Hello, everyone. Thank you very much for joining me for this uh presentation. Moving beyond A one C establishing a new personalized precision based standard for glycemic management of people with type two diabetes. My name is Jeff Hunger. I'm a family physician and a diabetes specialist, uh located in Southern California. And my job today is to talk to you about how to successfully and efficiently manage people with diabetes, whether it's type one or type two. And the reason is because we as family doctors manage people with chronic diseases, diabetes is certainly a chronic disease. It always gets worse over time. So what can we do to successfully and officially get these people to their glycemic target? And I can really do this using CGM within a period of 2 to 6 weeks. I'll show you how it's very simple. So these are our program faculty. Uh You already know about myself. We have Doctor Miller Miller who uh uh resides in Bend Oregon, who also is a family physician and a diabetologist. And we have Doctor Eugene Wright, uh who works in uh uh North Carolina, an amazing internal medicine doctor who specializes in the field of diabetes. How many of you in the audience? Really? No patients that enjoy doing finger sticks. The American Diabetes Association until recently recommended that people with type one diabetes do 10 finger sticks a day. Nobody does 10 finger sticks a day. And by the way, once they get the finger stick done, who interprets the data? How do you figure out what's going on? So there might be a better way. How do you do a finger stick? You gotta take a little lancet, you gotta stick the tip of the finger that causes a drop of blood to come out of the fingertip. You put that on a little strip, that test strip has gold inside. I'll talk about the expense of gold in just a second. But the gold serves to oxidize the blood, the blood and that goes out of the strip, the strip goes into a meter and the blood glucose level is red. Is there a more efficient way to do this? Yes. So what we do now is we take a little filament about the size of an eyelash. It's four millimeters in size. It gets inserted into the subcutaneous space and then the glucose levels are read every 1 to 5 minutes. So if you're reading glucose levels, every 1 to 5 minutes, that gives you uh about 1440 readings in a 24 hour period or over 20,160 readings in a two week wear of one of the sensors out there that gives you a lot more data. Well, you might say, what is the subcutaneous space? Why is it different than the subdermal region? The reason is the sub subcutaneous space is the area that bays all the cells in the body with glucose. So if you're K in that area, you can get a lot more information about what the body is experiencing. One more thing of importance, the subcutaneous or the sub uh subcutaneous area is the location that the brain lives in. We live in subcutaneous fluid. Our brains do. So when you do a glucose level from a sensor and it reads 78 that is what the brain is actually seeing at that moment in time. There are a lot of different continuous glucose monitors out there and some of these do different things. There is a desk com six sensor and a desk com seven sensor. These are applied to the abdomen or to the arm and they transmit data into a reader or into the patient's cell phone. The advantage of these two devices that they connect to insulin pumps and also smart Peps. We also have the Abbot Freestyle Libre sensors and there's different types of these sensors, but they get inserted again into interstitial space. You can see the little filament there. Uh and they give you a lot of information, all these sensors give you information on not only what your GLU glucose level is currently but also what the trends might be. So people using CGM can actually figure out what's going on with their glucose trends in relation to meals, exercise, medication, sleep and travel. And there's one more important thing, these sensors do, they actually alarm when your glucose levels go up and they alarm when your glucose levels go below 70. So for people that like to exercise and they have diabetes, one of the things that happens when you exercise, just sweat, you get a little shaky, you get a little tired and how do you know if you're going low when you excise, you don't when you're doing finger sticks but you do when you're using a sensor and then we have on the right, the guardian Medronic puppet sensor, these two devices connect together, they talk like husband and wife and that allows the patient to get very good glucose control when they have type one or type two diabetes. So now it's time for a true or false question. This is something you should actually ask your patients. Uh when you first see them, give them a quiz. Diabetes is the number one cause of adult blindness, amputations and kidney failure. Ask them, I ask doctors this all the time. They always get the answer wrong. What is the answer to this question? True or false, false, poorly controlled diabetes is the number one cause of adult blindness, amputations and kidney failure. So you see if you have well controlled diabetes, there is a very good chance you're gonna live a long and healthy life. This is one of my favorite slides because a lot of