Thank you everybody for joining us today for our webinar titled Clinical Conversations on Diabetes Technology and ACE Guidelines Update. Our speaker today is Dr. Jeffrey Unger. Dr. Unger is a board-certified family physician, diabetologist, and clinical researcher who directs the Unger Primary Care Concierge Medical Group in Rancho Cucamonga, California. He has published three medical textbooks on diabetes, one on migraine headaches, as well as over 160 peer-reviewed manuals. Dr. Unger has participated in over 150 clinical trials, including the LEADER cardiovascular outcomes study. He recently co-authored the 2021 American Association of Clinical Endocrinologists Guideline on the use of advanced technology in the management of patients with diabetes. Although he has no athletic ability, Dr. Unger has served as the physician for the Anaheim Angels baseball team, mixed martial arts organizations, as well as the World Wrestling Federation. You may even recall Dr. Unger being thrown through a wall by two female wrestlers during WrestleMania 7. And so, Dr. Unger, thank you so much for being here with us today. I'll go ahead and turn it over to you. It's an honor and a privilege to be here presenting this slide deck to you, and thank you very much for joining. And by the way, thanks for all you do for all of our patients with diabetes. You're going to enjoy this talk. It's very entertaining, as was that introduction that Amy mentioned. As Amy mentioned also, I'm a family doctor, as well as a diabetologist. I'm going to start this presentation by telling you a little bit about Henry. Henry is 72 years old. He came to see me six months ago for diabetes. I believe I was the eighth or the ninth doctor that he'd seen over the last 15 years when he was initially diagnosed as having diabetes. And Henry cannot get his A1C down below 9%. So I asked Henry, Henry, what have the doctors told you about the reasons that you cannot get your A1C under control? And he was very upset, very upset, not really with me, but upset with the entire process. Let me tell you something, doctor. I am sick and tired of going to clinicians, and all they tell me is I got to exercise more and I've got to eat less. But by the way, they haven't changed my medicines in 15 years. I'm still on metformin and esophaguria, and I'm getting sick and tired of being treated to failure. What are you going to do for me that's different? Well, the first thing I did was find out a little bit more about Henry. It turns out he is a Vietnam War vet. He spent six months living in Agent Orange. You may know that Agent Orange exposure causes severe insulin resistance, and this makes diabetes very hard to treat. So as primary care physicians or anybody dealing with diabetes, I want to make certain that my patients get treated successfully, not unsuccessfully. Nobody wants to go to the doctor and be given the wrong treatment. It just doesn't make sense. So we're going to talk today about how to successfully manage people with diabetes. Here are the disclosures. We're going to talk about using technologies to help people manage their diabetes. I'll talk about continuous glucose monitors, connected pens, insulin pumps, integrated devices. And my job here is not to teach you everything about all this stuff, but to get you involved with determining which patients might benefit from these outstanding technologies. We'll also talk about special populations and how you even onboard these devices within primary care. Diabetes patients, 80% of them are managed within primary care. This is a primary care disease state. We need to be involved with this type of technology. I'm not going to play the video. Yes. Sorry to interrupt. Your slides are not advancing. Okay. Yes. Now we're good. Thank you. Can you see that? Okay. Let me go back here. Sorry about that, Amy. So let me go back. This is Roy. And Roy is one of my patients that was diagnosed as having type 1 diabetes back in 1961 at the age of 15. He was told by his doctor that he would not live to be older than 20. Because at that point in time, there's really nothing you can do except put people on insulin. Remember, they didn't have any blood glucose meters. They certainly didn't have any technology. But Roy beat the odds, despite being on injections of pork insulin once a day, sometimes twice a day, doing urine testing. He has done extremely well. Back in July 2020, we placed him on what's known as an integrated hybrid insulin pump. Now what this means is that Roy's insulin pump and continuous glucose sensor are talking to one another. And this has made life extremely happy for Roy. So after about four weeks of being on this device, I had Roy come back to the office. I said, Roy, what do you think about how easy it is to manage type 1 diabetes at this point in time? And he just started crying. I mean, literally crying. He said, you know what? I only thought about this. I only imagined this back in 1961. And here it is. I'm wearing it. And he really likes this type of technology. So why use continuous glucose sensors? The idea of A1C, which became the gold standard by the American Diabetes Association in 1993, was that A1C gave us a prediction of the risk of developing long-term diabetes-related complications. We now know that even though A1C is an important aspect of care and follow-up and so forth, the problem is the A1C does not give you the entire story. So a lot of us still, we go by A1C, it's fine. But the problem is there are now 250 different ways to manage diabetes. 