Chapters Transcript Video Diabetes Update: How to Overcome Barriers to Optimal Glycemic Control It's my very uh high pleasure to introduce our very own. Doctor Terry Gad, who is a long standing and beloved faculty member here at Children's Oakland. Uh He obtained his medical degree from New York Medical College and completed his pediatric residency at Cleveland Children's in Ohio. Uh He finished up his pediatric endocrinology fellowship at Chl A in 2006 after which he joined us at CHO and has been with us ever since then. Um He has a number of research interests which include uh endocrine pathologies in patients with thalassemia, um antibody marker testing for type one diabetes, uh and novel therapies for other rare diseases such as uh congenital adrenal hyperplasia. And so without further ado, here's doctor Tari Gamal. All right, thanks Jay. Uh I'm gonna jump right into it um Since I have about 50 minutes to talk to you all about the amazing innovations and technologies that have come by in the last few years to kind of help. Um our as I put in the title, Overcome Barriers to Optimal glycemic control in our T one D population. Um The disclosure slide is here just to show that um I do have a relationship with, with the laboratories that will not be discussed uh nor any products from that company. Um And I do intend to discuss some uh products that are not FDA approved for um certain indications and uh the context of which I discussed them will become evident as I proceed in the presentation. So um this is the title slide and I just wanted to um kind of highlight these two studs here uh with T one D uh Michael and Patrick who uh overtook a project called uh 50 of 50 to, to hike the 50 highest point in the 50 states uh in the United States. Um And doing so, obviously, with TND is, is somewhat of a challenge, but I thought the metaphor was quite on the nose with the overcoming barriers to optimal glycemic control and their, and their little literal overcoming of the summit in the United States. Uh I had the privilege of partaking in Michael's care when he was younger guy. And I, I work with Patrick at the diabetes youth camps for diabetes T one D uh which I'll talk about later. Um So, yeah, how to overcome these barriers or at least try, right? Um That's, that's our intent. Um Quick shout out to doctor Edison G, um our diabetes director here at U CS F. She was very helpful in um helping me with a lot of these slides and of course, I just want to do a quick shout out to all my patients and their families because uh they continue to teach me about diabetes and um how to, how to care for it and how to best manage it. Uh The object this real quick, um you guys got this already um about identifying factors uh that may contribute to suboptimal diabetes care uh and lead to burn out uh recognizing a normal physical exam, findings related to the use of insulin pumps and discuss with families, et cetera, et cetera. You know, my real, my real intent though is to disseminate some of the technologies that you as health care providers or even a specialist can help share with your cohort of kids who may have T one D or any diabetes, secondary diabetes type two, et cetera. Um Because again, I feel as our role as providers is to really uh inform our population what options are out there and to make their life easier. Uh and hopefully even better quality. Um And I'm not saying that you have to cure diabetes in this 15 minute visit. Um You guys have such, especially in the primary care office, there's such short intervals that you have, but just being aware of the technologies. Uh and even if they are using the technology already, what kind of they look for um with their tech is going to be, I hope helpful um after this presentation. So you have a little bit more affinity and, and knowledge of what questions to ask. Um This is our team just real quick, uh which is a huge team uh on the Oakland side, uh consisting of endocrine nurses, the um nutritionists, the social workers. Um We're yet to get some psychologists, but obviously we, we want to uh in future state have some sort of um mental health um uh provider in our practice. Uh But what's missing and I'm really, again, trying to highlight is the primary care providers are community doc. Um And even our specialists because we all need to partner together um to take care of these kids. I don't want to feel siloed or, or have um the primary care doc think that, oh, it's T one D and we don't need to worry about it. The diabetes team's got it. Uh It really is a partnership I feel and I, and I love it when I, I get my messages from my PC PS mentioning, you know, have we thought about this for this kid or, you know, have we thought about this approach, et cetera? Um So some historical context about diabetes. This is um near the early part of the 19 hundreds. Uh uh one of our first T one D patients, as you can see uh is depicted here with the melting away of the fat. And you can imagine in an insulin deficient state, the individual goes into a cab bolic state. So they're literally melting away in front of you. Um And this is the same kid about three months later, uh after insulin was able to be extracted from the animals, um and then provided to this individual. And then that person can go back into an anabolic state, rebuilding the tissue. And that's what it is. That's what T one D is at its, at its heart is you're missing this one hormone and by replacing it, then you can um, reverse all that catic process. So this is a classic case that many of the um, office providers here have probably seen, um maybe within the last year or so. Uh This particular case was a 15 year old, previously healthy Indian girl and she had the classic three ps polydipsia polyuria, polyphagia that's been going on. And in the office, the blood glucose was greater than 500. She was also having knock bacteria, which is a nice distinguishing clinical feature for many of our T One DS that, you know, you'll have a lot of kids who complain, they're peeing a lot. Uh And then you sometimes don't know if it's behavioral or something that um, is not so much uh uh pathologic like T one D may be. And certainly nocturia is a nice way to kind of discern it because if they're able to sleep through it at night without waking up a lot of times it's not gonna be T one D. Uh But this particular case, she also had weight loss. It's a kind of a red flag right there. And it turns out there's also some autoimmunity in the family with mom having hypothyroidism. I provided some of the anthropometry measures here. The weight was pretty average. She was on the thinner side. She ended up having a little bit of an enlarged thyroid. Uh and her TSH was elevated and we did the antibodies for type one diabetes And lo and behold, as you might have predicted, uh two of the four antibodies were positive. So she's got T one D and I have this next slide saying, OK, we made the diagnosis. It's now easy, right? It's like riding a bike except the bike is on fire and you're on fire and everything is on fire and you're in hell. And um yeah, we've got to remember as a provider. Uh it's probably easy to make the diagnosis a lot harder to execute the actual management. Um And in the 19 thirties, uh there's this doctor Lawrence RD Lawrence, who's the founder of the British Diabetic Society. And he made this comment. Um and this again is in the 