our patients out there in primary care, they always wanna know. Uh, I'm, I'm taking something for blood pressure. I'm taking something for cholesterol. I'm overweight. I got sleep apnea. I gotta take this, that everything else. How doctor, how long do I have to take these medicines? My answer is, are you a good cook? If you're a good cook, let's make something together because frankly I'm a terrible cook. I can't cook a thing when I cook. People pray after they eat. So we're gonna make some soup today. I'm gonna take a big pot of water. I'm gonna bring it over to your house. I'm gonna put it on the stove. Let's add some ingredients to this and see how it smells. So, we're gonna add a little diabetes. We're gonna add a little hyperlipidemia, a little bit of hypertension, a little bit of overweight. A little bit of depression. Uh We're gonna, we're gonna add some sleep apnea. We're gonna add some erectile dysfunction. Whatever you wanna add, it's all in the soup. It's smelling really bad. So what are we gonna do to fix up this soup? We got a big party coming up here. So we're gonna add stats. We're gonna add aspirin. We're gonna get the blood pressure to target. We're gonna fix the diabetic kidney disease. We're gonna fix the sleep apnea and, oh, yeah, we're gonna use technology as well so we can make sure that the glucose levels are in the best control. We could possibly make it at the end of the day. Our soup that was initially smelling like crap. Smells pretty good right now. And we can move forward when patients see this. They understand that these meds and this technology is absolutely imperative to keep them safe. There is so much to think about when you have diabetes. It is, but it is really beyond imagination. Think about this diabetes is a chronic disease. It's like being on, uh, uh, being on work 24 7, uh, every day. You don't get a vacation from diabetes, but you can take breaks on occasion. For example, if you're, if you wanna watch the Super Bowl and, and party then fine, it's ok. Just fix the blood glucose levels later. But people with type one diabetes, you know what they can get concerned about hypoglycemia. When you have type one diabetes for more than five years, you lose the ability to recognize lows so you can go low and not even know it. And people with type two diabetes, what is the first question they're gonna ask you when they come to your office and you say Mr Smith, guess what? You got type two diabetes? Oh, no. What am I supposed to eat? For the rest of my life. Well, we got the food police out there. They're always telling you you're doing it wrong. I have type one diabetes myself and I was at the mall two weeks ago and uh I was uh scanning one of my own sensors and it looked like it was 1 75 some old ladies coming behind me looking at the results of the uh CGM scan and says, oh, you shouldn't be eating that piece of pie. Well, who are you? The food, please? Yes, I can do anything. I want as long as I know what to do in response to those elevated blood glucose levels. But this adds to a lot of anxiety and we can reduce this anxiety with the use of CGM. Look at all the stuff we got do and all of us. I I I'm guilty just like everyone else. We blame the patient for not achieving their glycemic goal or metabolic goal. But look at the things we gotta do. We gotta worry about a one c exercise, timing of medicine. Some of our patients taking medicine once twice, three times a day. Some of them were taken in the evening, sometimes in the morning, all this stuff going on. We gotta worry about carb counting. We I gotta worry about too much carbs, testosterone, work hours. Our spouse telling us we don't know what we're doing. All this stuff we gotta think about. Would it be better if we just use CGM. And then we can figure out exactly how to manage our metabolic control in relation to glycemia. So, here's the thing we gotta understand, good care of diabetes does not guarantee that patients will never develop diabetes related complications. However, with good care, the odds are excellent that the patient will live a long and healthy life with diabetes. Very important information. We wanna treat our patients successfully and we wanna do it efficiently as well. As I mentioned, hypoglycemia is a big deal and it's extremely expensive. We get people that, uh, get hypoglycemic all the time. In type one. This happens a lot. It doesn't mean that we're gonna die, but it does mean that there's a higher risk of developing a treatment emergent, uh, hypoglycemia unawareness. We don't know the glucose levels to go down and we're driving at that point in time. That could be problematic. So, did you realize that one visit to the emergency room is for hypoglycemia is gonna cost about $12,000. This adds up over time. I had a patient, uh, about five years actually, it was no, 10 years ago. That was uh type one. He is type one and he was driving on the freeway here in southern California. He had not one, not two, not three, not four, but five different cars on the freeway. Then he kind of rotated off to the side. He was there when the police found him. And the police said, sir, do you know what you did? And he goes, uh, so they took him to hospital and his blood sugar was uh 32. So he