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ECHO 2: Managing Insulin-Requiring Diabetes in Vulnerable Populations

Learning Objectives
1. Describe when to start insulin
2. State how to start and manage basal insulin and mealtime insulin
3. Discuss the unique challenges managing insulin requiring diabetes in a FQHC and for vulnerable populations of patients
1 Credit CME

This is part 2 of Project ECHO: Prevention and Management of Diabetes and Cardiometabolic Disorders in Community Health Centers. This series explores diabetes and cardiometabolic care from the endocrine perspective and the factors unique to the health center community, such as the need for clinical care integration and mindfulness towards health disparities. This 6-ECHO series will focus on approaches to cardiometabolic care and management in the primary care, and typically rural, setting and how to bring best practices to this unique arena. The ECHOs will incorporate endocrinologists and FQHC staff, such as certified diabetes educators, nurses, and behavioral health specialists, as they explore the many ways to manage diabetes and its comorbidities (such as depression, cardiovascular disease, hypertension, etc.) as well as considerations when working with the special populations FQHCs serve. This series will bridge the gap between specialty endocrine care and the primary care setting by focusing on FQHCs and their unique placement within these special populations.

This presentation describes when to start insulin, states how to start and manage basal insulin and mealtime insulin, and discusses the unique challenges managing insulin requiring diabetes in a FQHC and for vulnerable populations of patients.

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Video Transcript

Andrea Quiles-Sanchez: [0:03] I'm so excited to welcome you to our second ECHO in the series: Managing Insulin-requiring Diabetes in Vulnerable Populations. In the interest of time, I invite everyone joining now to introduce yourselves in the chat and where you're calling from. These sessions are designed to be highly interactive, and we do ask that you keep your cameras on and participate in the discussion with our facilitator.

Everyone in this room has something to teach and something to learn, so we invite you all to share your experiences and expertise. Everyone has been automatically muted, but you can send chats through the chat box or unmute and speak directly to the presenter. This session will take an hour and will feature a short didactic presentation followed by case discussions where we encourage you to participate freely.

Today, I am pleased to welcome Dr Christopher West. Chris West is a nurse practitioner who has practiced at the Eureka Community Health Center, and FQHC in rural northern California for almost 10 years. He received his MSN from Yale University and has a PhD in biological and medical informatics from UCSF. He has had Type 1 diabetes for over 30 years and is committed to working with people with diabetes. In addition to his busy primary care practice, he started a diabetes specialty clinic within the health center and has worked to integrate diabetes technology into primary care. He has also participated in many other ECHO diabetes programs, and in his free time he can be found on trail runs, cooking, and spending time with family. And with that, I will turn things over to Dr West.

Christopher West, PhD: [01:44] All right, thank you so much for the kind introduction. Let me see if I can share my screen... Let's see... Okay, seeing my Presenter View rather than the slide view... Okay. So today I'm going to be talking about managing insulin-requiring diabetes in vulnerable populations. I live in rural northern California, well away from any type of specialty care. We're about four to five hours from any major cities like Sacramento or San Francisco, but we have gorgeous, rugged coastlines, gorgeous redwood trees, so a pretty nice place to be, especially when the rest of the country is sweltering right now. I have no financial disclosures, or conflicts of interest regarding this talk. What I'd like to do today is to describe when to start insulin, state how to start and manage basal insulin and mealtime insulins, and then go through some of the unique challenges managing insulin-requiring diabetes that are in a federally qualified health center, and especially with vulnerable patient populations.

Just a very brief little bit about kind of normal physiology with insulin secretion: Typically, when you look at studies of how insulin's secreted you have, essentially, a background-level of insulin that's secreted—basal insulin—it's about 45 to 50% of total insulin used by the body throughout the day. Then, whenever there's any type of glycemic load, you get insulin secreted by the body to try to go along with those glucose rises. A lot of times what we're trying to do with insulin therapy and Type 2 diabetes especially, is by covering some of this basal insulin we can give the beta cells a little bit of rest and we can hope that they can take over doing some of this mealtime insulin work. I've gone through and put together some tables that look at basal insulin and bolus insulin, as well.

You'll have these slides eventually for your reference, so no need to memorize anything. But one of the things I really want to draw your attention to is because cost is such a consideration for underinsured or uninsured patients. With 340B program or GoodRX, even for the same molecule like glargine, the cost can vary wildly based off the preparation of insulin. So generic insulin glargine or lantis, it's $17 under 340B, but it can be $261 for basaglar. So, how you prescribe this and what you prescribe really, really matters to your patients.