19 thirties, the attempt to keep the blood sugar constantly normal may be ideal in theory, but in practice, it is very difficult to achieve. It makes the diabetic life unnecessarily hard without adequate benefit. Now, I told you he had T one D or maybe I didn't tell you, but he had T one D, he was actually one of the, uh, uh, recipients of insulin from bings and best, uh, when they were isolating their insulin. And it's interesting because that kind of quote made me wonder if that's why for the next 50 years there was a lot of complacency with how to manage diabetes. Uh, you know, take your insulin once or twice a day, check your sugar once or twice a day and you're, you got an A one C of nine and, and high five. Um but then in the 19 eighties, we did something called the diabetes control and complications trial. And that really revolutionized our approach and how aggressive we were in actually managing the A one C. So just to highlight this study, which really was the landmark study that changed our approach to diabetes. Um Everybody in the beginning of the study had a 9% a one C kind of like this complacent approach. And then they have this intensive group that was getting their blood sugar checked four times a day and they were getting multiple injections a day. Uh And this was going on for nine years and it was evident in the first year that the A one C came down quite quickly um and was maintained. Uh So in 1993 they published the data and what they showed was this dramatic reduction in complications from T one D or type one diabetes, retinopathy, nephropathy, neuropathy, all decreased significantly. Um And that obviously changed how we were going to not be so complacent about managing type one diabetes. And that we did want to bring down the A one C. So that as you can see here, as the A one C goes up, there's not just a linear increase in complications but an exponential increase. So we have these targets that came about to have 7.5. Former goal notice, I said former goal um but less than 7.5 so that the complication rate can be near the bottom here and almost flattened, almost zero, relative relative uh sorry, almost zero relative risk. I do want to point out real quick that I wanna be mindful of our teens. As I go further into this talk that I don't want to dismiss individuals who make an effort to bring down their A one C but only may bring it down 10% to down to 10% let's say not to go but only to 10%. And I wanna be mindful because if that kid, for example, was 11 or 12% prior that drop to 10% is still a significant drop in the relative risk. And I I wanna actually provide accolades to that individual and not be so judgmental that. Oh, why aren't you at goal? Yada yada ya. Because at the same time, we have to be um happy and impressed that they were still able to make some progress and, and that's kind of the mindset I want as the providers that also have in their own clinic. Not to be so judgmental about numbers per se. Now, in the DC CT trial, um there was this not, not notice that. Why don't we make everybody down to 6% because that would be, you know, basically nil relative ri risk. The issue was that when the individuals were brought down too low on the A one C, the relative risk for hypoglycemia would increase dramatically. Uh So here's the A one C on the bottom here and here's 6% down here. But you can see the rate of hypoglycemia, severe hypoglycemia would increase significantly when it was below 6%. So that was the dilemma and we made 7.5 the target. However, if you were to look at what the uh average. Um oh, sorry. So now I I talk about the current goal of the A one C is down to 7%. And the reason why we can bring it down to 7% is because with the technologies that I'm gonna share with you, we now have protection mechanisms to prevent the hypoglycemia because remember in this DC CT trial, we didn't have glucose sensors that can alarm you when your sugar was going low. Uh We didn't have the ability to stop insulin delivery uh because the sensor was sensing that your sugar was going low. It was just blood sugar checks and it was just insulin given by these injections. Uh And so, yes, the risk was really high if you're trying to keep the sugar in a tight range. Now, if I was to ask you what the average A one C is for our 15 to 18 year olds, and you were hoping that it was somewhere around seven. Unfortunately, that's not the case. Uh 9.3%. Um And this was from a, a collaborative study uh in the US. Uh showing that well, over half of our patients are not at where we want. And, and this is the issue. This is the whole reason for the talk. And this is why we try to disseminate as much knowledge as we can, not just to the providers um but to uh nurses, to schools uh to the families and then hopefully that carries forward so we can perpetuate what, how we can bring this whole group's a one C down. So the goals of therapy is not only just to optimize the glycemic control while avoiding hypoglycemia, but we also want to minimize disruption to this kid's life. We wanna uh make them have a good quality of life. We wanna improve their self esteem, confidence and socialization, et cetera. So let's just talk about some of these barriers to optimal care, subcutaneous insulin administration, insulin action, relative to carbohydrate, eating, the fear of going low. I had this mom of a teen, uh, the kid had diabetes for many, many years and the mom would wake up religiously again. This is before sensor technology and she would wake up religiously in the middle of the night every to poke his finger in the middle of the night, making sure he would not have a low blood sugar overnight. And even now, even with the sensor technology, I have parents that will keep the sugars in the two hundreds because they were just too fearful that the kid will have a low in the middle of the night. So the fear is real um accuracy and discomfort associated with the glucose monitoring or the little finger pokes uh access to health care. Uh and then the mental health and family support, all of these can lead to burnout. And this is really what we're trying to avoid uh at the end of the day. So what have we done to advance subcutaneous insulin injection? It I'm gonna really go over these really quick. Um Because I do wanna talk about sensors and pumps a little bit more, but I do wanna be appreciative of the fact that it wasn't too long ago that we had to reuse needles um at camps where I used to work um back in the early two thousands. Um my mentors would mention to me these sharpening devices they would use uh to reuse the needles recycle the needles and they would have to boil them every day. Um, obviously the pen needles, for instance, are really, really short, they're four millimeters long and 32 gauge. So that makes these insulin needles actually quite, quite, I'm gonna use the word benign. But, um, what I oftentimes offer the parents is to have the parents feel what the shot is like. Um So they have a little bit more understanding about what it is. The child is experiencing. A lot of the fear that these kids have surrounding the injections is really the kind of uh ritual associated with approaching someone with a needle, uh that's gonna be put in their skin. But these needles are really, really um thin and really, really uh uh short so that it, it's not as painful as they may as the parents may certainly