← Diabetes Core Update
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- [00:03]
A
Welcome to this special three part series of Diabetes Score Update where we will discuss the cutting edge topic of automated insulin delivery for people with type 2 diabetes. I'm your host, Dr. Neal Skolnick, professor of Family and Community Medicine at the Sidney Kimmel Medical College of Thomas Jefferson University. This special series of Diabetes Score Update is sponsored by Insulet. On the first podcast of this series, we discussed the benefits of automated insulin delivery. We will abbreviate that as aid for people with type 2 diabetes who are on insulin. Even with substantial benefits, though, new technology can be intimidating both to patients as well as to us as providers until we get used to using it. So in the second episode we discussed practical aspects of how to get started prescribing aid. And today we're going to discuss various aspects of aid prescribing, decision making and questions that come up regularly. Joining us for today's episode are two master clinicians who come at this topic from very different perspectives. First, let me introduce Davita Kruger, who joined us for the first two episodes and who is a certified nurse practitioner in diabetes for more than 40 years at Henry Ford Health in Detroit, Michigan. Her roles there include both clinical practice and research. She is a past president, Healthcare and Education of the American Diabetes Association. She served over the years as editor of both Diabetes Spectrum and Clinical Diabetes. She has been an author on over 100 publications, including, relevant to today's topic, two different trials that were published just this past year, one in JAMA Network Open and the other in the New England Journal of Medicine. Davita, welcome back to our podcast.
- [02:02]
B
Thank you so much for having me. I hope I sound as impressive as you just sounded, but thank you. I'm very excited to be here. This is a great group and a great topic.
- [02:13]
A
Thanks so much. And also joining us to discuss this from a very different point of view is Dr. Susan Cuciera. Dr. Cuchera is the Program Director of the Jefferson Health Abington Family Medicine Residency Program. She is Associate Clinical professor of Family and Community Medicine in the Sidney Kimmel Medical College of Thomas Jefferson University. And she is also a very busy clinician and teacher of medicine and comes at things from that really deep understanding of primary care. Welcome, Sue.
- [02:50]
C
Thanks for having me. I'm really excited to talk about this. The new cutting edge technology should be a great discussion.
- [02:57]
A
Yeah. And to start out, can you share with us a bit about your practice and where you come at this topic from?
- [03:05]
C
Yeah, absolutely. So I am a family doctor. I am a program director at a residency program. So we have a large Population of uninsured and underinsured patients. We have a lot of learners, medical students, residents. We have a lot of attendings. And when we think about this topic specifically, we have a fair number of patients who are on insulin and who have very significant access issues to get in with endocrinology, to be followed regularly with endocrinology. They have a lot of social determinants of health, transportation issues. So, you know, knowing that insulin pumps are really helpful for a patient's quality of life and the way they take care of their diabetes. We are still not typically managing insulin pumps in our office and a lot of this has to do with the operational and logistic issues that have come with pumps. We do a lot of troubleshooting when people can' access their endocrinologist with their insulin pump. So we know enough about them to help with some of those things, but we don't really manage an awful lot of them.
- [04:09]
A
That's a really important perspective and I think that perspective and place is shared by so many of us in primary care. While many of our endocrinologist listeners are well acquainted with insulin pumps, the reality is most of primary care are not. So it's important to be open and honest about the promises and the challenges. In fairness, it really wasn't until there was really good evidence about the benefits of insulin pump therapy for type 2 diabetes was really just about last couple of years. It was a year and a half ago that the fda, David and I know you were very involved in having, moving this along, that the FDA approved pump therapy for people with type 2. Is that right?
- [05:01]
B
That's correct. That's absolutely correct.
