MD Conference Express ADA 2011 - (Page 33)

months, none of the adolescents who underwent surgery had it (p=0.008) compared with 22% in the lifestyle group (p=0.13) [O’Brien et al. JAMA 2010]. Table 1. Hierarchy of Weight Loss Techniques. Therapy Lifestyle - Eat less and do more Drugs, Very low calorie diets Endoscopic - intragastric balloon et al Gastric banding Sleeve gastrectomy Laparoscopic RYGB Open RYGB Open biliopancreatic diversion (BPD) Laparoscopic BPD Reproduced with permission from P. O’Brien, MD. developmental maturity; failure in conventional programs; and an ability to understand the process and partner with the treatment team. He noted the need to follow the CORE indications, put together a knowledgeable and caring treatment team, make sure the kids know the rules, and collect data to measure the outcomes and learn. Rating 1.0 2.0 4.0 5.0 7.0 7.5 8.5 9.0 10.0 Immunomodulatory Therapy Trials in Type 1 Diabetes Written by Lori Alexander Figure 1. Laparoscopic Adjustable Gastric Band. Key Strengths: • Safe • Effective • Gentle, adjustable, reversible • Good evidence base Key Weaknesses: • Requires good follow up • Requires a “partnership” • Requires revisional surgery – ~ 10% in 10 years Gastric band As type 1 diabetes continues to be a worldwide epidemic, researchers persist in exploring new ways to prevent the disease from developing or to delay its development, especially in young children. Several studies have evaluated the safety and efficacy of immunomodulatory therapies, both as prevention strategies and as interventions for new-onset disease. No studies to date have demonstrated effectiveness in preventing diabetes. In the Diabetes Prevention TrialType 1 (DPT-1), oral insulin did not prevent or delay diabetes in subjects who were at increased risk for the disease. However, when subsets of subjects with high insulin autoantibody (IAA) levels were analyzed, there was a 4.5- to 5-year delay (IAA levels ≥80 nU/mL) and a 10-year delay (IAA levels ≥300 nU/mL) [Skyler JS et al. Diabetes Care 2005]. This finding suggests a clinically meaningful benefit for a specific subpopulation, said Desmond Schatz, MD, Diabetes Center, University of Florida Health Science Center, Gainesville, Florida, USA. In intervention studies, treatment with anti-CD3 (rituximab) led to significantly higher C-peptide levels (measured as the area under the curve) compared with controls for up to 1 year, as well as lower HbA1C levels and lower insulin dose (p<0.001 for all) [Pescovitz MD et al. New Engl J Med 2009]. Dr. Schatz said that the study indicated an immunological effect, in that the treatment completely depleted CD19 cells, with a near recovery of β-cells over the course of a year. An important finding was that the difference in outcomes between the treatment and control groups began at 3 to 6 months after the initiation of treatment. Dr. Schatz noted that anti-CD20 (teplizumab) and DiaPep277 (a synthetic heat shock protein 60 peptide) also led to significantly higher C-peptide levels, with the difference also emerging at 3 to 6 months [Herold KC et al. New Engl J Med 2002; Herold KC et al. Diabetes 2005]. These data suggest that the effectiveness of a prevention strategy could be identified early. 33 Small cuff of stomach Remainder of stomach Port Reproduced with permission from P. O’Brien, MD. In adolescents, established type 2 diabetes is a strong indication for weight loss surgery [Xanthakos SA, Inge TH. J Pediatr 2007; Pratt JSA et al. Obesity 2009]. Observational studies suggest that surgically induced weight loss may be an effective treatment for the disease. An unblended, randomized, controlled trial in adults [Dixon JB et al. JAMA 2008] found that 73% of patients in the surgical group achieved remission of type 2 diabetes versus 13% in the conventional therapy group. Metaanalyses by Buchwald et al. [Am J Med 2009] and Maggard et al. [Ann Surg 2005] found similar outcomes. In adolescents, O’Brien et al. [JAMA 2010] found that homeostasis model assessment–insulin resistance in the surgical group fell significantly from 2.94 to 0.95 after gastric banding versus 3.17 to 1.8 in the nonsurgical group. Prof. O’Brien cited Centers of Research Excellence (CORE) criteria for pediatric weight loss surgery. They include age >14 years; body mass index >35 kg/m2 (almost always above the 99th percentile); at or near full skeletal and Peer-Reviewed Highlights from the American Diabetes Association 71st Annual Scientific Sessions http://www.mdconferencexpress.com

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MD Conference Express ADA 2011

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