EASD 2019 (European Association for the Study of Diabetes)

September 16-20, 2019; Barcelona, Spain; Day #5 Highlights – Draft

Executive Highlights

  • We’re back from Barcelona one last time with our final highlights report from EASD 2019 – until our full report in due time, that is ;>.

  • In a Joint EASD/ESC symposium on heart failure, Dr. Javed Butler pushed for further investment into prevention of HF, underscoring that HF prevention indications should be given equal, if not more, weight than MACE outcomes. Dr. Butler also warned audience members to not get lost in the semantics of HF (regarding HFpEF vs. HFrEF - see more below) when considering prevention, as over-complication can sometimes impede meaningful results. He asserted: “It does not matter which HF you are preventing because the outcomes for all forms once you develop it are horrible.”

  • In tech, we heard a number of studies on FreeStyle Libre and FreeStyle Libre Pro. Data from the REFER meta-analysis from Germany, France, and Austria found a mean A1c reduction of 0.8% (baseline: 8.9%) after people with type 2 on intensive insulin began FreeStyle Libre real-time. Dr. Jens Kroeger compared the real-world data to the weaker results seen in 2014 in the REPLACE trial, crediting better patient and provider education as a catalyst for CGM’s increased effectiveness in driving change. Australia’s Dr. Jane Speight shared data from a secondary analysis of GP-OSMOTIC (n=299), an RCT with patients wearing blinded FreeStyle Libre Pro four times over a year. Between baseline and one year, there was no adverse psychosocial impact, but also no significant increases in patient empowerment; this came on the backdrop of primary outcomes in a poster at ADA 2019, finding an ~8% increase in time-in-range (+2 hours/day). We assume real-time data would have had a different psychosocial impact.

  • British powerhouse physician Dr. Stephanie Amiel (King’s College, London) outlined her education-focused approach to empower patients to reduce hypoglycemia. Dr. Amiel also outlined a role for technology (CGM and low glucose suspend, in particular) and improved provider education to reduce the global problem of hypoglycemia.
  • We also bring you coverage of the diabetes therapy exhibit hall booths. See below for our takeaways from interacting with the impressive booths brought to Barcelona by AZ, Lilly/BI, Novo Nordisk, Novartis, Merck, and Sanofi.

Hola from Barcelona, where EASD 2019 just wrapped up. What a meeting it’s been! Be sure to catch up on all the learnings that have happened so far by perusing our highlights reports from:

Diabetes Therapy Highlights

1. Dr. Javed Butler Gives Call to Arms for HF Prevention: “From My Perspective, All Patients with Diabetes Are at Risk for Heart Failure” at Joint EASD/ESC Symposium

An impassioned Dr. Javed Butler (Stony Brook University Hospital) pushed for further investment into prevention of heart failure (HF), underscoring that HF prevention indications should be given equal, if not more, weight than MACE outcomes. Dr. Butler was quick to note that the crux of his argument is not to say certain diseases are more important than others, but rather, to draw attention to the often-overlooked field of heart failure. According to Dr. Butler, while the prevention of CV disease has been of interest for quite some time (the landmark Framingham Heart Study was initiated in 1948), the focus has always been on atherosclerotic cardiovascular disease (ASCVD), and consequently myocardial infarction (MI) and stroke. HF was simply viewed as a product of ASCVD, and therefore, if ASCVD could be treated, HF did not need to be its own independent target. In reality, recent statistics paint a startlingly more negative picture of the state of HF. Dr. Butler cited that there will be 1,000,000 new onset cases and rising of HF in the US in 2019, compared to 790,000 new/recurrent MIs and falling. In addition, the risk of dying after hospitalization for heart failure (hHF) is 3x higher than that following hospitalization for MI. Heart failure in patients with type 2 diabetes is even worse. A 2004 paper in Diabetes Care denoted an astonishing 10-fold increase in mortality rate (HR=10.6; 95% CI: 10.4 to 10.9) in patients ≥65 years old (n=151,738) with type 2 diabetes and HF, as opposed to those without HF. 

