0:00

Hey. Listeners, It's two thousand and twenty four

0:02

and we are so excited for everything I

0:04

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0:06

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0:28

Paul I'm I'm going to start off by saying

0:31

I Hate this Pawn. Grow.

0:34

His blog and I'm sure I'll have it.

0:36

Oh, what did Mary Poppins saying to the

0:38

child with diabetes? A.

0:42

Spoonful of insulin makes the sugar

0:44

down. Yeah, pretty much it is.

0:47

pretty much yeah. Terrible. I'm. Surprised

0:50

audience. We. Need

0:52

some more insulin? Pons sugar puns,

0:54

there's there's nothing good, there's nothing to pick. Where's

0:56

the prize outta here? There's not a lot calmer

0:58

ones out there is I looked and there are

1:01

slim pickens. The

1:05

Curves Hundred podcast is are getting an education and information purposes

1:07

only. The topics discussed should not be used to lead. I

1:09

don't treat your orbit and a diseases or conditions but more

1:11

The few things express my cats are solely those are those

1:13

should not be interrupted Perfect official policy What doesn't have any

1:15

of the aside from past we've got i'm Wrong and Billie Outreach

1:17

programs if the there are any effect there are not much

1:19

we are muslims rubbish but we do your homework and that no

1:21

one. Will

1:29

come back to the Curves Actors I'm

1:31

Doctor Matthew Frank. We're out here with

1:33

my great friend and America's primary care

1:36

physician Doctor Paul Nelson Williams. Hype off

1:38

primer area. I'm good and. I'm

1:40

good because tonight we have many

1:43

times. Returning Guess Doctor Jeff

1:45

Coburn talking about. Continuous

1:47

glucose meters, a case, yams and

1:50

some some patterns that you might

1:52

see when looking at to people's

1:54

blood sugar readings and how to

1:56

troubleshoot those patterns. So various patterns

1:59

of hypo. and hyperglycemia. And

2:02

Paul, before we tell them, remind

2:04

them who Jeff is, can you please tell

2:06

them what is it that we do

2:08

on curbsiders? Sure,

2:10

Matt, we are the Internal Medicine Podcast. We use expert

2:12

interviews to bring you clinical pearls in practice-changing knowledge. And

2:14

Matt, why don't I let you tell us a little

2:16

bit more about our guest and the

2:18

practice-changing knowledge he imparted. Okay,

2:20

so Dr. Jeff Colburn is the

2:23

director of the Diabetes Center at

2:25

the Richmond Veterans Affair Medical Center

2:27

and serves as an associate professor

2:29

of medicine for Virginia Commonwealth University.

2:31

He has a passion for teaching

2:33

medicine with an academic focus in

2:35

areas like diabetes management and care

2:38

delivered via virtual technologies. He is

2:40

clinically active and teaches students, residents, and

2:42

fellows in the inpatient and outpatient settings,

2:44

which include a mixture of face-to-face and

2:47

virtual encounters. I can say that

2:49

I've known Jeff for 11 years now and

2:53

have been a huge fan of him. He's

2:55

taught me so much about diabetes and endocrinology

2:57

in general. So very glad to have him

2:59

back on the show. Before

3:02

we get to the show, I should

3:04

say that this and most episodes are

3:06

available through VCU Health for

3:09

CME at curbsiders.vcuhealth.org. And

3:13

also, if you haven't

3:15

signed up yet, check out our

3:17

Patreon at patreon.com/curbsiders, where you can

3:19

get twice monthly bonus episodes, ad-free

3:22

episodes, and now access to Paul,

3:25

our cash-lack vault with over 400 show notes, figures,

3:29

cover art, all our stuff, basically. Paul

3:31

is in there in a drive that

3:33

people can get access to on the

3:36

Patreon. So it's pretty cool. Look

3:39

smart on the wards. Look smart on the wards. Jeff,

3:45

welcome back to the show. So good to see you. Yeah,

3:47

thanks for having me. It's been a bit. Yeah,

3:50

it has been a bit. I know you've moved

3:52

jobs. You don't have to say where your new job is,

3:54

but I hope things are going well. How's

3:56

the move been? Good, I'm slowly

3:58

working my way up towards. taking

4:01

over Paul's position. I'm in the Northeast

4:03

now, so my secret is that the

4:05

S-Enroll has become within striking distance. Jeff,

4:08

you know we do this remotely. You don't have to

4:10

move. You can take my job. You don't

4:12

have to put yourself through this, buddy. I'm

4:15

overthinking this. I'm just trying to... Oh my

4:17

gosh, I totally overthought it. It's been going.

4:19

I'm in the same time as him, though,

4:22

so this makes life easier. Yeah,

4:26

I think Paul, last time he also

4:28

threatened maybe to steal your cat because

4:31

I think Ollie was recording with us.

4:33

Well, I bought a dog now and so

4:35

I bought a protector, so you're gonna have trouble

4:37

getting there now. Jeff,

4:42

did you have like a book, movie,

4:44

or TV show, something you want to

4:46

recommend to the audience since you've answered

4:48

all our standard questions many times already? Oh

4:51

boy, let's see. I'm rereading

4:54

a series that I had read

4:56

a few years ago by an

4:58

author named Steven Saylor. They're historical

5:01

fiction set in Roman times. He's

5:03

got several. They're very interesting. There's

5:05

an intrigue with the

5:07

character who's interacting with all of

5:09

these big historical figures like Julius

5:11

Caesar and tons of Roman folks

5:13

that are of historical importance that

5:15

I had never heard of before,

5:18

but they're an interesting series

5:20

of books and audio listening to them on

5:22

my commute and it's enjoyable. Jeff,

5:25

I hate to call you out like this. This is

5:27

previous recommendations you've already made because I actually started.

5:29

Oh really? Oh dang. Yeah,

5:32

I guess it's like a Roman detective. Yeah, so

5:34

I actually, I listen,

5:37

I'm re-listening to them because I feel like I'm in

5:39

this new job and so I'm kind of like re-exploring

5:41

some kind of thing again that I really enjoy. I

5:43

don't know what it is, but I'm just listening to

5:45

them again. There's like 15 of them. I just

5:48

love them. Sorry, I just keep that

5:50

as a double recommend. Yeah, that's okay. I

5:53

recently reread Dune, American

5:55

Gods, a couple of my old favorite

6:00

that I just every once in a while like

6:02

return to I think it's just like watching It's

6:04

like watching a movie that you haven't seen in

6:06

years Yeah, there's a plot twist and that I

6:08

totally forgot so I'm like starting to question my

6:10

own cognitive state I'm like, oh I should have

6:12

remembered that plot twist. How do you first Caesar

6:14

dies at the end? Yeah that one

6:19

Good stand All

6:21

right, well Jeff the impetus

6:24

for this episode was I guess

6:27

our most recent episode with you was just

6:29

talking all about Insulin and we

6:31

talked about hypoglycemia First of

6:33

all you mentioned on that episode Maybe

6:35

doing an episode on insulin pattern matching

6:38

which is what we're gonna be talking

6:40

about later in this episode But you

6:42

also mentioned that there's been some changes

6:44

around continuous glucose monitors. So Let's

6:47

start with a case and then we'll talk about those a

6:49

little bit first as a first part So Paul do you

6:51

want to read the case? Sure,

6:53

man, so we're gonna tell you

6:55

Jeff about mr. H. He's a 58 year old gentleman.

6:57

He weighs 100 kilograms He's got

7:00

type 2 diabetes. He has obesity

7:02

hyperlipidemia ckd 3a without albuminuria He

7:04

takes insulin-garging 35 units nightly and

7:07

metformin XR 752 tabs

7:09

daily his most recent a1c was 8.6

7:12

He doesn't really like finger sticks But his fasting sugar

7:14

is usually between a hundred two hundred fifty milligrams

7:16

per deciliter when he checks and he has not

7:18

recorded Nor does he report any lows? So

7:21

we were talking about CGM

7:23

and how this patient may benefit from and remain even

7:26

one It seems like it might be a better option

7:28

for him But before we get into the granular details,

7:31

could you just talk us through? Like

7:33

bare basics like you like we were talking off on you

7:35

can't get too dumb for me in terms of continuous glucose monitors

7:37

And sort of how you think about them who gets them What's

7:41

available to us? So you can't start too simple. So

7:43

just talk us through them and then we'll get more

7:45

advanced from there Sure. So just thinking

7:47

about this gentleman, you know, he's 58 So,

7:49

I mean age is relative, but I would

7:51

just call him probably youngish He

7:54

is struggling with obesity and so you

7:56

want to try to prioritize medications that

7:59

we might affect that well. And

8:01

so those are options that we would want to

8:04

consider for him. I often try to think about,

8:06

you know, what's the A1c target for the patient?

8:09

All of the diabetes guidelines have us

8:11

think about the risks that we might

8:13

impose on a patient by making the

8:15

A1c, you know, very like less than

8:18

seven for someone who's maybe more physiologically

8:20

fragile where that could be harmful by

8:22

causing lows. And so

8:24

this gentleman, he's got some CKD, but

8:27

otherwise seems to be doing okay. I think

8:29

we could probably seek an A1c target of,

8:31

you know, six and a half to seven

8:33

would be reasonable, try to get a little

8:35

bit tighter. He's currently like you'd mentioned, 8.6.

8:39

So he's quite a bit above where we'd want. And

8:42

like you'd mentioned, he's on basal insulin

8:44

and metformin. So you're thinking about options.