almost lost his license. However, we put him on CGM. Way back then, first generation of CGM, he goes to court, he shows the judge his CGM readings. Remember every minute of every day as 20,000, uh 160 glucose readings in a two week period of time. The judge says, what are you showing me? He said, look, these are all my glucose levels over the last two weeks. And the judge was amazed, said, oh my goodness, you're the safest driver on the road. And it tells you when you're going low. How do I get one of these as well? So, hypoglycemia is very problematic for type one and type twos and it results in a lot of expenses and using CGM, we see when the alarms occur and it's a lot easier to fix the glucose levels when you're at 60 when, when you're at 70 than you were when you're at 58. So, so what are some of the benefits of CGM? I've already kind of explained some of these to you, but it gives you insight into food exercise. What's happening on sick days? It gives you real time evidence of what your glucose levels are. There's something called time and range. I'm taught you about time and range. It's not all about the A one C anymore. There is a range we want to acquire that range is between 70 100 and 80. If we can get our glucose levels on CGM, between 70 100 and 80 70% of the time our A one C is are gonna be close to 7% directional arrows. We can see if the glucose levels are going up. We could see where the glucose levels are going down and that gives us comfort. And it also gives us an idea of what we need to do in regards to our treatment therapy strategies. There's alarms, we can use these devices to for Children all the way down to age two. We use them for adults as well. They connect to the insulin pump. So you've got a marriage between the sensor and the insulin pump. They talk when they talk, guess what happens in the morning when you wake up your blood sugar is they're perfect. When the glucose level starts going up on these connected systems, the sensor tells the pump, your glucose levels going up. No problem. The pump just makes more insulin to bring the glucose levels in the uh targeted range. And when the glucose levels start going down too quickly, the sensor says shut off the insulin. It does every morning when you wake up with type one diabetes. When you wear a pop in a sensor, your blood sugar is gonna be 100 and 1212 112 112. It's perfect. It is outstanding and that makes people very happy. You could connect to other clinicians, family members. So the data that you get from your sensors can be streamed to your loved ones. Now, as you know, I have diabetes and I made a terrible mistake. I decided to share my uh sensor data with my wife and, uh, about, uh, four or five weeks ago, she called me around 11 30 in the morning and said, Jeff, your blood sugars are too high, better fix it. So I fixed it and then two hours later, your blood sugars are going too low. So I fixed it. Uh, two hours later, she said, now you're up again. You better see somebody that knows what the heck's going on. Do you know what I did to fix that? I unfriended her. I no longer share my data with her and everything is quiet during the day. You can get improvement in a one C there's improvement in work performance because if you go low in the middle of the night, then it takes two hours to recover and you often can't really function very well. The next day, as I mentioned, there's a reduction in hypoglycemia risk and, uh, you stay out of the hospital, which is a good thing as well. Another fun thing that you can do is realize that there are codes that can be used to bill commercial Medicare, Medicaid insurance for your efforts. So if you on board, uh one of these devices in the office and, and show the patient how to use the device, you can bill 95249 one time in a year. And uh Medicare pays you about $45. And if you interpret the data, you can do this once a month, you can do it via telemetry. You can do it telemedicine, you can do it in person. You get almost $29 from Medicare using the 95251 code. So this is something that is easily done. It takes about uh four minutes to on board these sensors and the interpretation is I'll show you is easier than reading an EKG. What about the cost of these devices? Does that result? This is an expensive thing. No, it's not. What's the cost of managing somebody that has an M I and has type two diabetes? Well, for four days in the hospital in two stents, it's gonna be $56,000. What's the cost of a stroke? Well, if you have a stroke and remember people with diabetes tend to die of heart attacks and strokes, 80% of the time. So if you have a stroke, it cost $92,000 for one year, especially if you go to the nursing home. What about if you have uh dialysis it's $500 per session. All right. What's the cost of a single test? Strip, a single glucose test review, sticking your finger is a dollar 16 cents per strip. If you're checking five times a day, that means that somebody is paying about 100 and $74 per month. But if you using CGM, you're getting 1440 readings a day. How much is a single sensor value? 