Latest / Pharmacy Podcast Network / What’s New in Diabetes Care for Older Adults? A Standards of Care 2026 Update | Geriatric Pharmacy Focus

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What’s New in Diabetes Care for Older Adults? A Standards of Care 2026 Update | Geriatric Pharmacy Focus · Pharmacy Podcast Network

0:07
Speaker 1: Thanks for listening to the Pharmacy Podcast Network.
0:43
Speaker 2: Hello everyone, and welcome to the Geriatric Pharmacy Focus. I
0:47
Speaker 2: am blessed to have back with me today, Doctor Diana
0:50
Speaker 2: Isaac's host of the Diabetes Dialogue podcast and known as
0:54
Speaker 2: the Diabetes Pharmacist. And in December, the American Diabetes Association
1:00
Speaker 2: came out with the Standards of Care and Diabetes twenty
1:02
Speaker 2: twenty six, so we are going to be discussing that today.
1:05
Speaker 2: Just kind of some updates management of diabetes and our
1:08
Speaker 2: older adults and anything where I guess the conversation takes us.
1:12
Speaker 2: So welcome back, Doctor Isaac's great to have you with us.
1:16
Speaker 1: Awesome, Yeah, thank you so much for having me again.
1:20
Speaker 2: Yeah. So when I was reading through the update was
1:25
Speaker 2: I was most excited about kind of the whole person
1:28
Speaker 2: centered view of this update, where we weren't just looking
1:31
Speaker 2: at which medications have benefit for cardiovascular disease and things
1:35
Speaker 2: like that, which are of course so important, but also
1:38
Speaker 2: addressing diabetes distress and anxiety associated with diabetes, the language
1:43
Speaker 2: to use for people with diabetes, how to manage religious
1:46
Speaker 2: fasting for those with diabetes, the four MS framework. So
1:50
Speaker 2: that was my big takeaway with this update is we're
1:53
Speaker 2: looking at the whole person, not just medications and managing
1:57
Speaker 2: different disease states associated diabetes, but whole person care. I'm
2:01
Speaker 2: curious to know what your big takeaway was when looking
2:04
Speaker 2: at the update.
2:06
Speaker 3: Yeah, well, I agree with everything that you've said, and
2:09
Speaker 3: I think they've really made an effort to be more
2:12
Speaker 3: person centered and you can see that with the language.
2:16
Speaker 3: It's taken a few years, I think to really incorporate this,
2:20
Speaker 3: because I was on the committee from I'm trying to
2:23
Speaker 3: think it was like twenty twenty to twenty twenty three,
2:26
Speaker 3: and I know during that time, like we were trying
2:28
Speaker 3: to change patient to person and like, but it takes
2:32
Speaker 3: a while to really It's a long document. It's over
2:34
Speaker 3: three hundred pages, and it takes a while. And I
2:37
Speaker 3: feel like with this round, they really did a very
2:41
Speaker 3: good job with that, with all the recommendations and the
2:44
Speaker 3: narrative text as well.
2:46
Speaker 1: One of the things I.
2:48
Speaker 3: Was especially excited about this year was the technology updates,
2:52
Speaker 3: and especially with both CGM and insulin pumps and automated
2:58
Speaker 3: insulin delivery. I think the you know, the encouragement of
3:02
Speaker 3: using CGM really for all people with diabetes, but certainly
3:06
Speaker 3: those on insulin. And we see now CGM being mentioned
3:11
Speaker 3: really in almost all of the sections. Before it was
3:15
Speaker 3: just in the technology, but now when whether it's the
3:19
Speaker 3: pharmacologic management the older adults like, it's really it's mentioned everywhere.
3:25
Speaker 3: And then also with pumps, really a strong recommendation that
3:30
Speaker 3: we should be offering automated insulin delivery systems for anyone
3:35
Speaker 3: that needs meal time insulin.
3:37
Speaker 1: And yes this also applies to.
3:39
Speaker 3: Older adults too that can safely manage the system, either
3:42
Speaker 3: by themselves or with a caregiver. But I think you know,
3:46
Speaker 3: as obvious, we have the data to support that technology
3:50
Speaker 3: improves outcomes compared to asking someone to inject four times
3:55
Speaker 3: a day or more, that's very difficult.
3:59
Speaker 1: So I was very excited about that. And then also.
4:01
Speaker 3: There's some updates I think with the pharmacologic therapy, so.
4:06
Speaker 1: Lots lots of good stuff this year.
4:09
Speaker 2: It was it was so good. I haven't had a
4:10
Speaker 2: chance to read through the document in its entirety, but
4:14
Speaker 2: of course section thirteen on older adults I did, and
4:17
Speaker 2: then reading just different cliff notes in places where people
4:20
Speaker 2: listed key points of the updates, and I agree with
4:24
Speaker 2: using technology. I was just speaking with an older adult.
4:27
Speaker 2: The other day, I had called up the retail pharmacy
4:30
Speaker 2: and we were discussing as CGM and how much he
4:32
Speaker 2: liked it, and then we were discussing insulin and talking
4:36
Speaker 2: about those meal time doses and he's like, I just
4:39
Speaker 2: can't get myself to do it. I don't know why.
4:42
Speaker 2: There's my pen sitting there and I should do it.
4:44
Speaker 2: I just don't want to and I can't motivate myself
4:46
Speaker 2: to do it. And I said, well, have you ever
4:48
Speaker 2: thought about an insulin pump? You know, then you could
4:50
Speaker 2: fill it up and you could just let the pump
4:53
Speaker 2: do its job, or you could simply use your smartphone
4:56
Speaker 2: to give yourself a meal time dose. And he said
5:00
Speaker 2: he hadn't ever thought of it. And we got him
5:02
Speaker 2: started on some omnipods and he, I mean, his A
5:05
Speaker 2: one C has dropped and he's so happy. He just
5:09
Speaker 2: didn't know what it was, if it was giving himself
5:11
Speaker 2: all those injections or what it was. But suddenly with
5:13
Speaker 2: this omnipod, it's like, no big deal, so let's use it.
5:17
Speaker 3: Yeah, it is really hard to do multiple injections a day,
5:21
Speaker 3: Like there's multiple barriers. Some of it is just the
5:23
Speaker 3: psychological of like oh my gosh, I'm another needle going
5:27
Speaker 3: into my skin, but also like gathering of all the supplies.
5:30
Speaker 3: So yeah, something like omnipod, which now you know it's
5:33
Speaker 3: in the pharmacies that has helped a lot of people.
5:36
Speaker 3: There's also they make mention of other wearable types, so like,
5:39
Speaker 3: for example, there's secure Simplicity, which is basically they consider
5:43
Speaker 3: that like.
5:43
Speaker 1: A wearable insulin.
5:45
Speaker 3: It doesn't have like the sophisticated smart technology where it's
5:49
Speaker 3: got a bullets calculator and it's connected to your CGM.
5:52
Speaker 1: But what it does do is you wear it and
5:55
Speaker 1: you click.
5:56
Speaker 3: The sides of it and you can easily give a
5:58
Speaker 3: bullets without having to get your pen and need all out,
6:00
Speaker 3: and you can do it.
6:01
Speaker 1: Over your clothes.
6:02
Speaker 3: So there are a lot of tools out there and
6:06
Speaker 3: that are mentioned in our standards of care.
6:08
Speaker 2: Yeah. Absolutely, I'm thankful for that and thankful more people
6:12
Speaker 2: are using them. So there's also a focus on monitoring
6:15
Speaker 2: blood sugars and patients taking medications that may cause hyperglycemia.
6:19
Speaker 2: They mentioned corticosteroids, different chemotherapies, but can you elaborate on
6:25
Speaker 2: as far as the guidelines go, how we're supposed to
6:27
Speaker 2: monitor patients that are on medications that may cause hyperglycemia,
6:31
Speaker 2: and then the management of those patients.
