Diabetes Core Update – April 2026

Presented by: Dr. Neil Skolnik and Dr. John J. Russell
Date: April 1, 2026
Episode Duration: ~15 minutes

Episode Overview

This month's Diabetes Core Update reviews five recently published, clinically relevant research articles from ADA journals and beyond, offering insights and practical perspectives for frontline clinicians. Core topics include a new oral PCSK9 inhibitor for LDL cholesterol management, personalized diabetes risk reduction strategies, impacts of bariatric surgery in Type 1 diabetes, a new option for chronic kidney disease in Type 1 diabetes, and the effects of SGLT2 inhibitors in diabetic foot ulcer patients.

Key Discussion Points & Insights

1. Oral PCSK9 Inhibitor (Enlicitide) for LDL Cholesterol

Primary Source: New England Journal of Medicine
Segment Start: [00:28]

• Trial Overview: Large, multinational, double-blind, randomized, placebo-controlled Phase 3 trial.
• Population: Adults with major ASCVD or at-risk individuals (LDL ≥55 in ASCVD, LDL ≥70 with risk factors).
• Intervention: Enlicitide 20mg/day vs. placebo for 52 weeks; >2,900 participants (mean age 63, 40% women).
• Results:
  • LDL cholesterol reduced by 57% at 24 weeks in enlicitide group vs. 3% increase with placebo (p<0.001).
  • Other lipoproteins (non-HDL, ApoB, Lipoprotein(a)) also significantly reduced.
  • No demonstrated mortality benefit yet.
• Quote:
  • "This medicine showed that it decreased LDL by 57%. So pretty strong, really very good at getting people's LDLs down to lower levels." (Dr. John Russell, [04:55])
• Clinical Considerations:
  • Most patients already on moderate or high-potency statins.
  • Questions remain about mortality benefit and pricing.
  • Potentially game-changing if affordable—injectable PCSK9s are $500–$1,200/month, presenting access concerns.
  • Prior authorizations remain a significant practical barrier.
  • Guidelines evolving: Recent evidence suggests even lower LDL goals (possibly <55 for very high-risk patients). Universal recommendation developing for lipoprotein(a) screening.
  • Quote on guideline shift:
    • "Our ACC/AHA brethren... now have gone back to a number. So we should be below 70 for our high-risk patients. Maybe that's going to change to 55..." (Dr. John Russell, [07:53])

2. Individualized Diabetes Risk Prediction & Preventive Strategies

Primary Source: Diabetes Care
Segment Start: [09:47]

• Study Design: Used NHANES data (2015–2020), 2,700+ prediabetic participants.
• Interventions Compared: Standard lifestyle, metformin, intensive lifestyle, and "optimal" individualized intervention.
• Key Findings:
  • Mean 3-year diabetes risk: 18.4% (standard), 14.4% (metformin), 8% (intensive lifestyle), 7.6% ("optimal").
  • Intensive lifestyle "optimal" for 91% of patients.
• Quote:
  • "Potentially that could decrease 12 million people in the United States over three years from progressing to diabetes from prediabetes." (Dr. Neil Skolnik, [10:25])
• Modern Context:
  • Newer agents, especially GLP-1 and dual agonists, are changing the landscape.
  • The SURMOUNT trial: Tirzepatide reduced progression to diabetes by 93% in people with obesity and prediabetes (1.3% vs 13.5% over 176 weeks).
  • Importance of combining pharmacotherapy with lifestyle for greatest benefit.
• Quote:
  • "Really the world we live in now is one, when someone is at high risk and they have prediabetes, particularly if they also have obesity, we really are thinking, as we should, very strongly about GLP-1s..." (Dr. Neil Skolnik, [12:03])

3. Bariatric Surgery in Type 1 Diabetes

Primary Source: Diabetes Care
Segment Start: [12:56]

• Study Type: Multicenter, retrospective cohort; 162 adults with type 1 diabetes and obesity.
• Findings (at 1 year post-surgery):
  • Average total weight loss: 29.7%.
  • Insulin requirements dropped by >50% (from 0.75 to 0.32 units/kg/day).
  • HbA1c improved (from 8.0% to 7.6%), also significant improvements in lipid profile.
• Safety Considerations:
  • 15% incidence of postoperative DKA seen in prior studies—perioperative risk requires close attention.
  • "Everyone with type 1 diabetes needs some insulin every day... you don't give them zero amount of insulin that day." (Dr. John Russell, [15:34])
  • Careful insulin titration perioperatively is crucial.
• Clinical Implication: Bariatric surgery can significantly decrease insulin needs and improve glycemic and cardiometabolic outcomes, albeit with perioperative risks to be mitigated.