  • Dr. Butler listed numerous ways HF prevention has being neglected in the past, including (i) lack of research, grants, and publications; (ii) its absence from the Framingham Risk Score and ACC/AHA Pooled Cohort Equation; (iii) non-requirement in FDA Guidance on CV safety in diabetes medications; (iv) perception as a “soft,” subjective, and less important endpoint than MACE; and (v) lack of ACC/AHA, HFSA, ESC, or ACP guidelines on HF prevention. Of note, even when trials successfully reduce HF, these findings are often considered neutral or even negative unless MACE is reduced.

  • “We sometimes get really lost in the HFpEF, HFrEF, and HFmEF ‘this and that’ but for the purposes of my talk, it is an absolutely unimportant discussion. Whether you have this ejection fraction or that ejection fraction HF has therapeutic implications for management of HF, but when you’re talking about prevention of HF in a person who does not have HF, it does not matter which HF you are preventing because the outcomes for all forms once you develop it are horrible.” Dr. Butler warned audience members to not get lost in the semantics of HF when considering prevention, as over-complication can sometimes impede meaningful results. As an example, Dr. Butler brought up the controversy surrounding the HF reductions seen in SGLT-2 inhibitor CVOTs, calling the criticism of “we don’t know baseline ejection fraction in these populations” that has often been brought up as “completely meaningless.” In another light, he added, “If you prevent MI in someone with clean arteries or prevent MI in someone with 50-70% stenosis, how many times in a study that prevents MI would you say, ‘I’m not going to believe it because there was no hard cap on stenosis’?…If you’ve prevented an MI, you’ve prevented an MI” – just as any prevention of HF is a meaningful result.

  • Dr. Butler finished his talk by highlighting the current tools available to patients with type 2 diabetes to prevent HF. From his perspective, all patients with diabetes are at high risk for heart failure, so there is less of a need to dissect if risk is high or low. Measures like not smoking, exercising, weight loss, and now perhaps SGLT-2 inhibitors are universally helpful across the population. We commend Dr. Butler on his call to action and certainly agree – it’s time to make HF a real priority. We would love to see more investment in clinical trials that address HF prevention in patients with type 2 diabetes who not only have had HF, but also those who have not, along with trials in type 1. That being said, we are of course looking forward to results from DELIVER (dapagliflozin in HFpEF), EMPEROR-Preserved and EMPEROR-Reduced (empagliflozin in HFpEF and HFrEF), and SOLOIST-WHF (sotagliflozin post-worsening HF) on the heels of landmark positive results from DAPA-HF.

2. Dulaglutide Treatment in People with Type 2 and Binge Eating Disorder: A New Parameter in Prescriber Decision Making?

Dr. Andrea Da Porto discussed how GLP-1 agonists may confer superior weight loss by reducing binge eating behaviors in people with type 2 diabetes and binge eating disorder. After 12 weeks of treatment, non-drug naïve patients with diabetes and binge eating disorder given Trulicity (dulaglutide) showed greater decreases in binge eating behavior, more weight loss, and better glycemic control than patients given the sulfonylurea gliclazide. Specifically, patients on dulaglutide lost a median 1.9% of fat mass (p<0.0001; vs. 0.2% fat loss in the gliclazide group) and showed a median A1c drop of 1.07 (p=0.009; vs. 0.75 drop in the gliclazide group). Change in binge eating symptoms was also significantly associated with change in weight (p<0.0001) and change in A1c (p=0.033). Results potentially support the theory suggested by preclinical studies and clinical case reports that GLP-1s can influence appetite regulation by counteracting food cravings and overeating. Interestingly, the effects on body weight reported in the GLP-1 group were superior to what was expected from 12-weeks of treatment, further supporting the need to study appetite regulation and identify binge eating disorder in the diabetes population. Overall, binge eating disorder could represent a parameter for clinicians to consider in choosing among different therapeutic options to treat people with type 2.

