Wednesday, June 22, 2016

Summary of ADA 2016

Every year the American Diabetes Association holds the largest diabetes conference of the year.  This year it was in New Orleans.  Attendance was over 16,000 people with 58% international participation. Although I did not attend, I did read (or at least skim) all the abstracts, and read all the tagged tweets that came out of the meeting.  This is my summary.  There were 100s of abstracts, scores of talks, and 1000s of tweets, so I'm only mentioning the most interesting items here.  I've divided this posting into four sections:

  • A very quick summary of the most important findings.
  • Coverage of clinical trials aimed at curing type-1 diabetes.
  • Coverage of research aimed at curing type-1 diabetes (but not yet in people).
  • Other items of interest.
A Very Quick Summary

The big type-1 news was all about artificial pancreas research.  The "Do It Yourself" artificial pancreas crew had a poster or two, plus a few meetings, but they dominated the buzz for the first day of the convention.  The commercial / professional artificial pancreas developers took over for the second day, with lots of published data.  

There was also more focus this year on "Quality of Life" issues.  Not just better numbers, but a better life.  More discussion of the whole person, and not just BGs and A1Cs.  Memorable quote was "The data alone can't be enough to make a decision", but I did not write down who said it.  There was also some discussion of using more patient friendly terminology (especially in the type-2 world).

In the world of type-2, the LEADER study showing several good outcomes from using liraglutide‎/Victoza and more data from EMPA-REG (both huge studies) made big news.  Everyone was talking about Metformin as though it was the next Vitamin-D (or the Vitamin-C of the 1970s...).

You'll notice I didn't mention much about clinical trials aimed at curing type-1 diabetes, or even curing type-1 at all.  There were two posters on clinical trials aimed at curing type-1 diabetes, and less than 10 talks aimed at curing type-1 diabetes, and that was about it.

This is DiabetesMine's summary of ADA 2016 (they cover a lot of topics which I do not):


Reports From Clinical Trials Aimed At Curing Type-1 Diabetes 

Combination Therapy with ATG + GCSF in Established Type 1 Diabetes: Two-Year Outcomes
Poster 1676-P:  
These researchers had previously reported beta cell preservation at 12 months.  (Meaning that most diabetics lost beta cells over time, but for those treated with ATG and GCSF their beta cell count remained constant.)  The result here is that after two years, treated and untreated people with type-1 diabetes had the same C-peptide numbers, so whatever advantage was seen after a year was not seen after two years.  (There were some immunological differences seen, but the C-peptide numbers, which are the most important in terms of a cure for type-1, were the same.)

Update on BCG Clinical Program for Reversal of Established Type 1 Diabetes


This is an update on Dr. Faustman's  phase-II study of BCG, which I've blogged on before.  The key new information is that they have recruited 125 patients out of the 150 people they need.  For one year of recruiting at one site, that is strong progress.  It suggests they will be fully enrolled by the end of the year.  Since the study runs for 5 years, we can expect completion in late 2021 and publication thereafter.  

Also, there is a single line on the poster about "Clinical Program 3" which is a new study.   It will give repeat doses of BCG to people who were already in the phase-I trial.  I think of it as a follow on study to the phase-I trial.  Since only three people got BCG in the phase-I trial, this clinical program will be tiny.

5-IT-SY03 - What Is the Future of Immunotherapy for Type 1 Diabetes?
This session contained about 5 talks which focused on using immunology to cure type-1 diabetes. Unfortunately, there were no abstracts for the talks, and no information about them at all.  So my only knowledge is a few tweets and web articles.
  1. Here is the official ADA preview of the session:
    http://www.diabetesdispatchextra.org/new-trials-testing-immunotherapy-for-type-1-diabetes/
  2. There was general optimism about IL-2 (which I just recently blogged about).
    https://twitter.com/em_saidwhat/status/742120883129593857
  3. There was pessimism about antigen-based therapies (ie. blocking the immune system's reaction to a specific target):  "Antigen-based new onset and Immunomodulatory onset studies have really not showed any positive substantial results.  --Jay Skyler MD"
    https://twitter.com/Diabetesdad/status/742109575868882944
Safety and Tolerability Results from a Phase-I study of Phizer's PF-06342674
PF-06342674 is a antibody that blocks a part of the immune system (IL-7 binding). This trial is testing physical properties of the treatment (how much ends up in the body, how quickly the body sheds it, any adverse effects, etc.) This is called "safety and tolerability". This trial is not in any way testing that PF-06342674 will treat or cure type-1 diabetes, but based on what is learned here, future studies could test this as either a treatment or a cure.

