← Taking Control Of Your Diabetes® - The Podcast!
Taking Control Of Your Diabetes® - The Podcast!
MiniMed Flex, Dexcom G7 (15 Days) & Libre Instinct: What Type 1s Need to Know
00:40:12
Loading summary
Transcript96 lines
- [00:24]
A
So what? Diabetes technology is truly making a difference right now. Rachel Sud, the creator of the Diabetes Collective, joins us to explore the latest and greatest tools and diabetes tech, highlighting innovations that are helping people manage diabetes with more confidence and less stress. On the 100th episode of the Taking Control of your Diabetes podcast, I am one of your hosts, Dr. Jeremy Pettis, joined as always by my good friend and colleague, Dr. Steve Edelman. So, truly, it is our hundredth episode, so congrats to us, Steve. Like, you know, I don't want to be cliche, but it's gone by like that since we first did it. You know, our first podcast was in our old office. We did it at, like this kitchen table, kind of like checkers table, you know, now we're all grown up, so we're very excited to be talking diabetes tech, and we do this topic, you know, somewhat frequently. But we think it's important because things are changing so rapidly, and we have a little bit of a different slant on it today because we do have a very special guest. So do you want to introduce our guest?
- [01:21]
B
Yeah. Rachel Suit, who is the creator of the Diabetes Collective. And I want to know what you're collecting later on. And basically she lives in Louisiana, is in the trenches seeing patients with type 1 and type 2 and helping them get on technology, but also GLP1 therapies and things like that. And that's really important for us because we want to hear her perspective on how she's using this technology and helping her patients live longer and healthier lives.
- [01:49]
A
So say hi, Rachel. Tell us a little bit about yourself, your background, all that.
- [01:53]
C
Yeah, thank you so much for being here and Congrats on your 100th episode. I know it's really hard to be a doctor and a full time talker, so congrats, I'm happy to discuss. So, yes, I actually walked into a hair salon called the Blonde Collective several years ago and I thought, man, this looks kind of fancy. And it, like, smells good. And I'm like, why can't, like, an office be like this? And I'm like, it can be. So that's what I did. So I went ahead and opened my clinic. It's called the Diabetes Collective. It started as a clinic just how I've been trained as a nurse practitioner to sit in a room and see patients. But it's kind of slowly growing into a collection of different service lines for people living with or at risk for diabetes. So lots of big ideas, lots of things growing and changing, and it's been quite the journey. So I'm glad to, you know, share my experience as an NP and a DCEs with you and maybe talk a little bit about your experiences, too.
- [02:53]
A
Yeah, well, tell me a little bit more about that, because now I'm envisioning kind of a salon, and over here, you have, like, the nail person and the hair person. So is it like. When you say expanding services, is it like podiatry? Is it mental health? Is it like, what does the collective become?
- [03:07]
C
So it's funny, there's lots of people that reach out to me on social media and email, like, hey, do you want to train in Botox? Or, hey, do you want to do this, do that? And I'm like, no. We are a diabetes consulting firm. We are very much streamlined and focused on diabetes care, and that is all that we do. And if you need Botox or you need your nails done, you go do that. You get your car washed, you go do that. But this is our specialty, so it's very focused on people living with diabetes or maybe that are looking for a diagnosis or looking for a second opinion. I specialize a lot and offer people lots of diabetes technology, and it is direct care. So I get to spend as much time as I want with my patients, which has been. It's. There's. There's parts of business that are hard. Right. But it's a gift to be able to sit with your patients for two, three, sometimes four hours and not have to walk out of the room and have somebody else treat a low blood sugar. You actually get to hold them and do it, and there's no feeling like that. So I get to do these things. And it's kind of like my practice has come full circle. I get to kind of do everything and spend more time with my patients in this way. So.
- [04:15]
A
Well, can I ask this? What does direct care mean for people that are listening?
