← Juicebox Podcast: Type 1 Diabetes
Juicebox Podcast: Type 1 Diabetes
#1634 Grand Rounds: Inhaled Insulin
01:01:57
Pediatric endocrinologist Dr. Michael Haller explores inhaled insulin and the evolving approval process for children under 18. Free (non Facebook) ** Use code JUICEBOX to save 40% at smart meter and CONTOUR DIABETES app * or...
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- [00:00]
A
Welcome back friends. You are listening to the Juice Box Podcast.
- [00:15]
B
Hey Scott, Good morning. Thanks for having me on. I'm Dr. Mike Haller. I'm Chief of Pediatric Endocrinology at the University of Florida. Stories Long One goes back to desire to be in medicine as a child. My grandfather living with type 1 diabetes was also part of the inspiration.
- [00:34]
A
My Grand Rounds series was designed by listeners to tell doctors what they need, and it also helps you to understand what to ask for. There's a mental wellness series that addresses the emotional side of diabetes and practical ways to stay balanced. And when we talk about GLP medications, well, we'll break down what they are, how they may help you, and if they fit into your diabetes management plan. What do these three things have in common? They're all available@juiceboxpodcast.com up in the menu. I know it can be hard to find these things in a podcast app, so we've collected them all for you@juiceboxpodcast.com Please don't forget that nothing you hear on the Juice Box Podcast should be considered advice, medical or otherwise. Always consult a physician before making any changes to your healthcare plan or becoming bold with insulin. Foreign the show you're about to listen to is sponsored by the Eversense 365. The Eversense 365 has exceptional accuracy over one year and is the most accurate CGM in the low range that you can get. Eversensecgm.com Juicebox USMED is sponsoring this episode of the Juice Box Podcast and we've been getting our diabetes supplies from USMED for years. You can as well. Usmed.com juicebox or call 888-721-1514, use the link or the number, get your free benefits check and get started today with usmed. This episode is sponsored by the Tandem MOBI system, which is powered by Tandem's newest algorithm, ControlIQ technology. Tandemoby has a predictive algorithm that helps prevent highs and lows and is now available for ages 2 and up. Learn more and get started today at tandomdiabetes.com Juicebox Hey Scott, good morning.
- [02:30]
B
Thanks for having me on. I'm Dr. Mike Haller. I'm Chief of Pediatric Endocrinology at the University of Florida.
- [02:35]
A
Oh wow. How'd you get that job?
- [02:37]
B
Well, story is a long one goes back to desire to be in medicine as a child. My grandfather living with type 1 diabetes was also part of the inspiration then working with some of my mentors here at the University of Florida early on in my career. Even in high school, I had the opportunity to work in the lab on some of the early diabetes prevention trial work where we were learning that autoantibodies can be used to predict type one. Then I went off to college at Duke and came back to UF for medical school and went to diabetes camp. And diabetes camp was the final nail in the coffin for me in terms of pathways. It was pretty clear after that experience that I wanted to be a pediatric endocrinologist. And then I've been here at the University of Florida my entire academic career. Started as a assistant professor and then worked my way up and almost nine years ago, took over from one of my mentors, Janet Silverstein, as the division chief.
- [03:31]
A
What was the experience at camp that made you feel that way?
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B
Well, I was always just really enamored with kids and being in the care of young folks, so I kind of knew I was going to likely lean towards being a pediatrician. But the 247 experience there is what really did it for me. Just seeing what living with type one is really like, being with these kids, doing all the things that you do at camp, going out on the lake, going to do archery, playing Land Olympics, getting up at 2am in the morning with them to check glucose. As this was in the era where we just had glucose meters and an NPH and regular, so didn't have nearly all the tools we have today. And that experience was definitely transformative for me, just wanting to have relationship with those kinds of kids, going through those struggles and helping them find a way forward to live their best life with diabetes.
- [04:23]
A
Would it surprise you to know you're not the first endocrinologist to tell me that?
- [04:27]
B
Not at all. I think diabetes camp is actually probably our strongest single recruiting tool for convincing young medical students or physicians to have an interest in it. It's why I actually require anybody who wants to come shadow with me to volunteer at camp because I think A, you can't really know what it's like till you've seen it in that setting, sort of been with a person for a week 24, 7, and B, just that experience tends to be so transformational, foundational for people that it captures some folks who otherwise wouldn't have been interested in the field.
- [05:01]
A
Is it true that a lot of times people want to be endos but they almost get saddled with the diabetes? Is that why you have to make them interested in it? You know what I'm saying? That they're more interested in other endocrine specialties, but because they're the endocrinologist, they handle diabetes as well. Is that, is that a thing or is that something I've just heard? It isn't true.
- [05:22]
B
I think that's probably true in the adult side on the pediatric side, since about 50% of what we do is diabetes care. More than not, actually, the folks who come into endocrinology on the pediatric side are interested in diabetes care management in some significant way, even if that's not their core academic pursuit or what they become sub, sub specialist expert in our place is a little biased because we're such a well known, Strong historical type 1 diabetes clinical and research center that most of the folks who come train with us already have that desire to be in that space. But it is a harder sell, unfortunately. Diabetes care requires a whole lot more team members, is therefore more expensive to provide. Well, isn't super well reimbursed. And so, you know, in terms of running a business for people outside of academics, it does make a lot more sense to focus on the endocrine side of things, standard endocrine, and not do the diabetes care. So in the adult world, that is a common thing. There are lots of endocrinologists who don't do diabetes at all. The feed side, that's not very common at all.
- [06:28]
A
I see. Can I ask a couple more questions before we get to the inhaled insulin?
- [06:32]
B
Of course.
- [06:32]
A
This is interesting. So I did a series a couple of years ago. We called it Grand Rounds and we went to. So, Mike, you don't really know a lot about me. That's fair enough. I have a private Facebook group that supports the podcast that as of this recording has 72,000 active members in it. I went to those people and I said, let's make an exhaustive list of what you wish would have happened at your diagnosis. And that list turned into what they wished would have happened and what they wished wouldn't have happened. And I think we put together about 90 pages of notes from people and responses and called them down and, you know, put them together and created this. I think about seven or eight part series was really aimed at physicians to say, like, look, this is what people said. You know, their experience was almost like them filling out a survey after, after service. And I found that the series also served for people listening to say, like, well, this is what I should be expecting for myself or here's the things I should be looking for. And we kept it going by bringing in endos to talk about what their experiences were. So I'm going to ask you the question that I asked them, and very simply, I want to know what you think endocrinologists need to be doing, should be doing to make the experience better for people. And what do you guys find yourself sitting across from the patients wishing that they would do to make the whole thing be smoother?
