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Keith Campbell Transcript

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Steve Freed: This is Steve Freed with Diabetes in Control. We are here at the American Diabetes Association 77th scientific session. I did not attend to all 77, but I know the person I am talking to got to many of them.

Keith Campbell: 54.

Steve Freed: 54. It’s Keith Campbell. Maybe, Keith, if people don’t know who you are that are watching this, Keith is a pharmacist and a professor at the Washington State University. In fact, his Lifetime Achievement Award is going to be given to him this fall. They’re actually going to name a laboratory after him. I don’t know what it takes to get a laboratory named after you. I congratulate you.

Keith Campbell: Thank you so much, Steve! Did you say “laboratory” or “lavatory,” because they made us put a little plaque on the bathroom stalls that says, “Think of Keith.” (laughter)

Steve Freed: They should have named a building after you. So maybe you can start off by telling us a little bit about yourself, and what you do – or what you did – with your life.

Keith Campbell: I am a distinguished professor emeritus in diabetes care and pharmacotherapy. I was a professor for 47 years. I had diabetes 68 years and I’ve been on the insulin pump for 38 years, 4 months, 9 days and 6 hours. Almost to the minute. I got involved very early with the physician that had newly come to the Spokane area and he believed in tight control and in diabetes education, and letting the patient take charge of their diabetes. And he was one of the few in the country at that time that did that. So, I ended up having a really good mentor. Years later, when he died, they asked me to do the eulogy for him. We became close friends and he got me involved with the ADA. Early on I was involved with the Juvenile Diabetes Research Foundation. And I was one of the founding members of the American Association of Diabetes Educators. I’ve done a couple of terms on the board of the American Diabetes Association. I did a lot of continuing education programs, lots of lectures, and written a few articles here and there, and a book with the ADA called Medication for the Treatment of Diabetes. So, it’s really been a fun life and I’m just really glad that I got diabetes. (laughter)

Steve Freed: They don’t give you a Life Achievement Award for nothing. I have to say that I got most of my knowledge from your CE programs. Every program I ever picked up when I was learning has your name on it and I said I got to meet this guy. When I got involved, there weren’t that many pharmacists either, going back 15-18 years. So, my question is how many medical professionals – nurses, pharmacists, dietitians – have you gotten in front of or through your CE programs? How many of those do you think you’ve affected? Can you put a number on it?

Keith Campbell: It is tough to come up with a total number. But one time I tried to figure that out and it’s easily over 40,000 total, but some of them were lectures. Two or three thousand people at a time and talking about the role of the pharmacist and how you get involved caring for people with chronic diseases.

Steve Freed: Well, if you included the people who read your CE programs that you helped educate, now we’re talking at least in the hundreds of thousands.

Keith Campbell: Well, there was one CE program that over 200,000 people completed the first year that it came out so, we get up there in the numbers. But it is not about numbers. It is about people and having them get involved and improve the outcomes of care in people with diabetes.

Steve Freed: You have diabetes. When you started, things were a little bit different. We only had one oral drug for diabetes at that time. So, you’ve been around longer than most of people I have been talking to. You have seen a lot of changes. What has excited you the most…If you have to put 5 things that have had the most major changes in the field of diabetes, what would those things be?

Keith Campbell: I’d have to start with the development of insulins and cleaner, better insulins that work more physiologically. And a close second is self-monitoring blood glucose and I actually started in 1978. Ames actually brought out their first glucometer in 1979 and that really made a world of difference, in terms of knowing where your blood sugars were, what affected them getting high or getting low and that made it a lot easier to manage. When I come to a meeting like this and we see all of the products that are coming out as continuous glucose monitors, it’s pretty phenomenal. I’m really excited today, but some of the products that I saw that are smaller and easier to insert, less calibration and last a longer period of time. With the insulin pump, it makes it pretty easier if you know where you are, how much insulin to take, and what to do if your blood sugars are getting too low. We actually have one that is being promoted a lot here – Medtronic 670, that is kind of a smart pump along with their continuous glucose monitor that slows your insulin release if your blood sugars are going down, and increases if it is going up. They call it a closed loop type of system. A lot of excitement about that and who it is for. I think we’re going to get it better for blood glucose monitoring that more type two patients. I liked the Libre system when it comes out for patients. You put it on your arm. You can swipe it and it will tell you your blood sugar whenever you want it. It lasts for 14 days and I’m pretty excited that that’s going to really help promote more people with diabetes to monitor more often. There’s two things. Sorry, I am so verbose. The third thing is the A1C test, even though it’s not perfect, it gave people some numbers and the ADA did, you know, know your cholesterol, know your blood pressure and know your glucose numbers. The A1C number really helps people see if they’re taking pretty good care of themselves over a period of time and I think that’s had a lot of influence. Nutrition issues are something that have been so crazy my entire life. Here’s what you can eat and here’s what you can’t eat, and then came to the conclusion that if you know your blood sugar levels and you think and you eat healthy, avoid whites, avoid salt, avoid refined sugar and refined flour, and eat more fiber. Another area that I think is going to explode is the microbiome and what happens to the bacteria and viruses and other critters that are in our gut. I think that’s going to just explode in the next few years. There’s always lots going on with diabetes. The last and very important thing is education. Identifying patients early, motivating them to take care of themselves and then educating them in a way where they take charge of their own condition. Lot of things for kids…it was pretty nasty. I started on a 22-gauge, 1-inch needle and only injected it halfway and they were a little on the painful side. The lancets have gotten smaller, so it’s much easier to manage diabetes if you get into the healthcare system and I’m kind of concerned about that because a lot of people don’t always get into it and they don’t always get educated or they don’t follow the standards of care, so they could get much better outcomes and especially the prediabetes where we’ve got millions of them that are going to get it. We can identify them and get them in for exercise and better nutrition and on some medications. We could really improve the outcomes of care.

