In this Exclusive Interview transcript, Richard Bergenstal talks with Diabetes in Control Publisher Steve Freed during the AACE 2018 convention in Boston about emerging automated insulin delivery devices and a dual pathway approach for CGMS and medications. To see this interview in full, click here.
This is Steve Freed. We’re here at AACE in Boston 2018. And we have with us a very special guest, Dr. Richard Bergenstal, whom we’ve interviewed before, but things keep changing so fast, it’s always interesting to talk to him. Maybe you can just give us a very short overview of what you do and where you do it.
Bergenstal: Yeah. Thanks, Steve, for having me. I’m an adult endocrinologist and I’m the Director of the International Diabetes Center in Minneapolis. So, it’s a large diabetes center but built within a multispecialty clinic, so we work closely with endocrine but also with primary care and we do clinical trials. And our goal is just try to see the people with diabetes get the best possible care.
Freed: And you’re presenting here and I think the title was “The Evolution of the Management of Intensive Diabetes Management” and the specific topic is emerging automated insulin delivery devices. So, you’ve been involved way back when the DCCT trials (happened).
Freed: And now, you’re involved in other type of trials. How has, basically, the new way to manage blood sugars using the CGMs made an impact?
Bergenstal: Yeah, I know. It’s a really good question. And for better or for worse, I have seen the whole history here. So, the first 10, 15 years of my career were the DCCT and proving that good control mattered, and the A1C was king. Now, the last 10, 15 years have been sort of saying, “You know there is more than the A1C.” We actually would do much better in managing patients if we looked at their blood sugars. And now, CGM has allowed us to look at their blood sugars on a continual basis, so that’s been a huge — biggest breakthrough, I think, is moving to say, “Let’s really look at the blood sugars. Let’s look at them all day, all night. Let’s look for patterns and let’s adjust accordingly whether you’re adjusting yourself with diet, exercise, injections, or whether you’re now putting the adjustment into the hands of an algorithm and some mathematics.”
Freed: You know, the CGM, it’s really made an impact, especially for type 1s. That is no doubt. The studies have been done. The results are in.
Freed: Cost is not even a question anymore. You know, it makes a huge difference in a person’s quality of life. Let’s look at type 2s for a second. I foresee type 2s using CGMs whether they’re on insulin or not if the insurance companies ever decided to pay for it. Because I’m a firm believer that if a person eats a piece of cherry pie and they look at their blood sugars they’re — it’s only common sense that you’re going to say, “I can’t eat cherry pie anymore.”
Bergenstal: I can’t eat it as often anyway.
Freed: (Laughs) What are your thoughts of using it for an educational purpose for type 2s?
Bergenstal: Well, I think CGMs is rapidly making its way into the type 2 space right now. So, I mentioned that our diabetes center is sort of integrated into a multispecialty clinic. And so, we work closely with primary care and I must tell you, it’s taken a while but they’re now starting to say, “Why aren’t we looking at blood sugars?” They’ve really been in a mindset of A1C as king and they based all their — now they’re saying, “Yeah, I think you’re right. Looking at these glucoses is interesting.” And when we show them a CGM profile, they are amazed that they never had any idea what it was looking like. Now, you go, take it to a patient. And I agree with you. I think lifestyle modification is going to be a big deal in type 2 diabetes. And then, even medication selection. Moving a patient to start insulin or to start another drug and you can say, “Here is why. Look at your picture. And I’m selecting for you or hopefully with you the next medicine to try to smooth this out. Come back and we’ll look at your profile again in a few weeks and we’ll see if we’re achieving our goal.”
Freed: I can foresee with CGM, with intelligence, that if you ate three Big Macs, it would actually tell you, you did a stupid thing.
Freed: And it’ll prevent you from doing things in the future that’s —
Bergenstal: Oh, I think, yeah. The machine learning people, the guide to decision-making people are going to get into the act for sure and say, “Wait, you tried that before. It didn’t work so well,” or, “Here’s what happened.” So, yeah, we’re going to get — this is going to get smarter and smarter. Now, people still have to interact and agree and participate, but at least they can do it from a sense of having actual real data to look at.
Freed: And what do you think is the most exciting thing coming out of the AACE Meeting here? And what do think coming up at the ADA Meeting next month could be the most exciting?
