Diabetes Core Update – June 2016

Podcast: Diabetes Core Update
Hosted by: Dr. Neil Skolnik and Dr. John J. Russell (American Diabetes Association)
Release Date: May 24, 2016
Episode Overview:
This June 2016 episode delivers concise, clinically relevant insights on the latest diabetes research presented in ADA’s premier journals. Dr. Skolnik and Dr. Russell review and discuss findings from 5 current articles, focusing on lipid-lowering therapy, glycemic variability, advances in insulin formulations, adjunctive therapies, physical activity interventions, and the gut’s role in glucose homeostasis. The discussion emphasizes practical takeaways for frontline clinicians.

Main Theme

Translating New Diabetes Evidence Into Clinical Practice

This episode brings together new research from recent publications in ADA journals. The hosts focus on studies with immediate potential to impact prescribing, screening, and patient counseling – particularly in the management of type 1 and type 2 diabetes, cardiovascular risk mitigation, and evolving pharmacology.

Key Discussion Points & Insights

1. Lipid Lowering Therapy and Cardiovascular Outcomes in Type 1 Diabetes

Reference: Diabetes Care
Segment Begins: 00:55

• Large cohort study (>24,000 type 1 diabetics, median follow-up 6 years) assessed cardiovascular outcomes and mortality with vs. without lipid-lowering therapy.
• Findings: Statin use was associated with substantially reduced risks:
  • Cardiovascular death: hazard ratio 0.60
  • All-cause death: hazard ratio 0.56
  • Fatal/non-fatal stroke: 0.56
  • Fatal/non-fatal MI: 0.78
  • Coronary heart disease: 0.85

"The ADA recommends all folks with type 1 diabetes over the age of 40 be put on a statin... I could certainly see, based on a study like this, that we move that bar from the age of 40 to a lower age."
— Dr. John Russell, [03:02]

• Clinical Implication: Statins are both effective and well-tolerated; this data suggests possible benefit in starting at younger ages, especially given long diabetes duration.

2. Glucose Variability: Exenatide vs. Rapid-Acting Insulin in Type 2 Diabetes

Reference: Diabetes Care
Segment Begins: 04:10

• 26-week RCT comparing GLP-1 agonist (exenatide) to rapid-acting insulin as mealtime add-on, in high cardiovascular risk patients.
• Both arms maintained similar A1C (~7.1–7.2), but exenatide provided:
  • Reduced glucose variability
  • Significant weight loss (-4.8 kg vs. +0.7 kg with insulin)
  • No difference in hypoglycemic events

"What this trial shows is that a short acting GLP-1, exenatide, decreases the postprandial glucose excursions... but we don't have good data now that shows that decreasing glucose variability improves those outcomes."
— Dr. Neil Skolnik, [05:51]

• Clinical Implication: Exenatide offers real benefits in postprandial glucose control and weight, but hard outcome impact (CV/microvascular) from reduced variability remains undetermined.

3. New Insulin Therapies: Focus on Insulin Glargine 300

Reference: Clinical Diabetes
Segment Begins: 08:10

• Review of basal insulin analogs, emphasizing Glargine 300 U/mL (recently FDA approved).
• Advantages Highlighted:
  • Longer, more stable action than Glargine 100
  • Potentially lower risk of nocturnal hypoglycemia
  • Once-daily dosing feasible, even for high-dose needs (insulin resistance)
  • Possible reduced weight gain
• Cautions: Educating patients about different volume-to-dose ratios to avoid dosing errors.

"If we have people who are used to drawing up a product that is 1/3 as strong, we really need to educate people... use of pens and things like that can help control a little bit of that."
— Dr. John Russell, [10:27]

• Clinical Implication: More flexible, safer long-acting insulin options; importance of patient/provider education on dose preparation and adjustment.