expect. Um these pens even have the ability to talk to apps on the phone so they can keep track of the amount of insulin delivered. Um I only bring this up. We don't have too many kids on pens, but certainly if there is someone who's just very against having a pump on them or having an attachment on them, this serves as a good compromise as something that can still be techy. Um have the kids kind of involved on their phone and with the insulin delivery device because as we all know, these teens and preteens have a hard time parting with their phones. Um These are the old insulin pumps and I really wanna give a shout out to doctor Kaddish who um oftentimes is laughed at in this picture with this large pump, but I have to hand it to him because he was well ahead of his time. What people may not know is that this was actually a bi hormonal pump. So it was delivering insulin and Glucagon at the same time. Um As I grant you how cumbersome the uh outfit may be the practicality or actually the functionality I should say was actually pretty good as far as maintaining the blood sugars. Of course, the pumps have evolved to a much smaller size. Um And these are the current insulin pumps that we have available right now as we speak. Uh And I'm gonna talk briefly about them, the pluses, the minuses, et cetera. Um This is some examples of the wearability. Uh Mrs Sierra Sanderson was actually able to visit children's hospital Oakland. So it was really cool to have her uh walk with our patients and um take her pictures and stuff like that. She was Miss Idaho in 2014. Um This is Mr Universe in some year, I'm not sure this is the Medronic that someone's wearing there. So the infusion sets just really quick for those who don't know when you have an insulin pump. Um that's requiring a tube. What you're doing is inserting a plastic catheter tip into the subcutaneous fat as demonstrated with this finger here and there is a needle, introducing the plastic catheter tip. Uh and then it can be, the needle is removed and you have the plas plastic catheter tip uh remaining in the subcutaneous fat and that will have to be replaced after two or three days. Uh There is gonna be irritation from insulin being infused into that area. The issue comes about when you have someone who has a bent cannula, which can happen in an athlete and someone who's been moving around and when you don't have delivery of the insulin, then you go into a state of ketosis. So let's go back to pathophysiology really quick. Um In order to develop ketones, one would have to be in an insulin deficient state. And when you're on a pump, all you're getting through the pump is a rapid acting insulin. And so there's no basal insulin, there's just a rapid acting insulin that's being delivered periodically. And then when that cannula is bent, you're not getting the rapid acting insulin anymore. And that's gonna be cleared from the individual system within 4 to 6 hours. And therefore, ketones can develop um fairly quickly. So the pump just, you have to be mindful when you're on a pump that can, you can go into ketosis fairly fast. That's, that's counter to someone on insulin shots, assuming that they're getting basal insulin because the basal insulin as you know, when you get, it will last uh many times longer than 2024 hours and we'll go over insulin duration in just a little bit because right now we're just talking about infusion sets. Now, if it's bending a lot in some individual, you can have a, a metal uh infusion set with a metal needle, um that's replaced every two days. But then you sacrifice comfort having the needle in the subcutaneous fat um for the not bending of the, of the catheter tip. Uh and many individuals will like that. Many don't wanna have to deal with the bending of the tip even if it means a little bit of sacrifice in the comfort. I mentioned that it's replaced every two or three days. Um But there are uh FDA approved devices that last longer such as Medtronic has an infusion set that lasts seven days. Uh And I know the other pump companies are also working on creating their infusion sets to last longer too. But obviously, um this what, what this means for the kid or the teen or the toddler, et cetera is less injections with the catheter having to be inserted. Uh And hopefully, then again that it improves um or lessens the idea of burnout, uh lessens the frequency of burnout. Um And I I make a joke out of this particular uh picture. Uh This happens to be from Metronic website because this happens to be this perfect abdomen and the infusion sets going in there. But in one's clinic, particularly, hopefully the pediatricians are mindful and doing the physical exams and seeing what's going on with the infusion sets. We want, make sure that the sites that where they're being placed are relatively healthy. Um This is an example of someone who has a little abscess uh formed underneath the infusion where the infusion set was. So you have the redness, the swelling, uh and often maybe a fluctuant mass that you're feeling underneath. Um This is an example of contact dermatitis um from the adhesive. Uh So every time, you know, they're putting the adhesive on a particular site, they get the skin reaction. Um I will say that when uh we try oftentimes Flonase or nasal sprays, uh you do like, you know, 10 sprays, 5 to 10 sprays in an area, let it soak in for about 1015 minutes, uh then wipe away the excess and then you can try putting on the adhesive and that's something again, that would be really nice for PC PS to be aware of. It's a quick trick that oftentimes does um wonders for uh the skin not having to be so irritated from the adhesion. And then this is an example of lipohypertrophy. Uh I mentioned before that insulin is an anabolic hormone. Uh without it, we go into catabolism with it, we can, it's an anabolic hormone. But if you keep giving insulin into the same subcutaneous fat, then you get hy lipohypertrophy of that adipose. Uh And so this is what's forming in that in this person's particular abdomen. Um As far as I was mentioning about the insulins real quick. And so I wanted to talk about rapid acting insulin and basal insulins. Um And in an ideal world, uh this is a physiologic uh diagram of what happens in normal physiology. You have two phases to insulin release. Um You have this basal that's kind of going on in the background. And we all make insulin even if we're fasting, even if we're not eating anything, we all need a little bit of insulin to undergo the daily metabolic needs that every individual has. But when you have a carload, then you have a first phase release of the insulin um followed by a more tonic release of insulin so called second phase. And you can imagine this is pretty hard to mimic um with an injection. Uh So what happens in a real in a person who doesn't have type one diabetes is in an ideal world. You have the glucose go up with a meal followed by an insulin to kind of cover that meal. Uh Every time that person's eating and that's just depicted in the schematic right here. So regular insulin which ca uh which was, you know, available in the eighties was having a peak that occurred in about two hours. So ideally, you would have to give it about 30 minutes before that person would eat. So that when the insulin was peaking it's, someone matched the food when it was actually, uh, increasing because the food sugar, the sugar