Everybody, my name is Dr. Bob Gabay, and I am the Chief Scientific and Medical Officer here at the American Diabetes Association, and I'll be moderating today's session that is Initiating, Intensifying, and Deintensifying Insulin, and this webinar is part of a broader effort by the American Diabetes Association called Overcoming Therapeutic Inertia that is supported in part by Synophe Diabetes. So what is therapeutic inertia? In essence, it is the delay or inaction to either initiate, intensify, or when appropriate, deintensify therapy when glycemic goals are not met. So someone's A1C is not in the appropriate range, and no therapeutic change has happened, and that's what we'll be talking about specifically around insulin, and the reason this is important is that we know that this has a lot of negative consequences for people with diabetes in terms of their risk of complications in a number of different ways. There are a number of studies that demonstrate that. Also as healthcare professionals, health systems, and overall for the cost of care to society. So you can find out a whole lot more information about this important initiative that ADA is leading at our website, and we'll put that information in the chat, therapeuticinertia.diabetes.org. There'll be videos, podcasts, practice improvement resources, and please share that with your colleagues as well. It's all free for you to access. One of the things we've heard from a number of health professionals is that they could use more guidance on initiating insulin, the logistics of that, how to best intensify, and when it might be appropriate to deintensify insulin therapy, and so that's what we have. Today we're joined by a group of incredible experts that you'll hear from in a moment, and they come from three different settings, from a large healthcare system, from a primary care clinic, and from a federally qualified health center, and they're going to share some of their best practices to ensure the right treatment at the right time for the right patient, and essentially overcoming therapeutic inertia. I'm going to let the speakers each introduce themselves and start with Allison. My name is Allison Everett. I'm a registered dietitian and a certified diabetes educator. I supervise a small team of five registered dietitians and certified diabetes educators, and we are embedded in a primary care system, 14 clinics associated with UW Medicine. My name is Kevin Pantalone. I'm an endocrinologist at Cleveland Clinic in Ohio. I currently serve as the director of diabetes initiatives, which essentially means working with others across the organization to improve outcomes of patients with diabetes that are managed by our health center. I'm Marisa Rowan. I'm a clinical pharmacist for El Rio Health in Tucson, Arizona. I've been fortunate enough to work within this federally qualified health center for the past 20 years, where we utilize collaborative practice agreements, where the pharmacist is able to have a direct provider role. Great. Thank you. And here are the disclosures of our speakers, and you can see next the agenda that we'll be following. And maybe just let me, you know, as Marisa said, this is meant to be interactive, and so we'll ask you to type in your questions and comments in the chat. We'll look to cover as many of them as we can during the session. We hope we'll have some time at the end for questions as well, and we'll be having some polling questions, some multiple choice things where you can all respond anonymously and give us your thoughts. So please participate in that, and you'll see that on the webinar screen as well. Without further ado, I'm going to pass things over to Allison to start talking about initiating insulin therapy. Thank you, Dr. Gabay, and thanks again to the American Diabetes Association for providing this webinar and also for including a diabetes educator on this important topic and how we can contribute to reducing therapeutic inertia and patient barriers to getting started on insulin. So let's meet Annette. She is a 66-year-old woman that was diagnosed 18 years ago with type 2 diabetes. Her current A1c is 11.4%. Six months ago, her A1c was 9.8%. Her current medication plan of what she's currently taking is metformin, 1,000 milligrams twice a day, glimipiride, 4 milligrams per day, and a review of her glucose meter history reveals that she has checked her blood sugar six times in the last month, and the reason why she is in a diabetes education appointment today is two months ago with her A1c going up, her primary care provider in our system started her on or asked her to initiate 10 units of Glargine at bedtime. Well, she returned two months later, and she shared with her provider that she'd never started taking it. She felt that no one had explained to her how to use it. She shared with a good friend that she needed help, and her friend suggested a YouTube video, but she doesn't have a computer or a smartphone, so she was really just feeling unable to start. Also, it should be noticed that her last session with a diabetes educator or registered dietitian, for that matter, was 18 years ago when she was diagnosed. She's accompanied to our session today by her daughter, who is quite concerned about her elevated A1c, so when you are referred, when physicians and APPs in our primary care network refer a patient to diabetes education, the thing about our role and our contribution is we have the luxury of time. An initial appointment is 60 minutes with a patient, so we have about 30, 40 minutes where we can do a thorough assessment of kind of what the baseline knowledge of that individual is as well as kind of what makes them tick and finding out what barriers are. Annette shares with me during her assessment that she eats breakfast every day, but she usually skips lunch, and her biggest meal of the day is dinner. She's really upset about having to start insulin. She doesn't like needles, and she keeps repeating that, I haven't changed anything. I've been trying to do all the things my doctor tells me, and how could my A1c go up? So she's really baffled about that. Because she's starting on insulin, I want to know how she treats the low blood