- [07:54]
B
Yeah, that's a great question. I think at diagnosis, a lot of it depends on where the family is coming into the diabetes space. And physicians, providers need to do a better job of recognizing that there are big differences than somebody who has nobody in their family with diabetes and comes in DKA and they're worried about their kid making out of the icu, let alone understanding what a CGM or a pump is, versus somebody who's got a parent with type one or sibling with type one, is ticked up by way of antibody screening and, you know, is never even symptomatic at the time of their diagnosis. So I think that the heterogeneity of presentation is becoming even more broad as we pick up more and more people preclinical. And physicians need to understand that that heterogeneity is part of doing a better job of presenting what people need to know at the right time to make that transition to life with diabetes easier. And I've erred in this before personally, so I'm not suggesting I do it perfectly. I think listening and hearing people's, instead of jumping right into everybody who gets diagnosed needs to know X, Y or Z in this order is really helpful. Probably what physicians need to hear is remember, and this is true in every part of medicine, is remember to listen before you go in and talk and then take that information in before you figure out what you're going to say and then help use that to guide the conversation. I think something that our team does really, really well though, is tell folks from the very day of diagnosis that, you know, we're all part of a big team here to help you, the patient, manage your diabetes. And it's different than almost every other diagnosis out there in that we serve as coaches, but you at the end of the day are the player on the field of the sport. And you've got to make the day to day, minute to minute, game time decisions. Our job is to give you the skillset to do that as well as humanly possible. And I think when we set that philosophical tone from the beginning, it really helps our patients and families embrace that so that our goal is by the time they graduate from our pediatric clinic, they frankly don't need us or their adult endocrinologist for much. Obviously, they still have to have them to write prescriptions and help with some of the screening for complications and obviously giving medical advice when it's necessary. But the reality is we haven't done our job well if we aren't putting young adults out into the world who can do all this really well without anybody's help.
- [10:27]
A
Yeah, I have to tell you that. So this podcast has been. It's 11 years old. It has over 1600 episodes. It's been downloaded over 20 million times. It charts in 48 countries around the world. And I think that that's because I started making a podcast in 2015 and we used to tell people, like, everything you need is in those episodes. Like, just listen and you'll. And by the way, Mike, this is. There's no. No bs. Like, if you just listen to the podcast back then, you'd wake up with a 6A 1C. At some point it was that all the answers were in there, but, you know, they weren't. They weren't on a bullet list. They weren't like, learn this, then learn this, then learn this. It was sort of what I got out of it was just kind of what you were just saying is that, yes, there's tools, right, And I need to know what they are, but how am I supposed to guess which one you need right now? Like, where are you on that journey? What's the thing you need to hear today? And what the podcast allows is for people to jump in and out of it at their leisure at their home. And I think the limitation of going to see your doctor is very much that it's, you know, if you're lucky, a half an hour four times a year, and, you know, and if you have something in your head the day they show up and it's not the thing they need. I mean, there you go. It's six months between meaningful interactions. Again, I don't know how you're supposed to do the thing you're supposed to do. It really is incredibly difficult. Eventually we were able to put together, you know, the podcast had gotten so large that I was like, well, I can't just keep asking people. Just listen to 400 episodes. Like, you know, like, at some point it became ridiculous. So I took what I thought were my foundational ideas. And Mike, I want to be clear. Just a guy who started writing a blog when his daughter was diagnosed in 2006. I have no medical background, no training, but what I realized was I was a stay at home dad. I figured out how to take care of my daughter. And one day I realized that I had all the tools and all the ideas that I needed to keep her A1C in the fives. Actually, that diabetes no longer felt like unknown to me. Things happened. I knew what to do, I knew how to react. This thing that you were describing earlier. And I sat down and very thoughtfully put together what I thought were the, you know, the hallmarks, the bedrock of this idea. And I contacted a friend of mine, Jennifer Smith. She's a cdces, works for Gary at Integrated Diabetes. You might actually know her. And I said, I have these foundational ideas. I wanna put them in a series. And we made something called the Diabetes Pro Tip series. And now what people say is, I grab the list, I listen through it at my leisure, my A1C ends up in the sixes. So many people are angry at their physicians because they feel like, I have a question. They don't know the answer. They don't listen to me, what you just said. I just think it's an unfair paradigm. Like, I don't know how either of you are supposed to succeed in that setup. Let's talk about the Tandem Moby insulin pump from today's sponsor, Tandem Diabetes Care. Their newest algorithm, Control IQ technology, and the new Tandem Mobi pump offer you unique opportunities to have better control. It's the only system with autobolus that helps with missed meals and preventing hyperglycemia, the only system with a dedicated sleep setting, and the only system with off or on body wear options. TandemMobi gives you more discretion, freedom and options for how to manage your diabetes. This is their best algorithm ever and they'd like you to check it out@tandomdiabetes.com juicebox when you get to my link, you're going to see integrations with dexcom sensors and a ton of other information that's going to help you learn about Tandem's tiny pump that's big on control. Tandem diabetes.com juicebox the Tandem Mobi system is available for people ages 2 and up who want an automated delivery system to help them sleep better, wake up in range and address high blood sugars with auto bolus. When you think of a CGM and all the good that it brings in your life is the first thing you think about. I love that I have to change it all the time. I love the warmup period every time I have to change it. I love that when I bump into a door frame, sometimes it gets ripped off. I love that the adhesive kind of gets mushy sometimes. When I sweat and falls off. No, these are not the things that you love about a cgm. Today's episode of the Juice Box podcast is sponsored by the Eversense 365, the only CGM that you only have to put on once a year and the only CGM that won't give you any of those problems. The Eversense 365 is the only one year CGM designed to minimize device frustration. It has exceptional accuracy for one year with almost no false alarms from compression lows while you're sleeping. You can manage your diabetes instead of your CGM with the Eversense 365. Learn more and get started today at eversensecgm.com juicebox1year1cgm yeah, I agree with you.