8:47

It seems like there's something discordant happening

8:49

because it has fasting sugar, like you'd mentioned, as

8:51

100 to 150. So one of the things that

8:53

I teach trainees a lot is the

8:57

A1c to finger stick correlation. A lot of

8:59

times we talk to patients in A1cs and

9:01

they're used to looking

9:03

at sugars. And so just the way

9:06

I try to commonly relate this is in a

9:08

blood sugar of 126 is

9:11

equal to an A1c of six. You

9:13

have to know 126, that's the fasting sugar at

9:15

which we diagnose diabetes. So it's just a good

9:18

way to remember this 126 equals a six. And

9:21

then you just add 30 for every A1c

9:23

point up. So 156 is a

9:26

seven and so on and so forth. 186

9:28

is an eight. So this gentleman

9:30

at 8.6, you know,

9:32

he's probably seeing blood sugars that are

9:34

like around 200 on average. So that

9:36

kind of makes us think, well, these

9:38

fasting sugars don't make sense. And

9:41

so either the A1c is discordant. We

9:43

did a, we all did a talk on some

9:45

of the A1c kind of pitfalls

9:48

for why that falls apart. But

9:50

we want to try to investigate as

9:52

glucose otherwise and understand what's happening. And

9:55

so to get into talking about continuous

9:57

glucose monitors, you know, you could advise,

10:00

Why is this person does finger sticks more? That

10:03

might be where I start with this individual. He's

10:06

on just once a day insulin. And

10:08

so it could be reasonable that he does a couple

10:11

of days of testing in that way. But

10:13

it is exciting to now consider offering

10:16

a person a CGM. There's

10:18

two main kind of ways we can do

10:20

that in an office setting. So you can

10:22

do what's called a professional model or a

10:25

CGM pro. Each one where

10:27

the patient puts a sensor on, it's put

10:29

on in the clinic rather, and they'll

10:31

usually wear it for 14 days and

10:33

then they'll come back to the clinic. They

10:36

can't see any of the sugars, it's

10:38

just collecting the data. And then the

10:40

office can download the sensor and look

10:42

at the patterns of glucose. We

10:45

think that that's safe for the beginning

10:47

of some of these patients in

10:49

that they can't react to glucose

10:51

that they're not ready to understand and

10:53

start treatments on. And this

10:55

person is not on any treatments that he could titrate

10:57

too much on his own, maybe the glargine a little

10:59

bit. So that's kind

11:01

of a pro version. And then

11:03

what we're going to probably talk about mostly today

11:05

is the personal use versions. These are ones that

11:08

we prescribe to patients for them to have on

11:10

their own. The

11:12

main components of continuous glucose monitors are

11:14

going to be the little piece that

11:16

sticks to the patient called the sensor.

11:19

And most of them now, the

11:21

most upgraded versions have integrated transmitters,

11:24

meaning the Bluetooth signal that's sending

11:26

the data to either

11:28

their smartphone or if they

11:30

don't have a smartphone, a handheld reader. So

11:33

the transmitter is included in the sensors nowadays. It used

11:35

to be kind of two separate pieces a lot of

11:37

the time. So you put this little

11:40

sensor on their arm usually.

11:43

It's about the size of two stat

11:45

quarters or so. So I mean, these are

11:48

small nowadays. And you can

11:50

deem those data to their phone continuously.

11:53

That's the main setup. Did

11:57

you have any questions or thoughts before I just continue on

11:59

with some ideas? So just

12:01

to summarize, so the sensor is the thing that

12:03

they stick to their skin that they wear around.

12:06

Nowadays, a lot of them have

12:08

a built-in transmitter, and then they can

12:10

either use their phone to receive the signal,

12:14

or if they don't have a smartphone, I

12:16

guess there's some sort of handheld receiver

12:18

that would get the data from

12:20

the CGM. You got it

12:23

perfectly. And the handhelds have little screen on

12:25

there that basically shows the readout, like your

12:27

smartphone would show. If

12:29

you're a person with a smartphone, there's

12:31

no good reason to have to carry

12:33

this extra device that you have to

12:35

charge and then potentially also lose. So,

12:38

yeah, smartphone is, I think, the best

12:40

way, to be honest, to go. And

12:42

the added advantage is that the smartphones

12:44

can upload to the cloud all of the

12:46

data, so a clinic can download it from the

12:48

cloud, or a

12:50

family member can simultaneously and continuously

12:53

follow a family member's sugar. So

12:55

let's say you had

12:57

a parent who you're worried about and

12:59

has maybe some cognitive difficulty. As long

13:02

as it's transmitting to their smartphone, the

13:05

smartphone is going to be continuously with

13:07

their cellular Wi-Fi going up to the

13:09

cloud, and that can go down to

13:11

a son or daughter's phone

13:13

constantly, and you can get alerts. So if

13:16

they're having a high or low event, you

13:18

can be alerted and take action. Same thing

13:20

with a parent, with a child with diabetes.

13:22

This is something that would be huge to

13:24

make you feel comfortable. Okay,

13:27

so that makes me think, is

13:29

it necessary, should Paul and I be signing up

13:31

for provider portals? I know there's two types of

13:33

CGM's that I'm commonly seeing out there, two brands.

13:35

So should we be signed up for the provider

13:37

portal for both of them, and then we can

13:39

somehow link to our patients in there? Yeah, I

13:42

would say probably the biggest hurdle right

13:44

now is just workflows and clinics getting

13:46

the provider portal set up. It's probably

13:49

a good idea if a clinic team

13:51

wants to start using CGM in their

13:53

practice to talk about joining

13:56

a portal maybe together. And

13:58

you can even talk to the two companies. They

14:00

have representatives that will talk to you about how

14:03

you can manage a portal for a group.

14:06

That way if the patient sees, let's say, you, Dr.

14:09

Lotto, and then comes to

14:11

see another doctor, you

14:13

can still see the data. It's not like specifically

14:15

channeled just to you. It's to the practice. So

14:17

I think it's actually wise to talk about this

14:19

amongst your peers and to set it up as

14:21

a group. We often try to

14:23

avoid talking about brands, but there are two

14:25

main products out there. It's probably useful to

14:28

have to mention them. So Dexcom,

14:30

and I'll just say I don't have an

14:32

allegiance or any kind of relationship with either

14:34

company. So just to say that for sure.

14:37

But Dexcom is one

14:40

of the main producers that has been

14:42

out for quite a long time and updated

14:44

their products. The most recent

14:46

products called the G7, and

14:48

then the Abbott Freestyle is the

14:51

other big system that's out there. They

14:53

make the Libre system, and they have

14:56

recently gone from the Libre 2 to

14:58

the Libre 3 as their most updated

15:01

version that has the transmitter and sensor

15:03

in one and all of those features.

15:06

I'll be honest, they're very comparable. They're

15:08

becoming less different across time. The

15:12

Dexcom system, the little

15:15

sensor rather, is it's popped on the

15:17

arm. The same thing with the Libre.

15:19

They're both rather popped on the arm with a

15:21

little, it looks like

15:23

a little pod that's handheld and there's

15:25

a firing button that it slaps

15:27

it against the arm. It uses

15:30

a small needle to insert the catheter.

15:32

I'll be honest, I put these on 15 new

15:35

patients a week. I mean, I have a startup

15:37

clinic I'm doing now because of the use picking

15:39

up. And no one's

15:41

ever said it's painful, ever. So

15:44

it makes kind of a quick sound.

15:46

And then the needle is withdrawn out

15:48

of this little auto device, and there's

15:50

a catheter that's left inside that allows

15:52

the glucose to be sensed by

15:54

the small chemical reaction. The Dexcom can be

15:57

worn for 10 days. Again, it's about the

15:59

size of two stat quarters and it's got

16:01

a sticker underneath. You wear

16:03

it through the shower, you can swim with it, no

16:06

issues there. If you scrub over

16:08

it, I guess it'll fall off. And then the

16:10

ab at Libre system can be worn for 14

16:12

days. So fairly similar. Jeff,

16:15

and with the sensor, you

16:17

said that it doesn't hurt. Is

16:19

it a sticker that they put on? They don't

16:22

see any needle, right? You put it on and

16:24

then you press a button and the needle puts

16:26

the catheter in and then the needle retracts, but

16:28

they're not going to see a needle, that kind

16:30

of thing. Totally. I'm trying to

16:33

think of a common object that would look

16:35

like this pod. You ever seen like a

16:37

Keurig? Yeah, like a K-cop? It

16:39

kind of looks like that. It's like a little

16:41

pod and then you peel this aluminum

16:44

kind of like if you're pulling the aluminum

16:46

off a K-cop, you basically are peeling off

16:48

and it exposes the internals of this mechanism.

16:50

And then that is just held against the

16:53

arm and the button on either

16:55

of these fires it into the, I will

16:57

say the Dux-Time has a button and the Libre,

16:59

you basically just push it against the skin

17:01

and there's a little mechanism that when you press

17:03

it against it fires. It fires. But

17:06

yeah, they're actually, so the patients are taught

17:08

to apply these themselves. If

17:11

you're not great with the dexterity or kind of,

17:13

they're usually put actually underneath the back of the

17:15

arm and when they're placed, the person trying to

17:18

think of how to describe how to hold the

17:20

arm. If you were to flex your arm, like

17:22

doing a make a muscle like a bicep. Yeah.

17:24

Yeah. Like you're flexing a bicep. You're kind of

17:27

holding your arm up like that and

17:29

you do want to keep the arm kind

17:31

of loose, but it's popped on the backside

17:33

underneath the arm. Yeah. It's better to do

17:35

it like this than try to turn the

17:37

arm because it actually stretches the muscle a bit.

17:39

And when you put it in, it can keep the

17:41

catheter when you turn your arm over. So you want

17:43

to have your arm kind of upright

17:45

in this, like I'm flexing my bicep sort

17:48

of position. Yeah. And then you pop it

17:50

underneath the arm. That's the tricep. Correct.

17:52

Right. And that's the best

17:54

way to place it. This

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for $50 off their first month. So

19:29

Jeff, before I sign up for a patient

19:31

portal, before I'm slapping things on the

19:33

patient's biceps and having people make muscles, can you

19:35

remind me who actually even qualifies for these in

19:37

early 2024? I'm not sure we actually said

19:40

that part out loud. Yeah, no, that's great.

19:42

And this is why we're getting together on

19:44

this. So back in around the April timeframe

19:46

of 23, the Medicare and Medicaid

19:48

updated the eligibility criteria

19:51

to cover these devices.

