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Let’s talk about anything that you can think of on unmet needs, or future directions in the treatment of people with type 2 diabetes. What does it look like? One of the things I would throw out there is that we can no longer think of diabetes as a glucose disease. It’s a cardiovascular disease. The cardiovascular disease must be treated aggressively with all of the wonderful things you’ve brought to the table today. And your thoughts?

: That’s the staple to everything is getting ahead of a potential big problem. When we see someone who is a type 2 diabetic, it’s like thinking about that young woman I was telling you about who had gestational diabetes, for example. If we can get ahead of their type 2 diabetes and we can comprehensively work on their nutrition, their lifestyle, get them on the right national guidelines recommended medications, we can completely change and alter their heart health trajectory. That means avoiding strokes, avoiding heart attacks, avoiding amputations, and other terrible things that just can wreck a family. Trust me I know. Getting in front of this is not rocket science either but it definitely takes a comprehensive team, and it takes a team that understands all the nuances behind adherence and compliance and will sit and teach and take the time with the patient so that they understand why it is that they’re taking and they’re doing what it is that they’re doing. It’s more meaningful and likely they will be continuing the therapy more than 6 months or a year after you started them on it.

That’s like the patient who says to me, “Well, my blood pressure is good can I stop taking my blood pressure medication?” No, you can’t. To remind people that just by having diabetes they have lost 7 years on their lives and if we can prevent them from going on and having an MI [myocardial infarction] or a stroke, which will further decrease their life expectancy. That really is all our jobs to work together as a team to prevent that.

Thank you for all of your wisdom. I’ve learned so much from you today, Margo.

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: Thank you so much for having me and thank you audience for your attention.

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Limitations managing type 2 diabetes with new technologies used as monitoring tools that need to be addressed moving forward.

New Technologies, Type 2 Diabetes, and Cardiovascular Prevention

We’ve decided that every person who has diabetes should be given a CGM [continuous glucose monitor]. We’ve got that taken care of, now we have to just get the insurance companies to agree with us. Check. The other new technology, and again, I have to remind you one more time that I have been in diabetes for 40 years and you can’t believe what we did not have when I started in the world of diabetes. Now I came right in to work in the diabetes control and complication trial. That’s what I was hired to do. Insulin pumps for that study, this is not an exaggeration, they were this big. They were this thick. We had to plug them in at night and you had to dilute out the insulin and only metal needles were available, and we had to take those down and tape them down. I had to teach people to stop peeing on the blood glucose strip because they were so used to urine strips and now I was asking them to do blood glucose strips for the DCCT [Diabetes Control and Complications Trial] and other things in clinical practice. It’s been huge for me to watch the changes that have occurred. Now, we have itty bitty insulin pumps and I always laugh when a patient goes, “Oh my God, that pump is so big.” I’m like, “Oh, let me show you.”

You have no idea. But we also now have insulin pumps that will integrate with CGM, which is totally geeky. I just finished a study with Beta Bionics and that is an actual integrated pump that does everything for the patient. We use hybrids. We have a couple of hybrids that we use. But to me it’s just amazing what these pumps could do. They get the data from the continuous glucose monitoring and they adjust the insulin. If the blood sugar goes high, it gives more insulin. If the blood sugar goes low, it turns it off during sleep mode. There are all kinds of things that these pumps use and they’re kind of mind-blowing in terms of thinking about that. We’re giving more and more use for those individuals who have type 2 diabetes and they’re on insulin. They really want to move that out to that population as well and discuss how do we get these patients on insulin pumps.

: And can I say, it’s about time? Think about having a discussion with someone about a new pair of shoes or a purse that you were looking at. You go and hop online, and you get on your computer, and you go to search something and that purse that you were talking about pops up in the side window. They have been using AI [artificial intelligence] in marketing forever. To the point where we’re constantly having data gathered on us and almost everything that we’re doing. It would make perfect sense that they would be able to fine tune this pump to be able to utilize AI to inform the dosing of the insulin. So, bravo for getting all this put together and for helping to lead this because this is going to be life changing, especially for our juveniles. It’s vitally important that we’re able to help people to have a better quality of life, which is what it’s all about at the end of the day.

