Hi, my name is Jennifer Goldman. I am a Professor of Pharmacy Practice at the Massachusetts College of Pharmacy and Health Sciences in Boston, Massachusetts, and a clinical pharmacist at Well Life Medical and Peabody Mass. And that's where I direct and develop the cardiometabolic program. I wanna thank Diana for that presentation and now we're gonna move a little bit forward and take some of that information and, and apply it to some cases before we do that. Let's, um, discuss a little bit more. If anyone wants to contact me. Here's my, uh, information, but we're gonna really talk about a little bit about the patient engagement and satisfaction, but really start to move into application of cases. So, one of the things I just want to point out is that early control of glycemia really does make a big difference. But what you can see here in this slide on the left, if you look at people with diabetes, we'll call them group A. So the people with diabetes who start out early on the first decade of their, uh, diabetes having an A one C at around 7%. And then the 2nd 10 years, we're looking at 20 years, the 2nd 10 years, their A one C is 9%. And we can compare that to a person who maybe spent nine at 9% for the 1st 10 years and then got them self controlled and spent the next 10 years at 7%. So if you look at averaging that out, it's basically the same. But it really turns out that even though they have that same exposure, that same glycemic exposure over 20 years, those people who have earlier control uh on that first decade had a 33% reduction in the risk of cardiovascular disease and a 52% reduction in reduced egfr. So early control does matter, it makes a big difference. It you can uh decrease and minimize that association with kidney and cardiovascular disease. When we think about that, that concept is really thought of and known as the legacy effect so that when we early on help our patients get into much better control. And this was demonstrated, it is in this example by the UK P DS trial in the 10 year follow up that there's a legacy effect so that when you do that early control, early on, it remains. So, you know, decades later, you actually see that reduction continuing. So we saw in the UK P DS a a significant decrease in amputations and microvascular complications, uh diabetes related death. And again, this is from earlier earlier control. So as you've heard, you know, we're really thinking about now, time and range. So it's, it's time to basically move on away from a one C and A one C is a wonderful screen. It's a wonderful tool. But time and range is what is critical and this is because it captures everything. So that time and range is going to capture whether someone has lows or they have hives, whereas you have people who their A one C might might make a, an average. But it's really what's going on in that time and range. So when, when there was a uh study done in this research, it was an online survey for people with type one diabetes, type two diabetes on insulin and type two diabetes, not on insulin. And of course, those with type one diabetes were on insulin. On this survey, what they asked AAA bunch of questions. But basically what I wanna point out to you, what was of the utmost appoint uh importance to these groups with or without diabetes uh with or without insulin for type two diabetes or in type one was time and range was the number one for all of those groups. Uh in terms of importance, there was a another another study done about the association of CGM usage and treatment satisfaction among people with diabetes. So basically, looking at if you took these cohorts of patients with type one and type two diabetes, ho how do they feel about it? And the use of CGM was uh associated with a significant improvement in treatment satisfaction among both groups, both cohorts. It additionally frequently scanning. Uh CGM led to improved outcomes. So improved A one C. Now, the same study was also done in elderly patients. So what about elderly patients in terms of their treatment satisfaction? And in this study, also the uh the significant improvement in diabetes treatment satisfaction among elderly patients with type two diabetes. The other thing that was found was that more frequent daily scanning led to a reduction of A One C in this population. They all patients also had a greater ease in managing their blood glucose and experience better outcomes. 95% of them said they had a better understanding of their glucose fluctuations. 92% said it was easier to manage their mealtime glucose. 