values in 1,438 threshold suspend events Slide 49 Less nocturnal hypoglycemia (38% reduction) with threshold suspend feature Slide 50 No increase in hemoglobin A1c Slide 51 No difference in rare occurrence of ketosis between control group and threshold suspend users Slide 52 Bionic Pancreas Slide 53 5-day outpatient study in 20 adults and 32 adolescents with T1D Bionic pancreas vs conventional insulin pump Slide 54 Adults: average glucose 133 mg/dL (bionic) vs 159 mg/dL (pump); P