Natalie Bellini, DNP, FNP-BC, BC-ADM, CDCES

Diabetes Dialogue: Technology, Therapeutics, & Real-World Perspectives!

Diabetes Dialogue episode where hosts discuss Orforglipron topline results from ATTAIN-1 and ADCES 2025.

Diabetes Dialogue: Orforglipron Topline results and ADCES 2025 Part 1

Diabetes Dialogue: Technology, Therapeutics, & Real-World Perspectives

 features hosts Diana Isaacs, PharmD, an endocrine clinical pharmacist, director of Education and Training in Diabetes Technology, and codirector of Endocrine Disorders in Pregnancy at the Cleveland Clinic, and Natalie Bellini, DNP, program director of Diabetes Technology at University Hospitals Diabetes and Metabolic Care Center. They share key insights and takeaways from the Association of Diabetes Care and Education Specialists (ADCES) 2025 annual meeting.

Before the discussion on ADCES 2025, hosts discussed 

new topline data on orforglipron in patients with overweight or obesity

, an investigational oral, non-peptide glucagon-like peptide-1 (GLP-1) receptor agonist. The ATTAIN-1 study, a 72-week trial involving over 3000 adults with obesity or overweight and related medical conditions, demonstrated an average weight loss of 12.4% (27.3 lbs), significantly greater than the 0.9% (2.2 lbs) observed with placebo. A key distinction of orforglipron and oral semaglutide is its non-peptide nature, which removes the stringent administration requirements typically associated with peptide-based oral GLP-1 agonists, potentially enhancing patient adherence. The hosts anticipate this agent could revolutionize weight management pharmacotherapy and foresee its potential approval for both diabetes and obesity indications.

Insights from the ADCES meeting highlighted the expanding therapeutic scope of incretin-based therapies. During the "Incredible Incretins" session, phase 3 and emerging data were presented on GLP-1 receptor agonist applications beyond the traditional management of type 2 diabetes and obesity. Conditions for which therapeutic potential was discussed included 

metabolic dysfunction-associated steatohepatitis

,and even Alzheimer’s disease. Notably, the ongoing EVOKE study is investigating oral semaglutide for Alzheimer's disease, with results expected in September 2024. These broader indications are considered critical for improving patient access to these transformative medications, particularly given existing coverage challenges for obesity treatments.

The episode also delved into the growing integration of artificial intelligence (AI) in diabetes management. Isaacs emphasized the imperative for clinicians to adopt AI tools, drawing a parallel to the adoption of new insulins or continuous glucose monitoring (CGM) systems. Examples of AI applications cited include retinopathy screening and the Open Evidence tool. While AI is advancing rapidly, the hosts stressed the importance of verifying information and references.

The discussion also covered AI integration into mobile apps, such as Dexcom G7 for food recognition, and platforms like GlucoSense providing personalized insights from various patient data points, offering valuable support between clinical visits.

Lastly, the hosts reflected on a pre-conference workshop on implicit bias, led by ADCES President Veronica Brady, PhD, RN. This session aimed to foster awareness and discussion among diverse healthcare professionals about unconscious biases, which may inadvertently impede equitable access to advanced therapies and technologies for individuals with or at risk for diabetes.

Relevant disclosures for Isaacs include Eli Lilly and Company, Novo Nordisk, Sanofi, Abbott Diabetes Care, Dexcom, Medtronic, and others. Relevant disclosures for Bellini include Abbott Diabetes Care, MannKind, Provention Bio, and others.

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This episode includes a breakdown of topline data from ATTAIN-1 and part 1 of the recap for ADCES 2025.