77% of uh users felt that their hypoglycemia events reduced and 37% reports more physical activity. Now, these are all things that in my experience when I'm seeing patients, um in my practice, this is something that's of the utmost importance to them. So when I think of people, I I have all these patients that jump into my head when I'm thinking about these various things and particularly for example, type one diabetes and exercise type two diabetes when they're using insulin and exercise. So prior to having CGM available, not really knowing, you have one moment in time with a with a glucose test. But if somebody, for example, plays soccer on the weekends, they don't know what's going on with their blood sugar when they're on insulin. Right? So type two or type one diabetes, but this allows people to be able to live their life, so be able to go play soccer, go play baseball or whatever they're gonna do on the weekends without the fear of hypoglycemia. And there's a lot of long term consequences of repetitive hypoglycemia. The other thing. And I I find this data particularly um interesting and and really shocking when you think about it. If you think about the the the quality of life of hospitalizations, what happens to patients or the the cost to the health care system, the cost to patients in the flare study, there was a decrease in hospitalizations and work absenteeism in both patients with type one and type two diabetes. 66% reduction in hospital admissions, oh at 12 months and 58% reduction in absenteeism from the use of a sensor. So this is not drugs, this is not any, you know, major intervention with surgery, nothing like this. The use of a sensor led to this result six months after getting CGM people with type two diabetes who weren't on bolus insulin. So 30% reduction in acute diabetes events. So let that, you know, sink in very significant, you know, I've been practicing for 33 years. So when II I think about this and I think about the things that, that I've seen over these last decades. It's just so impactful. Here's two more very impactful trials. So the impact trial will replace trial. So patients with type one diabetes and the impact trial spend less time, 38% less time than hypoglycemia and type two diabetes, 41% less time in hypoglycemia. When you ask patients what's important to them and what they're afraid of hypoglycemia is is very significant and people who have a severe hypoglycemic reaction, it's almost like uh having long COVID, you know, there there's mental changes and cognitive decline and um executive functioning skills that decrease and it takes time to get that back and more often that happens the worse. It is so less time in hypoglycemia is also an impactful important issue for patients in this data. What we're gonna see here is the true impact of time and range on some other areas. So, mm I end stage renal severe vision loss, amputation. 10 years, all of those complications decreased, the higher your time and range were in both type one diabetes and in type two diabetes. And as you can imagine by improving time and range, you're gonna have a decreased cost. And this is it kind of shocking, right? We're talking billions of dollars. So both in type one and type two diabetes in by improving time and range to 70 to 80%. There was a savings in type one diabetes of 2.1 to $4.2 billion in 10 years and type 24 to $7 billion in 10 years. There's a 10 year cost reduction by lowering the rate of hypoglycemia events in people with type one as a result of improving time and range. So, if you just think about a 10% reduction in hypoglycemia rates 10% 1.2 billion and, and uh it goes up as you increase that, that risk reduction. So all the way, the cost reduction for 40% in hypoglycemia was $2.8 billion. So just briefly, you know, the standards of care and diabetes support the use of CGM, the use of CGM. And this is a direct quote, the use of CGM devices should be considered from the outset of the diagnosis of diabetes that requires insulin management. So it totally supported by, you know, all organizations. So with that, we're going to do some cases and these are all patients that we're gonna talk about that were truly real world um railroad patients that I saw. So the first case is this woman was referred to me uh during the uh height of the uh COVID panda. And so I actually was seeing, saw her on uh a video visit. So 68 year old, she was referred to me in 2021 for management of uncontrolled type one diabetes. She was first diagnosed in 2009 and had been managed by uh endocrinology with multiple daily injections. Uh, she checked her finger sticks intermittently. So she's sent to me by her primary care doctor. I'm in the, the primary care's office. Her medical history is significant for hypertension dys epidemic, anemia, anxiety, seasonal allergies and breast cancer stage two chronic kidney disease with the EGFRS 76 negative found area. So when she comes to see me, the medications that she's taking are insulin, glargine, 64 units a day and U 100 insulin aspart 20 units three times a day with her meals total daily insulin dose was 1.6 units per kilogram. So when I asked her, I, you know, she doesn't count carbs. So, uh, you know, she just has that fixed mealtime dose. She doesn't use any correction doses. She only does those four injections. I asked her if she had Gluco gone at home for an emergency. She did not, she treated hyperglycemia with orange juice. Her weight of this visit was 100 and £70 and her BM I was 31 at that time. She was sent to me and she's, you know, in front of me, her A one C was 10.4 everything else was within normal limits. So I'm