I want to go into then just kind of when we would start considering starting insulin for our patients. I want to point out that the guidelines differ a little bit between the American Diabetes Association and the American Association of Clinical Endocrinologists. Some of the main things that we're looking for is any types of signs of glucose toxicity, symptomatic hyperglycemia, whether that's the polys, weight loss, dry mucosae, blurred vision, fatigue, headache, confusion; or hypertriglyceridemia, ketosis, any of those types of situations are hallmarks that "Yes, this person would really benefit from insulin." This can help really quickly start reversing glucose toxicity, allow their beta cells, potentially, a chance to rest and can actually help slow down the progression of disease longer term by allowing those beta cells to function longer. Exactly where we make the decision of when to start insulin it, whether it's A1C of 10 or 9, that can be up to a little bit of clinical interpretation, especially when discussing with our patients their preferences. But one other really important nuance here is that if somebody's already on one or two other oral antihypoglycemics, and they're really not getting down to goal, adding the third agent really is not likely to get them to goal, so we should really consider insulin in that case. Whenever you got a new diagnosis of diabetes, when it's really not clear, when you've had a really rapid rise in A1C, now those are all times when you may want to more strongly consider it. And then finally, the guidelines are also pretty clear: If you're considering an initial injectable therapy, if they're not having the signs of symptomatic hyperglycemia, you know, maybe you do want to consider something more like a GLP-1, given the cardiovascular benefits, and also the weight loss that can go along with it. Insulin isn't the only injectable, just keep remembering that.

Typically, when we're thinking about starting insulin, you can either think about kind of a fixed dose or weight-dosing. Typically weight based will start 0.1 or 0.2 units per kilogram per day based off of the patient's expected insulin resistance—somebody who's more obese, you're likely going to want to start at the higher end of things—but practically, sometimes it's a lot easier for my patients when I just say "Start with 10 units, and then titrate up." But the key here is to titrate up, it's not just to stay at that 10 units for months at a time, but it's to get that dose up to where you're starting to see their fasting glucose levels getting on the goal. When you're writing that initial prescription for insulin, what you want to do is start off with a minimum—whether it's your .1 or .2 units per kilogram per day—and then also put a max on there, say it's 50 units or 0.5 units per kilogram, but something that will trigger the patient to come back and talk to you and see and see the health care team again if they get that high and their blood sugar levels are still elevated, because at that time, it's really time to reconsider care, it's time to think about "Should we be adding another agent or should we be adding mealtime insulin?" We shouldn't just keep pushing up that basal insulin blindly.

And really what is our goal with the... long-acting insulin? A lot of times what we're really trying to do is target that fasting glucose level, trying to get that down into range, regardless of where that A1C gets to. If we start getting down to fasting, but that A1C isn't considered at goal, then it's really time to evaluate for another agent. So what I like to do with my patients is typically go through a kind of treat-to-target type algorithm, we're really trying to push patient empowerment here with having them in control of driving their own doses, with some provider guidance. We put together a fasting glucose target for them, whether it's kind of 80 to 130, or we individualize it more based off of age, duration of diabetes, or even just their patient preference—they've had a friend who had really severe low blood sugars and a bad reaction, so maybe we want to be a little bit more conservative and say our goal is 100 to 150. Typically I'll have them start—after every three to four days—increasing by about two to four units until they can get that fasting glucose levels down into the target range. To help support this, I strongly advise frequent check ins, especially initially, whether it's a nurse, a clinical pharmacist, or even just a member of the care team calling and saying, "How's it going? How much are you taking right now?" and making sure that they're escalating that dose. Because there is nothing more frustrating to the patient or to the provider when they come back three months later, they've gone from 10 to 12 units because they were above the fasting target range, they're checking their blood sugar daily, they're giving the shots and they haven't made much progress on that A1C, and they don't feel much better.

And then once we get to the higher doses of the insulin, it really is kind of a tipping point over your risk of lows, and you do want to consider adding a secondary agent—a GLP1, SGLT-2 mealtime insulin, instead of just keep pushing the basal insulin. When I'm trying to teach my patients about how to use insulin, I very much like to try to help them give their first injection in the office. This has become a little bit more challenging as we've moved away from using samples in the clinic, so I'll typically prescribe the needles and the insulin, and then set up an appointment with a nurse a few days later for them to come in and do that first injection. I can't count the number of times that patients have been shocked or surprised themselves, when they put the needle in, they're like "That didn't hurt, that was so much easier than I thought it was going to be." We very much want to talk to our patients about insulin sites and rotation, trying to avoid buildup of scar tissue, which will lead to uneven insulin absorption.

Talking to them a lot about insulin storage. A lot of times people get told the insulin has to be in the fridge all the time, but that's really only true for insulin that is unopened. Once it's opened, you can keep it at room temperature for at least 28 days or longer depending on the formulation. And this is important, so that they can take it with them when they travel, so that if they're on fast-acting, they can take it to a restaurant and give their shot there because they don't feel like they have to keep it in the refrigerator all the time.

Then talking to them about low blood sugars, kind of the Rule of 15. What are your signs and symptoms: feeling shaky, lightheaded, confused. If your blood sugar is under 70, usually start with about 15 grams of carbohydrate, maybe 15 small jelly beans, half a cup of juice or soda, and then rechecking the glucose about 15 minutes later. If the blood sugar is under about 55, start with about 30 grams of carbohydrate.