from the food is gonna, uh, peak within the hour. Right. Um, and that was really hard to do for many individuals. No, especially teenagers. No one's gonna take insulin 30 minutes before they're supposed to eat. In fact, as you guys know, it's hard to even get insulin. Now, uh, and before the teenagers eat, um, needless to say regular insulin was not very good at covering the meal. Not to mention it had a long tail uh that would last many hours. So there was this also the susceptibility to low blood sugars. So along comes the rapid acting insulins in the 19 eighties. So this is an example of Lispro or HumaLOG. Uh and Lispro has a peak of about one hour. And ideally again, you still give it before the meal 10 to 15 minutes before because that's how long it takes for the onset of action to work. And you can see the tail is much less, which means less likelihood of hypoglycemia. So rapid acting insulins were innovative in the 19 eighties happened to coincide, right with the DC CT trial. Uh and when people were taking insulin injections more frequently. So a lot of it may have been ha having to do with these rapid acting insulins that were now available. So we have these better insulins and what I provided also are ultra examples of ultra rapid uh insulins that are peaking, not just in an hour, but even in 40 minutes or so, uh examples I put right here, glycine and fast acting aspart or Fiasp and literally made their own as well. So you have these much faster acting uh insulins in order to try to combat um that peak uh that's provided from a carbohydrate load. And some studies have shown with these ultra rapid, even if you give the insulin within 30 minutes after eating the meal that you still had good glycemic control or equivalent glycemic control. Um And that's assuming again that they still remember to take it. That main idea behind that is more so with toddlers, right, who are not, you're not sure how much they're gonna eat. Uh and then you can give it to the toddler after they ate. Uh and, and be sure that they're not gonna have a hypoglycemic event because they didn't eat all their meal and you gave the insulin prior a fresa is an example of an inhaled insulin. Um, that also has a very rapid onset and rapid escape from the system. Um It's time to peak is 40 minutes. Um There are some limitations to inhaled insulin as, as great as it sounds. Um And that is, you can't have any reactive airway disease, you can't have any asthma. Uh And as we know, a lot of our kids are in this cohort. So the inhaled insulin, um wouldn't be used in them. There's fixed dose and that was just an example of someone you don't want any smokers also taking the inhaled insulin, you only have fixed doses of the insulin inhaled. So you have 48 and 12. So you kinda have to add the meals around those fixed units. The fev one has to be monitored at baseline, six months and then annually. Uh and we don't really have long term data on the tumor risk since this only has been around since the early two thousands. Um So there's a theoretical concern. Um But right now, obviously, there hasn't been any uh evidence of increased tumor risk in the current cohort that's been um having this use of this uh insulin since the early two thousands, you also still need to take a basal insulin shot. So this is a rapid acting insulin. Uh And as I mentioned before, you still need to have a basal insulin at all times. So I mentioned to you the mom um who was worried and that's not just one mom, I'm sure there's several parents um who are worried about their child having a low blood sugar at night. Uh and the old basal insulins. Uh And for those who have been out there long enough, I remember in my camps in the early two thousands, this is our basil. We had to use the cloudy insulin or NPH and we had to have a bedtime snack uh at the evening. Otherwise, the NPH, which had a little bit of a peak in the middle of the night would cause this low. Uh And now we have insulins that have foregone, that peak. Uh Lantus is uh oftentimes used, um, it lasts about 2024 hours. It does sting a little bit. Um It's an acidic ph for those who don't know. Um And when the acidic glargine comes in contact with the neutral ph of the subcutaneous fat, it forms a colloid if you will. And that colloid then can release insulin hexamer throughout the course of the day. Um Demir or Levemir, which won't be available at the end of 2024 is what we have on our formulary here for now. And um that's an interesting long basal insulin because uh it, it does, it's not acidic, but rather binds to the protein in the bloodstream and then it can be released slowly uh throughout the course of the day. But like I said, um that's not gonna be available. The manufacturer is not gonna make it available. Um, at the end of this year, one of the newer insulins, uh Trece or, or Dagli actually has been one of my favorites in the sense that um you can give it at any time of the day since it technically has a half life that's longer than 24 hours. Uh So, uh I should point out that Lantis um while it lasts 2024 hours is often time given in the night time or evening time. Because if you gave it in the morning time and it only lasts 2020 hours or so, it may run out in the middle of the night and then the child or teenager will wake up with a higher blood sugar. Uh and keeping in mind the dawn phenomena when, especially in those who are in puberty or growing, you're most insulin resistant in those early dawn hours. And that's when you need the insulin the most. So even the manufacturer Lantis uh will say in their insert to give it in the evening at bedtime or dinner time. But like I was getting out with the Degla Tresiba has a, a much longer half life. So you can give it in the morning, you can give it at night. You don't have to give it at the exact same time each day. You can be off, you know, by eight hours. Even, you can give it one time at nine o'clock in the morning, another time at noon gives a lot of flexibility to the kid. And also it's not um stinging when it goes in. Uh And Glargine does make a more um concentrated form. So it has a smaller depot which has been shown to provide a more steady release uh of the Glargine um of the Lantus. So that's also um available. Uh And what I did provide, it's not if they approved yet. Um But there are uh weekly basal insulins uh that are being formulated and being investigated. ICADE happens to be approved in Europe uh for adults. Uh So these are once weekly basal insulins. Uh And then there's another one that's being under clinical investigation right now. Uh I will point out as, as awesome as these sound. It's interesting in the studies that were done in these adults. Um And that was that keeping in mind that the cohort already had fairly good A one CS like in the seventh, um they were not as satisfied with the once weekly injection compared to the daily Lantus, uh which was the comparison group. Uh And that may be because number one, there was more hypoglycemia, hypoglycemic events in the ICADE population. And then two, you don't have the ability to kind of micromanage the sugars. I mean, once you get that basal insulin, you're kind of stuck with that dose, right for the week. And for a lot of people who have good A One CS, they're really used to having a little bit more control or um uh uh micromanagement of their diabetes. Uh and then Glucagon, uh