Hi, everyone, and welcome to today's hands-on tips to improve diabetes care webinar. Today our panel will share their expertise on optimizing AID systems and care-based strategies for individualization, and we're glad you're here. I am Paige Johnson, and I will be moderating today's webinar. To just share a little bit about me, I'm an RN, CDCES. I work in an outpatient facility at Atrium Wake Forest Baptist Health in Winston-Salem, North Carolina, and I like to describe the job that I do as forensic diabetes. Basically, that was previously known as diabetes education, and a large part of my job is discovering barriers to care that keep diabetes patients from being very successful in their journey in diabetes. Diabetes topic is one of my favorite, because I really feel that I spend a lot of time in a pre-pump assessment referral with patients that are looking at different technologies, trying to match the right patient with the right piece of equipment. And to me, that's the key to success. It was so funny this morning, I trained a patient on a pump last night, and this morning I had a phone call from her, and she was just checking in, and she's 33 years old, just diagnosed type 1 in January, and she said, Paige, I just want to let you know that this was the first night that I have slept all night since I was diagnosed. And you know, I told her, I said that just made my year as an educator. I thought that was great. So, I'm so excited about today, and we will talk about the agenda next, we'll spend the next hour together following the agenda on the screen. We'll be using interactive features during today's session. We will send you important links in the chat about information throughout the session, and we'll use the Zoom Q&A at the end of the presentation for panel questions. If you think of a question as our presenters speak, use the Q&A box on your control panel to type the question. Finally, during our webinar today, we'll use an interactive tool called Kahoot, and this is to ask you knowledge-based questions and collect your answers in real time throughout the presentation. So, let's talk about connecting to Kahoot. If you have a mobile phone or tablet nearby, and that's often the easiest and the best method, but you can also use whatever device you have or you're using right now, and you'll need to open another window or tab on your browser to connect. Open your browser and type Kahoot, then enter today's game pin found in the Zoom chat and on screen, and I'm going to give you about 15 seconds to kind of get that connected and work with that. So, join us in our last hands-on webinar of 2024 and click the link in your chat box to register. Now, I would like to introduce the panelists for today's webinar. I'm so excited. We have Dr. Eric Johnson. He obtained his medical degree from the University of Nebraska Medical Center and completed a residency in family medicine at the University of North Dakota. He is board certified in family medicine. Dr. Johnson is the Director of Interprofessional Education, a professor at the University of North Dakota School of Medicine and Health Science, and the Assistant Medical Director of the Diabetes Center at Altru Health System in Grand Forks, North Dakota. Our next panelist is Dr. Eden Miller. She is a family practice physician specializing in diabetes and obesity. She and her physician husband founded Diabetes and Obesity Care LLC in Bend, Oregon. Today, they provide high level diabetes and obesity intervention for adults and pediatrics, utilizing technology and cutting edge research. Dr. Miller's adage for care is that she only succeeds as a provider if she turns her patients into experts on their own diseases. At this time, I'll let our panelists introduce themselves and discuss their disclosures. Hello, I'm Dr. Eric Johnson. I have no further disclosures today. Hello, I'm Dr. Eden Miller. I work a lot with a lot of different individuals, companies, and research. My disclosures are here. Well, welcome and good afternoon, everyone. I'm really pleased to be presenting today with Dr. Miller, with the American Diabetes Association and with Paige. I think this is a very exciting topic for us today. And these systems have really been game changers for many with diabetes. And I think you'll agree when we're done discussing today. Today, we'll be talking about optimizing automated insulin delivery systems with some case-based strategies for individualization. Our learning objectives today are to recall characteristics about automated insulin delivery systems, to recognize the different functionalities of commercial AID systems. We'll identify common barriers to using insulin delivery devices. And we'll also talk about age recommendations for AID systems. So let's start now with a word cloud from Kahoot. What has been your greatest challenge in picking an AID system? Well, we can see that there's a lot of interesting topics here that are brought up. Many choices, which algorithm, different technologies, cost insurance coverage, cost, technological considerations, coverage. We see that several times here. The right fit for the patient. I think we will definitely be discussing that today, as well as constant changes. This is a fast changing landscape to be certain. This is where it all began with insulin delivery devices. This is a picture of the first insulin pump, but actually it's a bi-hormonal system with insulin and glucagon as an intravenous automated system from 1964, so 60 years ago. Now here we are 60 years later, and we're looking at a bi-hormonal bionic pancreas in phase three trials from beta bionic. A lot of us think that this is really going to be an important piece for really developing these systems further. We also need changing sensor technology with dual glucose and ketone measurement, faster ultra-rapid acting insulin that has fast on and fast off properties, along with additional metabolic hormones like glucagon, and that'll truly be an artificial pancreas. However, having said that, I think you'll find that these devices we're discussing today do a very good job and have good performance characteristics. There are some pros and cons to insulin pump therapy in general, not exclusive to AID systems, and all of these problems need to be reviewed when we're considering a pump and empowering the person to live their best life with diabetes. And this has really been a quality of life game changer for many persons with diabetes. Some of the pros are reduction in hypoglycemic events, reduced blood glucose variance, management of dawn phenomenon. This was a big problem for us prior to the advent of insulin pumps. Improved quality of life on a variety of different fronts, and fewer subcutaneous insulin injections, as well as improved insulin absorption. Persons are at increased risk of diabetic ketoacidosis as persons who are using pumps do not have any long acting insulin on board. The devices just dispense rapid acting insulin continuously and with boluses. We need to change the cannula regularly, and this can be complex for different devices, and site rotation is critical for best insulin absorption. For some of the older devices that require calibration, we need to test six to eight times daily with some finger sticks. And cannula site infections, although rare, do sometimes occur, as well as pump malfunction and tube blockage. And then, of course, there's always cost. There are some issues with this. However, we find that many insurance providers cover these devices well for appropriate persons with diabetes. Other points to consider are the ability to use technology, the need to persistently and consistently check blood glucose levels. You actually have to