Hello and welcome to today's webinar, Standards of Care in Diabetes 2024 Update for Early Career Professionals. This session is brought to you by American Diabetes Association's ADA Scholars Program. We will be providing additional information on how you can join the ADA Scholars Program to get access to great sessions like this. Please note that today's presentation is geared for Early Career Healthcare Professionals and Endocrine and Diabetes Fellows. My name is Bhargavi Patham. I will be moderating your session today. To share a little bit about myself, I'm an Associate Professor of Clinical Medicine at Houston Methodist Hospital, and my primary focus is transplant endocrinology and lipidology. I'm also an Associate Program Director for Endocrinology Fellowship. None of this would be possible without the guidance of ADA's Early Career Advisory Group. We would like to thank the members for all their hard work to develop ADA Scholars Program. We are grateful for the support of Leona M. and Harry B. Helmsley Charitable Trust, who we made this session a possibility. ADA Scholars offers Career Development Program for graduate students and Endocrine Diabetes Fellows and Early Career Clinicians who treat diabetes and complications. The main ADA Scholars Program will take place in person at ADA's 84th Scientific Session in Orlando, Florida this June, so don't want to miss it. ADA Scholars Program will also include Sprint Lectures and many workshops plus networking opportunities. Attendees who participate in the ADA Scholars Program will be eligible for complimentary registration to the ADA Scientific Sessions. If you have not already been a part of ADA Scholars Program, we encourage you to join this free program. A link will be provided in the chat when you visit our website to learn more and submit your application. By joining the ADA Scholars Program, you will become a professional member of the American Diabetes Association. This free membership will provide even more opportunities to network and grow professionally. The ADA memberships include a variety of professional member benefits, including benefits such as meeting discounts, WinADA, interest groups, members' directory, members-only webinars, and so forth. As you can see, you will have access to lots of great resources as an ADA professional member. I have been a part of the ADA Scholars Program since last 8-9 years and have reaped a lot of benefit from it, so I highly encourage you to join us. Now we will transition to today's program with Dr. Robert Gabay presenting on 2024 Updates in Standards of Care geared for Early Career Professionals. If you have questions as we move through this presentation, please type them in the Q&A box in your control panel. We will be answering as many questions as we can at the end of the session. Now I have the privilege of presenting Dr. Robert Gabay. Dr. Gabay is a Chief Scientific and Medical Officer at the American Diabetes Association where he leads the ADA's effort to drive discovery within the world of diabetes research, care, and prevention. Previously, Dr. Gabay served as the Chief Medical Officer and Senior Vice President at Jocelyn Diabetes Center and Associate Professor at Harvard Medical School. We are truly delighted and excited to have Dr. Gabay presenting on 2024 Updates of the Standards of Care in Diabetes. With that said, I will turn it over to Dr. Gabay. Great. Thank you so much, Bhargavi, and I am excited to present really a lot of wonderful information about the Standards of Care. I also want to say that the ADA Scholars Program is really one of my favorites at ADA. It's one of the ways that we help people move through their career and be successful. So I appreciate all of you joining and I'm going to get started here. So first of all, I don't have any pertinent disclosures. What is the Standards of Care and how is this thing made? Well, as you might imagine, it starts with the evidence. So we do an exhaustive literature review of everything that has been published in the world of diabetes that impacts clinical care, take all that information and relate it to the recommendations from the year before. This is a yearly process. And then that information is brought to this incredible committee, the Professional Practice Committee, that really are experts in all aspects of diabetes and live within the different ecosystems of diabetes. So not only is it endocrinologists, adult and pediatric, but diabetes educators, cardiologists, nephrologists, behavioral health, really the whole ecosystem is represented. And they take all this evidence and they discuss, debate, and honestly sometimes argue until they come to a consensus. And that information is then brought to our board of directors for approval. And this is all independent of any industry funding. Just to give you a sense of the breadth of organizations, and you might see your organization here, there are 21 members of the Professional Practice Committee. And over the last couple of years, we've realized that even those 21 people cannot know everything about diabetes and be experts in everything. So we've started to bring in subject matter experts and we've added 19 of those really from across the country and