6:34
Speaker 3: Yeah, so they do now, especially in Section two, they've
6:38
Speaker 3: really kind of beefed up where they're talking about these
6:43
Speaker 3: different medications that could potentially impact glucose levels and how
6:48
Speaker 3: we should be monitoring that we should be whether it's
6:50
Speaker 3: checking fasting glucose, asking someone to monitor wearing a CGM,
6:56
Speaker 3: like doing a trial of CGM to see if they're
6:59
Speaker 3: starting to have glucose abnormalities. And there's certain medications like
7:04
Speaker 3: checkpoint inhibitors like gluco corticoids that we know, like a
7:08
Speaker 3: lot of cancer agents that we know impact glucose levels,
7:14
Speaker 3: and so we really should be monitoring.
7:17
Speaker 1: And then they also.
7:18
Speaker 3: Have guidance in terms of what that treatment could look
7:21
Speaker 3: like depending on the type of agent that's being used,
7:25
Speaker 3: whether it would be encouraging the use of insulin or
7:28
Speaker 3: encouraging other types of medications. But I think that was
7:33
Speaker 3: definitely added this year with more emphasis because you figure
7:38
Speaker 3: a lot of times whoever's adding those agents, they're not
7:41
Speaker 3: focused on diabetes necessarily, right, Like if someone's going to oncologists,
7:46
Speaker 3: they're they're trying to cure the cancer.
7:48
Speaker 2: They're not.
7:49
Speaker 3: Diabetes is not their first priority, but we hope the
7:54
Speaker 3: cancer will be cured or they'll be in remission, and
7:56
Speaker 3: so we do care about the diabetes. We do care
7:59
Speaker 3: about the hype glycetemia, which could lead to certainly acute
8:02
Speaker 3: complications like dehydration, electrolyte abnormalities, but also increases someone's cardiovascular
8:09
Speaker 3: risk as well.
8:11
Speaker 2: I've noticed it in older adults, mostly people with arthritis
8:15
Speaker 2: or some kind of autoimmune might be on a steroid
8:19
Speaker 2: long term. So I notice it that way, or are
8:21
Speaker 2: older adults on antipsychotic medications long term, I see their
8:25
Speaker 2: blood sugar is going up, and so oftentimes they're put
8:28
Speaker 2: on meta forman or now more recently they're put on
8:30
Speaker 2: GLP ones to help manage those kind of side effects
8:33
Speaker 2: associated with antipsychotic medications.
8:36
Speaker 1: Yeah, and I think it's important.
8:39
Speaker 3: So sometimes, like so, I do a lot with their
8:41
Speaker 3: post kidney transplant clinic, and they're only in the hospital
8:46
Speaker 3: usually for a couple days. So many times like steroid
8:49
Speaker 3: induced diabetes will be caught in the hospital, but not always.
8:52
Speaker 3: Sometimes people don't have elevations until a few weeks later.
8:57
Speaker 3: And they're typically only checking fast glucose, and so yes,
9:02
Speaker 3: fasting glucose will eventually be impacted if someone has enough hyperglycemia,
9:07
Speaker 3: but it's often going to be the last.
9:08
Speaker 1: Thing to be impacted.
9:10
Speaker 3: They're gonna if someone's taking for example, prenzone in the morning,
9:13
Speaker 3: we're more likely to.
9:14
Speaker 1: See very high glucose levels throughout the day.
9:16
Speaker 3: And so that's some of the reason why monitoring can
9:20
Speaker 3: be very helpful because someone maybe they wake up their
9:22
Speaker 3: fasting is in the low one hundred, so no one's
9:26
Speaker 3: really too worried about it, but they're going up to
9:29
Speaker 3: like three hundred four hundred during the day.
9:31
Speaker 1: That's that's not good.
9:32
Speaker 2: Yeah, and you know, if you watch it close enough,
9:35
Speaker 2: they'll probably be more thirsty, going to the bathroom more.
9:38
Speaker 2: But our older adults are tricky because you know what,
9:42
Speaker 2: they're not very thirsty sometimes.
9:44
Speaker 3: And yeah, and people attribute it to other they're like, oh, well,
9:48
Speaker 3: now that I think about it, I'm more thirsty, but
9:50
Speaker 3: I don't know, I just thought it was this other
9:52
Speaker 3: medication or like they don't always have the insight to say, oh,
9:57
Speaker 3: like that these are new symptoms, or maybe I have
10:00
Speaker 3: a high.
10:00
Speaker 2: Blood sugar right or even if there's cognitive impairment there
10:04
Speaker 2: that makes things even a little more tricky, definitely. So
10:09
Speaker 2: in section thirteen when it talks about older adults, of course,
10:13
Speaker 2: that's what I want to focus on today because this
10:14
Speaker 2: is the Geriatric Pharmacy Focus podcast. I was excited to
10:19
Speaker 2: see the four MS framework listed and it lists the
10:22
Speaker 2: four M so of course, medications, mobility, mentation and what
10:25
Speaker 2: matters most and talking about incorporating the forms into our
10:29
Speaker 2: practice and managing persons with diabetes, and so it talks
10:33
Speaker 2: about first of all medications which we know, you know,
10:36
Speaker 2: avoid hypoglycemia is a big priority for us, but also
10:40
Speaker 2: treatment burden when looking at multiple injections a day, looking
10:45
Speaker 2: at polypharmacy, which I was very happy was mentioned because
10:48
Speaker 2: so many older adults have polypharmacy. So that's kind of
10:52
Speaker 2: a few things that mentions with medications. With mobility, it
10:55
Speaker 2: mentions foot complications, are we monitoring to make sure they
10:58
Speaker 2: have sensation in their feetunctional abilities, fraility encyclopedia, which I
11:03
Speaker 2: was happy that was mentioned. With GLPS and our older adults,
11:06
Speaker 2: gait imbalance and dizziness, neuropathy and vision and hearing impairment.
11:11
Speaker 2: Then mentation, it mentions, the ability to self administer medications,
11:16
Speaker 2: the ability to use the diabetes technology that we have, anxiety,
11:20
Speaker 2: depression and diabetes distress, which seems to be more of
11:23
Speaker 2: a focus with this update, cognitive impairment and dementia, and
11:27
Speaker 2: then coping skills and self care. And then of course
11:30
Speaker 2: what matters most discussing goals with our patients and expectations,
11:34
Speaker 2: the disease, burden of diabetes and symptoms, meal and treatment preferences, risks,
11:40
Speaker 2: burdens and benefits of treatment, loneliness, social isolation, and overall
11:45
Speaker 2: quality of life, and then life expectancy. So when you
11:49
Speaker 2: think about those four ms, how do you incorporate those
11:53
Speaker 2: into your practice when you're dealing with older adults.
11:57
Speaker 3: Well, I want to say I love this four MS approach,
12:00
Speaker 3: and the diagram like included in the Standards of care.
12:04
Speaker 3: Is really nice that those visuals are really good because
12:07
Speaker 3: it's like, in practice, it's much quicker to look at
12:11
Speaker 3: these visuals and be like, oh yeah, the forms versus
12:14
Speaker 3: just reading a bunch of texts. So one of the
12:17
Speaker 3: things I really like is they have a table that
12:19
Speaker 3: they've added about quick screening tools that can be used,
12:23
Speaker 3: and they list several of them that are for all
12:26
Speaker 3: these kind of related conditions, And what I really like
12:29
Speaker 3: is that they say what the time is to complete them.
12:33
Speaker 3: And most of these they're designed to be screening, so
12:35
Speaker 3: if someone screens positive, you would ideally refer for a
12:38
Speaker 3: more lengthy assessment, but they're like one to two minutes,
12:43
Speaker 3: these different screeners. So I think the goal is these
12:46
Speaker 3: different areas like for example, you know there's depression, the
12:49
Speaker 3: falls or risk of falling, frail ty, malnutrition, pain, polypharmacy, circopenia,
12:56
Speaker 3: sensory impairment. You'd be assessing for these at least every year,
13:01
Speaker 3: and so you could, you know, with these being one
13:04
Speaker 3: to two minute assessments, I think it's easy to incorporate,
13:09
Speaker 3: you know, every if you're seeing someone every three months,
13:11
Speaker 3: for example, to be able to incorporate some of these
13:13
Speaker 3: different assessment tools into a busy practice. And there are
13:19
Speaker 3: more than just these listed, but I think it's really
13:21
Speaker 3: nice for someone trying to start to incorporate this because
13:25
Speaker 3: I think the thing is we are all seeing older adults.
