Diabetes Core Update – June 2025 Episode Summary

Podcast: Diabetes Core Update
Date: June 3, 2025
Hosts: Dr. Neil Skolnik, Dr. John J. Russell
Special Guest: Davida Kruger, NP, Henry Ford Health System
Theme: Key Updates in Diabetes Management from Recent ADA Journal Articles

Episode Overview

This June 2025 episode delivers incisive reviews of the latest clinical research from the American Diabetes Association journals, focusing on topics crucial for primary care and diabetes specialists. The discussions span intensive blood pressure control strategies, GLP-1 agonists' impact on dementia risk, advancements in automated insulin delivery for type 2 diabetes, optimal screening for advanced liver fibrosis in diabetic patients, and the nuanced risks of urogenital infections with SGLT2 inhibitors.

Key Discussion Points & Insights

1. Intensive Blood Pressure Control in Patients with Type 2 Diabetes

[00:02–03:52]

Study Reviewed: New England Journal of Medicine, large RCT from China (12,000+ patients, 4.2 years median follow-up)

• Design: Patients ≥50 years old with type 2 diabetes and elevated systolic BP were randomized to either an intensive (<120 mmHg) or standard (<140 mmHg) systolic BP goal.
• Primary Outcome: Composite of nonfatal stroke, nonfatal MI, heart failure hospitalization, or cardiovascular death.
• Findings:
  • Mean achieved SBP: 121 (intensive) vs. 133 (standard)
  • Hazard Ratio for primary outcome: 0.79 (21% risk reduction in intensive group)
  • Serious adverse events were comparable; symptomatic hypotension and hyperkalemia were more frequent with intensive control.

Dr. John Russell’s Clinical Perspective:

"There's been mixed messages...This is a very powerful argument for 120, partly because the control group was 130." [03:52]

• Notes study is “aspirational” due to population and medication count.
• Warns about higher risk of hypotension in the elderly.
• Emphasizes combination therapy for real-world practice and individualized patient goals.
• Not all patients need to hit 120, particularly the very old or those with side effects.

2. Cardio-Protective Glucose-Lowering Agents and Dementia Risk

[03:52–09:09]

Study Reviewed: JAMA Neurology, meta-analysis of 26 RCTs (~164,000 participants)

• Agents Studied: GLP-1 agonists, SGLT2 inhibitors, (pioglitazone; no metformin studies found)
• Findings: Overall, no significant dementia reduction with all drugs pooled (OR 0.83, CI crosses 1).
  • GLP-1 agonists alone showed a statistically significant 45% risk reduction for dementia (OR 0.55).
  • SGLT2 inhibitors and pioglitazone did not show benefit.
• Mechanisms Considered: Not just glucose lowering—potential anti-inflammatory effects with GLP-1s.

Dr. Neil Skolnik’s Reaction:

"I think this is one of the most exciting things going on right now in medicine...GLP-1s having a significant effect." [09:09]

• Observational trials suggested benefit, now supported by meta-analysis of RCTs.
• Current large clinical trials (Evoke, Evoke Plus) with semaglutide and FDA submissions may impact future guidelines.
• Population with diabetes highlighted as high-risk for dementia.

3. Automated Insulin Delivery (AID) in Type 2 Diabetes

[09:09–18:08]

Study Reviewed: New England Journal of Medicine RCT
Special Guest: Davida Kruger, NP

• Purpose: Assessing the role of insulin pumps (AID systems) in type 2 diabetes, expanding access beyond selective groups.
• Methodology:
  • Real-world inclusion: Participants on any insulin regimen, with varied education backgrounds, ages 18–75.
  • Diverse populations—racial, socioeconomic, and educational diversity prioritized.

Notable Results:

• HbA1c reductions of 0.7–0.9% over just 3 months, significant P value (<0.001).
• Greater time-in-range, less hypoglycemia, and lower diabetes distress.
• Effect held regardless of concurrent GLP-1 use.