250 ways. But only about half of our patients are achieving that glycemic target. Not only that, but patients like Henry, my Vietnam War vet, are getting frustrated. They're coming to you guys with questions like this. They say, why do I go to bed with 140? When I wake up in the morning, I'm at 225. And commonly what we're telling patients is, well, obviously, you're waking up at three in the morning, you're getting some twinkies, you're running back into bed, and hopefully your wife isn't going to find you that you ate these twinkies. But that's really not the case. The problem is there's something called glycemic variability, where the glucose levels go up and down. And glucose variability increases the risk of diabetes-related complications, as well as hypoglycemia. We'll be talking about hypoglycemia coming up. But it's important for us to know that there are other ways to monitor diabetes, rather than just using the A1C. The other problem is that not all A1Cs are identical. How do you even explain the A1C to a patient? It's important that they know what it is that you're testing for. Well, this is how I explain it. Diabetes is a very sticky disease. As the glucose levels rise, the glucose sticks to stuff. And one of the things the glucose sticks to is hemoglobin. When you stick the glucose to hemoglobin, you have a glycated hemoglobin. Now, the hemoglobin lives in the body for three months. So you have an idea that the A1C gives us an idea of level of diabetes control over that period of time. However, it's important to know that people that don't have diabetes have about 5%, only 5% of their hemoglobin glycated. People with diabetes are diagnosed with diabetes when their A1C is over 6.5%. And the higher you go above seven, the more complications you get. There are some disease states, however, that can shorten or even expand the lifespan of hemoglobin. That would be iron deficiency, anemia, hemoglobinopathies. People with sickle cell, they lack what we call an S-terminus, which allows the hemoglobin to bind glucose. You can't do an A1C on people with sickle cell. So you get false elevations of this A1C process. This is your lucky day, guys. You are told by your medical assistant, you have three patients coming in, all with the same A1Cs. And this is important because every time you get the A1C to 7%, you get a $5 performance bonus. So already, you're going to get $15 for the first three patients. But are all these patients the same? Patient A comes in, A1C 7%, good for you. But if you put them on a sensor and download their data, what you find is that 100% of these glucose values are in the target range. Remember, target range of 70 to 180. It turns out that if you get 70% of your glucose values in the range of 70 to 180, you could predict your A1C is going to be 7%. You got it. 100% of the numbers in that value, you deserve the $5 bonus. Now it's time for patient B. He comes in again with an A1C of 7%. Good for you, but wait a second. He's got 8% of his glucose values on a sensor, lower than 70 milligrams per deciliter. 8%. I'm going to tell you something very important that you need to remember. Hyperglycemia does not kill. It only increases the likelihood that you're developing long-term diabetes-related complications. Hypoglycemia kills. Imagine a patient that's 65 years old comes to your practice. In fact, he's patient number C, and he had a stent put in six months ago. He's got a history of cardiovascular disease. He comes in with 18% of his glucose values on a sensor low. Is this okay? Heck no, because when you get hypoglycemic, your coronary arteries are going to constrict. You're going to get a rapid heartbeat. You're going to get cardiac dysrhythmias. You're going to get inflammation in the blood vessels as well that will not lyse, will not resolve for seven days. You're likely to kill this patient. Hypoglycemia increases the risk of motor vehicle accidents. It's not just a single event. If you have a single event of hypoglycemia during the day, you're likely to have another one later on in the day because you've used up all your counter-regulatory hormones. Even though patients B and C have A1Cs of 7%, you get your performance bonus, we see by the sensor data that this is not a good place to be. Here's two patients with an A1C of 7.8%. You got patient A, you got patient B, both with A1Cs identical. The problem is their A1Cs are too high, 7.8%. You're thinking about putting them on a basal insulin at bedtime. Let's do that. The patient B with an A1C of 7.8%, he's got glucose levels that are hypoglycemic in the middle of the night based on our sensor reading. You can see that from one in the morning until six o'clock in the morning, he's low. He's also low in the afternoon. If you put them on 10 units of glargine, he's going to die. This is not a safe thing to do. The other patient in red, the patient A, if you put them on a glargine insulin, you might be fine. You're not going to induce hypoglycemia. Not all patients are the same and not all A1Cs are the same either. All right. You guys are smart. Take a look at this glucose chart here. This is finger sticking. By the way, do you know that the American Diabetes Association used to recommend that if you have type 1 diabetes, that you should be doing finger sticks 10 times a day? Does anybody do a finger sticks 10 times a day? If they really do, do they actually look forward to doing it? The answer is no. Look at these numbers. They're all about the same, 130, 140, 150. The question is this guy's got an A1C of 7.6%. You need to change his regimen because obviously what you're doing is not effective treatment. He's not being treated to target. What are you going to do? He's on metformin. He's on insulin deglutectin, merongatide. What do you want to do just based on these readings? I don't know. I have no idea. You can try some, come back in a few months and see if the A1C is going down, but there may be a better way and that is by using continuous glucose sensors. I already told you that we have a time and target range. 