  • Though results could mean promising strides in the future of both diabetes and binge eating disorder treatment, results may have been affected by methodological limits. This study’s limitations include small sample size, brief follow-up period, and the known magnified effects of GLP-1s on weight early in treatment. With this, no patients on dulaglutide stopped the therapy prematurely due to side effects, which is often seen in clinical practice. During Q&A, an audience member brought up a great point: SU use is often associated with weight gain. In response, Dr. Da Porto stated that he doesn’t believe such short use of gliclazide caused any confounding weight gain and agrees that the study should be extended to determine if this confounder exists.

3. Update on the UK DPP: ~Three Years In, ~20% of Referrals have Resulted in Program Completion, with Mean Completer Weight Loss of 4%

NHS England’s Dr. Jonathan Valabhji delivered a progress report on the UK’s DPP:  From summer 2016-December 2018, there were nearly 325,000 referrals for the group-based, face-to-face, 9-12-month diabetes prevention program. Of this pool, ~30% have attended at least one intervention session and ~5% have completed the program. Accounting for two sources of lag in the data – people deferring enrollment post-referral and the fact that the program takes a year to complete – the proportion of those referred who completed the program swells to a healthier ~20%. Those who are older, not Asian/mixed ethnicity, of higher socioeconomic status, and not obese are more likely to be completers to date; noting this trend, NHS has implemented a new policy to pay providers more for retaining the types of participants who are less likely to complete. While type 2 diabetes incidence results are not expected for another ~two years, Dr. Valabhji did present changes in weight loss. Completers saw mean weight loss of 4.0%, with 37% achieving the target of 5%+ weight loss. In the intention-to-treat analysis, mean weight loss was 2.7% with 24% achieving weight loss of 5%+. Greater weight loss was seen in individuals who were older, not Asian/black, of higher socioeconomic status, and overweight or affected by obesity. There was a clear “dose response”, as more sessions attended translated to a greater degree of weight loss. Dr. Valabhji concluded that initial data is encouraging, but further action is needed to address equity and access. On this front, he pointed to (i) the altered payment model that incentivizes providers to invest more in retaining those who are “black, Asian, minority, higher deprivation, and obese” (though someone in Q&A asked why not just pay the participants directly for sessions attended, rather than the providers – we’d love to hear more input on this); and (ii) digital modes of delivery, which have been shown to better engage younger people in early pilots. At a cost of ~250 pounds (~$310) per person and a capacity of 100,000 participants per year (soon to rise to 200,000 in light of a new ~$25 billion investment), the UK DPP model seems to be a scalable model. We look forward to seeing data on diabetes incidence and eventually cost and CV/mortality outcomes to better understand how this investment of >$30 million per year plays out. 

In one of the final talks of EASD 2019, a session on new insights from the TEDDY study underscored a potential link between the onset of type 1 diabetes and certain genes and viruses. Dr. Anette Ziegler presented on the genetic trends of first-appearing islet autoimmunity and their implications, while Dr. Heikki Hyoty presented on the viral etiology of first-appearing autoimmunity. As background: TEDDY enrolled 7,718 participants with high-risk HLA haplotypes via general newborn screening (418,709 were screened), plus 949 high-risk newborns via first-degree relative screening (6,417 were screened). For the first four years of enrollment, participants were seen quarterly (a variety of biosamples were collected, and blood was tested for antibodies and relevant biomarkers) and a battery of environmental variables were monitored via survey. After four years, only antibody-positive children were seen every three months, while all others were seen every six months, until age 15. The purpose of TEDDY is identify potential environmental triggers of type 1.