Quotes & Memorable Moments:

"We met people everywhere they were and included them, and they did very well." – Davida Kruger [13:32]
"Our job is not done just because we use incretins and SGLT2 inhibitors..." – Davida Kruger [17:01]

Clinical Implication:

• Universal sensor access advocated as a right.
• Insulin pump therapy should be considered and offered to all insulin-requiring type 2 diabetics, not restricted by education or previous regimen.

4. Screening for Advanced Liver Fibrosis in Diabetes (MASLD/MASH)

[18:09–23:23]

Study Reviewed: Diabetes Care, prospective multicenter study

• Population: 654 patients (majority type 2 diabetes, some with obesity/MASLD).
• Screening Tools Compared: FIB-4, FibroMeter, FibroTest, ELF (Enhanced Liver Fibrosis), various elastography techniques.
• Main Findings:
  • FIB-4 is a practical first-line test with high negative predictive value.
  • Half of diabetic patients screened can be safely ruled out from further testing with FIB-4 alone.
  • For FIB-4 >1.3, next step can be elastography (VTCE/SWE) or, where unavailable, ELF blood test.
  • Clear, algorithmic approach to stratifying fibrosis risk and avoiding unnecessary hepatology referrals.

Dr. Neil Skolnik’s Practical Take:

"We, with a high degree of confidence can not send on or do any other tests in about half the people...No other tests done with a very high negative predictive value." [20:38]

• ELF test gaining traction as a simple, blood-based alternative.
• Emphasizes updated, practical stratification model for use in primary care.

5. SGLT2 Inhibitors and Urogenital Infections—Updated Risk Data

[23:23–30:57]

Study Reviewed: Diabetes Care, large Danish cohort (~77,000 participants)

• Comparison: SGLT2 inhibitors vs. GLP-1 agonists as add-ons to metformin.
• Findings:
  • 1-year UTI incidence nearly identical (10%) in both groups.
  • Genital mycotic infections more common with SGLT2s (2% vs. 0.7%; RR~3).
  • No long-term UTI risk elevation with SGLT2s, but persistent higher risk for mycotic infections.
• Clinical Relevance:
  • FDA warnings for SGLT2s and UTIs may overstate the risk.
  • Contextualize the risk—most infections are mild, rarely necessitating discontinuation unless recurrent/severe.

Dr. John Russell’s Commentary:

"We thought there would be a much higher rate of UTIs...but it's not necessarily higher with this category of treatment versus the other." [27:05]

• Explains historical concerns and clinical anecdote.
• Argues for nuanced withdrawal decisions, with recognition of cardiorenal benefits versus rare infectious complications.

Notable Quotes & Memorable Moments

• Davida Kruger on Real-World Insulin Pump Access:

  "It doesn't take a college degree to use an insulin pump." [14:34]

• Dr. Russell on SGLT2s and UTI Risk:

  "It really becomes difficult to say, ...I'm going to take away this thing that might protect you from a litany of other things...Because of this." [27:05]

Timestamps for Important Segments

| Segment Topic | Timestamp | |----------------------------------------------------------------------- | ---------- | | Intensive Blood Pressure Control | 00:02–03:52| | Cardio-Protective Glucose-Lowering Therapy & Dementia | 03:52–09:09| | Automated Insulin Delivery in Type 2 Diabetes (with Davida Kruger) | 09:09–18:08| | Screening for Advanced Liver Fibrosis (MASLD/MASH) | 18:09–23:23| | SGLT2 Inhibitors & Urogenital Infection Risk | 23:23–30:57|

Announcements & Forthcoming Changes

[30:57]

• Podcast Rebranding:
  The show will soon be renamed Diabetes, Obesity and Cardiometabolic Update (DOC Update) to reflect broader coverage.

Summary

This high-yield episode provides practicing clinicians with clear, evidence-based guidance on critical diabetes comorbidities, evolving therapy paradigms, and practical screening strategies, delivered in a conversational and expert tone. The hosts spotlight actionable insights, push for broader adoption of new technologies, and advocate for patient-centered, data-driven care—inviting listeners to stay at the forefront of diabetes medicine.

For direct links and more information, visit: www.diabetesjournals.org