Optimistic Overview of Transplanting Pig Islet Cells Into People
http://www.ajmc.com/conferences/ada2016/islet-cell-transplantation-addressing-the-underlying-defect-in-type-1-diabetes
My comments: LCT is the company farthest along in transplanting pig islet cells.  They have done several phase-I and phase-II clinical trials, but the results have not led to a cure as yet.  As for islets from stem cells, Viacyte has started a phase-I trial.  Neither LCT nor Viacyte announced new data at ADA 2016 (that I know of).

Leptin (Metreleptin) In Patients With Type-1
We conclude that metreleptin was not efficacious in improving glycemic control in T1DM although it reduced body weight and daily insulin dose modestly.
My comments: In the past I have covered Leptin as a possible cure for type-1 diabetes.  However, this study suggests that, while it might lower insulin usage, it is not a cure.

Other Cure Research 
(I'm including a few AP papers here, but nowhere near all of them.)  From here down, this posting is mostly links to other sources of information.  Different people will be interested in different topics, so I encourage you to read the source material for the topics you care about.  My few comments are in italics.

Transplants  (But Still Need Lifetime Immunospressive Drugs)
http://www.abstractsonline.com/pp8/#!/4008/presentation/44271
My comments: one patient, but successful.

Tidepool
873-P / 873 - Pilot Study of Tidepool’s Blip Application for Data Visualization in Type 1 Diabetes (T1D)
http://www.abstractsonline.com/pp8/#!/4008/presentation/39609

AP Papers, Posters, Tweets, etc.

What do people think an AP is?  (It turns out to be totally different than what I think it is.)
http://www.abstractsonline.com/pp8/#!/4008/presentation/39746

More commerical AP links:



DiabetesMine @DiabetesMine
In designing AP pivotal trials, discussion is to make them 6-12 months to pursuade payers. Beyond FDA's 3-month requirement. #2016ADA
https://twitter.com/DiabetesMine/status/742167089453006848
My comment on this last tweet: The FDA has made it clear that they will approve APs based on 3 month clinical trials.  (I think this even covers bihormonal APs, which would include approving a lifetime of Glucagon micro doses with only 3 months of testing.)  However insurance companies may not pay for APs based on 3 months of data.  They might argue for more data to show it really is better.  Therefore there is pressure to run longer phase-III trials, so that one trial can lead to both FDA approval and insurance company payment.  But that would delay initial FDA approval while the longer trials completed.  There was a similar issue in CGMs.  They were approved by the FDA, but some insurance companies would not reimburse until the JDRF funded a longer study that showed benefits that the insurance companies could accept.


More "we are not waiting" (Homebrew AP) links:
While using #OpenAPS: self-reported outcome measures showed median HbA1c dropped from 7.1% (SD 0.8%) to 6.2% (SD 0.5%). #2016ADAWhile using #OpenAPS: self-reported outcome measures showed median HbA1c dropped from 7.1% (SD 0.8%) to 6.2% (SD 0.5%). #2016ADA
https://twitter.com/danamlewis/status/741671445911248896
#OpenAPS self-reported outcome measures showed median percent time in range (80-180 mg/dL) increased 58% (SD 14%) to 81% (SD 8%). #2016ADA
https://openaps.org/2016/06/11/real-world-use-of-open-source-artificial-pancreas-systems-poster-presented-at-american-diabetes-association-scientific-sessions/
Of note: user growth of #OpenAPS is doubling every 3 months, even though users must self-build these AP systems. #2016ADA
https://twitter.com/danamlewis/status/741671296245862401
My comment: that is a growth curve that any high-tech start up would be proud of.

Other Interesting Research
There were vast amounts of "my new insulin is better than your existing insulin" research.  None of that is included here.  If you care about the new insulins, I would search the ADA material directly, or wait for the press release announcing it is for sale in your country.

Easing the Child to Young Adult Transition
Two good tweets from Dan Browne:
Monaghan: for young adults, shared responsibility w/ parents for t1d care correlates with worse hbA1C. #2016ADA @collegediabetes
https://twitter.com/nakedsucrose/status/742719716632862721
#2016ADA Monaghan: protective factors for YA A1C: pers. responsibility, contact w providers, fear of hyperglyc. #2016ADA @collegediabetes
https://twitter.com/nakedsucrose/status/742719143649017856
My comment: what this seems to say is that giving young adults personal responsibility for their BG is a better strategy than shared responsibility.  I don't think that is conventional wisdom, however.  I do think this talk will be available on line in the future, and will be worth viewing when it is.

