Diabetes Core Update – March 2014 Episode Summary

Podcast: Diabetes Core Update
Host: American Diabetes Association
Date: February 19, 2014
Presenters: Dr. Neil Skolnik and Dr. John J. Russell
Episode Focus: A review and practical discussion of six recently published, clinically relevant articles from the ADA’s journals, with key takeaways for frontline clinicians treating diabetes.

Episode Overview

This March 2014 episode explores new research and clinical guidance from the latest issues of Diabetes, Diabetes Care, Clinical Diabetes, and Diabetes Spectrum. Topics covered include glucose control in older adults, pharmacogenomics of oral diabetes agents, strategies for insulin intensification, updates on SGLT2 inhibitors, the utility of dapagliflozin, and the real-world benefits of cognitive behavioral therapy (CBT) for patients with diabetes and depression. The hosts highlight implications for day-to-day practice and emphasize personalized, patient-centered approaches.

Key Discussion Points and Insights

1. Intensive Glucose Control in Older vs. Younger Adults—ACCORD Trial Subgroup (00:55–04:44)

• Study Overview: Subgroup analysis from the ACCORD trial (10,000+ patients, mean age 62, median A1C 8%) compared effects of targeting A1C <6% vs. 7–7.9%, splitting outcomes by age (<65 vs. ≥65).
• Findings:
  • Older Adults (>65): No difference in cardiovascular mortality between groups; higher rate of severe hypoglycemia with intensive control (4.5% vs. 1.4%).
  • Younger Adults (<65): Intensive control group had a hazard ratio of 1.71 for cardiovascular events (potential indication for increased risk), but results were less clear.
• Clinical Takeaway:
  • Elderly patients face greater hypoglycemia risk and potential mortality with aggressive control.
  • "We should individualize our diabetic care in our senior citizens and having tight control in the wrong senior citizen population could certainly lead to increased mortality." — Dr. John Russell (03:37)
• Notable Moment:
  • Puzzlement about increased CV risk in tighter control for younger patients, with hosts advising caution and individualized treatment targets.

2. Pharmacogenomics and Oral Hypoglycemic Agents (04:44–07:35)

• Study Overview: Systematic review of genetic variations and their impact on response to oral diabetes medications including metformin, sulfonylureas, repaglinide, thiazolidinediones, and acarbose.
• Findings:
  • Significant medication-gene interactions exist, but application to clinical practice remains limited.
• Clinical Takeaway:
  • Pharmacogenomics holds promise for individualized medicine but is "still distant from everyday practice."
• Quote:
  • “The reality though is that as exciting as it is, and as much as we hope to someday have individualized medicine...we're a long way from that day to day.” — Dr. Neil Skolnik (05:53)

3. Patient vs. Physician-Managed Short-Acting Insulin Titration (START Study) (07:36–11:02)

• Study Overview: Compared simple, patient-directed vs. physician-directed titration of pre-breakfast insulin glulisine in type 2 diabetes patients inadequately controlled on basal insulin alone.
• Findings:
  • Both methods were similarly effective (A1C <7% in 28% of self-titrators vs. 21% with physician management); safety (no severe hypoglycemia) similar.
• Clinical Takeaway:
  • Empowering patients with clear titration algorithms is feasible and may improve engagement and outcomes.
• Memorable Exchange:
  • “When we can empower the patient to really be a partner in their disease, people do better regardless whether it's diabetes, hypertension or anything else.” — Dr. John Russell (10:48)

4. SGLT2 Inhibitors—Mechanism and Clinical Data Review (11:02–16:53)

• Study Overview: Comprehensive review of SGLT2 inhibitors (e.g., dapagliflozin) focusing on mechanism, A1C and weight effects, and safety.
• Key Points:
  • Mechanism: Block glucose reabsorption in the kidney, leading to glucosuria, A1C reduction, and weight loss.
  • Efficacy: A1C reductions up to 1–2% (greater with higher baseline A1C).
  • Safety: Low risk of hypoglycemia, but increased genital and urinary tract infections.
• Practical Insights:
  • Best positioned as add-on therapy, particularly after metformin.
  • “This medicine is really going to be an add-on medication after metformin...Does this medicine cause hypoglycemia? No. Does this medicine lead to weight loss? Yes, it does.” — Dr. John Russell (15:27)

5. Dapagliflozin as Add-on Therapy (16:53–18:54)

• Study Overview: Phase 3, double-blind 24-week RCT of dapagliflozin vs. placebo added to sitagliptin (with/without metformin) in type 2 diabetes.
• Findings:
  • Modest A1C reduction (−0.5%) in moderately controlled patients.
  • Average weight loss of 2.1 kg.
  • Well tolerated; anticipated class-specific effects seen.
• Clinical Note:
  • Reinforces its role as an add-on agent, especially for modest A1C lowering and weight management.
• Quote:
  • “A 0.5 point reduction in A1C was a well tolerated medicine with not a whole lot of side effect profile and certainly saw the weight loss that we would be expecting.” — Dr. John Russell (18:47)

6. CBT for Depression and Diabetes Management (19:02–22:21)

• Study Overview: RCT of cognitive behavioral therapy (CBT) for depressive symptoms and medication/self-monitoring adherence in patients with uncontrolled type 2 diabetes.
• Findings:
  • CBT group improved medication adherence (+20.7%), self-monitoring (+30%), depression scores (−6.44 points), and A1C (−0.72) vs. control.
  • Benefits sustained at 12 months (adherence and A1C).
• Clinical Significance:
  • Depression is common in diabetes (~25% prevalence) and linked to poor adherence and outcomes.
  • CBT achieved A1C improvements comparable to new pharmacologic therapies.
• Quote:
  • “CBT…led to very real results with proven increase in pill adherence and an improvement importantly in A1C that is on the same level as most of the new medications that we use as add-on therapy.” — Dr. Neil Skolnik (21:20)

Notable Quotes

• On individualized glycemic targets for seniors:
  “We should individualize our diabetic care in our senior citizens…tight control in the wrong senior citizen population could certainly lead to increased mortality.” — Dr. John Russell (03:37)
• On pharmacogenomics' promise and reality:
  “As exciting as it is…we're a long way from [individualized medicine] day to day.” — Dr. Neil Skolnik (05:53)
• On patient empowerment in insulin titration:
  “When we can empower the patient to really be a partner in their disease, people do better.” — Dr. John Russell (10:48)
• On SGLT2 add-on use:
  “This medicine is really going to be an add-on medication after metformin…” — Dr. John Russell (15:06)
• On CBT for depressed patients with diabetes:
  “CBT…led to very real results… an improvement…in A1C that is on the same level as most of the new medications…” — Dr. Neil Skolnik (21:20)

Timestamps for Important Segments

• 01:00 – Intensive Glucose Control in Older vs. Younger Adults
• 04:44 – Pharmacogenomics and Oral Hypoglycemics
• 07:36 – Patient vs. Physician-Managed Insulin Titration (START Study)
• 11:02 – SGLT2 Inhibitors Mechanism and Effects
• 16:53 – Dapagliflozin as Add-on Therapy
• 19:02 – CBT for Depression/Adherence in Diabetes

Overall Tone and Additional Notes

• The presenters maintain an engaging, collegial, and practical tone, with a focus on actionable insights.
• The episode combines cautious optimism for emerging fields (pharmacogenomics, SGLT2 inhibitors) with pragmatism about current limitations.
• A recurring emphasis on patient-centered care and empowerment, with a strong endorsement of addressing behavioral health in diabetes management.

For further details and links to discussed articles, visit www.diabetesjournals.org.