More than 1,400 physicians gathered in Phoenix, AZ, last week for the 22nd Annual Scientific and Clinical Congress of the American Association of Clinical Endocrinologists (AACE). Our correspondent Wil Dubois was embedded with the "troops" covering the week-long convention, and files this report on the highlights that jumped out at him.
(In a separate article coming soon, he'll also report on AACE's just-announced new treatment "algorithm," their official alternative to the American Diabetes Association's diabetes treatment guidelines.)
Fifteen general sessions, 20 workshops, 17 meet-the-experts forums, 9 in-depth symposia, 11 special sessions, and row upon row of research posters being explained by scientific "tour guides." And what did I learn at AACE? I learned I don't want to be a molecular biologist when I grow up!
As many of you know, I'm both a patient and a community diabetes educator myself. I generally speak basic doctor pretty well, and have a better-than-average grasp of anatomy and physiology; but some of the sessions here were way too deep for me. I felt like my head was going to explode. And I wasn't the only one. There were many glassy-eyed stares as I looked around. But there was also no shortage of brain power in this crowd, and there were deep, probing questions from audience members at the end of even the most technical of sessions.
I learned there are a lot of smart people hard at work trying figure out what's under the hood of diabetes.
Of course, endocrinology is more than just diabetes. The conference also featured sessions on thyroid, bones, pituitary issues, adrenal disorders, gonadal dysfunction, and infertility. In fact, the conference was so complicated and extensive that participants were issued a poster the size of a small state flag to help guide them in choosing where to go next! And beyond the conference were dozens of industry-sponsored "satellite symposia" and meals, plus a trade show the size of a small Walmart.
Here is a roundup of sessions I attended, and the "takeaways" that stuck with me:
How Many Types of Diabetes... ?
When Graeme Bell, PhD, started his lecture on the latest research delving into the genetic underpinnings of diabetes by saying that type 1 is a "simple" disease, fellow D-blogger Scott Johnson and I exchanged a "this guy is out of his friggin' mind" look. But Bell wasn't saying T1 was easy to live with, or easy to treat, or easy to cure. What he meant is that it's a borderline monogenic disease. In other words, most type 1s have only three or four whacky genes that separate us from the rest of the human race. Type 2, on the other hand, is polygenic to the point of almost being ominigenic. Bell reports that 75 genes have been discovered, thus far, that are associated with type 2, and none of them seem more prominent than any of the others.
The only explanation that can account for the lack of associated genes that really stands out is that there are actually many kinds of type 2 diabetes all mixed together, Bell said. He speculated that type 2s in different gene pools actually have very different diseases, on the genetic level.
To my way of thinking, looking at type 2 diabetes as a cluster of many diseases rather than a single disease, is more like the way we look at cancer. We use the word "cancer" as a loose label for a host of barely related diseases. People understand that cancer is not one illness, but many. Diabetes may prove to be the same, making the food-fight over what to call the types even more complicated.
Bell states that full exome gene sequencing of large numbers of people will be required to sort it all out; but, of course, he also lamented that there's not currently enough bandwidth on the entire internet to do this.
So take your meds, my type 2 cousins. A cure is a long way off. Oh, and speaking of medications, Bell says that type 2 may also be physiologically different in different racial groups, and that this has implications for the development of medications in the future. Like racially specific treatments? Wow, we may have to tiptoe around that one.
While we're on the subject of meds, a detailed session presented by Derek LeRoith, MD, PhD, on all the various D-meds and the risk of cancer from each can be summed up by saying there's good news and bad news. The good news is that your D-meds absolutely won't give you cancer. Your insulin won't. Your Victoza won't. Even your Actos won't.
Oh. Right. Then there's the bad news.
The bad news is that if you already have cancer (even an itty bitty one you and your doc don't know about), many D-meds might speed up its growth. A variety of D-meds seem to serve as biological accelerators—like throwing gasoline on a small fire, turning it into a larger, faster-growing fire.
There's surprising news, too. Some D-meds might do the exact opposite for some cancers: They may suppress tumor growth. In fact, our humble metformin is being actively investigated as breast cancer drug!