sugar, because that is a side effect that many patients are fearful of. She reviews that she hasn't had a low for a while, but when she did have lows previously, she drank a big bottle of juice or soda, anything to make that feeling go away, and had a peanut butter sandwich. As part of my assessment, I mentioned that we do pre-knowledge, and I have a form that the patient fills out, and she shares with me that she forgot her glasses today, and that her daughter is going to help her fill it out. So I would ask you, what is your assessment of what's going on with Annette here? Do you foresee, do you see any gaps? And you can type this in the chat, share with the fellow participants of the webinar today, but does she have any gaps in her diabetes self-care knowledge that you might see from my little overview, or does she have any barriers? I'll just spend a minute here. Yes, definitely fearful around the initiation of insulin. Yes, what's going on with her inability to read, and definitely some knowledge gaps. So to start with, my assessment was that she did not understand that despite valiant efforts to do everything that her physician was asking her to do, that diabetes type 2 is progressive. Definitely she doesn't like needles, and that she has a history of over-treating lows, and barriers, especially in somebody that we're going to be titrating insulin on, not checking her glucose level is problematic in terms of getting her to her glucose goals. And yes, not reading, not having her glasses definitely kind of cued me in that she might have some health numeracy or literacy issues, and I have a quick little survey that I can do, and definitely determined that she had barriers to being limited reading skills. So in terms of the diabetes education that were provided, I reviewed, in a visual way, the action of her glarging insulin, and also spent some time talking about the progressive nature of type 2 diabetes. And then an approach that we use is see one, teach one, do one. I showed her how to take an insulin injection, and then I taught her how to give an insulin injection, and then I used the teach-back approach to have her tell me, assuming that I, you know, pretending I was a person that was new to an insulin injection, how to administer insulin. I also reviewed treatment of lows using the rule of 15, so important when somebody's starting on insulin, and because of her visual limited reading ability, I wanted to make sure she knew what I meant when I said how much to treat. So we use this strategy of a rule of 15, where we talk about 15 grams of carbohydrate, and actually describing for glucose tablets a half a cup of juice or a half a can of soda pop for her to know how much to treat, and then to check in 15 minutes, and then to see a number over 100 on her glucose meter, and if not, to repeat that treatment and recheck in 15 minutes. Also, how to record glucose checks in her logbook. We're starting out with fasting checks and bedtime checks, and then how to contact the office in the future. In terms of working with a patient that likes visuals, we described, I described a little bit about what happens, this first figure showing how insulin is normally secreted by a person that doesn't have diabetes. This person was eating breakfast, lunch, and dinner, and we see a squirt or a secretion of insulin following that carbohydrate component at those different meals, but also showing her that there is a little bit of insulin secretion between meals and overnight. So 50% of the total daily dose, you know, of insulin or that's made is that long-acting or between meal insulin, and then the other 50% is in response to the blood sugar raising effect of the meal, and what I'm doing is trying to plant the seed that if the long-acting insulin depicted in the upper right-hand corner is not effective in getting her to goal, that in the future we might need to add a mealtime dose. And then here is a handout that I use for patients with limited reading just to show in a visual way the treatment of Lowe's. I make sure she's got those follow-up appointments scheduled. I'm not going to send her to the front desk to schedule these follow-up appointments. I'm going to do it right there in my office to make sure that those appointments get scheduled. I'm going to call her in a week and check in with her, and then she's going to come back and see me again in two weeks, a month, and then the soonest that we could get her back in for her provider was three months, and this is often the case in our primary care network, and that's why our institution has instituted organization-approved diabetes medication adjustment and policies and procedures to allow a patient that's working with the nurse care manager or the dietician or diabetes educator that we can titrate or up or reduce insulin doses between visits. And this is just a guideline that we have. We use the American Diabetes Association kind of algorithms. We made them a little bit more conservative for our institution, but showing that a patient that is started is that as a nurse or a dietician that has demonstrated competency in these guidelines, we can make these adjustments to the patient's insulin doses as we are working with them. So with that, I think I'm going to tee it off to Kevin. Thank you very much, Allison. That was great. I just want to highlight that as a part of this Therapeutic Inertia Initiative, we conducted a systematic literature review and published a paper that highlighted that interventions via an empowered team of caregivers actually has a more meaningful effect on A1C goal attainment than actual provider interventions. So it's really important that we leverage our team approach to diabetes management because it can have a very significant impact on our patient's A1C goal attainment. So we're going to move forward and talk a little bit about intensifying and de-intensifying insulin in patients with type 2 diabetes. So Dr. Gabay mentioned the definition of therapeutic inertia, but just to highlight this one more time, it refers to the failure to advance therapy or to de-intensify therapy when appropriate in instances where patients' A1Cs are above target and nothing is being