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Robert Rapaport Transcript

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Steve:  This is Steve Freed with Diabetes in Control.  We are here at the AACE 2017 meeting in Austin, TX.  We have with us a really special guest, an expert in pediatric diabetes, who is a professor.  We can start by you telling us a little about your practice, and what you do, and where you do it?

Dr. Rapaport:  I am the chief of pediatric endocrinology and diabetes section at the Icahn School of Medicine at Mount Sinai. This is a division of the pediatric endocrinology and diabetes, so we have a triple mission of doing clinical care, doing research, and doing education.  We have a fellowship program for training in endocrinology and diabetes.  We see patients with diabetes and endocrine disorders, and we try to do a little bit of research as well.

Steve:  You are here [at the AACE meeting], and you are sharing a couple of presentations.  The title of one is, The Transition Process: A Key to Best Adjuvant Care.  Maybe you can start of by describing to us the transition from what to what?

Dr. Rapaport:  There are multiple areas of transition. Being at AACE, most of the attendees are adult endocrinologists and diabetes specialists. When children age out of our age group of comfort, we do want to have a place for these individuals to continue their care. That is what the transition program is all about.  When they become emerging adults, the idea would be to have them go from a pediatric practice to the adult practice.  The ways of doing that are the core to having continuity of care and assuring excellence in care.  There are ADA guidelines on the transition that have been published for youth with diabetes, focusing mostly on type 1 diabetes.  Over the last several years, maybe 10 to 15 years, we’ve seen an increased number of youth with type 2 diabetes, and that’s why I thought it would be appropriate to have an individual such as Dr. Brink from Boston talk about transition in type 2 diabetes.  While criteria for transition are mostly focusing on type 1 patients, there is a positive data about type 2 individuals.  While there is a huge increase in an epidemic of obesity, and there is an increase in type 2 diabetes in youth, I don’t think it’s quite of such of epidemic proportions.  Still, we see a lot more individuals with type 2 diabetes than we have previously seen.  It also depends on the ethnic background of the individual you see.  For example, in African Americans, Native Americans, Asians, and Pacific Islanders see a lot more of type 2 diabetes.  Overall, if you look at all youth with diabetes, still the majority have the type 1 diabetes.  Type 2 diabetes is interesting because there is only one approved medication for it, namely metformin.  There are numerous companies trying to do studies now to look for other agents to participate in clinical trials for other agents that may help with care for type 2 individuals, including injectable medications. Unfortunately, it’s very difficult to recruit for some of these studies, but I think it’s very valuable, worthwhile endeavor to do.

Steve: At what age do you feel comfortable transferring them over to an adult specialist?

Dr. Rapaport:  When I turn 50, I’ll try to transfer them then. [laughter] The age of transition varies tremendously, somewhere between 18 and 21, but most of our patients with diabetes we do take them through college and arrange for transition after that.  There is an impetus at  some pediatric practices to treat some young adults, and Dr. Brink actually mentioned that in his practice as long as they are doing it in conjunction with other healthcare providers, they do see young adults with diabetes to assure a continuity of care.  Certainly by the time of their mid-twenties, I think it is reasonable to transition them to an adult care practice.

Steve:  When you see a pediatric patient, you are not really dealing with that patient on a face-to-face basis, you’re really dealing with the parents.

Dr. Rapaport:  We are dealing with a whole host of things and the child is at the center of this care package.  But, certainly, the parents, other healthcare providers, the school system are all involved in the care of a child with diabetes. You asked about transition from what to what, but, in fact, there are multiple areas of transition.  When people say transitions, they usually mean transition from the pediatric to adult care.  In fact there’s a transition if a child develops diabetes, we have a child in the hospital right now who is less than a year of age, so there will be a transition for them when a child becomes 3 or 4 and starts going through school.  There will be a transition when he is going to start 1st grade.  There will be transition when this child enters puberty.  Ultimately, there will be a transition to an adult practice.  There are multiple areas of transition that most people lose in translation when they talk about transition.  It is really an ongoing course of transition.

Steve: I would imagine your youngest patient is a day old or not even a day old…

Dr. Rapaport: Not even a year old. Having diabetes at one day old is a different kind of diabetes. That’s very unusual. 

Steve:  OK. So at a year old, and you also have patients that are older.  What’s the oldest patient that you work with?

Dr. Rapaport:  Well, [laughter] it’s not fair but, it’s a patient who is well beyond what is regarded as the pediatric age.

Steve:  So they just can’t bear to leave you?

Dr. Rapaport:  There are few patients who do get attached, not only to us, but to our way of doing things.  Occasionally, we transition patients to the adult healthcare team and sometimes they come back.  That is why a successful transition needs a lot of work, a lot of preparation, and a lot of collaboration between all the members of the healthcare team, both on the pediatric and adult side.  And special transition units should be constructed.

Steve:  I would imagine that dealing with a patient who is a teenager, or in their 20s and 30s where you can sit and talk to them about hypoglycemia and things they are doing that can affect their blood sugars.  You are dealing with the child where there is ups and downs, highs and lows. Their activities you can’t control. Foods they eat, you can’t control.  You have a much more difficult task, I would imagine, than an adult type 1, even adult type 2.

Dr. Rapaport:  I never underestimate the complexity of taking care of diabetes.  And the complexity falls mostly to the patient and his/her family.  So, I never underestimate the complexity and occasionally the difficulty in doing that. Multiple issues come into play.  The idea of being “in control,” as I think your program is called, is somewhat misleading because it’s a relative degree of control.  We want our patients and their families to be empowered, to be able to exert as much control as possible. We will be there at the phone call’s notice, at an email or text notice, but we want to empower the patients and their families to be able to take care of their condition. Having said that, there are multiple things that interfere with that, including diet, exercise, psychosocial events, all kinds of other events that are a part of just day-to-day living.  One needs to recognize that and be adaptable and flexible to all of those things to achieve optimal control.