13:29
Speaker 3: Like the other thing that they mentioned now is that
13:31
Speaker 3: I mean people fortunately are living longer. There's obviously there's
13:35
Speaker 3: so many more people than ever with type two diabetes.
13:38
Speaker 3: The chapter actually opens off that twenty nine percent of
13:41
Speaker 3: people over the age of sixty five have diabetes, and
13:45
Speaker 3: obviously so most of those cases are type two diabetes. However,
13:50
Speaker 3: people with type one diabetes are now living much longer
13:53
Speaker 3: thanks to better therapies and technologies, and so this is
13:57
Speaker 3: kind of the first time ever that we now have
14:00
Speaker 3: several people that are older that are living with type
14:04
Speaker 3: one diabetes, and so this creates kind of a whole
14:07
Speaker 3: new world of oh, well, how do how do we
14:10
Speaker 3: manage that many of them are on pumps? And what
14:14
Speaker 3: happens with those pumps when they transition if they're in
14:17
Speaker 3: a home, like who can manage it for them? So
14:21
Speaker 3: all that to say is that this really important to
14:25
Speaker 3: incorporate these assessments into our practice. Also, I just want
14:30
Speaker 3: to say, like regarding the medications, I think they've done
14:33
Speaker 3: a very good job of talking about, Okay, what should
14:38
Speaker 3: we be looking for, like what are the glucose goals?
14:40
Speaker 3: And when can we back off and how should we
14:45
Speaker 3: back off?
14:46
Speaker 1: So there's actually a very nice like diagram of all.
14:49
Speaker 3: Right, let's say someone's on meal time insulin, how are
14:53
Speaker 3: you going to try to like lean them off, and
14:55
Speaker 3: in type two diabetes, typically we're trying to get them
14:58
Speaker 3: off of the meal time prandial insulin, but we would
15:01
Speaker 3: keep the vasal and then can we actually transition to
15:05
Speaker 3: non insulent agents and ones that don't cause hypo glycemia ideally,
15:11
Speaker 3: So I think this info is going to be really
15:14
Speaker 3: really helpful for clinicians because we're all like, whether you
15:19
Speaker 3: work in this area or not, Like, we're all seeing
15:20
Speaker 3: people over the age of sixty five. And there's also
15:23
Speaker 3: why differences in people over sixty five. So some are
15:26
Speaker 3: like healthy, very very healthy, right, probably we expect them
15:31
Speaker 3: to live several years longer, and then others are more
15:34
Speaker 3: frail and the way we treat them is going to
15:38
Speaker 3: be a little different.
15:39
Speaker 2: One of the four ms I think I overlooked initially
15:43
Speaker 2: was what matters most because sometimes you look at a
15:46
Speaker 2: patient's medications in their mid list and you think, oh,
15:49
Speaker 2: I got to get them off that med but that
15:51
Speaker 2: might be a medication that they have had really good
15:54
Speaker 2: luck with and have really liked and they don't want
15:56
Speaker 2: to go off that medication. Or maybe what matters to
15:59
Speaker 2: me is, yeah, geting him off meal time insulam, but
16:01
Speaker 2: that doesn't matter to them. So that's one thing I
16:04
Speaker 2: really overlooked in the beginning and now is like, to me,
16:07
Speaker 2: the most important afore him.
16:09
Speaker 1: I totally agree with you.
16:11
Speaker 3: I think starting with that is really really important. I
16:16
Speaker 3: had a patient yesterday who very lots of comorbidities, like
16:22
Speaker 3: significant cardiac issues, wheelchair bound, like very very very sick.
16:28
Speaker 1: And he he comes in with his.
16:30
Speaker 3: Wife and his wife is like, his problem is he
16:34
Speaker 3: eats too much chocolate. He like, he just he I
16:38
Speaker 3: bought these Hershey kisses and he just he's eating the
16:40
Speaker 3: Hershey Kisses and like, and it's like, well, wait a second, Like,
16:44
Speaker 3: let's ask him. I mean if he enjoys the chocolate, like,
16:48
Speaker 3: let the guy have some chocolate. So anyway, we talked about, Hey,
16:52
Speaker 3: is there a way to we can incorporate some Hershey
16:56
Speaker 3: Kisses into our lives regularly the glucose around them. So
17:02
Speaker 3: I think that is very important. And also like keeping
17:05
Speaker 3: in mind there's a lot of like depression, diabetes, distress.
17:11
Speaker 3: Those are our issues I see a lot, and if
17:15
Speaker 3: those aren't addressed, you could have the best medication regimen ever.
17:20
Speaker 1: But it's not going to mean anything.
17:21
Speaker 3: The person may not be motivated to do the self
17:24
Speaker 3: care behaviors.
17:26
Speaker 2: That's right. I have seen the diabetes distress in both
17:31
Speaker 2: you know, persons with diabetes and their caregivers. I see
17:34
Speaker 2: parents or caregivers that are so concerned. You know, they're
17:37
Speaker 2: going to be on a road trip and the pump
17:39
Speaker 2: is going to fail, so they come to the pharmacy
17:41
Speaker 2: to get a box of insulin pins just in case
17:43
Speaker 2: the pump fails while they're gone. And you see just
17:47
Speaker 2: the people who carry fruit snacks and juice boxes with
17:50
Speaker 2: them wherever they go, even if it's a walker around
17:52
Speaker 2: the block. And it does make such a big impact
17:55
Speaker 2: on patient lives when there is that fear or anxiety
17:59
Speaker 2: around have diabetes. Definitely, so the four ms I love.
18:04
Speaker 2: You mentioned that those screening approaches, and I do love
18:08
Speaker 2: those two Those are also in section thirteen, and it's
18:11
Speaker 2: just different screening approaches for geriatric syndromes. I'm going to
18:15
Speaker 2: read a few of these screening questions for people who
18:18
Speaker 2: have not had the chance to go read these. So,
18:21
Speaker 2: for example, the screening question for cognitive impairment is have
18:23
Speaker 2: you noticed any changes in your memory or ability to
18:26
Speaker 2: think clearly? To screen for delirium, what day of the
18:29
Speaker 2: week is it you can ask to screen for depression
18:32
Speaker 2: during the past month, have you often been bothered by
18:35
Speaker 2: feeling down, depressed, or hopeless? To screen for falls? Have
18:38
Speaker 2: you fallen in the past year or are you afraid
18:41
Speaker 2: of falling due to balance or walking problems? For frailty,
18:44
Speaker 2: have you felt unusually tired recently or had difficulty walking
18:48
Speaker 2: up steps without resting? To screen for malnutrition, have you
18:52
Speaker 2: unintentionally lost weight? To screen for pain, simply asked, are
18:56
Speaker 2: you experiencing any pain? And so there's about you know,
18:59
Speaker 2: seven to ten more of these just simple questions you
19:02
Speaker 2: can ask to screen. But I love these screening questions because, yeah,
19:06
Speaker 2: let's if they're starting to have cognitive impairment, let's catch
19:09
Speaker 2: it now. Do they need their hearing checked or are
19:12
Speaker 2: there anticholinergic medications that could be deprescribed? So I think
19:16
Speaker 2: these screening tools are so good to try to prevent
19:18
Speaker 2: the false prevent you know, having patients with depression that
19:22
Speaker 2: are untreated, having pain that's untreated, and just care for
19:25
Speaker 2: the overall person.
