Getting the right care, at the right time, is vital to helping people avoid the complications of diabetes and live long, healthy lives. At the American Diabetes Association (ADA) Scientific Sessions we heard the latest on research advances that could help to improve care and reduce the harm diabetes does.
RELIEF from DKA with flash glucose monitoring
Flash glucose monitors are a way of measuring your blood sugar levels without having to prick your fingers. The technology can give you much richer information about your blood sugars and the direction they’re heading, and at the ADA we found out whether it can help to reduce diabetic ketoacidosis (DKA).
The RELIEF study is the largest study to date looking at the impact of flash glucose monitoring on rates of hospitalisation for DKA. It involved 33,203 people with type 1 diabetes and 40,955 people with type 2 diabetes who used the FreeStyle Libre in France. DKA rates were recorded in the year prior to people starting Flash and in the year after.
The results revealed that flash glucose monitoring halves the risk of being admitted to hospital with DKA. Yearly DKA rates were reduced by 52% on average in people with type 1 diabetes and 47% in those with type 2 diabetes.
The greatest reductions in DKA hospitalisations were seen in people who previously didn’t monitor their blood sugar levels. But even when people had been frequently finger prick testing (they used more than five blood glucose test strips a day) there were big drops in hospitalisations.
This adds important evidence to the benefits of Flash – suggesting it can help people to identify and reduce high blood sugars so they can avoid DKA. At the moment, it’s available on prescription from the NHS for some people with type 1 diabetes who meet a clear criteria.
But the technology isn’t yet widely available. In part this is because there hasn’t been enough evidence collected showing its value or cost-effectiveness. New, vital research like this could help in the fight for everyone who can benefit from Flash to be able to access it, and help make sure technology is embedded into everyday diabetes care.
Getting personal with type 2 medications
Everyone with type 2 diabetes is different. There are huge variations between people in, for example, blood sugar levels, bodyweight and kidney or liver function. Professor Ewan Pearson, from the University of Dundee, explained there’s no good reason to think everyone within this wide population will respond the same way to the same diabetes medication. The question is, how can we use this variation to help predict the right treatment for the right person? This is called personalised medicine and it could help us move away from a one-size-fits-all approach.
Diabetes UK funded researcher Dr John Dennis has shown that easy to measure, simple characteristics, such as age of diabetes diagnosis, body mass index (BMI), sex and HbA1c – can help to decide which of three common type 2 medications someone will respond best to. There’s also evidence that our ethnicity could help to inform treatment decisions.
A study in the USA with almost 20,000 people with type 2 diabetes showed that metformin is more effective at lowering blood sugar levels in Black people compared to White people. Professor Pearson’s team have also combined the results from several trials and shown that Asian people respond best to DPP-4 inhibitors. On average the medication led to a reduction in HbA1c of 0.75% in Asian people, compared to those taking a placebo. While in White people DDP-4 inhibitors only reduced HbA1c by an average of 0.5%. Asian people were similarly found to respond better to SGLT2 inhibitors.
Professor Pearson flagged there’s a need for more individual studies to look into the impact of ethnicity further. But the evidence suggests that we can already start to think about personalising treatments using simple features like age and ethnicity. To go a step further, scientists are figuring out what our genes can tell us.
Professor Pearson identified genetic changes that seem to influence how people respond to metformin. In people who carry a particular genetic change metformin reduced their HbA1c by an average of 1.6%. In those without the genetic variant metformin was linked with only a 1.1% reduction in HbA1c. That difference of 0.5% is about the same benefit as we’d expect from introducing a second diabetes drug, so our genes are having a big impact on how well treatments work.
And this could be important in explaining why Black people tend to respond better to metformin than White people. About 70% of the Black population have this genetic change, compared to 30% of the White population.
With the costs of techniques to read our genetic blueprint plummeting, Professor Pearson believes we’re moving towards an era where we could all have this information in our medical records. At this point using our genetics becomes just as easy as using our BMI to help make decisions about which medications to prescribe. It’s an exciting prospect that could hugely improve diabetes care.
Imaging the brain to tackle hypos
Around a quarter of people with type 1 diabetes can lose their ability to spot the warning signs of a hypo, known as hypo unawareness, putting them at greater risk of dangerous side-effects. We heard from Dr Pratik Choudhary who, with our funding, is investigating why the brain stops recognising low blood sugars, with the hope that this will help us find ways to treat or prevent hypo unawareness.
Scientists can use specialised MRI scans to see which parts of the brain respond to low blood sugar levels. Dr Choudhary has discovered that different areas of the brain ‘light up’ in response to a hypo in people with and without hypo unawareness. When hypo, brain activity was lower in the thalamus and the frontal lobe of people who were hypo unaware.
The thalamus has the job of scanning to see if there is any unbalance in things like hormone levels and energy stores in our bodies. It then signals to other areas of the brain to do something to about it. If this region of the brain isn’t as active as it should be, it could explain why people don’t get any prompts that their blood sugar levels are dropping.
The frontal areas of the brain should then decide should I act on this? Is this hypo a friend or foe? What strength of response is required? And this then drives a change in our decision making, judgements and emotions which trigger a behavioural response. In the case of a hypo – reaching for those jelly babies.
But dampened activity in the frontal lobe in people who are hypo unaware could alter their response, and mean they struggle to make the right hypo treatment decisions. In turn, they may have more frequent hypos which puts them at risk of becoming hypo unaware.
Understanding this domino effect of activity in the brain is crucial to inform care for people with hypo unawareness. Dr Choudhary’s work suggests treatments need to address cognitions, thoughts and emotions – we need to change the response of frontal lobe. Some studies, including the HARPdoc trial, are already testing interventions that focus on changing thoughts and beliefs. We’ll be eagerly awaiting results, which could open up new ways of helping people to avoid hypos and get their awareness back.