in some cases across the globe to help put this together. So that's what it is. What are some of the general concepts that you'll see permeating throughout? And I'll tell you as we go along where to get access to this and all of the information around it. But really very much a person-centeredness approach. It's meeting people with diabetes where they're at, culturally informed care so we can reduce the inequities and the disparities that exist in care and help all of our patients, an inclusive approach to care. As you might imagine, one of the things that has really changed in diabetes pretty dramatically in a short period of time is the importance of technology, telehealth, artificial intelligence and digital interventions. And I'll briefly mention some of that as we go along. Here's where you can get all of the information that you need. There's the website. You can take a photo of it if you want with your phone and you can also see all of this information. The thing that I'll call your attention to, I think is one of the most valuable, is the app. You can download the free app, have it on your smartphone and literally pull it up when you're in an exam room with a patient. I've done that to be able to look up what's the most important information. Not only does it have all of the standards of care but lots of other professional education opportunities that are free. So I can't recommend the app more. So let's talk about the standards of care. So this is a 300 some odd page document. And how am I going to tell you everything that's in it in the amount of time we have? Well, what I'm going to do is break it down to five big themes. And what I'm going to really focus on is what's new this year. So this is the most up-to-date information. I'm not going to go over all of the things that were in there previously, although I might mention it a couple here and there, but we're going to focus on what's new. So this is really what's new. Type 1 diabetes, I'll share what's new there. Bone health, something that we often don't think about from the diabetes point of view, but is clearly very important. Technology that of course is really permeating diabetes care in so many ways. And then this last year, I think in many ways has been the year around obesity. And so sharing some important information and standards of care on that. And then finally, an area where I think you'll be able to use this information when you see patients next week, and that is around cardiovascular risk reduction, and I'll talk about that. So these are going to be the five themes, and we're just going to go through them one by one. So you'll see these sort of dividers that I have within the talk, and they're to help you find more information on this. So each of these is a different section within that document of the standards of care. So what's new around diabetes diagnosis and classification? And it starts with, as I said, type 1 diabetes and screening for type 1. So we call out the three antibodies that can be used to screen individuals for type 1 diabetes, anti-GAD, anti-islet antigen 2, and zinc transporter 8. Those are the three recommended antibodies. And individuals that have multiple positive antibodies should be tested for dysglycemia, and we'll talk more about how to do that. And if they have two or more antibodies positive, as part of a screening for possibly at risk for type 1 diabetes, probably be involved in a specialized center, and we'll talk in a moment about therapeutic options, which, as you know, are new this last year, to have an opportunity to delay the development of type 1 diabetes. So when it comes to the who do we think about screening, well, particularly when we're making the diagnosis of diabetes and we have an individual that presents with diabetes, who should we be thinking about based on the evidence that is more likely to have type 1? And as you can imagine, younger age, but unintentional weight loss, ketoacidosis, and a short time to insulin, and I'll show you an algorithm here that helps us think through this, and this is again in the app, it's in the chapter as well. So there are going to be people, adults, because in children we're often thinking about type 1 diabetes, but an adult that presents with diabetes, and then do they have one of those risk factors, and including low body mass index, that might make you think about them having antibodies, if so, test them, if they have two antibody positive, yep, they have type 1 diabetes, end of story. If they don't, you want to think about whether they might have a monogenic form, a MODY, for their diabetes as part of the algorithm. So what about screening other individuals for diabetes, and there's a callout for high-risk medications, glucocorticoids, statins, it's not a reason not to use a statin, but there is increased risk for some individuals for developing diabetes on a statin, thiazide diuretics, and some of the HIV medications, so consider screening those individuals, and then particularly those on second-generation antipsychotics. Those individuals should be screened at onset, and then 12 to 16 weeks later, and of course if they have symptoms, sooner. So many individuals are undiagnosed for too long that are