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Steve: We are here at the AACE meeting 2017 in Austin Texas and with us is a special guest Dr Elizabeth Buschur. She is an endocrinologist and an assistant professor at The Ohio state University in Columbus Ohio. Maybe we can start with you telling us a little bit about your practice.
Dr. Buschur: At The Ohio State University, I have a couple of specialized clinics. We have an endocrine disorders and pregnancy clinic as well as a type 1 diabetes transition clinic at Nationwide Children’s Hospital.
Steve: Do you deal a lot with gestational diabetes?
Dr. Buschur: I deal a lot with pre-existing diabetes in pregnancy. Some gestational diabetes that is diagnosed early and requires medication, but a lot of our pre-existing diabetes patients.
Steve: What is the title of your talk while you are here?
Dr. Buschur: CGM uss in pregnancies and special situations.
Steve: If we look at different populations, which populations do you feel will best utilize CGMs?
Dr. Buschur: The benefit of CGM could be for multiple patient populations especially our pregnant patients during pregnancies as well as the preconception period. CGM is very beneficial to help achieve those tight glycemic targets with minimization of hypoglycemia. Postpartum, there is huge changes in insulin sensitivity and requirements so that it can be very helpful.
Steve: For someone with pre-diabetes, will insurance companies allow them to reimburse for CGM?
Dr. Buschur: I am not an insurance expert, but I think not. I think with prediabetes and even with gestational diabetes there have been some research studies that have looked at CGMs but I don’t think that CGMs I don’t think insurance companies are reimbursing yet.
Steve: How beneficial is it to use the CGM for patients that want to become pregnant, that have diabetes in their family, that are a few pounds overweight, and have a A1c of 5.8?
Dr. Buschur: I think that is very beneficial because those patients would meet criteria to be tested early during pregnancy if they did get pregnant to be tested for gestational diabetes or even pre-diabetes; like at the first prenatal visit. I do think that is very important.
Steve: For people that have diabetes, especially that are on insulin, they know what to do when they see the numbers. For a person that is prediabetic or has diabetes in their family, are a few pounds overweight, most likely will become diabetic, what do they do with the information?
Dr. Buschur: It can provide motivation, so you can see; “Oh, I had that for lunch and this is the result in terms of the numbers and then I went for a 45 minutes’ walk and ‘wow’, look how steady things have been and how good things look. It can be very good motivation. You did raise a good point about people with diabetes knowing what to do with those numbers but I would argue that sometimes it can be very overwhelming to see all those numbers. People with diabetes aren’t checking 20, 30 or 40 minutes after their meal and see those spikes that are a little bit frightening.
Steve: Have you found that people with diabetes, especially type 1 but even type 2, don’t want diabetes to be their life; and adding a CGM makes it like every moment diabetes affects your life because every moment you are looking and checking it on a regular basis and before CGM, you checked your blood sugar a couple times a day and now it becomes a part of your life every minute of the day that you are a diabetic and you are reminded. How do you deal with that with patients?
Dr. Buschur: I think that is very hard especially, I see a lot of adolescents and young adult patients so that they really don’t want to be reminded extra times a day and even don’t want that extra site; even maybe they have a pump or they are on injections but they don’t really want an extra site for that CGM. But I think the patients that do very well except for the fact that it is part of their life and figure out how to streamline that. Some of the patients are even getting their CGM readings on their apple watch and they can just glance at it and make sure that they are doing okay. It is definitely a balance.
Steve: I think that for patients that want to become pregnant, that they are happy to use it because they want a healthy child and they are willing and are motivated and they are going to do whatever is necessary to get their blood sugars down. So, they are already 80% there. They have very good questions for you; “What does this mean? ……What should I be looking for?” They are very concerned obviously for very different reasons. So, I would think that dealing with a person that would not become pregnant or gestational; for a lot of these patients; “I’ve got a lot of these already, I wear it for a week and then I don’t want to see it again.” Have you come in contact with that?
Dr. Buschur: I have. Some offices do. Our clinic owns a few and several other clinics it’s a popular thing to do. So, you can have a patient wearing a clinic owned CGM for a week a couple times a year and that is reimbursed by insurance and is very helpful. So, for the patients that are really overwhelmed by the amount of data or don’t want to wear an additional site all the time, it can provide huge benefits in seeing the trends of their glucoses.