- [05:03]
A
And I know you were author on two of the trials that I mentioned that were very important. That form a lot of the evidence base now for us that also just came out over the last year or so. And let me just remind people before we jump into our discussion of the practicalities about those two articles, the first was in JAMA Network Open. It was called the Secure T2D Study. There were over 300 participants, average age 57, 7 years. Importantly, about 3/4 of the people in the trial were on multiple daily injections, but 21% were using basal insulin without bolus therapy. Following aid use, A1C levels decreased from a mean of 8.2, which is not an unusual level at the beginning of many trials, a mean of 8.2 at baseline to 7.4 at 13 weeks. So that was a mean difference of 0.8, a drop of 0.8% in a 1C and time and target improved. In both the trials, there was just a low incidence of hypoglycemia, so no differences there. And in the second trial that came out this year, the New England Journal trial, again a 13 week multi center trial, adults treated with insulin and type 2 diabetes were randomly assigned in a 2 to 1 ratio to receive either aid or to continue their pre trial insulin delivery method. And here the mean adjusted difference between those two at the end of 13 weeks was 0.6 percentage points of a 1C. So a difference in a 1C of 0.6%. Continuing their usual insulin delivery method versus aid. And the aid group again had more time and range. So these trials really establish some of the A1C benefits. There are other benefits we've talked about in terms of convenience, but it isn't surprising to me that primary care isn't fully on board yet, because this is new. Davita, your thoughts?
- [07:21]
B
Yeah, I just wanted to circle back to something sue had said. And when I think of her practice, which is a usual practice, we went out of our way and the FDA demanded mandated is probably a better word that we use older individuals, that we use racial differences, that we used high insulin, that we didn't require a bolus insulin because the pump is so able to do that. Different education, different socioeconomics. We took so many all comers that we really wanted to be able to say, okay, we did the research, we proved this. Now how do we hand it over or how do we share it in the primary care world? Because there wasn't anybody we did not include. And one other thing is that the higher the A1C, so we had double digit A1Cs, the greater the A1C lowering, and sometimes it was over 2%.
- [08:18]
A
That's fascinating, Davita, because that's the group I always worry about because it isn't just that they biologically have more resistant. Sometimes that's the case, but often it's operationally, it's hard to take four time a day insulin, it's hard to organize things. And that's really interesting. And we also have many patients with double digit A1Cs and it is tough. Were there differences, you mentioned this wide range of people that were in the trials, were there differences in outcomes between certain subgroups, older versus younger, that sort of thing?
- [09:03]
B
It did not appear to be. It honestly did not appear to be. I think it depended on the study. One study took people up to 75, took people up to 70, and you know, I don't think that's old. I would be happy to take older individuals, but that, that didn't, did not impede them from being able to be successful and education did not impede them. And then the other thing that I thought was super interesting is in the secure trial on entry, 31% of those individuals had insulin per day greater than 100%. 100 units. And those are individuals we would say, ooh, I don't know if we want to do that, but we did it. And at the end of the only 10% had greater than 100. Now, you and I, the three of us could say, well, were they taking their insulin? I don't care. In the study, they got less insulin, which probably means they were taking less. I mean, they were not taking at all. And that's okay because if I give them a pump, they do take it all.
- [10:01]
A
You know, that's such an important point, and you made this on a previous podcast, that we actually don't know what happens once someone leaves our office. And with the pump, we have a high degree of confidence that they are actually getting the insulin that's prescribed.
- [10:20]
B
Well, you know, you can see. So once they're connected, you can go in and look and say, oh, they took their pump off, or they didn't take a meal bolus, or they went for 12 hours without their pump. We can actually see those things. Not that that happens. That's not what we want to happen. But you can. When I put someone at mdi, I have no idea what you take.
- [10:44]
A
That's a really good point. And I think all of that, the data, the practicalities, is probably what led to the ADA standards of care this year coming out in favor or supporting automated insulin delivery. And before we jump into the cases, I just want to read from that because this really is new. The standards of care come out, as people know, in the journal Diabetes Care every January. And this is a big change from previous approaches. For the sake of clarity, I'm going to actually quote from the standards and it's section 9.27, if anyone wants to look in detail. And they said, quote, automated insulin delivery systems should be offered to all adults with type 1 and type 2 diabetes on insulin, depending on the person or caregiver's needs and preferences. And they rated that as an A level recommendation, a high level recommendation. And I find that fascinating because this is a big change in approach. And I do want to point out that they are saying should be offered. It doesn't mean that that has to be what is done, nor does it mean every prescriber has to be able to do it. It is offered as an option and then we decide with shared decision making as we do, you know, what, what makes sense. And, and it's kind of interesting because even though that seems like a large change, it wasn't that long ago. And, and sue, you, you know, we've talked about this in the office. It wasn't that long ago that CGM seemed foreign, right?