Systematic Population Screening, Using Biomarkers and Genetic Testing, Identifies 2.5% of the U.K. Pediatric Diabetes Population With Monogenic Diabetes.
http://www.ncbi.nlm.nih.gov/pubmed/27271189
via Eleen Ullman's tweet:
https://twitter.com/CureT1Diabetes/status/741676639096963073

CGMs Beat Diabetic Alert Dogs 
Basically, CGMs detected lows earlier than dogs, and dogs often alerted when there was not a low situation.  You can read more in this news article:
http://www.healio.com/endocrinology/diabetes/news/online/%7B7577bf07-3df7-4937-82fd-7bf741697f60%7D/service-dogs-can-detect-hypoglycemia-alert-companion
http://www.medpagetoday.com/clinical-context/Diabetes/58474
And three tweets on that talk:
https://twitter.com/dcarbohydrated/status/741645653969928192
https://twitter.com/KellyRawlings/status/741644965407789056
https://twitter.com/sstrumello/status/741649562847305728

Causes of Death for People With Type-1
http://www.abstractsonline.com/pp8/#!/4008/presentation/40218
1473-P / 1473 - Causes of Death in the First 100 Type 1 Diabetes (T1D) Donors in the Network for Pancreatic Organ Donors with Diabetes (nPOD)
My comment: the link above goes to an abstract.  It is tough to read but important.  Deaths directly caused by type-1 were very common.  So was suicide and drug use.  This is very cautionary data which should not be ignored.

Inhaled Insulin
MannKind announces more data (six posters) on their inhaled insulin: 


Dosing For Protein
Pratik Choudhary tweeted:
#2016ADA - preliminary results show 60 gms protein require 25% more insulin - practically - % increase of bolus with increased fat or prot
https://twitter.com/drpratikc/status/741760675622621184

Nasal Glucagon
https://twitter.com/SEDiabetes/status/742732325914562561

Type-1 Diabetes and Autism
http://www.abstractsonline.com/pp8/#!/4008/presentation/40873
http://www.abstractsonline.com/pp8/#!/4008/presentation/40901

Type-1 Diabetes and Sleep Apnea
http://www.abstractsonline.com/pp8/#!/4008/presentation/39594

Metformin (there was far more than this)
https://twitter.com/Doctor_Deena/status/741377801996009472
http://www.abstractsonline.com/pp8/#!/4008/presentation/39832

Type-2 
Shaming Is Common:
https://twitter.com/janespeight/status/742360128716984320
LEADER data:
https://twitter.com/kellyclose/status/742476794352144384
http://www.nejm.org/doi/full/10.1056/NEJMoa1603827#.V18nymZf1mY.twitter
My comments: If you have type-2, you may want to discuss this with your doctor.  (And even if you don't, your doctor may want to discuss it with you. :-)
EMPA-REG data:
https://twitter.com/RpratleyMD/status/742711726978699266
Position paper on terminology for "Diabetes"
https://static.diabetesaustralia.com.au/s/fileassets/diabetes-australia/9864613f-6bc0-4773-9337-751e953777cd.pdf
My comments: This statement misses what I consider the two most important rules:
Differentiate between type-1 and type-2 diabetes! (when appropriate)
Do not say "diabetes" when you mean "type-2 diabetes" or when you mean "type-1 diabetes".


More Interesting Tweets:

Doctor Deena @Doctor_Deena
Amazing #technology for #diabetes-- a skin patch using wavelengths to deliver #insulin into skin pores. #2016ada
https://twitter.com/Doctor_Deena/status/741745686526361600

Mark Harmel MPH, CDE @MarkHarmel
Results of DiaMonD study (CGM in MDI users) impressive. #2016ADA Fewer highs, lows and reduced variability. + Lower A1C by 0.9% at 24 weeks
https://twitter.com/MarkHarmel/status/742120533848936449
My comment: MDI is multiple daily injections.  What this study is showing is that even people who are not using a pump will benefit from using a CGM.  While I suspect this is true, I'm not sure it is useful, because I suspect these people don't want or cannot use a CGM for the same reason they don't want or cannot use a pump: they don't want an attachment or can not afford it.  Telling non-users "it is good for you" will not make them users: they know it is good for them.  They have other reasons for not using it.

Dr.Harsha Doddihal @Harshadod
Consuming #proteins followed by carbs could be beneficial in #glycemic control! Poster 62-LB
https://twitter.com/Harshadod/status/742123177766223872
My comment: is this news?  I always thought eating carbs after non-carbs led to smaller post meal BG spikes.


Joshua Levy 
http://cureresearch4type1diabetes.blogspot.com
publicjoshualevy at gmail dot com
All the views expressed here are those of Joshua Levy, and nothing here is official JDRF or JDCA news, views, policies or opinions. My daughter has type-1 diabetes and participates in clinical trials, which might be discussed here. My blog contains a more complete non-conflict of interest statement. Thanks to everyone who helps with the blog.

2 comments:

Rick said...

Great summary of the ADA meeting. Deaths of people with type 1? Wow, I will need to read that one.

I referred your blog to the TUDiabetes.org blog page for the week of June 20, 2016.

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