- [04:19]
C
Yeah. So, yeah. So in we are in the United States, there are three primary models of health care. There is managed care, which I think most people are familiar with. Like, here, here's my Blue Cross Blue Shield insurance card. Oh, you owe $25, Medicare, Medicaid. You give your insurance card, and so you pay whatever that fee is. Right. So that would be managed care. And that's mostly what all of our standard medical systems are based out of. And then all of our hot, large hospital systems, you also have something called concierge care, which essentially gives you a little bit of passive income because you say, hey, I'm Rachel. I'm a member. I'm going to pay you, Steve, $1,000 a year to be your patient. And in turn, I want X, Y and Z. And you'll say, okay, I get to see you three times a year, and I'm also available to you in a coaching class or this, and you get to have your labs done whenever you want. So that's concierge, so you pay a little bit when you have extra stuff, but you also have access to services. I think it's good, that model because it does provide some extra income for the clinic. Direct care is just a 1 fee for service. So, for example, you talked about nails. If you go get a pedicure, they say, rachel, it's going to be $75 for this pedicure. And it said that right then and there, you get just that pedicure, nothing else, nothing more. So direct care is exactly that. It's a cost for fee, for service. I actually use. There's some variations I see of direct care. I let everybody use their insurance, and so I outsource labs, you know, medications go to the pharmacy. People use their insurance, DME companies, just as they normally would, but they pay a price for a service, whether it's a new patient, consult established, and then I'm a certified pump trainer. So those are complimentary for everyone. So, yeah, that's direct care.
- [06:12]
A
Yeah. Well, that's great to know because there are a lot of different models out there, and now there's virtual clinics and different ways to do diabetes care. So kind of jumping into it, focusing on technology. I see mostly type 1 patients and Steve, too, and particularly for patients that come in, they're already on an aid system. I feel like now there's almost a fear they have sometimes that they're missing out because there's so much going on that there's always these updates on, like, did you hear about this new sensor or pump or whatever? So a very common question I get is kind of around the lines of, am I on the right thing? Should I switch to something else?
- [06:53]
B
Which one is the best?
- [06:54]
A
Yeah, which one is the best? So we have our take on this, obviously, but do you get that question? And if so, how do you handle it?
- [07:02]
C
Oh, yes, absolutely. So I mostly take care of people with Type one. That is just my favorite population. What I have is I have some cute boxes in my clinic, so I have some nice little tables and they're display boxes. So I have all the pumps that are on the market in one box and all the CGM in the other. And I have demos of just insulin pens and vials and everything. And we get the boxes out and we open them up just like you would go to a jewelry store and buy a diamond necklace, put it all out, let everybody touch everything, look at everything. I always tell patients, like, listen, your diabetes is going to change and I'm here for it. And I think a lot of times they're used to people telling them what to do, and I'm more the opposite. I'm like, what do you need? What do you want? I'll do whatever you want. You want to change, you want to change. Pumps is something different in your life. So we just reevaluate it and talk about it each time. And I'll just use a touch base, like, hey, is this working for you? And you know, why is it not? Or whatever. Well, this would be the option if that's not working for you. Do you like having that automatic bolus or maybe do you want something that doesn't have that, you know, so we just assess it each time. I feel like it's pretty quick, but I like bringing out my boxes. Okay. Yeah.
- [08:15]
B
You know, I think I'm the only one of us three that see patients with type 2 diabetes. But, you know, mainly because I go to the va, we run the diabetes clinic there. And we do use a lot of hybrid closed loop systems in type 2s and, and the VA, God bless them, the pharmacy, the powers to be, have really allowed them to have all the therapies that any other type one would have. Yeah. And it's a different type of person and I think it's more heterogeneous, meaning that you get some older chronologically, but younger thinking people that are tech savvy, they're on mdi, they do quite well with these hybrid closed loop systems. And then you get the younger chronologically, but just don't even know how to use a cell phone yet. So it's more variety and I think type one probably a little more homogeneous in that way.
- [09:07]
A
So, you know, I would say in terms of like different options, I think it's a good problem to have. It used to be not that long ago, like, are you on the cgm? You know, and now there are multiple options. So, you know, usually I'll tell people if they're doing well, like, you know, don't change that. There isn't really a compelling reason right now, in my opinion, with the different aid systems to change for a blood sugar reason. They all have similar algorithms and generally people do relatively well in the different systems. So right now it's More about personal choice. Do you want tubing? How does it look on your body? Those kind of features that are really kind of driving these decisions. So generally tell people, yeah, like, if it's not broke, don't fix it. I'll let you know. If there's some, like, major changes. Sometimes they'll come to me, you know, with something that I haven't heard about, which is always fun. But what about on the other side of it when somebody comes in and they say, you know, I'm on shots. I want to go onto an aid system. In addition to your boxes. Like, do you have kind of like a branching point? Like, do you start with tubing or no tubing? Like, how do you get to that? Through that web?
