1. Daily Summary – December 2 nd, 2015 Roopa Mehta Atlas approval ID: 931824.011 Date of preparation: November 2015 Expiry date: December 2016 ©AstraZeneca 2015 Intended for non-US healthcare professionals only

2. Towards solving the inflammation puzzle in diabetes

3. Towards Solving the Inflammation Puzzle in Diabetes IL, interleukin; T2DM, Type 2 diabetes mellitus 1. Donath M, et al. IDF 2015:a145; 2. Goldfine A, et al. IDF 2015:a146 The islets of patients with T2DM are characterized by the presence of cytokines, immune cells, β-cell apoptosis, amyloid deposits, and fibrosis 1 ‒ IL-1β and IL-6 regulate β-cell insulin secretion in both health and disease Studies of anti-inflammatory agents such as hydroxychloroquine and the interleukin-1 modulators anakinra and diacerein are ongoing 2

4. Towards Solving the Inflammation Puzzle in Diabetes: Brain Koliwad S, et al. IDF 2015:a143 Microglia accumulate in the mediobasal hypothalamus Excess fatty acid activates microglia and leads to the inflammation phenotype Depletion of microglia reduces inflammation Microglia may play a role in setting hypothalamic signal strength

5. Towards Solving the Inflammation Puzzle in Diabetes: Innate Mechanisms of Metabolic Homeostasis Chawla A, et al. IDF 2015:a144 Inflammation is the source of many disease states Cold temperatures induce eosinophils and macrophages and browning of adipocytes ‒ Adipocyte precursors become white or beige depending on temperature Mammals adapt to the cold by accumulating beige adipocytes, which participate in thermogenesis The myeloid cell is required for cold-induced browning of adipocytes in mice

6. Towards Solving the Inflammation Puzzle in Diabetes: Islet CV, cardiovascular; IL, interleukin; T2DM, Type 2 diabetes mellitus Donath MY, et al. IDF 2015:a145 The islets of patients with T2DM are characterized by the presence of cytokines, immune cells, β-cell apoptosis, amyloid deposits, and fibrosis Postprandial IL-1β promotes insulin secretion in animal models and shifts glucose uptake to immune cells IL-1 antagonism improves insulin secretion in patients with T2DM ‒ The CANTOS study (N=10,000) is currently investigating CV endpoints of IL-1 antagonism ‒ Anti-inflammatory drugs are effective in treating diseases that are comorbid with diabetes, such as gout, psoriasis, and arthritis Gevokizumab is currently being trialed in patients with diabetic nephropathy

7. Towards Solving the Inflammation Puzzle in Diabetes: As a Therapeutic Target HbA 1c, glycated hemoglobin; TNFα, tumor necrosis factor α; T2DM, Type 2 diabetes mellitus Goldfine A, et al. IDF 2015:a146 There is a direct link between insulin resistance and TNFα The benefits of treating diabetes with salicylates has long been appreciated ‒ Salicylates improve insulin sensitivity and glucose tolerance in rodents A dose-ranging clinical trial of salsalate (TINSAL-T2D; N=108) reported improved HbA 1c, fasting plasma glucose, and triglycerides in patients with T2DM ‒ White blood cell count was also lowered

8. Obesity: New concepts and treatment approaches

9. Obesity: New Concepts and Treatment Approaches CV, cardiovascular; T2DM, Type 2 diabetes mellitus Schauer P, et al. IDF 2015:a166 Bariatric surgery may improve obesity-related disease processes, including T2DM Observational studies have demonstrated decreases in short- and medium-term CV disease Benefits should be weighed against short- and long-term complications

