Progress in diabetes care: looking back at 2016
As 2016 draws to a close, our editorial board members reflect on the key advances in understanding and treating diabetes over the past year, and give their thoughts on the research to watch out for in 2017.
The year 2016 has been an exciting time for diabetes care. Two landmark trials reported the cardiovascular benefit obtained with use of the glucagon-like peptide 1 receptor agonists (GLP1RA) liraglutide and semaglutide. These trials, LEADER and SUSTAIN-6, built upon last year’s developments, when EMPA-REG OUTCOME become the first outcome trial to report cardiovascular benefit with a glucose lowering drug (empagliflozin). The year has ended with icing on the cake, as DEVOTE has announced its top line results, proving the cardiovascular safety of the ultra-long acting insulin analogue degludec in a high risk population.
As 2017 dawns, we hope for better care, and better outcomes, for all people living with diabetes. Forms of insulin proven to be cardio safe, other glucose lowering drugs with cardiovascular benefits, and optimal psychosocial care, provided in an integrated manner, should be able to help us achieve this.
2016 was a year of hope for people living with diabetes, with the announcement of changes in outcomes both cardiovascular and renal in major cardiovascular outcomes trials along with the addition of glucose lowering therapies that provide comprehensive diabetes care, reducing glycated hemoglobin, limiting weight gain and reducing hypoglycemia for the management of type 2 diabetes, and the encouraging news from the artificial pancreas work for type 1 diabetes. Add to this improved insulin therapies and insulin therapies with GLP1RA, our toolbox is becoming more patient-friendly and we are going to be able to push to the targets when knowledge changes quality and quantity of life for people with diabetes.
2017 promises more of the same with the results of several large trials expected, and in addition access to new and improved glucose monitoring systems, through which we will continue to improve diabetes care and quality and quantity of life.
My highlight of 2016 has been the emergence of the sodium/glucose cotransporter 2 (SGLT2) inhibitors. As a primary care physician I really was suspicious about the idea of a medication that would cause glycosuria. I felt like challenging one of the systems that "releases pressure" when we are hyperglycemic could not be good for the body. But quite to the contrary – as we saw in the EMPA-REG outcomes trial – indeed not only do these medications work but they improve patient outcomes including reducing cardiovascular events, death and even reducing the progression of nephropathy – this really forced me to go back and revisit the physiology of the kidney. I have come to appreciate that the glucose load is likely actually less to the glomerulus when you are taking a SGLT2 inhibitor because the glucose is not reabsorbed and not recycled.
In 2017, I am looking forward to advances in continuous glucose monitoring and introduction of newer systems like the "Libra" to the US market. Self-monitoring of blood glucose is a real challenge for patients and can be costly. Newer sensors have the potential of reducing patient burden and reducing cost. This will be a great step forward in patient-centered diabetes care.
In 2016, the outcomes of current practice in diabetes care remain poor; even in middle income countries such as Mexico, a high proportion of patients are not receiving basic care and widely available generic drugs that could make a real difference to their health and life expectancy. Even in the UK the national diabetes audit shows that only about 40% of patients achieve key care processes, and over a third are not reaching glycated hemoglobin targets. On a more positive note we saw the results of not one, but two outcome trials with GLP-1 receptor agonists for the treatment of type 2 diabetes, with both the LEADER trial (with liraglutide) and the SUSTAIN-6 trial (with the investigational once weekly GLP1 analogue, semaglutide), showing reduced cardiovascular events and mortality and improvements in renal outcomes as well.
In 2017, we all hope for an increased focus on doing the simple things well to improve outcomes for patients. We will see more cardiovascular and renal outcome data from newer diabetes drugs including CANVAS and CANVAS-R trials with canagliflozin. Further advances in technology are also expected in 2017 – we are getting closer to the closed-loop insulin infusion systems and the artificial pancreas for type 1 diabetes.