Nicolas Cuttriss, MD, MPH, FAAP: [00:00] Thanks, everyone for joining. And just as a reminder, as we kind of go through this, the didactic presentation, if you have questions that come up, please go ahead and just chat questions into the chat box. And then we've got a couple other club members here who are joining us—we can try to, they can try to chat in and respond, and I can address those afterwards. And then once we finish the didactic talk, we'll open up just for little discussions. And then we've got a case presentation that Cyd has submitted and we'll pass it off to Cyd and we'll discuss that case. And so let me just share my screen, and we'll get going with the didactic.
So just a few disclosures in terms of employment and consulting, not really relevant here. So our learning objectives today: we're going to address therapeutic inertia in your practice by addressing diabetes disparities, implicit bias, and also trying to focus on some language around diabetes. We'll review the ADA guidelines to identify evidence-based treatments for patients with Type 2 diabetes, regardless of A1C. And then also avoid identify some pharmacotherapy for patients with Type 2 based on indicators for those who are at high risk of ACVSD, CKD, or heart failure. And [I'll] divide this up just kind of four brief blocks.
And first, we'll just kind of start off, that it's not easy to meet A1C targets. And so we should try not to blame our patients. When we kind of see these patients come in, they're on your schedule for the day A1C over nine, and think of this, oh great, this noncompliant patient. And so you know, diabetes, it's not easy. It's a you know, a fine balance, you're trying to have your best blood sugars as possible, and let's not forget about blood pressure, lipids, and other things that you're grilling the patients on, as few uncomfortable lows as possible, and you know, PS let's have a life as well at the same time. So this is kind of Dr Bill Polanski's slide, who's a behavioral health specialist and just really...to reiterate that this is tough work. There's no other condition out there. Diabetes, 24 hours a day, 7 days a week, no vacation, and no one pays you to do the job. So people didn't sign up for this. And evidence-based diabetes sucks, and it's okay for patients to feel that way and for you to address depression or diabetes, distress, and supporting them through their condition, not their disease.
And if we look at outcomes on a national level, diabetes report card of what your medical directors share with you quarterly and how your patient panels are doing one A1C, over nine—were failing. And so when nearly half of the population have A1Cs greater than 9%—and I want to call out the disparity between Medicaid patients versus Medicare patients where almost 50% more A1Cs greater than 9% in the Medicaid versus Medicare population—this is not patient's faults, when we see this degree of failure. This is straight out system failure, and you all who are diabetes champions and frontline providers can really try to address this system failure for patients.
And you know, you may not have...your patients may not have access to specialists, like me and others, but you don't necessarily need them. You can use your resources and interventions addressing diabetes actually sometimes have better success when they're not MD led. So using a CDCS case manager, pharmacist, physician base, using the best of what you can and limited resources, and really calling... I want to call it attention to diabetes education, where many people don't even know that there's such a thing as a diabetes educator and knowing the critical times when to assess and refer for diabetes education. Now moving on to diabetes disparities and implicit biases that are endemic to our practice. And let me just kind of start you know, there's just not enough specialists in the US to see patients with diabetes and so you all are joining us today are our champions, because you're primary care providers and you have more ability to have touchpoints with patients living with diabetes than specialists. And so referring patients to specialists is not going to solve the public health crisis of poor outcomes for people living with diabetes. It's addressing it where you all are in the communities and in terms of possible reasons for hope.
And so diabetes, as you all know, affects about one in 10 people in community health centers. The burden of diabetes is double that in the general population, so on average, probably in your clinics, 20%, sometimes 30% patients living with diabetes. And so to say that you're going to refer 20 to 30% of your patients to a specialist who come in, probably half of your panel a day, that's ridiculous. So trying to feel comfortable and empowered in terms of how to manage people living with diabetes, that's what this program is about. One in three people living with diabetes have CKD, and more concerningly, four of them who are already advanced to stage three and four don't aren't even aware that they have CKD.
And the racial disparities that we see, just as an example of, of looking at diabetes, and CKD, in particular, we see black Americans are three to four times as likely to have CKD than white counterparts, Asians double that and seeing the rise in Hispanics' CKD rates for the past 20 years more than triple. Some of you who work with Native communities may have seen over the past 20 years, the kind of reasons for hope that maybe we can take away from what Indian Health Service has done to address disparities in CKD, and you can see that the rates of CKD in Native Americans have decreased by half over the past 20 to 30 years with that sort of targeted intervention and quality improvement initiatives.
And I mentioned CKD is three to four times the rate in blacks compared to whites.
