Diabetes Core Update – April 2015
Podcast: Diabetes Core Update
Hosts: Dr. Neil Skolnik & Dr. John J. Russell
Air Date: March 24, 2015
Episode Length: ~15 minutes
Episode Overview
This April 2015 episode covers six important recent studies and reviews published in ADA journals. Drs. Skolnik and Russell highlight new findings on bariatric surgery and diabetes remission, advances in insulin therapy, high intensity interval training, dermatologic manifestations of diabetes, the cardiovascular safety profile of saxagliptin (especially in renal impairment), and appropriate glycemic targets in older veterans with dementia. The discussion centers on translating emerging evidence into clinical practice for physicians and healthcare professionals managing patients with diabetes.
Key Discussion Points and Insights
1. Bariatric Surgery and Insulin Cessation/Remission in Type 2 Diabetes
[01:52]
- Study: Analysis of over 100,000 patients from the Bariatric Outcome Longitudinal Database, focusing on insulin-treated adults with type 2 diabetes.
- Procedures Compared: Roux-en-Y gastric bypass vs. laparoscopic adjustable gastric banding.
- Findings:
- 62% of insulin-treated patients who underwent Roux-en-Y were off insulin at 12 months.
- Only 34% experienced insulin cessation with gastric banding.
- Greater diabetes remission at all time points in the Roux-en-Y group.
- Clinical Takeaway:
- Bariatric surgery—especially Roux-en-Y—should be considered for patients with BMI >35 who are difficult to control with insulin.
- Offers substantial rates of diabetes remission and insulin cessation.
Quote:
"Depending on which procedure is used, between 30 to 60% of people were able to get off of insulin."
— Dr. Skolnik [03:15]
2. Insulin Glargine 300 Units/mL vs. 100 Units/mL: Prolonged Glycemic Control
[03:49]
- Study: Randomized, double-blind crossover trial in patients with type 1 diabetes.
- Findings:
- Glargine 300 U/mL provided a more even and extended activity profile than the standard 100 U/mL formulation.
- Maintained tight glycemic control for about 5 hours longer [compared with 100 U/mL].
- Clinical Considerations:
- Benefits: Longer, more stable basal control; promising for type 2 as well.
- Risks: Potential for dosing errors due to higher concentration (confusion between U100, U300, U500).
- Staff education is vital as new concentrated products come to market.
Quote:
"If it's three times as concentrated, you're going to give people three times less volume. So... there won't be kind of that look alike, sound alike [problem] with other products."
— Dr. Russell [05:24]
3. High-Intensity Interval Training (HIIT) in Type 2 Diabetes
[06:53]
- Review: Summarizes the evidence for HIIT compared to moderate-intensity continuous training in diabetes patients.
- Highlights:
- HIIT consists of short bursts (e.g., 1 min) of high-intensity exercise alternated with recovery.
- Shown to improve cardiorespiratory fitness, insulin sensitivity, glycemic control, and body composition.
- Some protocols as brief as 10 total minutes per session; even 2 weeks of HIIT led to meaningful glucose reductions.
- Superior cardiorespiratory improvements compared to moderate training; especially beneficial for time-constrained patients.
- Clinical Advice:
- HIIT is becoming practical and safe for many diabetes patients: aim for ~85% of maximal heart rate.
- Assessment can use perceived exertion or calculated maximal heart rate (220 – age).
Summary:
"High intensity interval training can be prescribed fairly easily… there’s mounting evidence supporting the potential [cardiometabolic] benefits of high intensity interval training for patients with type 2 diabetes."
— Dr. Skolnik [11:55]
4. Cutaneous Manifestations of Diabetes
[12:07]
- Review: Overview of common and less-recognized skin conditions in people with diabetes.
- Common Conditions:
- Xerosis (dry skin): Most frequent manifestation.
- Cutaneous infections: Especially intertrigo.
- Acanthosis nigricans: Velvety, hyperpigmented thickening, especially in neck/axilla—marker for insulin resistance.