- [10:18]
C
Yeah, this. And I think. I don't know. I think my answer, it's probably different than everybody's. I go off of the person. There's definitely no playbook. It's just that person. Like, literally, people will come in kind of to your point. They are concerned about looks and aesthetics. And I very much can appreciate that and like, lifestyle. I mean, I have ladies. I usually draw a lot of women, young women, moms. And I mean, because I am one, you know, we're all drawn socially to people that we look like and act like. Right. And a lot of them are going to Pilates classes. Class, or maybe they're newly on the dating scene. And so it is very concerning to them. These are big points that we talk about, like the look and the aesthetics of a pump or a cgm and where can I wear this and, like, when I can take it off, you know, when is it going to beep? Is it going to beep in church or my. My Pilates class and this and that. Or maybe they're going on a date or intimate. These are real conversations that patients have. And I love being able to. To be like that with my patients because it's real, because it affects, like, daily life. And so when we're choosing technology, I want to make sure that it matches, like, your needs. So I will start with, like, when I show people tubeless. Of course, we have the Omnipod 5, which is our only tubeless option currently on the market. Definitely one of my most popular pumps because of it being tubeless. But then we also have tube systems. And then, you know, you look at CGMs and CGM compatibility, and that certainly plays a role because I find a lot of people and you tell me if you have the same experience. I find a lot of people are more married to their cgm. Like, this is the one that I like, this is the one I use, this is the one I trust. And like, I'm not changing. And I'm like, okay, like, whatever you want to do, but then we'll go off of that. And these are your pump options if we want to do it. These are the pros and the cons. And then we can always look at cost. I always talk about money. I never don't talk about money. If people don't talk about money, they're like, I mean, they're hiding something. I mean, money affects everything, cost affects everything. And so we'll pick something sometimes based off that approval and then, you know, we talk about what's coming because a lot of people, I don't want them to make a decision on a pump, but then maybe the new version is coming out in three more months and then, you know, so I like to be transparent with people in that. So I wish it was like a clear cookie cutter, but it's really off the person. Like, I just roll with it, you know.
- [12:45]
B
Yeah, I think you're right about the sensor. I think the best example is the Medtronic 780G, which is a great system. I wore it myself. I'm a tubeless type of person. But a lot of people just didn't like the old sensor. And then when they got to the Simplera and then onto the extinct. I don't say instinct, instinct, you know, the, the Libre version. And you know that, that really drove a lot of people going to the 780G because they're married to their, their CGM, especially someone that's never been on a hybrid closed loop, you know, and that that's the big problem. So I think, I think in the future, because as Jeremy said, all these CGMs, they're getting pretty darn good, you know, the accuracy, you know, it's like we'll be able to pick, you know, as David on would say, you pick your favorite sensor, you pick your favorite pump, and then you marry them together. And, and I think, you know, when a patient picks it, they're going to be more successful.
- [13:43]
A
And he, I mean, it's funny you use the word marry because he talks about dating your systems, you know, and like you can kind of shop around a little bit, like, and things like that.
- [13:51]
C
Yeah, so.
- [13:52]
A
But I think.
- [13:52]
C
I love that you said that. No, I love that you said that because it pumps and using different things. It is kind of like dating. I'll say that. Like you're not Married to it. Like, we can try this out and what you're doing right now isn't working. So, like, there's that, like, what you're doing right now is not working. So let's try something different. If that doesn't work, we can always go back to what you're doing or we can try something else. Like there, you know, it's not like, no big deal.
- [14:18]
B
It's like dating. You sleep with it, you drink with it, you eat with it. It's just like dating. Sorry if that was inappropriate.
- [14:26]
A
Sounds pretty realistic minor for Steve Edelman comment, to be honest. But I think you're right. It comes down to all these things, right? Like, what sensor do you want to be on? Do you want tubing or not? What does it look like on your body? What is the cost? What is covered by insurance? But interestingly, in that conversation, again, is very rarely. This pump kicks ass in terms of getting your A1C or time and range down. I hope we get there with the next iterations of these algorithms. All of a sudden, the eyelid, I would say, is different in that it has a completely different feature of not really entering carbs and things like that. And that might be attractive to a certain range of, like, group of people. That's a whole different conversation. Do you like kind of micromanaging your diabetes? And there's nicer ways to say that versus would you be fine? Kind of being hands off. And that's like another part of this extensive conversation. So any thoughts there?