Diabetes Dialogue: Orforglipron Topline Results & ADCES 2025 Part 1

Diabetes Dialogue: Tirzepatide and SURPASS-CVOT Topline Results

On July 31, 2025, Eli Lilly and Company announced topline data from the SURPASS‑CVOT trial comparing tirzepatide (Mounjaro) to dulaglutide (Trulicity) in adults with 

atherosclerotic cardiovascular disease (ASCVD)

According to the data, tirzepatide met the primary non‑inferiority endpoint for 3-point major adverse cardiovascular events (MACE) (hazard ratio [HR], 0.92; 95.3% CI, 0.83 to 1.01), while also showing additional benefits in A1C, weight reduction, renal preservation, and a 16% reduction in all‑cause mortality (HR, 0.84; 95.0% CI, 0.75 to 0.94).

Diabetes Dialogue: Technology, Therapeutics, and Real-World Perspectives

, Diana Isaacs, PharmD, an endocrine clinical pharmacist, director of Education and Training in Diabetes Technology, and co-director of Endocrine Disorders in Pregnancy at the Cleveland Clinic, and Natalie Bellini, DNP, program director of Diabetes Technology at University Hospitals Diabetes and Metabolic Care Center, unpacked the top-line results of the SURPASS-CVOT trial. Eli Lilly and Company owns both drugs, which belong to the incretin class, but tirzepatide is a dual GIP/GLP-1 receptor agonist, while dulaglutide is a GLP-1 RA.

The trial included over 13,000 adults with type 2 diabetes and either established cardiovascular disease or at high risk. During a median follow-up of 4.5 years, the primary endpoint, which was a composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke, was reduced by 8% in the tirzepatide group relative to dulaglutide. However, the result did not reach statistical superiority due to the confidence interval crossing unity.

Isaacs and Bellini also highlighted significantly greater A1c (-1.73% vs -0.9%) and weight loss (12% vs 4.95%) with tirzepatide. Additional prespecified analyses comparing data with the placebo-controlled REWIND trial suggest tirzepatide could offer up to 28% MACE and 39% mortality risk reduction compared to theoretical placebo—findings that hint at broader cardiometabolic benefit.

Before concluding, hosts speculated about the potential subgroup analyses of interest for the trial, including heart failure and renal outcomes, as well as a brief discussion around Eli Lilly and Company’s intent to submit a regulatory application for a cardiovascular indication before the close of 2025.

Eli Lilly and Company. Lilly's Mounjaro (tirzepatide), a GIP/GLP-1 dual agonist, demonstrated cardiovascular protection in landmark head-to-head trial, reinforcing its benefit in patients with type 2 diabetes and heart disease. July 31, 2025. Accessed July 31, 2025. 

https://investor.lilly.com/news-releases/news-release-details/lillys-mounjaro-tirzepatide-gipglp-1-dual-agonist-demonstrated

Hosts offer perspective on the topline results from SURPASS-CVOT and what the cardiovascular data on tirzepatide means for care. 

Diabetes Dialogue: Technology, Therapeutics, and Real-World Perspectives!

Diabetes Dialogue: Guideline Updates for Diabetes & Pregnancy

00:00:00 Intro
00:01:25 Recommendations 1 and 2
00:02:27 Recommendation 3
00:07:11 Recommendation 4
00:09:58 Recommendation 5
00:14:51 Recommendations 6 and 7
00:19:05 Recommendation 8
00:23:11 Recommendation 9
00:25:11 Recommendation 10

In this episode of Diabetes Dialogue, cohosts Diana Isaacs, PharmD, an endocrine clinical pharmacist, director of Education and Training in Diabetes Technology, and co-director of Endocrine Disorders in Pregnancy at the Cleveland Clinic, and Natalie Bellini, DNP, program director of Diabetes Technology at University Hospitals Diabetes and Metabolic Care Center, discuss the newly released Preexisting Diabetes in Pregnancy guidelines from The Journal of Clinical Endocrinology & Metabolism, which offer 10 key recommendations to improve outcomes in pregnant individuals with 

1–2. Reproductive Counseling and Contraceptive Use

The first 2 recommendations call for routine pregnancy intention discussions between patients and their clinicians as well as contraceptive counseling. Despite their simplicity, these are often overlooked and underutilized in clinical practice. The hosts stress that preventing unplanned pregnancies in poorly controlled diabetes is crucial to reducing risks of congenital anomalies.

