In August, I had the pleasure of traveling to Atlanta, Georgia to attend the American Association of Diabetes Educators (AADE) annual meeting. I sat in on several seminars, the most interesting of which are summarized here.
Prediabetes, Diabetes, and Cardiovascular Risk: Can We Do More?
Dr. Richard Nesto, from the Lahey Clinic in Burlington, Massachusetts, emphasized the importance of managing not only blood glucose, but also blood pressure and cholesterol (lipids). “Keep in mind,” said Dr. Nesto, “that 70 percent of people with diabetes die of cardiovascular disease.” He felt strongly that people with diabetes, and even those with prediabetes, could benefit from taking a statin. Two studies were cited by Dr. Nesto, the Nurse’s Health Study and the JUPITER Study, both of which indicate that early treatment with statins reduces cardiovascular risk. It’s clear that patients who have diabetes or prediabetes, as well as those who are still just at risk for diabetes, should discuss statins and cardiovascular management with their healthcare providers.
Beyond GLP-1: The Future of Peptide Hormone Therapies
Dr. David Kendall, soon to be Chief Scientific and Medical Officer for the ADA, spoke about peptide hormone therapies for people with type 2 diabetes, including the drugs that are available now and those that are still under investigation. For 75 years, the only peptide hormone in use was insulin, but since 2005, new peptide hormones have become available. And it’s becoming very apparent, Dr. Kendall pointed out, that a number of peptide hormones play significant roles in diseases such as diabetes and obesity. According to Dr. Kendall, “Peptide hormone therapies have the potential to modify the abnormalities in metabolic diseases, but also the disease process itself, such as disease progression, islet cell function, and body weight.” He made it clear that with all we have available, it’s a combination of therapies that will eventually improve management of type 2 diabetes, including medical nutrition therapy, weight management, and emerging weight advantage therapies.
Beta Cell Replacement: Regeneration and Cellular Strategies
Jay Skyler, MD, MACP, described what we know about the causes of type 1 diabetes-some sort of environmental insult that leads to progressive decline in beta cell function and, ultimately, type 1 diabetes. In his discussion of beta cell replacement, he said, “I believe that in terms of islet replacement therapy, progress is being made toward being successful. But the technology is still in evolution, and we have a ways to go.” He also noted that the balance of risks versus benefits continues to be at the center of islet cell transplantation research.
Data from the Edmonton protocol show that three years after islet cell transplantation, 25 percent of recipients still have insulin independence and all recipients experience a dramatic reduction in severe hypoglycemia (the reason that most of them were accepted for the transplant). Those who do need insulin take between 15 and 20 units on average and continue to have function from their transplanted islets.
Causes of islet cell loss after transplantation include failure of the grafts due to inflammation, lack of beta cell regeneration, the toxic effects of immunosuppressive agents, and recurrent autoimmunity that selectively attacks beta cells. Ongoing research to address these hurdles is employing several tactics. Among them are using the anti-CD52 monoclonal antibody alemtuzumab (Campath-1H) to deplete lymphocytes; inducing chimerism to reduce rejection; using T regulatory cell therapy to induce tolerance of immunosuppressive agents; xenotransplantation of pig islet cells; using nanoencapsulation of islet cells to protect them from attack; giving immunosuppressive agents locally to lower the drug load and reduce side effects; using embryonic stem cells that can differentiate into islet cells and multiply; and using beta cell growth factor or drugs to induce growth. There’s also work on an implantable pump to locally deliver immunosuppressive agents.
Another obstacle to islet cell transplantation is a lack of islet cells available for the process. In making a plea for organ donors, Dr. Skyler asked the audience members to raise their hands if they were organ donors. Many hands went up. He noted that in some countries, citizens have to check off if they don’t want to be a donor. It’s an idea that might be worth exploring here in America.