An Interview with Dr. Vincent Woo on the SUSTAIN 9 Diabetes Trial

“So, it’s important to know that both of these agents, together, in this study both are safe and efficacious, and that when you add one to the other, you get improved effects.”

About: Dr. Vincent Woo, MD FRCPC obtained his medical degree from the University of Manitoba and his specialty training in Endocrinology and Metabolism at the University of British Columbia. He is a principal investigator at The Winnipeg Clinic and St Boniface Hospital. Dr. Woo is involved in many clinical trials including SUSTAIN 9. He has published a number of articles and abstracts and is a reviewer for many journals. He is actively involved with Diabetes Canada where he has Chaired Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada.

Q: Tell me about the new diabetes management research you supported with SUSTAIN 9 trial?

A: Sure, with diabetes, people with diabetes have increased risk of cardiovascular disease, heart disease or stroke, two to three times higher than those people without diabetes. Also, people with diabetes have very high rates of kidney disease as well. And diabetes is a leading cause of in-stage kidney disease. So, with the SUSTAIN 9 trial, these are two medications that are very important for people with diabetes because both of them have potential effects for improving glucose control potentially better than other medications. These two medications individually and, combined, decrease weight, which is important because most patients with diabetes are overweight, and both of these medications in separate trials have been shown to decrease heart disease. Also, with the SGL2 inhibitor, there is a significant decrease or improvement in kidney function, and there is also a trend towards improved kidney function with Semaglutide, the other agent.

So, it’s important to know that both of these agents, together, in this study both are safe and are efficacious, and that when you add one to the other, you get improved effects.

Q: What does this research mean for Canadians living with type 2 diabetes?

A: So, again, when someone has diabetes, they want improved quality of life, so that they don’t want to have the complications of diabetes, but, also, they want to sort of lower their glucose levels safely and not with say insulin, you can lower glucose levels. But insulin, which is always an option, increases your weight and has the possibility, especially in say older individuals or elderly population has a risk of hyperglycemia, which means a loss of consciousness, accidents and poor quality of life, so that we can use agents that have low risks of hyperglycemia such as these two agents that work differently, then you aren’t going to get the weight gain and hyperglycemia as well. But, also, these two medications will decrease your risk of cardiovascular events like heart attacks and stroke as well as stabilized long-term kidney function.

Q: What excited you the most about this new research?

A: Well, again, it’s just an extension of what we already know, so with semaglutide, it by itself probably as a single agent decreases weight the most, decreases glucose the most and, also, has been shown, as I said, to decrease these cardiovascular events. Then we have these SGL2 inhibitors. There are three of them available in Canada. They are anagliflozin (Invokana) dapagliflozin (Farxiga), canagliflozin (Invokana), and each of them has been shown to decrease cardiovascular events, renal events, glucose levels and weight. Both of these are somewhat or potentially preferred agents for the treatment of type II diabetes usually after metformin because metformin, we still use in our guidelines as the first agent just because of tradition and its been around for four years. And these newer agents, depending on where they are available in the world, range from anywhere from five to eight years or four to eight years less than semaglutide probably has been around for two years in Canada.

Q: Despite advancements in treatment, research shows almost half of Canadians with type 2 diabetes are still living with uncontrolled blood sugar. Why is this?

A: Because it is very difficult to improve glucose levels, so one of the problems is that we all get older. So, diabetes, most people don’t know, diabetes is progressive in individuals. So, you know what, I started with diet and exercise and I controlled my glucose levels, I could do it again, but they don’t realize as they age that their pancreas gets older too, so as that time goes on, its more difficult for you to maintain those glucose levels, and so sometimes when my patients come to me and say ‘what do I do so I don’t have to go to another diabetes agent because I want to improve my glucose levels.’ We always preach to do the diet and exercise, and don’t get us wrong, as that is still the mainstay of therapy, but what I have to tell them is that the only way to do it without that is that they have to get younger.

What they have to realize is as they get younger, no part of their body is getting better because they are aging, so diabetes is progressive meaning that we need more and more and more things to improve glucose levels. This means more diet, more exercise and more medications.

Q: What do you see as the greatest need surrounding type 2 diabetes treatment in Canada today?

A: So the need is many, but some of the important things is that some people do have to realize is that the best person off has the best glucose levels, the best blood pressure, the best cholesterol readings, the best people that don’t smoke, and these other important things, and that here in Canada, we have to make lifestyle changes and medications more cost-effective, so many patients have things that are not necessarily covered by their healthcare providers, whether it be the provincial drug plans, as there is always a hierarchy to do that. And there always is a time where people just want to give themselves 3-6 months before they go on those medications, so even though we say half or above 7%, the people that are just above represent an important place, where people just don’t quite want to give them something because they’re just above 7%. So, I would say that it is more like 40% and they do need something extra. And the ones that are very close tend to fluctuate close to the line for things like high blood pressure and high cholesterol, they probably get similar numbers for not reaching those targets as well.

The important thing also is that we did a study just a few years ago on people with diabetes that don’t reach their blood pressure, their cholesterol and their glucose targets, and only 13% actually did. So even though we said 50-50 for glycemic control, it is only 13% that have all of their glucose and lipid targets, so we still have lots to do.

Q: What are your thoughts on the healthcare commitments made by the federal government in Budget 2019?

A: So, the government is giving more money to the provinces for healthcare and really diabetes is one of many conditions that provinces have to cover including all these other conditions such as cancer, mental health, and public health, so we just have to spend our dollars wisely.

Q: Do they complement the recent research findings on diabetes management?

A: So, I think things that come into the press take a lot longer to get into changes in policy. We all see that not just in medicine, but in other places as well, so we do realize it does take time and that sometimes when you’re on the frontlines, we get a little frustrated that things aren’t immediately available, we don’t have very good evidence, or we know there is a hierarchy of things that need to be done, so, again, if we could shrink that time to have cost-effective measures, so you know it does take time for once a study comes out, you have to do a cost-effectiveness study, and, you know, what are the possible implications to the health budget and, you know, depending on where you want to spend your health dollars, so I am not a health minister. So, I just see many patients day-to-day with diabetes both type I and type II, so I have my asks for those people, but I realize that even within that budget, I think we could do better.