70% of our glucose readings should be in the target range of 70 to 180, but you know what? That's not always telling you the entire story. Here's a patient that's actually doing four finger sticks a day and all of those numbers are in the target range. What we're going to do now is we're going to put him on a sensor. What we find is this patient is spending at least 50% of the day in the hypoglycemic range. Is this his fault? Did he do something wrong? The answer is no. It's our fault. We put him on drugs that cause hypoglycemia and hypoglycemia begets hypoglycemia. The only way you're going to figure this out is to put them on a sensor because if you just look at the blood sugars themselves, they look really good. You're going to be saying, good job, Jack. I don't need to see you back for another three or four months, but there is a lot more that we need to do to protect and keep our patients safe. What's the value of using CGM patients with type 2 diabetes? First of all, I just showed you one example. You can determine if somebody is becoming hypoglycemic. It could be hypoglycemia based on what drugs they're on. It could be exercise, a number of different problems. I want to make sure that they're not getting hypoglycemic. Rule number one with sensors is always fix the lows. Rule number two is fix the postprandial peaks. The postprandial peaks go up. If we can see sensor data about this, the patient understands this, but also more importantly, you understand it so you can better direct his care towards appropriate therapy. When we start somebody on appropriate therapy, we can also put them on a sensor. I just did that an hour ago. I just put a patient with an A1C of 9% on a sensor for the first time. It only takes me about maybe two weeks to identify what we need to fix and no more than eight weeks to get these patients under control. In the old days, it used to take a year because you used to keep getting A1Cs every three months. By the fourth one, maybe you'll be in good shape here. We can individualize therapy. We can show patients what their numbers mean. Patients have actionable results that they can identify and be involved with. I tell you what, patients love the sensors. Nobody says, I'm not wearing this. Have you ever had a patient that said, do I really need to stick my fingers? They're very excited when you put them on the sensors and you tell them no more finger sticks. It is not necessary to do that. Who benefits from using continuous glucose sensors? This is an interesting slide. Don't even look at it. This is from ACE. When we did the paper for ACE on looking at technology, all of the authors agreed on one thing. Everybody benefits from CGM. Kids, adolescents, patients that are pregnant, gestational diabetes, type 1, type 2, everybody benefits from using this type of technology. Who doesn't benefit? I don't know. I haven't found a patient yet that may not benefit from these issues. What about the types of CGM that we use? More of this is continuous glucose monitoring. There's two types of this. One is professional CGM. I don't use a whole lot of professional CGM, but what you do is you put this on your office. It's a billable procedure. You have the patient come back in a few days. You download the data. You sit there with the patient. You go over what the data means. You direct therapy. You answer questions and so forth. We know that CGM is useful. It does lower A1C by 0.8% with even intermittent use. Patients, they like it. They don't complain. They get to identify where they need to really step up their own diabetes care. This can be used in patient populations where they may not be able to afford the device, although in California, pretty much everybody covers it right now. Even Medi-Cal covers this. I don't use a lot of professional CGM, but it's something that intermittent use of CGM may be beneficial for certain groups of patients. The personal CGM is what the patient uses on their own. They put it on on a regular basis, either every six days, every seven days, or every 10 days. It gives some actionable information about what happens when they eat and they use medications. The most important thing about personal CGM, it alarms when the glucose levels go below 70. It alarms when the glucose levels go above 240. We know that this type of CGM can reduce hypoglycemia risk. How long does it take? Oh, two days. You get 11% reduction in hypoglycemia, two days. The other thing it does is it reduces hospitalizations. How much does it cost for one hospitalization related to hypoglycemia? It costs at least $5,000 just to show up in the emergency room. It reduces absenteeism. Why? Well, because people that get low blood sugar in the night, they're up for a couple hours trying to fix it. And in the morning they can't get out of bed. So they have less absenteeism. Patients feel better using the CGM. You can actually exercise and get alarmed when your glucose levels are going low or even going high. So patients really are involved with their own diabetes management. And what makes this really fun is that you can download the data. You could do it remotely. You could do it in person. But patients like sitting right next to the clinician and saying, you know what? I've learned so much from this information. Thank you. Thank you for showing this to me. This becomes an educational process. And we as clinicians are educators first and foremost. This is Chuck. I'm not going to play the video, but this is one of the most amazing guys I've ever seen. He's 62 years old, has type one diabetes. He's had it for 20 years. Pay attention to his face. Look at how round his face is over here. He was prescribed by an HMO to take. NPH insulin and regulants and two shots a day. And he should be taking 280 units a day using syringes and vials, which by the way, nobody showed him how to use. They just assumed that he would know this. So if you do the calculation on this patient based on body weight, he should only be on about 74 units of insulin a day. And he's on maybe three to four times that amount. He had an MI two years ago with standing. Remember when I told you about hypoglycemia and cardiovascular disease? He doesn't do blood glucose monitoring and I don't blame him. He said, why should I do it? Nobody looks at it anyway. All I'm doing is poking my fingers. Nobody tells me what this stuff means. In the past month, he was admitted to four different