- [15:34]
B
I think Aaron Kowalski from Breakthrough T1D once did this analogy that really struck me, which is that patience spend less than 30 seconds on a 24 hour clock of their diabetes time with their provider. And when you think of it like that, of course it's not a fair fight in that sense of trying to impart all the wisdom we need to give to patients and families to do well. And I think that's why families need the kind of things that you put out in the world and why they strike home so strongly. Because people are yearning for access to information that's accurate, that speaks the same language they do, that doesn't have any bias necessarily from a physician, and they don't feel judged by listening to or trying to impart. Yeah, I think that's why everybody with Type one lives that unique experience and why it's so important that there are resources like amazing podcasts and social media chat groups, which I try to be in a lot of because I find out that's where I do a lot of sort of nowadays. That's my version of active listening. I just see what people and patients and families are writing about, thinking about, saying, and sometimes I interject because I see something that I think is really, really incorrect. But more often than not I just listen by way of reading because it helps me when I then see the next patient in real time to hopefully appreciate better what it is they might be thinking or going through or the question they are uncomfortable to ask and I can try to impart some wisdom to help them.
- [17:06]
A
One of the most valuable tools I have is that community, because you know what people say. I don't know how I hear from people all the time, like oh, the podcast always seems to have the topic or the answer that I need. And I tell them all the time, like, yeah, I'm watching 70,000 of you talk to each other. I know where you're struggling. Like, I know where the pain points are. And it's because of you that I understand what content it is you're looking for, what answers or ideas that, that you're lacking. Anyway, it's just, I think I, I bring all this up because that toolbox, from what I understand from everyone who's tried inhaled insulin, that toolbox would be really enhanced by being able to break a 250 or a 300 blood sugar. Even if you didn't use inhaled every day, all the time, if you just had it with you for those high blood sugars, that it might be a significant reduction in stress and time spent dealing with diabetes. I don't understand inhaled insulin enough, I can tell you. I've had people on it, on the podcast who use it, who are they proselytize about it. They love it so much, but every person I've ever interviewed struggles to explain it to me. It's tough to sell something when a person who loves it and tells you that it's amazingly beneficial for them. And I say, okay, so how do I dose it? And they go, I don't know, two or four and eight. Like, I'm like, I'm like, yeah, you know, like, you're not selling it. Anyway, you're on today because inhaled insulin, what have they done? They're doing research for a younger segment of people. Right. Can you tell me more about that?
- [18:38]
B
Yes. I had the pleasure of being the lead, the principal investigator for the INHALE1 study, which was the study designed to try and get FDA approval for inhaled insulin in the pediatric space. It's been approved in adults for quite some time, and there are many pediatric and adult endocrinologists who prescribe it. On the pediatric side, it's currently still off label, but much of what we do in pediatric medicine is off labeled just because it takes pharma companies much longer to get those studies done. And you're right, it is a very different paradigm to use inhaled insulin. And so it does make it, I think, harder for people to describe it sometimes to folks who are taught from day one that this is how we give insulin. It's through a needle and syringe or a pump. And this is what basal is, and this is what bolus looks like, and these are carb ratios, and these are correction scales. All that gets a little fuzzier with inhaled insulin. And so it requires a reframing of thinking about how you're going to use it and when, in what situations. But your initial analogy, I think is absolutely right. I think it's just one more really nice tool to have in your toolbox, one that I think many more people living with Type one should have and should feel comfortable understanding how to use. And if they did that, you know, they would see that it serves an important purpose and we'd get through to more folks. I think, though, the first step to doing that is just convincing more providers out there that it's an important enough tool that they should be using and trying with their patients. I think because of the previous historical commercial failures of some of the earlier inhaled insulin products, it's just been hard to break through that sort of shell for physicians to say, yeah, I'm going to try this different paradigm because people are comfortable with what they know. And getting people to do something new is always hard. This idea of therapeutic inertia is a very real thing in medicine. And so you've always got some of your early adopter kind of people, which I usually am in that category. So I'm always excited to try these new things. But there's the larger majority of folks who absolutely are not going to do anything until they see many more of their colleagues using it and having success with their patients.
- [20:52]
A
Yeah, it's interesting that there are spread out across this country, there are nurse practitioners and endos who will look their patients in the face and go listen, go listen to Scott's podcast. And in that same world, there are people who would say, I would never ever suggest anything like that to a patient. And I think it always does boil down to that, what you just said. There's some people are kind of like they're out on the, you know, out on the edge of the surfboard and there are some people who are in the back waiting to see everything flatten out before they'll say, yes, they're risk averse in a way that, and I'm not saying you shouldn't be risk averse, especially in medicine, there's a tipping point in there. I don't know where it is exactly, but you have to try new things. Like right now, I think I've been well out ahead of this for a couple of years now, but GLP1s for people with type 1 are incredibly valuable for those of them who have insulin resistance.
- [21:46]
B
Absolutely.
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A
Yeah. That's how I'm seeing it coming back to me. Like if, if you have type 1 diabetes and no real like insulin resistance issues, like, you know, anything that would make you look type 2 if you weren't type 1. I don't see people having as much benefit there. Those that have the trouble. A reduction of 20, 30, 40% of their insulin is not uncommon. And I've seen people have conversations right on this podcast of. There are two great episodes with the mom of a young girl who she's type one for four years using like 50, 60 units of insulin a day, starts gaining weight. The mom had had PCOS and was put on a GLP1 for weight and PCOS. She saw it really help her. Thought she was seeing her daughter having PCOS symptoms. Got the GLP to her and no kidding, had to take their pump off. Was using like a unit of injected basil a day for a long time. Now, you know, is it going to stay like that forever? It's not. And they're seeing a trend in the other way, but it lasted for years. Like, there's got to be something to learn from that, you know? And I think with the inhaled insulin, like, the same idea, like, because I still see people running around going, well, GLPs are not for type ones. I saw a very respected person in the diabetes space, somebody I respect who's been around forever and ever, one of the smartest people I've ever said, just kind of like philosophizing out loud Today, like, these GLP1s might have some value for type ones. I'm like, you're not just in the obvious. Yeah, wow. Wow. You're not just in the caboose of the train, right? Like, you're back at the station, like, looking up, going, like, I think I might be seeing a train up there. That's a person who's a thought maker with the inhaled.
- [23:20]
B
Yeah.
