Hello everyone, welcome. We're going to wait for a minute or two here before we'll begin this session. So let's see, hopefully a few more people will join. Hey, Lutz, good to see you here. Thank you for joining. We are right at the time, but I think I'm going to give 30 more seconds because I do say that a lot of people are still joining in. All right, I think we can start. So good afternoon or good evening, depending on where you are. My name is Viral Shah. I'm a professor of medicine in the division of endocrinology at Indiana University. And I also direct the clinical diabetes research program at Indiana University within our diabetes center. Today, we're gonna talk about what's new in the CGM. I think this space is evolving and a lot of things are coming up. And today we have a fantastic faculties that will talk about new updates in this space. Next slide, please, Laura. So after, I will introduce them in a second and they don't need introduction, but still I think as a moderator, I need to do that. They each will present their part, which will be updates on CGM, the over-the-counter CGMs and other things. Meanwhile, I would encourage you to really write down the question if you have. I will take those questions at the very end so that we can make sure we finish those presentations on time, but we'll try to make sure that we'll take most of those questions. So please do not hesitate to put your questions in a Q&A. Also, we wanna remind people that this is not an CME accredited event. So just an FYI. Next slide, please. So again, where to type your questions. It's a easy peasy. We have done Zoom for many years now, I feel like. So it's in a Q&A box, but look for the chat box as well because the ADA people, Laura and Nicole, might put some resources for you to look up So there may be a link, the bios of speaker and many more things. So you can look up at both the Q&A for your questions and the chat box for some general information. Next slide, please. Now, many of you have attended webinars by the ADA. The ADA has a lot of different interest groups and the webinars are organized by different interest group. If you are really interested to, number one, know about the interest group, what it is, what that mean, what kind of activities they do, please go to the professional.education at the ADA website. Again, I see that Laura has already put that in a chat field. You can look at that, click on that link. It will take you to that page. You have to be an ADA member. So by chance, if you are not, we encourage you to sign up. All these webinars are recorded and they are housed under Institute of Learning, IOL. So for example, the November's webinar about the hyperglycemic crisis, there is a new guidance by the ADA-EASD joint consensus on the DK and HHS. If you missed that webinar, it's already there. It's recorded. You can go and watch that video. Next, please. Same thing for our webinar. So if your colleagues have missed today's webinar, nothing to worry about, you can go there. Wonderful. I can see that site here. That's the procommunity.diabetes.org. Once you go there, you can look up the third part, the tab, it's called Institute of Learning. That's where all the videos will be there. You can also provide feedback, what you want to hear from us. You can be a part of our interest group as well. So don't be shy, please contact us, be in touch with us. It's all a community. Next, please. With that, I think my job as a moderator is pretty much done here. So I'm gonna not spend much time and I will let you hear from our three amazing young panelists and young investigator researcher, very well known in the field of diabetes technologies. The first speaker will be David Ann. Probably many of you already know him, doesn't need any introduction. So David, this virtual stage is yours. And after you, it will be Laia and Dr. Andrew Welsh. Great. Well, thank you for having me. Let me get my screen shared. And one of the themes I'll be sharing, hold on. Of course, the slides freeze when I try to actually do it. So give me a sec, we'll try this again. Share. Sometimes it may take 30 seconds or so when someone actually, oh, there we go. I can see your slides. All right, great. Perfect. So it's a great opportunity to be able to share with you about some updates in CGM. Like Dr. Shaw explained, the three of us are gonna kind of talk about our own separate segments. And then afterwards, hopefully there'll be a really robust discussion about some of these updates. So please populate your questions in the chat. I think the biggest value in my opinion, what I'm most looking forward to is actually the dialogue between all of us. So we'll get started. So here are my disclosures. I'm definitely involved in various technology companies. So today, my segment is gonna be talking to you about the Eversense 365, which is a brand new continuous glucose monitor that was approved in October and is now available as of November 1st, 2024. So many of you might be familiar with the Eversense over the past several years, but this is kind of what I like to think of kind of what I like to think of in its final form, not so much that future versions won't come out because there's definitely more upgrades coming, but it's a really evolved product now. Obviously from the name, the biggest thing about it is that it's a one year sensor. So it consists of various components. And since this is the one that you may be least familiar with, I'll kind of belabor the point a little. So here in this little gray thing, I described to my patients, it looks kind of like a Tic Tac. This is inserted under the skin in the upper arm, and it's a quick in-office procedure. Over that site, you wear this transmitter, which is removable. So you can pull it off and put it back on at any time. Basically this transmitter sticks to your skin with this adhesive. It's kind of like a double-sided adhesive. And it's really important to note that the adhesive is silicone based and it can be removed and reapplied several times without losing its stickiness. So that's a big distinctive over some of the other sensors, the transcutaneous sensors, because