hospitals on 10 occasions. His symptoms included confusion, difficulty, walking, sweating, chest pain and weakness. Each hospitalization resulted in three days of in-hospital care. Fortunately, all 10 of his MRIs were normal. None of the doctors ever told him what was going on, which makes Chuck a very unhappy guy. Remember his face, his round face. I'm going to get back to that just a few minutes here. It turns out he was hypoglycemic. This regimen they put him on caused hypoglycemia. Was it Chuck's fault? No, it was the prescriber's fault for doing this. This is Chuck 67 days after he put a CGM on. Look at his face. He's lost a lot of weight. That's because it didn't take long to figure out how to fix him. On the left, you see the CGM. And I'm going to go over the CGM in just a second here. But in the center of that chart, you see two lines going across. That is our target range of 70 to 180. He had no glucose levels in that range. He had an average sugar of 320. And he had something called a GMI of 11.7. So the GMI gives us an idea of what your average glucose level is during the time the sensor is worn. And it correlates very well with the A1C. So his A1C basically is 11.7% when he comes in to see me, despite being on 280 units of insulin a day. Is this his fault? No. July 23rd, 67 days later, look at the chart now. 79% of his numbers are in target. There's no hypoglycemia in his GMI, whereas A1C has dropped from 11.7 to 7%. Look at him smiling here. And just to show you again, he don't look happy there. Here he looks real happy. These are not staged photos. These are real life patients. So what about CGM? We have basically three different types of CGM. We have the Dexcom 6, which is inserted by the patient. It's onboarded in your office. You can do this or one of the members of the Dexcom team can come and show you how to do this. That gray thing there is the battery. It's called a transmitter and the transmitter sends data to either an insulin pump or to a reader or your cell phone. Then you have underneath, you have the Abbott Freestyle Libre sensor. This is worn on your arm. The Dexcom is worn on the stomach. There's a little sensor that goes in your arm. It's four millimeters in size. And this transmits through that little disc information to a reader, which can be your cell phone. And this does not have connectivity to a pump. Then you've got the Dexcom, I'm sorry, the Medtronic Guardian pump and sensor where the pump and the sensor, they're actually talking. So these sensors are a little bit different, but they all are extremely accurate. This is based on something called a MARD, M-A-R-D or a mean absolute relative difference. Now I'm not going to go through all the MARDs here. I'm just going to tell you that the lower the MARD, the better the device is in regards to accuracy. A finger stick MARD is around 18. The sensor MARDs are around nine. So the lower you go, the more sensitive it is. And you can see that these devices are not only accurate, but they provide the FDA with the ability to tell companies, all right, hook them up to the pumps because these things are really, really accurate to use. So that's something you need to consider as well. Now, when you put these sensors on, you're going to have something called an AGP report, which is an ambulatory glucose profile. I don't know if you can see this on the screen, but you can see that bar chart going up with the different colors. Look at the area in green. This is the first thing you look at when you look at these readings. So you want at least 70% of the glucose values in that green zone. And as far as lows, you want 4% or less. In this case, the patient has only 47% of his numbers on the target. Now that might be an okay place to start, but then in two weeks, you bring them back, you re-download this data. And guess what? He might be at 65%. That's good. What happens though, if you go the opposite direction? Like Chuck, he used to be at 70% in target and now he's in 20%. What's going on? He may or may not be taking his medicine. So you can use this to really evaluate and direct their therapy in a safe and therapeutic manner. On the left side, left upper side, you see the GMI. This is again, the A1C. This is the GMI. This is the A1C. These devices check your blood sugar at least 2,000 times. I'm sorry, 1,400 times a day. Or in a two-week period of time, you can get 21,000. 21,000 readings. Just take your. Take your figure 21,000 times. No, you're not going to get the data that you will with this technology. We also have something called glycemic variability, glucose variability. See that line in the middle of the chart there on the AGP. We want that flat line, that blue, that blue line that is going up and down like a hills and valley. We want to flatten that line. We love flat lines. It turns out that if more than 4% of the numbers are low, we need to fix that. We need to fix those lows in some way. The daily glucose profiles are kind of fun to look at as well. So what you see there is yellow. That's the bottom part of the graph. So you would ask this patient. What happened on this day, Saturday and Sunday? And they're going to say, well, I ate some cake. No big deal. I can't do it. Doesn't matter. But the important thing is the patient knows if they take. Watch the monitor, see what's going on. And maybe give a little bit more insulin or make some treatment. Adjustments for that. This again, the AGP profile. This is enlarged. I used to kind of see it. The dotted line at the end are where we're 10%. Up to 10% of the values lie. You can see in this case, that yellow arrow there. That this patient is getting frequently hypoglycemic in the middle of the night. This needs to be fixed. So when you look at these AGP profiles. You need to come up with a plan to fix the lows. Fix the highs and flatten the curve. We like flat curves. As diabetologists. Here's a flat curve. This is what it's supposed to look like. This is a normal person. See how flat that is. Diabetologists