0.007 cents? And the cost of a two week wear is $32. That is pretty spectacular. And if you're asking me, diabetes is a very expensive disease. But if you use these devices, it makes it much more efficient. And I believe, and I'll show you the data that your, uh, risk of developing diabetes complications will be significantly reduced. All right, this is Doctor Smith. Best day ever. Doctor Smith is told by his assistant, Becky that we've got three patients coming in all one right after another. All with the same, a one CS as 7%. You know why Doctor Smith is happy about this? Because every time you get the A one C less than 7% you get a $5 performance bonus for your efforts. Good for him. So that means by noon he cut out early because he's already got $15 in his pocket. He could, uh, buy lunch or romantic dinner uh for his wife. All right, let's take a look at these and see if all A one C are the same. So patient number one comes in and his A one C is 7% good. This is sensor data. If you look at the sensor data on patient 1 100% of his values are in the range of 70 to 100 and 80. Amazing. I never see 100%. Never. Every once in a while there's one dot That's too high, one dot That's too low. But in Doctor Smith's case, no, no, no 100% in the range of 70 100 and 80. Good for him. He deserves his $5. Here comes patient number two. And if you look at the sensor reading on this patient with an A one C of 7% he's got 70% of his numbers are in target good. But look at the red area. That's hypoglycemia. Now, there's 5% of this patient's glucose values in the hypoglycemic area. This is not good if you don't remember anything else. But what I tell you remember this hypoglycemia kills hypoglycemia kills, hyperglycemia does not kill. The other thing, hypoglycemia does is increase the risk for developing long term complications. Why does hypoglycemia kill? Because uh seven years ago, Elaine Chow in England did a very impressive study where she used CGM insulin infusions uh and the holter monitors and there were some metabolic testing that was done as well and she brought the glucose levels down and people that had coronary artery disease bound to less than 59 mg per dely. And what you found is that when you get low like that, your heart rate goes up, your blood pressure goes up. You get inflammation in the coronary arteries and the inflammation doesn't dissolve or resolve for seven days and you can get cardiac dysrhythmias called Tread Dupont, which are fatal dysrhythmias. You do not wanna go low. What about patient? Number? 3 7% uh uh in the 70% is the uh time and actually about 40% is time and range. The problem here is that even though his A one C is 7% look at, he's 20% low. Whose fault is that? Is that the patient? No, that's your fault. And Doctor Smith's fault for putting him on medicines that cause this severe treatment, emergent hypoglycemia. The number one cause of car accidents amongst people with diabetes in the United States is not hypoglycemia. It's having had one hypoglycemic event during the day because then you don't, uh, you lose count of regulator regu regulation. You don't get a second chance you don't feel the second event and that's when the uh accident occurs. So there's glucose variability in people that have diabetes or two patients that have the exact same A one CS of 7.8% and their glucose levels are not under control. So you wanna start basal insulin. Let's see. Here's patient number one and you can see that overnight. This is sensor data overnight. His glucose levels are going way down. He's hypoglycemic. Now, he doesn't know that, but he is hypoglycemic. Here's patient number two, same A one C but less glycemic variability. And you can see that at seven o'clock in the morning he wakes up and the glucose levels are high. So what are you gonna do? You're gonna put him on 10 units of baseline on what's gonna happen if you do that to patient B, he's the, the gray zone that's gonna go way down. And that is gonna be very problematic. If this patient has a coronary artery disease. He's over age 65. He just killed this patient. So sensors can alarm when the glucose levels go low in the middle of the night. People are not gonna wake up at three in the morning just to check the blood sugar randomly. It just doesn't happen. All right, here's a pop quiz for you. Here's a 42 year old construction worker. He's had type two diabetes for five years. And by the way, when you're told that you have diabetes for five years, that's when you were diagnosed, it doesn't take into account that the patient for seven years before that had impaired glucose regulation or prediabetes. His A one C is 7.6. How would you interpret this data? Look over there on the right? So, glucose levels kind are high uh throughout the day, but he's only, only doing glucose checks once or twice a day at most. He's on Metformin twice daily. He's on Insulin delac and he's on Lara type. What are you gonna do? What do you wanna do with his patient? I don't know. So you gotta put the guy on CGM to figure this out. So, here's somebody that's doing very well with his blood glucose levels. The target range 70 to 100 and 80. He's checking his blood sugars four times a day and every number, every numbers of the target range good for him. Now, we're gonna put him on a sensor and let's take a look and see what the sensor shows him. This is glycemic variability ups and downs. This is known as