using these high-risk medications, and that's why this has been called out in the standards. What about exocrine pancreas? This is something new. For individuals that have acute pancreatitis, we know that they are at risk for developing diabetes, and so within 3 to 6 months of their acute pancreatitis episode, they should be screened, and then yearly thereafter, for people that have chronic pancreatitis, again, trying to catch people earlier. And then the last piece about diagnosis is cystic fibrosis-related diabetes, and so here are the recommendations. Starting at age 10, individuals should be screened annually with an oral glucose tolerance test, and so specifically, not an A1C, because there are inaccuracies of A1C, and they're low sensitivity. If they have an A1C and their A1C is greater than 6.5, sure, that's great, but you're going to miss a lot of people if you only use an A1C, and then following these individuals that have diagnosed diabetes with cystic fibrosis, similar to the way we approach people with type 1 diabetes, 5 years after diagnosis, they should then be screened for the chronic complications of diabetes, yearly eye exams, microalbumin, et cetera. Okay, so that was about sort of diagnosis. What about prevention or delay of diabetes? And this is really the focus on new therapeutic options. First of all, a reminder of the stages of type 1 diabetes. So what we generally consider type 1 diabetes clinically is stage 3, in the last column on the right. That's where A1C is greater than 6.5, and we know they have diabetes, but there is stage 1, where they have their multiple antibody positive, but have normal glucose. Stage 2, where they have dysregulation of their glucose, and you can see the numbers here. Not enough to be diagnosed as diabetes, but there is some dysregulation of glucose. That is stage 2, and the reason that's important is that is where we know we can intervene with FDA-approved medications. So what do we do if someone is found to be antibody positive? A family member that is being screened for the risk of developing type 1 diabetes. An A1C every six months, and an oral glucose tolerance test annually are the recommendations. Let me also just highlight, if you see all of these recommendations had a little letter next to them at the end, here it's a letter E. A is the strongest evidence, multiple randomized clinical trials, B, and C is, and then E is expert opinion, and that's where this sits. So as you're looking through these slides, you can see the strength of the evidence on each of these recommendations. So what can we do to delay type 1 diabetes, and that's where teplizumab has been approved for individuals with stage 2 diabetes, meaning dysglycemia, but not frank diabetes, to prevent them from developing frank type 1 diabetes or stage 3. So that is a recommendation, and you see there's a randomized clinical trial, but smaller, and that's why it is level B evidence. So there's a chapter that looks at comprehensive medical evaluation and assessment of comorbidities, and this is where the new information about bone health is. So I mentioned the five big ones of what's new, type 1 diabetes, let's now talk about bone health. So it turns out that people with type 1 diabetes, there is significantly higher risk of fracture and osteoporosis, and that's why we're calling this out. But it turns out people with type 2 diabetes, who often, as you know, have obesity, you would almost expect them to be lower risk because of their obesity of bone disease, but they're actually higher. And so the recommendations are first to assess fracture risk in all of our patients with diabetes, regardless of the type, and to get a bone marrow density if they're over age 65, and then repeating that every two to three years, and younger if they have other risk factors. So screening for bone health, and then when we're thinking about treatment of these individuals, we should be considering avoiding medications that we know can be harmful for their bone health, such as pioglitazone, and when we're thinking about medications to manage their blood glucose, fall prevention and the risk of hypoglycemia. So avoiding agents such as sulfonylureas that are likely to cause hypoglycemia, therefore a fall, and potential fracture. Then the last thing around bone health that are the new recommendations are important reminder about calcium and vitamin D supplementation, and antiresorptive therapy for individuals with a T-score of minus two or less. Okay, so we've gotten two of these down. This is a picture of Boston where I am right now. You actually can almost see in there somewhere is where I live. I won't tell you which spot there, but I'm in one of those buildings. We're going to move now to the next section. I want to make a few comments. There's an important chapter about facilitating positive health behaviors and well-being. I'll just highlight some of the things here. For diabetes self-management education referral, which you know really is underutilized. A call out of five times to think about referral. At diagnosis, that's more obvious. When they're not meeting treatment goals, these individuals, diabetes care and education specialists, can be really helpful in