like flat. If you're a cardiologist and you see a flat line, what are you going to do? You're going to take those paddles and you're going to shock somebody. Come back to life. What if you're a neurologist? If you see a flat line like this. Neurologist said, not nothing I can do. Not much they do anyway. But in this case, they have to just move along and find somebody else to do an EEG on. So flat is good in diabetology. This is something called a Clary report. This is Dexcom. And what this does is it analyzes data. Over up to a 90 day period of time. 90 Days of data. On this report. This could be emailed to the provider. But it also can be evaluated by the patient himself. And you can see 80% of the numbers are in target. Every once in a while, they kind of go high at dinner. So let's fix dinner. And you could also see the GMI is 6.7%. And you can see that the patients are doing extremely well with their diabetes treatment. And remember with the Dexcom there, there could be. There's a, there could be connectivity with insulin pumps as well. So this is very important and helpful data. That the patients can look at. So who should be. What do we do when we see an AGP? Well, there's basically four things. And I already gone over this. The first thing you want to do is you want to minimize hypoglycemia. So that's the red zone. That should be less than 4%. The next thing you want to do is you want to flatten out that glycemic variability curve. That's the curve that goes up and down. Glycemic variability up and down. 70 to two 40 to 40 down to 40. All that stuff does two things. It increased the risk of lows. And then the last thing you want to do is you want to flatten out that glycemic variability curve. That's the curve that goes up and down. So flattening out the curve is the most important thing that we can do. When we look at these different devices. So here's another patient. This is one of my patients as well. Remember I'm a family doctor. I do it all. So you can do it all. If I can do this, you can do this too. This is Lee. He's 48 years old. He's got some problems. He's got some problems with his blood sugar. He's got a complete occlusion. Of the inferior vena cava. He is opioid dependent. But we got him off the opioids. He used to use heroin. Not anymore. He's got portal hypertension. He's got a fatty liver. Oh yeah. Over the weekend. He wasn't feeling well. So he went to the emergency room. And turns out he has new onset diabetes. So he's got diabetes. And at least over the last 90 days, his blood sugars have not been under control. So he comes in on a Monday morning. Not feeling good. He was placed on metformin in the emergency room. Let's download the sensor nine days later. So on two 19, we onboarded to the office. Which by the way, takes about two minutes. I don't even give the patient a chance. I do not. I come at him with the sensor. Put it on the arm and we're good to go. And we're going to put it on the arm. And we're going to put it on the arm. And we're going to put it on the arm for a total of two minutes. So nobody gets a choice. In the office. They just get the sensor. You can see that only 13% of his numbers are in target. He's got no lows. You can see the AGP chart. But there's nothing really in the target zone. If you look at the daily glucose profiles there. You can see that the blood sugars are consistently high throughout the day. And you can see that the blood glucose levels are consistently high throughout the day. I'm going to put this. Here. So this is before and after eight weeks. Again, I'm directing the therapy. I'm not sending this guy to an endocrinologist. It could take months to get them into an endocrinologist. Primary care doctors can do this. 13% of his numbers were in target to begin with. Eight weeks later, we've got a hundred percent of the numbers in target. And we've got a hundred percent of his blood glucose levels under control. And even the daily glucose profile. This is easy to do. That's if this is not a big deal. He was placed on. On. And insulin. And we got us glucose levels under perfect control. Simple. So what do we do when we find somebody? In primary care. That has hypoglycemia again. More than 4%. Why do you get hypoglycemia? Well, it could be that they're on too much insulin. And they're giving an injection of insulin. And exercising after that. What about this? The sensors will tell you what the glucose levels are. At the time you either scan or look at the sensor device. But we'll also give you a directional area. Arrow. In other words, it'll go up. Down. And it'll tell you what the glucose levels are. And it'll tell you if you're on insulin. Or the glucose levels are stable. What about this? You've got a 30 year old. Type one patient with diabetes. That is doing finger sticks, but she's a soccer mom. She's got six kids in the car. They're going to soccer practice. She just ate two hours ago. And she gave herself an injection of fast acting insulin. I don't know which one doesn't matter. And it'll tell you what the glucose levels are. And it'll tell you if you're on insulin. What does that mean? Is she safe? What if she scans the device? What if she scans the sensor? Or the sensor alarms. And the glucose sensor says. There's a downward arrow. So you're one 10 with a downward arrow. This means that in 20 minutes, that patient is going to be hyperglycemic. So what do you do about impending hyperglycemia? So you have time to act. Rather than taking those six kids to a soccer game and not making it. Would you want your kid to be in that car? No. So if the. If there's hyperglycemia, we need to address it. What happens if the patients. Glucose levels are really bad. Only 15, 20% of the numbers are in target. Well, there could be a problem with medicine adherence. Remember these medicines are not cheap. So we want to treat patients. Successfully. Because we as clinicians have to. Adjust the medicines that they're on. We want to treat patients successfully. To target. Not unsuccessful. That never ends well. So what are some of the tricks to successful onboarding of CGM? Well, first of all, make it really easy, make it exciting for the patient. They're going to be able to see their time and range. They're going to see. They're going to see the effects. Of medicines that you place them on. They're going to be able to scan whenever they want. And they're going to be able to learn from what they're doing on a daily basis. The patient must bring in this information with them to the office, or it could even be uploaded into a cloud. And they're going to be able to see it. And they're going to be able to learn from it. And they're going to be able to learn from it. 