And I want to call out, some of you may still be thinking about adjusting EGFR based on race and ethnicity—that is no longer a recommendation. And that's perhaps one of the reasons why we have seen higher rates of CKD in the black race, and so that's no longer a recommendation; I'll go into some of the new screening as well. And before I get there, in terms of the burden of diabetes in general, breaking it down in terms of race and ethnicity, we see disparities beyond socioeconomics, and unfortunately, where I practice is most in the pediatric population, it is even more troublesome than the adult. For disparities when we talk about medication management and implicit bias, over 20 years ago back with metformin and thiodines therapy, there was disparities in terms of racial and socioeconomics, and now we're seeing the same disparities when we look at newer medications such as SGLT2 inhibitors and GLP-1s.
And so on the left here you can see claims data based on the different types of medications and on the right, the dollar amounts to GLP-1s, one of the higher costs right now followed by SGLT2s. And patients with low SES are less likely to be prescribed, and also black patients, regardless of SES, are less likely to be prescribed SGLT2s and GLP-1s, based off claim data we've seen over the past...this five year time range after the Affordable Care Act. And so many times we think, oh these medications are expensive in 340-B programs. You're going to have a GLP-1 or SGLT2 that's on formulary, and this is just an example of percentage of ... many don't require prior authorizations for SGLT2, or GLP-1s. So knowing with the different managed care organizations that you work with in terms of removing potential barriers of prior authorizations, if you will know that there's one on formulary that doesn't require a proper prior authorization, that might be the one to start with and then moving on to another one after that. But usually on each formulary, you can be able to define one SGLT2 or one GLP-1, regardless of what we might think about pricing.
The other take home message I want to emphasize is to think, to start thinking beyond glycemic targets and thinking beyond this A1C greater or less than 9% that is always on front of minds of every medical director and outcome reporting. And some of the following resources that I'm going to share with you, I want to turn your attention to the abridged standards of care by the American Diabetes Association. That gets updated virtually as a living document. And also some of the information sharing is also available from recent ECHO series we did on addressing disparities with Project ECHO with a focus on CKD.
So remember, A1C is just an average. It's not a one-size-fits-all: it doesn't capture hypoglycemia, it doesn't capture time spent in range, it doesn't capture glucose variability, it doesn't capture quality of life, and it doesn't capture cardiovascular and chronic kidney disease. And so this is just, on the right is, this is a resource by diatribe.org. If you aren't familiar with that organization, it's a great patient resource and also for providers of really trying to simplify the complexity of diabetes. These are three different faces of how A1C at 7% looks. And so if on number one, if I had a patient who had come in who I see their A1C 7%, I give them a high five before I look at CGM data and I find out they're having 25% hypoglycemia, they're going to think I'm crazy. What are you...? Why are you high fiving me for a day when A1C of 7% when I feel like crap? And so thinking beyond the A1C, before you before you go in there, and not thinking about oh, this is a good number, this is a bad number, you have numbers that are high, you have numbers that are low, you have time that's in target. And our goal is try to maximize the time in target, minimize the lows, and minimize the roller coaster of the standard deviation. So really encourage you to look past the A1C and also individualize what you're discussing with your patients.
Cardiovascular disease management, so the standards of care with the ADA. This is endorsed by the ACC, and this section has continued to get updated. And so glycemic management, blood pressure, lipids, and chronic kidney disease. And so some of the newer updates from this past year I want to emphasize—and we'll go through the algorithm and throughout this series, we'll come back to this—but it's consideration and rationale for combination of SGLT2 inhibitors and GLP-1 receptor agonist to address cardiovascular and kidney complications with patients with Type 2, and AC, atherosclerosis cardiovascular disease, or those who are high risk of that. There's also a differentiation in terms of the emphasis on how to approach patients who are already on medication management and also starting new and minimizing therapeutic inertia.
Blood pressure targets, previously 140, targets are 130 over 180, and once again, individualized for patients with diabetes and hypertension. If you're not already doing it, and if you have EPIC, there's protocols and add-ons on this where you can integrate in a CVD risk calculator. You can download this on your phone, on your computer, and this can really help assess in terms of triaging beyond A1C targets and to figuring out if someone should be on SGLT2 or GLP-1 therapy regardless of A1C.
New kidney health evaluation—this is new, and so this is the heat diagram from kidney do and EGFR is measure and also UARC. So looking at not just EGFR but UARC to look at response to therapy and also for diagnosing CKD. So this is going to be the, this is a new HEDIS measure for this calendar year and moving forward. Some of the health plans in California like Partnership they had taken off the kidney health evaluation, I'm not sure when or if this would come back on but from a national reporting standpoint, this is going to be in the new diabetes care package for NCQA. And so with regard to CKD, those who have UARC greater than 300 milligrams per day, must be reduced by more than 30% a slow progression of CKD. Finesterone, which is a new mineralocorticoid receptor agonist is also now indicated for people with CKD who are also at progression for worsening CKD or heart failure. And there's a major emphasis on categorizing patients with CKD by measuring albuminuria, not just EGFR.
