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Steve Freed: This is Steve Freed with Diabetes in Control and we’re here at the American Diabetes Association 77th Scientific Session 2017. We’re here to present you with some really exciting interviews with some of the top endos from all across the world. We’re going to start off with a very special guest: Dr. Steven Edelman, Professor of Medicine University of California-San Diego, Veteran’s Affairs Medical Center, Founder and Director of “Taking Control of your Diabetes” TCOYD. He’s been doing that for many years. Maybe we can just start off and tell us a little bit about what kind of practice you have.
Dr. Edelman: Well, I’ve been doing “Taking Control of Diabetes” for 22 years, but it all started off when I got diabetes when I was 15 years old. I wanted to become a diabetes specialist, so I became an endocrinologist and I work at the University of California-San Diego and the Veteran’s Affairs Medical Center. So I have a university based practice and I run a big clinic at the VA, mostly type 2s, but still a lot of type 1s these days. When I run “Taking Control of your Diabetes” putting on conferences around the country. I really have interaction with 1,000s of people every year. type 2 and type 1.
Steve Freed: Because you’ve seen so many patients throughout the country. Probably throughout the world. What do you think is the major issue? Why is it that most people are out of control?
Dr. Edelman: Well, we should put it in two buckets. The type 2 and type 1. Primarily in the States. type 1, you know Steve, it’s tough to control. SubQ insulin just acts too slow, it hangs around too long. It really shocks me that a minority of type 1s are wearing a continuous glucose monitor, which I think is one of the most important advances in type 1 diabetes since the discovery of insulin. Over 100 years ago. A device that tells your blood sugar every 5 minutes, trend arrows up and down, and warns you, then going to your phone to the cloud to help loved ones follow along. Why is it that so few people are on the continuous glucose monitor? We’ll get into that later. Type 1 is tough. They’re totally dependent on injectable insulin and there’s a lot of unpredictable fluctuations. You take type 1 diabetes exchange data, that’s the snapshot of 27,000 type 1s in the United States and they’re followed at major medical centers with good diabetes clinics. Only 30% have an A1C at goal. So it tells you that there is really, it’s hard to control type 1. Type 2, I can summarize it for you. There’s a lack of a sense of urgency. It’s a polypharmacy condition. Doctors don’t have time to talk to patients about why they’re prescribing multiple drugs. People don’t take them. I have data I’m presenting here at this meeting on adherence and persistence in type 2 meds and it’s unbelievable how many, when you look at pharmacy benefit manager refill data in large databases, administrative claims data, that the adherence, defined as percent of days covered, is horrible. These are drugs, even like the DPP-4s, that have no side effects that are once a day. There’s a big disconnect between people with type 2, they don’t understand the urgency, doctors don’t have time to explain things with them, develop a relationship that has a lot of trust. People don’t do the refills. It’s shocking, very shocking.
Steve Freed: When it comes to PCPs, you have to go back 50 years and we had one oral drug, it may not be the best drug today, but we had one oral drug. You go see the doctor, you had type 2 diabetes, he’d put you on a sulfonylurea, it was a no brainer. It took us all the way up to 1995 before we had two drugs, that was Metformin, and from 95 until today, there’s probably over a million possible combinations, if you use triple therapy and add the insulin to it. Now, how does the PCP, figure out what is the best drug for their patient? Is it just trial-and-error, you try this combination, you try that combination. How does know what to prescribe?