- [15:22]
C
For sure. I think it's a problem also with all of us managing diabetes, because if you think about, like, the spectrum of care, like, I came onto the playing game of diabetes, like when CGMs were just coming in and where we had, like, sheets and faxes of glucose logs each night on the fax machine. And this is like how we were titrating pumps, and that was like, crazy. And I never want to go back to that ever, ever in life. But, like, now we just. We have so many options and, like, you don't have to. You can use so many different things. I mean, I can't imagine a world without cgm. See, I usually will start with. I usually start with cgm and then we kind of go off of that and kind of match the pump to that. But I. I hope one day that there will be a day that we can say your CGM that you are on. Yep. You can have whatever pump you want because that's often the barrier. Right? Like, somebody will be on the cgm, but it doesn't go with that or it doesn't. Like, they're always kind of.
- [16:25]
B
The other thing I think that's important. That hardly ever gets mentioned is the time it takes to set up a pump after three, four days, because there's a huge difference. As you know, Rachel, the Omnipod takes two minutes. And when you travel, you don't need to carry a lot of stuff. And there's so much paraphernalia. And I think that's a big deal. And I think that's why every single pump company on the market now is working towards a patch pump. And you probably know these developments, you know, and that's a little bit what Medtronic is doing coming out soon, too.
- [17:00]
A
Yeah. You know, let's talk about that a little bit. You know, I'm thinking I'm actually getting married next week, Rachel. Going on a honeymoon. Yeah. Thank you. For a couple. So I'm gonna go.
- [17:09]
C
Congratulations.
- [17:10]
A
Thank you. I'm gonna be gone for quite a while for the wedding and the honeymoon. And, like, I just feel like I need a bag of just stuff like insulin and tubing.
- [17:19]
C
And if you don't mind me asking, what system do you use currently?
- [17:24]
A
So I use the Medtronic, and I did want to talk about it because we didn't use it for the longest time because of the sensor. Really, it was pretty antiquated. And a couple things have happened that now I can use the Instinct sensor, which is a Libre. So that's like, state of the art. The algorithm I really like. But the one thing that is still kind of outdated for them is the pump itself. I mean, if you've seen. Looks like a very medical device. It looks like a medical device.
- [17:55]
C
Clunky.
- [17:55]
A
Yeah, it's clunky.
- [17:57]
C
Yeah. Not sleek.
- [17:58]
B
It goes along with Jeremy's personality.
- [18:00]
A
I'm clunky.
- [18:01]
C
Are you?
- [18:03]
A
So they're launching something called the minimed Flex, which I'm happy about, which looks like a much more modern, sleek pump. It's like. It kind of looks like a couple vials of insulin stacked together is how they describe it as. This kind of, like, narrow thing holds 300 units controlled by your smartphone. So I think it's another way of Medtronic kind of coming back on the scene. So do you use mini Medtronics, or do you think you'll use it more with these developments?
- [18:28]
C
So it's interesting. The first pumps I ever put people were on. I flipped an entire clinic. It was all type 2 patients on MiniMed and of course, Medtronic. Has rebranded. And I think it's a good time for them because we're seeing a lot of new technology and people have been waiting for it because it does work. The system works great. That's what I started with. I put any and every single patient in my clinic because I'm like, how can I work smarter and not more hours, Right? So I put everybody on closed loop, mostly type twos. I mean, this was years and years ago and then kind of got into type one. But, you know, there's something to be said about a button. So just hear me out. Yeah, like, like some people and like, you will not change them. They like having that button. And even if you take like a tandem, like a T slim, it's a touch screen button, it's not the physical button. And that bothers some people, I'm telling you. So I hope that I like the new pump that they're coming out with the way it looks. It's going to be compatible with seven day wear, you know, less, you know, it's white, so I noticed that it's white in color, not black. Twist is the white pump. So it's like, okay, now we're having. Are we going to have color choices now? But there are a lot of mini med users that very much kind of started on that system because that was one of the original players and they very much like having that. They like being able to see their insulin. You know, like, you can see it, it's clear. You can see the insulin, put it in. They like being able to take the battery in and out. They like all of this. And some people don't want to switch to that phone. That's not all people, but I definitely have a group. So I hope that when we do have this new system come out, the new pump, I hope that the old one kind of stays around. It's hard for people to change. I know that. I just want people to have their buttons.
- [20:19]
A
It reminds me of like the Mobi, you know, at least on the Mobi you have the one button, you know, so you can bolus if you need to. And that, like, I think you're right. Provides some reassurance.
- [20:27]
B
Yeah. And people are creatures of habit, you know, I mean, they get used to their system and it's tough for them to change.