And finally, thinking about pharmacotherapy to treat beyond A1C. So traditionally, we've been trained to only think about glycemic targets, but if you think kind of big picture, why are we focusing on minimizing A1C? We're doing it for beyond A1C things—we're trying to minimize micro- and macrovascular complications of diabetes. So now we have agents that directly do that, in addition to glycemic targets. So now we can be even more efficient, with the end goal of what we're trying to minimize in terms of complications. In the following flowchart I'm going to share with you, it looks at thinking about your patients in terms of comorbidities, so ASCVD or high risk of it, heart failure, and CKD are the big things to keep on top of your mind. And then consideration of hypoglycemia, consideration of weight reduction, access and costs, and also efficacy.
And so this is the American Diabetes Association guideline treatments for Type 2 diabetes. You can see off the bat regardless of A1C, if you look at the left side—I don't know if you can see my pointer working—therapy is going to be based on does your patient have ASCVD or a high risk, yes or no? Then usually you'll move to at least a GLP-1 plus or minus SGLT2. If there's heart failure, SGLT2 tends to be the preferred treatment option. We have people going to see cardiologists; they're prescribing SGLT2s and yeah, probably more so than many endocrinologist are right now unfortunately. And then CKD, SGLT2 plus or minus GLP-1. But usually SGLT2 is preferred and patients to start with CKD.
Thinking about hypoglycemia, ways to minimize it, and getting off sulfonylureas or minimizing basal bolus if you don't need it, and thinking about GLP-1 or SGLT2. And weight, you've... You're all probably familiar with the GLP-1s now and new medications like Ozempic, Wegovy, a semaglutide for weight and then a new medication just came out by Eli Lilly, a combination of GIP and GLP- 1 receptor agonists. You'll be hearing more about that. And then for your patients who don't have access to 340B or where there's issues with costs, there's other options to them that might be, that you can think about but usually there's patient assistance programs where we can, if there's a care coordination, you can kind of overcome that.
So this is really a flow sheet that'd be great to continue to come back to in this series for you all to share out to your colleagues and your clinics to remind them really the first thing, it's not what is your A1C, it's what are your risk factors? You know, once again if they are overweight or obese, they're interested in decreasing their weight, let's get rid of this shame and blame and stigma around that, and there's now pharmacotherapy to help them address that and really thinking about it, for example, a GLP-1 receptor agonist or a combo therapy, in that setting, would be helpful for that patient.
And then finally, I'm going to close with just kind of some concrete, actionable items that you all can take and share with your colleagues of how we can start right now, without even getting into the pharmacotherapy with your colleagues about how we could potentially decrease A1Cs and get patients more engaged. And one way to do that is trying to get rid of this shame and blame and stigma around diabetes, and changing the language that we use in our clinic. And so instead of calling labeling someone as a diabetic, they have—you know, this is a condition. This is not, this shouldn't be what defines them. So yes, we might slip and say diabetic, you know, we're not like the word police. This is more for just, you know, how to think about the concept of someone living with chronic with chronic disease. Oops, my... Can you still see my screen? Okay.
Maggie Graham: [21:23] Yes, we can still see your screen.
Cuttriss: [21:25] And so try to think not about this is a good book blood sugar, a bad blood sugar or being you know, judgmental about this, but it's in.. you're in range or below range.
Graham: [21:37] Sorry Dr Cuttriss, you're actually back on the flow chart. So I think you need to go forward another slide. Apologies.
Cuttriss: [21:42] Okay, great. And so there's diatribe destigma.org. It's a great resource as well, that has some additional videos and language around language, and also some patient perspectives about hearing from them how language and what we say or how we judge does make a difference in how they engage in their care. And so I'm going to stop there. And we can kind of open up for questions and discussion before we move on to our case presentation.
Graham: [22:18] Fantastic. Thank you so much, Dr Cuttriss. So you actually have a few questions in the chat, which I'm happy to read or you can, but if you could, read them out loud so we can capture them on the recording as well.
Cuttriss: [22:28] Sure. Let's see here. Is it appropriate to prescribe SGLT2 for patients with Type 1 or Type 1 1/2. And so it's a, it would be an off-label. You can—it's FDA approved—so you can prescribe it however you want. And Jay or Rayhan, you can also chime in, but there's also kind of some protocols to think about and we can chat in here, like the stitch protocol or things to be careful about in terms of euglycemic DKA. And so if you are going to prescribe SGLT2 for someone with Type 1, you do need to monitor, kind of teach them how to monitor for ketones and be a little hypervigilant about euglycemic DKA. And especially for a sick day management: if they were to get sick, you'd want them to stop the SGLT2 inhibitor and really counsel them. And so you know, patients can do it even if their...but they need to be educated and empowered about how to do that. Or Chris, do you want to comment too on that? Do you have any patients in your panel?
Christopher West, PhD: [23:50] I don't have any of those Type 1 or 1.5 on GLP or SGLT2s right now.
