The full results on Lilly’s tirzepatide for obesity will likely dominate the headlines from the American Diabetes Association (ADA) 2022 Scientific Sessions, but the conference program is jam-packed with new findings — and new paradigms — in both type 1 and type 2 diabetes management and prevention.
Taking place June 3-7 both in-person for the first time in 3 years, in New Orleans, and virtually, the “hybrid” meeting is mandating COVID-19 vaccination and mask wearing for all on-site attendees.
A major topic will be new findings and thinking in the treatment of type 2 diabetes, including the new twincretin tirzepatide, as well as discussions about the role of weight loss and the concept of “remission.” In type 1 diabetes, sessions will examine intervention trials to prevent progression, progress in islet transplantation, and the latest findings in diabetes technology.
Other key conference themes include the often interrelated topics of disparities, mental health, and COVID-19.
“I think that the scientific planning committee has put together a really outstanding program this year, covering the entire spectrum of diabetes care and research and translation for both type 1 and type 2 diabetes,” Scientific Planning Committee Chair Dana Dabelea, MD, PhD, professor of epidemiology and pediatrics at the University of Colorado, Anschutz, told Medscape Medical News.
Tirzepatide: The Next Big Thing?
The presentation likely to generate the most buzz will take place Saturday morning, with the full detailed results from Lilly’s phase 3 SURMOUNT-1 trial of its dual-incretin tirzepatide for weight loss in people with obesity or overweight with at least one comorbidity but not diabetes.
Top-line results released by Lilly in April 2022 showed that the drug induced weight loss of up to 22%. Tirzepatide was approved May 13 by the US Food and Drug Administration for type 2 diabetes under the brand name Mounjaro. It is not approved for weight loss.
Robert A. Gabbay, MD, PhD, ADA chief science & medical officer, told Medscape Medical News: “Certainly the general public will latch on to this idea that there is a drug they can lose 22% of their weight on. It’s hard to comment on a press release, so that’s why this presentation is going to be key.”
Another tirzepatide analysis, this one comparing its use to insulin glargine on kidney outcomes in participants with diabetes in the pivotal SURPASS-4 study, will be presented as an ADA Presidents’ Select Abstract on Friday afternoon.
“I think tirzepatide could be the great new thing, but I think we need to know a little bit more. Weight loss seems to be better than with glucagon-like peptide-1 (GLP-1) receptor agonists. Renal outcomes are important. Next will be to see if it has cardiovascular benefit. It makes one think about its use versus GLP-1 agonists,” Gabbay said.
Managing Type 2 Diabetes: Shifting Paradigms
With the emergence of tirzepatide and other pharmacologic agents with benefits beyond glucose-lowering, there has been much discussion in recent years about alternatives to the current metformin monotherapy first, stepwise approach to managing type 2 diabetes.
As has been done previously, on Monday afternoon, there will be a joint ADA/European Association for the Study of Diabetes (EASD) session during which a draft of the latest update will be presented on the management of hyperglycemia in type 2 diabetes. The final version will be presented at the EASD meeting in September.
While it won’t include tirzepatide, as the drug is not yet approved in Europe, there will be discussion about the role of weight loss goals in type 2 diabetes management, Gabbay said.
The concept of a 15% weight loss as a primary treatment goal of type 2 diabetes management is a new focus, initiated at the EASD 2021 Annual Meeting and published in The Lancet.
“With tirzepatide becoming available, there’s the opportunity for more significant weight loss. So, there’s been this debate, starting with the somewhat controversial opinion piece in Lancet…Maybe it was stating things a bit too far but it certainly got everyone in the field thinking. You’ll see that come up in lots of places at this meeting,” Gabbay said.
Indeed, those sessions include a Sunday morning symposium entitled: “Obesity Management as a Primary Treatment Goal for Type 2 Diabetes — It’s Time for a Paradigm Shift,” in which speakers will address both lifestyle and pharmacologic intervention. On Saturday afternoon two speakers will debate the question: “Weighing the Evidence — Should Obesity Be the Primary Target of Treatment in Type 2 Diabetes?” Yet another session on Sunday afternoon will cover, “Incorporating Weight Management Strategies for Obesity Into Type 2 Diabetes Care — Medical Management and Surgery.”
From Weight Loss to Type 2 Diabetes “Remission“?
Related to the issue of weight loss as first-line therapy is the concept of type 2 diabetes “remission.” Gabbay noted, “There is a school of thought that says early in the course of disease we probably want to be a lot more aggressive because there’s a greater chance of putting someone into remission. The opportunities for remission after someone has had diabetes for a number of years are relatively low.”
In September 2021, ADA, along with EASD, the Endocrine Society, and Diabetes UK, published a joint consensus statement aiming to standardize use of the term “remission” in type 2 diabetes.
At the ADA meeting, a symposium on Monday afternoon entitled, “Definition and Interpretation of Remission in Type 2 Diabetes,” will cover lifestyle, pharmacotherapy, and metabolic surgery approaches. One noteworthy talk in that session will address the question: “Can Type 2 Diabetes Remission Be Diagnosed While Glucose-Lowering Drugs Are Being Used?”