use the device. And of course, the equipment is on the person for all day, every day. There are alarms for highs and lows and trends, for example. Sometimes persons with diabetes can develop alarm fatigue from this. And like with any intensive insulin management program, there can be weight changes. So let's talk now about different devices for insulin delivery. Let's define what we're talking about first. What is automated insulin delivery? Well, right now, every United States pump manufacturer has an AID system available. In 2020, a network meta-analysis demonstrated that among the studied technologies, AID resulted in the most significant improvements in time and range, or TIR, A1C, and severe hypoglycemia, which is, I think, what a lot of us were observing in practice. For most people with type 1 diabetes, the benefits of AID clearly outweigh the risks. And AIDs can be considered for people with type 2 diabetes if they've been on multiple daily injections of insulin or a previous pump system. Now, I'm presenting these devices in no particular order, and I'm not endorsing any particular system. They all have their pluses and minuses and some minor variations in features. The MiniMed 780G from Medtronic is what we call a tethered system. And it has a tube and a subcutaneous cannula that takes the insulin from the pump and places it in the subcutaneous tissue. This device uses a proprietary Medtronic Guardian 4 continuous glucose monitor sensor. And like a lot of these devices, it depends on the user to enter carbohydrate intake. This is very important for best performance. It holds up to 300 units of insulin. And like most of these, it has a phone app with shareable data. And you can see there on the phone app, on the phone pictured here, it shows the blood glucose value plus some graphic data. And then on the device itself, you can see the blood glucose value. And you can toggle through different screens to see things like graphic data. The Insulin Omnipod 5 is unique in that it is a wearable tubeless insulin pump or a pod. That's the thing that looks like a white turtle shell there in the picture by the reader. This device actually goes on the body itself. There is no tube. It just delivers insulin to the subcutaneous tissue. This device can use a Dexcom 6 or a Dexcom G7 CGM sensor. And like some of the others, it's dependent on the user to enter carbohydrate intake. It has a handheld personal device manager that looks like a smartphone display. And this is the device that actually runs the pump. There are no buttons or displays on the pump itself. It has a phone app like the others. It holds 200 units of insulin. And like the others, it has shareable data. The Tandem T-Slim X2 with Control IQ technology is a tethered system as well. Like the Medtronic, it has a tube that goes to a cannula that delivers insulin from the pump to the subcutaneous tissue. It uses the Dexcom G6 and G7 CGM, as well as the Freestyle Libre 2 Plus CGM. Like the others, it is dependent on the user to enter carbohydrate intake. And this one has a touchscreen instead of buttons. So it's a little bit different in its functionality. You can see that the blood glucose value is listed, the time the insulin on board is listed, as well as some graphic data. And you can toggle through to different screens for different information. It holds up to 300 units of insulin. And this device, like some of the others, adjusts insulin to give more insulin when necessary for corrections or to increase basal background insulin. It has a phone app, and it also has shareable data. The Tandem Mobi is a little bit newer pump. It's smaller. It's a tethered system with the tube and the cannula. And the phone app actually controls the pump with this device. You can see the blood glucose value with the trend is listed, as well as some of the graphic data. This doesn't really have a display or much for buttons on the device itself. So the phone app is really a key piece for this. It uses the Dexcom G6 or G7, and like the others, it's dependent on the user to enter carbohydrate intake, either grams of carbs or exchanges for some of these different devices. It has shareable data and also holds up to 200 units of insulin. The Beta Bionic Islet is a tethered system with a tube and a cannula. This one is interesting in that it only needs the weight of the patient to start. With the other devices, you have to enter parameters like insulin to carb ratio and insulin sensitivity factor, as well as basal insulin values. This one does not require that to start. It works with a Dexcom G6 and G7 sensor or a Freestyle Libre 3 Plus, which just became available in quarter four of 2024 for this device. This is the black and white screen version, but they're going to a color screen. And like the others, it is dependent on the user to enter carbohydrate intake, but it's a little bit different. It doesn't require grams of carb or carb exchanges. It's more of a meal announcement where you can enter a usual meal, less than usual or more than usual meal. It has a phone app and it holds 180 units of insulin. The Twist is the newest pump. It's a tethered system, just recently approved in the last few months. It uses an algorithm from Tidepool in a Deca pump. It has a phone app and can be operated with the phone or an Apple smartwatch, which is a neat feature. The CGM is to be announced. We're expecting to hear that anytime. And this holds up to 300 units of insulin. And as I mentioned, this device was just approved and you can see it's a little bit smaller. It doesn't have a display or buttons on the device. It's controlled by the phone app. There's also something called DIY looping or do it yourself looping. We could probably do a whole hour on just this alone, but these are open source automated insulin delivery systems where older pumps and certain CGMs can be used to deliver a closed loop, not a hybrid closed loop. This is very exciting to some people. And this is a fast changing landscape with these particular devices. They're not FDA approved other than the Tidepool loop, which is FDA cleared. There are a number of different systems that are used for this. And we've included some of the websites where you can look these up. But this is really an interesting part of automated insulin delivery systems. But again, not FDA approved. All of these devices have CGM data sharing platforms. They're all proprietary to their particular device to upload to the website or download the data directly. Dexcom's Clarity, Medtronic Care Link, Tandem Source, and Abbott Leray View all have similar data reports. And Dr. Miller will be spending some time on these. In the era of telehealth, this ability to share and remotely monitor data is more important than ever. I have a very rural practice, as you might expect, in Northeast North Dakota and Northwest Minnesota. I have some patients who live 250 miles away from me who I've never met in person. But to be able to view them with high quality video and look at their data at the same time has really been an important piece of management for us. And there are some non-device specific platforms, such as Gluco and Tidepool, that can handle data from multiple different types of devices. So, going to our next word cloud, what are some challenges that patients face with the use of AID pumps? We've got a little under 30 seconds here. Now, we're accumulating quite a few answers here. Looks like cost is coming up for some people, the different varieties in technology, exercise settings. That's a really important piece for this and sometimes underutilized. Data overload, that's a real issue, as well as technology knowledge and uploading data and trusting the