Charles F. Shaefer Jr, MD

One of the best features of the American Diabetes Association ADA Scientific Sessions is the Poster Hall. Here literally thousands of posters are displayed sharing the work and findings of numerous participants. Monday is always my poster day.

The posters are broken into numerous sections that reflect various large areas of diabetes care. As a diabetologist, I’m always most interested in the new therapies and clinical practice topics. While there are few new therapies this year, many posters focus on the safety and efficacy of recently introduced therapies such as SGLT2 inhibitors, GLP-1 receptor agonists (GLP-1 RA), and DPP-4 inhibitors. The sheer number of reports reflects how prevalent these therapies are becoming in clinical practice.

Of particular interest was a poster demonstrating that the new GLP-1 RA albiglutide, when added to basal insulin, reduces post-meal blood sugar equally as well as rapid- acting analog insulin. This seems an interesting alternative to mealtime insulin since albiglutide leads to weight reduction and does not introduce hypoglycemia-two dreaded consequences of adding mealtime insulin. A saxagliptin poster exploring the effect of this DPP-4 inhibitor on patients with advanced renal insufficiency showed usual efficacy with no detrimental impact on renal status at all. This is important since DPP-4 use may be progressively relegated to patients with renal impairment in light of GFR restrictions with the SGLT2 inhibitor class and some GLP-1 RAs. In the population with type 2 diabetes, 20% to 40% has some degree of CKD.

Clearly there is great interest in the SGLT2 inhibitors based on the number of posters outlining various aspects of their use. Perhaps one of the most compelling findings reported is the power of SGLT2 inhibitors in combination with DPP-4 inhibitors to reduce A1C in patients not well controlled on metformin alone. Posters showing the benefit of dapagliflozin with saxagliptin and empagiflozin plus linagliptin both showed significant A1C reduction with very few side effects. I wonder if glucagon regulation by these two DPP-4s may be at the heart of this beneficial combination?

I spent the afternoon at a session of oral reports on GLP-1 RAs. While it is clear that these drugs are very effective as monotherapy or add-on agents, the most fascinating data related to the use of basal insulin and GLP-1 RAs in fixed-dose combination. These combinations were very effective and, probably due to the slow up-titration of the GLP-1 RA component as the basal insulin is titrated, they all seem to have much less negative GI impact than when used alone. It seems that soon we will be using such fixed-combination agents to treat fasting and prandial hyperglycemia together.

I closed the afternoon with a conference on preservation of the beta cell. Several speakers delivered information on how early insulin use, select agents like incretin therapies, and other potential strategies can delay the deterioration of the beta cell. Since failure of the beta cell is central to causation and worsening of diabetes, any strategy that thwarts that failure will certainly be beneficial to millions of patients with diabetes.

By 2 pm the posters were being taken down and the exhibit hall disassembled. Clearly the end is near. More about the closing day tomorrow.

Articles

Posters at ADA 2014 showcased growing popularity of the incretin therapies and SGLT2 inhibitors. Most fascinating to this diabetologist blogger was use of insulin and a GLP-1 RA in a fixed-combination product.

Charles F. Shaefer Jr, MD

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ADA Posters: Incretins, SGLT2s, and New Fixed-dose Combos