seeing her during the video. So I just want you to pause for a second before you kind of move on and think about this for a sec for for just think for a minute, what would you wanna ask her? What do you wanna do with her? What are you thinking about? So what happened was I said to her um you don't check your blood sugars. I don't have any data. I don't, I'm not gonna do anything. So I taught her how to use AC GM sensor over video and I said I'll see you in two weeks cause I don't know what's going on. All I know is her A one C is 10.1. That's all I know. And I know what her insulin doses are and this is what I got back. So take a look at this, a GP report that you, you know, learned about. So take a look and you can see she has no grade, she's 0% in the target range zero and um she's very high or high 100% of the time. Now she, in this case, she's only active 68% of the time. And that's because um at the time of this uh visit, she had uh this is the sensor that was available. So you had to scan and you had to scan every eight hours. If you didn't scan every eight hours, you didn't capture 100%. So now when we have um the newer versions of this sensor, it will capture 100% of the data. But in this case, she used to sleep like 10 hours uh a night. So uh because of that sleeping 10 hours at night, we didn't get the full, but you can get the idea. It's pretty close. You can see straight across. She is very tight. Her glucose variability during that 68% of the time is 14.2%. So she's always right up there. Her average glucose is 300. So all the way across. So if you drill down, I'm not gonna show all of them to you. But if you drill down a little bit, you can see she's making notes for me in her app and telling me, you know what she ate, my blood sugars are based on that. So this is something I look at and you can see this is right across very tight. It's always the same always, you know, 300 to 3 50. So what should we do? Think about this for a second? She's on 64 units. U 120 units three times a day. What do you wanna do? So do you wanna increase her, her U 100? Do you wanna increase her? Do you mean her gine? Do you wanna increase her aspart? Do you wanna increase both? Do you wanna do none of these? So let me show you and let me tell you what happened. So when I'm talking to her on, on that two week appointment, when I saw those blood sugars and I also suspected this when I, when I met her. But at the beginning of that very first visit, when she told me she was on 64 units and, uh, and 20 units three times a day. So she's on 100 and 20 units with an A one C of 10.1. I actually asked her, has anyone ever suggested that you have type two diabetes and not type one diabetes? Because remember she was diagnosed 10 years, pre pre prior with type one diabetes and has been on vasal bolus therapy for 10 years. And she said, no, nobody's ever suggested that. So when I saw that, I I said, thought that but when I saw the results, I said, I said to her, I really think you have type two diabetes. I don't think you have type one diabetes. So I'll order some blood work. So I'm gonna order some antibody test, but I'm gonna give you some Metformin because if you take Metformin, it's not going to hurt you if you have type one. But if you have type two, it's gonna be a miracle. And this is what happened if you take a, take a look so I could remotely monitor her. So when I gave her one pill of Metformin, one pill, that was it in one day, her blood sugars went down 100 points. So when I saw her for visit, number three, she had missed her in between visit. But when I saw her three months later, she was taking, I had given her a titration of Metformin to the full dose and she was still on the same amount of insulin. And when she came back, her time in range was 71%. So she went from 0% to 71%. With the addition of Metformin. I also did get the antibody test and they were all negative. So based on that, what do you think we should do next? Should we con continue her Metformin and continue her insulin? So no change. Should we continue Metformin and her basal insulin and end the mealtime and add an SGLT two inhibitor. Should we discontinue her mealtime insulin and instead a G LP one receptor agonist once a week or should we uh discontinue her mealtime insulin and stag GLT two. What do you think? So this is what I did is I actually stopped her mealtime insulin. I stopped her mealtime insulin. She had been complaining of G I side effects from the Metformin. So I lowered her Metformin dose to 1000 mg a day and I started dulaglutide 0.75 and I continued the um basal insulin, but I had switched her to degrade um because of the pharmacokinetics and when she came back on that regimen, her time and range was now down to 27%. So, what did I do next after that? So what I did was I increased her um to Lago type and increased her um gloc and she went to 37%. Hmm. Now, what am I gonna do? I'm not adding back that mealtime insulin. We have someone with type two diabetes. So I added um empagliflozin. So I added that to that regimen. She comes back her time and range is now 