since the transmitter can be removed and reapplied at any time, it doesn't have to be so sticky that it stays for 10 days or 15 days. Because in general, users are expected to kind of change out that adhesive every day. So it's much more gentle on the skin. And if the transmitter gets knocked off, you can put it right back on. So this is a great option to consider for patients who might be struggling with skin rashes or skin irritation, or they have trouble making their sensor last long enough, the full, you know, seven or 14 or 10 or 10 days. Now it has a MARD of 8.8%, and that's, you know, a very high or a very good accuracy metric. Under 10% is generally looked very favorably upon. Another nice thing that's unique to the Eversense 365 is that it has minimal compression loads. And that's when a sensor can read artifactually too low when you sleep on the sensor. Now this sensor, the technology, there's no filament penetrating into the skin. So it has much less variability and vulnerability to compression loads. Another unique aspect of the Eversense is that this transmitter that's worn on the body actually can vibrate with a unique pattern for highs and lows. So if your patient doesn't have their phone on them, or if they're giving a presentation, like I am right now, in theory, they could be able to tell if they're going high or low based on the vibratory pattern and they can feel it without alerting, you know, their colleagues next to them. It does have a longer warmup period. It's a 24 hour warmup period, but keep in mind, of course, this is a one year sensor. So you get 365 days after that 24 hour period. It is certified as an ICGM device. So it is capable of integrating with automated insulin delivery. Although their official pump partners have not yet been announced. It does have smartphone view, as you can see on the screenshot, and it does have an Apple Watch app. There's no first party receiver. So there's no official reader that you can get with the sensor at the moment. And one hidden benefit to this 365 day product, a lot of people kind of maybe were hesitant to use or prescribe the Eversense before because it had a pretty aggressive calibration schedule. But now I think it's pretty reasonable. For the first two weeks, it's a once daily finger stick calibration. And then from days 15 to the rest of the year, it's a weekly, once weekly calibration. So as you can see, it's a very distinct and kind of unique type of continuous glucose monitor that may be a benefit to your patients. Now, this is just some data to show that it is very accurate across all the different ranges. This is the breakdown of the MARD from their one-year approval study. And as you can see, their MARD, which they're particularly fond of, is 7.7% in the severe hypoglycemic range of less than 54 milligrams per deciliter, and 7.8 in the standard hypoglycemic range, 54 to 70. So it performs very reliably even in the low blood glucose ranges. And it does have a very reliable alert. So when you set your alerts to these different thresholds, this is a confirmed event detection rate where it's appropriately alerting your patients. And these metrics are all very, very impressive. One thing that is kind of hard to convey when you're just reading a press release about the Eversense is that because you're using the same exact sensor over the full 365 days, one of the nice things about it is you don't have a day one of the sensor every seven, 10, 14, or 15 days, right? So for example, this is just the MARD of the 180-day product, marched out and mapped out over 180-day period. And as you can see, in gray, they're kind of comparing the MARD of a transcutaneous sensor that's reapplied every 10 days. So in this system, you can see that the MARD will spike above 10 on that first 12 to 24 hours of each day one of a new sensor. So it is kind of nice that for your patients, yes, there's a little bit of a settle-in period for the MARD in the beginning, but once it kind of settles down, the Eversense has pretty consistent reliability and MARD for the rest of that entire lifecycle of the sensor. So that's kind of a unique advantage to it as well. Another thing is that in their internal study data, so all these sensors that we present today had to do internal studies to get approval, and they found that 90% of the sensors in their study survived the full 365 days. And this is basically just showing what percent of the sensors lasted the full, to what different time periods across the X-axis. And a sensor survival of 90% is quite impressive as you'll see from some of the other slides and compare it to the published data from other sensors on the market. So to summarize for the Eversense, because sometimes it's hard to kind of put our mind around it because it's such a different type of sensor, I kind of summarize some of the advantages and disadvantages to be fair. So one, an advantage is that it has the removable transmitter, right? So if it gets knocked off, you can put it back on. If you're going swimming or something like that, you can take it off and then put it back on after your swim session is done. And, but the downside is that you do need to charge that transmitter every one to two days. It charges pretty quickly, 10 to 15 minutes, but it does need to be charged. If you think about it, there's actually much less supplies when you carry around the Eversense. So if you're going on a month long trip to Asia, then really the only charging supplies you have is a charging cable and just adhesives. You don't have to carry around boxes of inserters or anything like that. So it's a lot less packaging to carry around. Now, of course, another disadvantage is that you do have to calibrate it once weekly versus other systems that are zero calibrations. A unique advantage that I already talked about is the vibratory alerts on body. A disadvantage, of course, is that you have to go into the office for a procedure, although hopefully once a year is doable. Like I mentioned before, virtually no compression lows with the Eversense, but it does have that 24 hour warmup period where you do not get any readings. And it does take about a