the roller coaster of diabetes. Nobody wants to be on the roller coaster. They are gluten hypoglycemic throughout the day. Look what happens overnight in the middle of the night, his glucose levels are gonna go down. So what does he do? He wakes up with a low, he eats some cake drinks, some orange juices, blood sugars go sky high again only to drop down again before he wakes up in the morning. This is dangerous. And what we wanna do is put him on a sensor and adjust whatever treatments we can use to keep him safe up until now our goal is to get the A one C level to be less than 7% with these patients. But the A one C is not the answer because I already showed you about glycemic variability ups and downs and the the risk of developing hyperglycemia. So A one C is pretty easy when you know, when you get the A one C, less than 7% you've achieved your targeted goal. And you could also, you also know at that point in time that you reduce the patient's risk for developing micro and macrovascular complications. So in other words, if the A one C is less than 7% the patient has less risk of developing problems, kidney problems, nerve problems, heart attacks and strokes. But it doesn't tell you the whole story. You can't dose insulin based on just the A one C alone. There are a lot of factors that you've got to look at in relation to this A one C, you cannot predict hypoglycemia. In fact, if you have patients with A One CS above 12, yeah, they get hypoglycemic and the seve the severity of the hypoglycemia is much worse than you have. You ha if you have A one C is around 7% you know, you can't determine what the glycemic variability is either because you can have patients with glucose levels 40 to 400. If you average them out, you're gonna have a 7% A one C. Also with you, when you look just at the A one C, it always delays the onset of new treatments. Uh If you look historically at the way we used to treat diabetes back in 2006, what were the ad a guidelines back at that time? Easy. Somebody comes in with type two diabetes. You start on my Metformin Good. Bring them back three months later. If the A one C is at less than 7% at a sofa with in this three months. Now, if in three additional months, now, six months with this, you can't get the A one C down with Metformin Sina. Let's add uh A T CD. And then after a year of not having good A one CS add insulin that takes a year, we can get diabetes in control in a period of 2 to 6 weeks, we can do it. But you've got to use CGM. And the other problem here is that there are a lot of errors in a one C interpretation. I'll just give you a couple of them. Uh One of them is iron deficiency anemia. If you have somebody that is iron deficient, then they're gonna become hyper glycated. They over glycate. So if you have somebody with uh a hemoglobin of 11% or have 11 g that you can have an A one C of 8.2. But if you look at their CGM levels, it's perfect. If you have somebody that has a hemoglobinopathy like sickle cell anemia, they can't even like it. They can't. So you can have a glucose uh or an A one C one week of 14, the other one is six. It doesn't matter, it's not gonna help. And if you have somebody with uh diabetic kidney disease, they under glycate. And that's because there's a rapid turnover of uh red blood cells. So in these patients, you need to use CGM. This is what we look at. When we look at AC GM report, it's called in uh ambulatory glucose profile. So we'll start with the top right. What you wanna see is uh time and range of 70%. So in this case, only 47% of this patient's numbers were in their targeted range. Is that good? Well, maybe what if one week earlier you're only at 22% and now you're at 47%. 0, ok. He's doing better. The treatment is working. What if three months before that he had 90% of his uh numbers in target. But right now he's only at 47%. What does that mean? He's not taking his medication in regards to the low, who wanna get less than 4% of the low? As you can see in this case, he's at 10%. That's not good. Also look at the left side, there's something called a glucose management indicator. It's also known as the GM I. This is a really good indicator of what the A one C is predicted to be. In this case. It's 7.6. So in a week later, if I could bring him back and his, uh gm I has gone from 7.6 to 7.2. I know I'm going in the right direction. And how long did that take? One week? Maybe? Then we have glycemic variability. This looks at the roller coaster ride, the ups and downs. And you can see on the second of the middle graph there that this guy is all over the place ups and downs. And you can see that glycemic variability increases the likelihood of developing treatment emergent hypoglycemic hypoglycemia. So we want glucose variability to be less than 33%. And in this case, it's 49%. If you look at that second graph, look at how often he's getting hypoglycemic. He's waking up with hypoglycemia and he's also getting hypoglycemia again in the middle of the day. So this is treatment emergent hypoglycemia and he's getting uh uh he's lost his ability to counter regulate that low. So this is something we need to see and we can do this using the inventory glucose profile, which puts all this data that you have all these sensor