problem-solving, why they're not meeting goal. Annually, everybody should meet with an educator. Then when complications begin to develop, complicating factors in particular, it could be medical, it could be physical, etc, and when there is a big change in their life. You'll see information about nutrition, having a more inclusive food-based dietary pattern. Really stressing the general principles of good nutrition and not just focusing on eat this and don't eat that. There's also a valuable section around religious fasting and guidelines for that for our patients that engage in that. The concept of chrononutrition, the timing of when one eats can affect the circadian rhythm and also blood glucose levels. Same food, different times can make a difference. That's highlighted. There had been this notion about alcohol, and that alcohol could be cardioprotective. There was an interpretation that, well, if you have cardiovascular disease and you don't drink, you should start drinking. No, we're not recommending that people start drinking. When it comes to non-nutritive sweeteners, they can be useful when they are a substitute for sugar that a person was going to consume anyway, better than sugar, and at the same time, not something one needs to seek out excessively to consume. It's really what it's going to prevent you from prevent our patients from consuming sugar, which we know is not in their best interest. We're two out of five here, and I think we're good on time so far. We're going to get into three meaty sections, one around technology, obesity, and then cardiovascular disease risk reduction. Put your questions in the comments because I'll be glad to answer them at the end. What to say about diabetes technology? I'll just remind you that last year, the standards care made the really very clear recommendation that says, if you are on insulin, any type of insulin, basal insulin, insulin pump, basal bolus, at any age, child, adult, older adult, you should be offered a continuous glucose monitor. So that was last year. What's new this year? A few things. One is offering technology to patients early on in their course, and offering all of these options to our patients. CGM in particular, early in type 1 diabetes, no need to wait. It can be something really shortly after diagnosis. People are empowered because it can be such a valuable tool. One needs to also organize your practice so that you can offer early on insulin pumps, automated insulin delivery. And this is a call out as much to our primary care provider community that healthcare professionals at this point need to be comfortable using diabetes technology, particularly continuous glucose monitors. This is such a mainstay of management of diabetes that if you're taking care of a person with diabetes, you need to know how to use them. And we have a lot of programs at ADA Professional Education to help individuals become more comfortable. Thinking about insulin pens and injection aids for those that have either dexterity or visual challenges. And we'll talk more about this later, the use of, if someone is using a CGM, they should be allowed to continue to use that CGM in the hospital. But we'll talk about how that data is used at the end. So that's the big updates around technology. And now what about obesity? And I don't know about you, but this past year was really in many ways the year of obesity. And it's interesting that it happened a decade after the American Medical Association recognized obesity as a disease. I think we're finally treating it like a disease. And I think that is a real step in the right direction. So first of all is how do you assess obesity? And body mass index is still the key measure but the standards are now recommending using other things like waist circumference and waist to hip ratios, other ways to assess individuals anthropometric measures should monitor at least annually. And one should do this in a private way, not calling out the weight in the waiting room so that everybody hears, things like that to avoid the stigma associated with obesity. Highlighting an individualized approach. This is again, getting to that person centric, talking to your patient, letting them know what the options are, negotiating what is the thing that they wanna do to help manage their obesity. And then a new section on weight maintenance. So when people have lost weight in whatever manner they have, what do we know works in terms of preventing weight regain? And the literature is pretty clear on a couple of things. One, some form of monthly contact or support doesn't need be by the physician, can be anyone on the healthcare team and a need for them to increase their physical activity over the typical recommendations of 150 minutes to be 200 to 300 minutes per week. And then really ongoing support for those individuals so they don't regain the weight. What about pharmacological therapy? Obviously transformed, I'm sure for all of you. And I continue to see patients at Jocelyn. In fact, I did this morning. And the interest in these therapeutic options and the way it's changed the way we manage diabetes, I think has really been revolutionary. So there's a call out here because there are a lot of weight loss