  • Forty-seven single nucleotide polymorphisms (SNPs) found in TEDDY can help identify children in the general population at a 25-fold increased risk for islet autoimmunity and subsequent onset of type 1. With this, children with a genetic risk score coming from a combination of HLA and non-HLA genes have over a 10% risk of developing islet autoimmunity (stage 1 of type 1 diabetes) by age 6 and over a 12% risk of developing it by age 10. Analyses found that the BTLN2 gene was associated with type 1 risk, while DR4 was associated with insulin-first and GAD-first autoimmunity. These genes can be incorporated into screening tools to improve risk stratification and increase sensitivity in identifying stage 1 of type 1 onset. However, risk of type 1 onset is also affected by a child’s environment and maternal type 1. Interestingly, maternal type 1 status protects a child from insulin-first autoimmunity but is less effective in protecting from GAD-first or later appearing autoimmunity. An individual’s risk for islet autoimmunity also decreases exponentially with age, making it possible for an equation to model disease progression and assist in effective screenings. Though these genetic links are fascinating, Dr. Ziegler emphasized that these genes have limited influence on disease progression beyond stage 1, signaling that more work lies ahead.

    • Dr. Ziegler also announced that the GPPAD primary prevention platform is active. A genetic risk score based on the 47 SNPs identified by TEDDY will be applied to high-throughput infant screenings in Europe. Participating infants will be enrolled into the platform’s POInT study. We last heard an update on POInT at Diabetes UK 2019, where Oxford’s Prof. John Todd gave an update on the UK arm of the trial, announcing that four participants in the UK have been enrolled and 68,587 newborns across all five participant countries have been screened. As a reminder, children in POInT will be given daily oral insulin (titrated to 67.5 mg daily) or placebo until age three, starting at 4-7 months old, then they’ll be followed up to 6 years. The Helmsley Charitable Trust awarded five grants totaling $52 million to GPPAD, led by the Institute of Diabetes Research, Helmholtz Zentrum München, in December 2017, its largest-ever investment in type 1 (and one of its largest ever, period). The higher dose of oral insulin and earlier intervention (genetic risk, as opposed to after autoantibody development) have been cited as reasons for optimism despite lukewarm oral insulin results to date.

  • Dr. Hyoty presented data from viral studies that may link insulin autoimmunity to respiratory and gastrointestinal viruses. Based on stool virome analyses, development of autoimmunity was associated with species B enteroviruses – with early infections associated with the appearance of the type 1 antibody IAA. Results also showed that prolonged exposure to enterovirus B may be a risk marker for the development of type 1 diabetes. Species F adenoviruses were associated with the IA antibody, while Norwalk (Noro) virus was associated with the GADA antibody. To confirm or deny these links, Dr. Hyoty suggested that future studies use other types of samples, carry out viral serology tests, and examine viral mechanisms to identify a possible causal relationship between viral exposure, immune responses, genetic polymorphisms, and type 1 diabetes onset.

Diabetes Technology Highlights

1. Psychosocial Impact of FreeStyle Libre Pro in Type 2s (n=299): No Adverse Effects, but No Significant Increase in Patient Empowerment

Dr. Jane Speight (Australian Centre for Behavioural Research in Diabetes) opened a packed session on CGM with mixed results on the psychosocial impact of the blinded FreeStyle Libre Pro in 299 adults with type 2 diabetes. The intervention group in the two-arm randomized control trial, GP-OSMOTIC, wore the blinded FreeStyle Libre Pro every three months for a year. Each CGM session was followed up with a clinic visit, which included data interpretation. The control group conducted clinic visits every three months, without CGM data, and all participants in the study wore FreeStyle Libre Pro for two weeks at twelve months for data collection. The primary outcomes from GP-OSMOTIC were shown in a poster at ADA 2019, finding an ~8% increase in time-in-range (+2 hours/day; p=0.004), but no significant A1c improvement at 12 months. This secondary analysis showed assessments on emotional well-being (WHO-5), diabetes-specific quality of life (DIDP), satisfaction with glucose monitoring (GME-Q), perceived involvement in clinical care (PICS), and diabetes self-care activities (SDSCA) at baseline and twelve months. The WHO-5 and DIDP surveys revealed no additional psychological burden from wearing FreeStyle Libre Pro four times over the course of a year. Satisfaction with glucose monitoring was also not significantly affected by wearing the blinded CGM. Disappointingly, participants’ perceived involvement in their care was also not affected, nor was diabetes self-care – that is perhaps not surprising, since FreeStyle Libre Pro is worn blinded and data is only engaged in the clinic. We are not sure how to assess whether the patients were guided toward therapeutic, nutritional, or other changes. Dr. Speight did note that at baseline, participants had low levels of emotional distress, which may not be representative of most people with diabetes (especially those with type 2 diabetes facing stigma). Additionally, about a quarter of general practitioners who conducted clinic visits had not received any training related to CGMs. To us, the results suggest the importance of understanding blinded vs. real-time CGM as it relates to engagement and empowerment. Of course, there also remains a need for providers and people with type 2 to be better trained to take advantage of intermittent CGM data (either blinded or real-time). Further, qualitative analysis of the data will be performed in the future to better understand patient experiences.