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And they're going to be able to learn from it. And they're goin the patient's right hand, there's something called a PDM, I call it a remote control, because using the wireless control, the patient could adjust insulin levels. You could also give a bolus through the pump. And people like these, if they're like into water sports and swimming and so forth, the problem is if you lose the remote control, you're out of luck because you can't give a bolus. The Vigo insulin pump on the right, I started one the other day on a 78 year old man. And I like these pumps, they're so simple. I call them pumps for dummies because anybody can do it. All you gotta do is put the insulin, put it on your stomach, push a button, and you're ready to go. I called the patient yesterday to see how he was doing. And he said, Dr. Unger, you're right. This is a pump for dummies. It works great and I don't have to do nothing. And my wife's not yelling at me anymore for being incompetent. So we also have connected devices as well. You've got the Descom sensor that's connecting to a tandem insulin pump. And I'm coming up with more of that in just a second. You've got the Medtronic 670G and you've also got the sensor here. So the pump and the sensor, they're talking. This is what Roy determined was really saving his life. If you get talking between the pump and sensor, your blood sugar is gonna be so good that every morning the patient wakes up, the glucose level is gonna be around 110. It never fails. How many times you try to screw it up, 110, 110, 110. Why use a pump with an integrated sensor? Well, the reason is easy. Think of it this way. If you just give Glargine at nine o'clock at night, that Glargine is in your body and it's gonna work. It's gonna bring glucose levels down, but it's not that easy. You can see on the lower chart over here, you've got a green line. That's the glucose levels. On the blue bars, that's the insulin adjustments that's being made. So the sensor knows what the glucose level is. It's sending a note to the pump to change the flow of basal insulin. You see when the green lines go up, there's more insulin that is produced by the pump, delivered by the pump. So you'd notice here each one of those bars is a five minute interval. Every five minutes, the pump and the sensor are talking. They're like husbands and wives. You can't do one without the other. And in the morning when you wake up, your blood sugars are outstanding, near perfect. So that's why we use these different devices. So who gets these devices? Well, let's take a look first at insulin pump with CGM. Anybody with type one diabetes that has a history of hypoglycemia, poorly controlled diabetes, they should get the pump and sensor. It is really easy to use. It's fun and the insurance companies are paying for this for type ones. Connected pens can be used in patients that are using three or more injections of insulin and they like the technology involved. They may be hypoglycemic as well. So they may be stackers. So you can use either one of these, but it doesn't matter which one to me. As long as you use something, you're more likely to get the patient's glucose levels are under better control. We recommend automated insulin devices. That's the pump and the sensor married to anybody with diabetes that has a history of hypoglycemia. Now, it's also important to note that we have what we call team pumpers. I have some patients that are incapable of using insulin pumps for whatever reason, Parkinson's disease, whatever. But they have their spouses doing all the work for them. I've got like three or four and their blood sugars are perfect. The spouse monitors everything, puts the pump in, and it really is kind of a neat thing to watch. We had this discussion when we were doing the paper for ACE on technology. Should everybody and every clinician be using these devices? And the answer is, it'd be really good if they did, but if you're really nervous about it, then get some help to begin with. All you gotta do is one or two of these and you're good to go. It's kind of like, if you don't know how to take out an appendix, it may not be a really good time to learn today, especially if I'm your patient. So if you need help with this, there's a lot of people that can help. We call these sensor mentors and ACE can help you. They can get in contact with doctors that might be able to mentor you during this time. So that's really kind of a neat thing to know that you can do this. What about patients in the hospital? Well, it turns out I have type 1 diabetes myself. I'm wearing two sensors right now. I've got an insulin pump as well. A few years ago, I had appendicitis. I went to the hospital and some nut suggested I take off my pump and let them figure out how to deal with my diabetes. I said, no, it's not gonna happen. He said, well, you're in luck because what I'm gonna do is I'm gonna have the pharmacist help you with your glucose control. I said, you know what? You're fired. Nobody's touching my pump and sensor. As long as the patient is able to function, as long as he's got the cognitive ability, let them keep their devices, their technology in the hospital. Most of these patients can do it better than the doctors can. This is Chuck. And