done. That is by definition therapeutic inertia. So our hope is through this webinar that we will learn how to identify and overcome these barriers in routine clinical practice, particularly when it comes to insulin therapy. So we're going to start with a case. This is Esther. She's a 56-year-old woman. Weight is around 80 kilos. Her kidney function is good. She has a seven-year history of type 2 diabetes. She's currently receiving the DPP-4 inhibitor citagliptin 100 milligrams daily, metformin 100 milligrams or 1,000 milligrams twice daily, and 50 units of insulin glargine at bedtime. Her A1C, however, despite this regimen is 8.3 percent. She is very good about checking her blood sugars. She has followed up with our educator team. She feels very comfortable when it comes to managing her diabetes. But I think when you look at this profile, you can identify a pattern of glucose control. And so I want you to just take a look at that and look from the pre-breakfast values to bedtime on a daily basis. And if you don't mind, if you can put into the chat what some observations that are being made. So that's a very good point. Too much basal insulin. Her fasting blood sugars are lower. Someone says she might need pre-meal bolus insulin. And certainly, you know, I think what this highlights here is that if we just stick with fix the fasting first and we only paid attention to the fasting sugars on this patient and we did not have any of the other data later in the day, we would think, oh, this patient's blood sugar is a goal. But there's a disconnect. If the A1C is in the 8 percent range and her fasting sugars are essentially 70 to 90 milligrams per deciliter every morning, clearly her blood sugar must be high at some point if it's not high in the morning. And I think the answer here is you can see that it progressively rises throughout the day, peaking at bedtime. So what is the most appropriate next step in this patient? A, move the existing dose of insulin glargine to the morning. B, increase insulin glargine to 60 units, add an SGLT2 inhibitor, or D, add glipizide. And we'll go ahead and take about 15 seconds. So what is the most appropriate next step? Some had suggested moving the existing insulin dose to the morning, increasing the insulin-glargine dose to 60 units. That would be problematic because we would probably drive those fasting sugars that are currently in the 70 to 90 range down even further. And moving the dose of the once-daily insulin-glargine in most patients on this dose of insulin with this level of insulin resistance is also not going to solve this problem. Adding glipizide is essentially going to increase the insulin secretion in the background and essentially have an effect on driving down those fasting sugars, but it's not going to have an effect on improving the postprandial hyperglycemia that is observed to be a progressive problem in this patient. They were starting out the day very nicely and then every little time they ate a meal, you could see that the patient's blood sugars progressively got higher and then peaked at bedtime. So the correct answer is C, add an SGLT2 inhibitor. Why may that be? Well, that is because the SGLT2 inhibitor, oh, before we get to that, I guess. So just summarizing the observations that we've made from this case, that the patient's blood sugar is currently dropping considerably overnight. You saw bedtime blood sugar values in the 190s to 220 range, yet the patient is waking up in the 70 to 80 range. So when you have a patient who's dropping their blood sugar by that much through the night, that is a concern because that patient would be at a very high risk of hypoglycemia, particularly if they went to bed with a blood sugar that wasn't in the 200 range. And sometimes you may not have all this information in front of you, like a blood sugar log that's very detailed here that Esther was taking. So that is where CGM or professional CGM could come in as a valuable tool to hook the patient up to, to identify these patterns that may be being missed. Insulin overbasalization increases costs and the risks of side effects, particularly hypoglycemia and weight gain without really providing an additional benefit in managing patients with type 2 diabetes. And so what the real problem here is that what happened is everybody kept going up and titrating that basal insulin and making sure those fasting sugars look good. But the reality is that the sugars later in the day were too high and those should have been addressed prior to going up further on that basal insulin. So this lack of an impact on glycemic control here in this patient on this regimen is likely due to the failure to add additional agents, which target postprandial glucose. So who are the patients who are at particular risk of being overbasal insulinized? Well, in many patients, a basal insulin dose of about 0.5 units per kilo is kind of that high end of the sweet spot. Once you start getting up into 0.7 and one unit per kilo, not in all patients, but in many patients, that is overbasalization. Then, as in this example, if the blood sugar at bedtime to the morning differential, the BAM, is 50 greater than or equal to 50 milligrams per deciliter, that also means that the patient is likely being overbasal basal insulinized. So when you subtract that bedtime sugar from the morning, if you consistently see a difference of greater than 50 points, you're giving too much basal insulin. And what you really need to do is decrease that basal insulin and add something that's going to address those postprandial excursions. Another tip off should be if you see elevated postprandial glucose values above 180 milligrams per deciliter. If the A1C is above target, as in this case, the A1C was 8.1, but the fasting glucose profile looked good. That's another indicator of overbasalization. Hypoglycemia, if patients are aware of it, or even if they're unaware of it, is another good sign that you're getting too much background insulin. And then if patients have a high degree of glycemic variability, that is also oftentimes a concern that they're getting too much basal insulin and that you may be seeing these excursions because people are constantly