Putting the Patient First: Top Insights From ADA 2022

Akshay B. Jain, MD


July 26, 2022

This transcript has been edited for clarity.

Welcome. My name is Dr Akshay Jain. I am an endocrinologist based in Vancouver, Canada, and I am one of the columnists for The Sugar Beat column at Medscape.

I'm super-excited to share with you my top learnings from the American Diabetes Association (ADA) 2022 conference. Just like every year, this year the ADA conference had a lot of feature-packed information, and I wanted to discuss what I feel are the most clinically relevant or clinically impactful aspects that we need to know, both right now and a little into the future. Without further ado, let's get right into this.

The most important, game-changing information that came out recently was the draft ADA/European Association for the Study of Diabetes (EASD) joint statement on the management of hyperglycemia in type 2 diabetes as reported on Medscape. The final version will be released at the EASD meeting in Stockholm in September. Personally, I feel that this completely changes the way we have been looking at diabetes. We are no longer glucose centric; in fact, we have a more holistic and patient-centric way of approaching type 2 diabetes management.

What the current consensus guideline recommends is, among other things, that language matters significantly. It's very important that we move away from negative connotations and that we stop using derogatory terms like "diabetics" or "an obese individual." In fact, we should be using terms like "person with diabetes."

Also, something very refreshing was the focus on social determinants of health. The consensus guideline statement suggests that it's important, while managing diabetes, to address social determinants of health. This is really important for the holistic management of type 2 diabetes.

The very important aspect about this guideline statement is that they have a very patient-centric focus here, and among other things, they suggest that we should look at the personal aspects of the patient, including, but not limited to, weight, A1c, age, frailty, and access to care.

Also, it's important that we individualize care and use individualized targets. It is also crucial that we utilize shared decision-making, including the patient and his or her family members. At the same time, it's important that we utilize smart goals — goals that are specific, measurable, achievable, realistic, and time sensitive. This becomes really important when we are managing diabetes. Then we move forward to implementation of these goals, constantly reviewing and reassessing, and giving the patient support whenever needed.

A very interesting part of this guideline statement is that we have moved away from being glucose centric. The guideline statement now suggests that we give equal importance to glycemic control as well as weight management, reduction of cardiovascular risk factors, and improvement of cardiovascular/renal outcomes. In a sense, for glycemic management, we want to use medications that have the most efficacy without the risk for hypoglycemia.

Weight management has come into the forefront with these consensus guideline statements, and it is suggested that we should be trying to help patients with obesity and diabetes to reduce their weight, going to the root part of diabetes. Also, we want to reduce cardiovascular risk, so blood pressure control and cholesterol control become really important, and finally, of course, cardiovascular and renal reduction of events.

This was the ADA/EASD consensus guideline statement. I feel that this is really changing the outlook of management of diabetes. This is something that we need to start incorporating in our clinics right away and we will have possibly the best outcomes that we can achieve.

This second very interesting session that I attended talked about the RECOLAR study. This four-arm crossover study by Dr van Raalte and his group looked at 24 patients. We know that ACE inhibitors, ARBs, and SGLT2 inhibitors help individually with kidney protection in those with diabetes, but this study was designed to investigate what happens when we use the two together.

Essentially, they looked at patients who were in a four-group crossover study. The first group was empagliflozin only, the second group was losartan only, the third group empagliflozin plus losartan, and then the fourth group was placebo. They saw that empagliflozin only helped with blood pressure reduction of about 8.5 mm Hg systolic. Losartan only had a blood pressure reduction of about 12 mm Hg systolic. Combining the two, the blood pressure reduction was about 15 mm Hg.

More importantly, this study demonstrated that in individuals in whom we are worried about glomerular hyperfiltration, the combination of these two medications helps with efferent vasodilatation, so essentially it reduces renovascular resistance. Because of this, we can potentially have even better long-term kidney protection outcomes.

In this study, it was seen that the glomerular filtration rate (GFR) drop with the empagliflozin group was about 7 points, that with losartan it was also 7, and then combining the two had a GFR reduction of about 10.5, which essentially shows that we are reducing that increased pressure at the level of the glomerulus, thereby leading to better kidney outcomes.

A third study that I wanted to talk to you about that could possibly change the way much of the management is being done in the inpatient setting will be the use of continuous glucose monitoring (CGM). This was a study by Dr Ilias Spanakis and his group out of the University of Maryland. They took about 180 patients and divided them into two groups. Group number one received point-of-care capillary blood glucose testing, the same that's being done usually as standard of care across the world. The second group received Dexcom G6 CGM. These are noncritically ill patients who are admitted to the hospital and are on insulin for management of their type 2 diabetes.

In the Dexcom G6 CGM group, they saw similar mean daily glucose levels, total insulin being required, time in range, and time below range. It is very interesting to note that in those individuals who have at least one episode of hypoglycemia while they're in the hospital, in the Dexcom CGM group, reduction of recurrence of hypoglycemia — blood sugar less than 70 mg/dL — was reduced by 47% relative risk reduction. If you look at a threshold of 54 mg/dL, recurrence of future episodes of hypoglycemia had a relative risk reduction of 63%.

Personally, I find that very impactful. Perhaps not everyone may need a CGM right away when they go to the hospital and are admitted while on insulin, but those individuals who have had at least one episode of hypoglycemia in their inpatient stay would benefit significantly from going on a Dexcom G6 or other CGM while they are in the hospital, based on this study.

Finally, fourth but not least, I wanted to talk about the very interesting ReTUNE study presented by Dr Roy Taylor and his group. We all know that the results from studies like the DiRECT trial showed that among individuals with obesity or overweight and type 2 diabetes, if they lose a certain amount of weight, then their chances of achieving remission of type 2 diabetes go up significantly.

In the ReTUNE study, they looked at those individuals with normal BMI — essentially those who did not have obesity or overweight — and they investigated the chances of achieving remission of type 2 diabetes with weight loss. They enrolled people who had up to three cycles of 5% weight loss or more. These individuals were given 2-week cycles of 800-calorie diets or a restrictive 800-calorie diet by meal replacement plus vegetables that are nonstarchy.

In those individuals, especially those who had about a 10% weight loss, the chances of achieving remission, which is an A1c less than 6.5% without any diabetes medications on board, were about 70%, which is very impactful. These are individuals with a mean BMI of 24.8.

Also interesting was that there was a significant reduction in the level of pancreatic fat, hepatic fat, triglyceride levels, and fasting insulin levels. I feel that this study further augments the reason why we want to make sure that individuals with type 2 diabetes, where we know that the diabetes essentially could be related to adiposopathy (increased ectopic fat), if they are able to lose weight, then we can help achieve the target of remission of type 2 diabetes.

These are only four of multiple studies that I found very impactful at ADA this year. As always, please do check in with The Sugar Beat column. We will continue to keep you updated on the latest and greatest from a clinically relevant point of view in the world of diabetes and obesity. Take care.

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