As far as talking to the patients about insulin—you know, insulin is just one of these tools that we have to help manage glucose levels. It's not a punishment, it shouldn't be an option of last resort. A lot of times when I'm talking to my patients about their ideas about insulin, they tell me stories about their grandma who lost their foot three months after they started on insulin and are really fearful and feel like they're going to have bad effects from the insulin itself, and a lot of that was predicated on insulin really being the last resort. This was when the diabetes was elevated for really long periods of times and patients weren't doing well, that's when they finally went to the insulin. And helping them to understand that if we start on insulin earlier, we can really help prevent some of those things down the road. Especially with kind of early on in the course of that disease. The insulin doesn't have to be forever. A lot of times if it's a new diagnosis, their A1C is 11 or 12 and you're getting them started on Metformin or maybe a GLP1 along with the insulin, after a couple months, you can oftentimes pull back on that insulin and get them off of it now that they've gotten out of glucose toxicity, and their beta cells are able to kick back into gear.

Finally, make sure we look at their injection sites besides the scar tissue, that's hypertrophy that can build up and cause uneven insulin absorption. I'd like to go through a brief case here. A gentleman I'm going to call George, a 51-year-old male with Type 2 diabetes for about six years. He's currently taking Metformin 1000 milligrams twice daily, glimepiride eight milligrams in the morning, and glargine about 70 or 80 units daily, kind of whatever he feels like, not very standardized in his dosing. Now what we've seen his A1C has been rising steadily over the last few months, despite six months ago being on about 45 units of insulin, he's already up to 70 or 80, and the A1C is progressed. Now he's concerned that he feels shaky and sweaty if he's working hard outside, he also kind of feels that way shaky around 3 or 5 pm if he skipped lunch, he does know that he feels better if he eats. He's eating a snack just before bed just in case because sometimes he's woken up in the middle of night feeling kind of shaky and sweaty, and then he ends up skipping insulin at the end of the month when money is tight and he doesn't have as much food available. On exam, most notable for a little bit of an elevated BMI, truncal obesity, doesn't really have any hypertrophy. Reviewing his meter, he's checking blood sugars once or twice a week, random times throughout the day, ranging anywhere from about 91 to 400 and mostly in the 200s. His breakfast today consisted of ham. Yesterday, he had waffles. Lunches, usually leftovers and dinners, whatever mom makes, it's usually his largest meal of the day.

To review this case quickly: We've got George here. His A1Cs are up at 11, he's having lows overnight and when skipping meals. What am I thinking about when I'm seeing him is over basal iced teas tending to drop low overnight or if he skips meals, he's on too much long-acting insulin. He's taking well over 0.7 units per kilogram, and that really puts him at higher risk for hypoglycemia. In these types of cases, the risk really may not outweigh the benefit of being on that high dose of the insulin. He's also on two agents that can be dropping his blood sugar levels: the sulfonylurea and the insulin. He's definitely got some significant insulin resistance to be up at 70 or 80 units a day and still having an A1C that's elevated. Struggling with food insecurity, and then he's really not effectively using his glucose monitoring to help manage his insulin dosing.

Thinking about how we could adjust his treatment, you can feel free to chat in if you feel any of these really strongly. We could just keep increasing the dosage glargine and get that A1C down, we could consider starting on a GLP, which would probably help with glucose levels rising after the meals, we could stop the balloon that arrived and add a mealtime insulin, we could start them on a next insulin. But we should also remember about thinking about referring him for diabetes self-management, education, and support, maybe some talk around nutrition and helping him that way, and maybe talking with case management, maybe there's some food resources that he could access to help them. What I really want to point out here is it's really not a one size fits all solution, there's a lot of complexity that's involved. And none of these by themselves is the right answer.

So what did I decide to do with him? We ended up stopping sulfonylurea and had him work on slowly decreasing the glargine dose until he achieved a stable overnight blood sugar level. I saw him back about three months later, he's stabilized at about 60 units of the long-acting insulin, blood sugars in the mornings, particularly 100 to 160, which is pretty close to goal for him, and A1C, though it remains above goal at 9.2, is improved and he's not having any more overnight lows. Certainly a significant improvement here for him, though, still not a goal.

The next thing I asked him to do is to think about doing a mealtime blood sugar challenge, think about checking his glucose level before the meal and then about two hours later, and just seeing what was happening. And what we found is post dinner, he was getting over 100 points of blood sugar rise. In this case, because this is a talk about insulin, I decided to add insulin, but a GLP 1 would also be something I would strongly consider in that case.

