Diabetes Core Update – Special Edition: New Therapies (June 25, 2014)

Overview

This special episode of Diabetes Core Update is focused on "New Therapies" for type 2 diabetes, highlighting recent advancements and challenges in diabetes pharmacotherapy. Dr. Neil Skolnik and Dr. John Russell host Dr. Carol Wisham, Clinical Associate Professor of Medicine at the University of Washington, who shares insights from her presentation at the ADA’s “Diabetes is Primary” conference (June 2014 Scientific Sessions). The discussion covers new medications introduced in the previous year, including a once-weekly GLP-1 receptor agonist, SGLT2 inhibitors, and a new inhaled insulin formulation. Emphasis is placed on clinical characteristics, safety, patient communication, and the evolving landscape of individualized therapy.

Key Discussion Points & Insights

1. The Need for New Therapies in Type 2 Diabetes

• Traditional therapies have limitations: increased risk of hypoglycemia, weight gain, and limited long-term control ([01:00]).
• Clinical trials highlight these shortcomings, driving innovations toward safer, more sustainable options that avoid hypoglycemia and weight gain.

"There has been a drive to try to develop medications that can help effectively lower glucose, avoid weight gain and hypoglycemia."
—Dr. Carol Wisham, [01:41]

2. The Once-Weekly GLP-1 Receptor Agonist: Albiglutide

• Albiglutide is a new, once-weekly GLP-1 receptor agonist offering enhanced convenience and tolerability ([03:29]).
• Mechanism: Boosts insulin secretion, suppresses glucagon, decreases appetite—thus typically weight-neutral or even inducing mild weight loss.
• Comparative effectiveness: Equivalent to exenatide twice daily for A1C lowering; possibly less effective than liraglutide; better GI tolerability but may confer less weight loss.
• Clinical benefits include improved adherence potential and fewer GI side effects due to the slow rise to steady state levels ([04:15]).

"The advantage of giving a medication once weekly is obvious... better GI tolerability than either of the medications and perhaps isn't associated with quite as much weight loss."
—Dr. Carol Wisham, [04:12]

3. SGLT2 Inhibitors: A New Class

• Function: Blocks renal glucose reabsorption, leading to glycosuria and reduced blood glucose ([05:35]).
• Benefits: Effective at many stages of disease (independent of insulin), oral administration, low risk of hypoglycemia, modest weight loss, and preferable for patients wanting to avoid injections.
• Side effects: ~10% vaginal yeast infection rate in women; slight increase in urination and possible mild volume depletion (especially on starting therapy); modest bump in LDL cholesterol as a class effect ([06:45], [08:09]).
• Drugs in this class include dapagliflozin and canagliflozin; not studied directly head-to-head, but similar side effect profiles.

"Patients will opt for the meds that don't cause weight gain and don't cause hypoglycemia… they tend to gravitate towards the SGLT2 inhibitors."
—Dr. Carol Wisham, [09:50]

• Patient-centered approach: Dr. Wisham stresses collaborative decision-making, providing "bullet points" on pros and cons—including cost—to support patient choice ([08:55]).

4. Inhaled Insulin: Technosphere Insulin

• An FDA advisory panel has recently approved a new inhaled insulin formulation—technosphere insulin ([10:31]).
• Advantages over previous inhaled insulins:
  • Exists as insulin monomers (not hexamers), yielding quicker absorption and faster action
  • Smaller inhaled particles for more efficient systemic uptake
  • Can replace rapid-acting, prandial insulin requirements for both type 1 and type 2 diabetics—though not a substitute for basal insulin ([10:45]).
  • Improved convenience (especially outside the home) and social acceptability relative to injections.

"They would just take an inhalation of insulin before they sit down to have their meal."
—Dr. Carol Wisham, [11:22]

• Fewer concerns about pulmonary toxicity compared to earlier inhaled insulins; though a mild cough in some patients is possible ([12:19]). Safety profile is reported as reassuring.

5. Communicating Medication Risks with Patients

A. Incretin Therapy & Pancreatic Risks ([12:53])

• Patients often worry about pancreas safety with incretin-based therapies (GLP-1 agonists, DPP-4 inhibitors).
• Dr. Wisham’s approach:
  • Explains FAERS database limitations and reporting biases
  • References large studies that have not found excess risk with incretin therapies
  • Informs of pancreatitis symptoms, urges vigilance, and offers reassurance drawn from clinical trial and real-world experience

"I just reassure them using these medications for now, over 12 years... I’ve not seen any cases of pancreatitis happen related to the medication."
—Dr. Carol Wisham, [14:10]

B. SGLT2 Inhibitors: Risks & Patient Management ([16:41])

• Candid, practical advice on managing SGLT2-associated risks:
  • Educates about possible vaginal yeast infections, usually single episodes; hygiene tips provided
  • Reviews blood pressure and adjusts antihypertensive or diuretic therapy accordingly
  • Stresses hydration, especially at therapy initiation
  • For patients on insulin or sulfonylureas: considers dose reduction to avoid hypoglycemia due to rapid action

"This medication works the day they take it… they can tell that they're lowered immediately. It works that fast."
—Dr. Carol Wisham, [18:17]

6. The Value of Individualized, Patient-Driven Therapy ([15:24])

• Emerging data shows improved adherence and satisfaction when patients are actively involved in selecting their regimen.
• Dr. Wisham recommends ongoing communication: patients are encouraged to report issues early so therapy can be adjusted promptly.
• Flexibility and choice enhance comfort, ownership, and outcomes.

"Having patients choose the medications they're interested in when I give them the option kind of takes some of that concern away."
—Dr. Carol Wisham, [14:51]

Notable Quotes & Memorable Moments

• On the personalized approach:

  "You have to move on and then say, okay, here's some other options for you... having patients choose the medications they're interested in... they're generally very comfortable with it when they leave the office."
  —Dr. Carol Wisham, [14:51]

• On adherence and patient comfort:

  "Telling patients what to expect, telling them to drink plenty of fluid as you get started ... has resulted in... a very significant proportion of patients. Patients have been very successful at improving their glucose control."
  —Dr. Carol Wisham, [07:01]

• On new medicines’ impact for primary care:

  "It's probably one of the areas of medicine that has the largest amount of research making it really very exciting for primary care physicians since it's a common thing that we take care of, but also very challenging to keep up with all the new medicines."
  —Dr. John Russell, [03:05]

Timestamps for Important Segments

• [01:00] – Rationale for driving new medication development in diabetes
• [03:29] – Introduction and characteristics of once-weekly GLP1 agonist (albiglutide)
• [05:39] – Mechanism and clinical use of SGLT2 inhibitors
• [07:49] – Safety, class comparison, and patient preferences in SGLT2 selection
• [10:31] – Introduction and clinical implications of technosphere inhaled insulin
• [12:53] – Communicating risk of pancreatitis with incretin agents
• [16:41] – SGLT2 inhibitor side effects and practical counseling pearls
• [15:24] – The role of patient choice in therapy adherence and satisfaction

Conclusion

This episode provides a concise and authoritative review of groundbreaking advances in diabetes therapy, emphasizing practical considerations, risk counseling, and, above all, individualized patient care. Dr. Wisham’s insight underscores the importance of patient engagement and the rapidly evolving options available to primary care clinicians managing type 2 diabetes.

For more information and further reading, visit: www.diabetesjournals.org