overreacting to low sugar values or trending low or high sugar values. So we want to avoid these. And that's why it's very important to recognize when you're getting to the point of using basal insulin and that dose is getting to the point where the patient's clinical parameters are suggesting to you that the basal insulin dose is getting to the point of being too much and that you need to change your approach to management. So here, again, this is the glucose profile that we shared at the beginning of this case. You can clearly see the fasting sugars in the morning look very good, progressively rising throughout the day, peaking after the biggest meal at dinner. So the bedtime sugars in the 200 range are of no surprise. So the problem in this patient is postprandial hyperglycemia, particularly after that largest meal dinner. So adding an agent that will help with postprandial control is the solution. Certainly you could add mealtime injections of insulin, maybe at the biggest meal or at multiple meals, but we would not want to move to such a complicated and cumbersome regimen very early in the disease process. You want to try to reserve prandial insulin for later down the road as long as possible, because that's really when the management burden of diabetes really gets to the patients, is when you add that bolus insulin. So adding an agent here that will help with postprandial control, such as an SGLT2 inhibitor, or you could even consider switching this DPP4 inhibitor to a more potent form of Enkerton therapy, a GLP-1 receptor agonist, or a dual GIP-GLP-1 receptor agonist, would be very good options in this patient to help with the postprandial hyperglycemia. So that would be what I would choose before adding additional insulin injections, simply because we are wanting to try to improve control, but do so with that least burden as possible. Now here is another very important issue, is that in the event here in this patient, if we did add an SGLT2 inhibitor, that's going to improve these readings later in the day. So if her bedtime blood sugar is now 120 and she drops this much through the night, 100 points, she's going to have an EMS come to the house and have a severe hypoglycemic episode, which is really going to become a barrier to further intensification, because patients understandably do not like low sugars. So when you add an agent to help address this postprandial hyperglycemia in a patient who's already on insulin, a dose of insulin glargine like this, who's over basal and insulinized, you need to lower the dose of that basal insulin, because the basal, the fasting blood sugar is already at goal. So again, if we made that bedtime sugar look 120, 140 by adding the SGLT2 inhibitor or adding a prandial dose of insulin at dinner or switching the DPP4 inhibitor to a once weekly GLP1 or GIP GLP1 receptor agonist, and we did improve those blood sugars nicely near bedtime, the patient's going to have a severe hypoglycemic episode if you don't correct and back off that over basalization that is currently going on. Okay, so intensification sometimes also has to occur with a de-intensification in order to address the primary defects in someone's glycemic management. So follow-up, dapagliflozin 5 milligrams daily is added and insulin glargine is reduced to 35 units. The patient was referred to a diabetes educator and nutrition. The patient began following a carbohydrate controlled diet, trying to limit carbohydrates to 45 grams per meal, and her follow-up A1C six months down the road was 6.8%. So it wasn't just the changes we made, but also reinforcing the education, reinforcing the nutrition component also clearly had a role in improving this patient's A1C upwards of one and a half percent. And we were able to do it very safely and effectively leveraging the team approach. So let's fast forward 15 years. The patient is now 71 years old. She had a myocardial infarction five years ago. She underwent bypass surgery with three vessel cabbage. She continues insulin glargine, dapagliflozin, sitagliptin, and metformin, but now her A1C is 9.1%. Well, the patient came to the appointment and she forgot her meter. I know this never happens, but I'm kidding. Obviously this happens all the time. It's very difficult to manage patients who are receiving insulin therapy or complex regimens when you don't have the data to make the right decisions. She says her blood sugar's fair, tends to run higher in the morning than in the evening. She notes her morning blood sugars tend to run around 160 to 210. She says now that dinner tends to be her smallest meal. She doesn't really have much appetite late in the day. So, you know, she feels that she's doing pretty well and she denies having any hypoglycemia. So we have an A1C that's above nine and the blood sugars are running high in the morning. And the question is, what do we do? The next step, do we increase insulin glargine? Do we add glomepiride one milligram? Do we see start GLP-1 receptor agonist therapy or none of the above? And I see somebody in the comments is recommending CGM. Certainly that would be a good option here to gather more information to help make the decisions. All right. So increasing the insulin glargine, while that is an option, as well as increasing the dose of glomepiride, that certainly would help the patient push down the fasting sugars a bit more. But, you know, in this patient, I would argue we really don't have enough information at this point. We know that her blood sugars are high in the morning, but we don't know really whether they're rising from bedtime until the morning or whether they're high all day. We're just kind of going by what she's telling us. But, you know, she probably doesn't remember really all the details of her day-to-day diabetes management. So, you know, really getting a blood sugar log, having them stop back and download the meter, arranging a follow-up appointment would be very valuable. And so I also believe starting GLP-1 receptor agonist therapy here is not the correct answer because I don't believe we have enough information in this patient yet. It would certainly be indicated given the A1C elevation in many cases, as well as the fact that this