19:53

Prior, a person would have to be on

19:56

what we call multiple daily injection regimen, meaning

19:58

you had to be on multiple. shots

20:00

of fast acting and some long acting

20:02

insulin in the day. So these are

20:04

usually complex patients, many of them in

20:07

a subspecialty office like myself. In

20:09

April timeframe, they changed that to say

20:12

that patients that are on even just

20:14

one shot of insulin a day, so

20:16

basal insulin, so if you're on just,

20:18

you know, their glargine or any other

20:20

basal they use, they are eligible to

20:23

get insurance to cover this. And

20:25

so most insurance provider

20:27

system payers are falling

20:30

in line with that because they usually follow along

20:32

with Medicare, Medicaid. So I think

20:34

an important reason why we're talking about this

20:36

is that a lot of these tools were

20:38

only in the subspecialty clinics. And

20:40

I will say we've drastically picked up our

20:43

use of them because it's easier to supply

20:45

them and the insurance is just covering it.

20:48

I think these are going to hit the

20:50

primary care clinics a lot more because it's

20:52

the types of patients aren't going to be

20:54

those complex multiple injection users. You're

20:56

going to have people that are on maybe just

20:59

a basal insulin that will be acceptable to use

21:01

it. And there's some other little

21:03

criteria in there. So they have to be seen by the

21:05

doctor three months after it's put

21:07

on, and then they have

21:09

to be evaluated by the prescribing provider

21:11

every six months. The reason

21:14

for that is they want the tool

21:16

to be useful. And

21:18

so they want the pattern of the sugar being

21:20

evaluated and not just for the

21:22

patient's own inspection. I do think it's valuable for

21:24

the patient to look at the insights on their

21:26

own, but the insurance criteria

21:29

have that as an outlined step.

21:32

And then they have loose language in there

21:34

like the patient should be able to navigate

21:36

and use the technology and understand

21:38

the training. But yeah, I mean, a

21:41

lot of our patients can use these now. I

21:43

will say that there are studies that show it's

21:45

not yet approved for coverage, but

21:47

there are studies that show that people not even

21:50

on any insulin that get on

21:52

these devices, their A1C gets better on its own,

21:54

just putting the device on. So you may think,

21:56

well, how does that work? Like, what's the magic?

21:58

And it's just a good idea. that the patients

22:00

now seeing like, okay, well, I

22:02

eat a bunch of pizza and

22:04

my sugar goes, whoa, it really

22:06

hits this peak. The sugars most

22:08

people don't see are their postprandial

22:10

numbers, the after the meal numbers.

22:13

And when they can see these

22:15

big bumps in sugar after eating

22:17

something, a lot of people just

22:19

automatically change their eating behaviors. And

22:21

so yeah, I mean, these are great devices.

22:23

I really think the future state

22:25

of diabetes is going to be finger sticks kind

22:28

of go away. And part of

22:30

that's the accuracy of these devices has gotten

22:32

way better. I don't want to

22:35

get into the statistics of what I mean absolute

22:37

relative differences. But the

22:39

the MARD is how they tell us how accurate these

22:41

are. And they used to be

22:44

not useful enough for the patient to treat based on

22:46

the number, you can only only look at a pattern

22:48

and say, Oh, I see a pattern. All

22:51

of the modern devices are so accurate that

22:53

the FDA has said patients can treat based

22:55

on the number they see is accurate enough

22:58

to say if I see a high or

23:00

a low number, that's accurate and

23:02

I respond to it. And unless I

23:04

feel like it's off and need to do a

23:06

finger stick to check it, you can

23:08

just treat based on the number you see

23:10

on the device. Jeff, so what would I

23:13

order for our patient? Mr. H here, let's

23:15

say he wants to see GM, he saw

23:17

it advertised on TV. We

23:19

think that would be a good idea, because he's

23:21

not really keen on sticking himself more than once

23:23

a day. So what what would an

23:25

order look like? Like how long do they wear

23:28

the sensor? And what would

23:30

we order? Yeah, so the initial orders, depending

23:32

on the healthcare system you work in the

23:34

first order, if they're going to get the

23:36

reader I mentioned, like let's say he won't

23:39

use the smartphone, those often

23:41

have to be purchased through a

23:43

prosthetics department or through like the

23:46

discussion with a prosthetics workflow. Like

23:48

a DME company? Yeah, like a

23:50

DME. Exactly. And so those come

23:53

from there. The sensors though

23:55

come from pharmacy, and they can get

23:57

them from whatever pharmacy get they get

23:59

their medication. from. And so they,

24:01

you know, they, you basically would prescribe

24:03

either the Dexcom, which is going to

24:05

be three sensors, covers them for a

24:07

month. Usually these are done

24:10

for a month. I guess you could do

24:12

up to three months. I

24:14

usually have not done it that way. And I

24:16

think maybe I could get to doing that. Part

24:18

of that is there are some supply issues because

24:20

these are getting used up so quickly. I do

24:22

think the pharmacy is a little bit nervous about

24:24

handing out a big amount of these. Yeah. And

24:26

then having them kind of get lost or things

24:29

or something. They're fair. They have been in

24:31

the past really expensive. They're actually getting a

24:34

little bit more affordable to where if you wanted

24:36

one without insurance, you might even

24:38

be able to just buy them. I mean, if

24:40

they're not exorbitant. And some people

24:42

might just want to do it for a month just

24:44

to see what's what, right? And you just buy three.

24:46

So each sensor is 10 days. Yeah.

24:49

So for the Dexcom and then to go

24:51

to talk about the Abbott freestyle system, the

24:54

Libre system, those last for

24:56

14 days. So you need to write

24:59

for two sensors for the month. And

25:01

again, if they are not needing

25:03

a reader, they basically download the app

25:06

for either Dexcom or the Libre, whichever system

25:08

they're getting. The Dexcom has two apps they

25:10

need to get. They're getting the newest sensor.

25:12

It's going to be the G7 app. It's

25:16

on the Google Play Store and on the Apple

25:18

Store. And they need

25:20

to download their patient portal called the

25:23

Clarity. That's the cloud

25:25

basically. And they run both

25:28

apps on their smartphone. For

25:30

the Libre system, all they have

25:33

to do is download the Libre

25:35

and the app. It's called Freestyle

25:37

Libre 3. And they go

25:39

to the Play Store or the Apple Store

25:41

and they download it, install it. And it

25:43

walks the patient through. It actually has pictures

25:45

of how to put the sensor on, how

25:47

to pair it. They have to allow the

25:50

Bluetooth connection. It's actually

25:52

pretty self-explanatory. I will

25:55

say one of the things I'm

25:57

learning, and this is not meant to be

25:59

ageist at all, but a lot of

26:01

people of every age struggle

26:03

with like remembering a password that they make

26:05

for an account or and so this can

26:07

be actually a little bit of a challenge

26:10

for people that aren't you know using their

26:12

cell phone a lot and making accounts and

26:14

just some of the routine stuff that you

26:16

do when you set up an app but

26:19

you know a lot of individuals they really

26:21

want these they get family members involved if

26:23

they're not good with their device so

26:26

anyhow yeah that's how they

26:28

set it up okay so

26:30

the one meter is the Dexcom has

26:32

three sensors per month 10 days each

26:34

freestyle has two sensors per month about

26:36

14 days each and let's

26:38

say mr. H gets his he

26:41

gets his new continuous glucose monitor he's

26:43

wearing it now he's using his smartphone

26:46

and he comes back to see us like

26:48

what what are we going to be looking at what are

26:50

we gonna let's say we don't yet have a our

26:53

practice hasn't set up a portal for

26:55

providers yet so what would be the best

26:57

way to look at his data at that visit yeah

27:00

so like you'd mentioned the portals are a

27:02

useful tool partly because you can get the

27:04

data and then you can copy paste it

27:06

into your note which is nice but

27:09

if you don't have the portal set up you

27:11

can still do okay the patient can pull up

27:13

their smartphone and you can literally just you know

27:15

if they're okay handing their phone to you once

27:19

you pull up the app you can just

27:21

scroll through and look at the graphics of

27:23

the glucose there are daily trends there's a

27:25

lot of different things that the apps they're

27:27

frequently updating but they try to show

27:30

insights one of the pieces

27:32

of data that's probably the most important

27:34

is something that's called time and range

27:36

or TIR and you'll see

27:38

with the American Diabetes Association they've

27:40

put out the a1c target which

27:42

I think most providers are very

27:44

familiar with and the

27:46

time and range target to try to achieve

27:48

for most people would be to get the

27:50

gold glucose so between 100 so a

27:53

lot of them actually listed as 70 but

27:56

so between 70 to 180 is considered time and range And

28:00

you want to have them in that range at

28:02

least 70% of the time So

28:06

a good way to remember that so we all

28:08

have remembered a 1c of 7 You

28:10

know get less than 7 older sicker patients

28:13

between 7 and 8 to target But you

28:15

can remember time in range 70%

28:18

and you want to get in rain in range more

28:20

than 70% of the time It

28:23

will also each cgm will list out to

28:25

you right on the front page and it'll

28:27

be on his smartphone It'll give

28:29

you the amount of time that he's low and

28:31

very low and you certainly just want to minimize

28:33

those I mean less than 3% in

28:36

the low would be great in the

28:38

very low It should be 0 if you can

28:41

those are dangerous And then

28:43

it'll tell you the amount of time hyperglycemic And

28:45

obviously if time in range is going to

28:47

be more than 70% the hyper and very

28:49

hyperglycemia You'd want

28:51

to have just less than 30% of course, and

28:54

so you can just quickly inspect the statistics.