When we're thinking about starting mealtime insulin, especially for folks with Type 2 diabetes, we can consider starting with just one meal of the day—the largest meal—or where we see the largest glycemic excursion, starting with increasing by about one to two units about twice weekly because we know, based off of meal composition, you can't make a decision about increasing fast-acting based off a single meal, we need a couple of days of data here. It's also important to think about if you're starting on mealtime insulin and that A1C is less than 8, you may want to back off on their basal insulin, because you could be starting to trigger some lows. If that agency continues above goal at about three months, you may want to stepwise add mealtime, insulin to another meal, you could consider changing to a mixed insulin if they're getting tired of all the shots and don't want to add too many more injections, or you may consider adding another agent like an SLGT-2 or an SGLT-1.

As far as insulin for vulnerable populations, there's a lot of factors that really impact how insulin can work in these patients that are beyond just simply how they take the insulin. As we covered food insecurity is a huge one, if they're eating well one day and then struggling with affording food that isn't high carbohydrate another day, that's going to really impact how their blood sugar's turn out. Their stress response, if they're under a lot of stress for whatever reason, that's going to impact how well they processed that food and that insulin. There's a lot of cultural barriers, a lot of stereotypes around insulin that have to be taught through, worked through before you can succeed. Thinking about language, numeracy, literacy, that's going to really impact your ability to adhere to any type of plan that you're working on. I'm thinking also about our shift workers and their irregular sleep schedules. If they're giving the long-acting insulin at different times a day because of their sleep schedule, that'll impact things. Also their stress response for different days when they're sleeping differently—is it going to impact how that insulin works? Refrigeration, especially for our unhoused patients—you know, sometimes it's helpful to see if the pharmacy or even the clinic can hold on to half their insulin for the month in a refrigerator somewhere so that it's not out in the elements all the time. And then cost, especially for my Medicare patients. A lot of times their share of costs, their copays, are so high they can't afford their insulin, so it leads to rationing, so talking to them about that very frankly. And then thinking about substance use, are they using alcohol, methamphetamine, that's all going to play in.

I'd like to finish up with some tools that I use to help some of my patients. One of the number one things here is these frequent little check ins—it can be two minutes talking with a health coach or somebody that's on the care team to keep them going. But if you spot problems early, you can likely address them before they become so resistant to making changes down the road. Thinking about case management for things like food and housing, working on customizing your plan in a way that makes sense for your patient, maybe they don't feel comfortable adjusting their own insulin dose, like we were talking about, so maybe you have them come in and see a nurse every two weeks and adjust the dose that way. Maybe you go up 10 to 20% at that point, but at least go somewhere. Really being careful culturally around the nutrition and trying to provide examples that work with that. Celebrating the small things: George was amazing, he got his A1C down almost two points and stop having lows, that's huge. Tight glycemic control may not be safe or optimal for some of our patients, I've got some people who are really brittle, who tend to drop. I am quite happy if I can keep their A1C at eight because of the risk of low is so profound for them. And recognizing, finally, that sometimes other health issues are far more important than their diabetes. If they've got uncontrolled mental health issues, a lot of times you're not going to be able to get at the diabetes, and you just want to keep them as safe as possible, you're not going to be able to optimize things until you address the mental health or until you address that cancer diagnosis. I'd like to thank you all for your attention here and happy to answer any questions.

Quiles-Sanchez: [21:50] Thank you so much, Dr West. We don't have any questions in the chat quite yet. But if anyone has any questions, please feel free to unmute or leave questions in the chat.

West: [22:06] Uh, 51. [silence] Thanks, Leah, for your question about mom's health, who does the cooking. Her health is fair, she does have a very... old-school kind of meat and potatoes way of cooking and isn't much interested in changing that. We tried to get her in for an office visit to provide her with a little bit of education and she was not particularly interested in coming.

Rayhan Lal, MD: [23:08] Chris, I'll ask a real basic question here. Clearly insulin is an option and one we shouldn't consider an option of last resort or a negative option in any way, shape, or form. But as we assemble this army of drugs now that we have a disposal for glucose control, how do you separate out the people who need insulin from those who don't?

West: [23:41] Yeah, it's a challenging question. A lot of times what I think about is, are they having signs of glucose toxicity? Are they urinating frequently? Are they losing weight? Are they having blurred vision because of this? That's one set of population patients that it's the insulin seems more critical for. After that, a lot of it is thinking through the different options, the usually the ones that are highest on my list are the Metformin, the SGLT-2s, the GLP1s, but once we've gone through several of those, we're really not likely going to make much more progress long term if we just add a sulfonylurea and then acarbose, and the next thing and the next thing, so really thinking about insulin there. Finally talking to my patients and talking to them about the options that are available and letting them kind of guide some of their treatment.

Lal: [24:38] One useful strategy we've found is... the real question is: does this person make any insulin or not? If they don't make any insulin, and we need to give some so we frequently will just order a C-peptide in the context of a triple-digit glucose of any sort. If they are making some on insulin, you could use a lot of these alternative regimens to help make that insulin go farther. If they're not making any insulin, then unfortunately, our principal form of treatment is replacement.

West: [25:15] That's a great point. Right on. Question about that: do you had them do that as a fasting C-peptide or do you do just a random?