device. I think this is a very important piece. And some people just choose not to bolus and just let the device run, which is a little less than ideal and often trying to figure out what mode it's actually in. So let's start with the basic question, which I'm now going to turn over to Dr. Miller. Well, thanks so much, Eric. What a great overview that we were looking at. I mean, to be able to, you know, by no means did we go into the very, very deep thing, but what we're trying to do is begin that conversation because we got to start with the basics and looking at individuals and what is their ability to be able to do this pump and to be able to understand. And so to me, I start at the top. And I ask an individual, because remember my job is to turn patients into experts. My job is to match the technology to the person. So I start very, very simple. I really say, do you want something to be tubed or tubeless? In addition, sometimes there's occupational issues. I know one of the thing was related to cost and coverage. And so one of the tips and tricks I want to say is that sometimes people who their occupation is a hazard for a tubed pump. I mentioned in the documentation that a tubeless might be better. In addition, a secondary pearl for this is if I have an individual who wants to utilize what we call different site locations, it might be that a patch or like a Moby or an Omnipod 5 might be something that would be best suited. So this is the basic question that we have. Are you interested in a tubed or tubeless? I also give them a lot of information regarding all of the pumps. And then I start broad and I go from there. After that, I talk about some of the variables we need to consider. As Eric mentioned, we have different varying amounts of insulin. In addition, there's a brand new indication for one of the pumps, the OP5 for type 2 diabetes, but that doesn't mean that the other pumps by any means are contraindicated, but it really shows that we're expanding beyond type 1. We know type 1 is considered a standard of care that technology and IDD or AID is offered to an individual, but asking yourself how much units you need it to hold because that's going to be a fat burden. You have to change it every one day, two days, three days. And so that's one of the top line things I want for you to think about when you match that technology to the person. CGM integration is key as well. Sometimes people really love the current CGM system they're on, they like how it reports, they like how the length of wear, the different technology pass-throughs. One of the nice things, as Eric mentioned, is every day this is moving so fast, I tell you, stay tuned. 2025 is going to be pairing a lot of CGMs to a lot of different AID systems and it's going to level the playing field. I don't mean that it has to be leveled, but it's going to give people options, especially pediatrics when we look at size and length of wear, application, pass-throughs, whether it goes through a different watch or wearable, but 2025 is going to offer a lot of different integrations and options, including even Medtronic going with the Abbott system, so stay tuned. Now, meal announcement engagement in Carp County, so critical. I know you guys want this pump to put it on and run itself, but I did have a conversation with one of my colleagues because it's challenging, especially with what we call unengaged. In my opinion, an unengaged person is a highly distressed person, so I really try to intervene at that level, but I use analogies. Here's my analogy. We all know what a Tesla is, right? A Tesla is a self-driving car. It's amazing, I've never done it. I think I would probably touch all the buttons and the wheels because I'd hurt the wheel, the steering wheel, I don't know if I could trust it, but I tell kids who are a little disengaged with their diabetes, do you know what a Tesla is? Yes. How do you get into a Tesla? Well, you get in and sit there. How do you make it go? And they go, well, it drives you. I go, but do you have to tell the Tesla where you want to go? And they're like, yeah, and I'm like, it can't read your mind, and I said, your pump can't read your mind, and I don't want you to ignore your diabetes. I want you to tell your pump where you're going, what you're doing. I don't care if it's small, medium, and large, less than usual, usual, or more, fixed carbohydrate dosing, because I'm interested in getting my patients engaged with their disease, not disengaged, because if we have a pump that all we have to do is load it, put it on, and do nothing, then us as clinicians, what purpose are we for there? Because the machine's gonna do it. So we're learning to engage and empower our patients with diabetes, figure out how to do it, take the common and make it common in the AID system. Ask yourself about screens and complexities. What about fingers? Some of people have a little chubby fingers with arthritis. We have trouble going through that. Visual problems, being able to see it. So those are some of those nuances, as well as eases set up an operation. Are you gonna do it as a clinician? Are you gonna send it to our lovely CDC ESs? Are you gonna have the manufacturer help with that? Those are some of those issues. Remote glucose meter, device, apps, and smartphones. I got some parents that want it to go through a pass-through. I want some that don't want to use a smartphone. How to get around that, that's challenging. Can you do a smartphone that doesn't have phone capability and just data or Bluetooth? And the answer is yes. So you might have some of those things. Remember, downloadability and readability is imperative, but you as a clinician, it's not your choice to determine, I only like these pumps. I only like this readability. I only like this download. You should be proficient and fluent in all of those different pumps. How does it look? I call it the on-body wear. How do they like it? What's their adhesive footprint? What about the weight? I have them hold the weight and show the different locations because these are all those people are gonna wear it 24 seven. And so we want them to be at the center of the decision. Alarms and reminders and other features. Do you want predictive? Do you want lost control, a sensor? What are those things to go through? So you can see it's imperative. Now, we're not gonna go deep into the AID algorithms, but I will agree with you. We need to be able to talk about all of them. They're different. They're all like sports cars. One's a Ferrari. One's a Lamborghini. One's a Porsche. They all drive differently. And so that's one of those things that I encourage you to learn those different AIDs and those algorithms and how they are. Are they predictive? Are they 30 minutes? Are they 60 minutes? Because that's gonna empower you to empower the patient of what is the most important component that they want. Now let's transition a bit for frustrations with glycemic control and pumping. I'm gonna be, this is my first thing, not trying to steam the pump and override it. I call it upstairs pumping, right? The pump between your eyes because a lot of people do that. A lot of people have been on different pumps and they go to a new one and they're like, I don't know. And maybe one pump likes to be predictive, 60 minutes. Maybe one's more of a reactive pump. And so you're gonna have to get that person to say, you know what, you need to trust the pump because these devices are really good at preventing hypoglycemia. So I tell them, let's trust the pump because how am I gonna ever know if your settings are correct? If you keep overriding it, you keep touching the wheel, you keep trying to drive, you try to get it out of auto