Diabetes Core Update: Diabetes is Primary Special Edition 2

Podcast: Diabetes Core Update
Host: American Diabetes Association
Episode Date: September 5, 2013
Main Theme:
This special edition episode, recorded live at the ADA’s Diabetes Is Primary lecture series during the 2013 ADA Scientific Sessions, explores two critical topics: (1) best practices and research gaps in diabetes management in older adults, presented by Dr. Hermes Flores, and (2) updates on new therapies and basal insulins in diabetes care, presented by Dr. Charles Schaefer. The discussions focus on practical guidance for clinicians and insights into evolving standards of care.

Key Discussion Points & Insights

1. Diabetes in Older Adults (Dr. Hermes Flores, 01:39–05:39)

Scope and Importance

• Diabetes prevalence in older adults is increasing, with 1 in 3 or 4 patients aged 65+ affected.
• The growing demographic of elderly diabetic patients presents escalating clinical and research challenges.

Consensus Statement and Recommendations

• Dr. Flores participated in a recent consensus panel on managing diabetes in older adults, which reviewed:
  • Epidemiology and pathogenesis of diabetes in the elderly.
  • Evidence on prevention, management, and applicability of various guidelines (ADA, VA/DoD, European, AGS).
• Emphasized individualized care based on patient functional status:
  • Functional, independent older adults: Can be managed similarly to younger patients, goals may remain aggressive.
  • Frail, cognitively impaired, or very elderly individuals: Adopt conservative, less aggressive management.

Need for Further Research

• Clinical trial data gaps for tailored therapies in frail, older populations.
• Unresolved questions include:
  • Best medication choices and intensity for different functional classes.
  • Links between diabetes, prediabetes, cognitive decline, physical function, fall risk, fractures, and hypoglycemia.

"We came with a proposal that needs to be validated in clinical trials of actually tailoring, individualizing the approach for glycemic management, blood pressure management, and lipid management based on the functional status of the patient."
— Dr. Hermes Flores [03:53]

"We have an all growing population with a lot of osteoporosis, bone disorders, higher risk of fractures, and that certainly can have a significant impact on the quality of life of these patients."
— Dr. Hermes Flores [04:54]

2. New Therapies & Basal Insulins (Dr. Charles Schaefer, 05:42–16:11)

Shift to Patient-Centered, Collaborative Care

• New ADA guidelines (April 2012) promote:
  • Shared decision-making—clinicians and patients as partners.
  • Recognition of patient values, fears, lifestyle, socioeconomic status, and support systems.

"Now, instead of the clinician dictating what the individual should do, we actually are sitting down with the individual, opening up a dialogue...It's a new day for diabetic management."
— Dr. Charles Schaefer [06:47]

Physician Skills and Patient Education

• Emphasizes educating both primary care providers (on new medications) and patients (on self-management).
• Motivational interviewing and communication are increasingly important.

"This whole area of motivational interviewing...is something that we need to be pulling out."
— Dr. Charles Schaefer [08:18]

Reviewing New Drugs and Developments

• Incretins (DPP4 inhibitors, GLP1 receptor agonists):

  • Growing appreciation and expanded armamentarium.
  • New agent: alogliptin (DPP4 inhibitor); new GLP1 agonists in the pipeline.
  • Emerging understanding: some incretins provide basal (all-day) control, others are prandial (post-meal).

• SGLT2 Inhibitors:

  • First new class in years; acts in kidneys to block glucose reabsorption.
  • Promotes glucose loss in urine, leading to lower blood glucose and modest weight reduction.
  • Notable for:
    • Insulin-independent action.
    • No hypoglycemia or weight gain risk.
    • Side effects include potential for urinary and genital infections.

"A class of drugs that inherently does not cause hypoglycemia, does not cause weight gain, and produces sort of that holy grail of diabetic therapy..."
— Dr. Charles Schaefer [13:18]

• Ultra-Long-Acting Insulins:
  • Degludec (approved in Europe): ultra-long-acting, low hypoglycemia risk, flexible dosing.
  • Pegylated lispro under investigation: hepatoselective, potentially more physiologic and with weight neutrality.

Future Directions and Considerations

• Once-weekly DPP4 inhibitors raise adherence questions ("diabetes is really a daily disease").
• Ongoing trials may shape standards further.
• Ultimate goal: synergize clinician expertise with patient preferences.

"The optimal diabetic therapy will evolve from the clinician's expertise and the patient's desires."
— Dr. Charles Schaefer [15:55]

Notable Quotes & Memorable Moments

• On Individualized Care:
  "So it will not be exactly the same, treating a patient that is functional, living independently, without any cognitive impairment, without depression...while on the other hand maybe an individual that is age let's say 85, 90, that is requiring assistance...maybe in that patient we need to be a little bit more conservative."
  — Dr. Hermes Flores [03:36]

• On New Model of Care:
  "Now, instead of the dictatorial finger wagging, we have the patient and the clinicians sitting side by side, much like a pilot and a co-pilot in an airplane."
  — Dr. Charles Schaefer [07:13]

• Highlighting Motivational Interviewing Skills:
  "...the clinician sits down and really has a dialogue with the patient, is something that we need to be pulling out."
  — Dr. Charles Schaefer [08:23]

• On New SGLT2 Inhibitors:
  "That has some really significant implications. One is it's an insulin independent way of reducing glucose...and produces a glucose rich urine...a class of drugs that inherently does not cause hypoglycemia, does not cause weight gain, and produces that holy grail of diabetic therapy..."
  — Dr. Charles Schaefer [12:27, 13:18]

Timestamps for Key Segments

• [01:39] Dr. Flores on the scope and research needs for diabetes in older adults.
• [03:36] Explanation of individualized management for older patients.
• [05:42] Dr. Schaefer discusses the shift to patient-clinician collaboration in new ADA guidelines.
• [08:18] Motivational interviewing and patient education skills.
• [10:27] Incretin-based therapies: differences and clinical relevance.
• [12:27] SGLT2 inhibitors: mechanism and benefits.
• [14:16] Future drugs: once-weekly DPP4 inhibitors, ultra-long-acting insulins.
• [15:55] Concluding summary on evolving optimal therapy.

Conclusion

This episode highlights the ongoing evolution in diabetes management: from highly individualized care for older adults, backed by emerging consensus, to the integration of new pharmacotherapies and a more patient-centered, partnership-based model for all adults with diabetes. Both presentations reinforce the critical need for research, adaptation of guidelines, skills in communication, and the thoughtful application of new treatment options tailored to the patient's unique context and goals.