92%. So the addition of that, which is gonna target that meal time made that big significant difference to be at 92%. So here she is, she's now on 82 units of devo 1.5 a dulaglutide, 1000 mg of Metformin and empa 10 92% time and range. What should we do? So visit seven, what I did was I lowered her gloc to 60 units and continued her Dalla tide and her Metformin and I uh increased her empa to 25 mg. Her time in range is 89%. And you can see she has no low uh high as 11% but she's well within the um desired range. Uh since this time just so, you know, I have seen her, she's doing very, very well and um everything, her time and range is beautiful. She has no hypoglycemia. Um and I have switched her over to a newer sensor so that I can have 24 hour data without um any gaps at all. All right. So let's go on to another, another one of my uh patient cases and this, this is a lady I've been seeing for probably 12 years and I'll never forget the first visit. She was sitting in front of me and she weighed about 100 and £90 and she was on a self gonorrhea and we, we changed everything but, you know, fast forward to this is say, I don't know when this was a year ago or less, maybe even less. Um, she comes in her time and range is 61%. She's 66 years old. She's uh taking Dagli type 3 mg and um Metformin and a combination 12.5 mg and 1000 mg of two a day. So 25 mg and 2000 mg. And what had happened, she had been doing so well and she um did have obesity and we altered her meds and she lost a lot of weight and actually she was, she actually became too thin in this, in this case and she needed to not lose any more weight. So, but at this point, she is uh probably weighs 100 and £15 instead of 100 and £90. And um she's, she I had decreased her dulaglutide to 0.75 because of the weight loss. And I added some basal insulin. So uh she was on the empaled the dulaglutide 0.75 and I added some basal insulin. She comes back and her timing range is 39%. Her time above range is 61% and her glucose variability is 34.4% with a GM I of 8.5%. So, what are we gonna do? What should we do next? So th this is what we're looking at. She's only at 39%. The other thing that's happening with her is she's complaining of dizziness and fatigue and malaise and she had, had COVID, uh just prior to this and she's blaming it on the COVID. She doesn't feel good. And I, you know, I said to her, it might not be the COVID, it might be your blood sugars. So when we're looking here, what might you wanna do for her? She's on 20 units of glargine. Do you want to increase her glargine or do you wanna add mealtime insulin? So let me tell you what I did. I continued her empa and met at that dose and I continued her U 300 glargine 20 units daily. But what I did was I added four units of U 100 aspi to her biggest meal. Her biggest meal was dinner at the time. And I told her to monitor the impact. Historically, I know from knowing her that she's sensitive to insulin. She had been on insulin in the past. And so we're just doing, I'm doing basal insulin plus one basically, meaning plus one meal and we can always add a little bit more to a second meal or another meal uh dependent. So then what I did was I looked at her CGM remotely a few days later and what I saw actually prompt me to lower her U three underlying to 16 units and add two units of a spot with breakfast. So let me show you what happened. So by adding her, remember she was on 20 units of U 300 glaring and I had added four units at dinner time and now at this point, she's on four units at dinner time. So if you look around 6 p.m. here on the bottom graph, I had also given her two units at breakfast and her, her time and range is now 78%. So I lowered her U 300 glargine. So we also you're gonna look kind of what's happening with her fasting there and she has no low basically. And you know, if we're looking for a target of greater than 70% time and range, what would you wanna do here if you're looking this uh would you wanna continue with the same dose and leave everything alone? Do you wanna add 2 to 4 units at lunchtime or do you wanna increase the dinner dose? So look down at that bottom box at that inventory glucose profile. And where are you seeing excursions? Where are you seeing the trends? Where are you seeing where you might make an impact? So what I did is I actually increased dinner time by two units. So it's six units because that's, if you, you see that green line, the target range, you can see where most of the time it's going above. Is that dinner time? So that's what I did. And when she followed up with the primary care doctor in my office a month after this, she reported that her fatigue, her malaise her myalgia, you know, her lung COVID was gone. So all of those symptoms were gone. She said she felt fabulous and she attributes this to the addition of the short acting insulin. So she's doing spectacular and I just recently saw her. So let's talk about uh one more of my patient cases. And um this is a, a lovely lady that I've been seeing for a while. I also actually I think I met her uh at the very beginning of the