patient has established cardiovascular disease and would benefit from CB risk reduction afforded by specific GLP-1 receptor agonists. But in this condition, I think the correct answer based on what we have right now is none of the above. Okay. And the reason is as follows. We can see here that her blood sugar in the morning, actually when we have her check and write it down for a few days, her blood sugar is consistently in the morning, you know, above that 120 range. There's a lot of above the 120 fastings. We see that she persistently runs high around lunch, dinner, and then bedtime because she doesn't eat much for dinner. Her bedtime sugars actually tend to be the lowest. And so we see here some days at bedtime, she's 120. She rises up to 190. Other days she's 118. She rises to 170. And then there's a day where she's 150 at bedtime and she wakes up at 135. So in this instance, remember she said she wasn't having hypoglycemia. And so I think this is a big mistake. You can't just say to the patient, are you having hypoglycemia? Because she said no, and she wasn't lying. But the reason she wasn't having hypoglycemia is because she skips her dose of insulin glargine when her blood sugar is less than 120, because she's fearful of low sugars, because she had a very severe low about six months ago. So her variable and inadequate control in the morning is actually because she's not taking what we think she's taking. It's not because she needs more therapy to help her improve her blood sugar. So again, upon further questioning, the patient reports of having had a severe low blood sugar about six months ago. And since that time, she reports only giving half her dose of insulin glargine if her bedtime blood sugar is less than 150. And on further questioning, she says if it's less than 120, oftentimes she won't give it at all. So the reason this patient's A1C is probably high is in part because she is not taking the insulin doses that she should be taking. So the next step in this patient, variable blood sugar values are related in this case to variable dosing of insulin. Getting the data, looking at it, and reviewing it with the patient in a manner where you get as much information as possible, really provided us with the missing information that she wasn't taking what we thought she was taking. So more therapy is not required. Her A1C is high because she is not taking her existing therapy, insulin glargine as prescribed. So the correct approach would be to de-intensify with a reduction in basal insulin to ensure daily adherence and then reassess. Had the patient come back and her blood sugars were consistently in a good range or were made slightly elevated, at that point, I think eliminating the DPP4 inhibitor and adding a GOP1 receptor agonist that can provide cardiovascular risk reduction would be something that should be discussed. So hypoglycemia sometimes requires a different approach to questioning in order to identify it. Sometimes it's best to run through various scenarios. You know, Mrs. Smith, I see some days your blood sugar is very high in the morning and other days it isn't. You know, what do you do when your blood sugar is 150 at bedtime with your insulin? Oh, you take all of it. Okay, but what if it's 80? What would you do to your dose of insulin glargine? Would you take all of it or would you reduce it? Oh, you don't even take it. Okay, Mrs. Smith, it's clear that your blood sugars are elevated some mornings because you're not taking the insulin. So again, it's very important to ask the questions the right way to get the right information. Simply asking this patient, are you having low sugars didn't give us the answer we needed. She told us she wasn't having lows and she didn't lie. She wasn't having lows, but she wasn't having lows because she wasn't taking the insulin as prescribed. So remember the importance and the approach and how we ask the patients the questions. So follow-up, the patient's insulin dose was reduced by 20%. She's been taking the therapy consistently at bedtime. Professional CGM was performed and confirmed adequate glycemic control. Her follow-up A1C was 7.4%. Her individualized goal was less than 7.5% given her age, insulin therapy, and cardiovascular history. But even though she's at her individualized A1C target, there would still be an opportunity to optimize her regimen again with stopping the DPP-4 inhibitor and adding a GLP-1 receptor agonist that may help reduce cardiovascular risk as well as perhaps further improve control and help us to eliminate or reduce her current insulin requirements further. So we wouldn't be done with this patient. There's certainly other options, but it highlights that getting the more information is the right answer before adding a new therapy such as a GLP-1. So having said that, I will now hand off the presentation to my colleague. Thank you very much for the excellent two presentations before this. And I'm going to talk to you, as I mentioned in the introduction, about the role of overcoming barriers specifically related to the pharmacist role, but more specifically the role of federally qualified health centers with their integrated care model in helping those who are uninsured and or underinsured. So let's talk about Richard. So Richard is a 63-year-old man with type 2 diabetes for the last 25 years. He's been employed for about the last four months. Prior to being unemployed, he had managed and worked in his family-owned business, which was quite successful. He unfortunately experienced a divorce that he described he got the short end of the stick. So he, for a little while, was living out of his truck and had no problem getting to and from meetings he needed to do to run the family business, could easily get to work, sometimes even slept at work. But through challenges that occurred, he then lost his business and found himself experiencing homelessness. So he was living in a park here in town and he lost insurance coverage. He lost the ability to pay for basic necessities. He had really no limited, excuse me, no support system and was quite limited with anybody who was willing to help him with his current situation. And he was experiencing significant