Diabetes Core Update — February 2016

Podcast Date: January 24, 2016
Hosts: Dr. Neil Skolnik & Dr. John Russell
Produced by: American Diabetes Association

Episode Overview

This episode of Diabetes Core Update delivers a concise rundown of six clinically relevant research articles and a position statement from the ADA journals. The hosts, Dr. Neil Skolnik and Dr. John Russell, discuss new evidence and insights on topics ranging from novel hypoglycemia treatments for type 1 diabetes to diabetes management in long-term care, medication adherence, group visits, and the physiological effects of liraglutide on satiety and brain function. Designed for practicing clinicians, the episode emphasizes key findings and practical implications for diabetes care.

1. Intranasal Glucagon for Insulin-Induced Hypoglycemia in Type 1 Diabetes

Source: Diabetes Care
Segment: [00:55 – 03:51]

• Study details:

  • Randomized crossover, non-inferiority trial (75 adults with type 1 diabetes; mean age 33).
  • Compared novel needle-free intranasal glucagon vs. standard intramuscular (IM) administration for insulin-induced hypoglycemia.
  • Success: defined as plasma glucose >70 mg/dL or >20 mg/dL increase within 30 minutes.
  • Efficacy: 99% for intranasal, 100% for IM; time to success: 16 min (intranasal) vs. 13 min (IM).
  • Side effects: Head/facial discomfort in 25% (intranasal) vs. 9% (IM); nausea in 35–38%.

• Clinical Insight:

  • Intranasal glucagon is nearly as effective as IM and easier for families to use during emergencies.

• Memorable moment:

  “Not everyone feels super comfortable giving a needle… I really do not think a patient’s family member is going to have the qualms with spraying some rescue drug up someone’s nose…”
  — Dr. John Russell [03:51]

2. Adherence to Oral Glucose-Lowering Therapies and A1C Outcomes

Source: Diabetes Care
Segment: [03:51 – 06:18]

• Study details:

  • Large UK retrospective cohort; patients newly prescribed metformin, sulfonylurea, TZD, or DPP-4 inhibitor over one year.
  • Non-adherence rates: 13–15% overall, lowest with TZDs (8%), highest with metformin (~16%).
  • Non-adherent patients had significantly less A1C reduction (~30% less effective).

• Key Discussion Points:

  • Difference between drug efficacy (clinical trials) vs. effectiveness (real-world use).
  • True non-adherence likely higher when early dropouts included.
  • Metformin non-adherence likely due to GI side effects.

• Notable Quote:

  “There’s a difference that we often don’t think about between efficacy and effectiveness... adherence is part of the equation that goes into effectiveness.”
  — Dr. Neil Skolnik [06:18]

3. Liraglutide in Type 2 Diabetes with Moderate Renal Impairment

Source: Diabetes Care
Segment: [06:18 – 10:27]

• Study details:

  • 26-week, double-blind trial with 279 patients (A1C 7–10%, eGFR 30–59).
  • Liraglutide (GLP-1 RA) vs. placebo as add-on to standard therapy.
  • Outcomes: A1C difference −0.66% (liraglutide better); body weight reduction greater in liraglutide (−2.4 kg vs. −1.0 kg);
  • No change in renal function.
  • GI adverse effects more common with liraglutide (37% vs. 17%).

• Clinical Insight:

  • Liraglutide is a promising non-insulin option for T2DM patients with CKD stage 3–4.
  • Does not worsen renal function, offers decent glycemic and weight control.

• Memorable Observation:

  “This particular GLP-1 is a medicine that is not going to affect someone’s kidney function… might move a little to the front of our list…”
  — Dr. John Russell [10:27]

4. ADA Position Statement: Management of Diabetes in Long-Term Care and Skilled Nursing Facilities

Source: Diabetes Care
Segment: [10:27 – 13:43]

• Key Recommendations:

  • Individualize goals based on comorbidities and functional status.
  • Less stringent A1C goals (up to 8–8.5%) appropriate for many.
  • Avoid hypoglycemia at all costs—catastrophic for frail elders.
  • Simplified, non-complex regimens preferred; avoid sole use of sliding scale insulin.
  • Liberal diet strategies recommended to prevent malnutrition and weight loss.
  • Robust transitional care and communication at facility admission.

• Notable Commentary:

  “It starts with setting appropriate A1C goals… for older patients… an A1C goal of 8, even 8.5, is considered appropriate… That then lets us avoid hypoglycemia, which is… one of the most critical risks for our older patients.”
  — Dr. Neil Skolnik [13:43]

5. Group Medical Appointments for Diabetes

Source: Diabetes Spectrum
Segment: [13:43 – 18:16]

• Study details:

  • VA-based study (104 patients), A1C >8% referred for group visits.
  • Interprofessional team: NP/diabetes educator, pharmacist, psychologist, nurse.
  • Group visits vs. standard care: 50% in group appointments reached A1C goal vs. 19% in standard care.

• Discussion Points:

  • Peer support and interdisciplinary care may be key to improved outcomes.
  • Coding and logistics for group visits remain a practical consideration.

• Notable Quote:

  “Maybe we can look at this… things like Weight Watchers and things like Alcoholics Anonymous and say having some peer group sharing… might be where we’re going.”
  — Dr. John Russell [18:16]

6. Liraglutide and CNS Activation in Response to Food Cues

Source: Diabetes Care
Segment: [18:16 – 21:06]

• Study details:

  • Randomized crossover, 20 obese T2DM patients; liraglutide vs. insulin glargine; 12-week treatment periods.
  • fMRI used to measure CNS response to food images, before/after meals.
  • Liraglutide led to greater A1C and weight loss than insulin glargine.
  • Early treatment: liraglutide decreased brain activation (insula, putamen) in response to food cues, enhancing satiety.
  • Effect diminished over time, but may underlie weight loss advantage.

• Clinical Implication:

  • Liraglutide’s benefits extend beyond GLP-1RAs’ slowing of gastric emptying, directly impacts central brain mechanisms of satiety.

• Notable Quote:

  “Clearly it shows that GLP-1s in general, particularly liraglutide, have an effect… on satiety, which makes it easier for people not to eat more and… lose weight, one of the core features that make use of GLP-1s attractive.”
  — Dr. Neil Skolnik [21:06]

Episode Takeaways

• Intranasal glucagon is a nearly equivalently effective, more user-friendly rescue therapy for hypoglycemia in type 1 diabetes.
• Medication adherence remains a real-world barrier; addressing side effects and patient-centered regimens are crucial.
• Liraglutide is safe and effective in patients with moderate CKD and offers weight and CNS-mediated satiety benefits.
• Diabetes management goals and regimen complexity in older adults and long-term care settings should emphasize safety and quality of life over strict glycemic targets.
• Group medical appointments may substantially improve glycemic outcomes through collaborative, peer-supported care.
• GLP-1 receptor agonists like liraglutide may influence appetite via central mechanisms, not just peripheral effects.

For related links, articles, and more ADA resources, visit www.diabetesjournals.org.