19:28
Speaker 3: Yeah, I completely agree the other thing those and I
19:33
Speaker 3: like love that they listed all these different screening tools,
19:36
Speaker 3: especially like sample questions and then the fact that they
19:38
Speaker 3: are really short and seem like they'd be very easy
19:41
Speaker 3: to implement into practice. The other thing that I do
19:45
Speaker 3: is I'm big into demonstration, and if someone's like time
19:49
Speaker 3: and range, their glucose has changed recently, I want them
19:54
Speaker 3: to show me, like, hey, let's can you show me
19:57
Speaker 3: how you use this insulin pen, like how you die it,
20:00
Speaker 3: how you would give it, Let's see how you fill
20:03
Speaker 3: your insulin pump, because that way you can catch if
20:08
Speaker 3: there's issues like sometimes the visual, like they're just not
20:11
Speaker 3: able to see the way that they were before, or
20:15
Speaker 3: they don't have the dexterity to be able to use
20:19
Speaker 3: the devices. I think the other thing is incorporating like
20:23
Speaker 3: who in their life can help, because just because someone
20:27
Speaker 3: loses dexterity or loses the visual, if as long as
20:32
Speaker 3: they have someone in their life that can help, then
20:36
Speaker 3: we can still use all the things. But I think
20:39
Speaker 3: that support is really important with aging. Unfortunately, not everyone
20:45
Speaker 3: has that support. I think if someone if they can,
20:48
Speaker 3: like my patients, can bring someone with them to the
20:50
Speaker 3: visit to hear everything that we're saying and reinforce it
20:54
Speaker 3: and help it home. But not everyone has that, and
20:58
Speaker 3: I think that's a really important thing that we should
21:01
Speaker 3: stress with aging, having a support system, having some help
21:08
Speaker 3: on standby is needed.
21:10
Speaker 2: I agree even in the Standards of Care it mentions
21:14
Speaker 2: to just education for even the long term care facilities
21:19
Speaker 2: to educate staff on how to use cgms, how to
21:22
Speaker 2: use insulin pumps, so that education for people taking care
21:27
Speaker 2: of our patients is huge.
21:29
Speaker 3: Yes, it really is, and I would love to see
21:33
Speaker 3: them get more comfortable with CGM ideally with insulin pumps
21:38
Speaker 3: as well, because we don't want to have to stop
21:42
Speaker 3: technology just because someone's going into.
21:45
Speaker 1: A long term carecter.
21:47
Speaker 2: Yeah, I think the biggest barrier of cgms in long
21:51
Speaker 2: term care facilities, and I'm talking specifically skilled nursing facilities,
21:56
Speaker 2: is that there's a regulation that skilled nursing facilities are
21:59
Speaker 2: required to pay for all diabetic testing supplies. Well, that
22:04
Speaker 2: makes it really unfeasible to use cgms in skill nursing
22:09
Speaker 2: facilities if they have to pay for all the cgms
22:12
Speaker 2: for their residents. So I'm not sure, and I could
22:16
Speaker 2: be wrong about this, but I'm not sure how widely
22:18
Speaker 2: cgms will be used in skill nursing facilities until we
22:22
Speaker 2: can start billing those cgms to Medicare instead of to
22:25
Speaker 2: the skill nursing facility.
22:27
Speaker 3: Yeah, that seems like it's a problem, But at the
22:29
Speaker 3: same time, DGM is really not that much more.
22:33
Speaker 1: Expensive than testing supplies.
22:37
Speaker 3: The price has come down quite a bit that I
22:41
Speaker 3: bet they could work out some deal where I don't
22:45
Speaker 3: think the cost would be so much now. Pumps insolent
22:49
Speaker 3: pumps are a bit more money, but CGM is really
22:53
Speaker 3: with them all being disposable now has really come down
22:56
Speaker 3: in price. And when you think about the potential to
22:59
Speaker 3: reduce severe hypooklycemia events, to probably reduce DKA hospital admissions,
23:07
Speaker 3: I would think even if there is a slight extra cost,
23:10
Speaker 3: it would be very, very worth it. So I hope
23:14
Speaker 3: they can figure that out because I think it would
23:16
Speaker 3: benefit everyone.
23:18
Speaker 2: To do that agree and even to cut down on
23:22
Speaker 2: nursing time.
23:23
Speaker 3: Yes, And it would help me because I have some
23:25
Speaker 3: patients in these homes that I'm still trying to manage,
23:29
Speaker 3: and it's the communication is very hard since I don't
23:32
Speaker 3: work in these homes, and I'll meet with them for
23:34
Speaker 3: like a virtual visit and they're like, oh, I don't
23:37
Speaker 3: I don't know what insulin they're giving me, or I
23:40
Speaker 3: don't know, I'm not sure where my readings are, and
23:42
Speaker 3: then maybe a couple of days later, somebody faxes the
23:45
Speaker 3: readings to me, and then I'm like hunting down for information.
23:48
Speaker 3: I'm like, I just can't get an answer, and I
23:52
Speaker 3: don't know if the insulin's even given on to like
23:54
Speaker 3: is it given before they eat?
23:55
Speaker 1: Is it given after? Like there's just so many questions.
23:58
Speaker 1: And if they.
23:59
Speaker 3: Were wearing CGM, at least I could pair it up
24:03
Speaker 3: with our system and have all that glucose data, so
24:08
Speaker 3: that would really be very, very helpful for communication.
24:12
Speaker 2: Agree, there's got to be something that changes, because now
24:15
Speaker 2: it does it seems like we're, you know, these patients
24:18
Speaker 2: are getting such great care, they've got their CGM, they're
24:21
Speaker 2: being well managed. Someone's looking over their dexcom clarity or
24:25
Speaker 2: whatever data we have from these cgms, and then it's
24:28
Speaker 2: like they go into these skilled nursing facilities and all
24:31
Speaker 2: of a sudden, it all it all stops, and we're
24:34
Speaker 2: taking the CGM off and going to fingerpokes, and then
24:37
Speaker 2: the data is lost. So I agree with you that
24:40
Speaker 2: there's hopefully in the future. I wish someone would do
24:43
Speaker 2: a study on you know, cost and benefit and just
24:46
Speaker 2: show the benefit of continuing to use cgms even if
24:49
Speaker 2: the skill nursing facility has to pay for them. But
24:51
Speaker 2: I know they're on tight budgets too, And I guess
24:54
Speaker 2: I don't know all the answers, but I hope that's
24:56
Speaker 2: coming one day where we continue to incorporate cgms for
24:59
Speaker 2: all of our patients. Okay, so let's get into medications,
25:03
Speaker 2: and in section thirteen it does go over pharmacologic therapy
25:07
Speaker 2: and kind of little pearls for our older adults. So
25:09
Speaker 2: let's start with met Foreman. It lists met Foreman and
25:12
Speaker 2: some of the benefits. Of course, low risk for hypoglycemia.
25:16
Speaker 2: It does a nice job, you know, lowering A one C.
25:20
Speaker 2: It's easy to administer some of the cons gi side
25:24
Speaker 2: effects which we do see less with our ear formulations.
25:27
Speaker 2: Although if a patient's getting their meds crushed, you know
25:30
Speaker 2: that's not feasible either renal dosing, so you got to
25:34
Speaker 2: watch for renal impairment and then monitor B twelve les
25:37
Speaker 2: annually after they've been on the medication for four years.
25:40
Speaker 2: But I still really like met Forman. I don't know
25:43
Speaker 2: what your thoughts are on met Forman and our older adults.
25:46
Speaker 3: So I like that Foreman too, and it's so interesting
25:50
Speaker 3: because you hear like kind of a school of thought
25:52
Speaker 3: of like, oh, well, I'm trying to get everyone on
25:54
Speaker 3: s JLT two in hits and JLP ones and we're
25:56
Speaker 3: taking away the mat format. But the thing is, when
25:59
Speaker 3: someone lived with diabetes for so many years, they often
26:03
Speaker 3: like they need more.
26:05
Speaker 1: They often need.
26:06
Speaker 3: Multiple medications to manage and get to those glucose targets.
26:10
Speaker 3: And metformant is a great drug that it's very very effective,
26:15
Speaker 3: it's very safe, and so yes, I like Metforman as well.
26:21
Speaker 3: I think the biggest probably concern in older adults is
26:25
Speaker 3: just the GFR cutoffs, and so we don't use it.
26:30
Speaker 3: We don't start it if the EGFR is below forty five,
26:34
Speaker 3: and then if someone is already on it, we can continue.