issues related to food insecurity. So when our outreach worker met him, so we have a street team outreach, which is nurse practitioners who go to local shelters, that's where they encountered Richard. And so because they have a regular presence in the different shelters around town, the nurse practitioner recognized him as someone new. She went over and talked to him and started understanding his story. And so it intrigued her because there are a lot of things that she felt like she, as being part of the federally qualified health system, could help with. She also wanted to look at his medical needs. And so here we have his objective data. So first of all, you see labs from when he was insured and was connected with a primary care doctor back in May of 2021. He had not, he wasn't far off from his goal A1C with an A1C of 7.8%. And through conversation, he did volunteer. The main reason it was challenging to get all the way down to seven is because he loved the food he cooked. Working in the food industry, having a restaurant where he oftentimes was the cook, he'd nibble here and there. And so it made it a little bit challenging, but overall he did pretty well. His renal function was stable. His weight was about 176 pounds, which for him was reasonable based on his height and his blood pressure, again, not optimally controlled, but was able to attribute that to lots of caffeine to keep everything running and probably a little more salt than he should. Now, when we're encountering him in the context of a shelter, which was August of this year, his A1C had a huge jump. So his A1C had gone from 7.8 to 12.4%. His EGFR had decreased significantly. His weight had also decreased significantly, which was a little concerning. And then his blood pressure was not optimally controlled. Now, these labs from August of 2022 were not drawn in the shelter, but rather were found as the nurse practitioner looked through emergency room records. So unfortunately, Richard while living in a park had been found unconscious one day and 911 was activated and he was transported to the hospital. So at the time of admit, they drew the labs that we just looked at, but there were some other things that were concerning. Before we go to what they found and some of the medication regimen that he had been on at that time, I'm gonna pause and again, like the other panelists asked you to participate via chat and answer two questions. What do you see are the immediate priorities for Richard and what are you most concerned about related to his objective data? So thank you. Declining kidney functions come up a few times. So yes, great responses, lots of responses related to renal function and blood pressure. Thank you for the issue about food insecurity. Great. So yes, we are worried about his weight loss, worried about the rapid decline in his kidney function. What does that do to the increase in A1C, the change in his blood pressure control, all very appropriate. So when he presented to the emergency room, obviously they knew he had been found in a park and that he was unresponsive. His unresponsiveness was actually due to hypoglycemia. At the time the paramedics responded, his blood sugar was 37. He was appropriately treated in route to the hospital. So during the HPI, after he was stable and had kind of, gotten back on his feet, he volunteered that he'd had these major life changes. He lost his support system. He lost his insurance, his health insurance. He had no money really to pay for anything, much, no food, no medications. And he was really struggling. Prior to all this major change in his life, he had been checking his sugars three times a day, as well as when he was symptomatic, just like he had been asked to do. He was on a pretty optimal regimen. His oral agents included metformin and peglaflozin. And then his injectable agents included insulin glargine, which he was giving 28 units at bedtime, and then somaglutide once weekly. So again, audience participation. What data points prior to initiating a change would you want to have? Medication adherence and finance, yes. Labs and blood pressure since being discharged from the hospital. Food habits, excellence. Basil bowl as dinner. More affordable regimen. Typical meal patterns. Yay, you all get an A. This is excellent. Thank you for participating. So yes, cost had obviously become an issue. It's very obvious that the loss of revenue can impact you in many ways. But the other thing that I want to bring light to is that even with patients who are insured, sometimes the cost of their regimen, even with just having to manage a co-pay is quite significant. Just this morning prior to presenting, I was in clinic seeing patients. And I had someone who said, I started this new GLP-1 receptor agonist. I love the benefits. I see the weight. I'm not gaining anymore. I'm actually losing. I see my insulin needs coming down. But when you add up all the different co-pays that I'm paying monthly, I just can't do this anymore. So here, oftentimes we hear the realities of the cost of insulin. And I'm not trying to minimize that in any way, shape, or form. It is very significant. And especially what if Richard had been experiencing, or a patient who experienced type 1 diabetes? This is a need. He can't live without it. So insulin, rightfully so, should be in the media and should be discussed. Here's some links to some of the different companies that have options for patients who need affordable insulin. And then also the American Association of Clinical Endocrinology has a really great resource as well. There's also a website, goodRx.com, that if you haven't seen the graphic, I would encourage you to look at. But it looks at the price change trends from 2014 to 2019 for a lot of different things related to diabetes. So whether it's non-insulin diabetes medications, insulin as a option for treating diabetes, testing supplies, and then all the other things that we recommend for the comprehensive care and management of this progressive disease, it can really add up over time. So for Richard, some of the options, and thank you again for participating, is we could make no changes to his current regimen, current being what he volunteered