3. Discontinuation of GLP-1 RAs Prior to Conception

The third recommendation advises discontinuation of GLP-1 RAs before conception, rather than waiting until pregnancy is confirmed. This includes agents like semaglutide, liraglutide, and tirzepatide.

While observational data suggest no clear signal for increased congenital anomalies with GLP-1 RA exposure, the guideline prioritizes caution due to the absence of randomized controlled trial data.

Isaacs and Bellini highlight the real-world tension clinicians face: stopping GLP-1s can lead to glycemic deterioration and weight gain, both of which are detrimental in early pregnancy. The discussion emphasizes the importance of careful insulin titration prior to conception and underscores the need for individualized care planning, especially given the long half-life of agents like semaglutide.

4. Metformin Use in Pregnant Individuals with Type 2 Diabetes

Recommendation 4 advises that metformin should not be routinely added to insulin regimens during pregnancy for individuals with pre-existing type 2 diabetes due to concerns about fetal outcomes like small-for-gestational-age infants and potential long-term metabolic risks.

Isaacs and Bellini explain that while metformin’s convenience is appealing—especially in gestational diabetes—it may not offer added benefit in insulin-requiring patients and may introduce unnecessary fetal exposure. The evidence supports a primary reliance on insulin for managing dysglycemia in this population.

5. Individualized Carbohydrate Targets in Pregnancy

The guideline recommends that pregnant individuals with diabetes follow either a carbohydrate-restricted (<175g/day) or standard carbohydrate diet (≥175g/day), depending on clinical context.

Isaacs and Bellini commend the move away from rigid carb targets toward individualized nutrition, while cautioning against overly restrictive diets (<100g/day) linked to neural tube defects.

The sixth and seventh recommendations relate to glucose monitoring technologies and glycemic targets, deeming CGM and BGM as appropriate tools for self-monitoring in pregnancy with type 2 diabetes. Standard pregnancy glucose targets remain preferred over CGM time-in-range (TIR) metrics.

The hosts underscore that while CGM use is expanding and shows promise, especially for reducing glycemic variability, current data are stronger in type 1 than in type 2 diabetes. They also stress that focusing on individual glucose points remains crucial, as a high average glucose could still fall within an acceptable TIR range, potentially masking hyperglycemia.

Recommendation eight suggests hybrid closed-loop insulin delivery systems should be used over standard pumps with CGM or MDI + CGM when feasible. When feasible, hybrid closed-loop insulin systems are preferred over standard pump or MDI therapy. However, FDA-approved systems for pregnancy are lacking in the U.S. Isaacs and Bellini discuss adapting care using available technologies and centering patient choice.

The evidence supports improved overnight glycemia and reduced burden, but the hosts point out a significant challenge: while systems like the MiniMed 780G and CamAPS FX have pregnancy indications in Europe, no systems are formally approved for this indication in the US. To work within these limitations, the hosts suggest transitioning patients to more pregnancy-compatible technologies and emphasizing patient choice.

9. Timing of Delivery Based on Risk Stratification

The ninth recommendation supports delivery by 38 weeks or earlier when clinically indicated based on individual risk assessment.

Given the elevated stillbirth risk in diabetes—especially with obesity or comorbidities—the hosts say clinicians must balance proactive delivery against patient preferences for full-term birth.

The final recommendation emphasizes postpartum follow-up with an endocrinology team, alongside standard obstetric care. This is essential for managing glycemia, selecting lactation-safe medications, and planning future pregnancies. The hosts highlight the need for better transitions of care and system-level strategies to ensure follow-up, particularly in newly diagnosed type 2 diabetes.

Isaacs and Bellini close by emphasizing the importance of these guidelines in standardizing care for a high-risk population. While many recommendations are expert consensus-based, they represent meaningful progress. They call for increased uptake of preconception counseling, more research on nutrition and technology in pregnancy, and investment in team-based, longitudinal care.