Dr. Edelman: Well, let me just add on to your first comment is that: since 2005, we’ve had over 40 new diabetes medications approved by the FDA. Not different classes but combinations. When you look at the NHANES database, the number of people in America with an A1C less than 7 hasn’t changed in 10 years, despite all of these new medications. GLP-1s, DPP-4s, SGLT-2 inhibitors. The answer to why that is such a shocking statistic. If you don’t take medications, they’re not going to work. I don’t want to throw people with type 2 under the bus. There’s a lot of issues with people: fear, and things like that. So, how is a primary care doctor able to do it? It’s almost impossible. Then you take 15 minutes and he has to spend 7 or 8 of those minutes doing perfunctory things like checking off the review systems, making sure the correct level, making sure you’ve reviewed the drugs. Nothing has to do with why that patient is doing poorly. No time to develop any relationship and it’s a complete disaster. They’re so busy, they don’t even use the 0-pay copay cards that people can get with some of these newer medications. That’s why I run “Taking Control of Your Diabetes”. Exactly because I want patients to learn about how to manage their own diabetes, learn about all the new strategies, medications, and injectable. And if they don’t have and they think it will help them, go to their caregiver. The caregiver, they’re there to help people. And if a patient says, “Hey, doctor, I think I learned about this new medication, I think it might help me. I learned about it at a conference. What do you think? Could I try it?” And 85% of the time, based on our market research, they say yes.
Steve Freed: When it comes to diabetes, most people don’t die from diabetes. They die from heart disease, strokes, heart attacks, cancer, Alzheimer’s, every disease known to man.
Dr. Edelman: Aspirin has a lot of side effects. More than some of our diabetes drugs.
Steve Freed: The SGLT-2 drugs have been shown, it increases your risk of amputation of your toes primarily. So far. It seems as time goes and more patients are on the drugs we find out more things. What are your feelings about the GLP-1s and the SGLT-2s?
Dr. Edelman: Well, don’t forget GLP-1s, they have been out over 12 years. They have withstood the test of time in terms of safety. What is the common denominator with all of them? The practical ones are nausea, if you titrate it too quickly. Occasionally you get vomiting. The whole issue of association with pancreatitis, it’s an association, no direct cause and effect relationship. And this whole C cell hyperplasia, that’s laboratory animals, never seen it in humans. That class of medication that leads to weight loss, really nice drops in A1C and now you can take home once weekly. Maybe in the future with the Intarcia implantable micropump, once a year. I think that class is incredibly important and safe in terms of, we haven’t discovered anything. You remember the old troglitazone story. The first TZD that led to idiopathic liver damage, and it got taken off the market. So, with SGLT-2s, I think we’re going to need a little more time to be honest with you. We’ve got the DKA issue, we’ve got the amputation, which is kind of strange with canagliflozin or Invokana, it’s only seen in the cardiovascular outcome trial. The phase 3 trials, which were over 8,000 people, they saw a decrease. Not statistically significant, but a trend. Is it because the older folks that were a good candidate for CVOT trials had reduce circulation, because they already had some evidence of heart disease. I think we just have to be careful not to jump onto these side effects, make them a class effect. Or even, wait till they’re proven to be due to the drug itself. I’m not trying to defend any of these drugs, I just know that when you get an imbalance in side effects, relatively small numbers, like DKA. That news release today was double the rates. 1% to 2%, it’s a relative versus absolute risk. I do think that we need to have them on the open market for a while before we really know the true safety.
Steve Freed: The new technologies that they’re coming out with just blow your mind. We have driverless cars. I know you drive a nice car.
Dr. Edelman: How do you know that?
Steve Freed: I saw a photograph. It’s yellow too.
Dr. Edelman: That’s my old Porsche. I have a used Range Rover now, because I ride my bike. But thank you, it is a nice car.
Steve Freed: But, technology is changing, we’re talking about smart insulins. Where you give yourself an injection and it knows when to release it. The CGM came along and it’s a huge breakthrough, certainly for type 1s, there’s no question, because insulin is a dangerous. You can take a look at it and you can predict it and so forth. But what about for type 2s the CGM? What are your thoughts in using that as an educational tool?