Not Marching in Lock-Step
There's a recognized lack of agreement on many issues in diabetes, and the AACE conference organizers set up a number of sessions as expert debates. In one session about the wisdom of cracking open the medicine chest for people with pre-diabetes, DeFronzo argued that while weight loss and changes in lifestyle have been clinically proven to change the course of the disease in many people, it doesn't work out that way in the real world. He called for the use of medication to keep the genie in the bottle, saying of diet and exercise, "It's time we face reality, and the reality is that this doesn't work on a long-term basis." He also had some convincing stats on how early "pharmacologic therapy" impacted conversion rates, compared to lifestyle intervention studies.
On the other side of the fence was Vivian A. Fonseca, MD, who pounded away with statistics on medicine side effects, said clinical evidence shows lifestyle change does work, and called for changes in lifestyle at the societal level.
Hmmm... as trench warfare technician myself, I gotta say that a doc can write a script for metformin, but he can't write a script to change society (that's off formulary).
Still, a great number of heads were nodding in agreement with Fonseca.
An even more enjoyable squabble was the moderated argument over whether or not analog insulin is superior to traditional insulin. George Grunberger, MD, argued that analogs are more effective, safer, have less weight gain associated with them, and in the long run cost the system less money when you factor in the cost of treating hypoglycemia. In fact, he said, "I'm tired of people telling me analogs are too expensive," and stated that we need to focus not on the cost "of acquisition," but on "the cost to the system... to society."
Loading the cannon for the other side was Mayer Davidson, MD, who was very dismissive of studies that show increased rates of nocturnal hypoglycemia with old-school insulins, saying "in those studies no one instructed the patients to eat a nighttime snack." (Seriously, he said that.) Further, he insisted he uses a lot of older-school insulins, makes his patients eat a bedtime snack, and all are apparently doing just fine and dandy, thank you very much. Fellow D-media member Scott J muttered under his breath, "Make them eat cake!"
Scary Stuff You Didn't Know About Blood Sugar
Speaking of insulin, Paresh Dandona, MD, PhD, scared the shit out of the few of us PWDs in the room when he showed us stats on mortality from heart attacks and strokes and blood sugar levels on admission to the hospital. If your blood sugar is 127 mg/dL, your heart attack mortality rate is estimated at 6.6%; but if you sugar is mildly higher at 144 mg/dL, the death rate jumps to 14%. And Dr. D states this is not a linear curve. It gets rapidly worse. After hearing this, D-Mom Wendy Rose, who was seated next to me, leaned over and hissed, "Wil, bolus if you feel chest pain!"
And it's even worse for strokes. A blood sugar of 116 mg/dL sends 20% of people to the morgue. Raise the sugar to 142 mg/dL and the death rate leaps up to 45%.
In one of those wish-I'd-gotten-it-on-video moments, one of the AACE brass made the mistake of asking Dandona his opinion about the organization's blood glucose targets (probably hoping he'd say something supportive about the AACE not loosening up targets as the ADA recently did), to which Dandona replied he felt the AACE guidelines are in "lethal ranges," and he felt they should adopt more strict (!) targets.
I'm guessing he's off the Christmas card list now.
A $35,000 Bathroom Scale to Test for Neuropathy
Speaking of Christmas, I got to see one whopper of a gift idea for the PWD in your life. I took off my shoes and socks, stood barefoot on a shiny plate of metal, pressed my palms flat against another set of plates on a table, and two minutes later had a clean bill of nerve health thanks to a device called the Sudoscan, which received the blessing of world-renowned neuropathy expert Aaron I. Vinik, MD, PhD, FCP, MACP, FACE at the meeting.
The machine got FDA clearance last year, and Vinik notes he gets a better reimbursement rate from Medicare for using it than he would get for spending a whole hour with a patient!
How's it work? It involves low-voltage nickel electrodes, sweat glands, ions, the stratum corenum, and... Oh, never mind. It's magic. But Vinik states that the device has a sensitivity of 80% and a specificity of 90% for diagnosing peripheral neuropathy. It's more precise, and faster by far, than any other method for diagnosing neuropathy, and it can be operated by a trained monkey (or any other uncertified medical team member). Overseas, interestingly, the Sudoscan is actually used as a noninvasive diabetes screening tool, as many undiagnosed diabetes patients already have detectable neuropathy.
I couldn't find out how many units there are in the field, but the company states that they are doing well, and that there's a lot of interest amongst physicians.
Maybe one will be coming soon to a doctor's office near you.
Stay tuned for Wil's second AACE 2013 installment soon.