28:56

So it's pretty easy And then

28:58

you'll look at the daily graphs and

29:01

this is where it gets to be a difficult

29:03

If the patient has not been doing a little

29:05

journaling, you know You can try to have them

29:07

go through and say okay, even if they haven't

29:09

been you can say, you know Walk me through

29:12

a usual day. You'll often see some bumps maybe

29:14

around breakfast or lunch or dinner You

29:17

might see the the graphic, you

29:19

know drop out overnight and those

29:21

all will give us insights We'll talk about in

29:23

our pattern management on our talk here But

29:26

you can still use that information and

29:28

say What do

29:30

you think you're usually doing and then try to pin

29:32

down what the medications and activities are doing to their

29:35

sugar It's ideal to have a

29:37

little bit of some journaling of well, here's

29:39

what I've been eating. Here's my exercise time

29:41

I remember being low at this time and

29:43

I was like cutting the lawn a long time or whatever it

29:45

was I want to

29:48

say something else just quickly to

29:50

time in range is very Important

29:52

more so than an A1c it

29:55

responds more quickly to our medical

29:57

interventions Any changes we do for the

29:59

patient? We know in A1C it's

30:01

a three month capture. Time and range

30:03

is your glucose now, and

30:05

in particular for the last testing period. So if

30:07

it's a Dexcom, it's the last 10 day

30:10

sensor or the last 14 days

30:12

on the Libre. I

30:14

will say the other thing about

30:17

CGM's is they reflect glucose variability,

30:19

whereas in A1C doesn't. So

30:21

I could have a glucose that is like 126

30:23

all day and all night. It's the only

30:26

time in medicine

30:29

we like a flat line.

30:31

It is a graphic of my

30:34

glucose across the day. But if I was

30:36

126 across the day, my A1C would be a

30:38

six. Or I could be

30:40

like 60s and like 250s, like back

30:42

and forth, back

30:45

and forth, and I could still look like an A1C

30:47

of six. And so A1C

30:50

doesn't reflect glycemic variability. And

30:52

a lot of times the thing or six people do

30:54

aren't enough to show that either. And

30:56

then the last thing I'll say

30:58

is that the CGM's are not

31:01

affected by physiologic or pathologic factors

31:03

that will affect the A1C. So

31:06

we talked about this a lot before,

31:08

but just briefly, you know, if I

31:10

have an iron deficiency

31:12

anemia and my red cells are

31:15

circulating longer, they will build

31:17

up sugar and falsely elevate the A1C.

31:19

None of that stuff affects the CGM. And

31:23

so there's none of those factors. Now

31:25

I will say there are some factors

31:27

that can affect the sensor readings, and

31:29

those are explicitly updated by the sensor.

31:32

So high dose vitamin C is one

31:35

thing that can affect the sensor.

31:37

There's a variety of things that

31:39

they continually list for these sensors

31:42

as they improve the sensors that can interfere

31:44

with readings. But yeah, those are

31:46

key items about it. And

31:48

Jeff, as I'm being attached to my cat here for

31:50

the people who are just listening, so it's nice to

31:52

have these trends. I'm sure these graphs are extraordinarily helpful,

31:55

but if someone is saying they're very low, do these

31:57

things have the capacity to alarm in real time? Same

31:59

thing for August. So you didn't mean hyperglycemia.

32:01

Yeah, qualifications or that kind of thing.

32:03

You picked up on probably one of

32:05

the most key features of these that

32:07

is helpful for patients. So yeah, you

32:09

can adjust the alarms too. So

32:12

ideally if they're using a smartphone or

32:14

even with a reader, they'll have an

32:16

alarm and you

32:18

can set it for whatever sugar you want.

32:21

So if your individual tends to get in

32:23

trouble kind of fast, you could set the

32:25

low alarm at like 90. You

32:27

don't have to wait till they get to 70. So you

32:29

can adjust that. And the alarm can make their

32:32

smartphone buzz. It can have their

32:34

alert go to a family member. So

32:36

you can have lots of safety kind of built

32:38

in. I will say one of the things I've

32:40

noticed is that for my people, I'm trying to

32:42

help their sugars when they're kind of getting high

32:44

sugar a lot and they're getting their alarm going

32:46

off a lot. It's default at

32:48

250, which a lot of our

32:50

patients are struggling above that until we are helping

32:53

them get down. But they kind

32:55

of are like, oh, this thing's alarming all

32:57

the time. I'm just gonna turn it off or

32:59

put it in the other room. And I don't

33:01

know why I made an older person kind of

33:03

voicing there. I'm sorry if I'm not very, not

33:05

trying to be eudis. But

33:07

it really brought me there. I felt like

33:09

I was in the room with the patient.

33:11

It was incredible. It's just a grumpy voice,

33:13

but it's like, get this thing out of

33:15

here. Well, if they just get rid of

33:17

it, that's not helpful. So

33:19

if they're struggling with, I'll just tell them temporarily,

33:22

let's get that high number. And you can also

33:24

reset that to a higher number. But

33:26

yeah, you've keyed into one of the key

33:28

features is that when you're doing finger sticks,

33:30

you're only poking your finger when you think

33:32

that you should be, or if I'm feeling

33:35

kind of sick. Whereas this

33:37

is constantly chucking the sugar. One

33:39

last thing I should say though also is

33:42

that the continuous glucose monitor, it's

33:44

not testing blood sugar. It's actually

33:46

testing interstitial fluid. And

33:48

that is in an equilibrium with our blood

33:50

sugar, but it's about 15 minutes

33:53

delayed from what the blood sugar is.

33:55

So let's say my blood sugar is

33:57

like screaming down. I took a bunch

33:59

of. insulin, I haven't eaten enough and my

34:01

sugar's like screaming down. By

34:03

the time the CGM, which

34:05

is, again, 15 minutes delayed,

34:07

is showing some alert signs,

34:10

my blood sugar actually might be much

34:12

lower already and in a hypoglycemia causing

34:15

some health problems. So that's one of

34:17

the reasons why for people that struggle

34:19

with that, I will try to get

34:21

their low alert to set to a

34:23

higher point so we can catch it

34:26

before we get way down into the

34:28

lower numbers. They are constantly

34:30

improving these CGM's so that period of time

34:32

of delay is getting shorter and shorter but

34:35

it's usually listed somewhere between 10 to 15

34:38

minutes delayed. So the delay is not a

34:40

big deal if your sugar, like you said,

34:42

is the ideal where it's just kind of staying

34:44

similar because it will be the same 15 minutes

34:47

from now as it is now. But if it's

34:49

screaming up or screaming down, then you're going to

34:51

be behind what's

34:54

actually happening. Yeah, and that's

34:56

one of the key pieces of teaching

34:58

that patients get. Another brief piece of

35:00

teaching that you might think, why is

35:02

having more data harmful to a person?

35:04

Like why would that ever be bad?

35:07

So if a person has fast acting insulin, a

35:09

lot of our patients, they really want to

35:11

have better blood sugar. When

35:14

you think about what you're doing with a finger

35:16

stick, you're usually testing before your meals. And

35:18

usually if I'm testing, like let's say, for example,

35:21

breakfast, lunch and dinner, it's kind

35:23

of naturally spaced like four to six hours

35:25

apart. Fast acting insulin,

35:27

like Aspart or any of the other

35:29

fast actings, its duration of

35:31

action is four hours. So

35:34

its onset is 15 minutes, its peak is an

35:36

hour, and it's often four hours. So

35:38

between my meals and my testings,

35:40

I'm going to be okay not

35:42

stacking the insulin. An issue with

35:45

the CGMs that I've noticed and part of the

35:47

teaching for patients is if I am

35:49

checking my sugar all the time, I'll have patients

35:51

that like, say, eat their breakfast, they take their

35:53

fast acting, and then like an hour or two

35:55

later, they're like, oh, dang, my sugar is like

35:57

250, 300. Well, I'll

35:59

just take some more insulin. I got to get this

36:01

thing fixed and I'll take a dose and then an hour

36:04

later they'll look, ah it's still kind of high, I'll take

36:06

a dose. Well the breakfast

36:08

dose hasn't had its fullness of time

36:10

to work and so they're stacking insulin

36:12

doses because they're doing their insulin before

36:14

that full four hours is done. That

36:17

is one of my concerns with these

36:19

devices and patients that's a safety feature.

36:21

People have to be told you know

36:23

follow the regimen, show us the patterns,

36:25

you know don't start taking any extra

36:28

insulin in that, okay. So that's a big

36:30

one to bring out. Alright well let's start getting

36:32

into some patterns Paul. So Paul do you want

36:34

to read the first first pattern here? You can

36:36

read the case and we'll talk about it.

36:38

Sure. So we'll talk about Mr.

36:40

Age again. So we'll say his CGM shows his

36:42

glucose is above 180 to 200 milligrams per deciliter

36:45

after lunch and bedtime. So his blood sugar will

36:47

actually dip to 65 milligrams per

36:49

deciliter overnight and in the morning he's got these

36:51

kind of nice fasting blood sugars of 100 to 130 milligrams

36:53

per deciliter. So we've uncovered he's

36:55

having some nocturnal hypoglycemia. How do we troubleshoot this?

36:57

What kind of adjustments can we make? Well first

37:00

just to say it's amazing that the CGM picked

37:02

up on it. So normally you

37:04

know you're not finger sticking in the middle of

37:06

the night unless you're actually woken by the low.

37:09

Lows usually do wake people. You know

37:11

you've got a few mechanisms that a

37:13

healthy person so number one the beta

37:15

cells stop making insulin. Number two glucagon

37:18

is released by the alpha cells cause

37:20

liver to release its

37:22

glycogen storage. Then you

37:24

get into three and four which is

37:26

growth hormone and cortisol release. Those are

37:28

some stress hormone responses and the person

37:30

usually will wake from those. Cortisol wakes

37:33

us. It's the hormone that wakes us

37:35

in the morning and it raises sugar

37:37

and the fifth response

37:39

of hypoglycemia is

37:41

the fight-or-flight hormones from the adrenals. So

37:44

your epinephrine or epinephrine which causes your

37:46

shakiness and you are a

37:48

kind of high alert state. Those usually will

37:50

wake the patient and those people might finger

37:52

stick but we caught this pattern now with

37:55

the CGM and so I'm

37:57

curious to know what he's been doing. Some

37:59

people they're not responding at all and

38:01

those counter regulatory hormone systems are just

38:03

bringing the sugar up on its own.