4. Adding Liraglutide to Insulin in Type 1 Diabetes

Reference: Diabetes Care
Segment Begins: 11:45

• 12-week RCT studied liraglutide (GLP-1 agonist) at three doses (0.6, 1.2, 1.8 mg) vs. placebo, as adjunct to insulin in type 1.
• Main findings:
  • Only the 1.2 mg group showed significant A1C reduction (-0.78) and lower glycemic variability.
  • Both 1.2 and 1.8 mg groups saw significant weight loss (~5 kg) and reduced insulin dose.
  • All liraglutide groups had more GI adverse effects and more time in hypoglycemia.

"It may be that liraglutide has a greater effect in patients with type 1 diabetes who are overweight... with that weight loss decreasing some insulin resistance even in obese patients with type 1."
— Dr. Neil Skolnik, [13:21]

• Clinical Implication: Possible future for select type 1s (especially overweight) to benefit from GLP-1 agonists, mainly via weight and insulin dose reduction. More research is needed.

5. Breaking Up Sedentary Time in Type 2 Diabetes

Reference: Diabetes Care
Segment Begins: 14:07

• Small RCT: 24 adults with T2DM; compared uninterrupted sitting to sitting interrupted every 30 min with 3 min of either light walking or simple resistance exercises.
• Both activity interventions led to improved postprandial glucose, insulin, and C-peptide levels.

"Perhaps the new OSHA related diagnoses are not so much musculoskeletal but are metabolic. Is obesity and diabetes an offshoot of what we've created as an economy?"
— Dr. John Russell, [16:14]

• Clinical Implication: Even brief, regular interruptions of sedentary behavior by very light activity can have measurable metabolic benefit—an important, simple counseling point for patients.

6. The Gut and Glucose Homeostasis

Reference: Diabetes Care
Segment Begins: 17:45

• Recap of gut physiology in regulating postprandial glucose, emphasizing the “incretin effect” (hormonal augmentation of post-meal insulin when glucose is delivered orally).
• Key mechanisms:
  • Gastric emptying, GIP and GLP-1 hormone release, SGLT1-mediated absorption, hepatic glucose regulation.
• Tie to "ominous octet" (eight organ systems now known to be involved in type 2 diabetes pathophysiology).
• Clinical link to modern drug classes (DPP-4 inhibitors, GLP-1 agonists).

“It’s incumbent upon us who take care of patients to really do our best to understand these increasingly complex systems, because that understanding directly relates to our comfort in using these incredibly potent and important medicines for our patients.”
— Dr. Neil Skolnik, [20:52]

Notable Quotes & Memorable Moments

• On statin initiation for type 1 diabetes:

  "Whether this is going to move the bar on that age that we're going to start using a statin."
  — Dr. John Russell, [03:02]

• On glycemic variability interventions:

  "That’s the linchpin here… if we’re going to make the leap from saying short acting GLP1 agonists... actually leads to improved outcomes."
  — Dr. Neil Skolnik, [05:51]

• On implications for office workers:

  "Maybe we do need to encourage people that every 30, 45 minutes they should get up from their desk, walk around the office and move on from things to kind of help with their own health."
  — Dr. John Russell, [16:14]

• On the complexity of diabetes:

  “The change from the old days where we thought that type 2 diabetes was just a product of insulin resistance and not enough insulin…”
  — Dr. Neil Skolnik, [20:52]

Timestamps — Episode Structure

• [00:55] – Article 1: Lipid-lowering therapy in type 1 diabetes
• [04:10] – Article 2: Exenatide vs. rapid-acting insulin (glucose variability)
• [08:10] – Article 3: New insulin therapies (glargine 300)
• [11:45] – Article 4: Liraglutide with insulin in type 1 diabetes
• [14:07] – Article 5: Breaking up sedentary time
• [17:45] – Article 6: Gut, incretins, and glucose regulation

Overall Episode Tone & Takeaways

The episode is brisk, practical, and evidence-focused, providing succinct but nuanced commentary for clinicians. The hosts balance enthusiasm for new therapies with cautions about implementation and the need for continued research. They stress the need for patient education and clinician understanding as therapies become more sophisticated.

For additional details and access to discussed research, listeners are referred to:
www.diabetesjournals.org