just so you guys know this is kind of the old kit that might have, everybody might have been trained on in, in med school, et cetera. The red kit where you had to mix the diluent into the powder and then administer when someone was having a severe low to the point even that they had a seizure from insulin induced um hypoglycemia. But um now we have inhaled Glucagon and so kind of imagine if you had of an EpiPen, but you can use like an EP powder that you can spray into the nose. It's just a lot more simpler. Uh This is a study that was done to show um when individuals um were giving the Glucagon shot that actually a many, many of the participants uh in this case, it was uh about, you know, uh over half or so were actually not giving the Glucagon correctly uh because they weren't mixing it. Um They weren't a lot of them would in the stress and anxiety of the situation would just quickly give the injection and would forget to mix it with the powder. Um obviously with the inhaled and some, it was a lot better as far as the ability to administer it. There are some premixed Glucagon pens too if the inhaled insulin is not being covered by the insurance. And again, this is again for the the primary care provider to kind of ask about um you know, the I mentioned the pens, maybe another thing they can also ask about is like the medical bracelets. I mean, these are all part of maybe a checklist that one can make with the TND uh patients that come through your office. And then as far as advances in accuracy and comfort associated with glucose monitoring. The blood pokes are probably the most painful part uh of, of the diabetes experience, in my opinion, and I've given myself the shots, I've been on a pump, I've put sensors on myself and I really do hate the, the finger pokes with the lancet. In the old days, we have the urine strips that would actually give you a range of what the sugar was based on, you know, this chemistry kit and what the color does on the urine. Um And we can also check ketones uh through the urine or by blood. Uh And this is an example of an old lancet and this guillotine like device had this exposed uh needle poker and the little five year old would be like, you know, completely anxious as they're putting their finger underneath this tray. I don't know why I'm demonstrating it on the slide here. You guys are on your Zoom cameras, but I'm putting my finger uh figuratively underneath this guillotine like device and it's super scary. Um Rather we have these uh quieter uh adjustable lancets that can control the depth. Um And these are some example of the meters and how far we've come uh because they're much smaller, requiring much smaller amounts of blood. And what we're getting at is that these meters are somewhat becoming a little bit obsolete. Um And why, right, we have the sensors and, and when you take that meter and it checks the sugar. It gives you this point in time, but it doesn't tell you right where it was coming from? Was it steady at 220? Was it coming up from a lower blood sugar or was it, is it coming down even from a higher blood sugar? So along come the sensors and the sensors have this metal filament that's going in the subcutaneous fat and it's doing a check of the glucose in the interstitial fluid. And this is reflective of the blood glucose. But if you're checking the sugar every five minutes, you can imagine rather than the four times a day checks that we were hoping to get from the DC CT trial, you're getting 288 checks a day, right, every five minutes. So, not only are you getting the checks, but you're also responding to those sugars. Hopefully, uh when you have an individual whose alarm is going off because their sugar is out of target, these sensors can last depending on the manufacturer anywhere between seven and 14 days and they do not cause lipohypertrophy. In point of fact, if you do have an area of lipohypertrophy, you can put the sensor on that particular spot. Um But what the sensors have done is created now a different metric that we can follow something called time and range. So you'll hear this a lot from your patients, from your families, from your parents. And so hopefully the providers here can now be a little bit more familiar with this term time and range. And that refers to the time you're spending in the target range between 7180. And the goal is to have 70% time and range. Because if you do have a 70 time and range, that would correlate to a hemoglobin a one c of 7%. Remember what we did in those curves. What I was showing you is that's the goal to minimize those complications, neuropathy, retinopathy, nephropathy. And if we can keep them at a time and range in 70% then we're achieving likely a hemoglobin. A one C of 7%. So this is an example of a download. Uh This is from 2019. It looks like I I took out the patient's name, but this kid was 17 years old, has diabetes for pretty much all their life since they were two. The A one C is 8.9. Now, when you have an average here that looks like 180 you might think to yourself that looks pretty good right at an average of 180. Um And, and what I'm getting at with the sensor now is we get more data is what's happening in between and what we find particularly at night. This is 12 a.m. overnight to about eight in the morning. Is there is a lot of lows in the seventies and this is where we can have in action that this is where we can intervene. Uh And there's not just lows in the night time, there's some lows during the day, but there's a lot of standard deviation, there's a lot of range and variability. And so we can take the average would look pretty good, but actually make a lot of changes and interventions. Um whether it's from the diabetes team or the primary care provider or the nurse or the nurse at school, they can kind of see this data and act on it, which I think is helpful. These are some examples of the sensors that are currently available. You have the G six and the, the newer G7 on top the Libre three here on the left arm of this individual uh Medronic hazard and light. Um But you can see that they're getting much smaller and they're getting thinner. Uh The Dexcom in the last seven days uh but the freestyle does last two weeks, which is kind of nice. Uh And this is a depiction of the CGM use or the sensor use over the years. 