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Diabetes Core Update
Diabetes is Primary Special Edition Part 3
00:12:30
This special edition of Diabetes Core Update was recorded live at the Diabetes is Primary Conference, a part of the American Diabetes Association Scientific Sessions 2013. This is Part I of a three part special series. Todays podcast will...
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- [00:02]
A
Hello, I'm Dr. Neal Skolnick and this special edition of Diabetes Core Update is being recorded live at the 2013American Diabetes Association Scientific Sessions meeting during the Diabetes is primary portion of the meeting, which was a day long conference devoted to the educational needs of primary care physicians. What we've done today is ask each of the lecturers from this conference to talk for a short period of time about what they feel are some of the most important learning points to take from their talks. For further and detailed information about their talks, please just go to www.professional.diabetes.org primary and you can download and watch full webcasts of the meeting. Today we are going to hear from Dr. George Bakris discussing diabetes and kidney disease. Dr. Jay Shubrick discussing atypical diabetes type 1, type 2 or type 1 and a half and Dr. James Chamberl discussing blood glucose pattern management. We'd like to welcome Dr. George Bakris, who is a professor of medicine and director of the ASHE Comprehensive Hypertension center at the University of Chicago, who just gave a wonderful talk on diabetes and kidney disease. Welcome, Dr. Bakris.
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B
How are you?
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A
Good. If you can go over some of the high points of your talk for our listeners.
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B
Sure. So the main high points of the talk are, number one, when you're treating blood pressure and especially if you're using angiotensin receptor blockers or ACE inhibitors and you see that the blood pressure is now nicely controlled, but the creatinine has gone up 20, 30%. There's no problem with potassium, there's no problem with anything else. It's simply the creatinine's gone up. Do not reduce the dose of the ACE inhibitor or the arbitrary. Continue therapy and recheck it in two to three weeks if it's stable even though it's elevated. If it's stable and the blood pressure is controlled, you continue that therapy. Because there are now four papers in the literature that suggest that that actually turns out to be a good thing for kidney function in the long run and you will further slow progression of kidney disease. So that's number one. Number two, the new guidelines for blood pressure goals in people with diabetes. The ADA says less than 140 over 80. The international kidney guidelines say less than 140, 90. Basically it's not less than 130 over 80. So the suggestion is that for people with kidney disease and diabetes, you definitely get the blood pressure below 140, 90, but you do not need to get it below 130 over 80. There's no additional benefit and there may be more side effects. And then the third and final point is that all drugs are not created equal. The preferred diuretics to be used based on guidelines and evidence for outcomes are the thiazide, like diuretics, specifically chlorthalidone and indapamide, not hydrochlorothiazide. And I think that's very important in your selection of diuretics for medications because those medicines will actually give you better blood pressure control because of their longer half life. And those are really the three main issues.
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A
That's great. Thanks so much and appreciate your joining us.
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B
Thank you.
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A
Our next speaker is Jay Shubrook, who is director of the Clinical division of the Diabetes Institute at Ohio University in Athens, Ohio. And Dr. Shubrook just gave us a wonderful lecture on atem diabetes. Is it type one or type two or type one and a half? Jay, welcome.
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C
Thank you very much. Thanks for welcoming me.
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A
I'm going to ask you to go over some of the important learning points and the high points of your lecture for our listeners.
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C
Sure. So, you know, we all are very familiar with type 1 and type 2 diabetes, but there's actually many types of diabetes. And unfortunately or fortunately, 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. So we really want to start finding those people with atypical forms of diabetes to improve their health.
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A
That sounds good. And now can you go over how we will distinguish between the different types?
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C
Sure. So one thing that we want to kind of do is take how people vary from the norm. So 10% of people with type 2 diabetes who at least have been diagnosed with type 2 actually have a form of slowly progressive type 1 latent autoimmune diabetes. The adult. And one of my colleagues very simply said, be wary of the skinny type one, skinny type two. Excuse me. And you know, someone who doesn't phenotypically look like they have type 2, who doesn't have a family history of type 2, but might have a family history of autoimmune disease, might indeed have a different form of diabetes, even though they don't need insulin right at diagnosis. So that would be an example and.
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A
That would be important to diagnose early because it would give you direction on treatment.
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C
Absolutely. If someone has LADA and is not properly diagnosed, they eventually will go on to complete insulin deficiency and may even have diabetic ketoacidosis. So an earlier diagnosis helps them now and it may actually improve the stability of their disease over the long haul.
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A
That's important. And what is type 1 1.5 diabetes that you talked about?
