Diabetes Core Update Special Edition – Diabetes is Primary 2015 Part 2

Podcast Date: July 10, 2015
Presented by: American Diabetes Association
Hosts: Dr. Neil Skolnik & Dr. John J. Russell
Featured Speakers: Dr. Charles Schaefer & Dr. Jim Chamberlain
Focus: Practical approaches after basal insulin is insufficient and the challenges of hypoglycemia management in diabetes care

Episode Overview

In this special edition, Dr. Neil Skolnik and Dr. John J. Russell interview leading diabetes specialists who presented at the Diabetes is Primary Conference, June 6, 2015. The episode centers on two crucial clinical topics:

• Strategies for managing type 2 diabetes when basal insulin alone is no longer effective (Dr. Charles Schaefer)
• The clinical significance and management of hypoglycemia (Dr. Jim Chamberlain)

Both discussions are highly relevant for practicing clinicians aiming to translate up-to-date evidence into primary care practice.

Segment 1: "When Basal Insulin Doesn't Work" with Dr. Charles Schaefer

Timestamps: 01:49–08:46

Key Discussion Points

• The Basal Insulin Plateau

  • Basal insulin is commonly added when oral agents fail, but it's effective in achieving target A1C in only about 42% of patients.

    "Only 42% of them ever get to a target A1C. So in fact, basal insulin doesn't work more than it does." — Dr. Schaefer [02:17]

• Traditional Next Steps: Mealtime Insulin

  • Historically, clinicians added mealtime (prandial) insulin, often escalating to multiple daily injections.
  • Newer evidence shows a “basal plus” approach (one mealtime insulin injection at the largest meal) can also achieve desired A1C reductions.

    "You don't have to go to the full monty... a single injection of basal insulin at the largest meal of the day may... get you that A1C reduction." — Dr. Schaefer [03:05]

• Trend Away from Insulin Escalation: Adding Oral/Incretin Agents

  • DPP-4 Inhibitors: When added to basal insulin, offer A1C reductions of 0.5% or more, without hypoglycemia or weight gain.
  • GLP-1 Agonists: Agents like exenatide and liraglutide provide A1C reductions of 0.7–0.8%, weight loss, reduced basal insulin doses, and no increase in hypoglycemia.

    "He actually showed weight loss... ability to reduce basal insulin... and also no introduction of increased hypoglycemia." — Dr. Schaefer [04:45]

  • SGLT2 Inhibitors: Also produce 0.7–0.8% A1C reduction, promote weight loss, lower blood pressure (useful due to common comorbidity of hypertension), but recent FDA warnings about rare diabetic ketoacidosis (DKA) require caution, even in type 2 patients using insulin.

    "On May 15, the FDA said... we're now seeing some random cases of diabetic ketoacidosis... a warning that these drugs should be used with that in the back of our mind." — Dr. Schaefer [05:46]

• Inhaled Insulin

  • Technosphere insulin (inhaled at meals) provides rapid onset, reduced hypoglycemia risk, and offers a needle-free alternative.

    "You puff this rather than injecting it... for patients who may be needle phobic, this is an exciting alternative." — Dr. Schaefer [06:29]

• Recognizing When Basal Insulin Alone is Inadequate

  • Clinicians often pursue fasting glucose targets zealously, but benefits plateau (typically at 0.4–0.5 U/kg basal insulin).

    "Once you reach a basal insulin use of about 4, 10 to 5, 10 of a unit per kilo, you're very unlikely in a population basis way to further reduce fasting insulin..." — Dr. Schaefer [07:42]

  • Calls for timely addition of alternative agents or mealtime strategies.

Memorable Quote

"The good news is: lots of stuff to do when basal insulin isn't enough." — Dr. Schaefer [07:00]

Segment 2: “The Importance and Management of Hypoglycemia” with Dr. Jim Chamberlain

Timestamps: 09:03–17:49

Key Discussion Points

• Prevalence and Risks of Hypoglycemia

  • Hypoglycemia is frequent, underrecognized, and clinically significant—occurring at similar rates in patients using sulfonylureas and insulin.

    "Sulfonylureas are not necessarily safer than insulin... severe hypoglycemia rate being very similar." — Dr. Chamberlain [09:46]

• Symptoms and Hypoglycemia Unawareness

  • Autonomic symptoms (palpitations, anxiety, sweating) serve as warnings; loss of warning signs (hypoglycemia unawareness) sharply increases risk.