- [12:36]
C
Yeah, absolutely. I mean, I, this is one of those moments where I fully understand and appreciate the data and, and I realize what the data are telling us to do and huge operational lift in our practices. Right. And even, you know, if we think about CGMs, we have a lot of patients on them. How many of them am I logging into their cloud every time I see them? You know, it's not the same in primary care. It's just really challenging. And I think some of it has to do with, you know, you get better at things that you do more often, but if you have a schedule of 20 patients and one or two of them have a CGM, you're not doing that as much every day. Right. And I think when you start to think about pump based cloud systems that need to integrate with the cgm, GM based cloud, you know, cloud systems and the troubleshooting and the support, I, you know, again, this is a great idea and I love that it's an option for patients with type 2 diabetes now, but the logistics of it and to get good at it feel like it would be really challenging in primary care.
- [13:42]
B
So, you know, sue, you've said so many things that make me think that you're halfway there, which kind of makes me smile. And really, I'm thrilled you're doing. You're touching so much of this already. You said you're troubleshooting. I wish I could go back to my office and have all the endos be able to troubleshoot. So I think that you have. First of all, not all endocrinologists are experts in pumps, nor do they want to be doing them, nor do they necessarily do diabetes. But there are, you're right, there's a subset of I live and breathe insulin pumps. You know, I can in my sleep tell you how to make a change, but I think you are closer to using insulin pumps than you think. But also, I think not all primary care people like, not all endocrinologists are going to be. But we just need a few of you to raise your hand and we'll help you along.
- [14:44]
A
Let's go ahead and jump into a case. Thanks so much. Davida. And just as we talk about our cases, for all of our cases, we're not going to go over all of the person's medical problems. We're going to focus solely on the management of their diabetes and blood sugar. For the first case, we're going to look at a 55 year old male who has type 2 diabetes, hypertension, hyperlipidemia, comes into the office. He's on metformin 1000 bid, topagliflozin 10 milligrams daily, tirzepatide 15 milligrams weekly, insulin glargine 45 units in the evening, and lispro 8 units three times a day. And a week before coming into the office, his A1C was 8.2. Sue, what are your thoughts?
- [15:33]
C
Well, my first thought is this. This feels very common, right? This feels like something I see often. And you know, this is a person who. And I. This is where Davita and I will probably differ, but I'm like, this is a fair amount of insulin. You know, this is like starting to teeter on the amount of insulin that I'm like, yeah, I don't know, I don't know if I'm comfortable with. Um, and, but the first thing I would do is explore a few things that I do with all my patients. So one really talking about their diet and their medication adherence. Right. Um, these are areas I feel very adept at optimizing, at discussing. Um, and then I might consider like, does he have a cgm? Can we get him one? So all of that feels very comfortable to me. Um, but the truth is, is that if there wasn't a lot of movement possible with his lifestyle and in his adherence issues. So if I went through and I felt like pretty pret much like there wasn't a whole lot of movement to have here, I would probably say, you know, a pump might be a great idea or maybe we should send you to endocrine, because again, this is going to be like a lot of insulin for me in primary care. And so I guess my question would be, you know, for Davita is if I would, if I referred this patient to. Because I probably would, right? If I optimized all those things and I'm still not at goal and this is a young guy, I would probably say, why don't we get you in with endocrine and see what they think. So I would love to know what you would do with him when he walks into your office.