Lal: [25:22] Anytime I can get the glucose to be 100 or above, I'm usually happy. And then we can see are they insulinopenic or is it something else? They'll always be relatively insulinopenic but the question is, is it absolute or relative.

West: [25:40] And then Jay had a question about teaching insulin injections without samples. So—actually... from Jay also: So you order glucose and a C-peptide at the same time? Yeah, exactly. Teaching insulin without samples: a lot of what we do have is, we do have some kind of dummy insulin pens. These are kind of non-branded pens that you can play with and inject into an alternative surface. It's not as good as giving an injection into a person, but it gets uncomfortable with the devices and with the needles. A lot of times, the best thing is to have them get all their stuff from the pharmacy, bring it in, and then just do the teaching with their own supplies in the office, but really trying to do that within a couple of days of making the initial insulin prescription so it doesn't get pushed out. [silence] I think I'll take one more question regarding the talk. And then we should move on to the case presentation.

So the question is what point during the case would you introduce CGM difficulties getting them covered for a lot of people with a variety of insurance types prior to them being on prandial insulins, or if multiple injections and testing throughout the day? Yeah, and I think it's a challenging situation, because I've seen a lot of people who do very, very well with CGM at any point of their diabetes diagnosis. But as far as where I would usually push for them is when I'm starting to see evidence of really big glucose spikes postprandial or I'm starting to see evidence of low blood sugars, I can document the low blood sugars, oftentimes that can be really helpful with getting the CGM covered. [Silence] And then, how early in the day would you do basal insulin that is bedtime dosing in the office? As far as when to do the dose of the basal insulin, I'm really more concerned with trying to do it whenever the patient feels like they can be consistent first and foremost, if they want to do it at noon, great. Do it at noon. Ideally, if you're trying to suppress overnight hepatic glucose production, the night might have slight benefits there, but I'd rather get the insulin and consistently more so than really stress any particular time. On the flip side, if they're having lows overnight, I often will switch them dosing to the morning first thing so that they can be awake when that insulin's a little more active.

Quiles-Sanchez: [28:36] Okay, perfect, Dr West, thank you. In the interest of time, we're going to move on to the case presentation, which I will be sharing my screen very shortly.

Okay. As a reminder, we are taking submissions for case presentations, we've gotten a couple of really good ones, but we're always wanting more, so if you have any cases that you would like to discuss anything that you have any questions about, please feel free to fill out using this form. If you have any questions or concerns, you can always reach out to me with questions. But just to emphasize there, we will take any case, all cases are good cases, this is an opportunity for all of us to learn together. So, thank you!

West: [29:50] The case I have for everybody today is a—first of all, this is not a case that's an example of ideal diabetes management in any way, shape, or form, but I thought it was really interesting and made me kind of think about how I'm doing things, so I thought it would be helpful to present.

We've got a 59-year-old female who was referred to me for her Type 2 diabetes along with, she's also got PTSD, depression, anxiety, smoking, hyperlipidemia, asthma, with some COPD overlap, chronic low back pain, history of alcohol abuse—she's been sober for about five or six years now. She's had diabetes for about 31 years, so a longer duration of disease, and our complications include hypoglycemic unawareness and, at one point in time, there was a questionable diagnosis of gastroparesis in her past. She has a history of blood sugar variability with lots and lots of highs and lows. She lives alone, she's not working, she struggles with food insecurity because of this, and she typically has walked all over the place for her transportation, but now it's really limited. She had a recent severe ankle sprain and then... another provider stopped her narcotic pain medication for her back pain, which has resulted in her being really, really immobile.

You can see her medication list. On dietary review, she mainly eats one large meal a day, which is her dinner. She'll have coffee in the morning, which tends to spike up her blood sugar, and she admits that she struggled with portion control, especially with that dinner or if she starts snacking. Going through her GAD-7 and PHQ-9. Most recently this was done in March, still struggling with the anxiety, the depression is doing a little bit better than it had a couple of years ago. [Silence]

You can go on. When I initially saw her back in about 2018, she was on about 42 units of glargine once daily. She was struggling with going low with activity—whenever she would walk she would just drop precipitously, or if she ate a lighter meal for dinner, she would drop out overnight. At that time, we really worked on decreasing her long-acting and adding some fast-acting insulin with the largest meal of the day. Given the questionable gastroparesis, I was concerned about possibly adding a GLP-1 at that point in time. I ended up seeing her back about three months ago and at that point, she was taking 40 to 50 units of regular with her main meal of the day, and about 20 to 30 more throughout the day, had completely gotten herself off of all of her long-acting insulin, and she reported that being due to lows. At so at that point in time we tried to change her insulin dosing to better balance the long- and the fast-acting. We ended up with 24 units in the morning, 10 to 20 units of fast acting with each of the meals, and then a correction of roughly two units for every 50 points starting at 150. Her total daily insulin dose is about 70 units.