Selected Question and Answer

Q (Dr. Kirsten Nørgaard): Did you have the chance to ask the physicians on their perception of using this device?

A: We haven’t got quantitative data from physicians, but we have interviewed some of them and we’re going to be analyzing some of those data. We’ve got some preliminary data from that interaction and we feel the care model has been really important. When the general practitioner, or practice nurse, did interact with the person with diabetes really felt that this was important for their care.

2. REFER Meta-Analysis from Germany, France, & Austria: Effectiveness of FreeStyle Libre on A1c in Type 2s on Intensive Insulin Has Increased Since 2014

Dr. Jens Kroeger from the Centre for Diabetology in Hamburg, Germany, presented results from a three-country meta-analysis of FreeStyle Libre that suggested A1c reductions delivered by FreeStyle Libre for people with type 2 on basal-bolus insulin are better in real-world use than in the REPLACE trial. The retrospective review looked at patient records from Germany, Austria, and France across 18 medical centers. In total, 363 records were analyzed from adult patients with type 2 diabetes on basal-bolus insulin, with a baseline A1c between 8%-12% before starting FreeStyle Libre, and at least three months of recorded FreeStyle Libre use. The studied periods ranged from January 2015 to January 2019. Mean age for study participants was ~64 years. After initiating FreeStyle Libre, mean A1c dropped from 8.9% to 7.9% in Germany (n=183), 8.8% to 7.9% in Austria (n=92), and 9% to 8.2% in France (n=88). Notably, the reduction was similar across time windows up to six months after initiation, suggesting sustained improvement. FreeStyle Libre was effective across all subgroups analyzed (sex, age, duration of insulin use, and BMI). Dr. Kroeger compared the results from his meta-analysis with the REPLACE RCT (read out at ATTD 2016) which missed its primary endpoint A1c reduction, finding a similar 0.3% reduction in both its FreeStyle Libre and SMBG groups. Dr. Kroeger credited increased understanding of FreeStyle Libre and its applications for the increase in A1c reduction. On a related note, he cited much improved education around AGP and other CGM-data interpretation from both patients and providers.

 

Baseline A1c

Final A1c

Change

REFER Combined

8.9%

8.0%

-0.9%

  REFER Germany (n=183)

8.9%

7.9%

-0.9%

  REFER Austria (n=92)

8.8%

7.9%

-0.9%

  REFER France (n=88)

9.0%

8.2%

-0.8%

REPLACE FreeStyle Libre Group (n=149)

8.7%

8.4%

-0.3%

REPLACE SMBG Group (n=75)

8.7%

8.3%

-0.3%

Selected Questions and Answers

Q (Dr. Bastiaan Eduard de Galan): Do you have any data about the risks of severe hypoglycemia or time spent in hypoglycemic range?

A: We have this data from the REPLACE study. There’s a reduction in the amount of hyperglycemic events. For time <70 mg/dl, there was a reduction of 41 minutes/day. For me, the important question is ‘Where do we have the level set?’ Internationally, we set the level at 70 mg/dl and 54 mg/dl. But, what is more important for the people with type 2? We must define where the important zones are for people with type 2 diabetes. (Editor’s note – this topic received extensive conversation when guidelines were being created – they were created for people with both type 2 and type 1 as shown in the guidelines – see more here and in the Diabetes Care June 2019 article - Clinical Targets for Continuous Glucose Monitoring Data Interpretation: Recommendations From the International Consensus on Time in Range.)