medications that have been around over the years. But if one is gonna go to pharmacological therapy, it's clear first line medications are semaglutide and trizepatide because they are by far the most effective therapies. And then preventing therapeutic inertia. So assessing how people progress in terms of the weight loss strategy that is being used. And then if they're not meeting their goal, do something else. That can be adding additional therapy. It can be what often we see is titrating up their medication if they're on pharmacological therapy and not missing a chance to be able to continue to advance their therapeutic options until they get to goal. I'm gonna just briefly remind you this is not really new information, but it's such an important part of the standards of care. And that's the pharmacological approach to glycemic treatment. There's a whole section on type one diabetes, different regimens, and spelled out in great detail how to choose a starting dose, how to make adjustments. I'm gonna talk a little bit about the type two diabetes side. First, the things that are new is really the, honestly, the continued focus on cardiorenal risk reduction on heart failure risk. And I'll talk more about that later. Early use of automated insulin delivery for people with type one diabetes, no reason to wait a long time. There are studies to support that. A lot more information on use of insulin. And again, this idea of therapeutic inertia. Someone's not at goal on the current therapy, think about how you should change that therapy to get them to goal. So this is the all-encompassing diagram algorithm for the pharmacological management of type two diabetes. And I'm gonna highlight the top part of this so that you can see it, because I know it's too small to be able to read. So here's the basic idea. We think about healthy lifestyle behaviors, diabetes self-management, education and support, and social determinants health. That's at the top. Everybody gets that. And then what therapeutic option you choose starts with on the left-hand side of this diagram. Do they have either atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease? First step is to go to the left side. If, and decide on that. And at the same time, you have two other things to think about. So we have three things to think about when we're managing our patients in terms of pharmacological therapy for type two diabetes. What comorbidity they have on the left? What is the glycemic goal we have and how likely is that agent we choose gonna get them to goal? That's the second. And the third is their weight management goals. And it's really all three that need to be considered in choosing therapy. Okay, so this is, if you're wondering, this is Lake Louise. I should ask you to sort of put your guesses in the chat, but tell me what province Lake Louise is in to see if you can sort of get that right. Okay, so we're on the home stretch here and we're gonna have plenty of time for questions. So think about what questions you have. So we've talked about type one diabetes, bone health, technology, obesity, and now finally cardiovascular disease risk reduction. Probably some of the biggest changes I said here, around heart failure, and I'll talk about that in a moment. And just a reminder that I suspect you're all familiar with. So why do people, what is the number one killer of people with diabetes? Cardiovascular disease. So this obviously is important for our patients. Okay, so there is a whole section that is specifically devoted to this. And all these recommendations are co-endorsed and co-developed with the American College of Cardiology. So we sync up with other organizations for some of the standards of care sections. So first, what to do with statin intolerance and benpedoic acid has been approved and now recommended for treatment in individuals that are statin intolerant. Remember though, that many people that think they're statin intolerant may not be. Switching to a different agent, starting at a lower dose, still first things to do, but if they clearly are intolerant, benpedoic acid. For those that have diabetes and atherosclerotic cardiovascular disease, then one can consider PCSK9 inhibitors as an additional agent. So this is really the biggest change, I think, in the cardiovascular area, one of the biggest, is screening for heart failure, because this literally affects some millions of individuals with diabetes. And because we know that people with diabetes increase risk for heart failure, and there are stages of a heart failure where individuals are asymptomatic, but already have structural abnormalities, the recommendation is to screen, consider screening adults with diabetes and risk factors with BNP or NT pro BNP. And you see that's level B, so that's quite strong evidence. And if the natriuretic peptide levels are elevated, they should get an echocardiogram to be able to evaluate their heart, and that's level A evidence. So I suspect that we all have patients that fit into this, that we've not ordered these tests on, and that is a new recommendation. So keep that in mind. The other big change here is around screening for peripheral arterial disease. And this is really, comes from the fact that, first