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CIDE Scholars
Visits
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Etzwiler
Scholars
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WHAT’S NEW IN DIABETES
June–July 2016
Select Scholars from
CIDE Program Visit IDC
and Mayo Clinic
International Diabetes Center (IDC) and
Mayo Clinic hosted two groups of China
Initiative for Diabetes Excellence (CIDE)
Scholars June 20–24 and June 27–July 1, 2016.
During their week at IDC, each group learned
about new diabetes medications, treatments,
and technologies. The Scholars also saw the
power of team management of diabetes by
observing IDC staff working with patients.
In addition, Scholars traveled to various
community sites to learn more about diabetes
management in action. Community activities
included traveling to HealthPartners to learn
about using electronic medical records for
clinical decision support, touring Methodist
Hospital and learning about hospital diabetes
management, touring the YMCA and learning
about the Y’s diabetes prevention program,
touring a supermarket and learning about
label reading and carbohydrate counting, and
touring Melrose Center and learning about
eating disorders and diabetes.
Scholars also had the opportunity wear a
continuous glucose monitor (CGM) for the
week. Those who participated watched their
glucose numbers change as they ate various
meals, exercised, and slept. At the end of the
week, Scholars received their own ambulatory
glucose profile (AGP) report to review
and understand. This activity helped the
Scholars empathize with their patients
who have diabetes.
continued on page 2
The Latest Research On …
The Positive Effects of SGLT2 Inhibitors and
GLP-1 Agonists on Cardiovascular Outcomes in
People with Type 2 Diabetes
The American Diabetes Association’s 76th Scientific Sessions was held from
June 10 to 14, 2016, in New Orleans, Louisiana. A main theme at this annual
conference was recent data from 2 studies1,2 that showed the positive effects
of SGLT2 inhibitors and GLP-1 agonists to improve cardiovascular (CV)
outcomes and lower CV risk in patients with type 2 diabetes who either had
established cardiovascular disease (CVD) or were considered at very high
risk for CVD.
The EMPA-REG Outcome study examined the effects of the SGLT2 inhibitor
empagliflozin, as compared with placebo, on CV morbidity and mortality in
people with type 2 diabetes at high risk for CV events. The results showed
a clinically significant reduction in myocardial infarction (MI), stroke, and CV
mortality: 14% reduction overall, 38% reduction on CV mortality, and 32%
reduction in all-cause mortality. The number needed to treat was 39 for 3
years to prevent one CV death. These benefits align with the benefits of
other established therapies in diabetes, including statins and ACE Inhibitors.
Most notable, protective effects were seen within the first 3 months of
taking empagliflozin and continued throughout the duration of the study.
How did empagliflozin reduce the risk of CV problems so quickly? Ele
Ferrannini, a professor of internal medicine at University of Pisa, Italy,
presented his hypothesis at the conference.3 Ferrannini hypothesized that in
the EMPA-REG Outcome study, participants who took the SGLT2 inhibitor
better avoided a CV event because their body tissues could better withstand
ischemia.
Why? A side effect of SGLT2 inhibitors is a slightly higher glucagon level,
leading to enhanced lipolysis and a rise in free fatty acids, which in turn lead
to low-level ketone production. For people with type 2 diabetes at risk for
CV disease, perhaps low-level ketone production is beneficial because these
ketones can get into many body tissues—including the heart—easily and
enter into the energy-producing Krebs cycle. In addition, the diuretic action
of SGLT2 inhibitors increases the hematocrit that enhances the potential for
oxygen delivery to the heart. The diuresis that accompanies SGLT2 inhibition
also results in a modest reduction in blood pressure, which has the potential
for cardioprotection.
Another major presentation at the conference described the results of
the Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular
Outcome Results (LEADER) trial, which analyzed the long-term effects
of the GLP-1 agonist liraglutide on CV outcomes and other clinically
important events.
continued on page 2
The Latest Research On … (continued from page 1)
Like the results of the EMPA-REG Outcome study, the results of
the LEADER trial showed a significant reduction in CV events:
13% reduction overall and 22% reduction in CV mortality.
The number needed to treat was 66 to prevent one CV event.
Protective effects were seen within 9 to 12 months of taking
liraglutide. Treatment with liraglutide did not increase the risk
of pancreatitis or C-cell tumors, conditions that have been
associated with liraglutide, as indicated on the package insert.
The exact mechanism of liraglutide that produces these
cardioprotective effects is currently unknown. The beneficial
effects of liraglutide (such as weight loss, lowered blood
pressure, improved lipid panel, lowered glucose level without
hypoglycemia, and reduced inflammation) may likely underlie the
cardioprotection that was demonstrated in the LEADER trial.
The diabetes community eagerly awaits the results of other trials
that focus on the safety of SGLT2 inhibitors and GLP-1 agonists
on CV outcomes. The results will help determine whether these
effects are due to the class of medication or whether something
inherent in the individual medication caused these effects.
The results will also help determine the placement of these
medications in glucose lowering algorithms.
References
1. B. Zinman, C. Wanner, J. M. Lachin et al. Empagliflozin, Cardiovascular
Outcomes, and Mortality in Type 2 Diabetes. NEJM 2015; 373:2117–28.
2. S. P. Marso, G. H. Daniels, K. Brown-Frandsen et al. Liraglutide and
Cardiovascular Outcomes in Type 2 Diabetes. NEJM 2016; published online 2016
June 13.