Chuck, again, is feeling much better right now. We're about a year into this. He has had no hospitalizations for hypoglycemia. He feels great. He's not in a pump yet because the HMO won't allow it, but his glucose levels are in near perfect control. I'm gonna tell you about the CPT code for professional reimbursement because you deserve this. For just putting somebody on a sensor in your office, which takes a minute or two, you could bill a 95250 in California. I think that's $60. And then every time they come in, at least once a month, you could download this data either virtually or in person, and you get another $40. So this can be billed on a monthly basis as well. This is how you can get a little bit more income for doing these types of devices. In summary, this technology really works. It's safe, it's effective. It gives you a lot of options. Amy introduced me, and Amy doesn't like me to talk about this, but I'm gonna talk about it anyway. Remember that patient that I talked to you about at the beginning, the Vietnam War vet? His name was Henry, he had an A1C of 9.2. Never able to get his glucose levels ever below 9.2. So I saw him again two months ago. He now has an A1C of 7.2, his blood sugars are perfect. And what makes Amy, this is the part Amy doesn't like me to talk about, it turns out that Henry at age 72 got married to his high school sweetheart. Because the high school sweetheart said, Henry, if you can get your glucose levels under control, guess what, they got married. And it was a beautiful ceremony, which I attended. And I was honored to be there for him to show support. So please consider this technology as part of primary care. It is not in the realm of endocrinology because we see all these patients. We should be doing this. Try to get an appointment with an endocrinologist. And if there's a good chance that endocrinologists are not gonna know anything more about diabetes and technology than you are, you can do this. I know you can. If you need any help, any resources, here's a website you can go to. And I appreciate your time. I thank you for all of the things that you are doing for all of us with diabetes. And I'm honored to present this information on behalf of my colleagues at the American Association of Clinical Endocrinologists. So I will stop right now. And Amy, if there's any questions, I'll be happy to answer them. Please make them simple. I don't wanna be confrontational. Thank you. Thank you so much, Dr. Unger. That was wonderful. I have a few questions here for you. And please, audience, if you have any questions, feel free to enter them in the chat box. One question that we do have is how do primary care physicians who are not accustomed to sensor evaluation incorporate this into their workflow? Yeah, it's easy. First of all, call the company. Call the company. You've got Descom, you've got Medtronic, you've got Freestyle, Abbott. And just say, I'm interested in doing this, and they will help you. They're the easiest. The easiest one is the Freestyle Libre. It really is. It takes, I showed you several of those slides. The Descom takes a little bit more time for you to not really evaluate the downloads, but to onboard in the office. And the Medtronic is a little bit more complicated as well. So if you really wanna learn how to evaluate this stuff, have the people from Abbott come by your office. They'll be happy to show you how to do it. They'll sit with you, and they may even give you my name to call me, and I'll be happy to help you as well. I don't mind. I like doing this stuff. And after one or two of these, Amy, I promise you, you'll be good to go, and the patients will like it as well. Now, I'm gonna give you one more example of what I just said. I'm not making this stuff up, but I had a patient, he's actually a rocket scientist, and I'm in Southern California, and about 20 miles away, we have Pasadena, where they have the JPL. So Bob's the guy's name. We put a sensor on him. 10 days later, he comes back in the office, and he knocks on the door. He comes in. He says, I gotta see Dr. Unger right now, right now. And so I went over there, because it looked like he was really excited about something. And he brings in reams of data. I mean, pie charts, P values, hazard ratios, all sorts of colored charts. This thing, remember, he's a rocket scientist. I said, Bob, what are you showing me? It's only been 10 days. He looked at me and he said, did you know that when you exercise, your blood sugar goes down? No. But that's what Bob said. He didn't know that, and he's a smart dude. He didn't know that. We've got other patients that I caught, because I could see the daily values of all these sensor readings. And I noticed on February 13th, he had a big, big spike in his glucose values. Turns out that was Super Bowl Sunday. So this guy ate from 10 in the morning to three in the afternoon. How hard is this to figure out? Anybody can do this, Amy. And I really think that you, everybody in the audience could and should. Thank you. Another question. Do you recommend the use of CGM in patients with prediabetes? That's a really good question. And the answer is these devices are not approved for use in prediabetes. However, the FDA doesn't tell you how to practice medicine. And we do it all the time. We do it. If the FDA knew what I did here for off-label use of stuff, they'd be coming down, have a G-Man on ropes coming through my chimney here. No, no. You can do it. We do it with diabetes, gestatial diabetes. We do it with pregnancy and diabetes, even though it's not approved. But absolutely, yes, because that gives us a view. An A1C may say 5.7, 5.8, but if you look at the values of the sensors, they could show postprandial spikes. This is our chance to fix the problem early on. If we see postprandial spikes, we can put them on medication that may be able to preserve beta cell function. Remember, there was a SAM study done by Ralph DeFranco about 10 years ago. And Ralph said that if you're in the prediabetic