Podcast Summary: Diabetes Core Update July 2015

Podcast: Diabetes Core Update
Hosts: Dr. Neil Skolnik & Dr. John Russell
Date: June 24, 2015
Episode: July 2015
Duration: ~15 minutes
Theme: Review and discussion of key clinically relevant studies from ADA journals relevant to diabetes management

Overview

This episode of the Diabetes Core Update podcast offers concise but detailed analyses of the most recent and clinically significant articles from ADA’s four science and medical journals. Geared towards practicing clinicians, the hosts unpack how new findings can be applied in patient care, covering topics from novel therapies and drug safety to self-management, nutrition, and exercise.

Key Discussion Points & Insights

1. Citagliflozin – A Dual SGLT1/SGLT2 Inhibitor in Type 1 Diabetes

(Diabetes Care)
[00:55 – 03:39]

• Study Design: 33 patients with type 1 diabetes were randomized to citagliflozin (an oral dual SGLT1/SGLT2 inhibitor) or placebo as an adjunct to insulin for ~1 month.
• Mechanism:
  • SGLT2 inhibition (well-known) decreases glucose reabsorption in the kidney.
  • SGLT1 impacts glucose absorption in the gut, often underappreciated clinically.
• Outcomes:
  • 32% reduction in bolus insulin requirement.
  • Lower mean daily glucose and a 0.55% A1C reduction in treatment group vs. placebo.
• Safety: Noted 2 cases of diabetic ketoacidosis (DKA) among participants — an important concern, especially after FDA safety communications about SGLT2 inhibitors and risk of euglycemic DKA.

Quote – Dr. Russell [03:39]:
"I think this is an interesting article and I think we need to be mindful...if something does not seem quite right, that certainly we should be assessing their acid base status."

2. Position Statement on Diabetes Self-Management Education & Support (DSMES)

(Diabetes Care)
[03:40 – 06:59]

• Key Definitions:
  • DSME = building knowledge and skills for self-care.
  • DMSS = ongoing support for coping and sustained behavior change.
• 10 Standards Proposed: Internal structure, external input, access, coordination, trained staff, written curriculum, individualized care, ongoing support, progress tracking, and quality improvement.
• Impact:
  • DSMES can reduce A1C by 0.5–2%, similar to adding a new medication.
  • Under 10% of Medicare patients currently receive DSMES, possibly due to limited referrals or implementation logistics.

Quote – Dr. Skolnik [06:59]:
"A number of studies have shown that...the benefit with regard to something that's incredibly clear, a 1C reduction...is the same as adding an additional medicine."

• Future Directions: Hope for new models like the "medical home" to embed diabetes educators into primary care for easier access.

3. Metformin, Acid Suppressors, and B12 Deficiency

(Clinical Diabetes)
[07:00 – 11:57]

• Clinical Problem: Many people with diabetes (esp. type 2) are on both metformin and acid suppressants (PPIs or H2 blockers), increasing risk for B12 deficiency — which mimics neuropathy symptoms.
• Prevalence: B12 deficiency seen in 5–36% of those on metformin; use of PPIs or H2 antagonists increases risk further.
• Consequences:
  • Confused diagnosis: B12-deficiency neuropathy vs. diabetic neuropathy.
  • Risk is magnified by high rates of long-term PPI/H2 use in the US.
• Practice Implication: Routine B12 monitoring may be warranted for those on both metformin and acid-suppressing drugs.

Quote – Dr. Russell [11:57]:
"[B12 monitoring is] something that we are going to follow routinely in these patients just to see if...we can have an early detection of a very treatable neuropathy."

On acid suppressors:
"We put someone on a medicine and then we leave them on that medicine forever and ever...But this potentially would raise a point that if we do have people on those medicines concomitantly...perhaps these are folks that we do need to do some follow up vitamin studies..."