3. E. Ferrannini, M. Mark, E. Mayoux. CV Protection in the EMPA-REG
OUTCOME Trial: A “Thrifty Substrate” Hypothesis. Diabetes Care 2016 Jul;
39(7):1108–114.
CIDE Group 3 at IDC June 20–June 24, 2016 (with a
few IDC faculty and staff)
Select Scholars...continued from page 1
At Mayo Clinic, the Scholars toured research units,
laboratories, and other Mayo facilities. The groups also
observed diabetes patient visits with Mayo medical staff
and attended lectures on current diabetes-related topics
from Mayo Clinic faculty.
These visits culminate the 5-year CIDE program, which
involved training 500 endocrinologists in China. It has
been IDC’s pleasure to partner with Mayo Clinic faculty
to lead this comprehensive, cutting-edge program. We plan
to continue to work with these recently trained physicians
in China in a new capacity in the near future.
The CIDE program was made possible as the result of
generous financial support from Sanofi China through
an unrestricted educational grant. With Sanofi China’s
support and partnership, IDC has been able to further its
vision of providing advanced diabetes medical education
to improve the lives of people with diabetes throughout
the world.
See below for photos of the Scholars’ visits.
CIDE Group 4 at IDC June 27–July 1, 2016 (with a
few IDC faculty and staff)
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IDC hosts week-long
program for 2016
Etzwiler Scholars
From April 25 through April 29, 2016, IDC
hosted a stimulating and exciting program for
the Class of 2016 Etzwiler Scholars.
The program featured such diverse topics as an
update on new therapies, management of kidney
disease in diabetes, technology-based research,
nutrition around the world, contemporary
issues in diabetes management, and new diabetes
pumps and patches.
We enjoyed hosting the Etzwiler Scholars
Class of 2016 at IDC for this challenging and
inspiring program!
Class of 2016 Etzwiler Scholars at IDC April 25–29, 2016
Back row: Akshay Jain, MD–Canada; Mohammed Hassan Zeitoun, MD, PhD–
Egypt; Professor Richard Bergenstal–IDC; Gregg Simonson, PhD–IDC; Andrew
Lansdown, MD–United Kingdom; Krishnan Swaminathan, MD–India
Front row: Nevena Yankova Chakarova, MD, PhD–Bulgaria; Ines Khochtali, MD–
Tunisia; Dina Melnik–IDC; Jane Norstrom–IDC
Note: Class of 2016 Etzwiler Scholar Hemant Makan, MD–South Africa will attend
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Ideas for newsletter topics?
Contact Jane Norstrom or Gregg
Simonson
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Meet Two 2016 Etzwiler Scholars
Dr. Nevena Chakarova obtained her master’s degree in medicine from
Medical University of Sofia, Bulgaria. She started postgraduate studies at the
University Hospital of Endocrinology and Gerontology, Medical University
of Sofia. The title of her dissertation was “Cardiovascular risk in prediabetic
states—impaired fasting glucose and impaired glucose tolerance.” After
obtaining her PhD, she continued working as assistant professor and chief
assistant professor at Bulgaria’s only specialized department of diabetology
at University Hospital of Endocrinology and Gerontology. Since 2010, Dr.
Chakarova has specialized in endocrinology.
Nevena Chakarova
MD, PhD
Chief Assistant Professor
University Hospital of Endocrinology
Medical University of Sofia
Sofia, Bulgaria
Dr. Chakarova’s clinical work includes management of patients with type 1
diabetes and patients with type 2 diabetes in the hospital setting as well as
screening and prevention of individuals at risk for diabetes in the ambulatory
setting. As an assistant professor, she trains medical students and participates
in university lecture courses and in national scientific conferences. Her
main interests are diabetes prevention, management of high-risk individuals,
management of cardiovascular risk factors, treatment of type 1 diabetes, and
continuous subcutaneous insulin infusion therapy.
Dr. Krishnan Swaminathan is a consultant endocrinologist at Kovai Medical
Center and Hospital (KMCH), Coimbatore, India. He is also president of the
KMCH Research Foundation, a not-for-profit research organization whose
aim to improve health care research in India.
Krishnan
Swaminathan
MD
Consultant Endocrinologist
President of the KMCH Research
Foundation
Kovai Medical Center and Hospital
Coimbatore, India
Dr. Swaminathan completed his undergraduate medical education from
Madras Medical College, Madras, India, and received specialist training in
diabetes and endocrinology from renowned institutions in the United
Kingdom, including Guy’s Hospital and St. Thomas’ Hospital, London;
Addenbrooke’s Hospital, Cambridge; and Ninewells Hospital, Dundee. He
attained Membership of the Royal Colleges of Physicians of the United
Kingdom in 1999, was awarded Fellowship of the Royal College of Physicians
of Edinburgh in 2009, and completed his research MD degree in diabetes and
cardiovascular disease. He has been credited with nearly 50 publications in
peer-reviewed international journals.
Currently, Dr. Swaminathan is pursuing a PhD from the Indian Institute of
Technology–Madras, focusing on environmental endocrine disruptors and
diabetes. His other research interests include gestational diabetes, type 1
diabetes, and diabetic complications. Dr. Swaminathan founded aTTiTude,
a club for children with type 1 diabetes. He is the founding trustee of
Idhayangal, a registered charity that funds various charitable causes, especially
those for poor children in India.
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