Diabetes Core Update – October 2014

Podcast by the American Diabetes Association
Hosts: Dr. Neil Skolnik and Dr. John J. Russell
Date: September 18, 2014
Episode Summary:
This episode reviews and discusses the latest research from ADA journals, focusing on clinically relevant diabetes topics for healthcare professionals. The discussion covers five key articles published in ADA journals, examining new data on weight cycling, diabetes medications in renal impairment, GLP-1 receptor agonists versus insulin, HbA1c monitoring frequency, and a comparison of diabetes care guidelines.

Main Theme and Purpose

The October 2014 episode of Diabetes Core Update delivers a concise yet comprehensive review of recent research articles from ADA journals. The hosts, Drs. Skolnik and Russell, dissect each study’s findings and clinical significance, equipping practitioners with practical knowledge to optimize diabetes management strategies.

Key Discussion Points and Insights

1. Weight Cycling, Weight Loss Maintenance, and Diabetes Incidence

• Study Source: Diabetes Care
• Summary:
  A prospective observational study from the Diabetes Prevention Program analyzed weight loss, regain, and cycling over two years among 1,000 patients.
• Key Findings:
  • Weight loss in the first six months was mildly protective, but sustained loss over two years led to a 10% decrease in diabetes risk per kilogram lost.
  • Weight cycling (yo-yoing) notably raised risk: hazard ratio 1.33 (a 30% increased risk of diabetes) and also elevated systolic blood pressure.
• Clinical Dilemma:
  • Weight regain after initial loss is highly common (~75% of patients).
  • Episodic (short-term) interventions might backfire; long-term lifestyle modification and commitment are essential.
• Memorable Quote:

  "Weight cycling, where we lose weight and then gain weight, actually increases the risk of diabetes... our advice to lose weight might actually backfire and increase someone's risk of diabetes."
  — Dr. Neil Skolnik [03:09]

• Key Message:
  • Sustained behavioral change, not just episodic weight loss, is crucial. Clinical support should focus on ongoing motivation and multi-visit counseling.

2. Albiglutide vs. Sitagliptin in Patients with Renal Impairment

• Study Source: Diabetes Care
• Summary:
  A 52-week, randomized, double-blind trial compared once-weekly GLP-1 agonist albiglutide and DPP-4 inhibitor sitagliptin in type 2 diabetes patients with varying degrees of renal impairment.
• Key Findings:
  • Both drugs were effective and safe; albiglutide led to greater HbA1c reduction (-0.83% vs. -0.52%).
  • Similar safety profiles, but gastrointestinal side effects were more common with albiglutide.
  • Dosing for sitagliptin was adjusted for kidney function; albiglutide required no such adjustment.
• Clinical Nuance:
  • Options for diabetes management in patients with chronic kidney disease (CKD) are limited; GLP-1 agonists show promise.
  • Caution: Few studied had advanced CKD (stage 4), so close monitoring remains prudent for this subgroup.
• Highlight:

  "A newer medicine that is part of our armamentarium for using our diabetics who have impaired renal function."
  — Dr. John Russell [07:05]

3. GLP-1 Receptor Agonist (Exenatide) vs. Bolus Insulin

• Study Source: Diabetes Care
• Summary:
  An open-label, 30-week randomized trial compared exenatide versus mealtime Lispro insulin (added to basal glargine and metformin) for patients with suboptimally controlled type 2 diabetes.
• Key Findings:
  • Non-inferior A1c reduction in both groups (~1.1% decrease).
  • Exenatide resulted in weight loss (mean -2.5 kg) while Lispro caused weight gain (+2.1 kg).
  • Fewer nocturnal hypoglycemic episodes with exenatide but higher rates of GI side-effects.
  • Higher patient satisfaction and perceived quality of life with exenatide.
• Clinical Implications:
  • GLP-1 receptor agonists are becoming attractive options: effective, promote weight loss, low risk of hypoglycemia.
• Memorable Quote:

  "We’re really seeing here in this study and others... the GLP1 receptor agonist class of agents emerging as an extremely powerful and attractive class of agents with both efficacy as well as a lack of weight gain and hypoglycemia."
  — Dr. Neil Skolnik [10:57]

