This month’s newsletter cannot help but be dominated by the recent European Association for the Study of Diabetes (EASD) conference in Vienna. Unfortunately, we were not able to attend in physical form due to the pandemic; however, the virtual experience was very good indeed. We got to pick our outfits and meet up in the plaza. We had great fun trying to jump in the water and teleporting into other rooms, and Beth made a joke to the organisers that we couldn’t find the toilets. Slight issue with the programme, though, as every time we left the plaza our default avatar would be a man on our return!

New insulins
This year, everyone was excited to hear about the new once-weekly insulin from Novo Nordisk, called insulin icodec. The results looked promising; however, its 196-hour half-life profile did raise some eyebrows. Questions about how it would work clinically in practice were on everyone’s lips.

Icodec is now into its phase 3 trials and so will likely not be as far away as we expected. The data shown at EASD, which pitched insulin glargine U100 against it, confirmed that there were no differences in body weight or HbA_1c between the agents. This medication might be good for insulin-naïve people who have type 2 diabetes. Hopes are that it will reduce clinical inertia and stop people holding back from starting insulin. The presenters also said this would not be available for people with type 1 diabetes.

A lot of discussion was had around hypoglycaemia risk, those with chronic kidney disease and the flexibility of the insulin; people who are active, for example, would potentially not benefit. The titration also remains a large issue; transferring someone to this would literally involve adding up their weekly dose and giving it as one single dose, and titrating the daily dose by 4 units would mean adding on 28 units to the weekly dose. Could it reduce district nurse visits, however?

The next trials are going to compare icodec to U100 and U300 insulins. There are talks, too, that other companies are now developing weekly insulins of their own. There is a lot to think about before we see it on the market.

Other “new” insulins which were discussed included the “Technosphere” nasal insulin and an oral insulin. Nasal insulins remain a little out of fashion as we have experienced them before. This new one did have some interesting data showing a decline in FEV₁ in a proportion of recipients over 2 years of use; however, this returned to baseline once the product was discontinued. There was no mention of the glycaemic effect of this product.

Use of oral insulin (in this case, Oramed’s ORMD-0801) has been tricky due to the way it is absorbed – there are a lot of obstacles to get over, such as the pH level in the stomach, the protease threat and mechanisms of action. However, there were some encouraging results in people with type 2 diabetes in a phase 2b trial presented at the meeting. There were no hypoglycaemia effects from using the oral insulin. The speaker suggested that this would be an adjunct therapy to tackle high HbA_1c and glycaemic variability in people with all types of diabetes; it would not be a substitute for subcutaneous insulin.

Lyumjev (insulin lispro-aabc) is the new fast-acting mealtime insulin by Eli Lilly and, in case you were wondering, it’s pronounced “LOOM-jehv”, although that may take some practice! It comes in two strengths – 100 units/mL and 200 units/mL – and has a more rapid onset and offset compared to insulin lispro (Humalog). The 100 units/mL concentration is suitable both for subcutaneous bolus regimens and also for insulin pumps.

The EASD session on Lyumjev was presented by Dr Emma Wilmot and explored study data from the phase 3 PRONTO-T1D and PRONTO-T2D clinical trials. Lyumjev resulted in lower post-prandial glucose excursions compared with Humalog, an effect which lasted up to 4 hours. For those with type 1 diabetes, at 1–2 hours post-injection, it reduced the glucose level by 1.6–1.7 mmol/L, compared with 0.7–1.0 mmol/L in the type 2 diabetes study.

The conclusion was that Lyumjev helps to increase time in range (TIR) without increasing the risk of hypoglycaemia. We know that less TIR can increase the risk of microvascular complications. For those living with type 1 diabetes who have access to continuous or flash glucose monitoring, it is much easier to assess the percentage of TIR; however, for those living with type 2 diabetes the focus is generally very much on pre-prandial glucose levels; should we be routinely suggesting post-prandial monitoring?

VERTIS CV
Further results were presented from the VERTIS CV trial of ertugliflozin, the fourth SGLT2 inhibitor to come to market. The results showed that, although safe in terms of major adverse cardiac events (MACE), ertugliflozin was not superior to placebo in people with type 2 diabetes and established atherosclerotic cardiovascular disease. The agent also failed to show superiority in its secondary cardiovascular and renal endpoints.