Jay H. Shubrook, DO: [23:56] Nick, I could add something I typed into the chat, as well. If you're new to SGLT2s, you probably want to stick to Type 2. If you have a patient who is ketosis at-risk, you know whether someone's got Type 1 or sometimes 1.5 means a lot, it means different things to different people—that is a very effective tool, but it is off label and you really want to have a plan for, as Nick mentioned, sick day management. And there are good protocols that you can look at. But I would say do that if you feel comfortable being able to help the patient manage the risk.
Graham: [24:36] Any other questions for Dr Cuttriss about his didactic before we move into the case discussion?
Shubrook: [24:46] Nick, I actually have one for you.
Cuttriss: [24:48] Yes, Jay.
Shubrook: [24:49] You know, you have a really great overview and it feels like there's so much we need to do with our patients. How do we manage this because I can't possibly do all all of these things at every visit. So, you know, do you have any strategies when, you know, we have only maybe four visits a year, but so much to cover?
Cuttriss: [25:10] Yeah, so I think you know, one—and that's why I kind of ended on language—I think just like the basics of, even if you can't go in depth, you want your patients to remain, you know, engaged. And so there's many times where patients stop coming to see the specialist or might come in to you, you don't even realize it, but it might be kind of more judgmental. So the, the more, you know, the more touchpoints you have, the more likely you are for a change. And so trying to keep your patients engaged and leveraging other resources in your clinic, so if there's not a provider panel maybe they come back and meet with the social worker to assess social determinants of health and just food insecurity and maybe nothing directly related to the medication management, but very related to their kind of behavioral health and in overall, you know, wellness. So trying to keep those touchpoints as frequent as possible, but it might not need to be with a provider clinician, it might be other ancillary support as well.
Graham: [26:19] Great. And then we have one more question in the chat before, I think we'll need to move on to the case discussion. It's from someone asking if there's a resource for medical providers to help them understand how implicit bias affects patient care and treatment.
Cuttriss: [26:34] So yes and no. There's...some tools out there regarding implicit bias and obesity. Harvard has a good assessment tool for multiple different conditions, HIV. There isn't one that I'm aware of right now, specifically for diabetes.
Graham: [27:01] And if you do end up having other questions you'd like Dr Cuttriss or any of the hub team to answer, if you send them in through the chat, we will be saving the chat so we'll make sure the hub team gets it. And we'll sort of send out those responses at a later point. But in the interest of time, I do think we want to move into the case discussion. Cyd, are you on the call? I think I see you.
Cyd Bernstein, LCSW: [27:21] Yeah, I'm here. Do we have a half an hour?
Graham: [27:25] I think we have about 30 minutes left in the session.
Bernstein: [27:29] Yep, ready.
Cuttriss: [27:30] And Cyd, let me, I'll share my screen. I've got it just a summary up and you can describe the case however you want.
Bernstein: [27:38] Do you also have the decks comms?
Cuttriss: [27:41] Yep, I've got the decks for it up there as well.
Bernstein: [27:44] Great, thanks.
Cuttriss: [27:49] Let me know if I'm in the right mode, or if I need to flip flop.
Graham: [27:53] Looks great to me.
Graham: [27:56] And this is just if any of you want to submit your own case for future sessions, it's a link in the QR code. And Andrea will also be emailing out the link.
Cuttriss: [28:04] And then just a reminder for those kind of new to ECHO. So we'll do a... Cyd will kind of share summary of this, and then we'll open up to clarifying questions. So as Cyd's kind of going through this, if you have some questions, go ahead and try to chat in the chatbox. And then after we do clarifying questions, then we'll open it up and talk about recommendations. So very challenging patient. Cyd, I'll pass it off to you.
Bernstein: [28:30] Thank you. So I'm a health coach and diabetes educator and I work with a team who, we've been working the past couple years on identifying our patients with A1Css over nine and then bringing them into this kind of holistic team care model.
So this is someone who our team has been working with for about a year. And let me... please do also, you know, read the slides as you need to. I might not get to everything on here, but we saw her, we brought her into our care about a year ago and at that time, she was insulin requiring Type 2, diagnosed in 2009. She did have left ventricle, she...sorry. She was diagnosed with left ventricular hypertrophy without heart failure and CKD stage 2. She was also overweight, with a BMI at that point of 31. She was a smoker, she is still a smoker. She has a history of alcohol use but is not currently drinking. And she also has a history of hypothyroidism and rheumatoid arthritis and was last, was hospitalized in 2016 with DKA.
So when my team met with her a year ago, she was on 100 units of basal insulin and 20 units of humalog just before dinner because that was her largest meal of the day. She was experiencing a lot of symptomatic lows. She also experienced symptomatic highs. She had...her A1C was 8.5 at that point, but you know, as we saw on that side from Nick, that was a lot of highs and a lot of lows combining. Previous to 2021, she had her A1C is hung out more in the 10, 11 range.