Steve Freed: You’ve deal with a lot of drug company. What do you know of or what’s in the pipeline? You mentioned a few things that is probably going to be out very shortly, but looking into the future, diabetes has changed dramatically because of the new drugs and new technologies. It took us 50 years to go from one drug to two drugs. Now it happens every 6 weeks. What do you see in the future, from your history and looking into these things, because you have a huge interest in diabetes. What do you see coming down the pike?

Keith Campbell: I think we’re going to better studies and we’re going to market the studies better. One of the statistics it’s always kind of concern me is that in most medical schools, primary care physicians get 4 hours of lecture on diabetes. So, then they get out to practice and they get a patient with diabetes and they simplify the treatment. They really don’t like putting people on injectables, especially insulin because they can get hypoglycemic and have a wreck, or something like that. Whereas if we really understand how to take care of diabetes, we could avoid a lot of that.  We’re going to see an explosion of apps for your smartphone. We’re going to see better, smarter pumps. We’re going to get smaller devices that can sense your glucose continuously that need less calibration under smaller and easier to insert and talk to your pumps and so on. That whole area, I think is going to explode in a big way. The types of medications we have, 12 to 13 different classes of drugs depending on you count them. The combination of those drugs, either in fix doses or add one to another, whatever, can really help most people with type 2 diabetes get under good control. I think as we get more and more studies, were going to see this fine-tuned and we’re going to see outcomes in terms of your average blood sugars. I started on Jardiance (Empagliflozin), an SGLT2 inhibitor…

Steve Freed: And that’s off label.

Keith Campbell: Yes, but I’ve always believed the physiology of, the pharmacology of how it works is that the big market for the company was to treat type 2 because that’s where most of the patients are, but I think they’re doing studies in type one. But since I’ve been on that I seldom have a blood sugar over 200. What’s interesting is I hardly ever get below 70 or 60, so it’s really reduce my hypos, which doesn’t necessarily make sense. So, I read a lot about it, I keep hydrated. If anything happens to me in terms of a trauma, infection or anything like that, ysou really watch your blood sugars closer to avoid any possible complications. I think you’re going to see more drugs being brought out that treat type 1 diabetes in addition to insulin and I think the SGLT2 are going to be good. Novo has some interesting research with an oral GLP-1 agonist (semaglutide). I’m pretty excited about that and the reason I am is that when it’s brought out orally and if It has the impact it looks like it might have, they’re going to just blow away the GLP-1 market in my opinion.

Steve Freed: When you first started, you were educating medical professionals because you were a professor. You talked about diabetes, which is your passion. It was pretty straightforward. You had one drug, which was sulfonylureas as I mentioned before, but now we have over, probably if you figured it out if you include insulin possible combinations, it’s probably over a million possible combinations. So, what do you teach or what did you teach towards the end? How do you determine which drug or which combination of drugs…You can go through trial through a person’s lifetime and changing it every 30 to 60 days before you find the right one. What is the best way to determine if it’s a combination type of thing?

Keith Campbell: Well, in the first edition of Medications for the Treatment of Diabetes, I had a chapter on an algorithm and what was fun about that, because I didn’t see that anyone else was working on algorithms, is here’s the things you have to know about the patient before you decide what you’re going to use. There’s probably 15 or more things you need to know about the patient: what does their insurance allow is a big barrier and if they don’t have insurance what can they afford; what’s their kidney function and what’s their liver function; what are their fat levels in their blood; what’s their blood pressure; what medications have they tried before that worked or didn’t work; and in what doses. When you go through all of that, you can then individualize the treatment for each patient. About 10 years ago, the ADA started promoting individualization because there’s no two patients exactly alike. I thought that was a tremendous movement to move in that direction and when you do that you can come down with most type 2 patients. I’m a huge fan of Ralph DeFronzo and so you know some metformin, SGLT-2 inhibitor, and maybe a GLP-1 agonist or a DPP-4 inhibitor, depending on what the patients are willing to do. Are they monitoring and have they take charge of their own diabetes and have they been educated? So, it’s really frustrating, if you are health care provider, when you see the new insulin and then you see the combination of the new insulin with other things, then the combination with those and what studies have been out there. The last 5 years I get calls all the time. “What do we do here?” This is overwhelming as to what’s going on and you said you could have a million different choices as to what to do. Some of the companies do a phenomenal job with educational materials for patients. I know some of the Novo Nordisk educators and then you have medical science liaisons and they helped train the expert, you know, the endocrinologist and they help get the word out as to how they’re treating, so if you really look into the literature and you pay attention and there’s a site that you might want to know about. It’s called website called Diabetes in Control and I’m not being funny here. It is a phenomenal website. I’m so proud of you and David and what you have done there. I hear from people all the time. They go to that. They’re on twice a week and they have all kinds of things. It really help motivate people and give them some confidence to feel up to date and to know what’s happening and what new things are coming down the pike and I like the ADA site and I like the AADE’s site. There’s some really good information out there. As everyone know, we Google whatever it is. So, the key is to having the patient be excited about taking care of their diabetes and there’s a lot of people in denial, there’s a lot of people that are angry, there’s ways to confront the patient in a positive way and get them to overcome them.