- [23:21]
A
I guess what I'm wondering is, is when you go to another, when you go to a colleague and say, look, you should be learning about this and giving it to people. When they push back, what do you hear them pushing back on? You've probably heard me talk about US Med and how simple it is to reorder with usmed using their email system. But did you know that if you don't see the email and you're set up for this, you have to set it up. They don't just randomly call you. But I'm set up to be called if I don't respond to the email because I don't trust myself 100%. So one time I didn't respond to the email and the phone rings at the house. It's like ring. You know how it works. And I picked it up, I was like, hello. And it was just the recording. It was like, US Med doesn't actually sound like that, but you know what I'm saying? It said, hey, you're. I don't remember exactly what it says, but it's basically like, hey, your order's ready. You want us to send it? Push this button if you want us to send it. Or if you'd like to wait. I think it lets you put it off like a couple of weeks or push this button for that. That's pretty much it. I push the button to send it and a few days later, box right at my door. That's it. Usmed.com juicebox or call 888-721-1514. Get your free benefits checked now and get started with US Med Dexcom Omnipod Tandem Freestyle. They've got all your favorites, even that new eyelet pump. Check them out now@usmed.com juicebox or by calling 888-721514. There are links in the show notes of your podcast player and links@juiceboxpodcast to us Med and all of the sponsors.
- [24:55]
B
I think there have been a number of barriers to it that are sort of systemic of US healthcare. So certainly in the pediatric endocrine world, when things aren't FDA approved, that puts up a barrier. There are some physicians who just won't prescribe it and patients and families who won't feel comfortable. And I understand that, but we've now not quite yet, but we've effectively taken that barrier away. The clinical trial we just completed showed that for all practical purposes, inhaled insulin is non inferior to injected rapid acting insulin in a basal bolus setting. And to your point about GLP1s, it was associated with lower weight gain and improved patient satisfaction. So if you've got those things, why wouldn't you consider it as an important tool? But because historically insurance coverage has been more challenging for non FDA approved things, it's created a bit of a disparity where you know, only families who could afford to get inhaled insulin and pay for it or figure out the logistics of getting it direct from the manufacturer when they were offering it at a discount has led to just it not being used as much. I remain very hopeful that as it works its way through the FDA approval process in kids, that that barrier will go away and people will have more opportunity to try it. And you know, the offices will receive samples because pharmaceutical companies won't bring samples for things that aren't approved to a pediatric office. So I think all those things are going to help it get past that big hurdle. And the other one is just lack of awareness and understanding. It is the fastest acting insulin we have objectively by quite a bit because of you inhaling this biomaterial technosphere that regular human insulin is bound to. It goes into the lungs, it disassociates with the ph change and the insulin is absorbed within a couple minutes. It takes sub Q insulin 15 minutes on a good day to even be detectable in the bloodstream. Inhaled insulin is in and working and peaking in almost that same timeframe and is completely gone within 30, 45 minutes is the other big advantage. So you don't get that tail effect like you get from injected insulin. So it has so many sort of use case advantages that I really think it's just getting people past that inertia, that therapeutic inertia of trying it, using it, you know, getting those barriers out of the way so that they will, will try it, I think will in this case, you know, finally lead to success.
- [27:19]
A
Could this be like a Betamax VHS thing? Are you too. Am I too old or are you young? Are you old enough to understand that reference?
- [27:26]
B
I am. Although I use that, I use that analogy all the time with patients when I'm talking about CGMs and I say, you know, imagine telling me your favorite movie with an old VHS tape versus a Blu Ray disc. And they look at me like they don't know what either of those things are anymore because everybody streams stuff.
- [27:41]
A
Yeah.
- [27:42]
B
As I'm describing CGMS as more like using a Blu Ra and checking blood glucose with a meter was more like six still frames on an old VHS type. But yeah, I think it's just technology uptake. It's moving with the times. It's getting past enough people with experience and comfort with it that it reaches a critical mass and then it will take off more.
- [28:01]
A
Well, Mike, I sort of more meant that back. I'm 54, so back when, before BCR, as people are like, I don't even know what that is. But you didn't used to be able to watch something that was recorded in your home. And there were these two competing ideas. Betamax was one tape, VHS was the other. VHS was bigger. It didn't look as good quality on the screen. Betamax was smaller, it looked better. And for reasons that I don't know that anybody completely understands, the public drifted towards VHS and Betamax went out of business.
- [28:33]
B
Ah, yeah, yeah, right, yeah, no, that that kind of thing that plays into. Sorry, I misunderstood the analogy you're making. Yeah, I think it's just injected insulin has such a stranglehold on the, the psyche of how you manage Diabe 80s that even when offered something that has objectively advantages over it, people kind of shrug their shoulders and say, no, no, this is how we manage type one, we're going to stick with this stuff. This is faster, easier in some ways to take, doesn't have some of the risks associated with it, and yet people still choose the VHS tape to your point. So yeah, I think there's going to take some work to get people to get past it.
- [29:07]
A
What are some of the risks that it doesn't carry?
- [29:10]
B
I think really that it's that post injection hypoglycemia that a lot of certainly young active people see around sports, that it really helps reduce the risk of those exercise induced insulin potentiated hypoglycemias. Because inhaled insulin is in, does its glucose lowering and is out in such a short period of time, you can send your young athletes out on the field with a normal blood glucose, not worrying that their lunch injection from two hours ago is going to keep pushing them further and they're going to plummet and have a hypoglycemic event out on the field. So it really does have an advantage in that kind of situation.
- [29:52]
A
So in a very specific use case, your kid comes home from school and has soccer practice at 5, child's incredibly hungry, you're not going to tell them, look, we don't want active insulin during soccer practice. So don't eat, we'll eat after you don't do that. So you feed them, you give them the insulin, they go upstairs, they get changed, you drive them to soccer practice, they're running around, they have a ton of active insulin and they crash low. Now they're eating bars and drinking Gatorades and having a bad time. You're saying if they eat that same meal and took insulin inhaled that by the time they got to soccer their blood sugar would be stable, the food would be handled and there wouldn't be any active insulin to make them low while they were running around?