10. Precision Medicine in Obesity: Implications for Behavioral Weight Loss Treatment Dr Jeanne McCaffery explained that behavioral interventions to induce weight reduction in obese indiviuals involve reduction of caloric intake and increased physical activity, and form the basis of front-line therapy for obesity ‒ Such behavioral interventions reliably produce initial weight reductions of 7% or more and result in clinically important health benefits; however, individuals differ substantially in the magnitude of initial weight reduction and maintenance over time ‒ In addition, the health benefits of weight reduction can be different in different populations. For example, data show that each copy of the MTIF3 gene was associated with greater weight reduction following intervention over 4 years; however, most obesity genes tested were not associated with greater weight reduction or weight regain, perhaps due to small effect size or genetic loci related to weight increase being different from those related to weight reduction In conclusion, genetic differences could be leveraged to improve the treatment of obesity, with new genetic testing methods potentially yielding new information and also biomarkers with potential to help determine those patient groups that would benefit from behavioral interventions McCaffery J, et al. IDF 2015:a163

11. Metabolically Healthy and Obese: Facts vs Fiction It has been shown previously that increased weight may not necessarily result in cardiometabolic abnormalities in all individuals, and there appear to be groups of individuals who are obese but have no metabolic dysfunction, the so-called ‘metabolically-healthy obesity’ (MHO) These individuals represent an unusual phenotype, that may have particular characteristics protecting them from the development of CV risk factors that would normally develop in obese individuals, such as hypertension, T2DM, and dyslipidemia Previous studies that attempted to investigate individuals with MHO have provided important insights regarding the potential ‘protective’ characteristics, such as age, a more favorable distribution of adipose tissue, and general fitness; however, despite presenting without apparent adverse cardiometabolic disturbances, these individuals are still at an increased risk for adverse events, T2DM, and CVD, suggesting the ‘benign obesity’ may be only a transition stage CV, cardiovascular; CVD, cardiovascular disease; T2DM, Type 2 diabetes mellitus Kramer C, et al. IDF 2015:a164

12. Roles of Microbiome and Gut Hormones in the Outcomes of Metabolic Surgery Dr L Kaplan pointed out that gastrointestinal regulation of metabolic function is a complex process, and that highest weight reduction is seen in patients undergoing gastric bypass surgery, compared with those undergoing gastric banding; this is likely due to effects on cholesterol, taste, hormones, glucose, various gastrointestinal factors, and energy balance ‒ The positive metabolic effects following gastric bypass surgery are mostly physiological, rather than mechanical. For example, in animals models it is evident that even excessive energy intake is not associated with weight gain after gastric bypass, suggesting an increase in energy expenditure ‒ Bile acids are able to create an array of metabolic signals, and could be one of the physiological effects underlying the effect of gastric bypass surgery; bile acid levels increase after gastric bypass and may normalize postprandial glycemia, resulting in an improved metabolic profile Obesity is associated with specific changes in gut microbiota, which has been shown to change following gastric bypass surgery. Microbiota following gastric bypass has been shown to promote energy expenditure; in addition, microbiota transfer experiments revealed that animal recipients of human gastric bypass microbiota lost weight, compared with those receiving control microbiota Kaplan L, et al. IDF 2015:a165

13. Surgery vs Medications for Diabetes: Current Data, Future Possibilities A substantial number of randomized controlled studies have confirmed that gastric bypass surgery results in superior glycemic control compared with medical treatment ‒ CV risk factors improved with surgery ‒ Surgery significantly improved quality of life in patients with diabetes compared with medical treatment ‒ Non-RCT data demonstrated that surgery reduced mortality and CV events ‒ Rates of both perioperative morbidity and mortality were very low The IDF 2011 guidelines state that gastric bypass surgery should be used in patients with T2DM and severe obesity BMI (≥35 kg/m 2 ), and in those who are unable to adequately control their disease using pharmacotherapy and have other major CV risk factors Dr Philip Schauer concluded that gastric bypass surgery is safe, effective, and cost-effective, and should be used in conjunction with pharmacotherapy to reduce or eliminate complications of T2DM and obesity BMI, body mass index; CV, cardiovascular; IDF, International Diabetes Federation; RCT, randomized controlled trial; T2DM, Type 2 diabetes mellitus Schauer P, et al. IDF 2015:a166