Steve Freed: I have to say you’re in good company. We have two of your favorite people were here yesterday. Ralph DeFronzo was here. Steve Edelman was here. So, you are in good company. We only invited the smartest people and you have been here a few times.

Steve Freed: If you had just a couple of things that you would like to tell medical professionals to provide better care in all your teachings and in your experience, what information would you want them to know? I was told that the sign of a good presenter – and you’ve done umpteen number of presentations – the sign of a good presenter is when you provide information that the audience takes home and utilizes. You can have a beautiful presentation with 200 slides in color and people walk out the door and they can’t remember. That was a waste of that person’s time, so what would you like medical professionals to take away from your presentation?

Keith Campbell: I have seen, in the years I’ve been around medical schools and colleges of pharmacy and so on, a change in emphasis. The change I’m seeing is to train people to be empathetic to care enough. Let them be individualized. One of the best talks I’ve heard from my dear friend Dr. Richard Aguilar and he focused it on caring for patients that speak Spanish. And the steps that he went through as to how you should talk to the patient when they’re in your office and care for them and show them respect and listen to them and have them help you make the decision. This is the movement that I talked about that the ADA is doing – individualized therapy, get the patient involved. That it is so important that the healthcare system does that, yet the healthcare system, in my opinion, is a bit messed up because the average family medicine doctor, if they spend more than 6-8 minutes with the patient, they’re getting behind and so it’s come in, what’s the matter, how you feeling…so the emphasis is on pain and cough and cold and things like that, where the chronic diseases need more effort. So, luckily we have got nurses, dietitians, pharmacists, physician assistants and nurse practitioners that are developing huge practices where they sit down and go through the details as to how do you program a pump, how do you insert the infusion set and so on. That, to me, that movement is there, but we still have a lot of people that are seeing healthcare providers that are really worried about teaching them to go on insulin. The average A1C level has been going down, which is just phenomenal news, but the average is still much higher than it should be. It’s a great time to kind of watch these changes. And through web activities like yours, that really is important because if you looked at this meeting and you’re walking down the hallway. You see a hundred people going like this [looking at smartphone] and 95 of them are running into each other.

Steve Freed: You’ve had type 1 for a number of years. Obviously, you pay special attention to studies that show possible cures for diabetes. We heard there are cures for I don’t know how many years.

Keith Campbell: 65 years, I have a file that is literally 2 feet thick where the title says something about “cure for type 1 diabetes will be here,” on those days they called it juvenile diabetes, “within 5 years.”

Steve Freed: So, where do you think that is now? Because our knowledge has grown dramatically and I’ve seen so many different studies that show possible cures. All of them have failed so far.

Keith Campbell: Once the damage has occurred to the beta cells, I don’t know if we’re going to have a cure in what people think the cure really is, but if you confront you have type 1 diabetes and you learn about it and are motivated to take care of it, you can do pretty well. I’m at 68 years and I’m hoping to go too much longer at least. Been a long time. I think there are going to be some breakthroughs that may be help prevent type 1 and then really make it much easier to live with. That’s already happened in my lifetime. It’s so much simpler.

Steve Freed: Some of the studies say that you didn’t lose all your beta cells. They’re just suspended and they’re looking for ways to bring it back to life. That could be a possible cure. All you have to do is keep the bucket half full and repeat it over time.

Keith Campbell: I do think that whole area of Immunology and things… If I were starting over again, I would go into Immunology and Microbiome and a few other things.

Steve Freed: The one thing I have said many times here is that people that are involved in diabetes, like you, are very passionate about what they do and most of them have diabetes. Everybody that’s developing new products, they all have diabetes because they know what it’s like and they are trying to make it easier for the patient. Just like you, you decided education was the way to go and you became very passionate about it, so I have to say thank you and you deserve the award. I’d give you a Lifetime Achievement Award, but you’re just going to have to settle for dinner. (Laughter)