3. Dr. Stephanie Amiel: Technology is “Only as Good as the Person Using It”; Patient Education Should be First-Line Treatment for Hypoglycemia

British powerhouse physician Dr. Stephanie Amiel (King’s College, London) opened the session on “Supporting Diabetes Self-Management” with her suggested approaches to treating hypoglycemia. In line with the session’s title, Dr. Amiel’s first-line approach involves empowering patients through structured education for MDI with SMBG or hypoglycemia-specific education before adjunct approaches, such as pumps with low glucose suspend or even islet transplantation. Emphasizing the importance of patient-empowerment, Dr. Amiel shared a quote from American author Robert Persig, “Technology presumes there’s just one right way to do things and there never is.” To support her patient education-focused approach to preventing hypoglycemia, Dr. Amiel showed results from multiple studies. A 2014 national audit of UK’s standardized, five-day DAFNE course (“Dosing Advice for Nutritional Education”) found a 74% relative reduction in severe hypoglycemia. A meta-analysis (Yeoh et al. 2019, Diabetes Care) found that seven of eight structured education programs were effective at reducing hypoglycemia. Notably, the analysis found that general diabetes education programs were just as effective as hypoglycemia-specific education. Additionally, Dr. Amiel cited HypoCOMPASS (MDI vs. pumps, SMBG vs. CGM, with equal education) and REPOSE (pumps vs. MDI, holding education equal between the groups).

 

  • Dr. Amiel’s talk was part of the “East-West Forum,” and in the talk, she underscored hypoglycemia as a global problem. She cited British studies showing impaired awareness of hypoglycemia (IAH) in one-fifth of adults with type 1 diabetes and one-tenth of insulin-treated type 2s. In Australia, about one-fifth of adults also showed impaired hypoglycemia awareness and a Japanese study showed 10% of insulin treated type 2s with IAH.  

  • Despite her education-focused approach, Dr. Amiel outlined a role for technology (e.g. CGM and low glucose suspend) in her talk. Using an illustrative graphic with 100 people, she highlighted the 40% who enter DAFNE with IAH. While education restored awareness to 43% IAH patients, Dr. Amiel highlighted the remaining portion, stating “technology will help many of the rest.” She also showed results from the HypoDE study on CGM on type 1s on MDI and SMILE study on low glucose suspend in IAH type 1s.

4. University of Dresden’s Prof. Peter Schwarz: Governments Should Utilize Targeted Digital Communications to Reach Vulnerable Populations

Professor Peter Schwarz (University of Dresden) presented on the role governments can play in prevention and treatment of diabetes worldwide, emphasizing a role for digital technologies to target vulnerable populations such as children, the pregnant, and the elderly. While not mentioning specific devices or apps, Prof. Schwarz cited his 2018 analysis showing digital interventions could be more cost-effective measures for cardiovascular disease prevention compared to traditional pharmaceuticals, such as GLP-1s and DPP-4s. In the same vein, Prof. Schwarz previously emphasized the role for less drug-driven diabetes prevention approaches last year at WCPD. Dr. Schwarz also discussed how effective policies in schools that reduce fat and sugar consumption, while increasing fruit/vegetable intake can improve healthcare outcomes. Children, he noted, are especially vulnerable to social media messages from food/beverage companies. For pregnant women, he highlighted risk factor screenings as part of prenatal care, lifestyle counseling, and increasing leisure time and physical activity are crucial. Lastly, he encouraged that the elderly receive “structured disease management programs.” We look forward to the role CGM and coaching might play in all of these populations!