week, seven to 10 days for the accuracy to really settle down. But after that settle down period, you don't have to deal with sensor to sensor variability for the first year because you're not changing sensors every seven to 15 days. It does have the best low accuracy performance when you look at their MARDS and the low blood sugar range. The transmitter at this point as a downside is bulkier than the competition. The Libre and the Dexcoms have gotten quite small and elegant, whereas the Eversense transmitter is kind of similar to the last generation sizes. Really good wear, long lasting, 90% lasts the full 365 days. While there is an Apple Watch, I will say the Apple Watch functionality is not as graceful as the Dexcom. There's no complication or widget on the home face. You have to launch the app to actually see your blood sugar. The last advantage I wrote here for the Eversense is that it's less likely to cause skin sensitivity or rashes. And obviously a major disadvantage for many of us is that as of now, they don't have any automated insulin delivery partners. Just to kind of color the rest of our conversation, I did take pictures of the various sensors. Obviously some of them have similar form factors. So I did not have a separate picture of the G7 and the Stello. The main difference is a color change. And this is the side profile below. And that's it for my portion of the slides. So I'll throw up some references or some ways to get in contact with me, and then I'll stop sharing my slides. So Dr. Akshapur can take over. Thank you, David, for a wonderful presentation and sharing so many exciting features of Eversense. Okay, I'm gonna go ahead and share my screen. Okay. Is it good? Yes, I see your slides. Okay, perfect. Thank you. So, I'm Laia Eklaspour, a pediatric endocrinologist at the University of California, San Francisco. I'm also a clinical researcher and have been involved in device studies for several years, so I do work with several companies. So, during my presentations, I provide a few updates on the sensors that you've worked for many years by now. So, I start from the sensors made by Abbott Company, Libre sensors. As you know, at this point in the market, we have Libre 2 and 3. I do have a table here that I wanted to compare Libre 2, 2+, 3, and Libre 3+, which basically, I'm not going to focus on the differences in word or accuracy like that, but I think I have this table just to point out, one, as a pediatrician, we always look at the age indication, and Libre 2 and 3 are both for 4 and above, and 2 and 3 plus are for 2 above. That doesn't mean, obviously, that it's not being used by a younger age group, but that's what it's been cleared for. And in terms of the sensor duration, Libre 2 and 3 are for two weeks, and plus, it's 15 days, for 15 days wear. And in terms of Bluetooth communication, Libre 2, both for 2 and 2+, is about 20 feet, and for 3 and 3+, it's now increased to 33 feet. And I think the big thing now in sensor works and we as providers are all for options, right? We want to make sure that our patients do have options to choose, and in terms of both insulin pump and the sensors. So, plus is the version that does work with pumps to make it an automated insulin delivery. For Libre 2+, works with Omnipod 5 and Tandem, and for Libre plus, the most recent version, at this point, it currently works only for beta bionic islets. So, the other update from this company is about, I think, I do encourage you to learn about, to, you know, to look at companies' website. And Abbott recently has launched their medical affair portal that you can look at the most recent publications and some updates on the systems that they make. And I think the other piece that I do encourage is look at the educational grants, because once the systems are in the market, it's necessary, I mean, they are FDA approved, but there's so many questions that come into mind as providers and investigators that necessarily not the, you know, they will go and find the answers. But as investigators, we can look at, like, subpopulation or specific questions about use in groups that we do take care of. The other exciting update that this sensor had for the community is that now Libre 2 and 3 are approved for use during medical imaging. These are for, like, common imaging, like x-rays, CT scan, MRI. On their websites, what they do provide that during the procedure, like the MRI, for example, there might be some issues with the function, but it goes back to normal after about one hour. And they recommend is that if it's, you know, scans to, like, areas like pelvis or sternum higher, like pre-test level and above, it should be limited to 12 minutes maximum, and then two minutes in between scans. I think that's also a huge deal for patients. Not that these sensors are approved for use in patient use, but we do have patients that continue using their sensors coming to the hospitals, and they have to take it off for the procedures. But, or if they come for an outpatient procedure, they can keep the sensor on. So after that, I will get some, a few quick updates on Medtronic sensors. I think once available sensors in the market called Guardian. So Guardian as a standalone CGM, Medtronic use it as a system combined with InPen, which is a smart insulin pen. I mean, during these webinars, I'm not going to really focus much on, you know, different methods of insulin delivery, but for people with diabetes that prefer to stay on injections, InPen with the app basically tracks insulin dosing, and you can have different, you can have the ratios in the app, and it does get recommended. Both says it gives you a reminder. And as providers, we find it's very, very helpful when we look at the data to, you know, we look at the logs and the history to come up with recommendation to change the ratios. Because we're talking about Medtronic products, I added this iPort Advanced Injection Port, which is also new. And that's also a nice device for patients that want to stay on injection, but they're not ready to switch to pump yet. So if you are on injections for more, a few times a day, you can use this port, but basically