- [16:55]
B
Well, I think first of all, when you look at type 1 diabetes, that's probably not even that much insulin for somebody with type 1 diabetes. We look at about a half a unit per kg of body weight in type 1 and 1 to 2 units per kg of body weight in type 2. So it really isn't a huge amount of insulin. But we don't want to push the insulin without getting a better outcome. So I agree with you, diabetes education and also mnt, but this would absolutely be an insulin pump person got him on four injections a day. And the best way to deliver that insulin, and if I want to be assertive, aggressive, whatever the correct word is with his insulin, the best way to do it is through an insulin pump. Now I suspect too that if you miss one injection of glargine a week, that's going to affect your A1C. If you know, you're busy during the day and you miss lunch, you come in for dinner, you miss dinner, those things all affect the A1C. Not so with an insulin pump. You put the pump on, most of them, you're going to wear for three days without having to refill it. And the pump looks at that data from the cgm. It's integrated with the cgm. So the CGM says to the aid insulin pump, oh my goodness, your blood sugar's high, it's above 160. Let's give you smidges of insulin. Not enough to cause hypoglycemia, but we're gonna get that blood sugar under control. And if the blood sugar starts to trend down, it lowers and pauses the insulin cause. You all know sustainability. Your biggest concern here is the same as the patients, hypoglycemia. That's why you're looking at this. I'm assuming one of the reasons you're looking at this and saying, oh my goodness, so much insulin, is you do not want to cause hypoglycemia for this patient. That's the rate limiting factor to getting someone to treatment goal. So if I put him on an insulin pump, all of those concerns go away. And the pump is the one that going to say, more insulin, less insulin, more insulin, less insulin. And even if the patient misses his mealtime insulin, that pump will correct.
- [19:01]
A
You know, it's interesting, David, as you're talking about hypoglycemia, one of the things I always get scared about. So this is the patient who I have that detailed history about following their diet and I go over how important it is to take their insulin. As I'm saying that to them. I'm also afraid if they start Listening to me because. Well, because if they really haven't been taking their insulin very often or missing a lot of doses and suddenly they realize how important it is, that is potentially a dangerous situation. And it strikes me, and I hadn't thought about this before, that a real advantage here as opposed to that lecture, is much more safety that as someone's getting their insulin, they're not going to have as high a likelihood of overshooting.
- [19:55]
B
So let's circle back to those patients that were on greater than 100 units a day that we entered into the secure trial. Now I don't think they were all taking all of that insulin, which is why they went from 31% of those entered the study down to 10% needing greater than 100. Right. So now we put them on this pump and it's only the first pod that the data we enter for the basal rates are the ones that the pump uses and they use it very gently. So it's not the max of whatever it is. Then based on the glucose level, the pod is making those changes and those decisions. And that entered basal rate is no longer what we use. It's the pumps decision with the CGM data. So the patient, now if you got that patient who's saying they're on 100 units a day to take 100 units a day and they weren't, or that patient, you're looking at the data and what do you do? You increase the insulin because you're seeing hyperglycemia and it's because they're not taking their insulin, you're going to get hypoglycemia, glycemia. Not if you put em on a pump.
- [21:09]
C
I agree with you, Neil too, that this is the most compelling reason for me to want to learn more about this is that I'm terrified of insulin pumps because of hypoglycemia. But I should probably be more scared about my patient on four times a day insulin who may or may not be taking it as I prescribe it. And I do. I think it's a really compelling reason to be curious in the primary care space about how this could work for our patients.
- [21:34]
A
Yeah, it's interesting. I wonder if that's one of the drivers for. And I'm going to read another statement from the Standards of Care in the technology section and in section 7.25 and I want our listeners to have the references if they want to read in more detail. It says, and I'm going to quote again, the aid systems are the preferred insulin delivery method over MDI in people with both type 1 and adults with type 2 diabetes both had an A level of evidence. In children and adolescents with type 2 is an E level of evidence. And the standards go on to say, and again I'm going to quote. Although aid systems have been shown to improve outcomes compared with MDI and insulin pump therapy alone, the choice of insulin delivery system is up to the individual. With support from the diabetes care team. We live in this amazing age of choice, but I suspect a lot of what went into those. And Davita, you might have actually insighted insight what went into those statements. Any insight to Vita into why they had this as such a high level recommendation?