26:37
Speaker 3: But typically we don't use more than five hundred milligrams
26:40
Speaker 3: twice a day or a thousand milligrams extended release once
26:43
Speaker 3: a day, and then when the GFR fit goes below thirty,
26:47
Speaker 3: we do discontinue. And that's just because we worry about
26:50
Speaker 3: the accumulation in the body, which in theory could put
26:54
Speaker 3: someone at higher risk of more side effects and potentially
26:57
Speaker 3: lactic acidosis is the big.
26:59
Speaker 1: One, very very rare.
27:02
Speaker 3: But otherwise, if someone's kidney function, if it's within those thresholds,
27:06
Speaker 3: it is a great, great option to use. And I
27:10
Speaker 3: think I'm also glad that they mentioned the B twelve
27:12
Speaker 3: and specifically the four year callout, because I think people
27:16
Speaker 3: were like initially confused, They're like, when do we monitor?
27:19
Speaker 3: But now having that exact guidance, I think is very helpful.
27:23
Speaker 3: And I think the B twelve is very important because
27:26
Speaker 3: being deficient in B twelve can cause memory issues, it
27:30
Speaker 3: can cause neuropathy, like all things we don't want in
27:32
Speaker 3: our older adults. So I think that that is good
27:36
Speaker 3: and we can supplement with B twelve if needed as
27:38
Speaker 3: well if someone's.
27:39
Speaker 1: Levels start to go lower.
27:41
Speaker 2: Yeah, I was happy about the B twelve two because
27:43
Speaker 2: most of our older adults are also on a proton
27:46
Speaker 2: pump inhibitor, so I do think the combination of those
27:49
Speaker 2: two can really plummet B twelve levels. When my patients
27:52
Speaker 2: get into a nursing home, you know, I don't always
27:55
Speaker 2: know how long they've been on met form and so
27:57
Speaker 2: I just monitor yearly. But it was nice thing included
28:00
Speaker 2: the four years as a market when to start monitoring.
28:04
Speaker 2: So the next step is pulgletizone, which I really happen
28:07
Speaker 2: to like puergdisona as well because it's good for insulin resistance, right,
28:13
Speaker 2: and so of course we have to use caution for
28:15
Speaker 2: our patients with heart failure, fluid retention, you know, monitor
28:18
Speaker 2: weight gain. I listened to a podcast recently on Peter
28:23
Speaker 2: Attilla's podcast. It was a diabetes episode. They kind of
28:27
Speaker 2: mentioned that pelglidsone induced waking is more from the movement
28:32
Speaker 2: of fat from the organs to more subcutaneous So wasn't
28:36
Speaker 2: necessarily a bad thing. What are your thoughts on that?
28:39
Speaker 3: No, that is true, right, it's moving the fat to
28:44
Speaker 3: the healthier places. So the weighting in itself isn't isn't
28:48
Speaker 3: necessarily a concern in of itself. The other thing is
28:52
Speaker 3: we're sometimes worried, like with our older adults, we don't
28:55
Speaker 3: want them to lose more weight, and that sometimes is
28:58
Speaker 3: a barrier with GLP want drugs because we don't actually
29:01
Speaker 3: want them to lose weight.
29:03
Speaker 1: So therefore, you know, the.
29:06
Speaker 3: Waking and of itself isn't always an issue, But there
29:08
Speaker 3: are some other things with pioguidizone that you know, some concerns,
29:13
Speaker 3: so it can you know, there is a higher risk
29:15
Speaker 3: of osteoporosis, which isn't great in an older adult as well,
29:20
Speaker 3: and then fluid retention, so we really have to watch
29:24
Speaker 3: out if someone has heart failure, we're not going to
29:26
Speaker 3: use this agent.
29:28
Speaker 1: But there are also other benefits as well.
29:31
Speaker 3: So in addition to like improving the insulin resistance, there's
29:35
Speaker 3: also positive benefits on stroke, so if someone had a
29:39
Speaker 3: stroke that it can be a good agent to use.
29:41
Speaker 3: And then also for liver help, so for massyl D
29:45
Speaker 3: and MASH it has benefit probably because of how it's
29:49
Speaker 3: redistributing the fat and taking it away from the liver
29:52
Speaker 3: to other areas. And so I think in the right
29:56
Speaker 3: circumstances it can be a good drug to use. You
29:58
Speaker 3: just have to weigh kind of the and cons and
30:01
Speaker 3: decide for the individual is it's going to be a
30:03
Speaker 3: good choice or not.
30:05
Speaker 2: Absolutely. The next one is one I'm not a fan of,
30:09
Speaker 2: and that's the sulfonel aureas, just because of that high
30:11
Speaker 2: risk for hypoglycemia, risk for bone loss and fractures. And
30:16
Speaker 2: then of course the pros would be that they're very
30:19
Speaker 2: inexpensive in their oral so you don't have to do injections.
30:22
Speaker 2: But that's on sulfonal aureas.
30:24
Speaker 1: Do you ever use them, Well, yeah, unfortunately we do.
30:29
Speaker 3: We're trying, you know, they've really fallen out of favor
30:32
Speaker 3: a lot because of their risk of hypoglycemia, and especially
30:37
Speaker 3: unpredictable hypoglycemia, because it's like if someone doesn't eat or
30:42
Speaker 3: there's some change that's happened, it increases the risk. We
30:48
Speaker 3: never want to use glibyride in an older adult, and
30:51
Speaker 3: I would say we just try not to use glybride.
30:53
Speaker 3: Usually if we're using a sulfona urea, it's going to
30:55
Speaker 3: be glip aside orgela mypride. There are I just think
30:59
Speaker 3: there's some situations where we still end up using it.
31:02
Speaker 3: It is a generic, super cheap medication. And if someone
31:09
Speaker 3: is just they're they're having a lot of hyperglycemia and
31:12
Speaker 3: we're not able to get another another drug, sometimes this
31:16
Speaker 3: is something that can quickly resolve the hyperglycemia. But just
31:21
Speaker 3: definitely a lot not not one of our preferred agents
31:25
Speaker 3: because of the hypoglycemia. And there's also no cardiovascular benefit either,
31:31
Speaker 3: and there can be weight gain as well.
31:34
Speaker 2: Yeah, and the glibiera. The reason that's the highest risk
31:36
Speaker 2: is it's the longest acting, right, so the highest risk
31:38
Speaker 2: for hypoglycemia.
31:40
Speaker 1: Right.
31:41
Speaker 3: And interestingly, one of the things they call out in
31:44
Speaker 3: this section is the drug interaction with fluoroquinolones es bactrum
31:50
Speaker 3: that they can increase the amount of sulfoniureea, so basically
31:54
Speaker 3: they can increase hypoglycemia.
31:56
Speaker 1: So I think that's important. Drug interactions also aware of.
32:01
Speaker 2: Yeah, unfortunately one that I think gets clicked through. We're
32:03
Speaker 2: kind of ignored, but can be a major issue when
32:08
Speaker 2: you look at what can result as as a result
32:12
Speaker 2: of hypoglycemia.
32:14
Speaker 1: Right.
32:15
Speaker 2: So the next one is the DPP four inhibitors, which
32:18
Speaker 2: aren't really my favorite anymore. I don't know what your
32:20
Speaker 2: your thoughts are. They are well tolerated, a few side effects.
32:23
Speaker 2: I don't see a large, you know, decrease in a
32:25
Speaker 2: one C. There are a large glucos luring effect from them,
32:31
Speaker 2: but you know, minimal, minimal risk for hypoglycemia. Linaglypton is
32:35
Speaker 2: kind of nice because it doesn't require renal adjustment. If
32:37
Speaker 2: you have that patient that has low kidney function has
32:40
Speaker 2: to come off met foreman and doesn't want an injection
32:43
Speaker 2: or anything like that. Another thing with the DPP four
32:45
Speaker 2: is no you know, reduction of cardiovascular kidney disease either, right.