in the hospital, in the emergency room he had been on prior to the hypoglycemic event in the park. We could encourage him to try diet and exercise only. We could convert him to an oral regimen only, or we can consider a modification of the current therapy based on what we find from Richard after a more in-depth conversation. So there's a poll. Please answer the polling questions. Yes, you are absolutely right. So we should consider modification of the current regimen, but we really do need to engage Richard and see where he's at, see what is going to make sense for him. Here's a man who's in transition. His world's been changed upside down. So what next? So the basic starting point would really be to have those conversations, like many of you mentioned, around his food insecurity issues. So to make it a more meaningful conversation, perhaps we say, would you be willing to tell me more about when and where you're eating currently? We acknowledge that there's issues around cost. We might need some objective data to see what's going on. And here's just some examples of log sheets that we did use with Richard. And so the open spaces are asking if you're able to please check at that designated time so that we can get some information to help us guide therapy moving forward. And we talk about the role of a federally qualified health center. So in this case, we had an outreach team, and thankfully our nurse practitioner was very familiar with those living there and was not shy to introduce herself to new residents. So she talked to Richard about his desire to seek healthcare, what his goals were, and fully recognized that within the walls of a federally qualified health center, there are resources that could help him get appropriate vaccinations to help decrease risk of infection. He'd have access to resources that could help apply for patient assistance programs. There would be transportation because he had no way really to get anywhere. He didn't have a vehicle and he had no money to pay for public transportation. Community food banks, partnerships with different organizations, addressing his oral health, all things that we know can impact glycemic control and influence the decisions we make as clinicians. So she welcomed him. She welcomed him to consider becoming a patient at our federally qualified health center. She helped get him enrolled as a patient. She asked what he felt his biggest barriers were. She welcomed open and honest dialogue. She engaged other team members, which in our case was our diabetes self-management education team, which is pharmacist run and works under a collaborative drug therapy management program that does include prescriptive authority. We engaged him also with people who could address many other social determinants of health. Also things related to behavioral health. He was experiencing anxiety, living with unstable housing, some symptoms of depression. We worked towards creating a safer and affordable regimen. So like the patient I saw this morning, Richard had the same thing. He really needed to have something that was affordable and could pay when he could. And then we agreed on a monitoring schedule that was realistic and safe, understanding the role of having information so that we could optimally control his diabetes with him guiding this process so that hopefully his kidney, his acute kidney injury didn't advance to chronic kidney disease that would require other interventions to minimize the risk of cardiovascular events. And so here I show you us, us being El Rio Health in Tucson, Arizona, but it's just a reminder that federally qualified health centers play a major, major role in the United States. I'm proud to say, it's not my data, but you can find this anywhere on the HRSA website as well as the National Association of Community Health Centers, that in 2021, federally qualified health centers served over 30 million patients across 14,000 clinic sites in the U.S. So please don't forget us and our teams. So like I said, here's us as El Rio. It really shows that we can work with anybody regardless of their ability to pay, but also those who do have insurance. We have millionaires that choose to come here because they love what we've all been talking about today, that comprehensive team-based approach to diabetes management and other chronic diseases. So in the case of Richard, he thankfully was able to become a patient of ours. We were able to get him the labs that he needed to have repeated. The outreach team continued to engage with him when they went to his shelter. We also arranged for transportation so that when we had agreed upon times that we would meet in the clinic space, he had a way to get there. He was able to meet with a dietician and talk reasonably about options and the barriers that he faced there. And then the pharmacist team through their prescriptive authority was able to not only help address his diabetes that was not optimally controlled, but also his blood pressure and identify gaps that could help with his care. And so the pharmacist role as part of the care team, I would highly encourage any of you who don't have a team that includes pharmacists to not only think about the role of the community pharmacy and what they offer at the point of medication dispensing, because they play a huge role giving insight to providers, not only about adherence, but also when you might think somebody is rationing their medications, helping to find manufacturer coupons, manufacturer-sponsored programs, and helping to redesign affordable options that will help to overcome the fears that might exist both on the patient and the provider side, appropriately so related to safety and access to medications. But then on the clinic side, how we now across 48 different sites can engage in collaborative drug therapy management protocols. So American Pharmacists Association has an excellent toolkit that was put together that really just walks people through, how do we do this? How do we expand our care team and have everybody working at their top of their license? And that could include technicians and medical assistants, also serving in the role of a certified diabetes care and education specialist and marrying that with prescriptive authority. And then also making sure we're optimizing things like in-house pharmacies, so it doesn't create another trip to another location. 