the skin will be poked just once, and you can use this port up to three days for multiple injections per day. So as I mentioned, the available sensors in the market by Medtronic is Guardian 4 and 3. Guardian 4 is approved for age older than seven, and we have Guardian 3. So Guardian 4 does work with the Medtronic, as you see the clinical app and the sensor and the Medtronic 7 ADG, which is basically the whole combination is a Medtronic 7 ADG with an advanced closed-loop algorithm. So in terms of updates in Medtronic sensors, Simplera, as you saw a picture in David's last slide, that Medtronic Simplera CGM, the standalone CGM, is currently approved for a patient with diabetes that are older than 18. So Simplera SYNC is not a day approved yet, but that's the sensor that once it's clear can be used with 7 ADG. I do have this table, not that necessarily I want you to look at the details of the glycemic outcome, but once I was doing my literature review for what we have available on the use of Simplera in the past few years, Simplera has been the sensor being used in Medtronic 7 ADG, the most recent one that was published, was presented at ADA 2024 with the use of Medtronic 7 ADG and Simplera sensor. And the last slides that I have here is one update for Dexcom G7, which is very, very exciting. And it's about the connection between Dexcom G7 and electronic health record. That's going to be a huge deal in diabetes care overall. This process should be started from the institution with Dexcom company and what the provider can send the message to the patient who requests this connection and wants the patient approved. And this process has been started on the provider side. The patient can accept this request and complete the linkage. And what does that mean? This means that data will come directly from Dexcom G7 to medical record system EPIC, which can make the workflow in our clinics much cleaner and nicer and more organized. So this way, the clinicians can look at the data and this gives a lot of opportunity in terms of the future steps. For example, quality improvement studies, looking at overall increased benefit of FASED. And we can talk about like the charges following the FASED. So it's a huge step. And here, this was my last slide. I'm going to ask Andrew to continue, and I think we take questions and start the conversation once this ends. Thank you. Great. I'm just getting my slides shared. And Andrew, I don't see your video, so probably you want to- Then that's what I will do. I will click that button as well. I'm thrilled to talk to you today about over-the-counter glucose biosensors. We'll be comparing the Stelo, the Lingo, and the Rio, which is just fun to say all of those in a row. I think the best, I should also say I have no disclosures here, but I think the best metaphor for continuous glucose monitoring is trying to understand your glucose without a continuous glucose monitor is like walking on a foggy mountain path, where you have a hard time knowing how high you are, how far you've come, and where you need to go next, though you can kind of guess. What came to my mind is this statement. You can't fully appreciate your challenges until you can see them. And what becomes a foggy mountain path now becomes a mountain range, and you know exactly what you need to do to target your glucose and manage it appropriately. I think mountains are also a great metaphor because they just happen to look exactly like tracings from glucose monitors. This is the age that we're in, where increasingly people have access to their own glucose data through continuous glucose monitoring. The principle that a lot of these over-the-counter sensors are based on is the idea that when people without diabetes or with prediabetes are able to see their glucose, they're able to make healthy changes in their lifestyle through diet, exercise, stress, and sleep in a way that can help prevent complications of diabetes or progression of diabetes. And the other statement that comes to my mind is this. Are we ready for a world where glucose is no longer invisible? Because that is the world we are in. I wanted to show the different indications for the over-the-counter biosensors by using the no diabetes, diabetes, and insulin categories. What we're most familiar with is the Dexcom and Freestyle, as we just learned about systems, which are approved for people with diabetes and on insulin. The Dexcom Stelo is approved for patients or people without diabetes and also with diabetes, but not on insulin. Abbott has also released the Lingo, which is for people without diabetes only. And in the process of releasing in the United States, the Companion Rio, which is designed for people with diabetes, but not on insulin. And we've already seen a lot of pictures of this, but this is just a reminder that the Stelo looks just about identical to the Dexcom G7, except for some kind of color differences. And the Lingo and Rio look exactly like the Freestyle Libre 2 products. I had a huge chart of all of the different specifications and comparing them, but in the end, I decided to share the three most interesting. These sensors have glucose updates, but the Stelo will measure the glucose every five minutes, but only reports it every 15 minutes. And I've confirmed that when you have a download of this data, you can see every five minutes, not just every 15 minute dots. The Lingo is updating every one minute, as well as the Rio. Hyperglycemia alarms. The Stelo has a system called spike alerts, where when the blood sugar is rising more than average and above 140 milligrams per deciliter, the user will get a spike alert saying that you're having a spike of glucose, and you can ignore it or you can interact with the app. The Lingo does not have any specific hyperglycemia alarms, but I assume that the Rio will, but I haven't been able to try it out. Hypoglycemia alarms. There's really none that will alert an individual that they're having a low blood sugar, but there are low pattern insights through the Stelo. And I confirmed that that comes if somebody is having more than 1% of glucose below 54 milligrams per deciliter. And it's not that