of all, amputations, unlike most all other diabetes complications that are essentially going down over the years, amputation rates are rising and there's significant health disparities. A black individual is three times more likely to have an amputation than a white person. And so we're really committed to making a difference in that. And so the biggest step here, one of the big steps is screening for peripheral arterial disease. So here's the recommendation. If someone is over 50 and has any microvascular complication, so retinopathy, nephropathy, neuropathy, they should be screened for peripheral arterial disease with an ankylobrachial index. That is level A evidence. That's top evidence. So that's one group that should be screened. And if someone has had diabetes for more than 10 years, you might also consider screening them with an ABI. So this is very new and very different than what has existed before. And again, the goal is to capture these people early so that we can intervene. So getting back to heart failure, the importance of SGLT2 inhibitors for individuals with either preserved or reduced ejection fraction. So really anyone with significant heart failure should be on an SGLT2 inhibitor. Those with diabetic kidney disease, the recommendation is to be on finarinone. That's again, level A evidence, large randomized control trials, because again, prevention of hospitalization for heart failure. And then individuals with diabetes that have had an MI, well, they need to be on essentially the standard cocktail of ACE or ARBs, a mineralocorticoid receptor antagonist, a dual agonist, and an SGLT2 inhibitor. And that really is the same as would be true if someone did not have diabetes, but it's an important reminder for our provider community. In terms of blood pressure management, you can see this algorithm and I'll highlight the top here in particular. If their blood pressure is a greater than 150 over 90, they need two agents right off the bat. The other recommendations are not so different, but here's something, excuse me, that was in the recommendations last year that you may not have caught. And that is that the recommendation for blood pressure goal is, say it to yourself and see if you get it right, less than 130 over 80. So it is lower than it used to be over 80. I won't ask you if you got that right. Okay, brief comments about chronic kidney disease. You can see here on the left hand side, SGLT2 inhibitors down to GFR20, metformin, okay to use at reduced dose down to a GFR of 30. Consider adding a GLP-1 receptor agonist on top of that. The importance of lifestyle. Let me just finish up with diabetes care in the hospital and what's new. And first of all, a strong recommendation that validated written or computerized provider order entry sets should be available not only on the floors, but in the emergency department, the ICU, non-ICU floors, OBGYN delivery units, dialysis suites, psychiatric wards. This is something that is not present in all parts of the hospital. And this is for those of you really clear clinical people, this can be a great project of quality improvement for you to do within your hospital. And again, having the recommendations by the American Diabetes Association helps to get everybody's attention to move that forward. The next is about the use of continuous glucose monitors and automated insulin delivery in the hospital. So I mentioned that if a patient has the CGM, they should be allowed to continue to use it in the hospital. But the dosing decisions should still be done based on finger stick. If they're hypoglycemia, check with a finger stick because of, again, some of the potential inaccuracies in the hospital. Really, you need to still do point of care testing of glucose in the hospital. I know there are a number of randomized control trials that are being done right now, and this could change in the coming year. You might be institutions and part of some of those studies. So, but for now, check with a typical finger stick. Inpatient use of SGLT2. So there's a study demonstrating its safety. And so if someone is hospitalized with heart failure, they should be started on an SGLT2 in the hospital or at discharge. Everybody should get that. That should be part of a standard of care. And then I'll just point out, there's a lot of information on non-alcoholic fatty liver disease. The under diagnosis and need to diagnose it, a FIB4 index, something calculable from data you probably already have on your patient in the electronic health record. And then the importance of lifestyle as treatment for that, and the possibility of consideration of GLP-1 receptor agonists that have been shown to be effective in their therapy. And there's a slew of new therapeutic options that are in the pipeline right now. Just brief mention specifically about retinopathy here. And that's that if you haven't followed this area, there are now FDA approved artificial intelligence readings of retinal images. And so this is now something that is mainstream and certainly endorsed. And you might say like, why does the ADA make some of these statements? Not only are the standards of care read by clinicians around the world, it's accessed I think last year, three