14. Diabetes and atherosclerosis: New insights from the bench to the clinic

15. Diabetes Promotes Atherosclerosis: Mechanistic Mouse Studies TLR4, toll-like receptor 4; VLDL, very low-density lipoprotein Bornfeldt K, et al. IDF 2015:a167 Dr Karen Bornfeldt presented data from mouse models showing that the initial stages of atherosclerotic lesion formation (the accumulation of macrophages at the basal lamina) are accelerated in the diabetic environment Histopathological analysis showed morphological similarities between human and mouse lesions, suggesting similar pathophysiology ‒ Early lesions in diabetic mice are larger than those in nondiabetic mice due to increased macrophage accumulation. This can be prevented by insulin treatment Similarly, diabetes promotes intra-plaque hemorrhage ‒ This seems to be due to the induction of a specific inflammatory signature in leukocytes, monocytes and macrophages and inflammatory activation of myeloid cells ‒ The accumulation of macrophages in atherosclerotic plaques is mediated via TLR4 Similarly, diabetic mice have elevated VLDL levels when fed high-fat diets ‒ Such diets markedly accelerate atherosclerosis in diabetic mice, particularly in advanced lesions, which may be independent of hyperglycemia

16. Diabetes Impairs Atherosclerosis Regression: Mechanistic Mouse Studies IL, interleukin; T1DM, Type 1 diabetes mellitus; T2DM, Type 2 diabetes mellitus; TLR4, Toll-like receptor 4 Goldberg I, et al. IDF 2015:a168 Dr Ira Goldberg pointed out the difficulties of studying atherosclerotic plaque progression in models of diabetes because such models usually also have high cholesterol levels, which are a known accelerant of atherosclerosis Instead, some researchers have turned to studying the regression of atherosclerotic plaques when cholesterol levels are lowered – a process that is defective in diabetic mice ‒ Monocytes and neutrophils are elevated in diabetic mice, but monocyte and neutrophil levels were reduced when blood glucose levels were lowered by induction of renal glucose excretion ‒ Similarly, glucose reduction also improved lesion regression, directly implicating hyperglycemia rather than insulin resistance This process is mediated via the S100A8 and S100A9 genes – both of which are also elevated in the peripheral blood of patients with T1DM and comorbid coronary artery disease However, this effect of reducing glucose level on atherosclerosis did not seem to be present in mouse models of T2DM or patients with T2DM – instead the process seems to be mediated by adipose tissue and is dependent on TLR4 and IL-1β These data suggest a fundamental difference in atherosclerosis between T1DM and T2DM

17. Mechanisms of CVD in Humans with T1DM or T2DM AGE, advanced glycation end-product; CVD, cardiovascular disease; IL, interleukin; LDL, low-density lipoprotein; T1DM, Type 1 diabetes mellitus; T2DM, Type 2 diabetes mellitus Laakso M, et al. IDF 2015:a169 Dr M Laasko pointed out that hyperglycemia develops within weeks in T1DM but may take decades in T2DM, and the contribution of insulin resistance and hyperglycemia to atherosclerotic risk is unclear However, insulin resistance is associated with an increased risk of atherosclerosis in individuals with or without diabetes Insulin resistance in muscle tissue leads to hyperglycemia, whereas in adipose tissue it results in dyslipidemia and low-grade inflammation. It also has effects in the sympathetic nervous system, endothelial cells, and macrophages Insulin resistance can be quantified in muscle, liver, and adipose tissue. The greatest statistical association with CVD was liver insulin resistance Higher levels of AGEs are associated with cardiovascular mortality in both T1DM and T2DM Recent genetic analyses have shown associations between certain genotypes (such as certain variants of IL-6 and LDL receptor gene) and an elevated risk for atherosclerosis Mendelian randomization approaches suggest that some risk factors are causally implicated in atherosclerosis ‒ These include insulin resistance, insulin secretion, hyperglycemia, blood pressure; LDL-cholesterol, and IL-6