These findings were interesting and confusing, as the participant demographics and characteristics were very similar to the EMPA-REG OUTCOME trial of empagliflozin. There appeared to be a consistent effect with respect to reductions in hospitalisation for heart failure (HHF) across the SGLT2 inhibitor class, but MACE reductions in the cardiovascular outcome trials have only been statistically significant for canagliflozin and empagliflozin.

So, with four SGLT2 inhibitors and all their trial data, which one should we be using? That is the question, and we think really it has to be based on science, data and, most importantly, individual patient needs. Will this cause confusion for primary care? Possibly yes, and there are also CCG and local formulary issues and cost-saving work, which will of course vary across the UK.

EMPEROR-Reduced
EMPEROR-Reduced was a phase 3, randomised, double-blind, placebo-controlled trial looking at empagliflozin for the treatment of chronic heart failure with reduced ejection fraction in people with and without diabetes. The composite primary endpoint was the time to first event of adjudicated HHF, with secondary outcomes being first and recurrent adjudicated HHF events and the slope of change in eGFR from baseline. The results showed a 25% reduction in risk for the primary endpoint and a 30% and 50% reduction in risk for the first and second secondary endpoints. So it looks like we may have some exciting times ahead in terms of treatments for heart failure.

It’s not all about EASD!
Autumn has arrived, and with this has come an increase in the number of COVID-19 cases. The increase was not unexpected as lockdown has eased, schools and universities have opened their doors and people are once again having more contact with each other. Unfortunately, this has meant that restrictions have begun to be reintroduced, and now businesses must be closed between 22:00 and 05:00. We are once again being encouraged to work from home where possible. When we are out and about, we must all remember “Hands, Face, Space”.

As part of the Government’s test-and-trace system, the NHS COVID-19 app has been released, which enables those who register to know their local area’s risk level, check into venues using the NHS QR code, check symptoms and read the latest advice.

Language Matters website
The Language Matters publication was released in 2018 and should be at the forefront of our verbal and written communication with people with diabetes. At the DSN Forum, we as specialists in diabetes are extremely proud and passionate advocates about getting the language we use in communication with people living with diabetes RIGHT! We see so many referrals with the following terms:

“Poor compliance”
“Poorly controlled diabetes”
“Diabetics”

This month, the new Language Matters website has been launched. Please have a look at the website and share widely with colleagues! Let’s challenge colleagues who use poor examples and end the stigma for people who have diabetes.

If you have a look in the voices section, you may recognise a few people, and we even made a TikTok video to advertise the new site.

QiC Diabetes nominations
We were very excited to find out that Tasmin and Vicki have been nominated for Diabetes Healthcare Professional of the Year 2020, each by their colleagues within their diabetes teams. You may have seen numerous voting posts across our social media platforms and across their own NHS Trusts and social media pages. Voting closed on 14 September, and we wait in anticipation to find out if they become finalists for this year’s virtual ceremony, taking place on 15 October.

Twitter masterclass
We love everything about social media, and so on 29 September we gave a masterclass alongside our friends at the Inpatient Diabetes Forum, which was set up by Professor Gerry Rayman. The masterclass took place on Zoom and we recorded it too. We had loads of people attend and listen to us give some of our top tips about how to use Twitter. It’s such a great platform to showcase your work, gain CPD and network with colleagues. Watch this space, as the DSN Forum team plan to do many more of these in the future, focusing on all forms of social media. If you prefer to lurk but would like to know about how to use social media to improve your knowledge or contacts, we hope to be at DPC showcasing our tips for Twitter, TikTok, Facebook, LinkedIn and Instagram. So do come along!

Hypo Awareness Week
Last but not least, Hypo Awareness Week is here, and this year our competition is all about raising awareness using TikTok. If you are unsure how to do one, check out our account, @dsnforumuk. We have a host of different TikToks that we’ve made for various education sessions. The app is quite user-friendly – just give it a go, and if you get stuck, give as a shout on Twitter or email and we’ll give you a hand. Vicki and Amanda are our resident TikTok experts!