So fast forward to this year, we have made a lot of progress. She now is on Invokamet, 51 000; she's on Ozempic, one milligram weekly; and we've reduced her basal insulin to 45 units. She is now though...her A1C In April of this year was 7.8. But as you'll see, when we get to the decks comm slides, it looks like she has been trending up for the past month or so. She is still getting some hypoglycemia, especially in the early morning hours and she finds anything under 70 pretty debilitating, kind of knocks her out for the whole day. And then she also has highs.
So I'm hoping that the hub team and that everyone else can just look at her CGM with me and kind of see something that I'm not seeing, and then I'd love to have a discussion of where we go with her where we go from here with her management and, you know, anything else that's jumping out at people that that we're not seeing, I think she's a good case of someone who really there was a lot of clinical inertia around this case for a long time. We've made some really good changes, and I think recently there's been some more inertia.
Cuttriss: [32:16] This is Nick, I'm going to go ahead and share the CGM data. I can talk through this or you can interrupt. So this is just the overview report that you can see that was referenced before. So you can see kind of the beyond A1C metrics, so time in range, the green that's 49%; time below...low, it's less than 70, and then also kind of less than 54, like the very lows. So overall minimal lows here and minimal very highs. And then you can also see the standard deviation 59. So overall, the glucose variability, 182 divided by 59, less than 33, around 33%, which is probably a lot less than what it was before. And just a refresher on the kind of...in general for Type 1 and Type 2, but this needs to be individualized depending on age and circumstances, kind of target time in range 70% or greater, time below range 4% or less. Obviously with this patient, it sounds like she's very sensitive to hypoglycemia.
So once again, going back to her report, this is the overview. As you can see, 12am to 12am, you can see kind of where the average blood sugar is hanging around. So it's hanging around like 180. And then you can see overall, these past two...over the two weeks, you can see a little bit higher blood sugars in that kind of 6pm to midnight range. And on your reports, if you were to upload this or review it in clinic, you can change the time from a one week review, two week review, a one month review. So if you recently made some medication adjustments, it defaults to two weeks. So if you have them come in one week later, you could adjust the dates and look at what's happened in the past week, as well. And then, so this is the overview for the two weeks. A reminder that you can also look...it gives a report on what the settings are and kind of what the alerts are set for. So sometimes people might get alarm fatigue, or maybe they want to be notified of hypoglycemia before 70, or so just kind of taking a look to see where the alarms are set to or assessing for that. These are some dailies for the for the past week. And so once again, you can kind of see some higher blood sugars in the afternoon and the evening. Then as Cyd mentioned, you see the blood sugar kind of coming down and stabilizing out around in the 70s, 80s in the mornings some time. Any particular days you want to call out, Cyd?
Bernstein: [35:17] Um, there was this June 7th, I think back one side. She had this low in the morning, and I think she got a down to 44, and that's not that unusual. Like, if I go back and look at her 60 or 90 days, that's, that seems to happen fairly often. Probably every, like two to three weeks that happens. And she can't really identify a pattern around like, does she do something differently the day before? Or you know, is there a change in the way she's taking her meds? So that's, that's puzzling, and it's just something that she would really like to address because again, if she has a morning like that, it kind of wipes her out for the rest of the day.
Cuttriss: [36:04] Alright. And then, so I have a clarifying question on this: does she feel symptoms...like when this happens? Or does she just get, does she get scared?
Bernstein: [36:15] No, she feels symptoms. She feels, yeah, really tired. Yeah, she definitely feel those and she really says she feels anything under 70.
Cuttriss: [36:32] Alright, so I just stopped sharing my screen. And now just if there's some...I'm going to look to see if there's some, anyone chatted anything in. And just go ahead and unmute yourself, and if you have any clarifying questions for Cyd, please go ahead and ask.
Bernstein: [36:51] I will say I went back... Oh, interesting, Rayhan. Um, I went back and looked at her initial diagnosis, which happened in clinic in 2009. And she came in with a random of, I think 450, 500 after having been diagnosed with diabetes for maybe a year. It wasn't, didn't have ketones in the urine, but I think it'd be interesting to get a C peptide on her to just, you know, kind of rule out LADA or other kinds of diabetes. Yeah. Rayhan, that's interesting, and I did think about that. I think that—Rayhan was just saying maybe the lows are to do with compression. And yeah, I think that's definitely something to explore. She does tend to have early morning lows—that one was a little extreme—but they they seem to happen and she does seem to feel them in general. She has been on the one milligram for about a month now. She felt really sick when she started on the point two, five, but is wanted to perservere. So she's maybe we could titrate that up. But she...yeah, she has felt pretty horrible.
Graham: [38:25] Someone else also asked: what other types of interventions have been utilized thus far?