mode, which I get is fine, but I really work on that because if you have settings and they're what I call lying to the pump, I don't wanna sound negative, but they really are. You're not telling the pump details. I had one yesterday. She was having trouble with slight hypoglycemia or variability where you dive with your blood sugars and feel terrible. And I said, are you using the activity mode? Are you using the exercise mode? And she goes, no. And I said, well, you're kind of lying to your pump. And she goes, what do you mean by that? I said, you're doing an activity, but you're not telling the pump you're doing it. You're not communicating. And so that's what we talk about engagement. My first thing, if I can tell you to improve control is to say, please don't override it. I need to know where the pump stands so that way I can adjust from there. And let's make it so you feel comfortable trusting the pump and then we'll go back and do that. Okay, infusion site, rotation. We have a lot of individuals who don't rotate. Some people have been living 10, 15, 20, 30 years with diabetes. And so we gotta understand it's that site choice. And that's why certain types of pumps may offer ability to do some of those different sites. Yesterday, I had a patient who was troubled. She had diabetes for 40 years. And I talk about an angled site. We talk about a steel cannula. For adults, different locations. I have some kids in my practice that are overcome. They have the location fear, right? I only do it on my arm. I only do it on my butt. I only do it on my belly. And so one of the things I do sometimes is I have them be a part of choosing a second site. I know that's your preferred. What's your second preferred? In addition, sometimes the little skinnies, right? The little skinnies that are using different infusion sets, especially the OP5, that on-body. When I adhere it, I tent the skin a little bit. I pull up on it as I do the infusion. It really helps with that. It really helps with that site preservation. You can also use angled sites with those. One other thing that is very passionate. Many of you have heard some of my speaking about provider engagement and really imploring primary care to not abandon the diabetes baby, right? We wanna make sure that they're engaged with that. And again, I'm gonna go back to that when providers are like, I just wanna pump to run it themselves. And so that way when my patient doesn't engage in their disease, it's controlled. I'm like, you know what? That's being a little hyper-empathetic. We have to understand that distress with diabetes or lack of engagement is really these emotional issues. And that apathy does equal overwhelmed. And it might be that that day you become a counselor, that you become an encourager, a cheerleader, and maybe you don't touch the settings at all, but you're trying to say, hey, listen, I noticed that you looked at your phone like 10 times since you've been here, but why can you not look at your pump? And what are some of the things you do every day? I sometimes tease my kids. I noticed you got dressed this morning. I bet that was very hard. And I tease them and I say, you know what? Don't let diabetes own you. You have to own diabetes. You have to have diabetes. It doesn't have to have you. And so you have to meet the person where they're at. You have to try to figure out what those barriers are. Many of them are mental. And in addition, adolescents, new thing I've been doing is again, just small, medium, and large. Can you do that? For some of them, they want to know what those carbs are, 30, 45, 60, or usual or below usual or above, because I tell them your pump works best if you tell it what you're doing. It can't read your mind. And that's what I want you to do because there are those barriers. And not only that, reevaluate them. Don't assume you know them. Ask the person with diabetes, what's the most frustrating part of your disease that I can help you with? And do it every time you see them in your interactions and engagements. Okay, so there are limitations. We got physical barriers of insulin pumping. We got logistical, because sometimes you can have some risk. And then user problems because of external tubing. We talked about safety hazards, right? Getting it yanked out. Why are doorknobs so lethal to certain kinds of pumps? Malfunctioning or mishandling or cybersecurity. I get this question a lot. Does that individual compromise their data? What about if they share it through the cloud? Those are those things you have to discuss. There are some wild stuff. For instance, I have a sweet boy who is in high school and he's going to do a welding class. Anybody on the line ever thought about a welding class and technology in a pump? It can't have those arcs. And so how are we going to manage that? Not only that, there's been some new changes in CGM and use with imaging, right? Some new release with CT and x-ray. Those are those things that are important to understand those barriers and limitation. Also talk to them. What are some of the things? I don't like people to see it. I've heard that before. You've heard it before. I want it to be kind of a little discreet. Me on the other hand, I flash my pump just like it's a badge, right? It's there, it's a conversation. But understand this is that individual's journey. They might feel it's complex. We sometimes think, oh, if you're an advanced age individual, you're not going to be able to use this system. Not true. Show them at the level of cognition it is. Show them that they're able to do it and that they're able to walk through. Have those demos. Understand that that's that unique journey and you're going to honor those things. We all know that there are limitations with adhesives. They're really working on that. In fact, many of us have been involved in that and many of us are finding that it's actually the plastic behind the adhesive that's leaching. And so they're developing these less type of alert, allergenic type of things, but you need to look at that as an issue and provide helpful hints, whether it's flownase before, whether it's a barrier, whether you're using Unisolve when you take it off so you're not ripping the top layer of skin on, whether you're having different locations, whether your footprint is smaller and so they have less of an allergenic response. There's all those things that go into that as you as a clinician to help them overcome that. You know, we talked again, there's a frequent issue of dosing that as you go onto a pump, you might need to reevaluate. How long is your pump lasting? Is it two days? Is it three days? Is it the infusion sites? I know some of them stretch it longer because what is it about being a person with diabetes that we have to be like super cost-effective? Why? Because we don't have any margins. So build those margins in. Build in those extra supply margins for things that fall off. Unfortunately, with CGM, we can't do that as an RX type, but you can have them go to the manufacturer. So those are those things that really lessen the distress of having diabetes by padding the amount of insulin, padding the amount of supplies and pods, allowing them, giving them empowerment to go to the manufacturer to get those replaced, because it's hard to live month to month. Now, I'm going to go a bit, we know that type one diabetes, we all know that the ADA standards of care is utilization of technology with them because the evidence is overwhelming. That variability, that hypo, that protection, and that's why type one is considered gold standard for CGM as well as AID systems. But one of the things we haven't talked about a lot is type two and there's varying