Steve: So two years from today, you come to the AACE meeting, you are going to the airport, you call a cab and a car pulls up and there is no driver in it. My question is when it comes to technology, nothing is 100%. There are always problems whether it is an insulin pump or driver of this car. First of all, would you get in that car and let the car drive you to the airport?
Dr. Buschur: I don’t know about that. You can go first.
Steve: I haven’t found anyone that is willing to go in that car yet. What are some of the disadvantages of CGM?
Dr. Buschur: There are some disadvantages. One you mentioned an additional site. So, just real estate in terms of where to do it. You also brought up having a constant reminder of what the glucose is; that can be overwhelming. Also, patients need to be trained, I think some basic training on how to respond to those values. If it is after 30 minutes after their huge carbohydrate load, should they get more insulin if they are seeing the numbers in the 250s or is that to be expected? Some training on what to do with those values is needed. There are also accuracy issues, but that has been improving over the past 10 to 15 years. So, it doesn’t measure blood glucose. It is measuring interstitial glucose and there is some lag time as well especially with rapid rates of change; so for instance, with exercise or rapidly changing glucoses.
Steve: So, obviously you have to interpret the results and you can talk for hours when you look at the results for example results for two weeks and they have a food plan that they have written out. How do you interpolate that? Do you sit down with them and go through every single meal? What do you do that preserves your time and you can get the results that you want using the information to interpret?
Dr. Buschur: That’s a great question. It can be overwhelming even for the clinician to know what to focus on. Usually I will try to find a couple of key areas to focus; maybe even looking at their post prandial glucose in one instance then their fasting glucoses and try to see the pattern and ask them questions like…. “Are you possibly snacking and missing boluses or is this rise physiologic?” That will mean changing insulin dosing. It’s a good question.
Steve: If you look at the report and you pick the areas where they are having issues and deal with those because where its normal there’s not much to talk about.
Dr. Buschur: It’s always nice to point out where things are working and where patients are doing well to keep the motivation going. Usually most of the reports have a patient-focused area and a physician-focused area so that patient-focused segment of the report might have just what the target glucose is as well as what percentage is in that range, what percentage is low and what percentage of the day is high. Also, they will have aggregate data of the two-week average on a graph instead of looking each day individually which can be cumbersome with the patient. It is helpful to say over these two weeks it looks like after dinner really is the troublesome time, what do you think is going on there? What do we do to fix that?
Steve: I can remember when we started to use computers and download blood glucose meters. I was working with Abbot at the time and this was when laptops first came out and they were expensive. Abbot gave me a laptop and I would download blood glucose monitors. I generated these beautiful 30page reports in 12 different colors, pie charts, graph charts and blood sugars from Mondays through Wednesdays, and Tuesdays through Saturdays. It was beautiful. I am a pharmacist and the doctor came to the pharmacy. I jumped over the counter and had this reports in a leather binder and showed them to the doctor. He looked at me and asked; “What! Are you, nuts? If you want to send me a report, do it on one page and give me a 2-sentence summary and I will look at it.” You are dealing with a lot of information and you have to consider what you are going to use to talk to the patient about because you can probably talk a lot with all this information. How do you determine what you are going to talk about with that patient?
Dr. Buschur: So, that’s a good question as well. I try to look at the overall average and see if there is a trend in terms of something that we can focus on rather than focusing, “Hey what happened Tuesday? You went up to 400” or 300 or something like. If it was an outlier, I try not to focus on that, but obviously it needs to be addressed somewhat, but focus really on the key areas that you think you can make a difference. And a lot of times the patient will be able to say; “You know, on Tuesdays I snack after dinner.” Or when they actually see the results of that, they can actually be able to pinpoint what they think is the cause.
Steve: What is the most useful purpose of using a CGM for pregnant patients? Studies have shown… in that we’re seeing not so much improvement of blood sugars, but we are seeing a reduction in hypoglycemia, which is the major factor in CGM and obviously that’s something that’s good, but why do you think we haven’t seen an improvement, per se, in HbA1c values as much as we thought we would see?
Dr. Buschur: That’s a good question. I think some of it has to do with newer or more rapid-acting insulins that may be on the horizon here. So there is some timing of bolus delivery to match a meal and things like that, that glucoses do rise with a normal diet that has carbohydrates at a meal, but I think the trends of hypoglycemia reduction are not quite there. But if you really talk to the patients, they do tell you, “You know, I’m catching my blood sugar going up in the 200s rather than it reaching very, very high values.” Especially some of those patients that maybe were not checking as frequently as recommended previously. They find the CGM very, very helpful.