pandemic and saw her for the first time too on video. Strangely enough. And at this point in uh care with me, she is 78 years old. She's on de Glod U 218 units and Metformin er 500 milli milligrams two tables twice a day. Has Gluca gone at home? She cannot take an SGLT two inhibitor or G LP one receptor agonist due due to significant adverse effects. And so this is all she's taking and her point of care it would see it, this visit when she came in to see me was 8.1% when I looked at her CGM. This is what I saw. So I had, you know, good data, 14 days of data active to 76% of the time. And what you see here is her target range is only 33% with 67% of it being, you know, above range, right? High or very high with a 28% glucose variability. So if you look over to the inventory glucose profile here, we need to bring this whole thing down to get it between those two green lines. That goal, right? Bring that entire everything down. So, um if you look at the times which 12, 12 and 12 is uh just a pivot points to see what's happening here with her. So what do you want to do? Do we want to increase her DLOD from 18 units to 20 units? Do we wanna add rapid acting insulin before breakfast, before breakfast and dinner or before breakfast, lunch and dinner? What do you think? Now, I'll tell you what I did. So, um actually I did both. So I increased her DLOD from 18 to 20 I initiated insulin uh aspirate at four units before breakfast. The reason why I did that and not the other meals is you can see here on her a GP from the moment she starts eating, that's when her blood sugars go up and they stay up and would it be wrong if I gave her a little bit of insulin at these, all these meals. It, it would. But I decided for her, she's 78 years old. She's a little bit, um, nervous about things to ease her in with using a plus one at breakfast. The reason why I chose breakfast over anything else is she starts hot. She starts her day out very high and stays high. So if I can adjust in that morning, she'll be going into her other meals, not as hot. So let's see what happens if I do that just at that first meal, it's possible that that might be enough so that she's going in better at the other meals. And so this is what happened, um, two weeks later when she came back, she was now in target range, 66% of the time with the GM I of 7.2. And you can see here if we take a look, everything's down. Remember, I increased her um tegla by two units. So she's, you know, pretty, relatively sensitive to her insulin and I had given her four units with breakfast. So I'm gonna show you this, uh A GP again and ask you, well, what do you wanna do next? So here's your choices. Uh continue the current doses, add a spot to lunch, add a spot to dinner or add a spot to lunch and dinner. So we could do a continue with uh uh basal plus one or we can do a basal plus two or a basal plus three. So, taking a look over here. What, what, what are you thinking? So, what I did was I added a little bit of um, a spot at, to dinner time. So uh continued everything else, the four units with breakfast and I added a little bit of a spot to dinner and I had to do four units, breakfast and dinner. She's now at target range, 86% of the time and her uh gm I is 6.6. And do you have any, any thoughts? What you, what you're thinking about this? So what I'm thinking about this when I saw it was, wow, this is wonderful. But you're 78 years old. I'm worried about you falling. I'm worried, uh, you have no lows. I, I'm a, a little bit concerned about hypoglycemia for her. So I actually did make it an adjustment to her dlod. So I, um, I did remote monitoring. I lowered her glock to 16 units from 20 units. And um, I'm, I'm a more comfortable with this for her because of her hypoglycemia risk, her fall risk. So in this case, just all I did was lower that four units and she's now in target range 76% of the time. So she's doing very well. So, you know, to just kind of wrap things up a little bit. I, I, some of the takeaways I want you to really consider is that early good glycemic control early leads to that legacy effect with a greater reduction in the risk of complications. And that's in both type one and type two use. The use of CGM leads to be better patient satisfaction that was in people with both type one and type two and also in people, elderly patients. And there was also a significant reduction in hospitalizations and work absenteeism with the use of a sensor. We know that improved time and range results in decreased M I end stage renal and severe loss and uh vision loss and amputations cost savings. So to keep, you know, keep that in your radar, the standards of care, the ad a standard of care recommend CGM at the outset in in people requiring insulin and also in other situations in people with type two diabetes and healthcare providers like yourself are in key positions to educate and provide CGM to patients to improve uh outcomes. Certainly. So with that, I want to thank you for your time and I hope this is helpful, feel free to, to reach out to me.
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