Exenatide (Byetta) launch
Lilly UK hosted a one-day symposium, entitled Targeting Type 2 Diabetes: A New Choice in Patient Care, on Tuesday 13th March.
The first session of the day addressed beta-cells in type 2 diabetes and the role of incretin hormones in glucoregulation. Clifford Baily, Head of Diabetes Research at Aston University in Birmingham, focussed on glucagon-like peptide 1 (GLP-1), which under normal conditions binds to surface receptors on β-cells and potentially stimulates glucose-dependent insulin secretion and suppresses glucagon secretion. In people with type 2 diabetes or impaired glucose tolerance, GLP-1 response is significantly reduced or absent.
The clinical evidence for the use of exenatide (Byetta; Lilly, Basingstoke), an incretin mimetic sharing many glucoregulatory actions of GLP-1, was evaluated by John Buse, Chief of the Division of Endocrinology at the University of North Carolina School of Medicine. In the studies he described, exenatide significantly improved glycaemic control, body weight and some CV risk factors compared to placebo, with the main reported side-effects being gastrointestinal in nature.
In comparison to a long-acting insulin, Chair Melanie Davis of the University of Leicester showed that exenatide was non-inferior in people with type 2 diabetes suboptimally controlled by metformin and/or sulphonylurea.
The final session of the day, Exenatide: Theory into Practice, saw Jiten Vora, Consultant Physician of the Royal Liverpool University Hospital, confirm that while metformin will continue to be the agent of first choice, exenatide is likely to be used in the pre-insulin stage of treatment of people with type 2 diabetes.
Diabetic neuropathy symposium
On the evening of March 14 the Boehringer Ingelheim and Eli Lilly satellite symposium Neuropathic Pain: From Mechanisms to Medicine was held at the conference venue.
The speakers examined the mechanisms of chronic pain, the advances in clinical treatments for painful diabetic neuropathy and how people with neuropathic pain feel physically and emotionally. The overall conclusion was that much more effective ways to treat neuropathic pain are needed.
Irene Tracey, Professor of Pain Research at the University of Oxford, outlined the pathways by which pain is experienced and the difficulties in targeting the central cause of the pain. ‘We must have a multidimensional approach because it is a multidimensional experience,’ she said.
Solomon Tesfaye, Consultant Physician/Endocrinologist at the Royal Hallamshire Hospital, Sheffield, discussed the advances in combination therapy that can be used to treat the pain.
In the final presentation, Edward Jude, Consultant Diabetologist at Tameside General Hospital, Manchester, reviewed some of the psychological issues that affect those with diabetic neuropathy and suggested that mental health was 40% lower in this group compared to the rest of the population. He said, ‘We have to look at treating the pain effectively if we are to improve their quality of life.’
Social deprivation linked to poor psychosocial adjustment
Researchers interviewed people from a hospital diabetes service about their physical abilities, social support, diabetes knowledge and psychological adjustment to the diagnosis of type 2 diabetes. The results indicate that those living in the most deprived areas find it more difficult to adapt to the demands that diabetes places on them. Positive psychosocial adjustment to the diagnosis of type 2 diabetes is known to be a predictor of good management outcomes. These data can be used to design resources and information campaigns.
Blood glucose monitoring today
Jo Head, Lead Clinical Nurse Specialist at the Winchester diabetes team, spoke first at the Bayer Healthcare symposium, held on the occasion of the Diabetes UK APC. She stressed that blood glucose monitoring (BMG) does not improve glycaemic control or decrease complications – instead, it must be used to adjust medication, diet and activity levels.
Additionally, post-prandial BGM can monitor other risk factors associated with diabetes, including atherosclerosis and macrovascular problems, she said.
Simon Grant, Deputy Director of Medicines Management, Bradford and Airedale tPCT, addressed the current restrictions on BGM test strips. Research has not found a convincing association between BGM and HbA1c and this has been misinterpreted by some UK PCTs as an indication that BGM is unnecessary.