4. Optimal HbA1c Testing Frequency and Diabetes Control

• Study Source: Diabetes Care
• Summary:
  A UK data analysis (400,000+ HbA1c tests, 80,000 patients) investigated retesting intervals and glycemic outcomes.
• Key Findings:
  • Testing every three months (quarterly) was associated with the best glycemic trajectory (3.8% reduction in A1c) for those with A1c ≥7.
  • Less frequent monitoring (annual) linked to worse control (1.5% increase).
  • Excessive testing (>4x/year) did not confer extra benefit.
• Clinical Takeaway:
  • Adhering to quarterly A1c checks enhances glycemic outcomes, especially in poorly controlled patients.
• Notable Reflection:

  "The patients who aren’t coming in regularly, their glycemic control is not as good as I think it is... I need to have good mechanisms in place to make sure my patients are at least getting twice a year A1Cs."
  — Dr. John Russell [15:05]

5. Comparing Current Diabetes Guidelines: Consensus and Differences

• Study Source: Clinical Diabetes
• Summary:
  Surveyed and compared five major clinical guidelines: ADA, WHO, AACE, Indian Health Service, and CMS.
• Key Convergences:
  • Universal agreement on self-management education and nutritional therapy.
  • Lifestyle modification (physical activity, weight control) emphasized for prevention.
  • Most recommend metformin as first-line therapy, except AACE (more individualized).
• Key Divergences:
  • Diagnostic criteria: A1c ≥6.5% is not universally adopted (excluded by WHO and CMS).
  • HbA1c targets: ADA/WHO/IHS <7%; AACE <6.5%.
  • Statin recommendations: ADA, IHS, and AACE support statins regardless of baseline lipids.
  • Screening: Some (e.g., CMS) have stricter coverage criteria.
• Notable Quote & Analogy:

  "Any map will do... The important thing when we look at differences in the different guidelines isn’t always what the small differences are, but rather that you adhere to some set of guidelines."
  — Dr. Neil Skolnik [20:40]

• Clinical Pearls:
  • Minor differences exist, but aligning care with any established set of guidelines offers patients the best consistency and outcomes.

Notable Quotes and Moments

• On the risk of weight cycling:

  "Weight cycling, where we lose weight then gain weight, actually increases the risk of diabetes... it increases the risk of diabetes by 30%."
  — Skolnik [03:09]

• On the shift to incretin-based therapies in renal impairment:

  "A newer medicine that is part of our armamentarium for using our diabetics who have impaired renal function."
  — Russell [07:05]

• On the emergence of GLP-1 agonists:

  "This is a class of agents where there's an increasing plethora of studies showing it has both efficacy better than competing agents... excitngly here as efficacious as insulin, but yet has attributes which distinguish it from insulin: lack of hypoglycemia and weight loss."
  — Skolnik [10:57]

• On importance of monitoring:

  "The patients who aren’t coming in regularly, their glycemic control is not as good as I think it is..."
  — Russell [15:05]

• On clinical guideline differences:

  "Any map will do... adherence to some set of guidelines is more important than the minute differences between them."
  — Skolnik [20:40]

Timestamps for Key Segments

• [01:51] – Weight cycling, weight loss, and diabetes incidence
• [03:09] – Clinical implications of weight cycling
• [07:05] – Albiglutide vs. sitagliptin in renal impairment
• [10:57] – GLP-1 receptor agonist vs. bolus insulin
• [15:05] – Optimal frequency for HbA1c monitoring
• [17:30] – Comparison of major diabetes care guidelines
• [20:40] – Importance of guideline adherence and summary reflections

Tone and Language

The conversation is collegial, practical, and focused on translating the newest evidence to day-to-day clinical care. Both hosts maintain a tone of experienced enthusiasm and realism, emphasizing nuanced, actionable advice for busy practitioners.

Summary Takeaways

• Sustained weight loss is protective; weight cycling increases diabetes risk.
• GLP-1 agonists (especially albiglutide and exenatide) are promising for patients with renal impairment and as alternatives/adjuncts to insulin, offering effective A1c reduction, weight loss, and lower hypoglycemia risk.
• Quarterly HbA1c testing produces optimal outcomes for patients with type 2 diabetes, particularly if initial A1c is uncontrolled.
• Despite differences among professional guidelines, the most important clinical step is adherence to a consistent evidence-based approach.

For more information and full articles: www.diabetesjournals.org