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C
Yeah, so diabetes 1.5 has actually become a misnomer because we would use 1.5 for LADA. But we also see people use type 1.5 for double diabetes, those that have the background risk of type 2, but then have autoimmunity and actually become insulin deficient. And some people have even used Lata. Excuse me, excuse me. Type 1 and a half for those with ketosis prone type 2.
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A
So.
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C
So those that are obese have type 2, but they are more likely to go into DKA. So type 1.5, that's a term really we should move away from because they really represent multiple different diseases that are not similar.
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A
That's a great point. So tell me more about double diabetes.
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C
So double diabetes is a condition, as a nation and as a world, we've become more obese and more and more of us are suffering from the effects of insulin resistance. So if you have the background of insulin resistance metabolically and then you have superimposed on that the immunologic hit where you develop insulin deficiency. Now you have the need for insulin for life, but also insulin deficiency, which means you're going to need a lot more insulin than someone typically with type 1, and hence you have double diabetes. We see this frequently in our children and adolescents, and this is a real problem because we already know from the TODAY study that many of our kids don't get the same durable benefit from treatments. And if they have need for insulin and greater insulin resistance during the adolescent years, they're going to be in a lot of trouble.
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A
Okay, and then my last question is, can someone with type 2 diabetes get DKA?
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C
Absolutely. So, you know, we know already that anyone who fits in the type 2 category, if they get sick enough, they can go on to have diabetic ketoacidosis. So an example might be if they have pancreatitis, if they have hypertriglyceridemia, that stuns the beta cells. But there's also a group of people who have type 2 diabetes who are ketosis prone. This tends to be more common in people with ethnic minority backgrounds, particularly African American descent, and more common than men than women. But this is something, again, that's important because that doesn't mean they have type one. You just have to be very careful that when they go into dka, you treat them with insulin and then appropriately stage back to their normal treatment.
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A
That's great. That's very helpful. Thanks again for going over all of this for our listeners.
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C
Thank you. Have a great day.
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A
The next lecturer we're going to talk to is Jim Chamberlain, who is the medical director of Diabetes services at the St. Mark's Hospital and St. Mark's Diabetes Center, Salt Lake City, Utah. And Dr. Chamberlain just gave a superb talk on blood glucose pattern management, a case based approach. Welcome, Dr. Chamberlain.
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D
Thank you.
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A
I wonder if you could go over some of the high points of your talk for our listeners.
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D
Yeah, you know, I thought it was really a fun talk to put together to try to take real world cases from my clinic over the last decade using glucometer downloads and continuous glucose monitor downloads. And I really encouraged the audience before we started to do this. I think any primary care diabetes clinic, especially primary care docs or NPs and PAs, seeing any significant number of diabetics. And by that I mean if you're seeing more than three or four diabetic patients a day on average, I think you need to be downloading glucometers. So we talked about the ease of that and the importance of it. I showed some cases where it really depends on what drugs you're taking. I think these days with respect to how low A1C should be pushed. I know that's a big topic that was covered in other talks today as well. But it really, I think is the hottest topic in diabetes right now is how do you, how do we get a 1C down? How do we control people without causing harm? And so we talked about hypoglycemia quite a bit. I showed some glucometer downloads of patients who had really good A1Cs in the low 6s but were suffering hypoglycemia almost daily. And again, I think if you're not downloading glucometers and seeing that or at least asking patients about hypoglycemia, you're going to miss it. And I think that's important. We spent quite a bit of time talking about basal insulin and the up titration of basal insulin in patients with type 2 diabetes when we're adding that to oral drugs. And it was really interesting. I was able to show some cases and some data from randomized controlled trials showing that patients blood sugars really drop through the night with type 2 diabetes on basal insulin. And I think it's not really well understood by a lot of providers. And so to show that and really to let these folks visualize that was important because we don't have time to talk about basal bolus insulin and the nuts and bolts, although it'll be in the webcast of my talk. But there's a lot of misunderstanding, I think, on how the adjustments you need to make to basal insulin. We talked about cutting back on long acting insulin when you transition from basal to basal bolus insulin. And I think that's really missed, not only by a lot of primary care providers, but even a lot of endocrinologists and diabetologists.
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A
Thanks, Dr. Chamberlain, for sharing that information with us. That concludes part three of our three part series of highlights, recorded live at the Diabetes Primary portion of the American Diabetes Association Scientific Sessions in Chicago in June 2013. If you would like to listen to and watch these lectures in full, just go see the webinar at www.professional.diabetes.org primary. Again, that's www. Professional.diabetes.org primary. For the American Diabetes Association, I'm Dr. Neal Skolnicker. Thank you for listening.
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C
Sam.