Bergenstal: Well, I think AACE is always a good meeting for — to me, really practical, in the office, we gotta get this done. And so, to me, I’ve heard a lot of really good discussion about logistics. You say CGM is important. How do you get everybody to download and get the data, and get it in front of you, and get it to the EMR and get it usable, and make it work with the workflow? And AACE is really good at that. So, I’ve been impressed that innovations that are coming are actually going to get used more because of meetings like this with AACE.
I also know there was an amazing discussion this morning about regenerating beta cells. And so, at least we can dream into the future to say, “Maybe this closed-loop stuff, as exciting as it is, is a stepping stone to the next breakthrough.” You mentioned ADA coming up, I think there’s going to be some more trials there that are showing the real benefits of utilizing CGM in practice, some in type 2. There are some exciting new insulin therapy studies coming out, even though people are saying, “Oh, insulin is old school now. We have these new drugs that don’t cause hypoglycemia.” There’s going to be some exciting studies (on) the effective use of insulin. So, ADA, some new definitions of some new standards about the estimated A1C maybe being replaced or brought back into the glucose reports. So, anyway I look forward to learning some more things next month.
Freed: So, as an endocrinologist and working with patients over the years —
Freed: — you’ve developed certain tricks and tools that have benefited your patients. Does that make you different than other endocrinologists, or at least you have your own personal set of the way you do things?
Freed: Obviously have been successful, otherwise you wouldn’t still be in practice. So, what are some — can you give us some of those tips, techniques that you can share for other medical professionals?
Bergenstal: Yeah. I mean, a lot of them are sort of cliches or common sense but they’re real. So, the first trick is get a good team. And I’m really a firm believer in the team, so the nurse and nutritionist are just critical, and psychologist, to my practice. They’re not there everyday, every moment but they are critical. Number two is really listening to the patient. We all have a tendency to look at the medical record, make a decision, go in and tell the patient, and you just can’t do it. You’ve got to sit down and have a discussion, and agree on something.
Looking at the data, you know I’m a huge fan of Ambulatory Glucose Profile, a way to display glucose data. If you can put a report in front of a patient that they understand in 30 seconds they can see where they’re high, where they’re low, it just makes all that decision-making and the adherence to the therapy much better. Then, I’ll say one more thing, an occasional phone call after a visit. I know people say I don’t have time, I’m too busy, I’m not paid for it. The times I call a patient back a week later, make a note to say, “Call this patient,” it just works that they say, “Oh, my gosh. One, you cared. Two, yes, I did try that and I was hesitant because of this.” So, little things like that.
Freed: I think that’s huge, like you say calling the patient. If they really think that you care, they’re going to be more careful and just as a reminder that they have to be more active in their own care.
Bergenstal: It makes a difference. You teach self-management but a little support along the way gets people much more engaged.
Freed: With your knowledge of diabetes and with all the trials that you’ve participated in, what are you looking for into the future that could be one of the greater achievements? You know, like we have SGLT2s and DPP4s and we have CGM, all these things have come within the last five or six years. What are you looking for into the future, if you can have your way and have — ?
Bergenstal: Yeah. Well, I think — for me, my future is going to be — I think, actually, first implementing. I think we’ve had those two major breakthroughs. CGM has been a major breakthrough and these drugs for type 2 that are non-hypoglycemic and have cardiovascular benefits. Okay. So, we have two things now. And right now, I’m afraid they’re competing. Oh, no, you can’t — we have to use SGLT, GLP-1s, and we can’t — we don’t need CGM or we can’t use — I think it’s a dual track that we’ve got to get across. The macrovascular diseases are going to need some of these new drugs, so we’ve got to have that pathway. What’s the cardiovascular risk should I use one of these? And then, we need the glucose control pathway for the microvascular. So, to me, my next five years is seeing that primary care sees this dual pathway; cardiovascular, microvascular. Let’s have it all. If we can get that done, we’re going to save a lot of hearts, and eyes, and kidneys.
Freed: Any future studies regarding those issues?
Bergenstal: Well, I think, here’s what I’d love to do. So, to put those together I want to — these cardiovascular outcome trials that are coming hot and heavy still, I don’t know if they’re going to continue forever, but I want to add CGM into those trials, so we can finally say once and for all, “Why does the SGLT2 and the GLP-1, why exactly are they preventing heart disease? Does it have anything to do with glucose variability, hypoglycemia?” So, I’m trying to marry those two. If I can get that done, I think we’ll all learn a lot.
Freed: Well, I want to thank you for your time. We appreciate you stopping by and giving us some great information. And look forward to seeing you at ADA.
Bergenstal: Yeah. Pleasant talking to you, I hope we can talk again.