- [22:49]
B
Well, you know, level A signifies strong clinical evidence from a randomized, well controlled or a meta analysis. The research we did and the research we published on these studies was very high level, strong, compelling and transferable and used in the clinical practice. So it's, you know, it's utilizing, we're utilizing that data. So I'm not surprised that it's level A. So. And sometimes there are standards that are not as high because they don't have the same clinical evidence. But in these trials, you know, we did a great job. The trials were well thought out, the inclusion was great. I'm just not surprised.
- [23:32]
A
Okay, that's helpful. Let's jump into another case and this is that of a 60 year old woman with type 2 diabetes. Obesity. CKD3A on metformin, a thousand units daily, dapagliflozin, 10 milligrams daily. Her A1C was 10.26 months prior. that point she was started on semaglutide and she tolerated it well. It was titrated over a few months at the max dose of 2 milligrams weekly. And she was thrilled with the effect on her weight. She lost about 12% of her body weight. She understood the other benefits of her GLP1 because we talk about it cardiovascular, renal. Nonetheless, her A1C prior to coming in this visit was still 8.6. Davita, your thoughts about next steps?
- [24:24]
B
An insulin pump or an insulin pump or you could offer an insulin pump. I mean, so, you know, I think you, this patient's got the best of the best. You know, she's got CKD and we're using semaglutide. We all know the studies that go with that. She's got cardiovascular issues. Most likely she's got semaglutide. But we gotta get her A1C under control and her weights come down. That's all good stuff. So the best way for this individual, and you know, it took us a while to all be able to wrap our heads around high A1Cs does not mean non compliance. It means we just don't have the diabetes where it needs to be. I recently enrolled somebody in a type 2 study that's ongoing that had an A1C of I think almost 13%. And I got a call from the coordinating center and they said, is this patient gonna be able to do the study? I said absolute. The patient wasn't given what they needed. They were not yet on a sensor, they were only on basal insulin. They needed mealtime insulin, they needed a bunch of other things. They needed education. And the thing is, if you're going to deliver insulin, why would you use four syringes a day when you can give somebody an insulin pump that makes decisions for them, that helps them with high blood sugars and prevents low blood sugars? So I think that's a no brainer for this individual. I would absolutely offer from an insulin pump. And certainly, sue, if that's not a comfort level within primary care. Here's what I would love to see happen is obviously we have a big partnership, but with primary care. But if you want me to help you start them, then take them back into your practice and work with me. Because once a patient's on an insulin pump, if they have Medicare and some of the other insurances, they have to be seen every three months to get their pumps or 90 days. I had someone who was 90 days and couldn't get supplies. And so, you know, I can't do that many for a huge amount of patients. So even the partnership, and you're already troubleshooting the pump is making the decisions for you. And the insulin pump companies will come in and support you. They do your education, they do your trainings, they help you write the prescriptions. So again, like I said before, I don't think you're that far off. I think you need to order three or four of them, follow them, and then you're going to be the expert.
- [26:54]
C
And again, the more I learn, like I'm, I'm getting there. We're close, you know, Tavita, I see, I hear this case and I'm like, I just put her on some basal insulin once a day, right? That's what I would do next, you know, and thinking that her other medications will give her some mealtime benefit and maybe we give her a once a day basal insulin. So I guess in your experience, because you were like, like 100% a pump and a pump would not even have crossed my mind on this case specifically because I'm like, ah, 8.6, like, I don't know, we might be able to get her there with some basal insulin. Can you talk, talk me through, you know, your decision points there. Cause it really, I would not have thought of a pump for her.