- [20:33]
A
I mean, and then Steve, like, if something goes wrong with your Omnipod, I mean, he has to take it off and suck the insulin out, like MacGyver it and, you know, inject himself. So it's a great. Yeah, but it Would be nice if there's a little button on the Omnipod. I don't know.
- [20:46]
C
I wish there would be a button on the Omnipod. That is one of my wish lists, because there's nothing on the Omnipod to control it. But at least you have a backup pdm which I'm sure you carry with you at all times, right?
- [20:57]
B
Absolutely.
- [20:57]
C
Charged.
- [20:58]
B
Absolutely. You know, I would say being an Omnipod user for many years, but trying all the other systems, and I do think all the other systems are excellent and it really takes what you put into it, you know, if you bolus early, if you set your settings correct. But I just do not like tubing. And also, you know, a lot of people need more than 200 units in a reservoir, unless they have to change it too often. So different strokes for different folks. And I like your approach where you give people the choice and it's not so much you're choosing it, but they'll ask you questions and they would say, what would you use if you had diabetes? So here's my question to you.
- [21:35]
C
Oh, what would I use? Oh, I've already thought about this. So yeah, my pancreas works at full capacity, so hopefully you don't hold that against me. I know, I know. I'm drinking this regular Pepsi. Let's see.
- [21:45]
A
Oh my God, that's not right. Oh, geez, you're gonna get a for that.
- [21:51]
C
I would rather a Coke, but all they had was Pepsi. So let's see, what was it?
- [21:57]
A
What were you use?
- [21:58]
C
Oh, what would I use? Yeah, I would probably start on the Omnipod 5 with the Dexcom G7 10 day, not the 15 day. I don't like wearing sensors for a long amount of time. They just aggravate me and itch me and I just don't know that I want 15 days. Like, I want to be able to, like, I don't want to commit that long. Fifteen days is a long time to commit to anything. Like, if I cook spaghetti in our house, like, we're only going to eat it a few times. Like, and then it's time to change. Like, I can't. I don't like it.
- [22:25]
A
That's interesting right there because that's always been the name of the censor game. Right. It started off with a three day that we wore, then seven.
- [22:32]
C
Right.
- [22:32]
A
The hustle's always been to make it longer and longer. And it sounds like you're saying they've gone too far for you, but, like, there will be a limit of. Of where People want it to land and maybe it's somewhere right around two weeks or ten days.
- [22:46]
C
Yeah, maybe. I would also, I love Tandem's algorithm. So I would probably do Omnipod 5 with a Dexcom G7 10 day. Or I would do a Moby. I definitely see myself as a Moby girl.
- [22:57]
A
Got it. Well, tell us, since we're on Dexcom a little bit, what do your patients say about 15 days? Do you have a lot of patients calling to switch from 10 to 15? And where is it at with integrating with the pumps also?
- [23:12]
C
Yeah, so Dexcom's, you know, product line, we have our Dexcom G6 as, you know, is going out in the summertime and there are a lot of people mad about this and I feel bad, but look, I'm not in charge, you know, so we all have to move on with our lives. You know, the iPhone original is not out either, so. And we don't have Android flip phones anymore. Or do we? I don't know. But the G7 10 day we have as an option, and that pretty much integrates right, with most of our pumps. G7 10 Day integrates with the Tandem systems, both T Slim and Mobi, and Omnipod, it integrates with the Eyelet system by Beta Bionics. It does not integrate with Twist. That is coming. I think everyone is very anxious about that. People are waiting and I think, not to get off on a tangent, but because Dexcom doesn't integrate with Twist. And this is just my personal opinion, when I talk to people sometimes they are married to their Dexcom G7 and they're like, I don't want to switch to a different sensor, therefore I'm not going to try that pump.
- [24:13]
B
But just one quick interjection is that some people appreciate the implantable ever since. And of course, the Twist is the only one that integrates with. So I don't know how huge amount that is, but there are a certain amount of people that like that model for their cgm.
- [24:27]
C
Yeah, no, absolutely, I agree, I agree. And that's like, not as much interaction at all. So, yeah, G7 10 day, some people are definitely switching to the 15 day. I usually just ask people, like, when we're done, like with a visit, like, I'm like, all right, let's make sure you got your backup pens, your insulin valves. What do I need to refill? Like, what you need, what you want? And I'm like, are we switching to 15 days? Do you want to stay on 10 days? You want to go to 15 days? So right now, as it stands, unless something came out in the news today that I missed, I don't think Dexcom and Tandem have formally said that the 15 day integrates. I think it kind of does, FYI, but it's not. It doesn't. Yes. So we are not doing that. But it does. The 15 day does integrate with both the eyelet and Omnipod 5. And then of course, you know, not to leap. I know we talked about minimed, but they have their own system with their own CGM line. So dexcom does not integrate with that. It does integrate with their older inpen.
