Optimizing Diabetes Therapies with New Classifications

As the pharmacologic armamentarium for diabetes becomes more intricate, there’s increasing validity around the prospect that the disease of diabetes itself should be more intricately defined in the individual patient. Namely, there’s clear evidence there are more than just 2 “types” of diabetes—and some specialists emphasized it only helps to treat some patients if that were better acknowledged.¹

In the second segment of an interview with HCPLive during the American Academy of Physician Associates (AAPA) 2024 Conference & Expo in Houston, TX, this week, Ji Hyun “CJ” Chun, MPAS, PA-C, BC-ADM, an endocrine physician assistant at OC Diabetes Endocrinology and La Verne University, further discussed the proposal to expand diabetes nomenclature to include subtypes including the following:

• Severe insulin deficient diabetes
• Severe insulin resistant diabetes
• Severe autoimmune diabetes
• Moderate obesity-related diabetes
• Age-related diabetes

As Chun explained, the American Diabetes Association (ADA) partnered with organizations including the European Association of Study in Diabetes (EASD), National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), and the JDRF Diabetes Foundation in 2018 to establish the Precision Medicine in Diabetes Initiative (PMDI).² The coalition established 5 pillars of precision medicine in diabetes: diagnostics, prevention, treatment, prognostics and monitoring. Beginning with diagnoses, Chun said, advances to genomics and environmental has helped to refine criteria for establish what subtype of diabetes a patient is encountering.

“And that can also predict which therapies can be a better fit for these patients—not only the type of medication based on the risk factors…but as well as pharmacogenetics, in terms of if you and I could take the same medication, but the absorption, and end result may be very different depending on our genetic data,” Chun explained.

What’s more, the advances to wearable device and other monitoring tools has helped to better inform the role of patient activity and food intake in their diabetes status. The massive influx of this and genomics data is becoming better streamlined via artificial intelligence into material that which may inform a precision diabetes diagnosis and treatment plan for the individual.

Regarding the effect a nomenclature change in diabetes may have on therapeutic advances for patients, Chun pointed to the recent example of the renaming of non-alcoholic fatty liver disease (NAFLD) to metabolic dysfunction-associated steatotic liver disease (MALSD).³

“Now in the diabetes field, we have a lot of great options, right?” Chun said. “We see a great study showing like 30% reduction in whatever endpoint that we're looking at—it's kind of a one size fits all, everyone gets put on that medication in the hope that they're in that group of 30% less risk, right? But rather than that, maybe we can now further streamline it. So, who are other more likely patients who are going to benefit—that less than 30% reduction rate?”

The shift to acknowledge new diabetes subtypes may help to refine the utility of the approximate dozen drug classes at the disposal of specialists as well. As Chun noted, DPP-4 inhibitors are “kind of going out of favor” in terms of options used to reduce cardiovascular disease risk in patients with type 2 diabetes.

“But maybe as we get more genomics data, maybe we can find the right patient that that might be a good option,” Chun said. “So, I think with the development of this AI, the precision medicine, re-aligning and reorganizing the priorities of these 12 different classes for each individual might be a good advancement—plus additional classes, where new agents will definitely help us as well.”

References

1. ^{Kunzmann K. Should We Reclassify Diabetes Subtypes? HCPLive. Published May 22, 2024. https://www.hcplive.com/view/should-we-reclassify-diabetes-subtypes}
2. ^{Nolan JJ, Kahkoska AR, Semnani-Azad Z, et al. ADA/EASD Precision Medicine in Diabetes Initiative: An International Perspective and Future Vision for Precision Medicine in Diabetes. Diabetes Care. 2022;45(2):261-266. doi:10.2337/dc21-2216}
3. ^{Brooks A. From NAFLD to MASLD: 2023 Brings New Liver Disease Nomenclature. HCPLive. Published December 13, 2023. https://www.hcplive.com/view/from-nafld-to-masld-2023-new-liver-disease-nomenclature}