Diabetes Core Update – November 2015

American Diabetes Association Podcast
Hosts: Dr. Neil Skolnik & Dr. John J. Russell
Release Date: October 24, 2015
Duration: ~15 minutes

Episode Overview

This episode offers concise, clinically relevant updates by reviewing recent articles from ADA’s scientific journals. Dr. Neil Skolnik and Dr. John Russell discuss studies focusing on new diabetes medications, adherence to vaccination guidelines, triple therapy approaches, the link between sleep and glucose metabolism, and individual variability in energy expenditure. All discussions are tailored for practicing healthcare professionals, emphasizing real-world clinical implications.

Key Discussion Points & Insights

1. Weekly DPP-4 Inhibitor: Omegliptin

Article from Diabetes Care (Nov 2015)
[01:42 – 02:54]

• Summary:
  Multi-center, double-blind, 12-week dose-ranging study among 685 treatment-naïve type 2 diabetes patients evaluated omerogliptin, a weekly DPP-4 inhibitor.
• Findings:
  • Dose-related reduction in A1C, postprandial glucose, and fasting blood glucose.
  • 25 mg dose achieved greatest efficacy (A1C reduction ~0.72%).
  • Adverse events and symptomatic hypoglycemia rates were low.
  • No effect on body weight.

Memorable Quote:

"This is exciting – the advent of once-a-week treatments for diabetes... One of the big issues in any chronic disease, and certainly in diabetes, is the issue of compliance."
— Dr. Neil Skolnik [02:54]

• Clinical Insight:
  Simpler regimens may improve adherence, though evidence that once-weekly dosing is better than daily remains to be seen.

2. Vaccination Rates in Patients with Diabetes

Article from Clinical Diabetes
[02:55 – 05:19]

• Summary:
  Single-center cross-sectional study assessed adherence to vaccination recommendations (Hepatitis B, Pneumococcal, Influenza) among 100 hospitalized patients with diabetes.
• Key Stats:
  • Influenza: 41%
  • Pneumococcal: 37%
  • Hepatitis B: 0%
• Commentary:
  • Study limitations include reliance on patient self-report and lack of outpatient records.
  • Many diabetic patients remain under-vaccinated, despite the heightened risk.

Memorable Quotes:

"It might not necessarily been the really kind of the right way to investigate this... probably the truth is that people are not as good at getting these vaccines."
— Dr. John Russell [05:19]

• Practical Guidance:
  • Review vaccine needs regularly, especially before and after age 65.
  • Pneumovax: Younger diabetics need one dose before 65, and a second after 65.
  • Prevnar 13: Reserved for special populations (dialysis, cancer, immunocompromised).
  • Hepatitis B: Important for diabetics primarily due to risk in group glucose testing or future dialysis.

3. Triple Oral Therapy: Dapagliflozin + Saxagliptin + Metformin

Article from Diabetes Care (Nov 2015)
[07:28 – 10:21]

• Summary:
  Phase 3, 24-week RCT assessed adding dapagliflozin to saxagliptin plus metformin in 320 patients with type 2 diabetes (mean A1C: low 8s).
• Results:
  • Triple therapy led to greater A1C reduction (−0.82% vs −0.2% with placebo).
  • Better reductions in fasting and 2-hour postprandial glucose, and body weight.
  • Low risk of hypoglycemia.
  • Increased rate of genital infections with dapagliflozin (5% vs 0.6%).

Memorable Quote:

"This is very similar to when we treat hypertension... using multiple medicines that work through different mechanisms. That's the model that we've now moved to with diabetes."
— Dr. Neil Skolnik [10:21]

• Clinical Insight:
  Using drugs with complementary mechanisms targets more aspects of T2DM pathophysiology, akin to hypertension management approaches.

4. Sleep Disturbances & Glucose Metabolism

Article from Diabetes Care
[10:22 – 13:02]

• Summary:
  Analysis of ~6,000 adults (age >65) from the Cardiovascular Health Study assessed associations between sleep disturbances (apnea, snoring, insomnia, daytime sleepiness) and markers of glucose metabolism.
• Findings:
  • Sleep apnea, snoring, and daytime sleepiness are linked with higher fasting glucose, worse insulin sensitivity, and higher risk for T2DM.
    • Sleep apnea: 80% risk increase
    • Snoring: 27% increase
    • Daytime sleepiness: 54% increase
  • No consistent link between insomnia and glucose metabolism or diabetes.

Memorable Quote:

"When we think about someone having Pickwickian syndrome, we think about someone so large that their OSA is manifesting itself 24 hours a day..."
— Dr. John Russell [13:02]

• Clinical Insight:
  Recognition and management of sleep disorders in at-risk patients can influence glucose control and diabetes prevention efforts.

5. Variations in Energy Expenditure & Weight Change Phenotypes

Article from Diabetes
[13:03 – 16:09]

• Summary:
  59 participants admitted for a 25-day inpatient study, randomized to fasting or different overfeeding conditions, then followed up 6 months later.
• Findings:
  • Two key phenotypes:
    • Those who conserve energy more during fasting tend to regain more weight post-diet.
    • Some individuals respond with greater energy expenditure to carb overfeeding, possibly faring better on low-carb diets.
  • Highlights significant individual variability in metabolic response to fasting and overfeeding.

Memorable Quote:

"There are essentially different phenotypes, different responses to food restriction... if you're the type of person who, without even thinking about it, decreases your energy expenditure, you tend to gain more weight."
— Dr. Neil Skolnik [16:09]

• Clinical Insight:
  There’s no ‘one-size-fits-all’ in weight loss or maintenance—individual physiological responses should guide realistic counseling and expectations.

Notable Quotes & Moments

• On Medication Adherence:

  "Patients on the average with diabetes only fill 60 to 80% of the prescriptions that are prescribed for them."
  — Dr. Neil Skolnik [02:54]

• On Vaccine Confusion:

  "The direct to consumer vaccination market... says remember to get your every five year pneumococcal vaccine. Not necessarily true."
  — Dr. John Russell [05:19]

• On Complex Therapy:

  "We’re hitting five of the eight potential mechanisms in DeFronzo's 'ominous octet’ with this combination."
  — Dr. Neil Skolnik [10:21]

• On Individual Variability:

  "We ought to...recognize the individual challenges and differences in outcome that [patients] might expect from achieving similar behaviors."
  — Dr. Neil Skolnik [16:09]

Timestamps for Key Segments

• Introduction & Article Overview: 00:55 – 01:41
• Omegliptin DPP-4 Weekly Agent: 01:42 – 02:54
• Medication Adherence & Compliance: 02:54 – 03:45
• Vaccination Rates (Influenza, Pneumococcal, Hepatitis B): 03:45 – 07:27
• Triple Oral Therapy (Dapagliflozin, Saxagliptin, Metformin): 07:28 – 10:21
• Sleep Disturbance & Metabolism: 10:22 – 13:02
• Energy Expenditure Phenotypes in Fasting/Overfeeding: 13:03 – 16:09

Tone & Style

Discussion is collegial, practical, and grounded in primary care experience. Dr. Skolnik and Dr. Russell balance detailed review of article findings with clinical anecdotes and pragmatic guidance for real-world diabetes management.

For full access to discussed articles, visit:
www.diabetesjournals.org