18. PCSK9 as a Novel Target CV, cardiovascular; LDL, low-density lipoprotein Ginsberg H, et al. IDF 2015:a170 Dr Henry Ginsberg focused on the potential of PCSK9 inhibition to reduce atherosclerosis by lowering LDL cholesterol The PCSK9 protein coordinates LDL catabolism by binding to the LDL receptor Under normal circumstances, the LDL receptor is internalized into the cell once LDL binds to the receptor. It then returns to the hepatocyte cell membrane once LDL dissociates from the receptor, while the LDL is degraded in lysozomes If PCSK9 is bound to the LDL–LDL receptor complex, dissociation does not occur and the entire complex is degraded in lysosomes, reducing the availability of LDL receptors Loss of function mutations in PCSK9 therefore results in lowering of circulating LDL cholesterol and is associated with a reduction in CV events. The opposite is true for gain of function mutations Inhibition of PCSK9 by anti-PCSK9 antibodies has shown significant reduction in LDL cholesterol levels The long-term effect on CV events of lowering LDL cholesterol via this mechanism remains to be confirmed in prospective studies

19. Oral and gastrointestinal tract complications

20. Oral and Gastrointestinal Tract Complications CVD, cardiovascular disease 1. Taylor G, et al. IDF 2015:a176; 2. Rayner C, et al. IDF 2015:a179 Observational studies have demonstrated both the adverse effects of diabetes on periodontal health and that periodontal disease is associated with increased risk for diabetes and diabetes complications, including CVD, cardio-renal mortality and renal disease 1 Diabetes is associated with an increased risk of gastroesophageal reflux, dyspepsia, diarrhea, and constipation 2 ‒ Disordered gastrointestinal function in patients with diabetes can result in impaired nutrition, and contribute to poor glycemic control ‒ Dietary or pharmacological interventions that modulate gut function may be beneficial

21. Definition and Distribution of Periodontal Disease HbA 1c, glycated hemoglobin; IGT, impaired glucose tolerance; T1DM, Type 1 diabetes mellitus; T2DM, Type 2 diabetes mellitus Taylor G. IDF 2015:a176 Periodontitis leads to oral tissue loss and loosening and loss of teeth Diabetes is an important risk factor for periodontitis, especially in patients who smoke ‒ Numerous studies, including SHIP and NHANES 2009–2012, have demonstrated that effects are more severe and develop more rapidly in patients with prediabetes and diabetes (especially uncontrolled diabetes) than in individuals without diabetes Poor oral health is associated with higher rates of insulin resistance and IGT, and higher HbA 1c levels Treating periodontitis can reduce the effect of infection A meta-analysis showed a small improvement in HbA 1c in patients with T1DM and T2DM who received treatment for periodontitis

22. Diabetes and Periodontitis ADA, American Diabetes Association; HCP, healthcare professional; HbA 1c, glycated hemoglobin; T1DM, Type 1 diabetes mellitus; T2DM, Type 2 diabetes mellitus Lalla E. IDF 2015:a177 Children and adolescents with T1DM and T2DM have increased gum bleeding and tooth loss compared with those without diabetes A subgroup analysis found an association between HbA 1c and periodontitis, but not between obesity or age and periodontitis Therefore programs are needed to prevent periodontitis in patients with diabetes. This should not be the responsibility of one group of HCPs but a collaboration between physicians and dentists A small study found that when dentists advised patients with periodontitis about the risk of diabetes and recommended they see a physician, patients followed this advice ADA guidelines recommend a dental check on diagnosis of diabetes, but patients should also have annual check-ups Physicians can help by screening patients with diabetes for periodontal disease – a simple visual check of the condition of the mouth is all that is required Dentists should be part of the multidisciplinary team caring for patients with diabetes