Bernstein: [38:32] Well, the CGM was huge. So she got on CGM about a year ago and that, I think, was responsible for a lot of her self-management and you know, her A1C was coming down before we made medication changes, so I think that was definitely part of it. She has had some...she's definitely had a lot of health coaching from us and we've been working with her on her diet and lifestyle. She's a park ranger, so she's pretty busy during the day, on her feet a lot. She also wears dentures so she doesn't really like to eat at work because it's pretty difficult, and so she's often not eating during the day and then only eating kind of large meals at night and we've worked with her around you know, carb content of those meals and you know, trying to incorporate more vegetables. Exercise she does a lot of in her work, but you know, we also have worked with her on exercise as well. Yeah, so Chris kind of to address that, she works pretty long days and then goes home by 6 or 7 in the evening, has a really big meal around 8 o'clock, I think stays up pretty late, stays up till about midnight. She is, she lives with a partner, she does not have children, and I don't have a huge sense of what her life is outside of her work life.
Cuttriss: [40:02] This is Nick. For the basal insulin, is she getting it at night or in the morning?
Bernstein: [40:08] She's giving it to herself at night. Yeah.
Cuttriss: [40:17] And oh— [crosstalk]
Bernstein: [40:24] Our conversations with her have been a lot about adding prandial insulin, because that was kind of where our team came to was like, okay, this is probably the next step. But you know, I wanted to put it out to everyone to see what you all thought, and if you have a better next step or if you have, you know, thoughts on the regime she's already on. Sorry, go ahead, Nick.
Cuttriss: [40:52] Oh, yeah, I guess before getting to that, the PHQ before was, you know, 19. And in terms of like intervention on the behavioral health side or depression, any kind of comments or how have things kind of come along with that?
Bernstein: [41:05] Yeah, thank you. That was that was about three years ago, I think—yeah, 2019. So I wasn't involved at that point, but I did look back and she did see a behavioral health provider. And in the note, the provider said they had good rapport, but she didn't necessarily believe in therapy. So I think that was kind of, that kind of got dropped at that point. I definitely think it's worth circling back with her on that, because I would say she's a really charming person, she presents as very, very competent, very capable of self-management and then I think will disappear for periods of time. And sometimes I wonder if that's behavioral related.
Cuttriss: [42:00] And what is this Nick again? What is her...was she, in terms of like, bolus insulin, have you brought that up? I mean, she was on it before and she was having lows. So kind of what's her kind of mindset? Or do you have any sense of like, is she asking for a type of...is she kind of wanting something and not wanting another type of treatment? Or what's your insight on that?
Bernstein: [42:25] I think that she's definitely open to it. She was really nervous to reduce her basal insulin. But she had a couple of days where she was, she wasn't eating actually, when she started the ozempic because she felt so crummy. And she had a series of lows. And so we just talked to her about over basalization, and that, you know, based on her weight, it was really a lot of basal insulin that she was on. So we've kind of slowly persuaded her to go down on the basal. I think that she would be open to adding prandial. I think that she really wouldn't want to do it at work. That's the only catch.
West: [43:06] Got it. This is Chris, I have a couple questions. I was trying to figure out with her kind of blood sugars that are fluctuating a little bit. Is there any correlation between like days she's walking a lot more at work and some of the drops that are happening overnight? And then the second question, which isn't quite related, is, has anybody done an exam to see if there's any scar tissue or areas where she's giving her injections where she may not get good absorption?
Bernstein: [43:34] Those are great questions. And I will follow up with her because I'm not sure. Yeah, that's great.
Graham: [43:40] So does anyone else in the room not part of our hub team have any questions? I know Rayhan just put something in the chat kind of encouraging people, as well.
Rayhan A. Lal, MD: [44:02] I also wanted to say I realize some of our roles may be slightly different in this ECHO. Chris and Jay are amongst our pilot sites or the Sanford ECHO. And so they are spokes there, but they're hub team members here. So it's a little change of roles for us so yeah, for whoever else is on the call, please feel free to drop questions and we'll be getting to recommendations in a second.
Bernstein: [44:37] I will just say one interesting thing about her is when we added the SGLT2 she felt an enormous difference. That was probably the medication that helped her the most. As far as her own sense of well-being she lost what she reported to be a huge amount of water weight after starting SGLT2. Her weight was 197 in 2021 and is now at 184. But a lot of that drop happened after the SGLT2 and more now after the GLP.
Cuttriss: [45:12] This is Nick, I saw there on the report and the recent EGFR, did you have one before starting the SGLT2s? Do you see improvement in that, or?
Bernstein: [45:23] You know, that's a good question. I feel like the one I shared was a little old.
Bernstein: [45:28] And so, I don't think we have—I don't think we have a more recent one.
Cuttriss: [45:38] And then, and then in terms of the kind of initial submitted question that Cyd had, anyone have any kind of additional thoughts on tweaking the medication management regimen or kind of approaches to that?