- [30:30]
B
Well, I can't promise the meal coverage would be. The latter part is definitely. Yes, that's the idea. The latter part is absolutely true. The lack of active insulin on board is just huge a safety advantage in situations where we know you go out there and exercise and any insulin that hasn't been vascularized is going to get there much quicker. And kids tank all the time. And it's a huge distraction. It affects their performance. It forces them to take on extra calories that they may not want to. They feel full and bloated because now they've chugged a juice, a protein bar or something. It definitely has those advantages. I think the challenge is just getting people kind of work around the different paradigm. So because the inhaled insulin only comes in currently four, eight and 12 unit cartridges, and the units, unfortunately don't equate to injectable insulin units, it just takes some time to get used to the notion that the inhaled insulin units, you need two, if not three times more to equate to the same injected amount. And I wish we could sort of call them different things. So we refer to them as a Fraser units when we talk to patients and families. And we did that in the study. And that always takes people a while to get used to, because nobody wants to suddenly take three times more insulin than they're used to. And again, it's not really that much more insulin. It's just the way that the units are the numbers counted when you give it inhaled. But, yeah, if you're willing to give an inhalation and you're willing to top it off, so to speak, every couple hours, you can really see a marked reduction in glycemic variability, far less risk for hypoglycemia. And so I think the sports case is just one really good use case. I think really pesky highs from challenging meals is another one. So you're out eating your Chinese or your pizza that notoriously requires three or four boluses or a square wave or dual wave, you can effectively approximate those things with inhaled insulin just by literally watching the rate of change of your cgm. And so it requires patients who are willing to put in a little bit of that work to kind of notice that. But if you're an attentive person, and nowadays almost everybody wearing a CGM can see their arrows in real time, and you just start to redose when the arrow starts to change its direction and you see it blunted back to a flat or a downward trend. It's quite remarkable. You really just can't do that with injected insulin, because by the time you wait for the arrow to change, everything's already happened, good or bad. And so it gives another significant timing advantage in those kinds of settings that I just don't think you can't achieve with injected insulin. So I'm not suggesting that the inhaled insulin is going to replace injected insulin for everybody. That's Just not likely to happen. But there are all these use cases where I think it can be an important tool and toolbox to help people achieve better control. To wake up with those A1Cs in the low sixes like you said, without having to fight as many battles with diabetes as everybody living with the disease knows is just the reality of it. It just makes things a little bit easier if you have that extra skill set.
- [33:39]
A
Yeah. Is it possible you already outlined the problem when you started talking because you said we, you know, give people tools, you can give them their scripts and everything, but in the end they've got to go home and make a decision to actively be part of this. I mean maybe that's it just there. If you have to do all the things that you just said to learn how to use it and to figure out where to put it in the right situations and everything. Like maybe that's just the bridge too far already. Like maybe the VHS of it all is that, you know, aid systems are, you know, it's one insulin. I don't have to mess with different versions of insulin. I put the pump on the algorithm makes the decisions and you know, it's not perfect but I'm also not involved all the time and I don't need to understand this like a science experiment make. I wonder if that isn't maybe just the simplicity of why usage isn't being done more. I think it's simple to say like people are scared to put stuff in their lungs because that is the first thing that scares me about it. But I'm also assuming that you wouldn't be here talking about it if you hadn't seen it be very successful for people and not an issue. I know there are some people who get that cough and stop, but that's not overwhelmingly what happens. Am I right about that?
- [34:48]
B
Yeah. So the safety issue is one that commonly comes up, but is has been pretty well put to rest in all the studies. There really is not any concerning safety signal. In fact, in the pediatric study, the pulmonary function changes that everybody sees with inhaled insulin were actually more significant in the group that was randomized to injected insulin than it was in the group randomized to inhaled insulin. You would have presumed it was the other way around. Perhaps if you thought there was an issue with the inhaled insulin causing any issues. The long term studies so far really don't show any concern. Unless of course you're a smoker or have known pulmonary disease like recurrent asthma that's severe, then that wouldn't be a good choice for You Right. But yeah, that too is a barrier for people to say, I'm willing to try this new thing. Yeah, I think you're right. The other things that we have now do a pretty darn good job if you use them appropriately. But not for everybody, in fact, not for a majority of patients who still aren't getting to goal. So I think we always have to be striving to generate new tools that hopefully get even a few more percent of the population across to the desired side of the A1C threshold for reducing their complications. And inhaled insulin can definitely do that for folks. I mean, there are definitely patients for whom they are using a basal insulin and inhaled insulin as their only rapid acting insulin. And they take inhalations before each meal, an hour after each meal and in between those meals and snacks to correct. So they might be taking eight, nine inhalations a day, but they don't have to do nearly as precise carb counting because it's a bit more of a paradigm, it's more like sugar surfing by giving a little bit more when the, you know, the error directionality changes or certainly if the number is higher. Is that modality going to work for everybody? No, it's just not. But definitely works for some and I think it would work for many more who were given the opportunity. The other things I'm really excited about in terms of use cases are to your point about pumps are using inhaled insulin in combination with the pump algorithms. So we all know that the biggest reason the current algorithms don't get us to goal as well as we'd like is that meal coverage is just not optimized. The insulin's not fast enough to do meals. Right. But if you had a Bluetooth enabled inhalation device for your Afrezza and you could essentially announce a meal by way of giving a single 4, 8 or 12 unit cartridge that you didn't even really think about dosing on. You just knew every time I'm going to eat, I'm going to give this little bit of inhaled insulin. I'm fairly confident that in the next few years the algorithms would be able to do the rest of the meal work without you having to do much of anything. And so I think that's a place where I'm already seeing patients do that. And I think that could be come sort of a commercially available use case for inhaled insulin over time.
- [37:45]
A
It even occurs to me that with the aggressive nature of some of the DIY algorithms, like you maybe wouldn't even have to announce the carbs right? Like you'd let the inhaled handle the spike and then. Right, and then let the algorithm mess with whatever drift you see.
- [37:59]
B
That's right. I was just having that exact conversation with a patient I saw this morning before I came over to do this podcast. And he's on a T slim and was interested in how he could further optimize his meal control. And while that algorithm does a pretty darn good job overall, he asked that exact question, what would happen if I took inhaled insulin and then didn't do anything? I said, you probably get about the same results as you're getting now. He said, well, that would be a lot less work for me. I might be interested in trying that. And so I think exactly as you're suggesting, as we start to evaluate the safety, the clinical outcomes, and then the mental burden, which at the end of the day, I think is still the biggest thing that people living with diabetes have to deal with day in, day out. If I can do something that gets me the same result with less burden and I can think about all the other things in the world I'd like to do that, don't define me as a person living with diabetes. I think that would be great for most patients. So I just think that's another space where inhaled insulin's got an opportunity to make a difference.
- [38:55]
A
Yeah, this is the first time I'm seeing it in my mind. My daughter's using trio, just so you know what algorithm I'm talking about. But what I'm seeing is if the inhaled takes 15 minutes to peak and basically food takes 15 minutes to hit you, you sit down, you inhale the insulin, you eat. Maybe you tell the algorithm, I had a few carbs, just give it a number so that it knows food is happening, but not enough of a number that it's going to make an aggressive bolus and then it'll address the drift up if it sees one, I think there's a way to game that up and make that work. I bet you people could figure that out as they were going, no matter what algorithm they're on, actually.