Isaacs and Bellini walk through the newly released Preexisting Diabetes in Pregnancy guidelines, discussing each of the 10 recommendations.

Diabetes Dialogue: 2025 Guideline Updates for Diabetes & Pregnancy

Diabetes Dialogue: GLP-1s, SGLT2s, and Diabetes Barbie at ENDO 2025

In this episode of Diabetes Dialogue, cohosts Diana Isaacs, PharmD, an endocrine clinical pharmacist, director of Education and Training in Diabetes Technology, and co-director of Endocrine Disorders in Pregnancy at the Cleveland Clinic, and Natalie Bellini, DNP, program director of Diabetes Technology at University Hospitals Diabetes and Metabolic Care Center, recapped highlights from the 

. They spotlighted advances, controversies, and ongoing unmet needs in 

They highlight Dr. Caitlin Love’s presentation on GLP-1 receptor agonists in type 1 diabetes, noting the small size and limitations of existing randomized controlled trials, most of which used liraglutide—a daily injectable with lower adherence and modest efficacy compared to newer, weekly agents. Despite inconsistent A1c reductions, trials showed meaningful weight loss and insulin dose reductions. However, they also lacked important endpoints such as time-in-range and treatment burden.

Isaacs and Bellini then turn to the regulatory landscape, where they reflect on the current lack of FDA-approved GLP-1 receptor agonists for type 1 diabetes, despite widespread off-label use. In contrast, pramlintide remains approved for type 1 despite being more difficult to administer and offering less meaningful glycemic benefits. The hosts underscore the pressing need for robust cardiovascular outcomes trials in the type 1 population, and they express optimism about an upcoming trial of tirzepatide led by Dr. Viral Shah. They note that this trial could mark a pivotal step toward gaining formal approval for this class in type 1 diabetes.

 protection, the hosts highlight the importance of studying therapies already approved in 

 within the type 1 population. They note the significance of ongoing studies with finerenone, an MRA currently approved for CKD in type 2 diabetes. The conversation also touches on the continued hesitancy around SGLT2 inhibitors in type 1 diabetes due to euglycemic DKA risk, positioning finerenone as a potentially safer alternative if efficacy is confirmed.

Dr. Anders Carlson’s keynote presentation is another focal point. The hosts praise his sweeping review of the DCCT and EDIC studies, now extending over 40 years, and his framing of glycemic control—particularly time-in-range—as the single most important determinant of long-term outcomes in type 1 diabetes. They reflect on the evolving definition of glycemic success, including the growing importance of time-in-tight-range (e.g., 70–140 mg/dL), and the implications for future regulatory endpoints and therapeutic goals. Carlson’s retrospective highlighted how far the field has come—from a focus on A1c to a more nuanced understanding of glycemic patterns, glucose variability, and the real-world challenges patients face.

The hosts also touch on public perception and advocacy, with the recent launch of a type 1 diabetes Barbie receiving both acclaim and controversy online. The doll, equipped with an insulin pump and CGM, was launched to promote visibility of the disease and normalization of its treatment. However, the hosts address problematic social media reactions—such as misinformed comments conflating type 1 and type 2 diabetes—and use the opportunity to emphasize the ongoing need for public education.

The episode closes with a nod to ENDO’s expanded efforts in provider education, particularly a dedicated fellows’ session on type 1 diabetes. Topics included accurate diagnosis, staging, the importance of antibody testing, and family screening. Isaacs and Bellini stress how essential it is for endocrinology fellows—many of whom may focus on other areas—to be equipped with the knowledge and tools to care for patients with type 1 diabetes in general practice. They also highlight evolving epidemiologic trends: most new-onset cases now occur in adults, and a substantial proportion of individuals with type 1 diabetes live with overweight or obesity—challenging outdated stereotypes and reinforcing the need for precise diagnosis and individualized treatment.

Isaacs and Bellini discuss the highlights of the Endocrine Society’s annual meeting, from upcoming treatments to public education.

Natalie Bellini, DNP, FNP-BC, BC-ADM, CDCES

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