opinions. Some are like, oh my gosh, type two is amazing for AID systems, it's so beneficial for them. Oh, they don't need it, they don't have variability. Oh, we don't need it due to, you know, they're pretty static, but the reality is as many of us that are these experts that live and work in the field of type two diabetes, they have a significant improvement of quality of life. They feel like they're more in control, there's less stress related to it. They can customize the basals. Not only that, does anybody on the line have any trouble with advancing basal insulin in type two diabetes, right? We're all have this terrible inertia with it. Not only that, adding another mealtime injection, adding a mealtime bolus, and then advancing from there. What about utilizing pumps from the beginning? Having this basal rate that morphs with them, these adaptive algorithmic pumps that then the individual can be empowered of how to add a bolus administration with the largest meal and going from there. So it really is important. And yes, persons with type two diabetes get hypoglycemia. Maybe not to the degree of those with type one diabetes, but guess what, a low is a low. I don't care if you're a type one or a type two. And many of these individuals with type two diabetes have cardiovascular complications and hypoglycemia for them can be lethal. So it is important to think about it, to expand our idea. We do not do well with insulin and type two diabetes. So why not start at the beginning and let the pump assist, let it assist us. We don't have a lot of time as clinicians too. And so I want you to really plant that seed that those with type two diabetes can benefit from insulin delivery devices because there are numerous studies that are showing out. Like I said, the OP5 is the newest one that had been FDA approved for type two. That means that the other, they're not contraindicated, but it has an actual indication. We see that it helps with inertia with insulin, time and range, improvement in A1C levels, better quality of life for the individual. It mimics that physiologic insulin that they still need as well. They can actually sometimes achieve a 20% reduction of the total daily dose. Why? Because they have too much basil and we know that basil is not a clean insulin. What do I mean by clean? It means that as you get higher and higher doses, it doesn't have the pharmacokinetics and dynamics. So you move somebody to an analog rapid active insulin in basil administration, they tend to use less insulin. In addition, it allows for better eating. They don't have to feed the beast of hypo. They don't have to eat all those different meals. And so it gives them that flexibility and it gives them feedback through that CGM system. In addition, continuous subcutaneous insulin infusion is more effective than MDI in overcoming that inertia and that burden. And we know that if we get ourselves used to utilizing insulin and pump form with those with type 2, it's gonna be able to grow with them as they advance in their disease and they advance in those needs. But again, there are barriers. We understand that. It's an individual choice. There are some literacy issues, but you know what? That's where you get your CDCSs involved. They're amazing. They're so great. I need them. They're like my right and my left hand that they can do frequent follow-ups. I have one right now who doesn't speak English, who goes in, who learns carb counting. We try to go beyond those racial and socioeconomic differences. It doesn't mean you don't offer it to them. I can't tell you how, because of racial and socioeconomic determinations by the prescriber, they don't even offer it. So you know what? Don't let that be a barrier. Understand that technology transcends race and socioeconomic literacy, because guess what? You want something to overcome the barriers. Why not utilize an AID system to help overcome that? They also can feel anxious. I have a gal, oh my gosh, she just came in yesterday. My husband was talking about it because he's the other Dr. Miller that works with me. And he says, you know, this lady hasn't even told her husband she has diabetes. Oh my gosh. Like talk about anxiety. You need to really intervene with that and try. It's a marathon, not a sprint. You got to just try to eke away at that. Not only that, we also have our limited expertise in healthcare. That's why we're having this webinar. That's why we're trying to make it easier. That's why a lot of these pumps have two things in mind. They have the person in mind and they have the prescriber in mind because they're trying to make it easier. But guess what? You have this amazing group. I'm going to shout it out again. The CDC ESs who love this, who live this. If you want to utilize technology, go ahead and identify the person, prescribe it and pass it off to them. And then they're going to help equip you. I still urge you to be able to know how to drive it because you know, it's frustrating when a patient comes in and you as a prescriber, like I've never seen it or touched it. So try to do that. But then it allows you to incorporate telehealth and distance learning. Have you ever started a pump on a telehealth? I have. It was challenging. I did it, but we did it in COVID. We did it back then. We can still remotely monitor these people. And it is so fascinating to be able to bring that to them in this different avenue. Remember, there is emerging evidence in type 2 diabetes. Why would they not benefit from it? Why? Because we have significant inertia in type 2 diabetes and insulin. You and I know it. We can't advance basal. We can't add from the bolus standpoint. So this is what I want to do. I want to open your mind because there are some new things out there that are helpful. Now I'm going to bring you a super cool case. This is one of my patients and it hits all the buttons on so many levels. So I'm going to start it out. So I call it the case of the mistaken identity diagnosis edition. And this is real. I had a 72 year old female. She lives alone. She lives kind of out on, she's got a ranch. She's kind of like one of the original cowgirls and she comes into me and she's doing her thing. And she's been diagnosed with type 2 diabetes 15 years ago. And I asked her kind of what started. And she says, well, it was initially placed on metformin. I'm like, have you been pregnant? She goes, no, but I just felt yucky. And I went into the doctor and they said I had diabetes and they put me on metformin. But she goes, I didn't really respond very well. And I was like, okay. And then she goes at the time and pH was added, one dose and two dose. And she currently comes into me and she is currently on mixed analog insulin. So her primary care provider said, you know what? I'm going to give her fixed dose insulin. I'm going to have it mixed. She's going to be on all the accoutrements of an ACE or an ARB and a statin. And her vital signs are pretty good, right? She comes in, her height to weight ratio is not bad. Yeah, she's a little overweight, but she does not have struggles with what we call class one obesity or above. Again, no family history of diabetes and never been pregnant. And her A1C at referral was 12.7. And she is monitoring her blood sugar twice a day. And she ranges from 110 to 400. And she reports hypoglycemia mainly afternoon. But she also says something to me that when you take all these nuggets, because I know you're good thinkers and I know you're already picking out those little pearls, like, wait a minute, this seems weird. She says to me, my blood sugars are all over the place. And I was like, okay. And so what did I immediately do? I immediately said, have you ever been on a CGM