it's going to alert them, it's just in the weekly insights, it's going to start saying that they're having a certain amount of lows. There are no low alarms either with the Lingo, but I assume there will be with the Rio. This was mentioned before, and I just appreciate that this data is being shared more freely, but both of the user manuals reported the percent failure rate. So 77.9 of the Stelo sensors lasted the full 15 days, and 77.1 of the sensors for the Lingo lasted the full 14 days. And this is a separate conversation, but I think it tells us a lot about how we expect these sensors to be lasting the full time, but they just don't, even in people who rely on them with diabetes and who use insulin. To understand the power of these devices, you have to understand how the apps look and feel and work. So the first thing that stands out is that these apps are also libraries of information and education. So there are dozens and dozens of articles, and you see that they're pretty short, usually about a three-minute read, where you can learn about why does glucose matter, what's the target range, the link between blood sugar and inflammation. You could spend all day reading these, but it's trying to help people learn on their own the importance of glucose management. This is a screenshot of what it looks like if there's a spike detection. It alerts you that a spike was started, the time, and then it gives you an opportunity to reflect and choose why the spike happened. You can choose the meal, stress, activity, and so on. I had the opportunity to wear a stelo, and I'm an individual with type 1 diabetes, so I kind of broke the rules, but I think I'm okay with that because I think that's what patients are going to do too. You can just order these online, and there's really few questions that are asked or double checks. But I wore the stelo on top of the Dexcom G6 at the same time, and I used the Clarity app to examine both of the sensors at the same time. So you can see there's a little bit of a warm-up. You can see that the stelo has a similar kind of a pattern to the Dexcom G7, where it doesn't have the smoothing algorithm quite like the G6 does. And you can see by the midpoint of my time, the sensors were right on top of each other. And then at the end of my 15-day experience, they were starting to separate, and the stelo was starting to kind of peter out over time. I'm going to shift to talk about the Lingo app, and it has a completely different approach. And to understand it, you need to understand the term Lingo count. And this is a, as far as I know, unitless number, which is an estimate of your glucose exposure when you eat food. And you can see on my screen here, this is a screenshot from when I wore one of the Lingo devices and used the app. Whenever I had a blood sugar spike, there's a small number underneath that represents the Lingo count. So this meal was a Lingo count of 64. The next meal was a Lingo count of 28, and so on. And it recommends a target Lingo count of 60. So I didn't do very well for that, but it also wasn't really designed for me to use as an individual with type 1 diabetes who uses insulin. But it also breaks down on a regular basis where are you getting the most Lingo counts. So for me, that was in the afternoon. And then it breaks down some of the meals and shows you what was causing the highest Lingo count. For me, that was the hot dog. Surprisingly, the lowest Lingo count was the Christmas party, and I'm not quite sure how that happened. This is just an image on the left of what the app looks like on your phone when you open it up, and it shows the normal range for people without diabetes. It also has some features around challenges. You can pick a variety of challenges, and it will remind you things like building a balanced plate, close the kitchen after dinner, and so on. And so the app wants to interact with you pretty constantly to help you make healthy decisions. I chose the challenge reduce hunger, and it was asking me every day how my hunger was. So I was thinking more about my hunger. I think it's important for healthcare providers to understand what happens with this app. If somebody has a blood sugar above 200, this is what it looks like. There's an article that appears, and it says, see a spike over 200. And when you click on it, it takes you to this article, which kind of describes some basics around what is a normal blood sugar with CGM. And it cites some studies where people without diabetes could have spikes up to 200 milligrams per deciliter for a very short period after certain meals. But a lot of these articles end with, please talk to your healthcare provider, and I think we should be prepared for that. My final slide is kind of this image of the fog clearing and seeing the rolling hills and you know, the many paths that exist. Again, a lot of these paths lead back to a healthcare provider for people who are having abnormal readings or questions about their glucose. Overall, I'm excited about this phase of technology and the opportunities that it gives for everybody to be able to see their blood sugar. I think the people who will benefit the most are people who are at risk of diabetes or have prediabetes and can make real-time changes to their lifestyle to manage their blood sugar. The concerns that I think we all have in the back of our minds are, you know, there's a lot of very healthy people who can become somewhat obsessed about their health data, and it can cause a lot of anxiety and worry. And I've seen a few examples of that with continuous glucose monitors, but overall, I think I'm optimistic and look forward to sort of this new phase. Thank you very much. All right. Thank you so much, Andrew. Okay. Now I see that the questions are coming in and I'm sure that there will be a lot of questions directed toward this over the counter. And I appreciate that you try to use it by yourself so that you can give your perspective in this presentation. I would like to have all of us with the camera on so that we can try to have this interactive question and answer. David, would you mind turning on your camera? Here we go. Perfect. Yeah. All