38:05

I interestingly had a patient ask me in clinic

38:08

recently they said is that okay if

38:10

I'm not like staying low if I just let my

38:12

body fix it? It is not. All

38:15

of those hormones are damaging. I was

38:17

like please don't do that. I mean

38:19

not only do you feel terrible hypoglycemia

38:21

is a very it feels terrible

38:23

but it's damaging and it's dangerous it's

38:26

a stress test on the heart and

38:28

it over time recurrent hypoglycemia can cause

38:30

brain damage and dementia risk. So

38:33

anyhow the rule of 15 is a person's instructed

38:35

to eat 15 grams of carb which

38:37

is usually four glucose tablets or

38:39

four ounces of juice or regular

38:42

soda and then you wait 15

38:44

minutes and test and so you can

38:46

follow your CGM you know you can have them

38:48

take their sugar treatment and follow the CGM. I'm

38:51

just curious to know what this guy has been doing has

38:53

he been riding it through the night or had no idea

38:55

and then it's just brought up in the morning or

38:58

has he been eating stuffs in the middle of the

39:00

night because he's low and so that I do want

39:02

to address how he's doing it do good hypoglycemia teaching

39:05

with him and then you want

39:07

to reduce his basal insulin. So we had mentioned

39:09

he's on netformin and he's on basal. Some

39:11

individuals like he's got CKD3 I would wonder

39:15

is his kidney disease kind of progressing and

39:17

therefore the basal insulin hanging around longer and

39:19

causing him to get low in the middle

39:21

of the night so you want to reduce

39:23

his basal insulin and that's gonna be step

39:25

one. You know what's fascinating is sometimes

39:27

when you do that if I you

39:29

lower his insulin and you know like

39:31

this guy's A1c is 8.6 you're telling

39:33

me to reduce his insulin are you

39:36

nuts or what kind of doctor you it's

39:39

fascinating sometimes you'll see their A1c go down

39:41

and you're like how is that possible well

39:43

if he's low every night and he's eating a

39:45

ton of sugar to bring it up that's gonna

39:47

be blasting his sugar up or

39:50

just all the counter regulatory hormones I

39:52

mentioned they actually for about 24 hours

39:54

create a physiologic situation of

39:57

insulin less responsiveness so insensitivity

40:00

So, for an entire day after the

40:02

low event, his body does a less

40:04

good job responding to insulin, which can

40:07

be raising his sugar too. So

40:10

just by lowering the basal,

40:12

preventing the nocturnal hypoglycemia, you're

40:14

going to lower this guy's A1c. So this

40:17

is, I'm glad that you made this the first

40:19

case, this is a common concern. Hypoglycemia

40:22

has been a priority for all of

40:24

the guideline organizations, and we

40:26

want to not over-treat him. Now later on, if

40:28

he has highs in the day, that

40:31

would indicate we should add some

40:33

other medications, and we'd probably be

40:35

considering if it's postprandial highs, a

40:38

GLP1, an Oscillative inhibitor, or

40:40

a prandial dose insulin, would be our usual

40:42

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41:43

I love that. The number of patients that I've

41:46

had that will endorse having just the worst possible food

41:48

manageable on their bedside stand for when they become like

41:50

a gloisty makeover night and then sort of counterbalance it

41:52

by eating like haves levo boreos. Like, you don't,

41:54

I can't fault them, but also, we're not helping. When

41:56

you're low, you're just going nuts. It's hard to just

41:58

eat a little bit. Yeah, and Paul

42:01

I had no idea that the

42:03

insulin resistance for 24 hours That

42:05

is probably protective because your body's like oh,

42:08

I almost died I don't want

42:10

insulin to be able to do its job as well because that could

42:12

kill me So that seems

42:14

like it's a good it's it's

42:16

good that that's built in but you know if

42:18

you're trying to control diabetes That's that

42:21

works against you and that's why priority

42:23

one and in the pattern recognition for

42:25

CGM patterns is to number one Address

42:28

lows and make modifications to the regimen

42:30

to reduce the lows before we even

42:32

start trying to do other things And

42:35

it's just so surprised so many times. I've

42:37

seen people's a onesies get better by reducing

42:39

regimen Yeah, and it's just safer, too. Okay.

42:42

All right, Paul. We have another case for Jeff You

42:46

bet your sweet Bippi what oh so we have

42:48

mr. H. I think it's gonna be mr.

42:50

H No, it's not mr. H all day long, but mr.

42:52

H joins a gym good for him starts Orange Theory shout

42:54

out uncle Bob He's doing workouts every

42:57

afternoon around 3 p.m. He had

42:59

to stop several recent workouts because he's having some nauseans

43:01

and business He has not checked his blood sugar during

43:03

these episodes, so We now have

43:05

the CGM so could possibly do some detective work But if

43:07

we didn't sir what would you think would be happening and

43:09

what we can do to make some adjustments here? Yes,

43:12

I'm glad that we're staying in the hypoglycemia Kind

43:15

of thinking pathway and so it seems like we've primed

43:17

this up for us to know what's happening Like

43:20

I mentioned one of the hardest things is just

43:22

seeing patterns of sugar and not knowing what were

43:24

the events And so this is where what

43:26

if he had been doing some journaling to

43:28

say here I'm doing orange theory at

43:30

this time and then his CGM is

43:32

showing these dips down after the

43:35

exercise What's interesting is that

43:37

for people? intense physical

43:39

exercise It can actually

43:41

for the first 30 minutes raise blood sugar

43:43

And then after you go for

43:45

longer than an hour of exercise the blood

43:47

sugar will tend to go down and become

43:49

hypoglycemic And for up

43:52

to five hours after exercise you

43:54

are more insulin responses So your

43:56

insulin sensitivity improves and you can

43:58

have hypoglycemia for up to five

44:00

hours very related to the

44:02

exercise. And so I think you've

44:05

given a good stem here to say he's

44:07

probably the workout, he's got the symptoms, but

44:09

we didn't have the data. He's on the

44:11

CGM. And so what can we do?

44:14

And so for this gentleman, again, we

44:16

might choose it's the same gentleman with

44:18

the glargine and the metformin, we might

44:20

decide to reduce some of his basal

44:22

insulin, maybe now he's actually in

44:25

a better health pattern, and he doesn't need as much

44:27

of that. And because of this

44:29

exercise, and so you just need

44:31

to again back off his regimen and then use

44:33

the CGM to detect areas to improve. But

44:36

that's how I'd start with him. Yeah, do

44:38

you ever have patients take a snack before

44:40

exercise? Is that something that sometimes people have

44:43

to do? Yeah, it's more so

44:45

type ones, but type twos as well. I

44:47

mean, anyone on insulin at meal times are

44:49

more of the risk to have the lows

44:52

like this. If they

44:54

are getting lows after exercise, the best snack

44:56

and your food preference will dictate but there's

44:58

been papers on having a person take a

45:00

half banana and add some peanut butter to

45:03

it. If you don't like peanut butter and

45:05

bananas, then I can't. There's other

45:07

things you can try. But okay. Yeah,

45:09

like kids like it. So I mean, it's like

45:11

you kids eat nothing and they'll eat this. So

45:13

like, it must be good. But

45:16

the reason the rationale is that there's a

45:18

complex carb, that's going to break

45:20

down slow and you have some protein and fats,

45:22

you have a mixture of foods. You

45:24

don't want to like drink Gatorade. You don't want to,

45:26

you know, just taking sugar itself.

45:29

It actually does poorly because you just get

45:31

a big spike up, you can just crash

45:33

afterwards. So it's just not that helpful. So

45:35

it's usually going to be something that's like

45:37

maybe there's a lot of different protein bars

45:40

out there. They usually have a

45:42

mixture of protein, fats and sugars. Those might

45:44

be actually okay, like a little protein

45:46

bar could be good. A

45:49

lot of them have a lot of jargon. The wrong- The

45:51

wrong- Yeah. The Ron Burgundy milk approach might

45:53

be worthwhile here and you get your protein,

45:55

you get some sugars in there. Yeah, maybe.

45:58

I'm We won't

46:00

endorse that, but yeah, there's,

46:03

I think that's actually a good strategy, Matt,

46:05

is to have a little snack that you

46:07

don't necessarily treat with more insulin on, and

46:10

that can carry them over, versus just trying

46:12

to have them drop some insulin somewhere, reduce

46:14

some of their dose. Yeah.

46:17

And, but a lot of people may not know, oh, I'm

46:19

exactly going to exercise at this time, they've already got the

46:21

insulin on board. Right. So what do you do? You

46:24

take a snack. Okay. Yeah. So,

46:27

you know, hypoglycemia land, if someone was on

46:29

a sulfonylurea and maybe not

46:31

insulin, but there's still, I've still had

46:33

some patients not on insulin having that

46:35

nocturnal hypoglycemia. Like if they're on the

46:37

twice a day sulfonylurea, do you knock

46:39

out the evening dose or how do

46:41

you troubleshoot that? Yeah. It's funny,

46:43

it's going to be tricky because, you know, they're supposed

46:45

to be taken with food because they do have

46:48

that immediate insulin release of the beta cells

46:50

that they're, that what, that's what they're doing.

46:52

Some of them can cause a lingering effect on

46:55

the beta cell. It basically poisons

46:57

the little potassium channel that allows

46:59

the beta cell to glucose detect.

47:02

So instead of having the beta cell say, hmm, I

47:04

wonder what the sugar is. Okay. It's

47:06

about here. I should make more insulin. It just

47:08

says blast out insulin. And some people,

47:10

there's a prolonged effect of those drugs, usually

47:13

in renal failure patients and in the elderly.