before? Let's try one. Why? Number one, I wasn't sure of where all the places she was visiting. Number two, she is already on mixed insulin. She lives alone. She has type two diabetes. She fits the criteria for technology, right? Medicare covers it. Not only that, it's a danger because she's reported hypoglycemia and the patient lives alone and she's on multiple fixed dose insulin. And so this is an easy slam dunk. So this is the CGM. I put it on her in the office and I had her come back three weeks later. Here's what she said. I said, what'd you see? She goes, oh my gosh, I am all over the place. I'm like, you are, right? And I said, fortunately, we have not seen any hypoglycemia here. She goes, well, that's because I was warned and I prevented it. I'm like, awesome. And she goes, wow, these numbers are really high. And I'm like, first of all, yes they are. But second of all, I immediately looked at this and what did I think? Oh my gosh, you are not a person with type two diabetes. You are something else. And she goes, how do you know? And I said, because I can see it in the CGM. I can see it in your dives, in your insulin sensitivity, in your wide ups and downs and the fact that your height to weight ratio and the amount of insulin that you're on. And so this is what I went through. How did you like the CGM? Like she said, I had no idea my glucose levels were so high and I didn't know the foods affected me. And then I said, have you ever been tested for type one? And the answer was no. And she was positive. She was positive for antibodies related to type one. And I called her up and I said, hey, I've got some news to tell you. I know why you're struggling with your diabetes control. I know why you have such variability. You have type one. And she's like, wow, let me process that for a minute. She goes, that would explain things. Then I said, what would you like to do? And I said, do you want to go on an adventure with me? I said, would you consider an insulin pump? So let's pause for a minute. Diagnosis of type two diabetes for 15 years. First time CGM, new technology, brand new diagnosis, fixed mixed insulin. And I'm going to jump, jump to a pump. Why? Many reasons. I want her to be safe. I want her to have something to run in the background. She's late to the type one party. She's late to the AID party. She's got advanced age. She doesn't have, she has limited technology understanding. Remember I went from CGM on phone and now I'm going to insulin delivery device. And I did, I went there. So I had questions for her. How did you like your CGM? How would you like your diabetes control to be different? What are some of your pain points? What do you wish you could do? Timing of meal activity out on the farm. Do you know what an AID system is? Would that be something that you would consider? How would you like to wear something on your body 24 hours a day? Do you, are you okay with the CGM? What if it remembered you had diabetes when you didn't want to? Do you have any concerns with learning technology? Any of the components, any of the prices? What are the initial questions that you have? And then I asked her, want to go on an AID adventure? And she said, I would. And from there, this is our follow-up. Six weeks, we chose. We continue to her on a sensor that was linked with the pump that she chose. This was after six weeks. Her current A1C is 7.1. Her time and range is 77%. Her less than 70 is 1%, less than 1%. She's doing amazing. But look at what she said. I have never felt so good in my life. I wish I would have started this years ago. It took us two sessions. Yes, I put the pump on. Why? I sometimes like to do that. I know it, I'm a unicorn. I enjoy doing that. I wanted to give her that extra time. I did the pre-pump assessment. We got everything laid down. I did all the vocab. I got all the technology, all the loops and links and things. And then I had her go live. And then I had a follow-up with her on the phone the next day. Just at the end of the day, I checked in with her. And then I saw her in different intervals. And this is what she did. She loved it. She's doing great. She is showing that it doesn't matter your experience, how long you've had diabetes, what your age is. If you match the technology to the person, if you identify those things that they need from their disease, their pain points, and their barriers, you equip them to be experts on their own disease, they will be successful. So let's pause for a word cloud. What are the features of AID that are most helpful to use a clinician? I love that you guys have been interactive. We see a lot of those pain points. And Eric and I would agree, the ones that I've seen are very similar to us. Exercise mode. I just went through that yesterday. I told a person, you know what? You need to announce, you need to talk to your pump like your best friend. It's your glucose buddy. You need to say, I'm gonna exercise. And your pump, I wish your pump could talk back. Thank you very much for that. I'm going to downregulate your basal as well as your target glucose. Remember, activity mode and exercise mode actually is higher than if you are lowering your target. So this is what we find is helpful. Auto mode. Oh my gosh, time and range. Sleep mode. I love sleep mode. I love these AID systems. They are just eliminating hypoglycemia nocturnally. Just amazing, right? Graphs and reports. Oh, that's a whole nother discussion of how do you dive into it? Here's my suggestion. Just look at one thing at a time. What is the first thing though? What's the first thing you need to do when you look at the graph and the report? Make sure they're not upstairs pumping. Because you know what? It's very, very hard to change settings when they're upstairs pumping because you're lying to the pump. You're not telling the whole truth. Okay? So that's what's amazing for us in empowering our patients with this. So Paige, I'm gonna turn it over to you to carry us home. I don't know where my girl, Paige, went. So I'm gonna just keep going on until I hear from her. Here's our five key tips and takeaways. Tips to improve diabetes care, look at these. Match the technology to the person. Technology and diabetes management is for all persons with diabetes. You gotta create a workflow. There's another module out there with workflow that's really helpful. Many of us have worked on that. We've got some tips and tricks. We also got another webinar regarding that. Try to learn the different AID systems. Put a little, you know, get them all there with the different high levels so you can have the patient being informed that it's their technology that they are having with their disease. I'm moving on. You're all eating. You have my back. Always, girl, always. Always challenging with technology. So we are gonna use some time to do some Q&A. Put your questions in the Q&A box. And I'd just really like to thank our panel for their wonderful presentations. We had some questions ongoing. Of course, I think everyone's like me. They always love the stories and love to share those. I'm gonna ask a couple of questions that kind of trickled in in the very beginning. One participant is in an outpatient setting without access to some of the provider settings or sliding scales that they use. How do you deal with that if that is a frustrating limitation? And that would be most likely from somebody that is in a center that you have an outpatient and an inpatient, I'm assuming. Eric, do you wanna take that one first and then I'll throw kind of my thoughts on it? Sure. I'd be concerned here that maybe the patient isn't receiving the proper education that they need to operate their device well. Because if they don't