Steve:  How long have you been in practice?

Dr. Rapaport:  About 2 hours. [laughter] More than 30 years.

Steve:  When you started practicing, we only had handful of insulins, we had maybe one oral drug.

Dr. Rapaport:  You mentioned oral drugs.  There is still one oral drug that is approved for pediatrics and that is metformin.  With the advent of more studies, there may be more medications that will be available.  There has been a huge change over the last few years, not [only] in terms of therapy, but also in terms of monitoring.  That is really one of the major advances.  When my teachers started teaching me about diabetes, we talked about doing 24-hour urine tests, and now there is finger-stick testing, now hemoglobin A1cs, other indicators of control, and measuring blood glucose level not just a few times a day, but using a continuous glucose monitor.  Having the monitor talk to another device, like a pump.  And obviously, the next phase is the artificial pancreas about which a lot has been written in the last several years.

Steve:  What are your feelings about the MiniMed 670G that came out just recently when it’s used for children?

Dr. Rapaport:  I think it is a very interesting advance, and probably very hopeful advance.  But, I don’t think there is yet enough of experience with it to be able to tell you.  But, it is a major advance in the field.

Steve:  CGMS has come a long way, I remember the first glucowatch, I’m sure you do also.

Dr. Rapaport:  The glucowatch had a checkered career, it wasn’t used very much, it wasn’t a such good product.  But, the idea was there, and I think its next grandchild is this CGM.  CGM is very important.  You briefly mentioned taking care of adolescents, and certainly CGM sounds like a no-brainer.  Yet, many adolescents either wear it for a short time then they stop wearing it, or they don’t want to wear it at all.  Those are areas we need to look into.  Why is it? What are the barriers to them using all the technology that’s out there to do that?

Steve:  I would imagine that you would prefer to have most of your patients on the CGMs because we have seen a better control and they know if they are getting low.

Dr. Rapaport:  What we prefer and what happens in the real life are two different things, but sure.  So, when I see a patient who doesn’t want to be either on an insulin pump or CGM, I tell them, “Look, it is up to you whether you want to be on it or not. Nobody can force you to do things. All I want you to do is to be aware of what’s out there and then you can make a decision what you want to utilize and when.”  And I think that’s very mportant, educating them about what is out there.  Whether or not they will use it, whether or not they will use it for a short time, it’s a secondary question. But, the education of the patient and their family is absolutely crucial. That’s why teamwork with nurse educators, nutritionists, social workers, psychologists are all very important pieces of this healthcare team.

Steve:  Studies have shown that the use of a CGMS has basically, not so much improved the A1cs, but it’s really reduced the amount of hypoglycemia.  Do you find that in your practice?

Dr. Rapaport:  It probably has and it’s certainly beneficial to use it; the more information we get – it’s better.  Concerns that some patients have and some parents have, quite justifiably, is unrecognized hypoglycemia, and CGM certainly helps with that.  Yes, it is a marked improvement to have that.

Steve:  Two years from today when you are at the AACE, and you want to go home so you call a cab.  The cab pulls up and there is no driver in it, it’s a driverless cab.  Are you going to get in that cab?

Dr. Rapaport:  As long as the car is wearing a CGM I will be happy to get in it.

Steve:  The technology has really changed the way we practice medicine.  Google and Dexcom are working on a Band-Aid, CGM, non-invasive.

Dr. Rapaport:  All kinds of things are coming down the pike, which will be really cool along with virtual reality, and by then they will probably have virtual physicians as well.

Steve:  Are you familiar at all with the smart insulins that might be coming down the pike?

Dr. Rapaport:  I am somewhat familiar with them.  Huge advances, better insulins, newer insulins, faster insulins, longer-acting insulin, less peak longer-acting insulins, all of these are very important.  I think, the technology is advancing tremendously, what needs to advance along with it is the understanding as to what makes the patient utilize these things and utilize them to their benefit.

Steve:  Have you ever used in your practice inhaled insulin for a pediatric [patient]?

Dr. Rapaport:  No, we actually never did.  I was a part of the team that evaluated one of the brands of inhaled insulin which did not go very far.  Other forms of insulin would be tremendously important; having non-injectable insulin as a large category is very important.  Non-injectable could be inhaled, which I’m not sure is going all that far, but also topical, buccal insulin, all these things are very important future advances.

Steve:  Assuming that your audience are family practitioners that deal with diabetes, not so much endocrinologists, what would you like to say to them as far as getting a new type 1 patient being transitioned from pediatrician [to adult practice]?

Dr. Rapaport:  For accuracy, the topic was type 2 in transition, but any child with diabetes who becomes of a certain age as an emerging adult needs to be transitioned to an adult healthcare team.  So, what we need to encourage is the collaboration and intermingling of the two camps to have transfer of information, to have open-ended discussions with the patient and the family, to have the family and the patient know the expectations, especially the young adult, have expectations that this will be slightly different that you’re used to in the pediatric practice, and what the expectations are. Transfer of records is crucial.  We want to make sure that whoever will take on the care of this individual is aware of all the previous health issues that the person has.

Steve:  I know each person is an individual and it is different.  But, on average where would you like to see your patients A1C in the pediatrics without hypoglycemia?

Dr. Rapaport:  It is an interesting question.  We want to see HbA1c as close to normal as possible while avoiding hypoglycemia.  As you know there are studies coming out that are saying that A1c is not probably the sole arbiter of good control.  We need to start now looking at fluctuations at blood glucose levels, highs and lows, the A1c is just an average thereof.

Steve:  I want to thank you for your time.  Enjoy the rest of your stay here.