- [25:24]
A
So what do you tell people? That the G7 had issues or has had issues with accuracy falling off, whatever. What do you tell people about where that's at now with kind of the regular G7? And is the 15 day anything different that might get rid of those problems? Do you tell people to come back to Dexcom now or what's that conversation like?
- [25:44]
C
Right, so this is an interesting conversation because I certainly think. I know that there was some type of issue with the stickiness and the accuracy. There was definitely a large bulk of that going on. I didn't get a ton of it in South Louisiana. I really didn't get affected by that. I will be very honest. I definitely saw a ton on social media. Other colleagues were telling me, but I didn't have too many people with this issue. So to be fair, I don't have a lot of that. Overall, there's definitely people that have mistrust right with their CGM because one or two bad things go wrong. I mean, you end up in the hospital. I mean, you can die like with really, really high or really low blood sugar. So just one thing wrong that will like that trust is hard to get back. I will tell people, like, why don't you try this? You can try the G7 15 day because it is improved as far as like stickiness. It is like slightly, slightly smaller. If I'm lying, it's like, you know, and see if this works for you. And it's definitely improved. I have samples in my clinic to let people try. I mean, we'll even try to see jgm. Like, I'm like, which one do you like? Like, let's just pick like, it's whatever you like. So, yeah, some people have switched to 15 days. Some people like that longer time period. I personally don't like wearing something that long though. But it's up to.
- [27:03]
A
It's nice.
- [27:04]
B
I would just say real quickly, Jeremy, that I haven't had one patient that said, no. They said, are you kidding me? Yes. So, like, you know, older, adult to the 15 day. Yes, to the 15 day.
- [27:13]
C
So really?
- [27:14]
B
Yeah, yeah. You know, different. You know, they're older and maybe, you know, their. Their biggest issue is. Is maybe falling off. So get. Get a stronger overlay than the one that comes with the. The G7. So, you know, most of my patients love less to put on, you know, less time, but the other thing, too, is if one goes bad and your insurance just gives you two a month.
- [27:38]
C
Two instead of the three, you're messed up.
- [27:40]
B
You're really.
- [27:40]
C
I know, I know. That's what they say. That's what my patients say. They're like, well, wait, I only get two. And I'm like, well, you can replace it. But it's like, yeah, yeah.
- [27:49]
A
Like, if it falls off, that's much more devastating.
- [27:51]
B
I'll just say real quickly. My. I think the complaints have gone pretty much away with the Dexcom 10 day. You know, we. We had a podcast with Jake Leach, the new CEO, and he. He really felt strongly that they were going to fix that problem before the 15 day. And he also said they'll do anything to replace it. They won't have a limit, and they'll send it out ASAP if you get the jam. So I think that's responsible at least.
- [28:16]
A
Well, the last piece of tech I want to talk about is your take on Abbott doing a dual continuous glucose monitor. Continuous ketone monitor, and it'll be the first of its kind, and it does just that. It'll measure glucose, but it'll also tell you when your ketones become problematic. Do you need to know what your ketones are all the time? No, but it would be nice to know if you get into high ranges or it can be dangerous. So how much do you think this will be important to you clinically? How much do you think patients will care about this? Where do you see this technology going?
- [28:49]
B
Jeremy's taking notes because he's in a big debate at the ada. He's on the con side, and he's debating Jennifer Scherer, who's a pediatric endocrinologist, which they should really do. Adult. Adult or peds to peds. But in any case, I'll root for you, Jeremy.
- [29:05]
A
Oh, thank you.