32:51
Speaker 3: So they exactly they are neutral for their cardiovascular kidney impact,
32:57
Speaker 3: and actually sacks gliptin in alogliptin showed increased heart failure hospitalization,
33:06
Speaker 3: So there are some concern on those two specific DPP
33:09
Speaker 3: four inhibitors and heart failure. But they can be good
33:14
Speaker 3: agents to use if you just need a little bit
33:16
Speaker 3: of glucose lowering because they're very well tolerated, so especially
33:22
Speaker 3: if you're concerned about we ging or weight loss, these
33:24
Speaker 3: are going to be weight neutral, and so if someone
33:28
Speaker 3: just has a little bit of glucose lowering that's needed,
33:31
Speaker 3: these can be great to use. They're also just like
33:33
Speaker 3: it's a once a day pill. So I think there's
33:36
Speaker 3: definitely circumstances. Probably older adults is the time where I'm
33:40
Speaker 3: more likely to use this class of agents, because otherwise
33:43
Speaker 3: I'd say, really GLP one drugs have taken over and
33:49
Speaker 3: we're using so much less of these. But I think
33:51
Speaker 3: that if this is a nice tool to have in
33:53
Speaker 3: the older adults where you get some glucose lowering in
33:56
Speaker 3: a very safe, safe way.
33:59
Speaker 2: Yeah, side notice there's no reason to be on a
34:02
Speaker 2: DPP four inhibitor with a GLP one based therapy.
34:06
Speaker 3: Correct, yes, and the guidelines do say that in section
34:10
Speaker 3: nine with the pharmacologic therapy, you don't want to have
34:13
Speaker 3: both of them. In theory there is a chance that
34:17
Speaker 3: could increase side effects, but also it's really just a
34:20
Speaker 3: waste of money taking an extra medication when.
34:25
Speaker 1: There's a huge duplication in their mechanisms.
34:29
Speaker 2: So next to the GLP one based therapies of course,
34:32
Speaker 2: really kind of blew the market out of the water
34:34
Speaker 2: when it comes to managing diabetes because they are highly effective.
34:39
Speaker 2: It's nice that most you know are just once a
34:41
Speaker 2: week low risk for hypoglycemia. You can use them with
34:44
Speaker 2: a reduced egf R even for patients with dialysis. They
34:48
Speaker 2: have cardiovascular and chronic kidney disease benefit. But they're not perfect.
34:53
Speaker 2: We have those gi effects and for our long term
34:55
Speaker 2: care or geriatric patients that already have constipation or maybe
35:00
Speaker 2: difficulty getting enough nutrition in that can be a problem.
35:03
Speaker 2: And then the muscle loss or cyclopenia is a concern
35:06
Speaker 2: for me, especially just because when I look at my
35:09
Speaker 2: older adults and especially skilled nursing facilities, they're not getting
35:14
Speaker 2: a lot of protein. It's a very carbohydrate heavy diet,
35:17
Speaker 2: so the protein intake is a worry for me. And
35:19
Speaker 2: then also the strength training if they if they're in therapy, great,
35:23
Speaker 2: but a lot of them aren't, so then that's a
35:25
Speaker 2: concern as well.
35:26
Speaker 1: Yeah, so you're absolutely right. I mean, these drugs have
35:29
Speaker 1: taken the world by storm.
35:31
Speaker 3: They are very effective at glucose lowering and for weight loss,
35:35
Speaker 3: and then we're discovering all these other benefits that they
35:38
Speaker 3: have too, like with MASH and massyle D, with sleep apnea,
35:43
Speaker 3: kidney disease, heart failure, with preserved dejection fraction, are you
35:48
Speaker 3: a vascular disease, even osteoarthritis, and even there's other conditions
35:53
Speaker 3: they're still exploring that may have benefit. So we often
35:58
Speaker 3: want to be able to use these if we can,
36:01
Speaker 3: but we do need to be very very careful on
36:03
Speaker 3: the GI side effects, which it can actually be constipation
36:07
Speaker 3: or diarrhea, so we have to watch out for that
36:10
Speaker 3: and definitely nausea, and then the food intake. So some
36:15
Speaker 3: people are very very affected and find that they're not eating,
36:19
Speaker 3: they may not be drinking, so they could get dehydrated.
36:22
Speaker 3: That actually could put someone at risk of a CUE
36:24
Speaker 3: kidney injury if they're having all these GI side effects
36:27
Speaker 3: and they're dehydrated. So there are some real risks here.
36:31
Speaker 3: One of the recommendations that comes from the guidelines is
36:34
Speaker 3: about getting enough protein to avoid sarcopenia, and they recommend
36:39
Speaker 3: at least point eight units per kilogram per day. And
36:42
Speaker 3: so I think working ideally having someone work with a
36:45
Speaker 3: dietitian diabetes educator, work with someone to come up with
36:50
Speaker 3: a meal plan that incorporates a lot.
36:52
Speaker 1: Of protein choices.
36:54
Speaker 3: And then also the strength training is so so important,
36:58
Speaker 3: and it doesn't have to be this, it doesn't have to.
37:02
Speaker 1: Be going to orange theory.
37:03
Speaker 3: It can be like chair exercises right like or dumbbells
37:08
Speaker 3: like that you're doing from the chair or getting seated
37:11
Speaker 3: to standing up. There's a lot of exercises if someone
37:15
Speaker 3: can learn these exercises, either I through working with an
37:17
Speaker 3: exercise physiologist if you have that luxury, or physical therapy.
37:21
Speaker 1: But most people, even if they have a lot of
37:25
Speaker 1: a lot of physical.
37:26
Speaker 3: Limitations, we can come up with some type of exercise
37:30
Speaker 3: to strengthen the muscles.
37:32
Speaker 1: And that's just that's going to be so so.
37:34
Speaker 3: Important to be able to yeah, to continue, be able
37:39
Speaker 3: to use these medications long term. Yeah.
37:42
Speaker 2: What I love about this is I think all of
37:43
Speaker 2: our older adults, regardless if they're on a GLP one
37:46
Speaker 2: based therapy or not, could use probably more protein and
37:49
Speaker 2: more strength training. So it's been good to put more
37:52
Speaker 2: emphasis on both of these things. Of Course, it always
37:56
Speaker 2: mentions using a GLP one based therapy with proven crdiovascua
38:00
Speaker 2: kind of kidney disease benefit. Which ones which omar GLP
38:03
Speaker 2: one based therapies do have those benefits. It's not all of.
38:06
Speaker 3: Them, It is not all of them, but it is
38:09
Speaker 3: most of them. So Interestingly, exenotide looks like it's exiting
38:14
Speaker 3: the market. So and in fact, they have a list
38:19
Speaker 3: in section nine of like all the different medications. They
38:22
Speaker 3: took it out of the algorithm and they don't even
38:24
Speaker 3: list the pricing anymore. So I think we're going to
38:26
Speaker 3: see that go away. But that was one that was
38:29
Speaker 3: kind of neutral. The data showed it was neutral. But
38:32
Speaker 3: Doula glue tide trulyicity has the cardiovascular benefit, so does
38:36
Speaker 3: lyri glue tide, and liraglue tide is a generic, so
38:40
Speaker 3: even though it's a daily GLP one we're sometimes seeing.
38:44
Speaker 1: More of it's used because it is lower cost.
38:47
Speaker 3: And then are kind of our two big guns, the
38:49
Speaker 3: magnetide or ozembic.
38:53
Speaker 1: Is.
38:54
Speaker 3: It has a lot of indication, has the cardiovascular indication,
38:57
Speaker 3: it has the kidney disease indication, and then for the
39:01
Speaker 3: obesity version that we go v it also has the
39:05
Speaker 3: mash indication as well, and then it's shown positive data
39:09
Speaker 3: for heart failure with preserved ejection. Fraction towards Zeppatize our
39:13
Speaker 3: other big gun, and that one's unique in that it's
39:16
Speaker 3: a GLP one gip agonist and Mount Jarrow for the
39:21
Speaker 3: diabetes version or zet bound for the weight loss version.
39:26
Speaker 3: The zet bound has the sleep apnea indication, so Mount
39:30
Speaker 3: Jarrow does not have a cardiovascular indication. But they recently
39:34
Speaker 3: published the surpass cbot trial and that trial showed that
39:39
Speaker 3: it was non inferior to dol glue tide, which does
39:42
Speaker 3: have a cardiovascular indication, and then there were trends toward
39:47
Speaker 3: improvements like less mortality, less cardiovascular events. It just wasn't
39:52
Speaker 3: statistically significant to reach superiority.
