Diabetes Core Update: Diabetes is Primary Special Edition Part 3

Date: October 2, 2013
Host: American Diabetes Association
Featured Speakers:

• Dr. George Bakris (University of Chicago, Hypertension/Nephrology Specialist)
• Dr. Jay Shubrook (Ohio University, Diabetes Institute)
• Dr. Jim Chamberlain (St. Mark’s Hospital Diabetes Center)
• Hosted by Dr. Neil Skolnik

Episode Overview

This special edition was recorded live at the American Diabetes Association 2013 Scientific Sessions during the "Diabetes is Primary" conference, focused on the educational needs of primary care physicians. The episode features highlights from three expert-led lectures on diabetes and kidney disease, atypical diabetes presentations, and blood glucose pattern management. Each expert summarizes the most crucial learning points from their respective talks, with a strong clinical emphasis on direct application in family practice.

Key Discussion Points and Insights

1. Diabetes and Kidney Disease

Speaker: Dr. George Bakris
Timestamp: [01:52 – 03:49]

Main Points:

• Creatinine Rise with ACE Inhibitors/ARBs:

  • A rise in creatinine of 20-30% after starting or increasing ACE inhibitors or ARBs, with stable potassium and no other issues, is not a cause for concern.
  • “Do not reduce the dose... There are now four papers in the literature that suggest that actually turns out to be a good thing for kidney function in the long run.” – Dr. Bakris [02:24]
  • Action: Continue therapy, recheck in 2–3 weeks; if the increase is stable and blood pressure is controlled, maintain current treatment.

• Blood Pressure Targets in Diabetic Kidney Disease:

  • New guidelines recommend less strict targets.
  • ADA: <140/80 mmHg; International Kidney Guidelines: <140/90 mmHg.
  • Lower targets (<130/80) are not beneficial and may increase side effects.
  • “You definitely get the blood pressure below 140, 90, but you do not need to get it below 130 over 80... may be more side effects.” – Dr. Bakris [03:12]

• Thiazide-like Diuretics Preferred:

  • Chlorthalidone and indapamide preferred over hydrochlorothiazide due to longer half-life and better outcomes.
  • “All drugs are not created equal... chlorthalidone and indapamide, not hydrochlorothiazide.” – Dr. Bakris [03:30]

2. Atypical Diabetes: Type 1, Type 2, or Type 1.5?

Speaker: Dr. Jay Shubrook
Timestamp: [04:15 – 08:18]

Main Points:

• Spectrum of Diabetes Types:

  • Not just type 1 or type 2—there are multiple forms with implications for management and prognosis.
  • “The identification of some of these less common forms of diabetes can, can have a big impact, not only the way you treat them, but also the quality of life of the person.” – Dr. Shubrook [04:27]

• Latent Autoimmune Diabetes in Adults (LADA):

  • 10% of "type 2" patients may actually have LADA—often thin, no family history of type 2, possible autoimmune background.
  • Early diagnosis critical to anticipate insulin dependence and prevent DKA.
  • “Be wary of the skinny type two... might have a family history of autoimmune disease, might indeed have a different form of diabetes.” – Dr. Shubrook [05:07]
  • “Earlier diagnosis helps them now and... may actually improve the stability of their disease over the long haul.” – Dr. Shubrook [05:41]

• Clarifying 'Type 1.5' Diabetes:

  • Term is ambiguous—sometimes means LADA, double diabetes (type 2 with autoimmunity), or ketosis-prone type 2.
  • “Type 1.5, that's a term really we should move away from because they really represent multiple different diseases that are not similar.” – Dr. Shubrook [06:31]

• Double Diabetes:

  • Occurs when insulin resistance overlaps with autoimmunity-driven insulin deficiency—a growing issue among youth due to obesity.
  • “If you have the background of insulin resistance... and then you have superimposed on that... insulin deficiency, now you have the need for insulin for life.” – Dr. Shubrook [06:50]

• DKA in Type 2 Diabetes:

  • Some type 2s, especially those of ethnic minority backgrounds, can develop DKA (“ketosis-prone type 2”).
  • “Anyone who fits in the type 2 category, if they get sick enough, they can go on to have diabetic ketoacidosis.” – Dr. Shubrook [07:32]

3. Blood Glucose Pattern Management

Speaker: Dr. Jim Chamberlain
Timestamp: [08:45 – 11:08]

Main Points:

• Routine Glucometer Data Download Encouraged:

  • Downloading data is essential for primary care clinics seeing several diabetic patients daily.
  • “If you’re seeing more than three or four diabetic patients a day on average, I think you need to be downloading glucometers.” – Dr. Chamberlain [09:02]

• Addressing Hypoglycemia:

  • Focus shouldn't only be on lowering A1C; must also recognize hypoglycemia, often seen in patients with "ideal" A1Cs.
  • “I showed some glucometer downloads of patients who had really good A1Cs... but were suffering hypoglycemia almost daily.” – Dr. Chamberlain [10:05]
  • Actively ask patients about hypoglycemia to avoid missing this risk.

• Basal Insulin Management in Type 2:

  • Emphasizes careful titration; blood sugars drop significantly overnight and require adjustments.
  • Many medications/transitions (from basal to basal-bolus) are often misunderstood and mishandled, even by specialists.
  • “There’s a lot of misunderstanding, I think, on how the adjustments you need to make to basal insulin.” – Dr. Chamberlain [10:53]

Notable Quotes & Memorable Moments

• Dr. Bakris [02:24]:
  “Do not reduce the dose of the ACE inhibitor or the arbitrary. Continue therapy and recheck it in two to three weeks... that actually turns out to be a good thing for kidney function in the long run.”

• Dr. Shubrook [05:07]:
  “Be wary of the skinny type two... might have a family history of autoimmune disease, might indeed have a different form of diabetes.”

• Dr. Chamberlain [09:02]:
  “If you’re seeing more than three or four diabetic patients a day, you need to be downloading glucometers.”

• Dr. Chamberlain [10:05]:
  “Good A1Cs in the low 6s but were suffering hypoglycemia almost daily. And again, I think if you’re not downloading glucometers... you’re going to miss it.”

Timestamps for Key Segments

• [01:52] Diabetes & Kidney Disease – Dr. Bakris begins summary
• [03:49] Dr. Bakris concludes; Dr. Shubrook introduced
• [04:22] Atypical Diabetes Types – Dr. Shubrook overview
• [05:57] LADA and “Type 1.5” discussion
• [06:39] Double Diabetes described
• [07:31] DKA in Type 2 diabetes explained
• [08:45] Blood Glucose Pattern Management – Dr. Chamberlain overview
• [09:02] Value of downloading glucometer data
• [10:05] The risk of hypoglycemia with low A1C
• [10:53] Basal insulin titration and common misunderstandings

Summary Takeaways

This episode delivers high-level, clinically relevant updates for primary care providers:

• Rising creatinine with ACE/ARB therapy (absent other issues) often signals renal benefit—don’t reflexively lower the dose.
• Target BP is now <140/90 for diabetic kidney disease—lower numbers do not confer extra benefit and may do harm.
• Differentiating unusual diabetes types (e.g., LADA, double diabetes, ketosis-prone type 2) can profoundly alter management.
• Routine use of glucometer downloads helps find hidden, dangerous hypoglycemia and improves outcomes.
• Insulin management in type 2: Titrate basal insulin carefully and understand necessary adjustments during transitions.

This episode empowers clinicians to individualize care, avoid pitfalls, and recognize the spectrum of diabetes presentations in practice.