My clinical questions here are: are there further refinements to the insulin dosing that you would consider recommending? What adjunct medications or treatments might be helpful for her? And then how can we help her to be a little bit more consistent with her insulin dosing and her fear of lows? She tends to kind of change the insulin plan completely from one visit to the next, and so helping her to be more consistent with that would really help us, I think, to make some progress. So you can see down here her pattern of a onesies over the last couple of years. All right, go to the next slide. Blood work from the past couple years. You can see right here, going from 67 to 566, just highs and lows swinging, a history of hyperlipidemia with elevated triglycerides, no microalbuminuria. All right next slide. We have been able to get her a CGM which has helped her taking her insulin doses at least regularly. She very much likes having the CGM.

I wanted to go through looking at this report quickly. Starting off looking at how often is she using the CGM. She's scanning it for about 62% of the data time. Looking at her time and target, her average blood sugar here in this most recent reading was 319. Her target, glucose and target range—the 70 to 180 which is what we're shooting for—was about 10%. Ideally, we'd love to see more than about 70% time in range. She has been successful in minimizing her lows, there's not much time spent on low very recently. Everything else is spent up much higher. Her glucose variability, about 26%. This is a marker of how far up and down the blood sugar levels are going. And typically we want to see less than about 33% or so. Next slide. The next part of the ambulatory glucose profile we can see this trend line with her overall glucose levels and then see that 25th and 75th percent variability around there. She's tending to run high in general, and at the bottom we have all of the data from two weeks all put together in a nice graph there. You can see she's high for a while, give some insulin and plummets and then ends up high for a while and plummets back down again. Alright, next slide.

Here's a little bit more data on some of the individual days. Go on to the next one. Here we are on the 20th is a day without any data scan, the 30th is a day when she scanned it a couple times. Each of these individual readings is one scan. You can keep going through these. Alright and the last one. [Silence] Thank you. I'd love to open it up to any of the spokesites now anybody; who has any questions about this case.

Leah Collins: [37:22] Is she on any other anti-diabetic meds or only the insulin?

West: [37:27] I believe it's only the insulin. She tried and failed Metformin in the past due to GI upset and there's a question whether or not she's been sent to GI to confirm or rule out the gastroparesis. She had had a gastric emptying study ordered at some point in the past, but that was never completed. In talking with her more recently that doesn't seem to be as much of an issue as it had in the past.

Quiles-Sanchez: [38:25] I'm seeing a question from Andrea Garcia: Has she been sent to GI to confirm or rule out gastroparesis?

West: [38:38] Yeah, so we just talked about that.

Quiles-Sanchez: [38:39] Oh, I'm so sorry.

West: [38:40] That's okay.

Lal: [38:43] Linda had had a question about whether there were resources available for helping with food insecurities, Chris.

West: [38:53] There are some resources. I think they're getting her set up with case management to see if she's qualifies for supplemental assistance and also maybe some farmer's market vouchers might be beneficial. It is challenging for her, especially right now with her limited mobility, to get out to even say go to a farmers market. Well if there's any more—yeah, Sandra?

Jay H. Shubrook, DO: [39:42] One also came in the chat too.

West: Okay, you're unmuted Sandra but we can't, for some reason we still can't hear.

The question from Martha in the chat was: what type of health interventions or education has she been given? She's been given some in-office health education, but she hasn't seen a formalized diabetes educator. Unfortunately, actually, in our community, we do not have any availability to refer for formal diabetes education, so it is done one off amongst the health care team.

Shubrook: Chris, I have a question for you. Thanks for a great presentation. It's a challenging case and I know she's in good hands. Do we? How much do we think she's drinking?

At this point in time, I actually believe her when she says she's not drinking. She's actually been more put together and less chaotic as I've known her for a little while. I do think the lack of pain medication for her has been a huge shift for her and has diverted a lot of her attention to focusing on that.

Lal: [41:22] Some great questions coming in, Chris. Martha asks, what about sending a community health worker? And then we have: Have you checked that C-peptide?

West: [41:37] As far as sending a community health worker, unfortunately, again, we don't have resources in our community to be able to send somebody out to see her, though I do think trying to get her hooked up with a health coach would be a good idea. As far as the C-peptide goes, I don't believe that that's been checked yet for her. I'm looking that up really quickly. [silence] No, that has not been done yet.

And then from Martha: there are free resources available for education through the ADA, and I believe those are typically online. And then the question of: Is she experiencing glucose toxicity? She denies frequent urination, blurred vision, a lot of those signs. And then her lipids have actually dramatically portrayed triglycerides have substantially improved over the past couple of years.

Shirley's question about the GAD score that hasn't really changed significantly since 2018. I think it's excellent. I think that she hasn't really been followed by any mental health professional over the past couple of years. We really do struggle with a lot of lack of resources. But that definitely is something that I think would be helpful for her. Paige is asking about a support system, like friends or family living nearby. She doesn't really have a strong support system, unfortunately. So she doesn't really have people she can turn to right now. Oh, go ahead.