understand their settings, that would be a concern for me. So I think I would go back to that and maybe work with them on some of the basics with that and assess kind of their understanding of what that looks like. So that maybe they can ask the prescribing provider a little bit more detail about what's happening with them. Having access to their data downloads is very important too because some of that information will be there as well. Yeah, and to get access to the data downloads, it's really just you as Team Diabetes is creating an account and then inviting the patient to share the data. You don't have to go into that provider's account to get that data or try to get it from them. Rather, I have many CDCESs, many PharmDs who create their own accounts through CGM, through the different views and then they also invite the patients so that way they can have that real-time data to discuss it. In addition, that's why we're doing these webinars. I have seen very well-meaning clinicians who start to use AID systems and it's kind of like they're not taking advantage of all the resources that the pump provides. They're kind of like taking their old way of doing it and trying to make it fit the AID system. But rather I say, hey, listen, you need to open your mind because this is a new way of insulin delivery and you got to kind of forget the past. That's also a challenge if we were to talk about the different algorithms between the three or the four. We don't have time today, but they are different. If we just for a moment talk about the OP5 algorithm versus the tandem algorithm, the OP5 is a 60-minute predictive algorithm. It's a 30-minute reactive type of algorithm. It's not good or bad, it just is how it is. And so sometimes familiarizing yourself with those to understand that some like the insulin front-loaded, some like it mid-range, and some are better reactive. And so this is that challenge that you have that opportunity for engagement and learning of our clinicians. You're not supposed to be experts. You're supposed to be continuing to wonder and continuing to empower the patient. One of the things to address, you know, communicating the settings kind of across the team. One of the things we started in our practice as the provider would see the patient, there was a part of our electronic medical record that actually had insulin instructions and it actually dumped that data if you filled it out on their aftercare summary, which I thought was really good because we use that to give the patient their settings on their devices, their pump. And we also use it to communicate their pump backup plan on that summary. So I thought that was really a nice change that we just have undergone. This is a question. I have a 62-year-old male patient with type 1 who stopped using a pump because he's very physically active and was getting lows even in exercise mode. Do you have any advice on how to get him to go back on a pump? He's Kaiser, so he also has limited options. I mean, that one's a tough one. I think, you know, one of the things that I really feel passionate about is physical activity and pumping. You know, both Eric and I live with diabetes as well. And so I talk to them about what's the issue you're having. Is it hypo or is it fall off? I mean, I'd have football players, I've had different things. You have to be very creative how to keep it on. You also have to understand this and I'm gonna say this to the group because they're a smart group. I was asked to discuss insulin delivery devices with elite athletes versus just elite athletes who don't have diabetes. And one of the things that this expert on exercise and diabetes was saying is that his clients were talking about how they were having hypoglycemia during events. And I said, what do you mean? And I said, well, they're doing a hundred mile bike ride and their blood sugar goes to 80 or 85 and they have to feed their diabetes all the time. And I said, well, whose fault is that? And they go, well, what do you mean? I said, is that the pump's fault or is it the fact that they're riding a hundred mile bike ride? I said, I bet you the person that's also riding the hundred mile bike ride that doesn't have diabetes also has a blood sugar of 80 and they're having to feed them metabolically. So understand that there is hypoglycemia related to insulin dosing and there's hypoglycemia related to glucose disposal. And so sometimes I'll say to my individuals, you know, wait a minute, your pump has been suspended for four hours. Your blood sugar is 75. Who's responsible? Is it the pump or is it your metabolism? Because remember, we don't know what other persons without diabetes have trouble with. Maybe they're low. It's because they're doing a hundred mile bike ride. So I tell them about what we call neuroglycopenia, severe hypoglycemia, and what's an indication as an elite athlete to just eat. Your job when you have diabetes is not to be able to exercise all day and never get a low. Even people who don't have diabetes do that. So when I reframe it for them, that it's the event and their metabolism and they need fuel and not the insulin, it takes away a little bit of that fear because they're maybe just needing fuel to fuel their activity and not necessarily that it's the insulin and that's the pump that's causing the low. That's kind of how I engage with that particular issue. This is a really good next question. It says, autocorrects after meals can be a pain. If you go out for a walk after dinner, then get unwanted corrections and hypoglycemia on the walk. I think this is still a good opportunity to be using an exercise mode in advance. Sometimes people flip the exercise mode on at the time of exercise. And actually it works better if you do it 30 to 60 minutes before. You may have a temporary target that's a little bit higher. And of course that's going to blunt some of those responses from the algorithm later. So that would be my suggestion is just get into it sooner. That's a really good point. So I use the, of course, I'm always the one trying to create comedy and that kind of thing. Imagine you've had a meal and your adaptive corrections, your adapted basals or boluses are chunking along and then you just tell the pump like, you know, an hour and a half later, hey, I'm going to exercise right now. The pump's kind of like, well, I just like corrected you for your high back there. So I really would appreciate a heads up before that because I wouldn't have corrected you so much. So I take, I do that exact approach as Eric. If you wake up in the morning, your glucose is pretty steady, meaning you haven't had insulin on board. You haven't had autocorrects. You're pretty flat. I might do a little snack, put it on activity mode at that time. But if you have variable glucose, if you have eaten a meal and you're like, hey, I'm going to go to the gym and you're doing it an hour and a half later, absolutely give it a heads up because you can't undo what the adaptive did to try to get control. And then you just decide to spring on the pump that you're going to go for a walk. That, I think exercise really is difficult for patients. I had a, I just had an anesthesiologist tell me, he said, I'm about ready to give up exercise as a type one. And I'm like, don't do that. So we kind of came up with a game plan that like Eric was mentioning, we cut on exercise activity about 60 minutes before, because he always exercises at the same time of the day after he gets off his shift. And he decided he was going to do like a high carb, low carb, high protein snack, like 15 minutes. And if he gave, he was going, he came up with the idea of giving like a minute little bolus. So it would cut