47:15

So, yeah, I would try to get away from that

47:17

drug for a patient having that issue or maybe like

47:19

you say, drop the evening dose. And

47:23

if you can, I mean, so

47:25

find a reason to cause weight gain. They

47:27

don't have added organ benefit outside of the

47:29

sugar lowering. So we all know

47:31

that probably the only reason we use that nowadays is

47:33

because a person doesn't have good insurance to cover the

47:36

better products. So I

47:38

find it's pretty tough on Medicare, like Medicare,

47:40

the newer agents are really tough for a

47:43

lot of patients on Medicare to get, I

47:45

guess because of the donut hole, the co-pays

47:47

tend to be really high. Yeah. We

47:50

talk all day about the medication costs, but

47:52

– Yeah. Okay. Yeah.

47:55

All right. Thank you. So

47:57

we'll go on to another, Paul. I think we have another case here for Jeff. Sure

48:01

enough, we got Ms. J. She's

48:03

a 42-year-old female. She weighs

48:05

90 kilograms. She has obesity,

48:08

hypertension, dyslipidemia, metabolic-associated steatotic

48:10

liver disease, and type 2 diabetes.

48:12

She takes Metformin XR 2000 milligrams

48:15

daily and Degladac 25 units every

48:17

morning. Her bedtime glucose is

48:19

anywhere between 180 to 250 milligrams per

48:21

deciliter, and her fasting glucose is 80

48:24

to 130 milligrams per deciliter. She

48:26

does not check after meals, and her last

48:28

A1c is 99%. So we have this patient

48:30

who's got pretty good fasting blood

48:32

glucose, but nighttime

48:34

sugars are up. So how do we troubleshoot this, and

48:36

what kind of things can we go after here? So

48:39

a couple of things. She's 42. Maybe

48:42

on the young side, average age of type

48:45

2 diabetes is

48:47

49. So I might kind of investigate some

48:49

type 1 antibodies. Nothing in the stem overtly

48:51

says, but I'm just going to mention that.

48:54

I like how you updated the non-alcoholic

48:57

fatty liver to the metabolic-associated. They keep

49:00

changing that terminology, but I'll try to

49:02

keep up, but you did good with

49:04

that. So, okay, try to get on

49:06

track here with, you know, she has

49:09

what looks like a glucose pattern where

49:11

she's doing fine fasting, and this is

49:13

actually frequently the case for patients because I

49:15

think we're most comfortable with and start with

49:18

medications like basal insulin, and she's on

49:20

the Metformin. And those are mostly going

49:23

to affect fasting sugars. Metformin

49:25

works by decreasing the hepatic output

49:27

of sugar, so that's mostly fasting

49:29

effect. Dr. DeFranzo, who's one

49:31

of the big wigs in

49:33

diabetes, he does not think that

49:36

Metformin is an insulin sensitizer, although we've all learned

49:38

that in med school, and he has a lot

49:40

of talks on this. And then Douglas

49:42

Deck, of course, is a basal, and both of those

49:44

are directed at the fasting, which look good. But

49:46

this person's A1c is elevated above target.

49:48

You know, 9 would be certainly above

49:51

anywhere she should get at her age.

49:53

And then her bedtime glucose is a

49:55

clue that she's building, building, building sugar

49:57

across the day, which is because she's

50:00

eating in the day. And so the

50:02

CGM can help because it can show

50:04

you which meals are mostly problematic and

50:06

the patterns of high. And again, you

50:09

could choose to start a number of

50:11

agents, like we'd mentioned, SLC2, GLP1, even

50:13

DPP4 inhibitor maybe, probably not going to

50:15

get the A1C down enough with that

50:17

one, or potentially prandial insulin to attack.

50:20

And usually I would start with the

50:22

biggest meal. So it'd be nice with

50:24

the CGM to say, okay, well, your

50:26

sugar is like the highest after breakfast.

50:28

Sometimes that's the case. We are most,

50:31

the most insulin resistant after breakfast due to

50:34

cortisol waking us in the morning. And

50:36

then breakfast foods tend to be carbohydrate heavy,

50:38

you know, cereals and pancakes

50:40

and things tend to hurt

50:42

people's sugars a lot more. Now it could be

50:44

that dinner, the biggest meal. And so again, a

50:46

little bit of a log from her, a CGM

50:49

could help us a lot. And

50:51

I think she's having some postprandial hyperglycemia. And

50:53

like I'd mentioned, there's a lot of ways

50:55

you can approach that. And Jeff,

50:57

I just wanted to mention, because you mentioned the daily

50:59

readings on the CGM and correct me if I'm wrong,

51:01

but it gives you like a graph,

51:04

right, where the y-axis is

51:06

blood glucose, and the x-axis is

51:08

the time of day, right. And

51:11

then it'll show you like a whole week or a whole

51:13

10 days, and it'll kind of give you a range like,

51:15

okay, at breakfast, they tend to be in this range. And

51:18

it shows you if they have times that are really

51:20

high or really low throughout all those.

51:22

So you kind of get this sort of like, it's

51:24

almost like a wave across the page,

51:26

right? Yeah. This is what we'd

51:28

be looking at if she had a CGM. Yeah,

51:30

it'll do it. It'll show you all of these

51:32

will have, they'll show you a stacked overlay, which

51:36

will show you the overall pattern. So you can

51:38

say, Oh, it looks like you're high, like every

51:41

morning. And then you can actually go down and

51:43

look at the daily pattern for the last in

51:45

the testing period. So you can see, like, let's

51:47

say their weekend is they're much higher because they're

51:49

doing other weekend activities that they don't do in

51:52

the week. So you can kind of break it

51:54

down by the day for the person. Okay.

51:56

It's really interesting. There's, there's some studies showing

51:58

that people like not on any. Although

52:00

this is not currently where the approvals

52:02

from insurance pay for these devices But

52:04

not on any insulin their a1c's get

52:07

better just because without doing anything special

52:09

Just giving it to the patient Because

52:11

the person is looking and saying oh I

52:13

eat that and my sugar goes up like

52:15

that and they're seeing it real time And

52:17

the graphic they tend to make some different

52:20

food choices and so yeah, it's helpful for

52:22

that And then one other

52:24

follow-up question you mentioned So

52:26

thinking about postprandial hyperglycemia

52:30

I always try not to start a prandial insulin

52:33

for my patients with type 2 so you mentioned

52:36

GLP1s SGLT2s and

52:38

and maybe DPP4s probably have

52:40

probably have a less of

52:42

insulin lowering effect Would you

52:44

would you say the GLP1s have the most

52:46

effect and then the SGLT2s and the DPP4s

52:48

if you're kind of looking for To

52:51

control postprandial hyperglycemia? Yeah, I think

52:53

that's correct the GLP1s and particularly

52:55

some of the newer products coming

52:57

out That have the

52:59

additional receptor functions

53:02

the GIP GIP-1 So

53:07

tears appetite and then semaglutide and

53:09

dulaglutide there's several of the GLP1s

53:11

that are very good And yeah,

53:13

they do a great job with

53:15

decreasing appetite They have mechanisms that

53:17

are central to nervous system and

53:19

brain responsiveness to nutrition to decrease

53:22

food seeking behaviors in

53:24

addition to lowering liver sugar output

53:26

and Decreasing

53:28

the speed at which foods process in the

53:30

GI tract Which is where most of the

53:32

side effects come from because you're getting some

53:35

GI slowing the SGLT2 inhibitor It just lowers

53:37

the renal threshold to reclaim glucose so

53:40

if you have a big spike after a meal the

53:42

kidneys will have a Easier time

53:45

off loading the sugar through

53:47

the urinary system But it

53:49

does seem to have less impact on postprandial

53:51

glucose But to be honest if you can

53:53

get them on both products and it's hard

53:55

sometimes with insurance could help a lot and

53:57

both have a weight losing and All

54:01

of the added cardiovascular renal benefits that we

54:03

know for both of those products Okay.

54:06

All right. So so we can definitely

54:09

help miss miss Jay with her postprandial

54:11

hyperglycemia With that.

54:13

All right, Paul any let's go. Let's

54:15

go to the next iteration All

54:18

right still miss Jay. She

54:20

stole metformin still on deglidic 25 units

54:22

every morning But in this scenario

54:24

her baseline her I'm sorry I should say her

54:26

bedtime glucose is less than 180 200 milligrams per

54:28

deciliter Fasting glucose

54:31

is imperfect at 150 to

54:33

200 milligrams per deciliter and her last

54:35

day one C is 9% So what what

54:37

did this pattern suggest to you Jeff and what kind of things

54:39

we do this weekend? Yeah,

54:41

so I'll just say dougleduck may not

54:43

be a basil that people are as familiar with it's

54:46

it is a basil that has been designed to

54:48

try to have a Longer half-life

54:50

and duration of action and so that it

54:53

has the time can be moved around and

54:55

potentially has last peak effect Particularly when heavy

54:57

doses are used. It's mostly used for people

54:59

that have type 1 not so much, but

55:01

you can use it for anybody But

55:04

anyhow just maybe one people aren't

55:07

as familiar with but you know You're mentioning

55:09

that her bedtime glucose is actually doing really

55:11

well and that her fasting sugar

55:13

is Looking

55:15

a little bit higher and so

55:17

this is an individual that might actually

55:19

need some more basil insulin Yeah Because

55:22

it seems like between the time at

55:24

her bedtime and when she's waking up

55:26

We're seeing the numbers kind of rising.

55:28

I mean so this individual,

55:30

you know She's we didn't mention metformin

55:32

dose, but we could have her go

55:34

up on the metformin You know the

55:36

max is a thousand twice a day.

55:38

So 2,000 total or if

55:41

you're using metformin extended release They can technically

55:43

take all of the 2,000 at one time

55:45

some people that get GI upset from that

55:48

But that's technically permissible to do and then

55:51

or we could dial up on her

55:53

basil insulin her her deglidek It's

55:56

interesting. Although, you know, the GLP 1S Lc2

55:58

are mostly directed

56:00

against that a lot of their

56:02

action is at the postprandial time.

56:05

Introducing either of those

56:07

agents potentially can help this individual as well.