- [27:35]
B
So it, it's not that basal insulin isn't good and it isn't. You give enough insulin that's taken and you get it under the skin, you should be able to get somebody to treatment goal. But you have to look at the potential risk. Potential risk is omission, not by choice, but just by life. Hypoglycemia, the fact that you're gonna most likely have to go from greater than one injection a day to more injections. And could you say, okay, I'm just gonna give her basal insulin. I gave her semaglutide. Semaglutide takes care of post brain deal. But it's probably not enough. It's probably not gonna be enough. So you could drag your feet and give her basil today and then the next three months she could give her mealtime, or you could just do it all at once and give that patient a pump so that, that patient's A1C is, I don't know, I'm going to pick a number 6.8 without hypoglycemia. And that's the other thing I think that's really interesting is that we no longer tiptoe around getting A1Cs at less than 7%, because we used to fear hypoglycemia, especially in type type 1s. But with both type 1s and type 2, and you know, hypoglycemia does occur with high A1Cs as well as lower A1Cs, I think that we're more comfortable pushing everybody's A1Cs to less than 7%. So my big thing here is that this patient's going to most likely need more than just basal insulin. So why pick the best vehicle and the best vehicle? To me, once you're thinking insulin, Insulin is an insulin pump that has a brain. It also makes my life easier because I'm not trying to give you, oh, four more units of basal insulin, and let's see where it's going to peak and onset and the duration, and you're going to have good absorption and what happens. And then, oh, wait, I'm going to give you three other injections and now I have four insulins peaking and onsetting in duration for that patient. So it actually makes you, your life easier in your clinical practice.
- [29:37]
A
You know, it's interesting as I'm listening to both options, we live in this world where there really are wonderful options. And I like the statement and the standards to offer and then discuss with patients. David, something that you mentioned really resonated with me, which was sending my patient to you to get started and then coming back to management because the technology is going to be. Is really clean and it does the heavy lifting, the beginning of starting it can be pretty intimidating. So I like that approach because it is hard, even in the Philadelphia area to get a patient into endocrinologist. It's about a four or more month wait to get in there.
- [30:24]
C
Sure.
- [30:25]
A
The other thing that strikes me as you're talking is that issue of titrating something that's simple, even basal insulin. And one of my favorite quotes in all of life is by Yogi Berra who said, in theory, theory and practice are the same. In practice, they're not. And you know, logically, you start someone on 10 units of basal insulin, you tell them, go up by one unit a day. Every time it's over, say 110, they have to by the end of the month be over 40 units. And they never are. And it just. There are some very real challenges in real life. Real life. Sue, do you have any practical questions that it would be helpful for DaVita to answer for us in primary care?
- [31:13]
C
Yes, so many. You know, I think one thing that would be really helpful for all primary care is maybe to talk a little bit about contingency planning. So I think with our patients, we talk about sick day management with their oral medications, you know, like, so what do they do if they're sick with their insulin pump? What if it malfunctions? Do they keep insulin, like in their fridge, like at the ready? What are some of the things that we should know in primary care if our patient. Maybe we're not managing their insulin pump, but, like, what should we know about it?
- [31:44]
B
So we always have them have a basal insulin as a backup. If your pump fails and you're waiting for another pump, you can take a basal insulin. Most of the pump companies will provide you the hardware that you need within 24 to 48 hours. But you can go back to long acting insulin. You already have the rapid acting insulin, which is in the. So, yes, we provide that as a backup. We also have them get glucagon so that if they had a severe hypoglycemic event or they don't think they Were recovering quick enough. You can take glucagon ketone sticks now hopefully we still soon will have integrated ckm. But ketone sticks or ketone blood testing so that if there's a problem that you know, sometimes we can manage it at home. If the patient is having say vomiting, diarrhea and you're not sure what's going on, whether you can treat them at home or send them to an ER knowing what the ketones are. But I bet you our sick day isn't that far off except for if your pump fails, you want to take long acting insulin. The other thing is if you treat, if you see a blood sugar that's. I'm going to pick a number again. 275, 285. And it's not coming down by the pump correcting and you correcting. You want to change the settings. It doesn't matter what pump it is. If it's a pod, you change the pod. If it's an infusion set, you change the infusion set. But the other things too is that you could partner with somebody like Insulet who will come in and do all your trainings and then they do follow up phone calls and then that helps you and takes a burden. We don't train pumps on our site either. We use all of the companies, trainers who come in and train our patients, patients on a one to one. The other thing is patients own their own diabetes. So the majority of my patients manage their own pumps, their own diabetes. After I say maybe three or four months, they own it. And so they are only coming back to you with some big questions, big problems, big concerns.