2018 is the most recent year here. This was published in 2019. This data and what you see is an increase in use of the CGM use. Interestingly though if you look at this white bar represents the cohort from 2010 and 2012 and compare them to the black bar which is 2016 to 2018, the teens don't tend to use the CG MS as much as the younger kids, which is probably parent driven. Uh And the uh older adult or younger adults, I should say. Um So you can see here. Uh So our teens, at least in this particular study, we're not using it as often. Um So if you have a sensor and I was telling you about the pumps and we have them talk to one another. Uh So that one can modify the delivery of the pump device. You've essentially created an automated insulin delivery system. And that's what we're kind of um moving towards. I mean, this is becoming essentially standard of care. This is an example of a download from someone on an automated insulin delivery device on a hybrid closed loop. And you can see uh an 18 year old again who's had again, uh diabetes for almost half their life, uh much less variability uh in the sugars because again, there's this constant feedback of the sensor to the pump every five minutes. Uh And it's adjusting uh based on its very the algorithm that it's been programmed to do. So, of course, all these pumps have their own algorithms of how they're going to keep the sugars in target. Uh I don't want to go into too much detail about what those algorithms may be. Of course, many are proprietary. So they're not developing too much, but just know that some pumps are more aggressive than others, for instance, the uh medtronic uh probably has the most aggressive algorithm because it has a meal. It's a patented copyrighted algorithm, meal detection system. So that if the person forgets, for instance, to bolus for a meal, the, the rate of the sugar increase will be detected by the sensor and it will know to give extra insulin to try to catch up uh with that Miss Bolus. Uh and these other devices don't have that um algorithm and, and then it may change as time goes on. But just to let you know again that the, the systems all have a different way of how they approach um the excursions that occur with the sugars. Um So I, I wrote here some of the hybrid closed loops that have tubes that are involved. There's only one system that doesn't have a tube and that's the Omnipod. So I just demonstrated it here. Um So there's no tube as you can see and it's wirelessly controlled by a Bluetooth Android device. Uh hope to be iphone or ios compatible later this year. Uh um At least they say that the, the manufacturer says, so this is data from tandem. Um This is the T slim device and it's showing basically uh overnight here is midnight to the morning and you can see that the time and range is much higher when they're on this closed loop system compared to when they're not in the um closed loop system. And keep in mind during the day, it's actually not too disparate, but this is one third of the day. So if you have one third of the day, particularly the vulnerable nighttime, when mom was so scared, her dad was so scared of having a hypoglycemic event. This is hopefully leading to a better quality of life for not just the kid, but also the parent uh so that they can sleep a little bit more easier. Uh And then this is an example uh in our, for our neonatologist who may recognize this abdomen um of a four month old who had congenital diabetes, diagnosed. And uh it's not if they approved the tandem pump, I I might have shown you it was six years old and approved uh six years old that it was approved for. But we're using this tandem pump with a Dexcom sensor in this baby in this four month old and prior to or in the early part of the pump delivery system, you can see the sugars here with an average of 287. Uh and then after about a month, uh we brought down the average and you can see a little bit more uh patterns of evolve uh with the course of using the sensor and pump device together, mom loves the system. Um because again, whenever the baby is feeding, she had to give an injection prior an insulin shot, right. And now and babies will feed very often right during, during this time of their life. And now with the pump device, mom knows how to just tell the pump how many, you know, grams of carb the child is eating and that's it. It's a push of a button as opposed to the injection. Uh And so you can again imagine how this improves the quality of life of the patient and the mom as well. Uh This is the omnipod five data. Uh I don't want to spend too much time. Just know that it works compared to controls as you would guess so. Oh, this is in the 6 to 14 year old group. Um uh You can see that the overall uh time in range was much better with the closed loop system versus the open. And um they had it also in the younger kids 2 to 6. So this is actually if they approve for two and above. Uh And yeah, the system works now is it is the newest pump that was approved last year in the fall. And I it is a very interesting algorithm. Uh Again, I can't divulge too much about the algorithm but know this, it actually operates not by entering any carbs or anti any sugars. All you do is tell the system that you're eating and you tell it that you're eating a regular meal more than usual or less than usual. And what I, how I describe it to families is it really is a I driven because what it does is it gives its insulin based on weight only. So it's algorithms just based on weight and it sees the rate of rise after that meal and you told it how much you were eating and it will see how off it was in the beginning and then it's gonna retain that information and then it's gonna improve itself the next time and the next time and the next time and the next time and so on. So you can imagine the first week is horrible. Or at least I've been told I know this data looks very clean. So this is from the eyelet. Um This is from a study that was using the eyelet pump compared to standard of care, which maybe about a third of them were in shot, some of them were on other hybrid closed loop systems. But you can see that, oops, that was my pointer that in the first week. Um They're just basically showing that the time and range with the islet, which was this BP is bionic pancreas. That's what they were calling the islet. Um is uh quite good compared to its comparator. Uh And this is in the first week and then the study was done for 12 weeks. Uh And so you can see on the ongoing weeks um how it maintain this tight sugar control. So, again, what's happening is that you have an individual who is using a I to take care of their diabetes and all they're doing is announcing when they eat, they're not counting the carbs, they're not counting, they're not even looking at their sugar. Uh, and they're really letting the system take care of their diabetes. Um, and this is not approved yet. We are striving or we are moving towards having a, a bi hormonal pump. So it's not just insulin being delivered but also Glucagon as well. Uh And this is actually, I think really close around the corner. I would, I would be willing to tell you in the next three or five years, we're going to have a system um that is delivering both uh insulin and Glucagon. Uh This was a study done in 2017, so pretty long ago, but what they were using was two pumps. So two tandem pumps, one for Glucagon and one for insulin, they were using a Dexcom sensor device. And the iphone was basically your your computer system uh with the algorithm. So it can control both and what it was, it's just showing that overnight on the top is the overnight. Um And then sorry, the day is the, this is the day time and the night time is below here. Uh And this dash line or the black line again is how often they're staying in the time and range uh compared to the comparator group. So more time and range in overall. And then also at night time OK. The disadvantages uh include cost troubleshooting tech. There's no basal insulin, remember. So you could go into ketosis pretty fast and the site changes do take about 1015 minutes. It is an attachment, but of course, the benefits as I was just alluding to is it's supposed to make your life easier. We recommend to the teenagers for instance, that you're supposed to check your blood sugar before you drive. So rather than having to take a poker out and poke it with a meter, you can just look at your phone and the sensor will tell you if you're