23. Oral Complications in Metabolic Disorders Including Diabetes and Obesity AhR, aryl hydrocarbon receptor; MMP, matrix metalloprotein; PAH, polycyclic aryl hydrocarbons; ROS, reactive oxygen species Tenenbaum H. IDF 2015:a178 There are pathological similarities between periodontitis and diabetes: vascular changes, activations of host defence (hyperproduction of cytokines and ROS), increased production of MMPs, and impaired wound-healing ‒ Even if there is no causal effect, these similarities are still important Diabetes and periodontitis also have risk factors in common, specifically smoking, oxidative stress, and socioeconomic status PAHs present in tobacco smoke bind to the ArH receptor, triggering inflammation reactions and production of ROS, and inhibition of bone formation The antioxidant resveratrol completely blocked the progression of periodontitis in a rat model. It has also shown efficacy in a model of diabetes Novel approaches for the management of diabetes and periodontitis based on AhR regulation and antioxidant treatment should be explored in the future

24. Gastroperesis and Intestinal Complications GI, gastrointestinal Rayner C. IDF 2015:a179 Many patients with diabetes have upper GI symptoms Gastroparesis is the most important of these – diabetes accounts for approximately one third of all gastroparesis – but is often overlooked as a cause of upper GI symptoms Gastroparesis also affects blood glucose levels – changes in the rate of stomach emptying affects the uptake of glucose into the blood, leading to disparities between calculated insulin dose and actual need Treatment of gastroparesis should aim to optimize glycemic control and nutrition (low-fibre, low-fat diet, more calories in liquid form), and treatment of symptoms of nausea and abdominal pain Other upper GI symptoms include reflux, dysphagia, and candidiasis Celiac disease, small-intestinal motility, constipation, and diarrhea (including diabetic diarrhea) are all more frequent in patients with diabetes than in individuals without diabetes

25. Omics in 2015 for the clinician: What does the future hold?

26. Omics in 2015 for the Clinician: What Does the Future Hold? GLUT2, glucose transporter 2; SNP, single nucleotide polymorphism 1. Burant C, et al. IDF 2015:a186; 2. Rossing P, et al. IDF 2015:a187; 3. Groop L, et al. IDF 2015:a189 Metabolomics can provide information on mRNA and protein expression and activity 1 Plasma and serum proteomics can be an effective method in identifying new markers for kidney disease in patients with diabetes 2 Genomic techniques have identified >100 genetic variants associated T2DM 3 ‒ An SNP in the SLC2A2 gene encoding for GLUT2 has been shown to be a strong predictor of future need of insulin therapy

27. Omics in 2015 for the Clinican: Metabolomics HCR, high-capacity runners; LCR, low-capacity runners Burant C, et al. IDF 2015:a186 Metabolomics can provide information on mRNA and protein expression and activity For example, gene expression profiles of rats that have either a low or high capacity for running show that genes associated with ageing alter much more in LCR, particularly genes involved with oxidative phosphorylation expression ‒ HCR have an enhanced capacity for fatty acid oxidation during exercise ‒ Ageing decreases the efficiency of oxidative capacity Gene expression profiles of humans who have either a low or high capacity for running show similar results to those of rats

28. Omics in 2015 for the Clinican: Proteomics eGFR, etstimated glomerular filtration rate Rossing,P, et al. IDF 2015:a187 Plasma and serum proteomics can be an effective method in identifying new markers for kidney disease in patients with diabetes ‒ All proteins in a cell are assessed ‒ Biomarkers can be used to predict development of nephropathy and intervene as necessary ‒ New treatment targets can be identified Using urine proteomic profiling, a composite of almost 300 peptides was identified to predict the risk of developing kidney disease ‒ Profile is elevated several years prior to albuminuria ‒ Profile is a better predictor of eGFR decline than albuminuria ‒ Profile predicted responders to treatment The Priority Trial (results due in 2018) is using proteomics to stratify individuals who are at high and low risk of kidney disease – high-risk individuals are treated, whereas those at low risk are observed

29. Omics in 2015 for the Clinican: Lipidomics BCAA, branched chain amino acids; BCKDH, branch chain kinase dehydrogenase; T2DM, Type 2 diabetes mellitus Newgard C, et al. IDF 2015:a188 BCAAs predict diabetes outcomes and treatment success, and are associated with insulin resistance and T2DM Restricting BCAA in the diet of rats improves insulin sensitivity and enhances muscle glucose uptake and glycogen synthesis BCKDH may be a potential therapeutic target – activation improves glucose homeostasis