Yes, and I see mostly 15 and above. But I must tell you that we probably have 2000 people on insulin pumps in our clinical practice, in our group. It is mind-blowing the changes and how much these impact and how much quicker we can get to patients to treatment goal when we have the assistance of the insulin pump doing its job. Because if the patient misses an injection or a bolus of insulin for a meal and the pump says, “Wait a minute something is wrong here.” Your blood sugar is going high after you eat and the pump says, “Oh, let me fix this. Let me fix this for you.” It really is mind-blowing how many more people can get to an A1c [glycated hemoglobin] treatment goal by doing that. Just a quick sidestep, I just want to remind people again that if your patients move to insulin there’s no reason that you must take them off of the GLP-1 [glucagon-like peptide 1] or the SGLT2 [sodium-glucose cotransporter-2] inhibitor. We just get to use less insulin if, in fact, we’re using both.

: And remember, we’re not just treating numbers. We’re treating risk. We have to think less about people as numbers and think more about people as an entity, as a whole self. That risk reduction comprehensively is the most important piece beyond whether it’s their blood sugar number, their hemoglobin A1c, or their lipid LDL for that matter.

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A description of hybrid artificial insulin pump systems for type 2 diabetes and a discussion highlighting potential integration with continuous glucose monitoring systems.

Hybrid Artificial Insulin Pump Systems for T2DM

What is interesting is the research in the past, 5 to 7 years [ago], research has been done in the children, the adults, the teens, the older individuals. I sort of get testy when we talk about older individuals because I’m not sure how to define that. If it’s old, it has to be older than me. But we’ve looked at all age groups. We’ve looked at all learning abilities. We’ve looked at different ethnicities to see how CGM [continuous glucose monitoring] improves lives and how it can be utilized in practice. We’ve done a great job to say that this can be applied to all people with diabetes and certainly in the world of type 2 diabetes that that outcome would benefit. For now, we have only coverage [for] multiple daily injections. It looks like we might, soon, get coverage for just basal insulin and then we’ll have to go from there. The other thing is it’s becoming more and more affordable. If, and you know I’d never want to spend anyone else’s money, but if people wanted to be able to purchase, there are ways to do that as well.

: The more that we can submit to insurance companies. You know we had the same thing with coronary calcium scoring, for example, and insurance companies not wanting to initially pay for that. Other types—the ambulatory blood pressure monitoring wasn’t always covered either. Those became out of pocket expenses that add up quickly, especially with the struggles that so many people are facing, especially those who have chronic disease management that us submitting information to these insurance companies helps to elevate that bar for more coverage. For more coverage for most, which is what should be happening.

: I agree 100%. It’s all about you know finger sticks, when they first came out, I jokingly say but seriously mean, I remember thinking, “Oh, who gets this?” And of course, everyone with diabetes should be doing either blood glucose monitoring or continuous glucose monitoring. I am now at the point where I feel like continuous glucose monitoring should be a right not a privilege and we should be offering to more and more people with diabetes. Think about that, if you had diabetes, for me, the greatest risk for being [able] to go to sleep at night would be, “Oh my gosh, what if I have a hypoglycemic event and I miss it and something happens?” If I wore a continuous glucose monitoring and it alarmed when it started getting low, then I would be able to. The other thing is that, as a healthcare provider, there’s a great way to learn how to interpret the data. It’s not complicated. It can be put on your computer and guess what, you can bill for those interpretations. We give too much away. Not that we shouldn’t be providing the highest level of care but because most patients who have type 2 diabetes are in the primary care world, we need to extend that into the primary care world. How do you use continuous glucose monitoring? How does it enhance your practice and your relationship with your patient? Let me tell you, you can bill for it and insurance companies do pay for the interpretation and, if you use a professional, for the placement of CGM.

: Yes, absolutely. And remember, we’re fighting a war on health equity here. When you think about those who don’t have access to CGM, it tends to be those individuals that would fall within these disparities. We need to stop this. This is unacceptable, especially when we have such robust data that we can significantly improve their lives. This really needs to happen and we shouldn’t, as providers, tolerate it. Or patients either, tolerate it any longer with what we currently know.

: I feel like too, the other end of the spectrum is our Medicare patients who do go into the donut hole, and they’ve been doing so well in the therapies we provide. Then we can’t get medication for them for a particular period of time and that’s heartbreaking.

: It is. It really is. I have a husband and wife that share medications and they will split up their meds because one of them is in a donut hole—it’s just…it’s so heartbreaking. This is when working with a pharmacist closely, is vitally important and another key takeaway, I feel, that is if you are working with a diabetes team then a pharmacist should be included in that care team and that there’s some great data demonstrating cost reduction for the institution when the pharmacist is included. Many times, they can help us combat these different barriers and find alternate ways of funding for essential medications.