  • Prof. Schwarz noted the role of evidence-based communication strategies with specific target audiences (elderly, pregnant, adolescents) that could enable access to life-saving information, especially those with low socioeconomic status or health literacy. To this end, we were reminded of Fitbit’s partnership with Singapore to provide a free Fitbit with the purchase of Fitbit digital coaching. The Singaporean Health Promotion Board (HPB) will help market the program, while Fitbit will share user data with HPB to help them create more effective health promotion campaigns.

Exhibit Hall

Diabetes Therapy

AZ

In the wake of Dapa-HF results, AZ’s booth included a large heart-failure centric message to EASD 2019. Large screens displayed the message that “heart failure is a more common first CV complication than MI or stroke in patients with type 2 diabetes” – this ideally would prompt attendees to more seriously consider the treatment and prevention of this serious yet often under looked complication.

We also noted new slogans for Farxiga and Bydureon on display. For Farxiga, a large structure with the word “TODAY” was squared in the center of the booth, referring to its slogan of “For Today, For Tomorrow” – paralleling Farxiga’s benefits on short term metabolic outcomes (lower A1c, lower weight, lower BP) and benefit on longer term cardiovascular and renal outcomes. For Bydureon, we noticed the slogan “Bydureon first…insulin later,” highlighting the push for GLP-1s as a first-line injectable over insulin. We’re glad to see this marketing from AZ for Bydureon, and overall, it seems there’s been improved promotion of the therapy in Europe than in the US following the launch of its BCise autoinjector last year.

Touchscreen stations in the company’s booth were devoted to AZ’s entire CVRM platform, including a specific focus on the DapaCare program for Farxiga. As a reminder, DapaCare includes DECLAREDapa-HFDELIVERDapa-CKD, mechanistic studies in DEFINE-HFPRESERVED-HF, and DAPASALT, along with recently added DETERMINE-Reduced and DETERMINE-Preserved. Reps were eager to go in-depth on DapaCare, detailing the deep investment that AZ has made in order to fully investigate Farxiga along the cardiorenal axis.

Lilly/BI

Lilly/BI’s large booth was at the center of this year’s exhibit hall, split into two distinct areas for different therapies. One side, predominantly dedicated to Boehringer Ingelheim, heavily spotlighted SGLT-2 inhibitor Jardiance, as well as Synjardy (empagliflozin/metformin HCl) and Glyxambi (empagliflozin/linagliptin) against a muted wood backdrop. Jardiance again used the shadow knight campaign we last saw at ESC 2019, consisting of a shadow knight (representing Jardiance) protecting the heart of a middle-aged man from shadow demons, representing the drug’s cardioprotective benefits. This year’s booth was a calmer approach than last year’s, which gave prominence to a giant ticking clock captioned with “every 18 seconds a type two patient dies of a CV event.”  The second area, colored in classic Lilly red, featured large upright screens for GLP-1 Trulicity – an interesting separation of GLP-1 and SGLT-2 inhibitor therapies between the two sides. In general, seating area and espresso drink were abundant at Lilly/BI – while some may have looked for more interactive booth activities, we believe that greater conversation was the goal.

Novo Nordisk

Novo Nordisk brought a sizable booth to EASD 2019, focused on the promotion of Ozempic (injectable semaglutide). As usual, Ozempic’s proven CV benefits were highlighted—a unique feature of Novo Nordisk’s exhibit booths in Europe, seeing as the EU label for Ozempic acknowledges a statistically significant CV benefit as well as significant risk reduction for nephropathy with semaglutide vs. placebo, without granting a formal indication; on the other hand, the FDA presents SUSTAIN 6 as a CV safety trial, with no allusion to cardioprotection or renal protection. Building off of this point, advertising materials also pointed out that the 2018 ADA/EASD consensus report recommends GLP-1s with “proven CV benefit” – making Ozempic one of these therapies recommended. We’re imagine future booths will make a similar connection with new ESC guidelines as well.