39:56
Speaker 1: So we'll see how the FDA responds to that.
39:59
Speaker 3: I can tell you are cardiologists very much think okay,
40:04
Speaker 3: it's got a cardio it's got a cardiovascular benefit, and
40:06
Speaker 3: they feel very comfortable using it. It's just depending how
40:09
Speaker 3: a drug was studied, it has different indications.
40:14
Speaker 1: And then one of the.
40:15
Speaker 3: Other things is there is the oral samaglatide as well
40:19
Speaker 3: as rebelsis, and that has a cardiovascular indication as well,
40:24
Speaker 3: and also very recently the oral we go V, so
40:30
Speaker 3: the high dose oral semaglatide, it goes up to twenty
40:34
Speaker 3: five milligrams, that just became available and it's in pharmacies now,
40:39
Speaker 3: and that actually has a cardiovascular indication as well because
40:45
Speaker 3: of the fact that we go V was studied in
40:48
Speaker 3: a population of obesity and showed a twenty percent reduction
40:52
Speaker 3: and the three point mas the major adverse cardiovascular events.
40:56
Speaker 1: And then I think because.
40:57
Speaker 3: Rebelsis also has this indication, that they they also granted
41:01
Speaker 3: this indication for the oral we go V as well.
41:04
Speaker 1: So it's very interesting this whole world.
41:09
Speaker 3: The indications keep growing, but I would say most of
41:13
Speaker 3: them have a lot of have very positive data. The
41:17
Speaker 3: one exception is which you probably don't see this that
41:20
Speaker 3: often is LIXI centotide, So that is a daily GLP one,
41:25
Speaker 3: but it's not available as a standalone. It comes as
41:28
Speaker 3: it's called siliqua. It comes in combination with insulin glargene,
41:32
Speaker 3: So sometimes we'll see people on that because of the
41:35
Speaker 3: convenience of a once a day and also it's one
41:38
Speaker 3: cope instead of two, so you're combining that GLP one
41:41
Speaker 3: with the long acting insulin. But that one lyxi setatide
41:46
Speaker 3: was studied and it it was non inferior, but it
41:49
Speaker 3: had no cardiovascular benefit. So it does seem like there
41:52
Speaker 3: is a little bit of a difference between the type
41:54
Speaker 3: of molecule. So we can't assume any GLP one drug
41:59
Speaker 3: would have the cardiovascular benefit, but it does seem that
42:02
Speaker 3: so far.
42:03
Speaker 1: Most of them do.
42:06
Speaker 2: I'll be curious to see, you know, in twenty twenty
42:08
Speaker 2: six how many prescriptions we get for the oral versions,
42:13
Speaker 2: because so far it's been minimal.
42:15
Speaker 3: I would say, well, it just literally became available on
42:19
Speaker 3: January fifth, and for the oral we go v and
42:23
Speaker 3: there is supposed to be like you can order it
42:27
Speaker 3: directly through Novo for one forty nine and I think
42:30
Speaker 3: there's good rxcubons, like you get the first whatever couple
42:34
Speaker 3: months for one hundred and forty nine and then it goes
42:35
Speaker 3: up to one ninety nine, so that cost is significantly
42:39
Speaker 3: cheaper than what our injectables had been for those that
42:42
Speaker 3: don't have insurance.
42:43
Speaker 1: Coverage for it, so it will be really interesting.
42:47
Speaker 3: Now I agree with you, Rebelsis, which has been out
42:50
Speaker 3: for years, has not.
42:53
Speaker 1: Really taken off in the way that we would.
42:55
Speaker 3: Have expected it to maybe, and I think what we're
42:58
Speaker 3: learning is people are like, a weekly injection is not
43:01
Speaker 3: so bad, so we for the most part, people are
43:06
Speaker 3: choosing that. Also, the thing with the oral smaglatite is
43:10
Speaker 3: it does need to be taken in a very special way,
43:13
Speaker 3: so empty stomach, maximum four ounces of water, no coffee.
43:18
Speaker 1: No other pills. You have to wait at least thirty
43:21
Speaker 1: minutes to take your other pills.
43:23
Speaker 3: And I think in talking to people about this, this
43:25
Speaker 3: is very inconvenient because people wake up, they want to
43:28
Speaker 3: have their coffee right away, they need to take their
43:30
Speaker 3: other pills. They don't want to have to wait or
43:32
Speaker 3: afraid they'll forget to take their other ones, So it
43:34
Speaker 3: is not the easiest drug to take. Now, there is
43:37
Speaker 3: supposed to be an oral non PEPTIDEJLP one coming out
43:41
Speaker 3: this year called or forg lecron and that one would
43:45
Speaker 3: not require any special way of taking it. It could
43:48
Speaker 3: just be taken with all the other pills, so that
43:51
Speaker 3: we might start to see greater uptake in that when
43:54
Speaker 3: that comes out, so we'll.
43:55
Speaker 2: See very interesting. Can't wait, all right? So the next
44:00
Speaker 2: class of medications as our SGLT two inhibitors, which have
44:04
Speaker 2: been shown beneficial for heart failure and also chronic kidney
44:07
Speaker 2: disease well tolerated. From what I've seen, the things we
44:11
Speaker 2: should be cautious of is volume depletion in our older
44:15
Speaker 2: adults and then monitoring for infections UTIs. But benefit well
44:20
Speaker 2: tolerated oral once a day seems to be a nice
44:24
Speaker 2: addition to our diabetes repertoire, I would say.
44:28
Speaker 3: Yeah, and the benefits for kidney disease, for heart failure,
44:32
Speaker 3: and in fact it's used a lot for those conditions
44:34
Speaker 3: irrespective of having diabetes. I think things to keep in
44:38
Speaker 3: mind or that if the GFR is below forty five,
44:41
Speaker 3: you're going to have very minimal impact on glucose levels
44:45
Speaker 3: because you need that you need the flow for it
44:48
Speaker 3: to be effective for reducing glucose. So if you're trying
44:52
Speaker 3: to use it for glucose lowering, not going to work,
44:54
Speaker 3: but still a great drug to use for that kidney function,
44:57
Speaker 3: that kidney disease. And then the other thing is that
45:01
Speaker 3: we if someone's glucose levels are higher, there definitely be
45:04
Speaker 3: at greater risk of those infections. If someone is taking insulin,
45:08
Speaker 3: they're also greater risk of the euglycemic DKA DKA where
45:15
Speaker 3: glucose doesn't get is high. And so those are you know,
45:18
Speaker 3: some of the things we worry a little bit about
45:21
Speaker 3: that we just need to use some caution with.
45:24
Speaker 2: Yeah, and not all the S two inhibitors have benefit
45:28
Speaker 2: for heart failure and chronic community disease, but most is
45:30
Speaker 2: that true?
45:32
Speaker 3: Yeah, it appears that they all have benefit for heart failure. Well,
45:37
Speaker 3: I should take that back because sagla flows in the
45:41
Speaker 3: drug the s GILT two inhibitor that was originally approved
45:44
Speaker 3: in cats that then gained the human approval, that doesn't
45:48
Speaker 3: have any data supporting any cardiovascular benefits. So there's just
45:55
Speaker 3: not data so anyway, that one doesn't, but all the
45:59
Speaker 3: other ones do. But really, cannon glow flows in, empaglophlosen
46:04
Speaker 3: and DAPA glophlowsen are the three big guns that have
46:07
Speaker 3: the most evidence. Like they all have evidence for kidney disease,
46:11
Speaker 3: for heart failure, for cardiovascular benefit, So those are going
46:15
Speaker 3: to be our three big ones. There's also or two glophlowsen,
46:19
Speaker 3: but that one it was very disappointing the results. It
46:22
Speaker 3: did have benefit for heart failure, but not for cardiovascular
46:25
Speaker 3: disease or kidney disease. And then there's also soda glophlows in,
46:30
Speaker 3: which is really a heart failure drug, so it's not
46:34
Speaker 3: always listed as like a diabetes drug, but you could
46:36
Speaker 3: use it for people with diabetes and it has the
46:39
Speaker 3: SGLT two one and two inhibitor, but I definitely has
46:43
Speaker 3: the heart failure benefit and the cardiovascular benefits.