- Skin tags: Can be linked to metabolic disturbances.
- Diabetic dermopathy: Light salmon-colored spots on shins, more prevalent with poor glycemic control.
- Eruptive xanthomas: Associated with hypertriglyceridemia.
- Rubiosis faciei: Facial redness in 3–5% of patients.
- Clinical Implications:
- High prevalence: up to 80% of diabetics have some skin manifestation.
- Importance of screening for underlying metabolic issues when dermatologic signs are present.
Quote:
"One of the things when we see people who have lots of skin tags...I think it would make sure that we’ve screened folks."
— Dr. Russell [13:29]
5. Saxagliptin and Cardiovascular Outcomes in Renal Impairment (SAVOR-TIMI 53 Trial)
[15:20]
- Study: Large RCT assessing saxagliptin vs. placebo and cardiovascular risk in T2D patients with varying renal function.
- Results:
- No increase or decrease in major cardiovascular endpoints (death, MI, stroke) regardless of renal function.
- Similar heart failure hospitalization rates across renal function strata.
- Reduced microalbuminuria in saxagliptin group.
- Practice Implications:
- Saxagliptin appears safe from a cardiovascular and renal standpoint for a broad range of renal function.
- Reassuring in the context of previous cardiovascular concerns with other diabetes drugs.
Quote:
"This article is reassuring that saxagliptin shows no safety signals, no concerns with regard to increasing cardiovascular outcomes."
— Dr. Skolnik [17:51]
6. Tight Glycemic Control in Older Veterans with Dementia
[18:45]
- Study: VA/MEDICARE cohort of >15,000 veterans (>65 y/o) with T2D and dementia on antidiabetic meds (2008–9).
- Findings:
- 52% had A1Cs <7 (tight control).
- 75% of tightly controlled patients were using sulfonylureas and/or insulin (increased hypoglycemia risk).
- Clinical Reflection:
- Tight control (A1C <7) may not be appropriate for patients with limited life expectancy or advanced dementia.
- Looser targets (A1C 7.5–9) probably safer, balancing benefits and risks.
- Important to avoid hypoglycemia, as it may worsen confusion and burden caregivers.
Quote:
"For our patients, we need to make it a little bit easier for caregivers and...someone who has severe cognitive impairment in an older person probably that seven and a half to nine is probably a very reasonable spot to keep someone's blood sugars."
— Dr. Russell [20:23]
Notable Quotes & Memorable Moments
-
"Bariatric surgery…is on the map as something to seriously consider as a method for gaining control of diabetes and decreasing A1Cs."
— Dr. Skolnik [03:25] -
On medication safety with new insulins:
"We really might need to stop for a moment and talk about some of the new products and...what's the benefit for them and also some of the different things we're going to have to do for administration."
— Dr. Russell [06:38] -
On personalizing A1C targets in older adults:
"Tight control makes lots and lots of sense in preventing a lot of...long term outcomes with diabetes [for young people]. For people who have moderate dementia...having tight glycemic control does not make...a whole lot of sense."
— Dr. Russell [20:05]
Timestamps for Key Segments
- 01:52 – Bariatric surgery and insulin cessation/remission
- 03:49 – Glargine U300 vs. U100: pharmacology/clinical implications
- 06:53 – HIIT and type 2 diabetes: clinical review & protocols
- 12:07 – Dermatologic manifestations of diabetes
- 15:20 – Saxagliptin’s cardiovascular profile in renal disease
- 18:45 – Glycemic targets in older/demented veterans
Conclusion
This concise update delivers timely evidence and practical pearls for frontline diabetes care: considering bariatric surgery for hard-to-control patients, cautiously adopting new insulin concentrations with staff training, embracing HIIT for suitable patients, recognizing common skin signs of diabetes, relying on saxagliptin’s cardiovascular safety in high-risk groups, and tailoring glycemic control targets for older adults with comorbidities. Throughout, the hosts emphasize applying new research thoughtfully for real-world impact.
For more details and article links:
Visit diabetesjournals.org