Dr. Edelman: Yeah, I love that question. I think CGM for type 2s can be fantastic. I’m looking at the whole spectrum, from prediabetes, oral agents, oral agents basal, MDI pump. I think, obviously, when they become more accessible, less expensive, easy to apply, easy to use, maybe not so many bells and whistles. But just think for someone with prediabetes. It’s going to really motivate them, they’re going to see the consequences of their actions in terms of exercise and what they eat. Same with oral agents, same with basal insulin to help titrate that basal insulin appropriately, a big problem in the United States. And, then of course, MDI and pumps, you get benefits like type 1. I think the key for type 2 is this. I know I’m right on this. You’re going to have to engage the patient to look at the number and then do something with the number. So, it’s all about engagement. We use CGM, we have a bunch of loaner ones. I want to make a big point, unblinded. I hate blinded CGM. If you had type 2, Steve, would you like to wear this thing and not even see what’s going on? I’m not going to take it back to my doctor, make another appointment and say “What’d you do Tuesday morning three weeks ago at 9 o’clock.” And say “Oh, I had a bagel or something”. You know what, patients need to see it. I won’t get off on that tangent. It comes down to activating the patient. I’m a believer that we really need to go unblinded, not blinded. I understand a lot of these companies like Abbot, need to come out with a professional version first, but that’s just an FDA requirement, they understand.
Steve Freed: You’ve been very successful in treating patients and educating other medical professionals. I saw a program recently on Ted Talks, “What Makes a Good Presenter”. I was at one of your presentations and I fell in love with it. I wanted all your slides which you refused to give me.
Dr. Edelman: You know what makes a good presenter? That’s a good question.
Steve Freed: This is what they said. A good presenter has his PowerPoint presentation and he presents it and has 150 slides and people walk out and they don’t remember a thing. What makes a good presenter is that you provide some information, they take that information and they use it in their practice. That is what makes a good presenter. Now your time isn’t wasted, otherwise your time is completely wasted and you shouldn’t even be there. So what do you do when you do the TCOYD presentations? What points are you trying to get across to people that they can take home, that you feel is most important for patients and then the same thing for PCPs?
Dr. Edelman: It’s the same strategy. I just want to say that just because someone remembers something to use in practice doesn’t mean it was a good presentation. It was good in the fact that it had good information and they used that in practice. But I think a good presentation to me is something that you have made such an impression on somebody, they don’t forget what you said. Hopefully, they said something good and you can use it in practice. You could have a great presentation with lousy information. It’s a small distinction. I would say this, that, my strategy is this. I think, not to have too many slides, not to have text heavy slides but to create some type of emotion during your presentation. You have humor. Humor is key, Steve. Not just an out in left field joke that has nothing to do with the content. The joke has to relate to the content. That’s what I spend a lot of time on is making my talks funny. Not the whole, it’s not a comedy routine, but I mix it up in there. Then you want to bring people through a range of emotions. You want to show them something that is quite sad, serious, side effects, death, but not just throw it in there to cause them to go home, “oh my gosh.” You want to bring them from laughter to serious. You want to not have too many difficult messages and then at the end, have some good take home points.
Steve Freed: So what take home points would you like when you do a presentation to medical professionals, PCPs, pharmacists, nurses, dietitians. What message do you want them to walk away with to make a difference in the way they treat their patients?
Dr. Edelman: I want them to walk away with this concept that there really are no patients that do not want to live a long and healthy life but they have barriers. I’m talking about type 2 a little bit here now. You have to sort of realize that when they come in, they haven’t lost any weight, they don’t bring their meter, they forgot it again, they didn’t refill their prescriptions, that instead of saying “You son of a gun, noncompliant patient, I don’t want to take care of you. You got heavy, it’s your fault.” I want them to say “gosh, this person has barriers. Let’s change my strategy of a perfunctory, formal H and P so I can get all the billing levels, but just start with an open-ended question.” Say, “Hey, Steve, your glucose control is really difficult. I know you’re having a hard time. What’s the hardest thing for you?” And then you have to listen and then you’re going to find out what’s going on. Bring a family member too, because then you’re going to learn a whole new level of information. So, it’s really having empathy and asking patients open-ended questions and then just listening and you’re going to find out what’s going on.
Steve Freed: I did a presentation at a physician’s office to their staff. One of theirs just started crying, right away. I said, “What did I say?” It was about grandkids and the importance of having a good quality of life with your friends and family. She said that she had diabetes and she wasn’t really being proactive with it and she’s got 6 grandkids she’d like to be around.
Dr. Edelman: That’s good motivation.