any kind of auto-correction boluses off for the next hour while he was exercising. So I haven't seen him yet. So we'll see how that goes. And it depends on the type of exercise too. I've worked with a number of division one athletes over the years here at University of North Dakota. And it depends entirely on the sport. Hockey is more difficult than baseball, for example. So not all exercise is exactly the same. Can you discuss how the main AID algorithms work and why one might suit a better, a patient better than- I know we talked about this Paige, Eric. We need to have a forum. We need to have a forum at the ADA that has every single one up there. Oh my gosh. I mean, I'll tell you my opinion, Eric can tell you your opinion. We don't know all the different algorithms. They haven't told us. Even though we impact with them and we're on advisory boards with them, they haven't told us. We have, there's different nuances. There's different percentages of correction. The Omnipod 5 algorithm, in order to accelerate it, you need to change your target. That's the takeaway. Target is key in the OP5. Don't adjust the basal. Target is key. And then total daily insulin, engaging with the pump to say, you increase your total daily insulin by announcing meals. If you don't announce a meal, it's going to go out of the auto mode because it won't allow you to run on its own. Again, it's a 60 minute predictive. So that my message with that is it's a predictive pump. It likes insulin at the front. It doesn't correct the highs as fast in the end because it's so good at hypo. So I tend to shift more insulin at the beginning. The Tandem has a more aggressive correction at the end. May not have as good of hypoglycemic data, but that's, I'm not here to say good or bad. It tends to have a different suspend rate when it comes to hypoglycemia. It has a little more aggressive correction and has less upfront and has more in the tail end. The Medtronic, you can kind of ignore it. And the Islet, you can kind of ignore it. And it does a decent job of getting most people under eight in terms of the unannounced meals. But again, not interested in people not engaging with their pumps. Eric, what other things have you noticed with using these algorithms that we kind of have to guess what the algorithms are? Well, I think that's the actual crux of the matter is it's kind of hard to know. And even with individuals on a given day, one algorithm might work better than another in a particular situation. So I think a big piece of this is engaging with your pump and using the advanced features. I think that really helps a lot with many of these and just knowing when and how to deploy them is the way to go. And probably take home, really address the upstairs pumping and not trusting the pump. Make the pump settings so the person trusts it and then go from there. Because when you add the variability of the brain, it's very hard to track that. Yeah, absolutely. I see that exactly. So a really good question for someone that was on a pump for over 10 years ago and they had just gotten back on one and they were always worried about scar tissue is what their problem is and causing problems with insulin delivery. Do you still see a lot of cases where patients that have been on pumps for a very long time or does the new technology help with that alleviate those problems? Go ahead, Eric. I don't think I've seen a huge change in that particular issue. Sight rotation is so critical that if you're like me who's had type one for a really long time, that can be a real issue. I also try to make sure that I'm avoiding areas that maybe I have overused a little bit more recently so that they don't become scar tissue and they get a chance to rest. So it's kind of a two-part system, really two different levels of what we're talking about here. Something that was chronically overused for years, that site is probably gone. Ones that potentially could be overused, I definitely try to rotate away from those for a while so they can heal. Yeah, that's well said. So another good question is, can you discuss the difference in how the different AIDs adapt bolus dosing? You know, that goes to the algorithm. It does, yeah. It's hard because even, like I said, I work at a very high level with many of the pump manufacturers and I'm constantly guessing, trying to fill in the blank and trying to get them to tell me and they still haven't told me. There, it's all what we see experientially and that can be difficult to do. But I think that's one of the things that we need to be able to work on clouded by lack of scientific data, because you're getting my opinion and Eric's opinion. I do know that, first off, settings are not universal. You're not going to take your pump settings necessarily and go OP5, tandem, Medtronic, and there's the same. That's the first thing I want you to understand. Those are basic foundational settings that are going to be adapted by the pump. They're just suggestions. For some of you who do these really weird basals like 0.5 for everything, don't do that. It takes longer for the pump to adapt. If you are in manual mode, then you're really, again, lying to the pump. Do the best you can to get a good foundation and good insulin to carb insulin sensitivity and correction, as well as insulin on board. But from there, you got different targets. The Medtronic, what does it go down to? 100, I think. The tandem is 110 with a 5-hour IOB. The Omnipod 5 is a 110 with a customizable IOB. You have different LEDs, so there's differences right there. The algorithm going forward, it's 60 minutes for OP5, 30 minutes for the other. You can see it's a different predictive. That predictive algorithm, that forward looking is going to depend on when it suspends. Some have said when you use the OP5, you need more with mealtimes. It's possible. It doesn't mean that your settings are worse. It just means they're different. Remember, we're now entering into a realm of the timing of insulin matters more than the amount. Maybe not more than the amount, but it really is the timing. Pre-bolusing is so imperative. Hardly anybody has a low when they bolus early enough with their best guess of carbs. When do we get lows after correcting? That's kind of a help a bit with the algorithm. It doesn't tell you all the, oh, it's doing every five minutes, every kind of thing. I would rather deal with the problems that I see or the barriers more than the algorithm. It's one of those big things. Upstairs pumping, not pre-bolusing, not announcing meals and overriding the pump. Those are kind of the top things. So before we end today's session, I want to explain what to expect from this point on. Later today, you will receive a post-test by email. Please complete it so you can claim your continuing education credits. Look for today's webinars recording on the ADA Institute of Learning page in a few weeks. I just want to make sure someone asks if the slides are going to be available. Remind any fellow members that they can watch the webinar for one continuing ed credit eligible until November 2025. I just want to thank all of our panelists today. You guys have done a great job. And I want to thank all the participants in joining us. And we hope to see you at another ADA webinar. And remember that's on December the 10th. And this concludes our session. And you guys have a great afternoon. Thank you, everyone. Dr. Miller, as always, great to see you and work with you. Eric, a pleasure. And thanks, Paige. Thank you. Thanks, guys.

diabetes care

automated insulin delivery

AID systems

individualized care

MiniMed 780G

Omnipod 5

Tandem T-Slim X2

insulin pumps

type 2 diabetes

patient-provider communication