- [39:35]
B
Agreed. But to your point, that will require some tinkering and people figuring out what works individually for them, depending on which algorithm or DIY system they're on. And they're definitely people who are doing exactly as you just described and finding that it works well, because the pharmacokinetics and pharmacodynamics of that little hit of super rapid acting insulin inhaled, and then the pump system following up with the rest to clean up what's left works quite nicely and again still reduces the risk of that post meal tail insulin causing a low in any situation, whether that be exercise induced or even just hanging out watching a movie.
- [40:14]
A
Mike, you alluded to something a minute ago. I'd like to go back to. I think that it's lost maybe on people listening to a podcast about diabetes. People who either are already seeing a 1Cs and the sixes or the fives, or have goals of it and are moving towards it, that that's not most people's reality. Right. Like if, if I said to you, you know, take a hundred of your patients, you know, what percentage of them have an A1C over nine. Do you know what I mean? Like, like how many people aren't playing the same game that you and I are talking about right now?
- [40:43]
B
Yeah, I think there's like sort of three distinct populations of people. There's the folks who are just struggling so, so hard, hard with their diabetes. They, they aren't able to adhere to whatever regimen we suggest that their A1Cs are like you said above, 9. And sadly that's still in our clinic, probably about 20% of the population. So that's a lot of people. And so any tool we can use to get them down is meaningful. So we've had many more conversations in our group now about offering the islet system to those patients because for them we know it will get them down to an A1C in the mid sevens. Is that where we want them? No. But is it a lot better than their double digit A1C? Absolutely. We have to sort of shift our thinking to what works for the patients in those populations.
- [41:25]
A
When I interviewed somebody from Betabionics, I said I would probably skip right over endocrinologist's office and go right to GPS and just tell them like, hey, you know, all the people you have with type 1 diabetes who have, you know, double digit A1Cs, like slap this thing on them, give them a 7.
- [41:39]
B
Yeah, it's funny you mentioned that. So we, we here at UF and also with our colleagues at Stanford, ran a Diabetes Echo program extension for Community Health Outcomes where we used tele education sessions to educate GPs. And I was shocked at the huge number of type 1 patients, not so much the adults, but even kids in both of our states that weren't seeing an endocrinologist regularly at all. And they were relying on their GP for pretty much all their management. And none of these gps had any comfort level at all with using a pump. Not a single one of them. It took a large lift just to get them to use a cgm. But yeah, I think there is a space for a system that doesn't require anything of the physician other than entering a weight and getting comfortable with prescribing CGM to consider improving control for those patients out there, because there's plenty of them. And so we've been working towards that in our echo sessions. And I think we will get to a point where we certainly have increased physicians out in the general community who aren't endocrinologists comfort level with, with using technology, and they're sort of in that pre contemplation phase. I think with using pumps, and I think pumps like Islet could certainly be a good opportunity for them.
- [42:50]
A
Is it, is it ever get heavy for you? It does for me. Like, does it ever get heavy for you? That idea of like, you know, the slow nature in which this all moves forward, that these tools exist and that you've got to talk someone into it or worse, wait for a doctor to age out so that the next one comes in in that community and like, you can, you know what I mean?
- [43:10]
B
Yeah. Many of my colleagues and staff will tell you one of my traits is definitely not patience. So, so I'm, I'm probably the, the least patient when it comes to waiting for people to adopt things that the evidence prove work well. And yet we still see this, you know, this therapeutic inertia towards them. So, yeah, it is frustrating, but it's also part of, like, you know, my passion project for helping improve the lives of people with type 1 by getting these tools out there. And so like we're talking about, like with inhaled insulin, I just think that it's an inertia game and we have to figure out how to win it by explaining it to people well, demonstrating the use cases for it, making sure there aren't other barriers in their way to use it, and then that will happen. And whether that's inhaled insulin or pump use from general, you know, providers for the folks who aren't coming to endocrinologists, I think all those things need to happen and need to happen much faster.
- [44:02]
A
Yeah, listen, I made a decision about 10 minutes ago that I'm going to take your recording and I'm going to make it part of the grand round series because you're, you're given a little master's class here about how to think about taking care of people with type 1 diabetes. So I appreciate that. I'll say inhaled insulin so people understand what they're getting still but this is part of a bigger conversation that I've been trying to have for a long time. There are just little dials to be turned, and things would be so much better for so many more people. I believe that doctors don't believe it half the time that it's even possible for people to improve. But making this podcast has shown me that there are many, many different ways to get information to people. A lot of people like to listen. A lot of people like to learn by talking to someone else online. They want to do something visual. You can't possibly know who all those people are. You can't know all the things they've been through before they get to you or how, you know, upbeat, they are depressed. Like, you know, I'm always fascinated that you'll talk to someone who just has the greatest attitude about everything and they can't tell you why they have it. They've been like that their whole life. And they got diabetes, and they just carry that attitude right through diabetes. And there's the next person who, you know, it's a woe is me right away. You know, the world's been coming for me forever. This is just the next thing on the list. I can't beat this. I can't fight this. There are so many different psychological, social, financial impacts that people with Type one have that. Like, I don't think that it benefits us to try to figure out each one. I think you just throw all the tools at them. You go look like, here it is. You go find the part that helps you. And the way I've done that is by. I have dumbed down diabetes into T shirt slogans. Basically, like, ideas that, like, I see somebody every day tell somebody about a high blood sugar, go crush it and catch it. Like, that's me, Mike. I made that up. I made an episode where I said to somebody, like, don't stare at a high blood sugar. You have to get it down. Don't take three hours to mess with it. Like, just. Just crush it and then be ready to catch it on the back end. And then we talked about how to do that, and now I see people all over the place doing that. I explained pre bolusing in a way that relates it to a tug of war that neither side's trying to win. Now, people. I see people all over the place go. I finally understand pre bolusing. Like, the way we talk about it from the doctor's office doesn't jive with most people.
- [46:32]
B
Yeah, I mean, you're clearly a gifted communicator. And being able to teach back things to people like they're in kindergarten is extremely effective. Your average physician is not. Yeah, not because you're kidding them. Like, they're not an intelligent person. Just keeping it simple and making sure the message actually hits. You know, we, we often over complicate things to the point that the patients then won't use the skills we're trying to teach them how to use. So, yeah, I think it's, it's important.
