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

Diabetes Dialogue: The Diabetes Collective, with Rachael Sood, RN, MSN, APRN

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

85th Scientific Sessions of the American Diabetes Association (ADA 2025)

 in Chicago, hosts Diana Isaacs, PharmD, and Natalie Bellini, DNP, speak with Rachael Sood, RN, MSN, APRN, NP, CDCES, founder of The Diabetes Collective, about modern approaches to 

, patient engagement, and the role of social media in education and advocacy.

The discussion highlights Sood’s innovative use of social media to make diabetes education accessible and engaging. Known for creative and widely shared content—such as her wedding-themed video announcing the Dexcom G7 and Omnipod 5 integration—Sood shares how spontaneous, relatable messaging can improve awareness and patient connection. Her content spans emerging therapeutics like GLP-1 receptor agonists, type 1 diabetes staging and screening, and technology updates such as ketone monitoring and CGM integration.

Sood reflects on the emotional impact of recent ADA presentations, including advances in islet cell therapy and the evolving treatment landscape for both type 1 and type 2 diabetes. She emphasizes the importance of healthcare providers offering clear, empathetic, and tailored care, recounting a patient case where basic interventions—CGM use, education, and therapeutic escalation—had a transformative effect after years of clinical inertia.

The episode underscores the value of clinician-led care, continuity, and communication, particularly in independent practices. Sood also points to the importance of collaborative energy within the diabetes community, noting the power of partnerships among healthcare professionals, patients, and advocacy groups to drive progress.


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, Sanofi, and others. Sood has no relevant disclosures to report.

Podcasts

Hosts sit down for a deep dive into The Diabetes Collective and what it's like operating a diabetes clinic in the modern healthcare landscape.

Panelists discuss how their key takeaways emphasize the importance of having a high index of suspicion for hypercortisolism, implementing routine screening in appropriate patients and educating primary care physicians to recognize the “big 4” symptoms of difficult-to-treat diabetes, hypertension, obesity, and bone disease.

Key Takeaways on Hypercortisolism Management

Video content above is prompted by the following: 

The clinical approach to hypercortisolism management emphasizes the critical importance of high clinical suspicion, particularly in patients who do not fit the typical phenotype for difficult-to-control diabetes. The “start low, go slow” principle is fundamental to successful treatment, with particular attention needed for older patients who may require dosing as infrequently as 2 to 3 times per week initially. Patient education about expected withdrawal symptoms and the timeline for improvement is crucial for treatment adherence and success.

Screening should become routine practice for patients meeting specific criteria: those on multiple diabetes medications with poor control, particularly when combined with multiple antihypertensive agents. The screening process using dexamethasone suppression testing is simple and cost-effective yet dramatically underused in clinical practice. Primary care physicians play a crucial role in initial recognition and screening, even if they refer patients to specialists for treatment management. The big 4 clinical indicators—difficult-to-treat diabetes, hypertension, central obesity, and bone disease—should trigger screening consideration.

The field represents a paradigm shift toward precision medicine in endocrinology, moving beyond broad-spectrum treatments to targeted, biomarker-driven therapy. The prevalence of hypercortisolism in clinical practice is likely much higher than currently recognized, suggesting that inadequate screening rather than disease rarity explains the apparent low incidence. Successful management requires not only biochemical control but also attention to the psychological and quality-of-life improvements that often accompany treatment, as patients frequently experience resolution of depression, cognitive improvement, and enhanced overall well-being alongside metabolic improvements.

Videos

Panelists discuss how future research should focus on understanding why hypercortisolism is becoming more prevalent, developing more specific treatments with fewer adverse effects, and determining optimal thresholds for circadian rhythm dysfunction and treatment duration.

Unmet Needs and Future Research Directions for Hypercortisolism

The fundamental question driving future research centers on understanding why hypercortisolism appears to be increasingly prevalent in modern society. Researchers propose that chronic stress from contemporary lifestyle factors—including constant connectivity, social media, and persistent stimulation—may be driving autonomous cortisol production. This parallels the historical evolution of subclinical hypothyroidism recognition, which progressed from being considered rare to becoming one of the most common referral reasons to endocrinology clinics. The pathophysiological mechanisms underlying this apparent epidemic require urgent investigation.

Future therapeutic developments focus on more selective and refined treatment options. The development of relacorilant, a more specific glucocorticoid receptor antagonist, promises to reduce adverse effects associated with mifepristone, including vaginal bleeding and endometrial thickening. Early data suggest relacorilant causes less corticotropin elevation and associated mineralocorticoid effects while maintaining efficacy in blood pressure reduction and glucose control. Additional compounds in development include CRH receptor antagonists and 11β-HSD type 1 inhibitors, which could provide tissue-specific cortisol modulation in liver and adipose tissue.

Research priorities include establishing thresholds for clinically significant circadian rhythm dysfunction and developing noninvasive continuous cortisol monitoring technologies. The potential for temporary treatment to reset circadian rhythms represents an intriguing therapeutic possibility that could transform hypercortisolism from a chronic condition to a potentially curable disorder. Understanding the relationship between insulin resistance and circadian disruption may reveal whether insulin sensitizers could help restore normal cortisol rhythms. The field also needs to address long-term management questions, including optimal treatment duration and strategies for preventing disease recurrence.

Monitoring for Treatment Effectiveness and Safety in Hypercortisolism Management.

New Data for Osilodrostat in Cushing Syndrome

Practical monitoring of patients on hypercortisolism treatment presents significant challenges, particularly with traditional markers such as 24-hour urinary-free cortisol collection, which suffers from poor patient adherence and collection accuracy. Most clinicians have moved toward a multimodal monitoring approach that balances safety concerns with therapeutic goals. Morning cortisol levels serve primarily as a safety measure to prevent overtreatment rather than as a therapeutic target, whereas late-night salivary cortisol provides a more practical assessment of treatment efficacy.

The monitoring strategy must account for the complex physiology of normal cortisol rhythm, which requires high morning levels and near-zero overnight values. Enzyme inhibitors such as osilodrostat can potentially flatten this natural rhythm, creating an artificial but not necessarily optimal cortisol pattern. The challenge lies in achieving adequate cortisol suppression without inducing adrenal insufficiency, requiring careful dose titration and frequent monitoring, especially during treatment initiation.

Clinical experience suggests that most practitioners are still developing optimal monitoring protocols for this emerging field. The approach typically involves periodic urinary-free cortisol measurements to ensure overall control, combined with regular morning cortisol checks to prevent dangerous overtreatment. The glucocorticoid receptor antagonist mifepristone offers some protection against adrenal crisis due to its mechanism of action, which allows the pituitary gland to increase ACTH production and drive cortisol levels up when needed. However, this can lead to secondary effects including hypertension and hypokalemia due to cortisol’s mineralocorticoid activity, requiring careful monitoring of blood pressure and electrolytes.

Panelists discuss how monitoring patients on hypercortisolism treatments requires balancing safety (morning cortisol to avoid overtreatment) with efficacy (late-night salivary cortisol) while acknowledging the practical challenges and evolving best practices in this field.

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

Articles