340B, if you're not familiar with that, advocate for it, it helps our patients because that money saved is directly reinvested into patients of the health center. Options like sliding fee scale or tier payment options. But the role of pharmacists and also the role of pharmacists in federally qualified health centers can be an opportunity for us to think outside the box, especially when we run into issues with primary care shortages, as well as specialist shortages in different areas. So I'm very excited to entertain any questions that may come up, but thank you for your time. Excellent, thank you, thank you. And we'll bring all the panelists back. And wow, there's already lots of comments in the chat and questions, so we'll get to whatever we can. First, I'll just say everybody appreciated your presentations as I did, so thank you. I think, and I'll also ask the viewers to just scroll through the chat because there are a number of resources that were put in there. The ADA EASD hyperglycemia management for type two diabetes, standards of care, information about costs, information around HRSA. You'll have access to the full presentation here in about a week, so feel free to share it with your colleagues. Maybe I'll start, Marissa, so one of the, I think a lot of people appreciated addressing costs because that clearly is something that our patients struggle with. And one of the issues that came up is what if I'm not at an FQHC and I don't have all of this good stuff and I know you touched on a little bit, so maybe what advice might you give to them to help their patients with cost issues? No, thank you very much for that question. And as far as the panel goes, we had some meeting prep. And so the other thing that we had talked about during that was don't forget the oldies, but goodies. They're not ideal, obviously, but there is an opportunity to use agents that have kind of fallen off the radar. So NPH, regular insulin. In the case of Richard, had we chosen to use that? We just have to be aware of the impact of his declining renal function and how that shifts the way we use different agents because it's gonna hang around a little bit longer. But that's where really thinking the big picture, not letting go of old agents and using your team-based care can really help with overcoming the cost issue. And then national movements, I know that there's a lot of things going on as far as affordable options. And thank you to organizations like ATA to help push those initiatives as well for affordable insulin for all. Yes, absolutely. We've been pushing very hard on this issue. Let me move, here's a common question that comes up that somebody asked is, and this could be any of you really, initiating insulin and weight gain and particularly people, this question was someone on a large dose of basal insulin and what can we do about the weight related issues that will sometimes happen? Kevin, if you wanna comment just on the large dose of basal insulin sort of thing for starts and anyone else chime in. Well, I think the important thing right off the bat would probably be we don't want people feeding their insulin. And if you're getting too much insulin, your blood sugars are running low or you're concerned about heading low, sometimes there's patients who panic when their sugars hit 80 and they will treat it as a low to prevent it from going lower. And so that can also drive a lot of weight gain. So I think engaging your educators as well as making sure patients are following a very good nutrition program by leveraging our nutrition support teams that we can help to try to do what we can to mitigate weight gain that will occur in most instances with insulin, given it is an anabolic hormone. But I also think recognizing the ceiling of the insulin and leveraging the therapies that can also help assist with weight management or mitigate further weight gain such as GLP-1s, the new GLP-GYP as well as SGLT2 inhibitors. So augmenting insulin therapy with those agents and avoiding the need for mealtime insulin I think would be another strategy to help minimize the weight gain that many will experience. Often when people have elevated A1Cs, they're really thirsty, they're drinking all the time. They have this hyperphagia and I think they eat a lot. And once they get insulin on board sometimes they have to kind of reset their thermostat. Also, they're so dehydrated because they're trying to pull all that sugar out in their urine. There is a fluid shift where they're not so dehydrated anymore. So we often prepare our patients for the fact that just getting rehydrated kind of getting their glucoses back in better glucose management, they might just lose, might gain some weight just because of the fluid that they really need to have on board is there again, so. Yeah, absolutely. I often sort of say, you know, you've been peeing out calories and now, you know, because your blood glucose has been so high and now you won't be. Unfortunately, we've run out of time. And so I wanna first, you know, thank this wonderful panel for all the valuable information. Really great presentations and, you know, the theme of working as a team clearly is there. Also, I wanna encourage people to engage in the Overcoming Therapeutic Inertia program, the website. We appreciate the support from Sanofi Diabetes as part of this. And I really wanna thank the audience who's been really active on the chat, going through the polls for joining us. And as a special recognition for attending, you'll be receiving a email set of infographics that highlights some of the key points of initiating, intensifying and de-intensifying insulin that you can use your practice right away. And thank you so much for attending and everything you do for people with diabetes. Take care.

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Dr. Bob Gabay

therapeutic inertia

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glycemic goals

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social determinants of health