Simon shared a table of recommendations and concluded, ‘We don’t need restrictions, we need sensible and pragmatic guidance.’
High risk of CV complications in the under 40s
According to a study published on the first day of the conference, younger people with type 2 diabetes have a greater risk of developing cardiovascular disease (CVD) than those over 40 years of age.
The study compared the CVD risk profile of people with early (< 40 years old) and late (> 40 years old) onset type 2 diabetes in people who had no history of CVD.
The researchers found that in those who were diagnosed with type 2 diabetes before they were 40 years of age, despite having lived with the condition for less time, there was a higher proportion of people with high blood pressure and poor glucose control. This group were also more likely to be morbidly obese than their older counterparts.
Dr Song, the lead researcher on this paper said: ‘Type 2 diabetes is no longer confined to the middle-aged and elderly population. We are seeing an increasing number of young adults diagnosed with this condition.’
The Director of Care, Information and Advocacy Services at Diabetes UK, Simon O’Neill added: ‘This research is extremely worrying, particularly in light of the fact that we already know that 80% of people with diabetes die of CVD. We are sitting on a health time bomb that will have a huge human and monetary cost if we do not take action now.’
Lack of consistent advice for drivers with diabetes
The authors of this study presented data describing whether advice given to drivers with insulin-controlled diabetes was consistent between healthcare professionals and care settings. They aimed to see if the current health care situation was the same as in 2000, when the results of a study were published showing that drivers were often given conflicting information about their fitness to drive.
Questionnaires were sent to consultant diabetologists, specialist registrars, GPSIs and hospital-based and community-based DSNs. Five case studies were outlined and the professionals were asked to comment on the advice that they would give the drivers.
A wide range of advice was given for all scenarios and in one there was a statistically significant difference between advice given from primary and secondary care (P<0.005).
The authors concluded that there continues to be a lack of consensus in the advice given to people with insulin-treated diabetes by different healthcare professionals and between advice given in primary and secondary care.
The Driving and Vehicles Licensing Authority stipulate that any driver with diabetes that is controlled by insulin must be able to recognise hypoglycaemia.
Retinopathy affects 1/3 of young people with type 1 diabetes
On the 15th March a survey was presented showing that one in three people with type 1 diabetes between 18 and 30 years of age already has retinopathy, with more than one in twenty suffering from an advanced stage of the disease.
The study of 103 individuals shows that those who had retinopathy were more likely to have a history of clinic appointment non-attendance than those who did not have retinopathy.
Despite government guidelines suggesting that young people with diabetes should be screened for retinopathy once every 12 months, recent statistics show that 26% of people aged 12–17 years with diabetes had not been screened.
Ritesh Rampure, the lead researcher on the study said, ‘Retinopathy is a common complication in people with diabetes but seeing such widespread signs of the disease in such young adults is alarming… we need to address the issue of non-attendance to stop people from losing their sight needlessly.’
Specialist diabetes services cut
On the first day of the conference, the Cuts in Diabetes Specialist Services report was launched by Diabetes UK. The report comprises survey results from 162 DSNs across the UK.
More than one-quarter of the healthcare professionals surveyed reported cuts in the funding to their diabetes team in the past year, 18% said posts had been made redundant and 43% said that vacant posts were frozen.
The report shows a decrease in the time spent with patients. Over half of those surveyed said that they now spend less time with patients than before and there was an increased delay in seeing a DSN due to redeployment onto general wards.
One-third reported an increase in hospital admissions while a quarter said that emergency admissions had increased. These extra admissions could have been avoided if people had been able to see a member of the specialist diabetes team.
Of those who completed the questionnaire, 77% were based in England, 10% each in Northern Ireland and Scotland and 3% in Wales.
Belief and depression data
Data describing the illness beliefs and prevalence of depression in people with type 2 diabetes attending a DESMOND structured education course were presented by Chas Skinner and colleagues.
Thirty-one per cent did not think they would have diabetes for the rest of their life, 80% believed they could affect the course of their diabetes, 60% worry about the complications of diabetes and 10% had indications of possible depression.