30. Omics in 2015 for the Clinican: Translating Genomics into the Clinic GLUT2, glucose transporter 2; SNP, single nucleotide polymorphism; T2DM, Type 2 diabetes mellitus Groop L, et al. IDF 2015:a189 A family history of diabetes increases the risk of developing T2DM Genomic techniques have identified >100 genetic variants associated with T2DM The ANDIS study revealed five genetically distinct forms of diabetes, each with a different propensity for complications ‒ Diabetes may be thought of as a continuum with T1DM and T2DM at the extremes An SNP in the SLC2A2 gene encoding for GLUT2 has been shown to be a strong predictor of future need of insulin therapy

31. Hypertension and diabetic complications

32. Hypertension and Diabetic Complications CV, cardiovascular; SGLT2, sodium glucose co-transporter 2 1. Thomas M, et al. IDF 2015:a208; 2. de Zeeuw D, et al. IDF 2015:a209; 3. Cherney D, et al. IDF 2015:a210 Radio-frequency renal sympathectomy represents a novel way of addressing sympathetic nervous system overactivity in patients with diabetes, and in particular to control blood pressure 1 ‒ Reductions in albuminuria and improvements in glucose control/insulin sensitivity have been reported Other studies have shown that endothelin antagonists may lower blood pressure and albuminuria, but also induce sodium retention with the risk of increasing CV/renal events 2 There is also a potential renal protective role for SGLT2 inhibition in patients with diabetes; dedicated renal and CV outcomes trials are ongoing 3

33. Renal Denervation CKD, chronic kidney disease; CVD, cardiovascular disease Thomas M, et al. IDF 2015:a208 Dr Merlin Thomas explained that activation of neuro-hormonal pathways to and from the kidney contributes to the development and progression of hypertension and vascular disease ‒ These pathways are activated independently in diabetes, feeding into a vicious cycle and contributing to a poor prognosis. One of the most important of these pathways is the sympathetic nervous system, the activity of which is increased in patients with diabetes, and more so in those with CKD or CVD Data suggest that reducing the sympathetic drive is associated with reduced morbidity and mortality in patients with diabetes; however, this is under-utilized partly because of poor tolerability, adverse hemodynamic and metabolic effects, lack of selectivity of β-blockers and the lack of specificity of other interventions Radio-frequency renal sympathectomy is an exciting new technique to reduce sympathetic activity and in particular to control blood pressure in patients with diabetes; however, the recent disappointing data from SYMPLICITY HTN-3 trial suggest that more research is needed to achieve clinically significant efficacy

34. Endothelin Antagonist, a New Future for Diabetes? ER, endothelin receptor; ERA, endothelin receptor antagonist; T2DM, Type 2 diabetes mellitus de Zeeuw D, et al. IDF 2015:a209 Dr Dick de Zeeuw discussed the potential of ERAs to treat renal complications in patients with T2DM; he pointed out that despite the state-of-the-art treatment approaches, the residual risk of renal complications remains high, and ER antagonism may be an effective way to lower this risk However, ERAs should be used with caution in patients with diabetes due to the sodium-retaining effects associated with this class, and the potential for edema and heart failure ‒ Bodyweight and brain natriuretic peptide monitoring are required when treating patients with this class ‒ Diuretic treatment may be necessary to mitigate risk of heart failure ‒ Careful patient selection may also be required The ongoing SONAR trial will provide definitive evidence on whether ERAs are a viable nephroprotective therapy for patients with diabetes