Liz A. Beverly, PhD: Yeah. I was going to ask a question... I'm not in California. Has there been expanded, like Medicaid coverage for telehealth, given the pandemic?

West: Yes.

Beverly: And then that would that be an option then for her to see mental health providers via telehealth and have it covered? Does she have access to broadband internet will be another question.

West: I don't know the question about broadband internet. It is an option for her to see mental health professionals online if she'd wanted to, but she adamantly refuses to do any type of virtual visit. We had been doing some kind of remote visits during the early parts of the pandemic and then she insisted on making sure that she came in for every single visit because she very much did not like telehealth.

Beverly: Yeah, I've heard of some mental health providers doing an initial visit, and then transitioning... I know it's an option.

West: Yeah, no, it certainly would be worth exploring. "We don't have resources for this, would you be willing to at least try this once or twice?" And seeing if we can at least get some initial buy in. We definitely can get her set up with an exam room in the clinic to do all of her telehealth here without a problem. And then, I think it may be time to open up the hub for questions around this case?

Lal: [45:38] I do think Andrea's question, here's a good one. Does she participate in AA?

West: [45:44] No, she does not.

Lal: [45:47] Chris, a couple of questions on this one. Now that we say, "Well, maybe the gastroparesis is not so bad,” would you consider any contraindications to GLP-1s or SGLT-2s?

West: [46:04] Yeah, so I think a GLP-1... as I was going through this case, I'm like, "Why haven't I started her on this yet?" That really stood out to me, because I think that could help a lot with some of her variability, and maybe reducing some of her insulin requirements overall. SGLT-2 to I'm a little concerned about mainly just with an A1C still hovering above 10, I don't usually like to start them unless that A1C's below about nine because of the risk of kind of genital mycotic infections increasing and then refusing that drug class outright. I might think about that down the road a little bit.

Lal: [46:49] Was the regular insulin being used in the past because of this question of gastroparesis?

West: [46:56] Yeah, she had been on faster, rapid-acting at some point and thought it was too quick, and so we bargained into regular instead.

Lal: [47:09] It can be very useful in most situations. So we totally get it.

Shubrook: [47:14] Chris, again, it's a really challenging case. I was asking about the alcohol because that to me, was also a concern about the GLP-1. Particularly if it's in binges, you don't want her to be at risk for pancreatitis, and then not be clear whether it's alcohol—which is the most likely cause—or that medication. Sometimes you can get away with acarbose, that might be something, I don't know if you've ever tried that. It's tricky, right? Because as high as she is, it sounds like insulin is the way to go. Is she clear about how often she misses her doses?

West: It's hard to get a great sense on that. I've tried to ask her to keep a little bit more diligent records, even for a week, and... yeah.

Lal: [48:15] We might be able to garner some data from the CGM, Chris, if we see... there's only so many things that'll lower blood sugar, so if you don't see too many collapses as the day goes on, that's probably missed rapid-acting at least.

Martha asks: What about drug interactions? Any concerns about any other medication she might be on?

West: [48:49] Did you have any particular questions or thoughts? Otherwise, I need to look back at our med list as well. Andrea, maybe you could pull up the first slide of the case?

Quiles-Sanchez: Yes. Let me pull that up right now.

Lal: Martha, if you're able to if you were thinking of any specific infraction, let us know.

Martha Vallin, MS, CHW/I: [49:15] Hello, everyone. The only reason why I was asking about drug interactions is because I did see a long list of drugs and sometimes it's not so much the drugs themselves. There's sometimes you know, there are some drugs that you cannot have orange juice or cranberry juice or some type of supplement that may interfere with some of these medications. Sometimes—not to say that every provider is perfect or that they're not perfect—sometimes we'll forget to ask about supplements or vitamins or things that they may be taking that may inadvertently interfere with the effectiveness of some of the drugs.

West: [50:18] I don't think I'm aware of any particular interactions that are concerning to me, though maybe other people looking at this list would see some. On my view, I think she is on some quetiapine, some Seroquel, so that can certainly be contributing to some insulin resistance for her and she takes three tabs... 300 milligrams at bedtime. Jay asked a question about having access to a clinical pharmacist. Unfortunately, at this point, we don't, so we're calling the patient's regular pharmacy and just asking those questions. Given that we're getting close to time, I'd like to open this back up to the hub sites and if there's any recommendations you have for this case, I'd be happy to hear those.

Lal: [51:40] Sorry, Chris, you meant spokesites?

West: [51:52] Spokesites, yes.

Lal: [51:52] No worries, no worries, guys. [pause] Martha just suggested maybe several pre-drug interaction checkers online. From prior, Shirley's comment about the follow up with mental health specialist given the scores. Maybe doing the C peptide check to see how much secretory capacity exists for her. It could also be pancreatogenic, given the past history.