    "Hypoglycemia unawareness... increases your risk for severe hypoglycemia about 6-fold." — Dr. Chamberlain [10:36]

  • Frequent episodes can blunt symptom recognition—“hypoglycemia begets hypoglycemia.”

• Clinical Consequences

  • Elevated risk for:
    • Mortality: 2–3x higher in patients with severe hypoglycemia, as shown in ACCORD, ADVANCE, and VA trials.
    • Cardiovascular Events: Substantially increased risk in patients experiencing severe episodes.

      "Arrhythmia deaths approaching 70 to 80% increase in those outcomes." — Dr. Chamberlain [12:27]

    • Cognitive Dysfunction/Dementia: Even 1–2 severe episodes can double dementia risk, especially in older adults.
    • Driving Mishaps: >50% of type 1 diabetics reported at least one event in a year; memory loss during episodes common.

      "A fair number of patients didn't remember driving home." — Dr. Chamberlain [14:36]

    • Patient Anxiety: Over half of people with diabetes worry about hypoglycemia most or all of the time.

• Practical Approaches for Clinicians

  • Screening: Download and analyze glucometer/CGM data; ask routinely about episodes (currently done in only ~30% of primary care visits).

    "You have to be asking, we have to be trying to get data from glucometers." — Dr. Chamberlain [15:44]

  • Root Cause Analysis: Every hypoglycemic event has an explanation—examine timing, recent meals, medication dosing, and activity.
  • Event Identification:
    • Basal/sulfonylurea-related lows: occur during fasting (night, early AM, missed meals).
    • Rapid-acting insulin: post-meal episodes.
  • Treatment Protocol: The 15/15 Rule
    • Treat with 15g carbohydrate, wait 15 minutes, recheck, repeat as needed—prevents overcorrection and rapid swings.

Notable Quote

"Every hypoglycemic event happens for a reason... you have to ask patients, what were you doing? When did you last take your medication?" — Dr. Chamberlain [16:12]

Episode Takeaways & Clinical Implications

• Expanding Options After Basal Insulin:
  Modern management goes well beyond simply adding more insulin—GLP-1 agonists, DPP-4 and SGLT2 inhibitors, and inhaled insulins present choices tailored to individual needs (weight, hypoglycemia risk, tolerance, comorbidities).
• Hypoglycemia Demands More Vigilance:
  It is frequent, dangerous, and should be proactively addressed—by asking, downloading data, educating, and individualizing therapy.
• Shifting Quality Measures:
  Quality frameworks are evolving to include hypoglycemia detection and prevention, not just A1C lowering.

Memorable Moments & Quotes

• On Basal Insulin Failure:
  "Basal insulin doesn't work more than it does... What do you do next?" – Dr. Schaefer [02:17]

• On “One Size Fits All” Approaches:
  "Now there's lots of choices as you went over." – Dr. John Russell [08:42]

• On Hypoglycemia Risk:
  "It's a pretty good recipe for killing people... in particular ischemic and fatal ventricular arrhythmias." – Dr. Chamberlain [13:15]

• On Patient Safety:
  "We have to be asking, we have to be trying to get data from glucometers." – Dr. Chamberlain [15:44]

Important Timestamps

• [01:49] — Dr. Schaefer introduces basal insulin management failures.
• [03:05] — Explains “basal plus” approach.
• [04:45] — GLP-1 and DPP-4 therapeutic additions.
• [05:46] — Caution with SGLT2 inhibitors due to DKA risk.
• [06:29] — Inhaled insulin as an option.
• [07:42] — Identifying when to transition from basal insulin.
• [09:46] — Dr. Chamberlain on sulfonylurea vs. insulin risk.
• [10:36] — Hypoglycemia unawareness and its dangers.
• [12:27] — Major mortality/cardiovascular trials overview.
• [13:15] — Mechanisms behind hypoglycemic mortality.
• [14:36] — Real-world driving mishaps & patient memory lapses.
• [15:44] — Clinical advice on screening and management.
• [16:12] — Individualizing hypoglycemia evaluation.

Summary

This episode delivers an evidence-based, pragmatic discussion for primary care providers managing type 2 diabetes after basal insulin failure and highlights the paramount importance of hypoglycemia detection and management. The landscape is rapidly evolving—requiring knowledge, vigilance, and individualized care strategies to keep people with diabetes safe and well-controlled.