Diabetes Core Update Special Edition – Diabetes is Primary 2015 Part 1

Podcast by the American Diabetes Association
Released: June 10, 2015
Guests:

• Dr. Andrew Reinhart (Chief Medical Officer, Glytech)
• Dr. John Buse (Professor of Medicine, University of North Carolina at Chapel Hill)
• Hosts: Dr. Neil Skolnik, Dr. John J. Russell

Overview

This special edition episode of Diabetes Core Update covers highlights from the 2015 “Diabetes is Primary” Conference, part of the American Diabetes Association’s Scientific Sessions. The episode focuses on:

• Updates to the ADA Standards of Care (Dr. Andrew Reinhart)
• New medications in diabetes, particularly SGLT2 inhibitors and insulin formulations (Dr. John Buse)

These segments are designed to bring practicing clinicians up-to-speed on important changes impacting diagnosis, screening, medication choices, and diabetes management.

1. Updates to the ADA Standards of Care

Speaker: Dr. Andrew Reinhart
Timestamps: [02:14]–[09:08]

Key Discussion Points

• BMI Cutoff for Diabetes Screening ([02:22])

  • New Asian BMI threshold for screening is 23 (previously 25 for all populations).
  • "Anybody that you have that is overweight, obese, meets these criteria and is at high risk for other reasons... those are the types of people we want to be screening." — Dr. Reinhart [02:36]

• Physical Activity Recommendations

  • Encourage patients to stand or move every 90 minutes during the day, not just remain seated for hours.
  • “I love my new Apple watch because it reminds me to get up every hour. And the standard is saying ... at least standing or moving every 90 minutes throughout the day.” — Dr. Reinhart [02:50]

• E-cigarettes

  • No strong evidence to support their use; not recommended in the guidelines.

• Immunizations

  • Now mirrors CDC guidance on pneumococcal vaccines (PCV13 and PPSV23); not a significant change, but ensures alignment.
  • “The only change was mirroring what the CDC is saying in terms of that vaccination.” — Dr. Reinhart [03:18]

• Glycemic Targets ([03:31])

  • Pre-meal glucose range changed from 70–130 mg/dL to 80–130 mg/dL.
  • Postprandial target (<180 mg/dL at 1-2 hours) and A1C target (<7%) unchanged.
  • Emphasis on individualization of A1C target: depends on patient’s diabetes duration, complications, and comorbidities.
    • “Some folks less than six and a half may be appropriate, some people closer to eight may be appropriate.” — Dr. Reinhart [04:15]

• Medication Choices After Metformin ([04:32])

  • SGLT2 inhibitors added as a new sixth class to consider after metformin.
  • Guide to individualizing second agent: consider cost, efficacy, risk of hypoglycemia, side effects, and whether glucose issues are fasting or postprandial.

• Blood Pressure Targets ([05:18])

  • New systolic/diastolic target is less than 140/90 mmHg (previously 140/80).
  • Tighter control (<130/80) may be considered when attainable without undue burden.

• Statin Use Guidelines ([05:50])

  • Statin initiation now based on risk, not LDL alone; mirrors ACC/AHA guidance.
  • All adults 40+ with diabetes should be on a statin.
  • <40-year-olds with CVD: high-intensity statin; without CVD, rarely indicated.

• Foot Care Recommendations ([07:02])

  • At each visit: Examine feet of any patient with insensate foot, foot deformities, or history of ulcer — not just annually.
  • “If you have somebody high risk or had problems, ... you really want to check them every time.”

• Targets for Children and Adolescents

  • Uniform A1C target of <7.5% for all children/adolescents (previously age-stratified).
  • “Especially for our family practitioners and pediatricians... less than seven and a half is our target for all.” — Dr. Reinhart [08:22]

Memorable Quotes

• “I think it’s really important to look at those things as we add those second agents.” — Dr. Reinhart [04:58]
• “Those are the big changes regarding adults, the only one regarding adolescents and children...” — Dr. Reinhart [07:56]

2. New Medications in Diabetes

Speaker: Dr. John Buse
Timestamps: [09:33]–[20:08]

SGLT2 Inhibitors: Mechanism, Benefits, and Risks

• Mechanism of Action ([09:53])

  • Inhibits kidney reabsorption of glucose, leading to excretion in urine.
  • Results in weight loss and modest BP lowering due to calorie and sodium loss.
  • “Most of us over the age of 50 spent the bulk of our career trying to keep glucose out of the urine. And so putting it there on purpose is ... a bit different than what we're used to doing.” — Dr. Buse [10:27]

• Clinical Efficacy

  • As effective as metformin, sulfonylureas, and DPP-4 inhibitors.
  • Additive effects when combined with other classes.

• Common Side Effects ([11:17])

  • Increased risk of genital mycotic infections: 10–20% of patients may have ≥1 episode; typically responds to OTC treatments.
  • "Probably somewhere on the order of 10 to 20% of patients having one or more episodes, probably near the lower end." — Dr. Buse [11:40]
  • Urinary tract infection risk is not clearly increased.
  • Some risk of dehydration; diuretics may be stopped when starting SGLT2i.

• Serious but Rare Side Effect: Euglycemic DKA ([12:37])

  • FDA warning: can occur without significant hyperglycemia.
  • Patients on SGLT2i who are unwell should have urine ketones checked.
  • “The absolutely critical thing to remember is ... particularly if they're on an SGLT2 inhibitor ... you should check urine ketone to make sure they don't have this euglycemic diabetic ketoacidosis.” — Dr. Buse [13:43]

• Use with Insulin ([15:33])

  • SGLT2 inhibitors can be used with insulin.
  • In insulin-requiring type 2 DM, addition of SGLT2i led to reductions in A1C, weight, and BP.

New Insulin Formulations

• Insulin Glargine U300 ([16:58])

  • More concentrated, allowing higher insulin doses per injection.
  • Longer duration of action, more stable profile, modest reduction in hypoglycemia.
  • Switches from U100 may require titration as U300 is a bit less potent.

• Biosimilar Insulin

  • First biosimilar glargine in the US; pending resolution of legal hurdles.

• Insulin Degludec

  • Structurally distinct, very long half-life, stable action, lower risk of hypoglycemia.
  • Several new options set to change insulin landscape in the next 6 months.

Memorable Quotes

• “It does make sense ... in at least one study of a rather dramatic effect of SGLT2 inhibitors. That is a great overview.” — Dr. Buse [15:53]
• “It is complicated these days to keep track of 13 different classes of diabetes drugs ... just an onslaught of information in the primary care community.” — Dr. Buse [20:08]

Timestamps & Segments

• [00:03–02:14] - Episode introduction & overview of all “Diabetes is Primary” segments
• [02:14–09:08] - Dr. Andrew Reinhart: ADA Standards of Care updates
• [09:33–20:08] - Dr. John Buse: New diabetes medications and insulins

Summary Takeaways for Clinical Practice

• Stay up-to-date on annual ADA Standards of Care—significant changes affect screening, glycemic and blood pressure targets, statin use, and foot care protocols.
• Screen Asian patients at lower BMIs (≥23).
• Emphasize frequent movement for patients to reduce sedentary time.
• SGLT2 inhibitors are now a standard second-line agent with benefits on weight and BP, but carry risks of mycotic infections and rare DKA.
• New insulins (U300, Degludec) and biosimilars will provide more treatment options—learn their unique dosing and safety profiles.
• Individualize treatment based on risk, comorbidities, and patient factors—especially when aiming for A1C and BP targets.

For more, including the full lectures:
Visit professional.diabetes.org/ce for webinars and additional resources.