Collins: [52:42] I was just thinking, I know she's has a lengthy list of meds that she's on, but my initial thought when I saw her was: due to time out of range, is adding in another agent, and automatically I was like "GLPS, GLT2, I totally agree with you on the mycotic, especially with women of that age range. I thought GLP-1 might be—if she can handle it in addition to other stuff and if she can be consistent with it—I think it might help bring some of those higher tier, because she's spending a lot of time in a very high range, would be my thought.

West: [53:18] I very much like that idea. Alright, if there's no more ideas from the spokesites, then I open it back up to the hub team for any other recommendations.

Lal: [53:46] I like a lot of these recommendations because we've heard from the spokes here. I think the GLP-1 if really, the gastroparesis is not a significant issue, one of the maddening things about gastroparesis is it's a hell of a condition to live with, in general. Significant quality of life impairments. But actually, as it turns out, the symptom scores end up being more important even than the actual gastric emptying time in terms of diagnostics. So just important to keep in mind that it even if you've got a gastric emptying, that still may not rule in or out.

West: [54:35] Do you have a preferred tool for looking at symptom scores?

Lal: [54:40] It's a good question. I know of some validated questionnaires that we've used in studies, but I think I think I would probably go to the latest gastroenterology guidelines and see what they're recommending these days.

Shubrook: [54:54] Chris we use the GISI and find it useful both in research and patients. And I think you know, again, really great comments from everyone. I think the hard part for her, she's got multiple other problems and it might be worthwhile letting her know that pain affects her glucose too, right? So if she's in pain, she's going to go higher, so giving her some slack for some of the non-diabetes related changes, but really emphasizing—again, it sounds like I'm on the AA kick—but emphasizing that drinking can cause hypoglycemia and unpredictable hyperglycemia, so the last thing we want to do is change her meds if it's related to a substance. And I get it, the substance might be therapeutic if she's doing it.

West: Right, right.

Shubrook: Great case.

Chris West: Go ahead.

Shirley Wong, PharmD: [55:50] I don't know if I missed this, but she's currently still on long-acting and meal time, but previously, she was worried about low so she had stopped long acting. At any visits, at any point, have you seen her injected insulin herself? Like watched her technique and see how she does it?

West: [56:08] No, I haven't had her come in to do that, and I think that's a great point.

Wong: [56:14] I'm thinking maybe that might be helpful. I know she has a fear of lows in the past and it could still... maybe at home, she feels inclined to tell you that she's using the medications, also because she has anxiety, so it's multiple components all added up together. I think mental health, like you mentioned in your other presentation, I've seen a lot of patients where if you don't address underlying mental health, it's really hard to get to the diabetes management in itself.

West: [56:47] All right. Well, I think we are drawing very, very close to time here. So I want to thank you all for your wonderful recommendations here. Certainly addressing the mental health with this patient is the key here talking to her more directly about substance use, thinking about adding a GLP-1 checking the C-peptide level, and thinking about having her come in watching her give her injections, really make sure she even knows which ones fast and long acting insulin are all certainly very helpful recommendations and I'll maybe I'll have a chance to represent her down at the end of the course.

Quiles-Sanchez: [57:27] Perfect, thank you so much, Dr West for that fantastic presentation. If anyone has any additional questions, please feel free to reach out. And thank you all for joining today's echo. I know that I learned a lot about insulin and the unique challenges you may face when managing insulin-requiring diabetes within vulnerable populations of patients, and I hope you did too. Please be on the lookout for emails regarding the next session on August 17. Where we will have Dr Jay Shubrook discussing treatment strategies for vulnerable populations with diabetes not requiring insulin. Have a great day everyone. Thank you.

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The faculty, committee members, and staff who are in position to control the content of this activity are required to disclose to the Endocrine Society and to learners any relevant financial relationship(s) of the individual or spouse/partner that have occurred within the last 24 months with any commercial interest(s) whose products or services are related to the content. Financial relationships are defined by remuneration in any amount from the commercial interest(s) in the form of grants; research support; consulting fees; salary; ownership interest (e.g., stocks, stock options, or ownership interest excluding diversified mutual funds); honoraria or other payments for participation in speakers' bureaus, advisory boards, or boards of directors; or other financial benefits. The intent of this disclosure is not to prevent planners with relevant financial relationships from planning or delivery of content, but rather to provide learners with information that allows them to make their own judgments of whether these financial relationships may have influenced the educational activity with regard to exposition or conclusion.

The Endocrine Society has reviewed these relationships to determine which are relevant to the content of this activity and resolved any identified conflicts of interest for these individuals.

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

Endocrine Society staff associated with the development of content for this activity reported no relevant financial relationships.

The Endocrine Society has reviewed all disclosures and resolved or managed all identified conflicts of interest, as applicable.


This educational activity is supported by an independent medical educational grant from Abbott Diabetes Care Inc.

Accreditation Statement: The Endocrine Society is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Credit Designation Statement: The Endocrine Society designates this Enduring Material activity for a maximum of 1.00 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.


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