and a half million times. So it is really widely used, but it's also used by payers to decide what to cover. And that's why we're mindful of what's in this document. And the committee is very careful about their deliberations. The importance of visual rehabilitation to be offered to individuals that have visual impairment. And so here's where you can get a lot more information. So I highly recommend you, again, I'll plug the free app where you'll find lots of useful information and all these other things. And so with that, I know I went through quickly, but I left a lot of time where we can get into questions and discussions. So I am going to stop there and see if we have any questions. Thank you, Dr. Gabbay for such an enthralling session. We have over 400 people listening in with rapt attention and over 900 who have registered who will probably be listening to this session with a cup of the coffee. It's actually a miracle that you have presented the essence of 335 pages in one hour. I tried and I hope I didn't go too fast, but the beauty is that you can rewatch sections of it. Yeah, it was fantastic. It did not even feel rushed, we loved it. I'll move on to Q&A and for everybody's convenience, so I'll read them out to you and the audience. Do we have any evidence or recommendation for oral medications adjunct to insulin in type 1 diabetes? Ah, interesting. So, there have been some studies with metformin as an example. Probably more beneficial effects on weight, mixed effects on in terms of A1C and the challenge there is, was the insulin adjusted appropriately enough and aggressively enough? So that might be some of the studies that have been negative. I think that's probably where the greatest evidence is. SGLT bitters have some evidence, but they also have safety concerns in terms of diabetic ketoacidosis. So that's a mixed bag. And then the last one I'll mention that isn't oral, but GLP-1. What I would say is that, and I'll say what I do in my practice, if people have type 1 diabetes and obesity, why wouldn't we use the same therapy that we would use for someone without type 1 diabetes and obesity? Thank you so much. I'll move on to the next question. Does SOC recommend peripheral arterial disease screening even if the microvascular complications are under control? Yes. Oh, thank you for that question, whoever asked that. I think that's an important one. Yes, the recommendations are not, the idea of linking the screening to microvascular complications is the sort of pathophysiology. If one has developed microvascular complications, the risk of peripheral arterial disease goes up. And therefore it's a marker for the likelihood of PAD even in the absence, even if their complications are well-managed. Thank you. This is a great one, and I want to know the answer to this one. Are there any recommendations or guidance for attention to preserving muscle mass in elderly with disease-related accelerated sarcopenia where weight loss may not be the best goal and how that notion might affect the medication choice like GLP-1? That is a great question. I'm interested in the answer as well. So what I would say is, first of all, it is an important call-out for older adults that becomes a big issue and making recommendations about exercise that can be strength building is important and highlighted in the standards of care. I think the issue around GLP-1 is an important one and I think is gaining more and more attention. And I will put a plug in for the ADA scientific sessions that some individuals that are accepted to be ADA scholars, but anyone is invited to join us in Orlando, there will be a session really digging deep into that, the physiology, what do we know? Why is it happening? What can we do about it? And I'm looking forward to hearing that session in just a few months. Thank you. Oh, can I add one thing to that though? That does seem to be clear is particularly during weight loss, it's important for the individuals on GLP-1 from what we can tell is to have adequate protein intake because often that's part of the issue is that they're often not so hungry, they don't need to eat that much. And so it's what do they stop eating? Well, if they're not eating a lot of protein, we know that will exacerbate the muscle loss. That's a great point. Thank you. Now we are getting into more specific kind of questions and they're fascinating too. In a female patient with uncontrolled diabetes, A1C of eight, with anal abscess that is not yet healed, would you award SGLT to inhibitors due to risk of hernias gangrene? Wow, okay. That's a very specific question, as you said. I don't think the risk is significant, number one. And yet at the same time, in such a rare circumstance, you might think of some other therapy until things are healed and then be able to move on. Yeah, I think that's a clinical judgment piece. So one hot topic question has come, what are the implication of intradent therapy on microbiome and its impact on diabetes? The implications of what therapy? Intradent therapy. Oh, intradent therapy. That is a good question. I don't know how well that has been studied as of yet. One could easily imagine that it is altering the microbiome in ways. And that may explain things