safe to drive. Uh when you're driving low, you are driving like you're, you're, it's like driving drunk. Basically, you have uh an awareness, you have slower reaction times and, and unfortunately you are more prone to get into an accident. Uh So it's really important for teenagers to make sure they're above 80 mg per deciliter um before they drive or at least show again with a sensor that they're 80 heading upwards, the arrows showing that they're heading upwards. So um yeah, improved quality of life overall is going to be better with the pump and the sensors, in my opinion. Uh And these kids really like the tech. Um I'm gonna, I don't have too much more time left, but I wanted to briefly discuss during COVID, we were definitely able to um really boost our telehealth services. And what it meant was that distance for a lot of people because we have a lot of people from, you know, uh Northern California, near the Oregon border, Fort Bragg Mendocino County. Um Eureka, these individuals could still telehealth with us. And because we can actually attain their data from their pump from their sensor through the cloud, we can review and analyze all their patterns from afar. And, and this also allowed us to do the time and range rather than the hemoglobin A one C as a metric of how, you know, how they were doing. Uh as you know, when we, they come in the clinic, we poked their fingers and we can do the hemoglobin A one C clinic. I mean, a lot of the PC PS office can do this too. Um But time and range, as I mentioned, can be a surrogate. Uh so during these telehealth visits, we're still able to do a complete, in my opinion, complete without the physical exam, but a very extensive uh visit uh and provide a lot of uh guidance as to how we can manage their diabetes. And that then also prevents burnout, right? Because they don't have to stress about the four hour drive, they don't have to stress about making it to clinic. Uh And then the mental health wise, I was making mention about how we don't have a psychologist yet. Unfortunately, in our clinic, but we are working on it. We do uh P HQ nine screens for depression. Um I also want to be mindful of the barriers that come about um to having uh our T one D population take care of their glycemic control because some of them do have separate households and there unfortunately may not be consistency uh between, you know, the way things are managed with the diabetes and that creates a, a strife for the individual for the kid. Um And so diabetes camps have just been something that not only did diabetes camps inspire me, pursue uh endocrinology and take care of this population. But I really have seen lives change in individuals who have gone. Um the confidence increase, the self esteem increase, um less shy about talking about their diabetes and they get exposed to other kids who may be using a pump or tech or sensors and uh have had kids at the end of the week who had been on shots, asked their parents, I wanna go on this libre, I wanna go on a Dexcom. So these kind of uh interactions really do have an impact on the kids. And, and again, in the old whole grand scheme of things, I feel uh contribute to preventing um the burnout that I was talking about before. There are diabetes dogs that do also provide uh hypoglycemia awareness. Um and they're trained to uh uh alarm you if they're having a low blood sugar. Um And so I, I wanna close on this last case. Um this and I'm sorry, I went kind of fast. I wanted to make sure I get all the slides. But this last case was really touching to me. Um, this is an individual who I've been following a long time. She's 21 now. Uh, she's had diabetes since she was three. Uh A one C is 11.5. You can see here and this is an example of her download and, um, I really am trying to be supportive all the time. Whenever these kids come to see me. The fact that she religiously came to her clinic visits is again a testament to the fact that she, she was wanting to do something, but it's always a struggle. There's always things in the way um her life, uh school kids, um peers, et cetera relationships. Uh and you can see she's 16% in range with the average of 273. So this is just a tracker of her hemoglobin. A one C over time. You can see there was a time when her A one C was uh in range. Uh And then for the last, you know, eight years, we, we had been struggling and she, we had our crying sessions. Uh mom would come into, uh and we would have the crying sessions. Uh And then this happened, right? She went from 11, 11.5 and she goes down below 7%. Uh and what we did, uh in that particular case, is we use the eyelid pump. Uh She was obviously burnt out. Um I was thinking that let's just take away or minimize as much intervention as we can from you. So you don't have to count carbs or anything like that. She comes back after uh five months on the islet pump average now is 170 time and range is pretty close to 70%. Um I asked her, you know, what is it, what is it about it? And she literally says to me like I just don't have to think about it anymore. So just be persistent um with your kids uh in your clinics, uh try not to be judgmental the kids um really take it to heart and many of them are trying hard. Uh But there's just so many variables that go into play and I told you these barriers um that are, are affecting it. I mean, these are just some of them, there's so many more, but I was just kind of highlighting where tech can hopefully um obviate um a lot of these barriers so that we don't have so much to worry about. And um I also wanna give a shout out to the many role models who've been uh historically uh out there doing what they do without this technology. Um Gary Hall Junior, um a medalist from the Olympics um in the nineties. Um you know, we didn't have sensor technology back then. Uh I met Charlie Kimball, um, who's a formula one driver. Uh, we did have sensor technology when he was driving in Indy 500. And, um, he would tell me on his steering wheel, he would have a sensor. So he would have, you know, the, the fuel gauge and he would have a speedometer, of course, but he would have his sensor and then on one side of his helmet, he had water and on the other side, he had juice in order to balance his sugars. Um, so you have these individuals who, who have been living their lives with no technology or, or some technology, but now we have hybrid closed loops and that's changing a lot of things. These are some of the rock stars, uh Supreme court justice Sonia Sotomayor and these are some of them, uh role models. Uh, and kids. I've had the pleasure of taking care of. Um, Alex is expecting a baby. Actually, I just, um, met his wife again at one of our diabetes events this week. So he's expecting a baby soon. Uh, and Spencer has just been a role model. He's in the Bay area. So changes you may want to make to your practice, please, please, please. Um, don't just think that this diabetes kid is gonna be someone, the diabetes team takes care of, be an active participant. If you don't know about the tech, ask about it, get involved. Um, consider asking families to upload their info in advance. Uh they can even bring their printouts. A lot of the um families. If they, if they, if you choose to, you can ask them, they know how to do it, they can print it out. Um If they're plugged in to that system, but particularly offer families the tech if you