Kate Kirley, MD, MS: [46:21] I have a question that might be the wrong tree to backup. And hi, everybody. I'm Kate. I'm part of the hub team, but really focus more on prevention and less on management of some of these more complicated cases of people with existing diabetes. To what extent is sort of the limitations that she has with her work situation, potentially, you know, sort of contributing to her challenges? And not that we would want to ask her to take on a position that would be uncomfortable for her and her work life, but is there any role for trying to help her figure out whether she can do anything different during her work day and trying to enable that, you know, as medical professionals, trying to get her permission to be able to do something differently within her workday that could potentially help her out her, or not? I'm just curious what the group thinks about that.
Bernstein: [47:26] Are you thinking, Kate, like to reduce the amount of exercise she's doing on the day and like, how often she...?
Kirley: [47:32] Yeah, or it sounds like she's saving all of her, most of her eating for the end of the day when she feels it sounds like more comfortable with being in a situation to be able to do that. And then given what you mentioned, with the dentures as well, you know, whether there's any rule for getting her some protected time to be able to do whatever she needs to do there from an eating or medication taking standpoint. You know, some people may not want to make requests like that at work and that's actually not desirable to them at all, but for others, you know, getting a medical professional to say that they need that might be helpful to them. And I'm just curious whether that might help her in this situation or not, potentially.
Bernstein: [48:14] Yet, she did have to change job duties because she had a foot infection about a year and a half ago, so I think that it's within the realm of possible, yeah. And Leah, who I think is also on this call, did a lot of work with her to kind of figure out what meals would work at work, like soups and smoothies and stuff that she could take, but it absolutely bears having another conversation with her about it.
Graham: [48:40] I see something in the chat, discussing how consistency in her exercise could help some, as well.
Bernstein: [48:51] Yeah, definitely. And I think, you know, back to Chris's question to just It bears having another conversation with her. I think part of the...what I think I'm seeing in the clinical inertia piece is we really focused with diet and exercise and lifestyle with her a year ago. We haven't really actually come back to those pieces in a while. Yeah, so yeah. Leah is saying she does have an accommodating supervisor.
Cuttriss: [49:23] And this is Nick, just going back to the CGM just wondering like, I think someone mentioned before, but sometimes in the middle of the night, if you're kind of stable then all of a sudden you see like 100 point drop, and especially with her who doesn't have like bolus insulin and just basal insulin, usually, that's something called a compression low. So if you're kind of sleeping on the CGM, and it's going into the muscle, you can kind of see that low, so that might… And some people are fearful of hypoglycemia, they might react to that and then over treat, and then cause even more hyperglycemia so that might just be something to, you know, counsel her on kind of given her history of hypoglycemia and her interest in minimizing that.
Adding on there are some days here where she doesn't, you know, have a lot of hyperglycemia with the meals and so maybe getting a better sense of looking at the total, like, you know, what are the days where she really spikes? What type of foods is she eating? And maybe using the CGM more as a kind of nutrition exercise education. And so, you know, versus kind of adding bolus insulin in, you might need to do that, but she might even be able to get away without that by focusing, once again, going back to the basics that you first started looking at a year ago, probably before you introduced or around the same time you did the CGM of okay, when does she get the spikes? When does it get minimized of how exercise can play into that? But I think if she's not very—and as Chris said, with the activity—if she's not very active and she doesn't have the bolus insulin relatively, that risk of hypoglycemia isn't going to be as big but you might, she might be... I think, what Chris was getting it, maybe considering on days that she's super active, maybe you could decrease that basal insulin by 20%. So if it's normally 45, give 40 that night. Chris was also talking about the work schedule for some people who are on variable work schedules, overnight shifts, and it's difficult to remember when to give the insulin. Tresiba is another long-acting insulin that might, she might consider or maybe moving the basal insulin to the morning to minimize the potential risk of loads at night, if she's up for that schedule. That might be the simplest thing and moving the dose forward, you can move it, you know, instead of giving it before bed, you could give it at lunch one day, and then breakfast the next day, or you could just wait 12 hours and skip the night and give it in the morning should probably be fine and wouldn't have that much hyperglycemia overnight.
West: [52:11] I might add to what Nick's suggesting is, if she sees her blood sugar suddenly dropped in the middle of the night, is confirming that with a finger poke, especially if he's not really feeling symptomatic.
Graham: [52:28] Also have a comment in the chat regarding adding bolus before dinner with a correction as needed to potentially reduce the basal and preventing overnight loads.
Bernstein: [52:44] Yeah, I think that's a great idea. I'm wondering, Nick, just to clarify, so you're saying potentially we don't need to adjust as if we go back to kind of diet and lifestyle factors and see if we can work from there. Or, like try that and then think about...