4. Dapagliflozin in High-Risk Type 2 Diabetes – Glycemic and Cardiovascular Impact

(Diabetes Care)
[11:58 – 15:21]

• Study: 900+ patients, 24-week placebo-controlled trial of dapagliflozin 10 mg.
• Endpoints: Improvements in A1C, body weight, systolic blood pressure.
• Findings:
  • 0.38% A1C reduction with dapagliflozin vs. slight increase in placebo.
  • More patients reached the combined endpoint (A1C, weight, BP) with dapagliflozin.
  • Results consistent across age groups (>65 years, ≤65 years).
  • No new adverse cardiovascular effects detected in this study.
• Limitations: Larger, longer studies needed for robust CV safety data.

Quote – Dr. Skolnik [15:21]:
"This study essentially is reassuring. It shows that in a high risk group...dapagliflozin does what you anticipate it to do...and that it has importantly no adverse cardiovascular effects."

5. Insulin Detemir’s Central (Brain) Effects on Food Intake and Weight

(Diabetes)
[15:22 – 18:00]

• Question: Why does insulin detemir result in less weight gain compared to other long-acting insulins?
• Finding: In animal models, detemir remains elevated in CSF longer than NPH insulin, resulting in more prolonged appetite suppression and less weight gain.
• Mechanism: Potential greater central (brain) action, influencing satiety and food intake.
• Clinical Relevance: May help differentiate future insulins based on their effects on satiety and weight.

Quote – Dr. Russell [18:01]:
"Certainly we're not going to be injecting insulin into third ventricles on a whole lot of patients. But...we might differentiate one product with another...on how much it impacts one of these eight sites of hyperglycemia."

6. Calorie Restriction vs. Exercise – Effects on Weight Loss, Insulin Sensitivity, and Incretin System

(Diabetes Care)
[18:00 – 20:36]

• Design: Overweight, sedentary adults randomized to calorie restriction, exercise, or both for matched 6–8% weight loss.
• Result: Insulin sensitivity improved twofold more when both interventions were combined versus either alone, despite similar weight loss.
• Significance: Both approaches good, combined is best; aligns with the “Diabetes Prevention Program” (DPP) landmark findings.
• Recommended Regimen (from DPP): Weight loss ≥7% and 150 minutes/week of moderate exercise.

Quote – Dr. Skolnik [20:36]:
"Both calorie restriction and exercise are good ways to lose weight and the best way is to do both."

Notable Quotes & Memorable Moments

• On SGLT1 and SGLT2 Inhibition:
  Dr. Russell [03:39]: “We really have ignored SGLT1. It has a fairly negligible effect in the kidneys...But here in the stomach we're seeing that impacting reabsorption can have an impact.”

• On DSMES Utilization:
  Dr. Skolnik [06:59]: “Under 10% of Medicare beneficiaries with diabetes get diabetes self management and education...Ultimately the main point is we need to somehow get patients to get diabetes self management and education training more often than they currently do.”

• On Polypharmacy and Neuropathy:
  Dr. Russell [11:57]: "I think it might change our practice...that people who are on metformin we might find ourselves in guidelines down the road that this is something that we are going to follow routinely..."

• On Differentiating Insulin Products:
  Dr. Russell [18:01]: "I think as we go forward...we might differentiate one product with another product on how much it impacts one of these eight sites of hyperglycemia."

Key Timestamps

• 00:55 – Article review begins: Citagliflozin (dual SGLT1/SGLT2 inhibitor)
• 03:40 – Diabetes self-management education and support position statement
• 07:00 – Metformin plus PPIs/H2 antagonists and risk of B12 deficiency
• 11:58 – Dapagliflozin cardiovascular and glycemic outcomes study
• 15:22 – Insulin detemir’s action in CNS and effect on weight
• 18:00 – Calorie restriction vs. exercise and impact on insulin sensitivity

Summary

The July 2015 episode of Diabetes Core Update is a must-listen for clinicians seeking to stay abreast of important clinical advances. The hosts dissect the evidence behind new combination SGLT inhibitors, emphasize the underutilization and major benefits of diabetes self-management education, caution about B12 deficiency risks in the context of polypharmacy, and review the benefits of exercise and calorie restriction for insulin sensitivity. The episode rounds out with a fascinating look at the potential for long-acting insulins to differ in central appetite effects—a possible future frontier in pharmaceutical differentiation.

For further details and article access, visit www.diabetesjournals.org.