56:10

So those wouldn't be you know out of

56:12

the the routine to consider for

56:14

the patient. But yeah I think

56:17

we have to try to figure out you

56:19

know she's snacking at nighttime or is

56:21

this just a rise that's occurring overnight because

56:23

her basal medications aren't strong enough.

56:26

But yeah she's on the two right products that

56:28

probably just need to be brought up potentially. Jeff

56:31

you gave us a bunch of options there

56:33

and you know I know your

56:36

mentor one of your mentors in diabetes always

56:38

says that there's what what he liked about

56:41

doing diabetes care was that there's always more than

56:43

one right answer or usually more than one right

56:45

answer. So yeah

56:48

and that can frustrate people that

56:50

are trying to practice diabetes care

56:52

because in medicine you know we

56:54

can feel a little

56:57

bit we want to seek the best thing for

56:59

our patients of course and when it seems like

57:01

there's just so many potential options we

57:04

maybe scare ourselves out of being involved

57:06

because we're worried we're making the wrong decision. I

57:09

will honestly say that you know there

57:11

are just so many right ways you

57:13

can go it's what the patient also

57:15

is willing to do. Sometimes

57:18

very complex regimens are difficult their work

57:20

life and home life their finances did

57:22

paid a lot. And so whenever I

57:24

see a case brought to

57:26

me as a subspecialist you know whatever

57:29

things had come about for a person to be

57:31

on what they were on we're just

57:34

what it had to be. There's just so

57:36

many factors to just talk about that are

57:38

involved in the decision-making but you're exactly right

57:40

and that's why we look for curbsites or

57:43

for a subspecialty consult so that

57:45

you can get them to the next step if it's

57:47

not working out. Can I ask

57:49

for the metformin XR

57:51

the extended release one if I

57:53

prescribe two 750 milligram

57:56

tabs or I believe that's

57:58

the highest the biggest strength rather rather

58:01

than prescribing four or five hundred milligram tabs

58:03

do you think there's a big difference between

58:05

like a 1500 milligram total

58:07

daily dose and a 2,000 milligram total daily

58:09

dose because yeah it's

58:11

a great question I don't think there's much

58:13

difference between them technically guidelines say to try to

58:15

get people to the maximum tolerated dose but just

58:18

clinically I don't think there would be a big

58:20

difference yeah and you're right we want to hone

58:22

in on what's more doable sometimes taking more pills

58:25

it's really interesting we talk about diabetes distress you

58:27

know diabetes is a lot of work it's intrusive

58:29

to your food and just I

58:32

think it's on people's minds a lot

58:34

lately there's all of these you know

58:36

magic cures for body weight now and

58:38

the medications aren't that actually they're very

58:40

helpful much more than had been in the past but

58:42

we put a lot on people and

58:45

I think I don't know I just I'm gonna make a

58:47

broad statement but I just feel like people are very stressed

58:49

nowadays and diabetes is just

58:51

seems like just another thing that's constantly intrusive

58:54

to your day and always thinking about it

58:56

and so yeah I think simplifying is good

58:58

I don't know Paul do any of your

59:00

any your patients like taking like four horse

59:03

pills every day no

59:05

no one's no one's clamoring for more gigantic

59:08

bills in their day yeah okay

59:10

yeah we'll throw a little potassium supplement in there

59:12

too just can't get enough well

59:15

I think we have one more scenario

59:17

here sure we've got

59:19

mr. V is a 71 year old male with

59:22

type 2 diabetes high blood pressure obesity CKD 3b

59:24

with an albumin creatinine ratio of 60 he weighs

59:27

110 kilograms and takes clip design

59:29

XL 10 milligrams daily dead a

59:31

mere 10 units twice daily he

59:34

cannot tolerate metformin his

59:36

blood sugars are in the 200s and

59:38

300s basically all the time whenever he happens to check

59:41

he brings in a log of two weeks of

59:43

finger sticks that show both pre and post prandial

59:45

hyper hyperglycemia I should say so where do you

59:47

start with this patient Jeff so a

59:49

lot of times when the my residents or

59:51

students or fellows are presenting to me you

59:53

know they'll come with this graphic and the sugars

59:56

are all really high and the students trainees very

59:58

distressed and like ah it's just high everywhere and

1:00:00

I'm like, oh, this is a great pattern. You

1:00:02

know, we just, we need to, we know we

1:00:05

need to add medicine or have them take the

1:00:07

medicine that they're on. But when it's like a

1:00:09

mixture of lows and highs, those are very challenging.

1:00:11

Cause it's like, okay, what, what

1:00:13

lows are prompting highs. And then it's

1:00:15

like, but the high all the time

1:00:17

fasting and postprandial hyperglycemia is what this

1:00:19

person's having. That's very doable. We,

1:00:23

you included in the script, and maybe I should

1:00:25

have tied you ahead of time, but this will

1:00:27

be a good teaching point that they're on Detemir

1:00:29

10 units twice a day. Well, Detemir is actually

1:00:31

going off the market. The company that make manufacturers that

1:00:33

is no longer going to produce it. So you'll

1:00:35

never, so that'll be an easy change we have to

1:00:37

make. We got to get off that. Good

1:00:40

riddance. Yeah. I think good

1:00:42

riddance, Paul. I think it's, I think this

1:00:45

month or next month's going to be the last. So you can

1:00:47

actually technically even get it. So I mean,

1:00:49

we'll probably put them on a bit once a

1:00:51

day, basil insulin, so that'll make life easier than

1:00:53

being on a twice a day. You

1:00:55

often don't need to do twice a day. Sometimes

1:00:58

when you get really high doses of basil,

1:01:01

like above 80 units of glargine, which is technically

1:01:04

as high as you can twist the pen up

1:01:06

to, we try to split it twice a day,

1:01:08

but often you don't have to do that.

1:01:11

So let's get back in on the case here. He's

1:01:13

not tolerating metformin. He's on the

1:01:16

Glipizide XL, which as a older

1:01:18

person with CKD, not my favorite

1:01:20

choice. And he's got sugars

1:01:22

that are two and three hundreds all the time,

1:01:24

high in the morning fasting and

1:01:27

after meals. You might want

1:01:29

to see like, is he some, a couple of things I'm

1:01:31

going to look for with the CGM. So

1:01:33

if he's going to bed with

1:01:35

a sugar of like, let's say 250

1:01:38

and he's waking up in the morning with a sugar of

1:01:40

like 170, 180, well,

1:01:43

even though he's technically hyperglycemic in

1:01:45

the morning and like postprandial in

1:01:47

the evening, you have to

1:01:49

really recognize that that sugar is taking, like

1:01:51

when he's asleep and fasting, that that sugar

1:01:53

is taking a pretty big fall, quite

1:01:56

a bit over that nighttime period. So where

1:01:58

it, so you could imagine. instead of going

1:02:00

to bed at 250 and waking up at like

1:02:02

180, if I have him go to

1:02:04

bed more at like 180, he's

1:02:07

gonna be waking up with sugars that are

1:02:09

getting close to hypoglycemia. So you

1:02:11

really have, that's one area I focus

1:02:13

on in these patients is I look

1:02:16

at that bedtime to morning time drop

1:02:18

and make sure I don't over-basal the

1:02:20

patient. So we do wanna

1:02:23

start him on some basal insulin depending

1:02:25

on how his fasting sugar looks and

1:02:27

on that nighttime drop. That's the first

1:02:29

thing to assess is the basal needs.

1:02:31

Backing up, we assess for hypoglycemia first, which in

1:02:33

the stem he's not having, but the first thing

1:02:36

you address is basal needs, then

1:02:38

you address prandial needs. And

1:02:40

so if he's still having highs with

1:02:42

pretty high dose glipizide, and he's taking

1:02:44

it once a day, I

1:02:46

wouldn't really be excited to fill that out

1:02:48

for all of his meals. And

1:02:51

it doesn't seem like he does great on

1:02:53

that product overall. If you could, if

1:02:55

he had insurance coverage, again, this is a guy with

1:02:58

CKD, I would love to have him on

1:03:00

a STLC2 inhibitor,

1:03:03

and then maybe GLP1 as well

1:03:05

after that. And so try to

1:03:07

treat his comorbidities with the products

1:03:10

and then improve his prandial glucose

1:03:13

as well. Now, if that approach doesn't

1:03:15

yet yield sugars that are great for

1:03:17

the prandial time, meaning mealtime, then you

1:03:20

should then look to do some mealtime

1:03:22

insulin. I often wait

1:03:24

till after we've tried the other

1:03:26

products if they're available, partly

1:03:28

because mealtime insulin doesn't have the added organ benefit,

1:03:30

and will usually come with weight gain across

1:03:32

time, and it has

1:03:35

more risk, certainly risk of hypoglycemia

1:03:37

when they're over-treating, it's just technically

1:03:39

challenging. I also

1:03:41

wanna just say though that mealtime insulin or

1:03:44

fast-acting insulin is not a bad guy. And

1:03:46

I feel like we often, for these types of

1:03:48

patients that are just high all the time, we

1:03:51

wait too long to get them on some insulin.

1:03:53

It's not the worst thing. Sometimes

1:03:56

it's instead of adding a whole bunch

1:03:58

of medicines, you add one. one

1:04:00

new intervention, which is mealtime insulin, you

1:04:03

slowly bring the doses up. And let's

1:04:05

say that you get them controlled and they're doing

1:04:07

better and feeling better, you can either leave that

1:04:10

running or you might introduce at

1:04:12

that point like a GLP1

1:04:14

S-shelty2 inhibitor and just back off on

1:04:16

the mealtime insulin. So there's

1:04:19

no right or wrong way, either

1:04:21

fix the basal, add on the

1:04:23

S-shelty2 GLP1 and then go for

1:04:25

the mealtime insulin or

1:04:27

add on the basal and add on

1:04:29

the mealtime insulin. And then you can

1:04:31

seek the other products when you get

1:04:33

your prior authorizations through, which take forever

1:04:35

and the finances and all

1:04:37

of that stuff. So I know that I gave you

1:04:39

kind of two styles to go, but I think both

1:04:42

patterns work. Now let's say he

1:04:44

has very poor finances, you

1:04:46

can have them get the glipizide with more of his

1:04:48

meals in the day. You have

1:04:50

to have him be watchful for hypoglycemia.

