Diabetes Core Update 2/10/2013

Summary

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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.

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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]

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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]

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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.

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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

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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).

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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.

Transcript

[A]

Hello, I'm Dr. Neal Skolnick and thank you for joining us for this special edition of Diabetes Core Update, which is being recorded live at the Diabetes Is Primary lecture series that took place during the 2013American Diabetes Association Scientific Citizen Sessions. This is part two of three recorded sessions. From the meeting today, we will hear Dr. Hermes Flores discuss diabetes in older adults and Dr. Charles Schaefer discussing new therapies and basal insulins. To hear the lectures in their entirety, just go to www.professional.diabetes.org primary for the full webina. We will now hear Dr. Hermes Flores discussing diabetes in older adults. Dr. Flores is the Interim Chief of the Division of Gerontology and Geriatric Medicine, University of Miami, Miller School of Medicine, Geriatric Research, Education and Clinical Center, Miami VA Healthcare System, Miami, FL. Dr. Flores is also one of the committee members for the recent consensus statement on diabetes in older adults published in Diabetes Care. Welcome.

[B]

Thank you. Thank you for this opportunity to share some of the lessons learned and certainly some of the gaps in research that we have addressing a growing problem of diabetes in older adults. As you alluded, I had the fortune to be a member of a panel that reviewed the literature and trying to provide some guidance from the perspective of what could be done and what needs to be done on management and prevention of diabetes in the elderly. Suffice to say that probably from our practice, one of every four of one of every three adults that we're treating are in the age 65 and older and with the epidemic of diabetes and with the grow change in the demographics with the baby boomers, this problem is going to get worse from the perspective of the challenges. So having said that, the consensus panel report covers several topics in a broad spectrum from the epidemiology and pathogenesis of diabetes. Then we emphasize what was the evidence that is available on prevention and management. We reviewed the guidelines in general, not only from the American Diabetes association, what has been done before, but also previous input from the diabetes management guidelines in the Department of Veterans affairs and Department of Defense, European guidelines and the American Geriatric Society. And from that we came with a proposal that needs to be validated in clinical trials of actually tailoring individualizing the approach for glycemic management, blood pressure management and lipid management based on the functional status of the patient. So will not be exactly the same. Treating a patient that is functional, living independently, without any cognitive impairment, without depression, we can be certainly as aggressive as we can do it in a younger individual. While on the other hand maybe an individual that is age let's say 85, 90, that is requiring assistance of the activities they're living, is frail, has cognitive decline, maybe in that patient. We need to be a little bit more conservative, less aggressive. And the consensus panel report provides some guidance on potential goals that will hopefully guide providers and the scientific community on the approach. Suffice to say also that an emphasis from the panel, from the agenda and research perspective is that there is a need for more clinical trial data and maybe take advantage of the ongoing registries to answer some of the questions. So what is the right therapy? What is the right medication for glycemic management? How aggressive we want to be in the elderly population that is more in the frail category as opposed to the younger category? What is the relationship between diabetes and prediabetes and cognitive decline? What is the same relationship on the decline, on physical function, dysmobility, risk or falls? We have an all growing population with a lot of osteoporosis, bone disorders, higher risk of fractures, and that certainly can have a significant impact on the quality of life of these patients. There are a lot of patients actually they are having frequent hypoglycemic episodes and because of that having more falls. So all these questions need to be answered and we are really grateful of the opportunity that the American Diabetes association has provided in coming together scientists, providers from different areas, different disciplines to guide us in this effort.

[A]

Thanks so much. That is really helpful hearing the emphasis on an individualized approach and hearing some of the details again.

[C]

Thank you.

[B]

Thank you again.

[A]

Our Next speaker is Dr. Charles Schaefer, who is an assistant clinical professor of medicine in the Medical College of Georgia, Augusta, Georgia. And he just gave a wonderful talk on new therapies and basal insulins. Welcome, Dr. Schaefer.

[C]