Steve: Now, do you deal with young adolescents also?
Dr. Buschur: I do.
Steve: I would think that a CGM would be more important to their parents than it is to them.
Dr. Buschur: That’s true.
Steve: They can live without it but their parents want that information to protect their children. How do you deal with the young adolescent when such situation come up?
Dr. Buschur: It’s a tricky situation for sure. I have had one family in particular that required their child to get a CGM before going off to college but that child was under 18 years old. An then other instances are when parents are begging their college children to share the data with them and the student is saying, “No way.” So if the person is over 18 years old, it’s a hard decision. It’s not my place to force them to share it with whoever.
Steve: Technology changes the way you practice medicine and if you go back 50 years, we had only oral drug for type 2 diabetes and now we have over 2 million combinations, plus we have CGMs which we didn’t have before and I know they are also working on a CGM that’s like a band aid, it’s noninvasive. Google has billions of dollars in Dexcom working on something like that where you just slap it on. There’s no reason to have a blood glucose monitor anymore that you’re checking once a week at 8 o’clock in the morning when you can get something that checks your blood sugars. So technology is really changing the way you practice your medicine. Where do you see technology going? I always ask when do you think there’s going to be a cure for type 1? Type 2 is a whole other disease, but for type 1, the research that I’m familiar with, that’s going on today…we’re so close it’s mindboggling.
Dr. Buschur: Those are wonderful questions, for sure. So, I think its a really exciting time to be treating diabetes. There’s so much new technology, like you said and each year, it’s seems like this past year, so many advances. So the FDA approved Dexcom that you can bolus off that value. That’s pretty amazing when for years it was not accurate enough. And now with the new Minimed pump coming out any day now, it’s very, very exciting. But patients will need to be trained, clinicians will need to be trained. I haven’t treated a patient that has a self-adjusting pump before, so it will be interesting, for sure. Those hybrid closed loop systems coming out is just the beginning of really exciting things to come in the next several years.
Steve: When we do drug studies, we don’t include pregnant women. We don’t include infants and children for a lot of different reasons. They do not get the benefit of knowing what an SGL tube might do. How do we overcome those things? What are the only oral drugs that you can use for gestational diabetes or for any pregnancy right now?
Dr. Buschur: Right now, we use metformin and glyburide exclusively. There are concerns about glyburide as well. But it’s a lot of insulin for patients that are not diet controlled.
Steve: You have patients that are borderline and have A1Cs of 5.7 or 6.4 and they want to get pregnant. The first thing you do is physical activity and nutrition and then work from that. How much time do you usually give them? They come to you, they want to have a child, they are prediabetes, the doctor referred them to you. What’s the time frame before you even consider putting them on insulin if their blood sugars are at that border point?
Dr. Buschur: Usually 3-6 months. But, patients wanting to get pregnant, a great patient population, they are very eager, very motivated. If you tell them to come back in three months and try these things, most of them will do that. It’s very impressive.
Steve: Let’s assume that your presentation, you are talking not to endocrinologists but you’re talking to family practitioners, nurses, pharmacists, and CDE specialists in diabetes care who are very knowledgeable, what do you want them to take away from your presentation?
Dr. Buschur: I think seeing the benefits of CGM use, so in a variety of patient populations, so like you alluded to, it can be used for prediabetes, although not yet approved. I think for preconception patients or transitioning young adults as well as any of our patients with complications of diabetes, especially nephropathy, which changes insulin requirements, any patients that are changing therapy modalities, initiation of an insulin pump, for instance, it would be very helpful to have that extra data.
Steve: I always felt that if I can invent a pill that would give you pain every time you had a hot fudge sundae, that you wouldn’t eat the hot fudge sundae. CGM is almost kind of like that because you can actually see when you eat the hot fudge sundae does, and if you really understand what the blood sugars are doing, and that you increase your risk for cardiovascular disease, maybe you can change your diet. I am a firm believer that diet is 75% what is causing the obesity epidemic and physical activity is a whole other topic. I want to thank you for your time and technology in two years is going to completely change the way you practice your medicine. It really is a very exciting time.
Dr. Buschur: Thank you. It was a privilege.