1:04:54

He does have to eat with that product

1:04:56

and then you could change that dead emitter

1:04:58

to the once a day basal. So

1:05:00

there's a range of options you can choose, but the

1:05:02

CGM will help you because when you make all these

1:05:05

little changes, you keep them on that

1:05:07

CGM and then he can come back and you

1:05:09

can look at the pattern and you can tweak

1:05:11

it even better. And he can

1:05:13

be really on the lookout for hypoglycemia with that.

1:05:17

And Jeff, I wanna make sure I'm understanding this conceptually

1:05:19

because I've seen the sulfonylurea

1:05:21

basal insulin combination before and I was like, that just

1:05:23

doesn't make sense to me because I always think of

1:05:25

sulfonylureas as a Hail Mary pass to keep people off

1:05:27

of insulin, but it sounds like this is serving the

1:05:29

duty of your cranial insulin

1:05:31

and you're trying to avoid it. I understand

1:05:33

that correctly, at least in some

1:05:35

cases. I'm 100% with you. I

1:05:38

think it's a stop gap while we're trying

1:05:40

to educate up the patient or get them

1:05:42

into a resource area, like if they need

1:05:44

some specialty consult or diabetes education, it's a

1:05:46

bit of a stop gap to

1:05:48

try to help them get beta cell insulin release. I

1:05:51

agree, I'm not a big fan of

1:05:54

basal insulin plus the sulfonylurea. I

1:05:56

think truly if they need sulfonylurea, probably some

1:05:59

dose-dense. insulin is going to be very reasonable.

1:06:01

But it's I think probably

1:06:03

it's a it's used a lot as a stopgap

1:06:05

while we're waiting to get them to that resource.

1:06:07

I think a lot of primary care clinics are

1:06:11

maybe not yet set up to have prandial insulin

1:06:13

use, but I don't want to take that away

1:06:15

from anybody. I mean, I think with cgms, all

1:06:18

of these tools are going to become a lot easier

1:06:20

to manage in a lot of settings. The

1:06:22

big hurdles are going to be getting it new

1:06:24

into your workflows. I think

1:06:26

it can be a time saver

1:06:28

over time once a provider and

1:06:30

practice get used to it because you

1:06:32

can basically get their data off the

1:06:35

cloud, you can copy and paste it

1:06:37

into your note instead of like, laboriously

1:06:39

going through their bloody fingerstick chart and

1:06:41

trying to figure out make sense of

1:06:43

things. But anything new is

1:06:45

going to be a challenge to get to

1:06:48

be efficient and to be, you know,

1:06:50

someone's, we call it the

1:06:53

FFT, the freakin first time.

1:06:56

The first time you do anything, it's,

1:06:58

it's just very frustrating. And it, I

1:07:00

think once providers use these tools and

1:07:03

get them in their workflows, I

1:07:06

feel like they're gonna never want to

1:07:08

go back, just because the fingerstick

1:07:10

thing, it just doesn't get you the data

1:07:12

you need to help people. Yeah.

1:07:15

Well, we've gone over a lot

1:07:17

of really helpful stuff. I mean, I feel

1:07:20

like now I know how to order and

1:07:22

how much to order what like the sensors

1:07:24

and also just going

1:07:27

over these common scenarios that I'm sure

1:07:29

people in the audience are seeing every

1:07:31

day. And then just because we

1:07:33

briefly mentioned it this time, and you mentioned it last

1:07:35

time as well, I do, I really

1:07:37

like the idea of like, everyone that starts prandial

1:07:40

insulin doesn't have to start three times a day,

1:07:42

prandial insulin, like, you know, you mentioned you could

1:07:44

start it with just your largest meal of the

1:07:46

day. And I have a fair amount of patients

1:07:48

that only eat one like true meal, like a

1:07:50

lot of them are just sort of like some

1:07:52

small snacks throughout the day. So I do like

1:07:54

that option. And that's still only two if they're

1:07:56

on a basil and with their largest meal, it's

1:07:59

still only two injections. So it's

1:08:01

a good option to think about. Yeah,

1:08:04

I think like you mentioned, you really

1:08:06

want to seek the patient. You want

1:08:08

to see what are they willing to

1:08:10

do, what is their support set

1:08:12

up like at home for themselves, their nutrition,

1:08:14

their finances, you know, what are they capable

1:08:17

to keep up with and we try to,

1:08:19

we make changes to try to help them get to

1:08:21

their goals. Paul,

1:08:23

any final comments before we go to take home

1:08:26

points? In this

1:08:28

last case in particular, you know, we've talked

1:08:30

in our hypertension episodes about this sort of

1:08:32

pseudo-resistant hypertension, which is just patients may

1:08:34

be burdened by the medications they take and I feel like

1:08:36

this isn't a chance for Mr. B here to actually make

1:08:38

sure that he's actually taking his insulin. Like usually I think

1:08:40

you see that in the patients where you keep

1:08:42

cranking up the dose and just nothing happens, but, and

1:08:45

he's in our theoretically a fairly low dose, but I think it's

1:08:47

also a nice chance to kind of go back and just check

1:08:49

adherence for these patients who just don't seem to budge no

1:08:51

matter what you kind of throw at them and just make sure

1:08:53

there's no barriers to cost or administration or storage, which can

1:08:55

be the case in a lot of folks that are

1:08:57

maybe a little bit embarrassed to talk about it. You

1:09:00

know, Matt, when you asked Paul for his like

1:09:02

wrap up summary, my computer, it just totally glitched

1:09:04

out. So I think that's just a sign that

1:09:08

I don't know that Paul needs to stay. I

1:09:10

got, again, I'm putting my application out there. I'm

1:09:12

telling you, my computer, I knew something. You just

1:09:14

wanted to block my applications

1:09:16

off. I feel like you're expecting a fight,

1:09:18

Jeff. I will hand the ground to

1:09:20

you, it is. Well,

1:09:24

we're going to go toe to toe at some point.

1:09:26

I know one of these, we'll get together at one

1:09:28

of these national meetings. I want to. I

1:09:30

feel like Jeff, I feel like Jeff wants a

1:09:32

fight and Paul's like, I'm just, all the

1:09:34

fights out of me. I'm just, I

1:09:36

was broken years ago. I'll just passive-reuse

1:09:38

my way through it. No,

1:09:41

but I was hearing the last video summary statement and

1:09:43

I guess I didn't catch it all. It was brilliant.

1:09:45

Don't even worry about it. I'm sure it

1:09:47

was amazing. It was. So, Jeff,

1:09:50

this has been a lot of fun as

1:09:52

always and we'll definitely have to have you

1:09:54

back as we do every

1:09:56

year in the future. But what are

1:09:59

the things that you're looking for? some take-home points that

1:10:01

you'd really like the listeners to remember from

1:10:03

this one? Yeah, a couple

1:10:05

of things. So continuous glucose monitors because

1:10:07

of Medicare and Medicaid updates to the

1:10:09

eligibility are going to become much more

1:10:12

widely available. If you have a

1:10:14

patient who's on basal insulin only, they can

1:10:17

access this device with insurance coverage.

1:10:19

There are some devices and patients with coupons and

1:10:22

other things that might just be able to buy

1:10:24

them outright. And so you can prescribe them for

1:10:26

people without any insurance coverage. And I do think

1:10:28

that there is evidence in

1:10:31

the literature to support doing that for

1:10:33

people not on any insulin. Patients

1:10:36

can use a smartphone or a handheld

1:10:38

reader from either of the two big

1:10:40

companies out there to look at their

1:10:43

glucose trends real time. It can alert

1:10:45

them for lows in particular

1:10:47

so they can respond and make sure

1:10:49

that they're protecting themselves from those. Most

1:10:53

people when they get good at

1:10:55

this over time, they don't like sticking their

1:10:57

finger anymore and this becomes just easy to

1:10:59

wear. They're slim profile. You just forget that

1:11:01

you have it on. And so the ease

1:11:03

of use is good. And then when you

1:11:05

come into the doctor's office, once we get

1:11:07

our workflows figured out, I actually think it's

1:11:09

so easy to pick through the graphic and

1:11:11

make our medical changes. I usually

1:11:13

turn my screen to the patient so we can look together

1:11:15

at what the line is doing

1:11:17

across different days and we can make a

1:11:19

discussion happen. And so this

1:11:22

is going to be the future

1:11:24

of diabetes care and monitoring glucose.

1:11:26

We still have to have, tell

1:11:28

people don't throw their fingerstick glucose

1:11:31

monitors out. Don't trash those because

1:11:33

the CGM isn't perfect yet. It

1:11:35

has some delay. And if the person's

1:11:37

feeling symptoms of low in particular that

1:11:40

the CGM is not showing, it

1:11:42

might be off and they should do a fingerstick

1:11:44

to back up and check what's going on. But

1:11:47

those would be all my takeaways. Fantastic, Jeff.

1:11:49

I can't thank you enough for all your

1:11:51

time. And you got to thank Juan as well

1:11:53

for letting you hang out with us. Yeah,

1:11:56

well, I usually, you know, I scare

1:11:58

you probably with my responses to

1:12:00

things that Juan's a much better administrator

1:12:03

of those things and I've

1:12:05

called her my domestic commander she's a physician in

1:12:08

her own right but oh my gosh I fall

1:12:10

off the wheels like a lot of us guys

1:12:12

that are married to wonderful gales. Well

1:12:14

I'm glad I'm friends with both of you so

1:12:17

I have access I still have access to you

1:12:19

via her when I need to get in touch.

1:12:21

Definitely please keep me she'll keep me in line

1:12:23

and I won't you know I won't fall apart

1:12:26

it'll be good. This

1:12:32

has been another episode of the curbsiders bringing you

1:12:34

a little knowledge food for your brain hole. Yummy.

1:12:36

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