Treatment simplification in Type 2 diabetes: A less-is-more approach to reducing the burden of disease
So, good morning everyone. Hopefully you're all hearing me and I'm seeing nods and welcome as well to people who are watching online. So, my name is Dr. Alice Chang. I'm an endocrinologist from the University of Toronto in Canada. And I was speaking about treatment simplification in Type 2 diabetes. So, here are my disclosures, having worked with many different companies related to diabetes as well as cardiovascular. And here is the disclaimer that everybody who is looking at this, this is obviously at the ATTD and this is not part of the main CPD event. So, why are we having this conversation? I think everybody is fully aware that those living with Type 2 diabetes, it's a progressive disease. And we know that beta cells continue to stop working over time. So, not surprisingly, people need to step up therapy over time. And people are going to require injectable therapies as their diabetes progresses. However, as that happens, there are barriers to advancing therapy. It's particularly when we're talking about injectable therapies and here you can see some of the common barriers that people may experience when trying to advance therapy. So, I think an important consideration is that we want to improve efficacy but lessen the burden of diabetes. And at this entire conference, we've heard a lot about the burden of diabetes for people living with it. So, the concept of treatment simplification has been raised in a number of different guidelines from around the world. And you can see there's a definition up top. And it's the idea, again, of reducing complexity and reducing burden. But the term, I think, is worth highlighting is what is the right term to use. And you'll see here many different terminologies that have been put into place. Simplification, de-escalation, de-prescribing, de-intensification, and liberalization. All words with too many syllables. And each word has a slightly different definition. And what I'm speaking about today is the concept of simplification with no loss of efficacy. And that's what we're looking at. We're looking at trying to give people great efficacy without making things more difficult. So it's not about backing off. It's not about giving up. It's not that concept at all. It's about great efficacy with simplicity. And that's the concept here. And that's where fixed ratio combinations of basal insulin and GLP1 receptor agonist can help with the concept of treatment simplification. So I think everybody here knows what are we talking about? We're talking about combining basal insulin with a GLP1 receptor agonist, but putting it in the same injection. So again, simplifying the number of times someone has to inject. And then you have the power of the two therapies, the basal insulin power with the GLP1 receptor agonist. And it's an option to simplify, reduce complexity. And you'll notice on the bottom that the ADA-ESD consensus does list it as a very high efficacy approach to managing type 2 diabetes. And why is that? So if we look at randomized control trial data, here on the left you have Soli Mix, which would be I-Glar-Lixi, Glar-Gin 100 with Lixi's enatide. Compared to that, head to head randomized control trial versus premixed insulin. On the right you have Jule 7, which is I-Deg-Lira, insulin-Deg-Lidek with Lyroglutide versus basal bolus. And from a glycemic perspective, you'll see either improved glycemic efficacy, as shown on the left, or similar. So therefore you've got similar or better glycemic efficacy, but with less hypoglycemia compared to premixed and better weight compared to premixed. And on the right, better weight and less hypoglycemia. So remember what I said earlier, the idea is to same efficacy, but simpler. One injection versus two, or one injection versus four, but you also get the advantage of less hypoglycemia as well as less body weight increase. That's in randomized control trial. What about in the real world setting? So here are some data from Soli Simplify, which is the fixed ratio combo compared to more complex insulin regimen. And here you can see again, A1C change similar. So in the real world, single injection versus multiple injections, similar A1C benefit, but again the benefit seen in weight. And then here there's some more real world data, but the concept here is not so much A1C in weight, because hopefully you're convinced about that by now, but looking at treatment persistence. Because it's one thing to initiate therapy, it's another thing for someone to continue this therapy, and that is often the struggle that we have in clinical practice. So here you can see treatment persistence, whether it's compared to premixed insulin in a real world setting, or compared to basal bolus in a real world setting, you can see better treatment persistence. Which again makes sense. One shot a day versus two to four, it's going to be easier. So to summarize, and then we can open the floor up for any questions, treatment burden remains a key barrier in the therapeutic advancement. We know that people need therapeutic advancement by virtue of how type two diabetes works, but yet the burden of it, the complexity of it is a very real barrier. We know that treatment simplification is something we should think about for all of our patients with every chronic disease, including type two diabetes. And the fixed ratio combinations of basal insulin GLP1 gives us an option of how to provide that simplification, but again with no loss of efficacy, which is a critical component here. And it serves as an effective and simple alternative to complex insulin regimens. And here I'm going to mention a study that was not shown on one of the slides, but one that was called Beyond, which is personally one of the ones that I really like. It was a randomized control trial where they took individuals and randomized them to get fixed ratio combination, either eye deglera or eye glarlicsy, versus basal bolus versus basal insulin with SGLT2 inhibitor. And it turned out that from an efficacy perspective, things were actually similar. And these were people who were on basal bolus to begin with. So again, conceptually, this is a good idea that treatment simplification is achievable. And then here again, one injection versus four injections. So I think it's something all of us as clinicians need to think about when we see a patient, is can we make life a little bit easier for this person? What are the ways we can do it? This would be one of the ways to do it. But other ways to do it is to combine pills. Does everybody need to be on all the different pills they're on? Can I make it the cocktail simpler? And I think these are things we must always consider. So thank you very much for your attention, and I'm happy to open it up to any questions that people may have.