- [46:59]
A
I often think, like, if you made me the, the lead salesperson at Beta Bionics, I'd sell a billion of those things. And you know, I know exactly what to say to people. I know exactly how to make it attractive. I know what you, you gotta go into the doctor's office, say, look, go find me five of your worst cases and like, watch over the next six months while we improve their life. Go find me these people and we'll show you how to use GLPs. Like that'll really help them. And then let the doctors go off and replicate that over and over again. The GLPs are fascinating to me, really. The, the amount of people are like, you know, oh, no, it's dangerous. I'm like, you know, you threw everyone on a GLP when you heard about it, and you've got some poor person here with type 1 for 35 years who's had an A1C in the eights and the nines for 35 years. Then they had a digestive issue like, well, no kidding, like, right. Like they probably have some version of gastroparesis to begin with. Then you slowed down their digestion more with, with this drug. That doesn't mean everyone's going to have that problem. And I was feeling that when you were talking about the Afrezza too. Because what I'm thinking is, is the healthier you. You launch into this endeavor, the fewer problems you're likely to have along the way. Like, you know, if you just hand it to a guy who's been smoking cigarettes for 35 years and his A1C has been in the eights for a while, like, well, he might cough. I get that. You know what I mean? Like, he's 50 pounds overweight. But I don't know. Like, I. Sometimes with these new things, the first thing people see is not usually the right answer, but it is the thing that sticks with them forever. Does that make sense?
- [48:28]
B
Yeah, I think most physicians and many families are risk averse and so they're gonna be extra tweaked to look for a bad outcome and then like you said, kind of focus on that even when it doesn't reflect the majority experience. I think there's always something to be learned from when things don't go right. That doesn't mean that a drug or a modality isn't a really good option for many people. I personally love using GLP1s and 30% of type 1 patients are obese in the US it doesn't get away from them just because they have type one Americans are heavier than the rest of the world and therefore they have more insulin resistance and it makes it snowball forward when they need to use more insulin. So I've had great success with using, using GLP1s as an adjunct for the right patient, just like I've had great success using inhaled insulin for the right patient as an adjunct. And sometimes even as they're only rapid acting insulin, I think we have to continue. It's why I like diabetes care. I think the field continues to evolve. We have all these tools and figuring out which set of tools works best for the right patients to me is the fun of trying to figure out what works best for, for people and helps helps more people get to that A1C target.
- [49:44]
A
And don't throw the baby out with the bathwater. The first thing that you see isn't, you know, like it's not a rule for everybody. So tell me something, what did this study show and why are you so excited about it for the, the new population that it's now available for?
- [49:57]
B
Yeah, so the, the inhale one pediatric study, you know, randomized kids to either getting inhaled insulin for all their meals, corrections, all the rapid acting use, or they stayed on a basal insulin and did multiple daily injections with rapid acting injectable insulin. And after 26 weeks of being on whichever group they were randomized to, the A1C at the end of the day was basically the same between the inhaled insulin group and the injected insulin group. And it was really well tolerated. Very few kids stopped using the inhaled insulin. There was actually only a small number of kids who reported having cough beyond the first couple weeks of use. So people that definitely got used to that and figured out how to mitigate that issue. Interestingly, there was increased perception of enjoying using the insulin that was inhaled versus the injected insulin amongst both the parents and the kids who were actually using the aphraza. So I think at some point that is something that's important to keep in mind, that it made their perception of living with diabetes a little easier and that's something that's really an important endpoint for folks. As we get more and more people to target. The next thing is well, how can I get to target with less burden? So I think that's important. And there was less weight gain in the group that was randomized to inhaled insulin. So that too, as you were just talking about, it's a big problem with obesity and type 1 in our patients and any therapy that can potentially reduce that risk somewhat is something that we should be considering as an option. So yeah, I'm excited to see it move forward and get that FDA approval.
- [51:34]
A
What's the reasoning behind the less weight gain, do you think?
- [51:37]
B
I think it has to do with more physiologic dosing. You're really talking about giving insulin much more like insulin that would be coming out of your pancreas into the portal vein directly into the liver. And so you don't have excess insulin being around that. You then have to feed to avoid the low, post meal, post snack, exercise related. So likely that's the modality.
- [51:57]
A
That's it. And then what? So this is with the FDA now or what's the process like?
- [52:02]
B
Yeah, the company has filed for approval. With these data it can be a six to nine month process to get all the way through. But with any luck, at the end of that timeline, they'll have the stamp of approval from the FDA and then be able to start marketing it and selling it to pediatric offices. And that means their salesforce will be able to visit and provide samples. And I think that will be one of the key things to getting over that therapeutic inertia, to have people have access right in their offices and say, oh look, here's some afraid, why don't we try it? And then I think you'll have many more patients and families who get to experience what we were talking about in the last hour and say, oh yeah, this really is a nice tool to have in my toolbox for those pesky highs or for these particular meals or for this sports situation. And then it will get out there and hopefully be part of the thought process. When people start to enter a room and say what's going to be best for the patient in front of me today.
- [52:57]
A
It just occurred to me as you were saying that great, this is the, this is maybe the most hopeful inroad to making people understand how well this works. Because you're not gonna, you don't change adults minds about anything. Right? So you get people when they're younger and they can become accustomed to it. See how valuable it is for them. They'll carry. They'll carry that into adulthood.
- [53:17]
B
Exactly. And to that point, I'm really excited about a study that they're planning coming up, which is going to be offering inhaled insulin at diagnosis. So imagine, go back to when your daughter was diagnosed, and the first thing, they walked in the room and they said, we have this way of managing diabetes. You'll take this one injection a day, and then everything else will be inhaled. And you never were presented with the need or the option to give multiple daily injections or be on a pump. My hunch is that's going to play really well with a certain population of folks and that they'll learn from the very beginning that this is the paradigm for how we deliver insulin, and they'll see that they have great control and they'll want to stay on it, versus trying to convince people to change what they're already doing when it's working pretty well for most.