The booth also prominently featured Novo Nordisk’s sponsored 5K Run/Walk at EASD, designed to bring together citizens of Barcelona and EASD delegates to emphasize the need for increased physical activity to help prevent diabetes and diabetes complications. We’re always happy to see this continued effort from Novo Nordisk that has been ongoing for so many years and incorporates all aspects of holistic diabetes care.

Regarding Novo Nordisk’s diabetes tech offerings, we also got our first look at a prototype, Bluetooth-enabled pen attachment for prefilled, disposable insulin pens – see our coverage from EASD Day #3.

Merck

Merck’s welcoming salesforce convinced one of our unsuspecting associates to put on an exhibit hall VR headset for the first time, and the experience was certainly worthwhile! In the game a robot guided the player through data regarding SGLT-2 inhibitor Steglatro, and users could decide between slingshot or golfing games that tested the knowledge afterwards. A large portion of Merck’s massive booth, which like last year, stood front-and-center by the entrance of the exhibit hall, was dedicated to Steglatro. The company’s area was entirely carpeted in eye-catching Merck purple and had bright lights in yellow, blue, and purple to create a striking atmosphere. The VR game was the main interactive activity. Touch screens for Steglatro, DPP-4 inhibitor Januvia, and Janumet (sitagliptin/metformin) displayed patient profiles, which we felt was valuable for conference goers’ to see, although it is not always easy to grab the attention of exhausted doctors (and other HCPs). In addition, a small theater area played a video explaining details on Merck’s therapies.

Novartis

Novartis’ modest booth gave homage to famous Spanish architect Antoni Gaudi and was modeled entirely after Park Güell with mosaics, real plants, and the famous lizard and tower that are the focal points of the park. This set-up definitely attracted many people to the booth - in our time there, we saw about 10 people take selfies in front of the lizard statue. Galvus (vildagliptin) and Eucreas (vildagliptin and metformin) were the therapies of focus for an exhibit hall booth. Ultimately, one large screen TV and another smaller-sized one played videos to advertise the drugs. The booth also featured interactive touch screens to let visitors explore the VERIFY trial and what it means for future treatment and earlier combination therapy in type 2 diabetes. It seems that Novartis utilized passive advertising, letting Gaudi attract and leave an impression on visitors versus the drugs.

Sanofi

Right at the main entrance of the exhibit hall, Sanofi’s booth illuminated the space, and as expected, also served coffee (some of the best at the exhibit hall!) front and center among grass, tables, chairs, and hardwood floors. As seen at ADA 2019, Sanofi’s “Your Type” campaign, which is comprised by the pillars of medicine, education, integrated care, and access, defined the theme of the entire booth. We were impressed to see a live, interactive basal insulin titration tutorial presentation, and have hope for Sanofi’s investment in education. With this, a large Your Type banner was also displayed outside the conference center throughout EASD, making clear Sanofi’s intention to be at the forefront of conference-goers’ minds. We were happy to see the Your Type campaign promote patient empowerment, education, integrated care, access, and individualized treatment plans. There were, of course, no mention of or imaging related to the Valyou insulin savings program (10 pack of pens/vials $99/month for patients without insurance) or Sanofi Co-pay card ($0 co-pay for patients with commercial insurance) since European countries do not have issues with access that relate to affordability – in most of the EU, the problem patients perceive is that various government payers do not agree to cover every therapy. 

Soliqua (insulin glargine and lixisenatide), Praluent (alirocumab), and Toujeo (insulin glargine) were the focal points of the company’s display. A video for each compound played on large TV screens in front of couches, and given the booth’s sizable Medical Affairs section and many representatives, personal interactions with representatives were certainly possible in addition to the interactive touchscreens. Some TV screens were also playing informational videos about the outcomes of the BRIGHT study and Sanofi’s recent UK launch of the Toujeo DoubleStar pen. We would have loved to see information Sanofi’s recent CGM partnership with Abbott, but given the timing, this would not have been possible.

 

--by Albert Cai, Ursula Biba, Ani Gururaj, Rhea Teng, Abigail Dove, Brian Levine, Martin Kurian, and Kelly Close