You’re absolutely right. That’s the one person we’re seeing in addition. We’ve always had the educator. We’ve always had someone in nutrition, but what I’m seeing more and more is the addition of the pharmacist for exactly the reasons you’ve described and also they can work closer with the patient too if they’re having drug-to-drug interactions. Why are you stopping a medication? They can watch for refills and making sure that the patient is in fact refilling their medication. Those are good points. Really good points.

Recommendations to address accessibility and coverage issues that affect the use of continuous glucose monitoring into widespread clinical practice.

Integrating Continuous Glucose Monitoring Systems into Clinical Practice

One of the newer things—it’s not really new for those of us in diabetes—I’ve been utilizing it probably for the better part of 20 years, but different iterations is continuous glucose monitoring [CGM]. And the beauty of continuous glucose monitoring is how accurate it is and the fact that if we place a continuous glucose monitor, and there’s professional and personal meeting on placing it for just a short period of time, 10 of 14 days, patient brings the data back to me, I get to look at it I guess to help me make decisions. And then there’s personal. The patients are utilizing personal. For type 2 diabetes right now...we get coverage, whether it be Medicaid, Medicare, or commercial. For type 2 diabetes, for the most part they need to be on multiple daily injections. And one of the things that we’re really working with Medicare on, because Medicare makes a decision and that’s how the world turns, is to look at all people with diabetes, but mostly to look at people who are on insulin period. If you’re on one injection of insulin, basal insulin you should qualify for continuous glucose monitoring, but the whole concept of CGM is just totally explosive in terms of what it can do in helping us manage people with diabetes. What are your thinking on continuous glucose monitoring? I almost don’t see a patient that is wearing it or using it.

: I can’t imagine that you would, because anything that is going to give more data, and accurate data, especially for those patients that have more aggressive or poorly controlled type 2 diabetes. Knowledge is power. These continuous glucose monitoring data is really, incredibly important, especially as we were just talking about for these the basal dosings. I absolutely was so impressed. We were just talking about the article that was in 

Journal of the American Medical Association

] that just very recently came out. And a very large meta-analysis that was going over how you can significantly reduce hemoglobin A1C in as little as 8 months just with the improved monitoring in and of itself. That awareness is essential.

 article, it came out in June 2021, was first of all, we were trying to complete it in the middle of COVID-19. That was one interesting thing. But the other thing is that it wasn’t managed by endocrinology. The patients had to come out of primary care. They could never have owned or worn CGM. They were on programs with just basal insulin. And we would upload it for the primary care provider, and we would tell them what we were seeing. But they were having the conversations with the patients. They were making any adjustments. They were the ones that were having the relationships. The fact that we saw such significant A1C lowering. The other thing is that there was another paper that was published in August of 2021. And what we did in that one was we kept one group on CGM, we took CGM away from the other group, and the increase in the A1C, which you and I would expect for those individuals who were now not on CGM was very significant. To show that even just a on basal insulin, when the patient’s getting that kind of feedback on a regular basis of what happens when I walk, what happens when I eat, what happens when I take my medication as prescribed is remarkable in moving that patient ahead.

: Absolutely. You can see how that would help improve their overall quality of life because they have increased self-awareness. And when you have increased self-awareness, I just feel that you start to do other things that are good for you inherently. This monitoring in places where people live gather, whether it’ a Fitbit or it’s a blood pressure monitor that communicates with your phone, your continuous blood sugar monitoring. There’s many different ways that we’re able to use AI [artificial intelligence] and other smart technology to be able to have real-time data and it’s really incredibly powerful for providers today and equally so for our patients that can come in and say, “Look at me. Look what I did. Look what I was able to accomplish.” Because then they can start to also see that their nutrition can make a difference. Just having that improved awareness is significant.

The other thing we find too is that if a patient does have low blood sugar that impedes their ability to keep getting their blood sugars under control. Because at that time of day someone will feed them, they’ll omit their insulin. They’ll omit their medications if they’ve had an episode or if they have one episode overnight somebody will feed them before they go to bed to make sure their blood sugars are 2 to 300 so they don’t have an episode during the night. These devices have alarms and alerts on them so that if you’re going low, they can let you know so that you can treat it right away.

: Way before. The yo-yo. The yo-yo phenomenon starts to take place.

A discussion on using continuous glucose monitoring systems to improve the management of type 2 diabetes.

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