Cuttriss: [53:00] Perhaps, or even just getting a sense of how much she's eating with each meal that...that'll help you with the bolus insulin. So I think just I think focusing on the nutrition, overall carb intake, you know, and maybe think about how much fat and protein she's doing. And I think that could potentially help you get if you need to do the bolus, but it might be that her just becoming more aware of it, she starts limiting the total intake. So it might be she noticed when she gets over, you know, 45, 50 grams, that's really where it pushes her over the edge. And you know, she's going to do her best not to do that. Or maybe the dentures is playing an issue, maybe there's kind of some liquid nutrition, you know, that she can kind of bring to work so she doesn't have to eat anything in terms of the denture she doesn't have to put those in. I don't know if anyone else had some suggestions on that front?
Shubrook: [54:00] Yeah, I certainly I think you guys are doing an amazing job. I mean, certainly don't lose the sight that she was at 10%. and now she's like seven something, and you've got around a lot less insulin. I think it's also good to let the patient know what a wonderful job she's doing. And now with that CGM, you have lots of choices to modify to let her have the best of both worlds. And maybe you still want to do dietary change, maybe not, but I think you know, you've made a lot of progress. And that's, I think it's worthwhile to celebrate that.
Bernstein: [54:36] Yeah, absolutely. And she feels much more empowered and like she understands her diabetes care way more than she did before, which is awesome. And what we're looking for.
Cuttriss: [54:50] To echo, Rayhan just typed in positive reinforcement, so.
Bernstein: [54:56] I think you know, one thing we're probably struggling with a little bit it's just me been away from the model of her physician giving her a, you know, fixed number of units of insulin. She's taking a day and coming back in three months and taking A1C and adjusting from there, I think that's pretty much been the way she's used to being managed. So there's like there is... I don't know, there's something there with the education of like helping her become a little more flexible with how she sees her own insulin, and her own self-management.
Cuttriss: [55:33] Excellent, excellent point. I mean, you're if you were to start bolus insulin—and the same thing that I was mentioning about the basaglar—like if she's more active, she could cut back so you recommend this as like a baseline. But you know what, if you're overeating, maybe give a little bit more. If you're, this is if you end up going on a bolus insulin there might be some meals where she doesn't need it, because she's not eating that much. And so now with the CGM, and that she's getting it, I agree with your approach.
Graham: [56:03] I see a couple of other great comments coming in through the chat, we are unfortunately coming right up against time. So Dr Cuttriss, I don't know if there's any kind of final words you'd like to say about this case, or any of the feedback that we've been getting. We'll certainly share the chat transcript, so you can get some more case management details.
Cuttriss: [56:25] Yeah, I mean, in summary, really, you know, a challenging case and you've come a long way this past year, and reinforcements—celebrate it. These are just numbers going back to it, there's no good and bad. And this is not a sprint, it's a marathon. And you all are continuing and you're addressing therapeutic inertia. So continue on that, and I think we've got some great suggestions and things to think about. And we look forward to everyone continuing to engage and share with one another and next month, Maggie, I don't know if you want to share the upcoming session and case submission.
Graham: [57:08] Yeah. So thank you so much, Cyd for sharing that case with us and giving us something to sort of put Dr Cuttriss's didactic session into practice a little bit. And thank you so much, Dr Cuttriss, for that fantastic presentation. If anyone has additional questions for our facilitator or tips, or ideas for Syd in this case management, please feel free to reach out to myself and Andrea and we'll make sure that they get them. And thank you all for joining today's ECHO and participating. I know I learned a lot about the fundamentals of diabetes and how bias and health inequity can impact patients and I hope you did as well. Next month, we will be working on managing insulin-requiring diabetes within vulnerable populations. So be on the lookout for some emails on that and we will be working with Chris West who is a NP from an FQHC in California. So hopefully we will all learn a lot there and we're looking forward to seeing you. Thank you all.
Cuttriss: [58:04] Have a good one everyone.
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The following faculty reported relevant financial relationships: Elizabeth Beverly, PhD - Journal of Osteopathic Medicine, Section Editor. Nicolas Cuttriss, MD - ENDO Diabetes & Wellness, Employer; ECHO Diabetes Action Network, Employer; The Leona M. and Harry B. Helmsley Charitable Trust, Consultant; Cecelia Health; Consultant; American Youth Understanding Diabetes Abroad, Board. Kate Kirley, MD - American Medical Association, Employer. Rayhan Lal, MD - Abbott Diabetes Care, Consultant; Biolinq, Consultant; Capillary Biomedical, DSMB; Deep Valley Labs, Consultant; Gluroo, Consultant; Provention Bio, Advisory Board; Tidepool, Consultant. Jay Shubrook, DO - Abbott Diabetes Care, Consultant and Advisor; NovoNordisk, Consultant; Astra Zeneca, Advisor; Bayer, Advisor; Eli Lilly, Advisor; Nevro and Nevro, Advisor.
The following faculty reported no relevant financial relationships: Christopher E. West, PhD, A-GNP-C
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ACKNOWLEDGMENT OF COMMERCIAL SUPPORT
This educational activity is supported by an independent medical educational grant from Abbott Diabetes Care Inc.