right. So let me start with this first question that came from James. Can the vibratory function for the high, low BGs of the Eversense 365 be turned off? If not, would it vibrate nonstop until your glucose in a range? Yeah, it's a great question. So you can turn off the on-body vibratory feature. I believe, and this one I'm not 100% sure on, but I believe the very low, kind of like on the CGM, the other CGM apps, you may not be able to turn off the very low alert. But I know you can turn off kind of the standard high and the standard low vibratory setting. Oh, great. So I think, again, all of you gave a really fantastic overview of all these updates that have happened over about a year now. The way I think is that the field is moving so fast and we as a physician are challenged to keep up with these updates. So my question to all of you, feel free to chime in, anyone. How do you receive this update? How do you keep yourself up to date? David, you can start. Yeah, I'll start. That's a great question. You probably know where I'm going to go with this, which is, I think social media, for better or worse, is a great place to kind of catch what's going on. Usually when there's a major announcement, the different manufacturers will push out messaging on their social media platforms, whether it's Instagram or Twitter or X. And I think that's usually where I actually find out first. A lot of my local reps and I, we kind of have an informal race to see who can text each other first with news. And I usually beat them because of social media. So that's been the best thing. Now, the hard part is also processing and remembering everything because it's so hard to remember it. And that's the challenge that we're all presented with. But I'm curious to hear how the other physicians feel. Laya, what do you do? So I guess now, as someone who's not a social media person, I mean, that was, I appreciate that and I understand that. But I think one thing, one comment that I have for you as a provider, especially physicians forget to, or either forget or they don't have the time to get into the practical aspects of diabetes. But the reality is that is diabetes. I mean, this is just not about the actual number at every moment. And I think it's very important to just pause and also ask these questions and about every person's perspective and experience on this. And I think I probably learned this through my studies, but that helped me to be a better doctor because once you hear from them, they share their experience with you and you can use that as, I mean, I don't have diabetes. So I think I use that as an example, to share it with other people. And there are definitely challenges that are not like the first time, challenges for someone, but you can have a conversation with the families and people in your clinic. Yeah, great. Andrew. So I'm a big fan of trying it as my presentation suggested. And I can tell you that the reps around you, particularly with Dexcom I found, they were very eager to let me try these things out and give me a sample. It was a little more challenging with Abbott, but you could consider buying one for yourself or asking for it as a Christmas present around this time of year. And once you're in the app and you're experiencing it, I think it really shapes how you see it helping patients. The other thing I'll say is just by participating in the American Diabetes Association Diabetes Technology Interest Group, I learn a lot. I mean, today I've learned already quite a bit. And then I also have to say, I learn a lot from patients. They come all the time and they say, hey, have you heard about this? Or what do you think about that? And then I have to learn, but yeah. Yeah, no, great. So I think I will summarize. And this is probably for many folks who are seeing patients with diabetes, both type 1 and type 2, or caring for someone with type 1 or type 2 diabetes or including pre-diabetes. Now, I think we want to include all this dysglycemic status into one large port right now is social media. So if you are a person like David, then I think social media is a good source to get this updates on diabetes technology. Andrew would like that coming from an ADA. So that's a professional organization where you can get, so attending this webinar, right? You learn a lot. And so I think that's one way. Laya, it's like, okay, doing a research because you're going to, the first one, you're going to do something that other people don't know. And that is the research that will be translated into the clinic. And also, I think there are other sources, like for example, Diatribe, ClinicLose, the patient organization sources where they update, you know, all this lot more information. So primary care providers or anyone who are looking for those different sources to keep yourself up to date, then I think these are the sources that we discussed here that may be helpful to you guys. We have about 28 people listening to this, but it feels like a little shy group here, not asking this question, which is okay for me because I think I can try to ask my question. So I think one of the things that you mentioned, Laya, is about the Dexcom's EHR integration news. As a provider, I feel like that's big. Now this is only limited to Epic at this moment, but the Epic is the larger EHR. So hopefully that will be applicable to larger institution. At the same time, I don't know how it's going to go. And does that going to increase the workload, at least initially for the health institutes and the providers like, you know, us? Excuse me. I'm still recovering from laryngitis, but the more I speak, it gets worse. And then you think that the people are expecting that, hey, you know, now my data and you're going to manage my diabetes more, kind of like having a direct watch. What do you think? I think I agree. I mean, I'm sure in the beginning, it's like, you know, I'm sure in the beginning, it's like everything else to have a setup. It takes time, efforts, especially from the institution to start this process. But the question, is it worth it? And I want to say for sure. I'm sure the beginning, there will be some challenges in