Diabetes Core Update – February 10, 2013

Podcast Theme:
This episode, recorded live at the 2013 American Diabetes Association (ADA) Scientific Sessions during the Diabetes Is Primary lecture series, focuses on two key areas: diabetes management in older adults (with Dr. Hermes Flores) and new therapies—including basal insulins (with Dr. Charles Schaefer). The episode provides expert insights for clinicians on tailoring diabetes care to the older population and adapting to new pharmacologic developments.

1. Diabetes in Older Adults (Dr. Hermes Flores)

[01:39 – 05:40]

Key Discussion Points

• Demographic and Clinical Challenge:

  • Diabetes in people aged 65+ is a significant and growing concern—1 in 3 or 4 patients seen are in this age range.
  • The problem is expanding with the aging population (baby boomers).

• Consensus Panel Recommendations:

  • Dr. Flores was part of a panel creating a consensus statement on diabetes in older adults (published in Diabetes Care).
  • The panel reviewed multiple guidelines (ADA, VA/DoD, European, AGS) to propose individualized management strategies.

• Individualized Glycemic, BP, and Lipid Targets:

  • Approaches should be customized based on patient functional status and comorbidities:
    • Active, independent older adults without cognitive impairment can be managed similarly to younger adults.
    • Frail, elderly patients, especially those with cognitive deficits or requiring assistance, should have less aggressive targets.
  • Quote:

    “We came with a proposal that needs to be validated in clinical trials of actually tailoring...management based on the functional status of the patient.” – Dr. Hermes Flores [03:35]

• Research and Knowledge Gaps:

  • Need more clinical trial data focused on this population.
  • Key unanswered questions:
    • Best therapies for glycemic management in the very old and frail group.
    • Relationship between diabetes, prediabetes, cognitive decline, reduced physical function, risk of falls, and fractures.
    • Impact of hypoglycemia on fall risk and quality of life.

• Collaborative Approach:

  • The ADA facilitated vital dialogue across specialties to create this guidance.
  • Registry data and ongoing studies are necessary to fill current evidence gaps.

Notable Quotes & Moments

• On the Aging Demographic and Care Challenges:

  “...this problem is going to get worse from the perspective of the challenges.” – Dr. Hermes Flores [02:13]

• On Personalization of Care:

  “It will not be exactly the same treating a patient that is functional, living independently, without any cognitive impairment, without depression...while maybe an individual that is...frail, has cognitive decline, maybe in that patient we need to be a little bit more conservative.” – Dr. Hermes Flores [03:45]

2. New Therapies and Basal Insulins (Dr. Charles Schaefer)

[05:42 – 16:16]

Key Discussion Points

• Paradigm Shift in Diabetes Management:

  • The 2012 ADA guidelines moved away from clinician-directed care (“dictatorial finger wagging”) to shared decision-making.
  • The patient and clinician now work together, like “a pilot and a co-pilot.”

    “Now, instead of the clinician dictating what the individual should do, we actually are sitting down with the individual, opening up a dialogue...learning what they fear, learning something about their lifestyle...” – Dr. Charles Schaefer [07:06]

• Importance of Communication and Motivation:

  • Motivational interviewing and understanding patient values/lifestyles are central.
  • Greater effort needed to educate primary care on new drugs and to develop communication skills.

• Emergence of New Drug Classes:

  • Incretin Therapies:
    • DPP4 inhibitors (e.g., allogliptin—newly approved at the time)
    • GLP-1 receptor agonists
    • Recognition of different properties (basal vs. prandial effects)
    • The approach is moving toward more nuanced selection (prandial vs. non-prandial effects)
  • SGLT2 Inhibitors:
    • Big news: SGLT2 inhibitors block renal glucose reabsorption, causing glycosuria and lowering both fasting and postprandial blood glucose.
    • “Insulin-independent way of reducing glucose…also produces weight loss.”
    • Requires attention to renal dosing and side effects (UTIs, mycotic infections).
    • Does NOT cause hypoglycemia or weight gain.
    • “Holy grail of diabetic therapy”: lowering both glucose and weight. [13:30]

• Formulation Advances:

  • Once-weekly DPP-4 inhibitors in development—may improve convenience, but questionable impact on engagement in a “daily disease.”
  • Ultra-long acting insulins:
    • Insulin degludec: Not approved in the US at the time, but promising for flexibility and low risk of hypoglycemia.
    • Pegylated insulin lispro: More activity at the liver; closer to physiologic insulin action, possibly weight-neutral or weight-losing.

    “The promise for an insulin that can be given pretty much anytime during the day and…without the risk of hypoglycemia and with the hope of perhaps even weight neutrality or weight loss is very, very attractive.” – Dr. Charles Schaefer [15:21]

Notable Quotes & Moments

• On Shared Decision-Making:

  “We have the patient and the clinicians sitting side by side, much like a pilot and a co-pilot in an airplane.” – Dr. Charles Schaefer [07:44]

• On SGLT2 Inhibitors’ Appeal:

  “A class of drugs that inherently does not cause hypoglycemia, does not cause weight gain, and produces that holy grail of diabetic therapy—that is, let’s lower the blood sugar and the weight at the same time.” – Dr. Charles Schaefer [13:31]

• Summation:

  “The optimal diabetic therapy will evolve from the clinician’s expertise and the patient’s desires.” – Dr. Charles Schaefer [15:44]

3. Episode Wrap-up

[16:11 – end]

• The segment concludes with thanks to the speakers and a preview of Part Three, which will cover diabetes and kidney disease, and differentiating between type 1 and type 2 diabetes.

Episode Highlights by Timestamp

• [01:39] Dr. Hermes Flores: Overview of consensus on diabetes in older adults
• [03:35] Importance of personalizing treatment targets by functional status
• [05:42] Dr. Charles Schaefer: Shifts in diabetes guidelines and patient-clinician partnership
• [07:06] Emphasis on dialogue and understanding patient context
• [09:10] Advances in incretin therapies—how new drugs differ
• [11:40] SGLT2 inhibitors: mechanism, benefits, and cautions
• [13:31] Potential of new drug classes to achieve glycemic control and weight loss
• [15:21] Developments in ultra-long acting insulins
• [15:44] Dr. Schaefer’s one-sentence summary

Summary Takeaways

• For Older Adults:

  • Individualized targets (glycemic, BP, lipid) are crucial; less aggressive goals in frail, cognitively impaired patients.
  • Ongoing research is needed to clarify best practices in this diverse population.

• For New Therapies:

  • Shared decision-making is now the standard approach.
  • Incretin and SGLT2 therapies, as well as advanced basal insulins, are transforming diabetes care.
  • Clinicians should stay updated and adapt to patient preferences and real-world concerns (comorbidities, social factors).

Maintaining the episode’s professional yet collegial tone, this summary captures the shift toward individualized and collaborative diabetes care, as well as the excitement and necessary caution in adopting new pharmaceutical options.