- [33:56]
C
Great. I would say can I have one more question? Do we have time? You know, I think the other question is I would love to hear, you know, what is operationalizing this in your practice look like? Right. So who's owning the CGM and the aid cloud logins? Who's pulling that data before appointments? What are some ways that you can set this up in your practice? I do think you need a fair amount of practice support to operationalize this.
- [34:23]
B
So the trainers actually set up the clouds so we don't have to deal with that at all. When they train the patient, they connect them in the cloud. All the clouds are icons on your computers and you just log in. The data's already there. We have our mas bring it up when the patient comes in and most of them have it on their phone so it's directly to the cloud. But we don't usually have to worry about that because again the trainers do all of that for us now. I'm obviously simplifying it. Cause, you know, if we had more time and we can do this offline too, is, you know, how do you, what prescriptions is it? CMN again, we've simplified this. The companies have simplified that. But leaning on the trainers from the pump company will get you 90% there. And then you just see the patient and learn how to interpret the data. And the companies offer those programs too. I just spoke actually to a new in practice endocrinologist to help her learn how to read some of the reports. So, you know, that's there for you as well.
- [35:25]
C
Amazing.
- [35:25]
A
Vida sue, this is so helpful we're getting toward the end of the podcast. We've covered truly a lot of ground and I think really helpful ground. It seems to me that some primary care clinicians will opt in and learn more about AIDS and prescribe them themselves. Some will be hesitant to do so, and that's okay. But hopefully they've learned enough about this through our podcast that they can discuss it with patients and refer the appropriate patients to our endocrine colleagues and perhaps, as you said, Davita, refer a patient to get started and then have the patient come back for ongoing care. What is absolutely critical is that we know about the availability and the advantages of aid for people now with type 2 diabetes, because if we're not aware of it, then we can't talk to people about it. We are about out of time. Davita, any final thoughts for our listeners?
- [36:22]
B
Yeah, I just want to remind people that the number one reason when you ask a patient why they're not on a pump, they'll say, nobody asked me if I would be interested. So I think we have to think about that. And then of course, if you're thinking about your next injection, why not think about using an insulin pump? You know, it prevents hyperglycemia and hypoglycemia and helps that patient get to time and range and treatment goals a lot better without hypoglycemia.
- [36:49]
A
So important. Davita Kruger, thank you so much for joining us.
- [36:53]
B
Thank you for having me.
- [36:56]
A
And sue, your final thoughts?
- [36:58]
C
Yeah, I mean, I think the data are convincing that this is good for patients. I think the logistics are still something to think about in operationalizing in primary care. I think there's a lot of role for partnership, which I think would be amazing. And I think that for, for primary care clinicians who have the right volume of patients, the motivation, the curiosity to learn more, this is like a really good option. Just to add into your practice. But again I think just something we'll have to wrap our heads around but exciting moving forward.
- [37:28]
A
Dr. Sue Kuchera, thank you so much for joining us.
- [37:31]
C
My pleasure.
- [37:33]
A
And most of all, as always, thank you to our listeners. Thank you for joining us on this third of a three part series on automated insulin delivery for people with type 2 diabetes, a cutting edge topic. In the first part of the series we talked about what aid is the evidence for its use in people with type 2 diabetes. In the second episode we had a discussion about practical advice. And here in the third episode, well, you just heard it. We talked about advantages, we talked about challenges and we talked about real world cases. This special series of diabetes core update is spot by insulet. We thank you for listening. And for the American diabetes association, I'm Dr. Neal Skolnick. Till next time, stay safe and keep learning.