feel like they, they haven't really been introduced to it or exposed to it. There is an unfortunate disparity. Um This is a study in 2021 showing in non Hispanic Black, the use of CGM devices or the sensors compared to pumps and how um how dis the uses in this population. Uh So again, we just have to be hopefully pushing this to everybody, to everybody who we feel is a good candidate too. Technology has revolutionized our approach to type one diabetes. We now have the ability to have lower A one CS without having that hypoglycemia that I was mentioning before. Um So this is hopefully improving the long term out outcomes. Um And then by approving the quality of life, we reduce the burnout. Um And the role of the pediatrician is also evolving. I'm trying to get to a point hopefully that you don't have this patient in your office who puts on their phone. Um because you kind of get bored by asking them about their diabetes by wondering about how their pump works by. I continue to learn from my families and so have them actively um engage in the communication. Uh and, and ask the questions and I the teens generally will answer rather than going on this phone. Um Yeah, so be aware of what's new. Uh and then how to interpret the sensor data. It's just another power that I hope you can take away from this talk. Um So thanks for all your attention. I have five minutes to spare. Uh And thanks again for being part of our diabetes team and helping all of all of our team take care of this cohort together. Um They did want me to put this uh QR code at the end here uh to get your CME credit. Um So that's it for me. Uh Jay. Uh Perfect. Thank you so much. Yeah, five minutes. We'll, we'll go quick. Uh We got a couple of questions stacked up for you. Um First one is uh could you please review some insulin adjustments? I guess also with these new techs that are out there um with the continuous pump and monitoring. It seems like in terms of kids who are febrile vomiting, not tolerating po or just in general, that that should be my second grand rounds sick day management. Well, the short of it that you have to know is that there are gonna be situations where insulin requirements will increase. Maybe this is what the person's getting at and that would include a febrile illness like this person mentioned. Um I mentioned really briefly one of the slides, even like having the first few days of a period when it's about to start, then the insulin resistant rises. Um, individuals, um, who are even just stressed, you'll notice that the, the sugars rise because cortisol and adrenaline, um cause insulin resistance. Um There's a classic one also seen in sports. So, uh during practices and um, routine kind of game days, so to speak. Uh I shouldn't say game days practices, the sugar goes down during the exercise, but when it comes to game day and Friday night lights and everything, the sugar goes up and the parents are like, what's going on? Why is the sugar going up? And that's the adrenaline that's causing insulin resistance. And in that circumstance again, I could give a whole talk on it. I do give a little bit of insulin for that spike. Uh That's happening associated with game day, but not during the practices. Then you need less going back to the sick day management. The general rule of thumb is that you can go up on the settings by about 10%. Um And during illness, keep in mind that you should always be checking for ketones because you can still have ketones form even if the sugar is not elevated. Uh And a lot of people miss that. Um So when you're insulin or when you're sick, you're more insulin resistant and you just, your insulin requirements are greater. And if you're not providing it, you can still develop ketosis. Uh So there was a question about, you know, how do you, how do you manage the blood sugars? Um Again, making small changes at a time? 10% at a time. Certainly the our families know to call us if they, if they see patterns of spikes after meals, for instance, that's generally gonna mean they need more insulin, the carb ratio. Um if you're waking up with a higher blood sugar in the morning, that generally means you need more basal uh insulin overnight. Um But I'm happy to discuss that with the person who's asking questions a little bit more. Um And then the second question is I'm going to combine these two questions is when we get a new diagnosis in the hospital. Um and we're about to send them home. Is, are any of these new systems an option for them to go home with or are we on the same old, same old and then transition outpatient? Great question. And we always teach all the kids uh boot camp one on one diabetes, right? Know how to use a meter, know how to use an insulin syringe. Um because if you're traveling and you, someone steals your pumps or it gets lost in the luggage, who knows? Um You'll always be able to get a meter and insulin even in the deepest alleys of Pakistan. I know because I've bought them, my I have two cousins with type one diabetes in Pakistan. And they, I wanted them on some newer insulins and they took me into the deep, deep alleys and this guy was selling insulin out of a fridge. But to this person's point, I do try to put a sensor at least on the individual as they leave the hospital. Um, so that yes, they know how to poke their fingers, but for ease, for sake of peace of mind for the overnight um, blood sugars. Then, uh I'm gonna provide the sensor and thankfully, the insurances are much better at covering these devices. Now, it wasn't the case even like five years ago, but now we can get them covered. Type two diabetes is a whole another story, but for type one, we and get it covered, um, the pumps are a little bit different. Um, the pumps, we generally have a class that they come back to after they're discharged and many of them come back within weeks of their discharge so that they can get the class. The reason being it's kind of like, you know, buying a car, you don't want to just kind of like buy the first car you drive. Um, you wanna test drive all of them because once you have the insurance cover one of the pumps, you're stuck with it for the warranty of the pump. Uh, so you want to kind of make sure that they have a, you know, test drive and you wanna make sure the kid likes it. Uh That's the actually most important decider of what system they're gonna go on. Does the kid like the the pump? Uh do, do they like to play with it? Et cetera? So yeah, we have them go to a pump class afterwards but the sensor we can get on, on, get on right away. Perfect. Um It sounds like we're running out of time right now. Um regarding your slides, uh You said you would be able to share them after we get rid of some patient. Yeah, I'm just gonna get rid of some of the the patient information, but I will have these slides available and you guys had my contact or QR Code um Christina and Jay knowing how to get a hold of me, but I'm happy to talk to anybody really because again, thanks again for everybody staying on this, but it's up to us as a group as health care providers to really share this information with all the families um and, and engage them so that we, we disseminate and spread the knowledge of this tech that's available to hopefully make everybody's life easier. All right. Thank you so much, Eric. All right. Thank you guys. Take care. You have a great day. All right, bye. Created by