- [29:06]
C
Yeah, that'll be interesting. I'll have to attend your session because there's definitely multiple sides of every story. So these are my sides. Okay. So for me, as a nurse practitioner, treating patients with diabetes, yeah, ketosis and decay is a big deal. I mean, I recently had a. I say, my friend, he's my patient. My friends are my patients. It's all the same. It all blurs. Right? Had an admission for dka and it was very traumatic and it was. It was crazy. And, you know, the hospital often doesn't know what to do. Right. When they go to any ER or whatever, it's like nobody knows what to do when to give insulin. And this just goes on and on and on and on. And we hear these stories over and over again, and it's exhausting. I think from our side and the patient side, we know that certain people are more prone to ketosis than others. Right. This is type one and type two. We definitely see more patients, certain ones that have more episodes at different stages in life. Right. I think using this, I'm excited. I'm very excited for it. I think that no one is ready for it. I'll be honest with you. I think it's going to be the way CGM was. And I know it's a dual. Like, we're going to have glucose and ketones and, oh, my gosh, so much information. But I don't know that we're all ready for it because this is biofeedback just like anything else. And so if you think about it, we have not had this information yet. Like, you and I like, sitting in our practice, when you come in, like, if you were my patient coming in, like, I just pull, like your. Your pump report, I'd pull, you know, what everything and look and stuff, but I couldn't be able to pull and see the levels of beta hydroxybutyrate. I wouldn't be able to see that. And now I'm going to. And what am I, as a clinician going to do with that information? I don't have it yet, so I don't know. And I know, you know, there's some working groups working on those guidelines and some guidance for when this comes out. Like, how are we going to do this? But I think it's going to let us know sooner. And I think we are going to be learning a lot more how to prevent dka. Now, having this information. Now, the patients, I hear a lot from patients. They're like, why do I need this? I don't want this. Why do I, like, is this really necessary? And I'm like, yeah, because I want to know. But sometimes I think knowing so much and alarms is overwhelming and a barrier to just technology in general. And sometimes more information is not always best. And a lot of patients, they don't want more, they want less. So, yeah, I'll be interested to hear your talk. What are your takes on it?
- [31:42]
A
Well, I think, you know, we could talk about this all day and I gotta sit down and come up with my arguing points. But I agree, I think it's very valuable information. I do really agree on the we're not ready part. At least with the CGMs we always knew what normal and abnormal glucose levels were. People just don't talk about beta hydroxybutyrate and most clinicians and certainly patients don't know what a normal number is or a bad number or a good number. So there's gonna be a whole lot of education that's required. But ultimately, sure, if we get to a place that every sensor can have this added as kind of like a background, heard people explain it as like airbags on your car. You don't need them, hopefully ever. But when it goes off in an emergency, you're sure glad you kind of had it. So that's kind of my thinking about this is that if it can prevent DKA, get type 1s to maybe use S22 inhibitors, all those kinds of things. So this will evolve. And when we did talk to Jake Leach, this is the way that sensing is going that they're thinking about adding potassium or lactate. So eventually it might be glucose plus. Oh, if you like, you know, I want to know what my glucose is. But if you have kidney disease, for example, maybe you need to know your potassium or, you know, so we're this in the next five, 10 years it's going to become pick your sensor, but also pick what your sensor senses, which I think is kind of cool.
- [33:04]
C
Yeah, yeah, yeah. You're talking about the Dexcom G8. I mean, I know we've all kind of been hearing and talking about it. It's been in development for gosh, it's 2026. I feel like I started hearing about it two years ago and I am excited for that technology. I am wondering too, when these new sensors come out, are they going to be compatible hopefully with pumps? I mean, I'm just a question. These are things and we need to know. Right, Right.
- [33:30]
A
And nobody's going to use them until they are. So that's going to be a must. But I think maybe you can leave us, Rachel, since we've talked through a lot of things, I'm left thinking that these aid systems have been fantastic and you can't pry mine away from me if you tried. However, there's still a lot of people not on them, even people that are using them. It's not like a set it and forget it, and all of a sudden your blood sugars are perfect. People still have hypoglycemia, dka, so there's still a lot of room for improvement. So is there things that you're looking forward to in the next five, 10 years that you think are going to make the biggest difference for you, your patients, your clinic, or hopefully leave us something hopeful to end on here?