terms of to make sure the patients understand that there might, there will not be a real time monitoring or depending on the institution, the organization, there might not be even a setup for, you know, automated alerts that get to the providers. Like, for example, if this patient have, you know, time in range below 50% for the past three months, like, you know, I mean, these are like the tools that there are other groups that are working on. But I think we get there. It just, it might be slow, but I think that's just the beginning of it. And it's very exciting. Yeah, no, I agree. Looking forward to that for a long time. So finally it's happening. So that's good. Andrew, question for you from Diane, is that any news about the Abbott Rio to be available in market? I asked this exact same question to the representatives that I work with, and I never got the answer. I know it's released in the United Kingdom. So I, and all of their websites say that it should be released by the end of this year, but clearly there's been a holdup. I don't know if any other panelists have updates on that. I have not heard anything. I don't know if, I don't think the Rio is available in UK, but we can double check that. One thing I think is worth mentioning about the Rio is that the full name of the Rio is the Libre Rio, which matters because the lingo is actually under a different division at Abbott. So you had mentioned, Andrew, that Dexcom sampled the Stello to you, the rep did, but Abbott did not sample the lingo. And that's because your Abbott medical team that supports you is going to be with the Freestyle Rio, but not supporting the lingo. The lingo is like a consumer health and wellness product. So, so it's an interesting fact. So another reason why that matters is that the lingo does not download data into LibreView, whereas the Libre Rio will whenever it comes out. But to answer your direct question, I do not have an answer for when it's going to be available. And I haven't heard anything like from, even from my, you know, behind the door conversations, no one seems to have any information that they're willing to share with me. Yeah. And, you know, again, I think what you tried to make a point, David, is that Abbott has now clearly made a wellness division separate from their medical division, and they are trying to keep it separate, which I understand. Another question from Jennifer, she is curious about the Dexcom and the ring, which is called Aura partnership. Any one of you have any updates? Andrew, did you use that? No, I thought about it because you can use your extra FSA money to buy an Aura ring. And, but I didn't do it. I, so along the lines of Andrew's suggestion, I do test these things out. So I'm actually wearing an Aura ring and something else I'll tell you about right now, which is, so, so to answer the direct question, I think it's, I think the press release is kind of seeming to be more than it really is. If you read it closely, it sounds like Dexcom is investing money into Aura because they believe in the product and there essentially is going to be some data sharing. So the Aura experience, cause I've been testing it out is very much kind of a wellness product. It talks about your rest score and your sleep quality and stress levels. It tests like heart rate variability and temperature and things like that. There's also some integrations with like period tracking for females. And so I think what, what that integration is going to do is it's just going to bring glucose data into the Aura ring app to kind of make that, you know, your metabolic health, a component of the wellness things that Aura tracks and vice versa. There might be some activity data or heart rate data or temperature data that gets pulled into the Dexcom app. So I think it's more of just the data sharing agreement. But interestingly enough, the reason why I'm wearing two is that there's a company called Ultra Human that I hadn't heard of, but they're in a company from India that actually has some sort of partnership with Abbott. And so their module is already turned on. So for example, the Aura ring Dexcom data sharing is not activated right now. So I'm just testing them out in parallel where I wore a Dexcom and I wore the Aura ring, but I did not know, but Ultra, Ultra Human or Superhuman, I think it's Ultra Human actually has live integration with the Libre3. So it actually gives some like a glucose feedback. It'll say like, oh, you had a spike. You might want to go on a walk. So in the end, the advice is still very similar to what you might get in the Stellaware lingo. But I think they're just trying to combine glucose data into kind of metabolic health and wellness, which is an interesting thing. There are pros and cons to that, but I don't want to talk too much. Yeah, no, thank you, David, for your input to that. And see, I think I want to tell our audience that why you should attend the webinars by the Diabetes Technology Interest Group is that, look at that. We all are using different things here to really provide you an insight on what it looks like. So I hope that people will appreciate that part. We have a couple of more questions coming up, and I think one of that is really, really great question. So I was yesterday in another like a community meeting, and I think someone asked the same question here. I have a prediabetes. When is the time for me to use this over-the-counter CGM, number one, and number two, how often I need to use that part. So anyone can start, anyone can chime in their opinion here. So, yeah, I think these are products that are very good for people who have prediabetes. When is the right time is kind of when do you feel motivated to make a lot of changes and synthesize a lot of data. You know, this may not be for everybody, but it's going to prompt you frequently to reflect on what you've done, what you've eaten, and to make changes around it. How often, that's a good question. I haven't had enough experience with people that aren't me. You know, for me, I got a little bit burdened by a lot of the alerts that were coming on by the Stelo, and that's just because it's really hard to