state, you already have lost 80% of your beta cell function. You are maximally insulin resistant. What are you waiting for? So yes, we do use it for prediabetes and very successfully. Thank you. And one final question, if we don't get another one, how difficult is it to onboard CGM for patients in the office? And is this something that can be done remotely? You know what I mean? It's hard to do it remotely. It can't be done. So what we do is I've designated a concierge pharmacy near us where if need be, the patient can go over there and get the sensors placed on their behalf. However, I think it's real important to do it in the office. It doesn't take any time at all. The companies will come and they'll give you samples. Dexcom will do it. Medtronic will do it. And the Abbott people will do it as well. Just to practice, in fact, practice on yourself. Put your own sensor on. Wait till you see what happens after you eat cake and ice cream and pasta on a day or whatever it is. But it's simple to use. It's simple to onboard. And I've never had a patient say no. In fact, again, I don't even tell them maybe what I'm going to do. I just do it. Because what are they going to do? They're coming to, you're the family doctor. You're the primary care physician. You're the PA. You're the nurse practitioner. They want your advice. What's the best thing to do? And your answer is, I'm going to put the sensor on. And you do it. Any other questions or comments? Yes, we just got one more in the chat. What can you tell about using in pregnancy? What can you tell? Well, you want to have the glucose levels near perfect in pregnancy. And this will help you establish what the treatments that you're giving during pregnancy are doing for you. There's something in California, I don't know if it's everywhere else, called Sweet Success, where they really manage the diet and the exercise issues and help with the glycemic control related to medications. But we want to see a flat line. We don't want to see glucose levels going above 140, 180, because that means there's a high risk of complications related to pregnancy. So we use it in pregnancy and we use it in gestational diabetes and it's really a valuable tool as well. Thank you, Dr. Unger. We got another question. Do you have thoughts on using CGM for those on dialysis? Yeah, because that's a great thought here. I don't know who submitted that question, Amy, but ACE needs to give them the prize today. I think you're giving away free Mercedes for people that are still online. Amy will take care of you later on. The reason is because if you're on dialysis and A1C doesn't count, your blood cells are being rapidly destroyed. So you can have an A1C of 8.9, and that's not really 8.9, it could be 7.2. So the lifespan of the red cell is going down. So the A1C is not effective. The only thing that's effective is using CGM, and it doesn't matter which one you use, but any CGM is better than no CGM. And blood, if you just do a finger stick, again, if you get a 137, what's gonna happen after dinner? I don't know. So we put all these patients that are on dialysis or heading in that direction on the census. Great question. And please make sure that you get a red Mercedes convertible from ACE. I'll never be speaking for ACE again, right? Go ahead. We may have to expense that to you, Dr. Unger, but the second part of the question from the submitter is, are there suggestions on how providers can help patients keep sensors on their arms or abdomen without falling out before the sensor is taken out? Yeah, so this happens. And the life of the sensor on Medtronic is six days. On Dexcom, it's 10 days. On the Freestyle Libre's, they're 14 days. Now, there are some people that just have like Teflon skin. No matter what you do, it won't stay on. There is now another sensor called Senseonics, not part of this talk. It was just approved by the FDA. It's a six-month wear. The thing is you gotta put it under the skin, and I haven't been trained to do it. I've seen the device. It seems to work really well. So if nothing sticks, Senseonics might be the way to go. Senseonics, however, you have to calibrate periodically as well. So the other suggestion is that these companies, Dexcom, Freestyle, even Medtronic, they have patches that you can put over the sensors themselves to keep them in place. When you put the Dexcom sensor on, it should go on the stomach. When you put the Freestyle Libra on, it's gotta go on the back of the arm here. Because if you walk through a door and the device is on the arm over here, then you're likely to knock it off. If by chance a sensor falls off prematurely, all you gotta do is call customer service and they will replace the sensor at no charge. Okay, that's wonderful. I see a question here for any resources on case-based questions regarding CGM interpretation and insulin management. We have some resources on the webpage that's listed on this slide. Dr. Unger, is there anything else that you can direct our attendees to? No, but if you need help with this, feel free to email me. I'll give you my email, write it down, and I'll send you anything you need. And the email is jun, like Nancy, j-u-n-g-e-r-m-d at aol.com. Again, that's jungermd at aol.com. And that should, I'll be happy to send you, I'll talk to you on the phone, whatever I need to do to help our patients with diabetes. Just, it's an honor and a privilege to do this. Okay, thank you so much. That's all we have time for today, Dr. Unger. Thank you again for doing the webinar today, and everybody, thank you for joining us. Feel free to visit this webpage that's listed on this slide, again, for additional resources as well as slides, and you will be receiving an email to a survey link that you can complete to claim your CME. Thank you all for joining us today. Have a great rest of the day.

webinar

Clinical Conversations

Diabetes Technology

ACE Guidelines Update

Dr. Jeffrey Unger

continuous glucose monitoring

CGM

glucose control

hypoglycemia risk