46:47
Speaker 2: So monitor EGFRs for patients on these and then remind me,
46:51
Speaker 2: is there a certain cutoff point where you have to
46:53
Speaker 2: discontinuum or you just won't get the blood you know,
46:56
Speaker 2: glucose lowering. If it goes lower.
46:59
Speaker 1: Yeah, you just won't get it.
47:01
Speaker 3: I mean, I think usually once somebody is on dialysis,
47:05
Speaker 3: we don't necessarily continue it. I have to check though,
47:09
Speaker 3: because the labels keep changing. They do you can use
47:13
Speaker 3: it to I mean really through ND stage renal disease
47:16
Speaker 3: like they have benefits and you can be monitoring albuminurhea
47:19
Speaker 3: and certainly monitoring the GFR. But yeah, once you know,
47:24
Speaker 3: once it's below forty five, and definitely when it's below thirty,
47:27
Speaker 3: you're just not going to expect to see the glucose
47:30
Speaker 3: lowering benefits.
47:31
Speaker 2: Got it. And last, but not least is our insulin therapy,
47:35
Speaker 2: And it does mention for older adults, a once daily
47:38
Speaker 2: basal insulin is a reasonable option without doing a meal
47:41
Speaker 2: time insulin. But it also does mention that you know,
47:44
Speaker 2: we don't want to have complex regimens for older adults,
47:47
Speaker 2: and that non insulin therapies are preferred due to lower
47:50
Speaker 2: risk of hypoglycemia and then the potential cardiovascular and kind
47:54
Speaker 2: of kidney disease benefits.
47:55
Speaker 3: Yeah, so I think insulin is going to It has
48:00
Speaker 3: so many risks of hypoglycemia and influence, a drug with
48:04
Speaker 3: a very narrow therapeutic window, so it's hard to dose
48:08
Speaker 3: it and get the glucose within target. But I think
48:12
Speaker 3: what you have to keep in mind is like what
48:14
Speaker 3: are the goals? And there's a nice table that kind
48:17
Speaker 3: of illustrates what the goals are if you have a
48:20
Speaker 3: healthier person versus someone with a lot more comorbidities.
48:24
Speaker 1: What you're looking for in those glucose goals, and even.
48:27
Speaker 3: If you have someone that maybe is really like end
48:30
Speaker 3: of life and doesn't have much longer to live, you
48:33
Speaker 3: still you want to prevent hypoglycemia, and you also want
48:37
Speaker 3: to prevent symptomatic hyperglycemia. And so even there may be
48:42
Speaker 3: situations where you say, we're going to do like a
48:44
Speaker 3: once a day long acting insulin so that we can
48:47
Speaker 3: keep the glucose ideally between like one hundred and two hundred,
48:51
Speaker 3: so the person's not symptomatic, and so insulin can be
48:55
Speaker 3: very effective at that and then it's just the meal
49:00
Speaker 3: time insulin, I would say, is when things just it's harder,
49:03
Speaker 3: and some people they still need it. But I think
49:07
Speaker 3: it's always about reevaluating what those goals are and not
49:10
Speaker 3: just A one C because A and C can also
49:13
Speaker 3: be skewed for a lot of different reasons, and so
49:17
Speaker 3: I think our guidelines do a good job of emphasizing
49:20
Speaker 3: using CGM when we can, like also looking at time
49:22
Speaker 3: and range and reevaluating what those goals are and then
49:26
Speaker 3: trying to back off therapies so that it's easier for
49:31
Speaker 3: somebody and they're not having side effects.
49:33
Speaker 2: Yeah, it does.
49:34
Speaker 3: Mention.
49:35
Speaker 2: As our adults get a kind of older and more complex,
49:38
Speaker 2: we've moved from an A and C of maybe less
49:40
Speaker 2: than seven to seven point five to more like a
49:42
Speaker 2: less than eight or eight point five. But you mention
49:44
Speaker 2: if they have anemia, their A and C may not
49:46
Speaker 2: be accurate. And then the time and range. We might
49:48
Speaker 2: go from a goal of time and range of seventy
49:51
Speaker 2: percent to fifty percent or just our goal might be, yeah,
49:55
Speaker 2: avoiding hypoglycemia and symptomatic hyperglycemia. So goals change, for sure.
50:00
Speaker 3: But even though I do want to emphasize, that drives
50:02
Speaker 3: me crazy sometimes is that someone will see someone and
50:06
Speaker 3: they'll be like, oh, they're over sixty five A one.
50:08
Speaker 1: C goal, now it's less than eight. Well wait a second, Okay,
50:12
Speaker 1: let's look at the whole picture.
50:14
Speaker 3: Right. So if someone is they're on no drugs, they're
50:17
Speaker 3: only on met foreman, they like, why are we saying
50:21
Speaker 3: less than eight? And I think sometimes we aren't doing enough,
50:26
Speaker 3: especially if you've got someone sixty five like healthy in
50:30
Speaker 3: front of you, Like, why wouldn't.
50:33
Speaker 1: You want to go lower?
50:34
Speaker 3: If you can do so safely with non insulin therapies.
50:38
Speaker 3: We've got our SGLT two inhibitors. Our GLF want agonize like,
50:41
Speaker 3: why wouldn't you want to do that? So I think,
50:45
Speaker 3: also we need to keep that in mind, and also
50:48
Speaker 3: that a lower A one C isn't isn't bad. So
50:52
Speaker 3: let's say you use these drugs, you use the GLPAN
50:55
Speaker 3: usemat Foreman a s GILT two inhibitor.
50:57
Speaker 1: They're a one C. It goes below and a half
51:00
Speaker 1: it goes below six.
51:01
Speaker 3: Well, if they're not symptomatic, if they're not sarcopenic, like,
51:06
Speaker 3: they're actually able to further reduce those microvascular complications with
51:12
Speaker 3: the lower ae C. So if this person in front
51:14
Speaker 3: of you still has many, many more years ahead of them,
51:18
Speaker 3: like why not? Why would you want to reduce those
51:20
Speaker 3: assuming they're not having side effects? So I think this
51:22
Speaker 3: is where the shared decision making comes in, having that
51:25
Speaker 3: conversation asking the person what's important to you. If someone says, well,
51:29
Speaker 3: my goal is to get off medication, all right, we'll
51:31
Speaker 3: try to get you off, right. But if someone says, well,
51:34
Speaker 3: I want to avoid any diabetes complications, I don't want
51:37
Speaker 3: to have torrop with you, I don't want to have
51:38
Speaker 3: kidney disease, why not use the therapies and get an
51:42
Speaker 3: even lower ae C.
51:43
Speaker 2: So that's my I absolutely agree. I'm so glad you
51:46
Speaker 2: mentioned that. I couldn't agree more because it does amount
51:49
Speaker 2: to quality of life at the end, and if you're
51:51
Speaker 2: sixty five, you might live another thirty years. So let's
51:54
Speaker 2: drop that goal a little bit if you're able to
51:58
Speaker 2: and prevent you know, other complications down the road. So
52:02
Speaker 2: this has been awesome. I always learn so much from you.
52:04
Speaker 2: Thank you so much. If folks, if you want to
52:07
Speaker 2: find doctor Isaac's you can find her on LinkedIn, diabetes
52:11
Speaker 2: dash pharmacist dot com, the Diabetes Dialogue podcast. What am
52:14
Speaker 2: I forgetting?
52:15
Speaker 3: Yeah?
52:16
Speaker 1: No, that's all good.
52:17
Speaker 3: Yeah, so Diabetes Dialogue if you look for that in
52:20
Speaker 3: my name on any place you find your podcast, you
52:23
Speaker 3: should be able to find that.
52:24
Speaker 1: And then also we have video versions on HCP live
52:28
Speaker 1: dot com.
52:30
Speaker 2: Yes, check them out. You'll learn so much. Thank you,
52:32
Speaker 2: appreciate it, and happy New Year everybody,