4. Finerenone for Chronic Kidney Disease in Type 1 Diabetes

Primary Source: New England Journal of Medicine
Segment Start: [16:19]

• Trial Design: Phase 3 RCT; adults with type 1 diabetes, CKD (GFR 25–90, albuminuria 200–<5000mg/g), already on ACE/ARB.
• Results:
  • Finerenone led to a 34% reduction in albumin:creatinine ratio (vs. 12% with placebo); 25% greater relative reduction.
  • Most common adverse event: hyperkalemia (10.3% finerenone group vs. 3.3% placebo).
  • Slightly greater transient eGFR dip with finerenone, consistent with other kidney-protective agents.
• Quote:
  • "Chronic kidney disease is also a big deal for people with type 1 diabetes, but there's only been one pillar of care available to that group: ACEs and ARBs. ... There's been a real need for treatment for people with CKD in type 1." (Dr. Neil Skolnik, [18:18])
• Clinical Impact:
  • Finerenone could become a "second pillar" for renal protection in type 1 diabetes with CKD.
  • eGFR dip is expected and not harmful—it's hemodynamic, not nephron injury.

5. SGLT2 Inhibitors and Diabetic Foot Ulcers: Mortality, Amputation, Healing

Primary Source: Diabetes Care
Segment Start: [21:30]

• Study Design: Retrospective cohort, French diabetic foot center; 452 patients with new diabetic foot ulcers, 94 on SGLT2s.
• Outcomes:
  • No significant association between SGLT2 use and amputation rate at 1 year.
  • Healing rates similar (6 months: 54% SGLT2 vs 44% non-SGLT2).
  • Healing time shorter with SGLT2s (mean difference: 44 days).
  • One-year mortality lower in SGLT2 group (1.1% vs 9.2%, p=0.009).
• Quote:
  • "... study on canagliflozin early on said maybe it's associated with an increased amputation rate, right? ... That has been carried a little bit as a scarlet letter through many years... correlation is not causation." (Dr. John Russell, [23:44])
• Clinical Perspective:
  • Reaffirms SGLT2 inhibitors' safety regarding amputation risk in diabetic foot ulcer patients.
  • SGLT2s provide multiple non-glycemic benefits and should not be withheld solely due to PAD/amputation concerns.

Notable Quotes & Memorable Moments

• On PCSK9 Inhibitor Guidelines:

  • “All care should be individualized. And 55 might be the new 70.” (Dr. John Russell, [08:41])

• On New Era of Diabetes Prevention:

  • "The world we live in now ... is one where someone is at high risk and has prediabetes, particularly with obesity, we really are thinking ... about GLP-1s..." (Dr. Neil Skolnik, [12:03])

• On Insulin Needs After Bariatric Surgery in Type 1:

  • "Everyone with type 1 diabetes needs some insulin every day." (Dr. John Russell, [15:53])

• On SGLT2s and PAD:

  • "... instead of kind of chasing this ghost that doesn't really exist for the SGLT2, maybe we should turn our peripheral arterial disease attention to that fact." (Dr. John Russell, [25:12])

Timestamps for Key Segments

• [00:28] – Article 1: Oral PCSK9 inhibitor (enlicitide)
• [09:47] – Article 2: Individualized diabetes risk reduction
• [12:56] – Article 3: Bariatric surgery in Type 1 diabetes
• [16:19] – Article 4: Finerenone for CKD in Type 1 diabetes
• [21:30] – Article 5: SGLT2 inhibitors in diabetic foot ulcers

Conclusion

This episode highlights several paradigm-shifting advances in diabetes care—oral lipid-lowering therapy options, more precise and potent diabetes prevention strategies, major metabolic and cardiometabolic benefits of surgery and pharmacotherapy for those with chronic conditions, and practical clarifications that can demystify past controversies. The practical discussions, grounded in frontline experience, provide actionable insights for managing complex diabetes and comorbidities.

For full articles and further information, clinicians are directed to www.diabetesjournals.org.