- [54:00]
A
Yeah. Well, I hope that companies in general realize at some point that it's not just a salesperson that you need at that point. It's a person who understands it. You know, like somebody who can actually talk about it with the care and concern that you and I have, but doesn't feel salesy and doesn't feel like a doctor. Like, I know that's strange, but, like, if somebody could sit down in that moment and go over those things with you, here are the options for how we do this. Here's the, you know, the pros and the cons. Yeah. Then let people make a decision that fits best for them, and they'll be more successful once they've done that. And you'll get more people who will do what is considered, like, a different idea. The way this is all set up, I know it's no one's fault. Like, I really understand that, like, most people are not sick most of their lives. When you're suddenly diagnosed with something, your expectation of the way medicine works is that you go to the magic man, and the magic man gives you a thing, and then you're better. Like. Right. Like, that's really people's understanding of medicine. I break my arm, and one day it's not broken anymore. I got sick. I took these 10 pills three times a day for 10 days, and when it was over, I wasn't sick anymore. You don't grow up with an expectation that you're going to be managing. You know, like, I've put it in the past, like, diabetes is like, trying to remember to make your Heartbeat. It's like if I put you in charge of like, you know, breathing and I said like, breathe in, breathe out. You had to say that to yourself every couple of seconds for the rest of your life. It feels like that. It's not the way people imagine their lives. They need to be set up for success very early on when they are. What I'm telling you I see, Mike, is that when you set them up for success early, they don't struggle as much and they actually have that success when that's over. So I hope that we can all find a way to that. It's right there. The Beta Bionics thing is one arm of it. The inhalable is one arm of it. The GLP is one arm of it. You just have to get the right message makers out there to let people know, I think so.
- [55:56]
B
You're again, very perceptive. The thing that ironically made the biggest difference in outcomes in our Echo programs was exactly as you described. Peer coaching wasn't the docs, you know, we're the last to be important in all this, frankly. It wasn't, you know, sales reps, it wasn't the tools. It was having somebody who had lived, shared experience, who could talk to people without, you know, bias and without judgment and say, well, here's some other options you might consider. And boom, we saw people seeing marked improvements in their outcomes.
- [56:27]
A
Well, let me pitch my last idea to you, Mike, as you go out the door. I think people's endo appointments for their type 1 diabetes should be in a group setting, not in one on one.
- [56:36]
B
We have done just that. It's extremely effective. The only challenge is the wonderful US Healthcare system and figuring out how to make it all billable. Yep. It's another reason camp is so great. Camp is like a one week long group education session. Highly effective for everyone.
- [56:50]
A
I'm sure you can do the same thing, but I have a crisp one hour talk. I could give it to you and you'll know how to take care of yourself when it's over.
- [56:57]
B
Yeah.
- [56:58]
A
And if you came back and build on that through Q and as. Like if the same group of 500 people showed up in an auditorium once every three months and build on their knowledge through Q and A's together, a year later, they'd be done. They wouldn't even need you anymore. I see how the podcast works and it can be replicated in real life. But like you said, like, every time I bring it up to somebody, the next thing they say is, well, we don't know how to bill for that. And so somebody's got to break the.
- [57:24]
B
System or the system's broken. Somebody's got to come up with a better way to do it and deliver it. And I agree. I mean, there's. Fortunately, there's a growing number of people who were setting up for success early on, like you described, who we've achieved that goal. They don't need us, they're doing great. We don't need to see those people every three months and make them come in for a check the box visit. And we've started to not do that as much in our clinic so we can put more energy in the folks who really need it. But even those folks need better ways of getting them information.
- [57:51]
A
It's difficult because you don't build lifelong customers. I had to, early on with the podcast tell myself my goal is for you not to listen to the podcast anymore, which is tough for me because it's hard for me to keep it going then. But I found ways to keep it going and other physicians could as well. There's a way to put people out into the world, healthy, in charge of themselves, where they're not going to see problems down the line nearly at the same rate. And right now, at best, we give people don't die advice. It's you're not going to die, but you're not really going to live well, and at least it's not on me. And that gets passed down the line and then some poor doctor at the end of the line manages you out at the end of your life. And, and it just, it's a weird setup. Like, I mean, we all know, like, we're probably preaching to the choir here, but there's ways to accomplish this. So I appreciate you giving your opinions today and adding to the conversation. Thank you very much.
- [58:46]
B
Yeah, it's been a pleasure to be here.
- [58:48]
A
Awesome. Hold on one second. For me, the conversation you just enjoyed was brought to you by usmitch usmed.com juicebox or call 888-721-1514. Get started today and get your supplies from USMED. Head now to tandomdiabetes.com juicebox and check out today's sponsor, Tandem Diabetes Care. I think you're going to find exactly what you're looking for at that link, including a way to sign up and get started with the Tandem MOBI system. Are you tired of getting a rash from your CGM adhesive? Give the Eversense 365 a try. Eversensecgm.com Juicebox beautiful silicone that they use. It changes every day, keeps it fresh. Not only that, you only have to change the sensor once a year. Okay, well, here we are at the end of the episode. You're still with me. Thank you. I really do appreciate that. What else could you do for me? Why don't you tell a friend about the show? Or leave a five star review? Maybe you could make sure you're following or subscribed in your podcast app. Go to YouTube and follow me. Or Instagram TikTok. Oh gosh, here's one. Make sure you're following the podcast in the private Facebook group as well as the public Facebook page. You don't want to miss, please. Do you not know about the private group? You have to join the private group. As of this recording, it has 51,000 members in it. They're active, talking about diabetes. Whatever you need to know. There's a conversation happening in there right now and I'm there all the time. Tag me. I'll say hi. If you're looking to meet other people living with type 1 diabetes, head over to juiceboxpodcast.com juicecruise because next June. That's right, 2026, June 21st. The second juice cruise is happening on the Celebrity beyond cruise ship. It's a seven night trip going to the Caribbean. We're going to be visiting Miami, CocoCay, St. Thomas and Saint Kitts. Yeah, the Virgin Islands. You're going to love the Virgin Islands. Sail with Scott in the juice box community on a week long voyage built for people and families living with type 1 diabetes. Enjoy tropical luxury, practical education and judgment. Free atmosphere. Perfect day at Coco Bay, Saint Kitts, St Thomas. Five interactive workshops with me and surprise guests on Type 1 hacks and tech, mental health, mindfulness, nutrition, exercise, personal growth and professional development. Support groups and wellness discussions tailored for life with Type one and celebrities. World class amenities, dining and entertainment. This is open from every age. You know, newborn to 99. I don't care how old you are, come out. Check us out. You can view staterooms and prices@juicebox podcast.com JuiceCruise the Last Juice Cruise just happened a couple weeks ago. A hundred of you came. It was awesome. We're looking to make it even bigger this year. I hope you can check it out. The episode you just heard was professionally edited by wrong way recording wrongwayrecording.com.