- [34:13]
C
Yeah. I mean, when I started out in diabetes, all I had was like a really early Dexcom that was like, huge, like a robot and the Medtronic pump, and those didn't connect. And so that was what everybody was on. So that's how I started out in diabetes. And I had lots of samples of Victoza pens and I used them. Okay. Like, I was just like, let's get it down. Like, let's get it together. Gosh, life has changed so much. So I think we're in a good sense spot. And there's so much that I tell people, especially when they're newly diagnosed. Like, we have so much for you. We have so many options for you. Just coming from that little phase of my life just 10, 15 years ago, what do I want to see? Low blood sugar is an issue. Low blood sugar is an issue. It will be an issue. It's a chronic issue. I mean, I have people calling still all the time, hey, I'm going to be NPO to go to my CT scan tomorrow. What should I do? And of course I want to be like, oh, you're in automated mode, so it doesn't matter. But what the patient was really asking was, if I go low, what do I do? That's what they were asking. Low blood sugar is an issue. I know that we're seeing a ton. I know you were both at ATTD and there's a lot of talk and showing an actual fully closed loop system with bihormonal. And I think I am going to be. Y' all are gonna. We're gonna be prescribing it, and that is so cool. How is it all really, really going to work and be feasible? You know, you like tubeless systems, right? And so it's like, are we going to be able to give all this tubeless and safely? So low blood sugar is an issue. DKA is an issue. Those are my two probably big issues with my patients with diabetes on technology. How can we get this all more accurate and how can we solve those problems? And, I mean, we're it looks like it's coming. It's coming. And I know we keep saying that, but. Okay, you've got the continuous ketone monitor, glucose and ketones. So we're looking at that. We're looking at the bi hormonal pumps. I really want to see. I feel like my wish list is. Is low. I just want all of the pumps and the CGMs to play well on the playground together. That's all that I want, really. Because I feel like if that could just happen, like the compatibility issue, and it's just it, you know, it's every few months. Oh, you got to do this, you got to do that. I mean, there's even an Omnipod that just for the Libre and G6, but it doesn't connect to the G7, so if they get the wrong pod. So I just want everything to be compatible. I don't know that I'll ever get that wish because companies have ownership things. But I want to see more autonomy. I want to see more people taking care of diabetes. I don't want it to just be endocrinologists or diabetologists. I hope primary care starts getting comfortable with doing stuff. And honestly, they have to, because there's no way to take care of everyone. Right.
- [37:09]
B
I mean, that's a tough wish list right there.
- [37:11]
C
I know.
- [37:12]
A
Well, I think, you know, we're getting very close to not having to bolus with these systems, which I think is going to be a major, like, huge lift. And especially if we start, like, opening up the playbook that we can use GLP1s more in type 1 diabetes. You know, we use Manjaro Ozempic all the time in our Type 1s. It's getting a little bit easier, but I see in the next couple years, it'll be insulin plus, you know, one of these other medications. Start using more of these drugs like we do in type two. That's gonna really help these algorithms out, make it easier. So I think within the next five years, we can be pretty much, like, bolus free for people with type 1, which is really 90% of the pain in the ass of type 1 diabetes of putting your carbs and causing your glucose.
- [37:52]
C
You saw that data, that omnipod released, huh? And slut released. I mean, it was a very small group of patients, but, I mean, there was a small group of patients on the new Omnipod 5 algorithm, and they did not bolus at all, and they were 70% in range, just without bolusing.
- [38:10]
A
Yeah. So we are pretty much there.
- [38:13]
B
Well, I can get 90% without eating.
- [38:17]
C
What about with this Pepsi? Can you do that?
- [38:21]
A
Well, we just want to say thank you so much, Rachel, because there's so much to talk about here, but I think we hit some real highlights and leaving people with a sense of feeling comfortable about knowing the space, what they're on, if something is attractive, that they can always make a change. It's getting easier to switch between systems and devices, things like that. Things are changing so rapidly that we really talk about things happening the next year or two when it used to be what's happening the next 10 to 15. You really got to keep up with this stuff. Thanks for educating us. Thanks for educating our listeners. I forgot to mention, I don't think we said that for people that are coming to our ONE Conference in August, which is for people and their loved ones with type 1 diabetes here, August 16th weekend. Is that right, Steve?
- [39:04]
B
Yeah.
- [39:05]
A
Whole Friday to Sunday thing. Super fun. Richa, I don't think you've ever been, but it's going to blow you away how fun it is. And being part of the Type 1 community, we just take over this resort. And what I'm trying to say is we're lucky to have you there as a speaker. So if you want to come meet Rachel. So we'll see you at the ONE Conference.
- [39:22]
B
Yep.
- [39:22]
C
Thanks, Rachel.
- [39:23]
B
Appreciate it.
- [39:24]
C
I'm so excited. And I have one more announcement. So I've had some requests that we should do some line dancing at the retreat because that's one of the things that I like to do. So I said if there's music and there's fun, we can definitely, hopefully incorporate that.
- [39:39]
A
We'll send it at the flagpole. I think it might be a no.
- [39:41]
B
Can you line dance with the Beatles music?
- [39:44]
C
I mean, if you want. That's what you want to do. We will make it happen. All right.
- [39:49]
A
We will see you in a couple months.
- [39:51]
B
Okay, Rachel, thank you.
- [39:52]
A
Bye.