data values within a 24 hour graph. Very, very simple to read. What we want is flat lives, diabetes, doctors love flat. Now to put this in perspective what the cardiologists do. When they see a flat line, they get really excited, they wanna pump on your chest, maybe a surgeon is gonna crack your chest and, and squeeze the heart, get the, the, the blood flow going. What about neurologists? What do neurologists do when they see a flat line? They lose interest? Nothing you can do. Uh just donate the cornea, donate the pancreas wherever you want. But don't bother me. There's nothing I can do. No diabetes doctors. We want flat lines, the better it is. And then in the lower graph there, you can see that little yellow mountain. These are daily graph summaries of what's going on. Remember, this is a job that requires 24 7 accuracy. Uh You need to be attentive to your details all the time. However, this happened to be Super Bowl Sunday. If the guy wants to eat on Super Bowl Sunday, take time off from diabetes. Ok. Ok. Just know what to do and how do you interpret this value? But you don't chew people out. You simply say, ah, you had a bad day. Ok, let's move on. This is one of my favorite patients. His name is Bob. Bob is a rocket scientist. He works in Hasina about 20 minutes from my office. Bob also has type two diabetes besides putting the Mars Rover up there on Mars and design that system. He also does uh uh artificial intelligence computers for NASA, but Bob has type two diabetes and uh Bob comes in the office with the sensor on one week later, he comes in without an appointment, knocked on my door says I got to see Doctor Unger right now. I've got some important information. And uh what is the important information Bob that you have to share with me right now? And the answer is that he brings them the stack of information. I have never seen so many charts this after just one week. He's got hazard ratios. He's got pie charts, there's color, uh examples of everything he wants to show me. There's zig zag lines, Bob, what are you showing me? And he said, did you know that when you uh when you exercise your blood sugars go down? No, I didn't know that, Bob. Well, you need to publish the stuff. He was very excited. But you see, here's the thing. People see what happens when they eat, they see what happens when they sleep. They see what happens when they exercise. They see what happens when they travel and they get into this. How long did that take? One week? So just real quickly, some of the clinical and economic benefits. I know we're all busy, but we've got to look at some of this data to see why are we even recommending these devices. It doesn't matter if you have type two diabetes, whether you're on insulin or oral agents, we can get the A One CS down to their targeted range very quickly using CGM and the higher the A one C baseline, the greater the drop of these patients as well. I don't like hypoglycemia. How long does it take to fix hypoglycemia? And people using sensors turns out when you use sensors, uh you get an 11% reduction in hypoglycemia in just two days. That's pretty impressive because people like the alarms, they understand what's happening when they're told at 70 their glucose levels are trending down. This is a very important slide because when you get people to their glycemic targets, when you improve time and range by 50% there's a 50% reduction in complications of diabetes. Ask your patient this question. Uh What scares you the most about having diabetes? The answer is always the same. I wanna lose my eyes, my kidneys, I don't wanna lose the leg and oh, by the way, I wanna watch my daughter walk down the aisle someday. When you hear this, you tell them nothing's gonna happen to you on my watch. I've got your back. That's when you put the sensor on and you're reminded in your heart that getting people to their glycemic targets in time and range will reduce the risk of these diabetes complications. So in summary, advanced technology really is beneficial for all people with diabetes. Uh I was on the writing committee for the Ace Guidelines 2001 for use of technology and we worked on this project for about a year. Our last uh uh meeting, a virtual meeting. Uh The question was asked who deserves CGM. And in the field of diabetes and the answer universally was everyone needs this. It doesn't matter. We need to put people on CGM. Nobody should be on just finger sticks. I have not used finger sticks in my office in the last uh three years. So technologies provide insight on eating, travel, exercise, sleep, everything that everybody works about in their uh uh status on diabetes. This is a chronic disease. We need to get them officially and safely to target. And most importantly, we could reduce the patient's risk of getting hypoglycemia and developing long term diabetes with complications. Look at that picture, look at the smiling between the patient and the doctor there. That's what we wanna do. When's the last time you saw a patient with diabetes? And you said, you know what, Bob? You're amazing. I am so proud of you. Thank you. Thank you for achieving your metabolic targets. I I feel so safe now that you're safe as well. Thank you very much for your time.
Related Presenters