Thank you very much, Neal. It's a pleasure to be here. It was fun talking to this group today about the new therapies and the new approaches to diabetic management. A lot has changed in the last year or so. We've had several significant turns in the area of diabetic management. We've had the introduction of one of the the first new classes of diabetes drugs that we've seen in a little while. And then finally, we are continuing to learn how important it is to rely on principles of early insulin use in a lot of our patients. So we dealt with those three topics during the lecture today. First of all, just the whole concept of using the new ADA guidelines that were released in April of last year. In my impression, this really has changed the whole pattern of diabetic Management in the old style. The clinician, with somewhat of a dictatorial wave of the finger, would state that, you must take this for your diabetes, or you must take that for your diabetes. And then all of that went away in April of last year. And over the last 12 months, we've really been trying to adapt to what these new guidelines mean for us in clinical practice. Now, instead of the clinician dictating what the individual should do, we actually are sitting down with the individual, opening up a dialogue, having a discussion, learning what that patient values, learning what they fear, learning something about their lifestyle, what they are able to do, given the work they do and given the money they have and the support system that's available to them in their community and at home. So I think that it's a new day for diabetic management. Now, instead of the dictatorial finger wagging, we have the patient and the clinicians sitting side by side, much like a pilot and a co pilot in an airplane. Now, one of the issues that arises in that metaphorical picture is that somebody's got to teach that co pilot patient how to fly an airplane. So I think in the last year we've had a great emphasis developing on educating the primary care community to be aware of new drugs, to be aware of diabetic staples when it comes to what we use to manage diabetes. And of course, we're going to have to develop some new talents to really get to communicate with our patients. This whole area of motivational interviewing, where the clinician sits down and really has a dialogue with the patient, is something that we need to be pulling out. And of course, the American Diabetes association wasn't the only group that was was active in giving new guidance. This year, the Clinical Endocrinology Group has released their new algorithm for the coming years. And in that particular paper, nothing really new or too surprising arose. But it was interesting that for the first time, the clinical endocrinologists are really looking at the importance of addressing some of the root causes of diabetes, such as obesity, and looking at how do we go about assessing this patient's degree of obesity, how do we go about assessing the needs that are going to be required to address and treat that condition. And we're including that now as a formal part of our diabetic treatment parameters. So I think an active year for clinicians in terms of how do we do diabetes differently. I think on the forefront of new medicines coming about, of course, we're continuing to get a deeper appreciation of the benefits of DPP4 inhibitors and GLP1 receptor agonists. Our incretin family of drugs. We have a new one that's just come on the scene, alligliptin, a DPP4 inhibitor. And we're probably poised in the next several months to a year to get a couple of new GLP1 receptor agonists. And I think as we bring these drugs into our armamentarium, we're beginning to learn that all incretins are not the same. Some incretins have largely a tonic or global or basal type of approach that lowers the blood sugar uniformly throughout the day. Others are highly prandial. They, that is they lower the blood sugar immediately following meals. So I think we're going to see a little bit of a shift in our incretin thinking as we divide these treatments into prandial and nonprandial and begin to look at how can these drugs help our other diabetic managements when it comes to addressing post meal needs and overall A1C reduction. So a bit of appreciation there. But the big news on the new drug scene was the appearance of the SGLT2 inhibitors. This sodium glucose linked transporter type 2 is a substance that's expressed only in the kidney. It's involved in removing glucose from the urine and actually redepositing the glucose into the blood of patients. And that's how we're able to to produce a urine output that's essentially free of sugar. The inhibitors to SGLT2, this new class of drug blocks that process and therefore there's incomplete reabsorption of glucose and hence we produce a glucose rich urine. And that has some really significant implications. One is it's an insulin independent way of reducing glucose in the bloodstream, which obviously has some impact on improving both fasting and postprandial blood sugars. In addition, you're wasting about 300 grams of sugar a day and that translates to calories and calories translates to weight. So it's been exciting to see that these products, currently there's one on the market, look like they're going to be generating a degree of weight loss, much like we're accustomed to seeing with the GLP1 receptor agonist. Now these drugs are going to require a little bit of a sophisticated clinician to use them. There are several different dose adjustments based on glomerular filtration rate and there's the possibility of both urinary tract infection and even more likely mycotic infections of the vulvovaginal or penile areas. So the clinician's going to have to be on his toes using these medications. But a great new addition, a class of drugs that inherently does not cause hypoglycemia, does not cause weight gain, and produces sort of that holy grail of diabetic therapy that is, let's lower the blood sugar and the weight at the same time. So very, very attractive there, I think, looking sort of through the binoculars and trying to peek over the hill at what's coming next. One thing of course is a new once a week DPP4 inhibitor. I don't think that particular medicine is going to add a lot of new properties, but it will raise a new question and that is to what extent will patients really value once Weekly Oral Dosing vs Daily Oral Dosing? And is that even a good thing for diabetic patients? Because diabetes is really a daily disease and perhaps we're sacrificing a little something when we don't face it head on every day when we go to the pill bottle. So it'll be very interesting to see how that sorts out for us. I think one other area that is looking very promising is the development of new sort of ultra long acting insulins. Degladec, of course, we've known about for more than several years. It's approved in, in Europe, it was not approved in America. But we continue to learn that this is an insulin that can be taken any time of the day with very little hypoglycemic or weight related issues. So I think we'll be getting more information back in the coming year or so about Deglodeq and probably a renewal of interest in approving that drug in America. Also, Lilly has a new long acting insulin, a pegylated Lispro, an insulin, interestingly, that's far more active at the level of the liver than in peripheral tissues. Now the reason that's important is normal human insulin goes to the liver first. Most of the insulin effect is experienced in the hepatic area. And so this drug is touted as being a bit more like endogenous insulin activity. It'll probably be a year or so before it's on the market. But a lot of phase three trials are ongoing now and the promise for an insulin that can be given pretty much anytime during the day and again without the risk of hypoglycemia and with the hope of perhaps even weight neutrality or weight loss, is very, very attractive. So to summarize what we talked about today, I think I can put it into one sentence, and that is that the optimal diabetic therapy will evolve from the clinician's expertise and the patient's desires. Hopefully today we've learned a little bit about how to go about learning about the patient's desires and we've expanded our knowledge a little bit as we'll do not only today but through the whole ADA conference to expand our expertise.

[A]

Thank you so much, Dr. Schaefer. That was a wonderful overview of your talk.

[C]

Thank you very much. Pleasure to be here.

[A]

That concludes part two of our three part series of highlights from the Diabetes Primary conference recorded during the American Diabetes Association Scientific Sessions in Chicago in June 2013. Please tune in for part three where we will cover the kidney and diabetes and distinguishing between type 1 and type 2 diabetes. If you would like to listen to and watch these lectures in full, just go see the webinar at www.propri Professional.diabetes.org primary. Again, that's www.Propri Professional. Diabetes.org primary. For the American Diabetes Association, I'm Dr. Neal Skolnick. Thank you for listening.