Asked how all of this — tirzepatide, weight loss, and “remission” — might play out clinically, Dabelea replied: “We are still debating the strategy. That’s why we’re having the scientific talks.”
“I think they will be very interesting and very well-attended, but there isn’t a strategy yet…The important thing is we have these ‘miracle drugs,’ if you want, and once we’ve learned all we need to know about how they act and who we should target, perhaps next year we can talk about a strategy.”
Type 1 Diabetes: Progress in Preventing, Treating, and…Curing?
Type 1 diabetes will also be well-represented at the conference, with topics covering prevention, treatment, and progress towards a cure. On Saturday afternoon, a symposium will cover data from a trial of low-dose IL-2 in people with recently diagnosed type 1 diabetes, while a Friday afternoon symposium will address “Emerging Approaches to Beta Cell Replacement.”
On Saturday afternoon, a symposium will provide an update on islet cell transplantation, including immune tolerance strategies, while an oral abstract session will cover “Clinical Outcomes in Islet and Pancreas Transplantation.” And on Monday afternoon, yet another symposium will examine “Emerging Data on Therapies to Treat the Underlying Autoimmunity in Type 1 Diabetes.”
As usual, there will also be numerous presentations on the latest in diabetes technology. Particularly noteworthy among these will be an oral abstract presentation on Monday afternoon, “The CREATE Trial: Randomized Clinical Trial Comparing Open-Source Automated Insulin Delivery With Sensor Augmented Pump Therapy in Type 1 Diabetes,” and results from the insulin-only “bionic pancreas” pivotal randomized clinical trial on Friday afternoon.
Dabelea commented, “I’m happy to see a plethora of studies in type 1 diabetes…As with tirzepatide in type 2 diabetes, we are witnessing discoveries and we need to have some time to really understand the results, understand who are they targeting, who is going to benefit, and then move into a strategy.”
However, she added that in both type 1 and type 2 diabetes, “we’re seeing these disparities [where] these novel technologies and therapeutics are not getting to the people who need them most,” which brings up another major meeting theme, COVID-19.
Overlapping Themes: Disparities, Mental Health, and COVID-19
The topics of health disparities in diabetes prevention, management, and care and promoting health equity, as well as the impact of COVID-19, are “certainly timely this year,” said Dabelea.
At least eight meeting sessions will address various aspects of disparity, including a Friday afternoon symposium, “Race, Racism, and Diabetes Research,” a Saturday morning oral presentation on “Mitigating Disparities in the Screening and Diagnosis of Diabetes,” and on Monday morning, the symposium “Disparities in the Use of Diabetes Medications and Technologies.”
A related topic, insulin access, will be addressed in a Friday morning “mini-symposium” that will cover the issue from US and international perspectives, including humanitarian crisis situations. Related to that, on Sunday afternoon a panel will discuss the Ukraine situation specifically.
Regarding mental health, one noteworthy session is a symposium on Saturday afternoon: “Suicide and Self-Injury — Unveiling and Addressing the Hidden Nightmare in Diabetes.” “It’s an underrecognized problem and we’ve devoted a symposium to really drill into it. I think that’s going to be an important story for all of us to think about,” Gabbay said.
Another mental health session on Saturday afternoon will examine “Stigma in Diabetes Care — Evidence and Solutions.” Dabelea noted, “Mental health is a rising concern in the US, especially in people with chronic diseases in the wake of the pandemic…Of course there’s overlap in mechanisms in type 1 and type 2, but I think there are also distinct pathways.”
COVID-19 will be somewhat less of a focus than in the past 2 years, but there will certainly still be plenty about it. A Friday morning mini-symposium will cover new findings in pathophysiology, another session on Monday afternoon will look at the impact of the pandemic on hypoglycemia risk, and COVID-19 will be the subject of several late-breaking posters on Sunday afternoon. One in particular will report a review of diabetes as a risk factor for long COVID.
Celebrating in Person in the Big Easy
But unlike the past 2 years, COVID-19 has not kept ADA from meeting in person in 2022. “I think it’s going to be amazing…We’re so excited to be in person and interacting,” Gabbay said.
He observed that virtual meetings — as ADA and most other medical societies have been forced into for the past 2 years during the pandemic — fail to capture “how science is advanced by the casual conversations in the hallway and collaborations and new ideas. It’s really this incredible incubator. For me, that’s the most exciting part.”
The location, New Orleans, also factors into his excitement: “What a great place to do this. It’s conducive to celebrating. It’s been a long couple of years.”
Gabbay is an ADA employee. He also serves on advisory boards for Lark Health, Reveal, Vida Health, Onduo, and Sweetech. Dabelea has reported no relevant financial relationships.
Miriam E. Tucker is a freelance journalist based in the Washington, DC, area. She is a regular contributor to Medscape, with other work appearing in The Washington Post, NPR’s Shots blog, and Diabetes Forecast magazine. She is on Twitter: @MiriamETucker.
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