35. SGLT2 Inhibitors and the Regulation of Vascular Function in Diabetes CKD, chronic kidney disease; HbA 1c, glycated hemoglobin; SGLT2, sodium glucose co-transporter 2 Cherney D, et al. IDF 2015:a210 Dr D Cherney explained that hypertension and hyperfiltration are the key culprits of progressive renal disease, with the number of functioning nephrons gradually reducing, and the remaining units having to compensate to maintain adequate renal function, ultimately resulting in glomerular injury and CKD ‒ SGLT2 inhibitors appear to preserve renal function compared with sulfonylureas, and reduce proteinuria by approximately one third to one half ‒ HbA 1c levels increase with CKD progression; however, the opposite effect is observed for blood pressure Renal protection observed with SGLT2 inhibitors may be a direct result of improved glycemic control, lower insulin levels and improved insulin sensitivity, reduced weight and blood pressure, as well as lower levels of uric acid. Indirect mechanisms may include the prevention of hyperfiltration, tubular hypertrophy, and tubular toxicity by reducing glucose levels Both SGLT2 inhibitors and thiazide diuretics have been shown to reduce blood pressure, but only SGLT2 inhibitors are associated with reduced plasma volume; no effects of SGLT2 inhibitors have been observed on sympathetic nervous system

36. Clinical Guidelines for Hypertension: Balancing Individualization vs Evidence? CKD, chronic kidney disease; CV, cardiovascular; T2DM, Type 2 diabetes mellitus Tuttle K, et al. IDF 2015:a211 Professor K Tuttle pointed out that hypertension and renal complications are common among patients with T2DM, and that even small reductions in blood pressure result in substantially lower risk of major CV events However, blood pressure targets have been increased in many recent clinical practice guidelines: ‒ <140/90 mmHg for most patients ‒ <150/90 mmHg for older adults (≥60–80 years) ‒ Lower blood pressure target maintained for patients with CKD Data from the SPRINT trial challenge the above recommendations, as target of <120/70 mmHg resulted in benefits on overall and CV survival, and heart failure; however, the trade-off was more incident CKD, electrolyte abnormalities, acute kidney injury, and hypotension Professor Tuttle concluded that individualization of therapy remains a core guiding principle for the management of hypertension

37. Fat: The good and the bad

38. Fat: The Good and the Bad 1. Rosen E, et al. IDF 2015:a212; 2. Tseng YH, et al. IDF 2015:a213; 3. Enerback S, et al. IDF 2015:a214 Data from the first large-scale epigenomical analysis of human adipocytes across a range of insulin sensitivity describe a catalog of unique features from these cells 1 Furthermore, clonal analysis and gene expression profiling has also been used to define unique sets of gene signatures in human pre-adipocytes 2 Strategies to increase the amount and activity of brown adipose tissue may become a therapeutic possibility 3

39. Fat: The Good and the Bad – Epigenomic Analysis of Adipose Tissue GR, glucocorticoid receptor; TNF, tumor necrosis factor Rosen E, et al. IDF 2015:a212 Data from a large-scale epigenomical analysis of human adipocytes across a range of insulin sensitivity describe a catalog of unique features from these cells In vitro data ‒ An upregulated histone profile with dexamethasone and TNF – more than 50 enhancers respond to both ‒ TNF cause GR binding to predicted motifs ‒ GR is required for TNF to induce insulin resistance ‒ Dexamethasone and TNF work via GR and the vitamin D receptor to induce insulin resistance Differences in cis-element profiles were identified in insulin-resistant and insulin-sensitive patients

40. Fat: The Good and the Bad – Metabolic Regulation and Brown Fat AMP, adenosine monophosphate Tseng Y, et al. IDF 2015:a213 BMP-7-treated mice have increased energy expenditure and reduced weight gain miR-455 was identified via microarray as a downstream component of BMP-7 expression ‒ Highly expressed in brown adipose tissue and in cold Necdin, Runx1T1, and HIF1an were identified in silico as potential targets of miR-455 ‒ Necessary for development of mature brown adipocytes ‒ Overexpression and inhibition of miR-455 confirmed that all three were the targets of miR-455 miR-455 has been shown to regulate AMP-activated protein kinase activity