keep the glucose that low when you're using insulin because I kept getting the spike alerts. But it's possible maybe for cost savings, you know, once a month or once every three months, somebody could purchase this and use it and sort of do a refresher course on their own glucose metabolism and maintain some of the changes that they learned from those sessions. Yeah, no, I agree. And I think I will add two cents from my side. So I do not have diabetes and I have used the Stelo. And my learnings from that is that, so to your point that, okay, when I agree that I think somebody needs to be motivated to say, I need that part. But the other way around, I think is that if you tell the people that, hey, there is an option, if they use it, then it may make them motivated to really think more about their pre-diabetes, you know? So that could be a motivational tool. Now, how often this is my N equal to one. So take that with a lot of grain of salt here, but I just feel like I'm really good when I have a Stelo on or Dexcom. I use Dexcom often. But when it's off, it's like, ah, you know, I'm back to kind of a normal. So I don't know. I feel like the motivation lasts only till you see something in front of you, right? And like, for example, in type one diabetes, we have a pretty strong data that the glycemic outcomes are better as long as you use it. That means you have to use it continuously. Now, I do understand for people with pre-diabetes or probably no diabetes, using that continuously, number one, may not be financially viable. Number two, I don't know whether it will change the outcomes because we don't know. I don't know. I just feel like the motivation doesn't last long. And so maybe that this kind of a device needs to be used more often than just once in a while. I don't know. That's just my, what do you think, David and Laya, do you have any perspective to this? I mean, I think I lean into kind of what Andrew was saying, which is, I think it's very user dependent. You know, a common question we have even back in the finger sticks days, right? Is patients, you know, their A1C might be good, but they say, how often should I be checking my finger sticks? And often I'll say, you know, if we know that overall your A1C is that goal, it's really up to you, right? You can stop checking it if your A1C remains good and other metrics look reassuring. But if it helps you and guides you to make good choices, like you were saying, Viral, then I say, then by all means, continue. And I feel like that's how it should be with these over-the-counter CGMs, as long as it's helpful and the user is getting accountability and benefits, but it can also be a burden. There's a commenter in the Q&A that mentions it can be sometimes burdensome or stressful to have really, you know, so much bombardment with data, or you feel guilty for eating something. And, you know, so I do think there's, it's kind of, it can cut both ways, but if it's helpful and the patient is benefiting from it, then I'm all for it. But I don't think, like Andrew said, everybody has to use it at all times. I'm going to make a quick comment, which I think is also relevant to the comment that was put by Elizabeth in the chat. I want to say, we really don't know the answer to any of these questions, right? So I think as providers, our job is also to educate people that we really don't know the answer to these questions. None of this is a method to diagnose diabetes or like pre-diabetes. These are just data. And, you know, we can't really answer any of this question as long as we have enough data over time and we can come up with guidelines similar to what we have for diabetes. I mean, these systems are not approved for kids, but even by now we do have like people who start wearing it because of concerns about highs, and then they notice a low, and then they come up, you know, with these concerns about low. I mean, this will come up and I hope that someone starts looking at this data and a group can come together to, you know, start working on the guidance. Right. I think a lot needs to be learned, right? I think over time. We have about two minutes. So I think there are two questions and a pretty easy one, which I think I can tell overall. So what about the insurance coverage? So Stelo and Lingo are over the counter, meaning by that, not approved by insurance. Anything that is over the counter, it's expected that you go to the pharmacy, pick it up, and you pay for it. Yes, you can use your HSA or FSA for those products. And it's typically cost around $99 per month. If you are buying that from pharmacy, plus or minus $5, depending on the discount that it might be giving you on their portal. But that's going to be the cost. Oh, already somebody, oh, David, perfect. Okay. You already answered that question. The other one is about the, what is normal glucose? You know, and I think that's what Laya, you also kind of alluded to that, that we are trying to learn that part, right? So what it is called like a time in range for people with diabetes, that's a 70 to 180. It's not really a normal glucose for people who have pre-diabetes or people who do not have diabetes. And so 70 to 140, that's what kind of an accepted right now, but I'm sure that it will also change over time because I personally think that the 70 on the lower end, it's a little higher because the mean glucose for people without diabetes is 99 plus or minus seven. That's a standard deviation, right? So anyway, that's just my two cents. So a lot needs to be learned. I think it's a time to now end, unfortunately, because we are right at like a five o'clock Eastern time, but big round of applause to all three of you, such a wonderful presentation, a lot of information, so many updates that like literally you cram that within 30 minutes or less with a wonderful panel discussion. So thank you everyone. Thank you to audience for joining this webinar. So thanks. Thank you for having us. Thank you.

continuous glucose monitoring

Eversense 365

Abbott Libre

Medtronic Simplera

Dexcom EHR integration

glucose biosensors

diabetes management

sensor technology

patient care

insurance implications