that we don't understand. That world of the microbiome is such a fascinating one and a difficult one to really sort out because there are all sorts of things that change the microbiome. And at the same time, we're not sure what those changes mean. You can easily measure changes, but are those changes leading to something else? Are they responsive? We're not often sure. Yeah, maybe in next few years. Yeah, I think stay tuned is the answer. And I know that we have sessions around the microbiome at Scientific Sessions. I wouldn't be surprised if somebody will be reviewing some of the literature on that. So several questions have come about costs of GLP-1s and SGLT2 inhibitors. And these are one of our first line treatment. Could you comment on ADA's approach in terms of the cost and also the supply? Sure, yeah. So I would start by saying, one of the unique things about the American Diabetes Association is that we represent the professionals like all of you, but we also represent people living with diabetes. And so we do a great deal of advocacy and an important effort that we've undertaken over this last year has been very specifically about obesity treatment. So here's a fact that most people don't know is that Medicare is legally prohibited from covering obesity medications. And so that like makes no sense, right? Like how can you exclude treatment for a disease? So that's been a battle that we've been doing. There's been legislation that we brought to Congress on this issue and we're hopeful that that will help. I think the other access issue is on the manufacturing side. And so that's been a challenge. We've been monitoring that closely. And so that seems better, but continues to be an issue. And so I think these are important considerations. I think where we've had real success has been around insulin. And it's probably like eight, 10 years fighting to put a cap on insulin costs. Eventually last year got it passed for Medicare over the last several years, 20 states have approved that. And then towards the end of last year, the three major manufacturers agreed to all cap their insulins at $35. And we'll continue to fight to ensure that no one changes that, but we're very mindful of the access to treatment. So we really believe everybody should have access. We truly appreciate your effort and ADA's effort in fighting this fight, if you will. There are still more questions pouring in. Does use of SGLT2 inhibitors in someone without diabetes increase the risk of hypoglycemia? No, I'm not aware of any evidence there. Yeah, and it's interesting to watch for those that haven't followed this story. Really now the cardiologists, this is like their go-to drug and they don't even think of it as a diabetes medication. It's as or more effective than most anything else they do around heart failure and seems to work for every type of heart failure. Are there any other newer medication recommendations other than teflizumab? Well, I think for prevention of type 1 diabetes or delay of onset, that's an important one. I think the first line treatments of obesity being a semaglutide and drizepatide are new medication recommendations. So there are a number of those that are in there. And then I talked about cardiovascular and statin intolerance. So there are a number of new medication recommendations depending on the broader aspect of diabetes that one's dealing with. Yeah. Do the insulin therapy algorithms change if someone is on ultra long acting insulin versus long acting insulin? I guess, depending on what, I'm old enough to remember Ultralente, which many probably don't even know what that is. And that was a very unreliable long acting insulin. I think the current long acting insulins really there aren't significant recommendation differences in dosages that are sort of highlighted in the standards of care. And I have one more question. So what it is apparent that insulin sensitivity in type one diabetes is being worsened in the presence of statin, does it warrant to discontinue it or to add as a therapy only or other therapies? Yeah, I'm glad that question is. So one of the things we did that the standards of care highlighted last year was for people that need a statin, whatever it does to their diabetes or risk of diabetes, they still should be on a statin and shouldn't be discontinued. Looks like we're winding down on time. That is correct. That is correct. And that was my last question. I truly thank you, Dr. Gabay, because it was just wonderful. So if you have not already done so, please submit your ADA membership and ADA scholars program. As a reminder, please make sure to apply for the 2024 ADA scholars program. Thank you again to Leona M. and Harry B. Hensley Charitable Trust for their support for today's program. I would like each one of you for joining us today. And this concludes our program for today. Thank you again for your time. And we look forward to connecting with you in person at the ADA scholars program in Orlando this June. See you all in Orlando. And thank you for the work you do for people with diabetes.

webinar summary

Dr. Robert Gabay

2024 updates

diabetes

type 1 diabetes

bone health

diabetes technology

obesity

cardiovascular disease risk reduction