41. Fat: The Good and the Bad – White Adipose Tissue MMP, matrix metallopeptidase; PTEN, phosphotase and tensin homolog; VEGF, vascular endothelial growth factor Scherer P, et al. IDF 2015: Many factors that are expressed in white adipose tissue may be involved in diabetes PTEN knockout mice have improved glucose tolerance and liver and lipid metabolism VEGF enhances the beigeing of adipocytes in mice MMP14 mice have increased weight gain

42. Islet transplantation vs embryonic stem cells: Where does the future lie?

43. Preclinical and Clinical Testing of VC-01 T1DM, Type 1 diabetes mellitus D’Amour K. IDF 2015:a217 This session presented early data on a system comprising pancreatic endoderm cells - human embryonic stem cell-derived pancreatic progenitor cells from an approved single-cell line These cells are encapsulated in an immunoprotective, retrievable delivery device for implantation in patients with T1DM. Together they are known as VC-01 In mouse models, these pancreatic progenitors differentiated into hormone expressing cells (approximately one half insulin, one half glucagon plus others) within a few weeks Kinetics of function were the same in hyperglycemic and normoglycemic mice, with durability of response of several 4 months An ex vivo study found behavior of the pancreatic endoderm cells was similar to that of isolated islet cells, but the magnitude of response was reduced A study is currently underway to establish the safety and efficacy of VC-01

44. Considerations for the Clinical Application of Stem Cells for Diabetes T1DM, Type 1 diabetes mellitus Kieffer T. IDF 2015:a218 This session described an immunoprotective delivery device for pluripotent stem cells that can develop into pancreatic cells ‒ In theory, fetal islet cells could be delivered from such a device; however, they can’t survive in the hypoxic environment at the transplant site Histologically, stem cells cultured for 8 weeks behave like fetal islet cells, but many did not survive transplantation It was hypothesized that cells at a later stage of development (i.e. those that are able to express insulin, glycogen, etc.) may be more robust Experiments in mice supported the hypothesis, but insulin expression was still lower than that achieved with transplanted islet cells A comparison of effects in mice and rats found interesting differences – in rats, transplanted cells matured faster, which seemed to be due to increased thyroid hormone production in rats ‒ This is of interest because 50% of patients with T1DM have reduced thyroid hormone levels

45. Positioning Current State-of-the-art Islet Cell Transplantation as Embryonic Stem Cell Therapies Move Forward in Diabetes T1DM, Type 1 diabetes mellitus Shapiro J. IDF 2015:a219 Some patients whose T1DM is not controlled on standard therapy may be eligible for islet cell transplant, unless the procedure is contraindicated for any reason Over 1500 patients have received islet cell transplants since the 1990s. Of the original patients treated under the Edmonton protocol, approximately one quarter are still insulin-free, approximately one third are on minimal insulin, and the majority are C-peptide free The survival rate in transplanted patients is close to 100%, and rates of retinopathy and kidney disease are reduced; results are similar to those achieved with whole pancreas transplant without the need for surgery The effects of autoimmunity can prevent grafts taking. Patients usually need more than one transplant and will require lifelong immunotherapy to prevent graft rejection Research continues to improve islet cell transplantation, including combining the procedure with pharmacotherapy The availability of islet-cell transplant, stem-cell transplant, and immune resetting of diabetic pancreatic cells means that we may now be moving closer to a cure for T1DM

46. The Role for Induced Pluripotent Stem Cells in Islet Replacement Therapy Rogers I. IDF 2015:a220 Induced pluripotent stem cells can be derived from the patient, providing an autologous source of cells ‒ Factors that affect differentiation capabilities include epigenetic effects, tissue source, patient age, number of prior cell divisions, and method of preparation These cells must undergo a ‘reprogramming’ process using a combination of chemicals before they can be returned to stem cell status ‒ This process is known to induce mutations which can increase the risk of developing cancer ‒ The process itself is straightforward, but it is difficult to reproduce the cell line stability seen with embryonic stem cells ‒ Project Grandiose is seeking to address these issues Cells derived in this way and reprogrammed as islet cells have not yet been implanted in patients