Steve Freed: I find that motivating people about quality of life issues, family and friends, that’s what life is all about. It’s not about making a huge amount of money, although that certainly helps, but it’s really about your personal life that really will make you a happier person. Humor certainly plays an important role also. I remember during your presentation that I saw, when you were in Chicago, that you had some funny slides.
Dr. Edelman: You know what, you ought to come to a new one, because I got some new material. I was going to say one other thing. I’m a big believer that humor leads to information retention, which as you suggested that’s a good talk if you can remember something. We all remember our undergraduate, graduate training, nothing worse than a boring lecturer. You don’t remember a gosh darn thing.
Steve Freed: Let me ask you a question. This is always my favorite question. If you don’t want to answer, you don’t have to answer. That is, you leave here, you go downstairs to the display room and they’re going to be offering free A1C tests and they stick your finger and get a drop of blood and they give you a result and it’s accurate and that little piece of paper has a number on it. It doesn’t say below 7, it doesn’t say between 5 and 8, there’s a number with a decimal place. I call it the quality of life number because that number really, there’s other factors, that number really determines pretty much when you’re going to die and what kind of life you’re going to have. If you could have number that you wanted on that piece of paper, regardless, forgetting about diabetes, if you could have any number that you want, what number would you want that to be?
Dr. Edelman: For the A1C. I would say low 7s. 7.2, 7.3
Steve Freed: When you say low 7s, that’s still diabetes?
Dr. Edelman: You didn’t say that someone cured my diabetes.
Steve Freed: I’m not talking about you personally with your diabetes. I’m saying forget about that, regardless of that. You’re just someone that gets a piece of paper, you don’t have diabetes, what would you like that number to be?
Dr. Edelman: Low 5s. Now if you’re someone that has diabetes, if you take away all the reasons why we have to individualize it, then I’m thinking somewhere below 7.5 is a very safe place for most people. I think the AACE says you got to get below 6.5, I don’t believe that. There’s a lot of good data to show that, if you can get in the low 7s, that’s a very safe range. If you’re taking diabetes out of it, yeah, average blood sugar 120, that’s like 6.
Steve Freed: So, for a patient that comes to you is a type 2, not a type 1, what do you try to get to, what kind of level do you try to get to?
Dr. Edelman: For most people, less than 7.5, if I can get below 7 with no hypo, I have no problem with that. I do think that less than 7.5 is a good first start and then if you have comorbidities, I’m really happy less than 8. Someone who’s 90 years old, no evidence of any complications at all, because we know that high glucose leads to microvascular complications, which take 5 to 10 years to develop. I’m looking at cardiovascular risk reduction for sure.
Steve Freed: What about the kidneys? Do you see a lot of patients that have kidney issues?
Dr. Edelman: Yep, that’s blood pressure. If your A1C is below 7.5, you’re not doing yourself a disservice.
Steve Freed: So, you feel comfortable with that for most of your patients.
Dr. Edelman: Put it this way, I like to get them to 7 or below. If it’s going to cost you any side effects, too much hypo.
Steve Freed: Without causing hypos.
Dr. Edelman: I’d like to get them down as low as they can go. Yeah, for sure, but I think I’m a realist, Steve, I see people, it’s just not that easy. Easier said than done to say less than 6.5. AACE guidelines just don’t make any sense to me, they’re just not practical, they’re not realistic.
Steve Freed: As far as, when it comes to type 2 diabetes, most people are overweight, a few pounds whatever the case.
Dr. Edelman: A few pounds, who are you kidding?
Steve Freed: What I’m saying is that, you have diabetes educators on staff, dietitians on staff. I’ve tried to figure out what percentage is the food that we put in our bodies and what percentage is physical activity. I always thought it was equal, but I’m coming to the realization that it’s what you put in your body that’s more important.
Dr. Edelman: 90%. When people try to exercise to lose weight, it never works. But, I’m a firm believer that exercise in addition to caloric restriction is just such a good combo. Getting people to do it over the long term consistently is tough. You’ve got to pick things that you like to do. I could tell you about my mother, she’s 98 years and she started walking 5 miles a day when she was 60 and now we don’t know where she is. A joke. Times up, Steve.
Steve Freed: I want to thank you for your time. I really appreciate it.