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Steve: This is Steve Freed with Diabetes in Control and we are here at the American Diabetes Association 77th scientific session 2017 and we are here to present to you some really exciting interviews with some of the top endocrinologists around the world. We are going start off with a special guest, Dr. Stuart Weiss who happens to work very closely with one of our associates who sits on our board, Joy Pape.
Steve: Tell us a little bit about your practice.
Dr. Weiss: I am a clinical endocrinologist in a solo private practice, I have nurse practitioners and nurse educators in my office. I have an academic affiliation with NYU, but as the academic institution… is hiring more and more people, I am less and less involved with academic because they have enough people over there on salary to do the work that I used to do for free.
Steve: One of my first questions is if you are in private practice and not associated with a large corporation, it’s important that you see enough patients to support yourself and your family.
Dr. Weiss: Well, I live in New York City too so seeing enough patients is a huge problem. The overhead for my practice is tremendous relative to other areas in the country where rent isn’t quite as expensive, so I barely make it through. I really do focus on taking care of patients and spending time with them; my office people are always rushing me to get through to the next patient. But I don’t think that it’s the best way to practice especially when you have patients with diabetes who are confused and anxious about their management.
Steve: What makes you special where you can actually have a private practice in this day and age? Why do people come to you? I know it comes from referrals, but why do people refer people to you?
Dr. Weiss: I think people come to me because of the fact that I spend time to listen and because I have a lot of insight into how to make diabetes management easier for patients; how to help them live as normal a life as possible while keeping the diabetes in mind.
Steve: One of my favorite questions I love to ask, endos especially…if you could have any number A1c, any number that you wanted, what would that number be?
Dr. Weiss: Well, the number would be as close to normal as possible. And normal is 4.5 – 5.7 and for anyone with diabetes, I tell them over and over again that this is where they need to be. Not that I expect them to get there because it’s very hard for people to change, it’s hard for people to modify their lifestyle, it’s hard for them to be compliant with their diet and it’s hard for them to always be taking their medications like they are supposed to. So, I don’t necessarily expect everybody to succeed, but I encourage everybody to succeed in getting as normal an A1c as possible – given a couple caveats of course. It’s very important to pay attention to the lipid profile, especially triglycerides in the type 2 diabetic. It’s very important to pay attention to blood pressure and it’s also very important to pay attention to whether or not there is any protein or microalbuminuria. Those things may ride more importantly than A1C alone. We saw from DCCT and many many other trials that blood pressure control is the single most important part of diabetes care.
Steve: I don’t know how long you’ve been in practice, but do you remember when we only had one oral drug for diabetes?
Dr. Weiss: I came in just about the time…. There were only sulfonylureas and at that time the only thing that we really had was diet and exercise but nobody really knew what diet and exercise meant.
Steve: So now we have metformin in ’95, and from ’95 to today, we have all these new classes of drugs…But today there’s over a million possible combinations if you include insulin…How do you determine which drug or combination of drugs that you want to…use?
Dr. Weiss: What I use is the general scheme. The general scheme is the patient comes to me, I have them learn how to use a glucose meter, I have them keep diet and exercise records for a week’s time. Writing down everything they eat and checking their blood sugars as much as I can get them to do, but before and after meals and bedtime. They do that first before I make any assessment about what kind of medications they’ll need. They usually come to me on a medication or two, usually metformin and something else. Very variable. Then when I see how they eat, what they eat I go from there and what their glucose profile is after discussion how they’re eating and what they’re eating and then I make adjustments in their medications. If they’re overweight that’s a consideration, if they have high blood pressure that’s another consideration, Nowadays I feel very comfortable with the SGLT2 class and also the GLP1s on top of metformin. There is a lot of arguments on whether or not metformin should be first line. But I’m not in control of the finances of the whole deal, so I’m using metformin as first line for that reason mostly and then SGLT2s, although I don’t like SGLT2 for the reason that people eat food and then take a pill to allow them to pee out the food that they’ve eaten I think it’s environmentally insane and I think that it’s something that works and I use tons of, but I don’t emotionally like using them.
Steve: So obviously, you favor GLP1’s.
Dr. Weiss: GLP1s are very very good medications, they work very nicely, they mimic what the body does, it addresses an early problem that we’ve ignored for quite a long time and that is the role of glucagon in diabetes management. So, hyper-glucagon is a huge problem in mobilizing sugar from the liver and it does raise blood sugars. I like the DPP4 products used early, early on like newly diagnosed or even prediabetes because they augment the normal physiology that’s lost. A normal person eats – glucagon levels fall, a diabetic eats – glucagon levels rise. In between in prediabetes glucagon levels don’t fall the way they ought to and they even rise more before insulin deficiency is seen.
Steve: I think one of the neat things about the GLp-1’s is that it’s a hormone that our bodies normally produce anyway where all the other drugs, they’re nothing that our bodies desire and have more side effects.
Dr. Weiss: Absolutely, the GLP1’s are great drugs and they’re easy to tolerate. Sometimes there is GI upset with the medication. What I like to do is tell patients that if they get GI upset before they eat, it’s the drug; if they get GI upset after they eat, they’ve eaten too much.
Steve: So let me ask you a question about one of the new drugs that’s probably going to get approved, I would guarantee you it’s going to get approved this year, and that’s Intarcia, I think it’s the 650, they call it. It’s an osmotic device they insert under the skin and it’s a year’s worth of GLP-1 that goes into that. What are your thoughts about something like that?
Dr. Weiss: There’s a couple of products like that in development that are great and the idea of having long-term exposure to GLP-1 seems very, very reasonable. I’m just waiting to see it come out and waiting to see how it works in my hands, but they’re all very promising. The idea of GLP-1 therapy is a great idea. The main thing that we need to do in terms of treating patients with diabetes is be aggressive early when diabetes is first diagnosed along with prediabetes so that we can use non-invasive therapies like DPP-4s that will enhance glycemic control and maybe make it so that the disease doesn’t progress.
Steve: Over your experience, obviously we’re seeing all kinds of new technologies. You wake up one morning and there’s a whole new technology, we have smart insulin pens. We’re talking to the gentleman who developed that. And we have all these apps that cover just about every aspect of diabetes. What have you seen in your practice that has helped you to provide better care for your patients? I now there’s the drug. What about technology?
Dr. Weiss: Technology is amazing now. I’ve been doing CGM since 1998. I had the first device in New York City and have been using it regularly since. I was using it in patient with type 1 diabetes who were taking lente insulin NPH insulin and I saw so much hypoglycemia that it blew me away. I had to adjust my whole thinking about insulin dosing and how to match insulin up to food and the secret to management with insulin is matching the insulin up to food.
Steve: So when it comes to CGM, there’s a couple of different things out there. Which one do you like to use?
Dr. Weiss: Well, I love the Dexcom and I download at least a couple a day and I find it very accurate and a nice tool. Some of the programs that they have come up with in newer software is not as good as I would like it to be. The CareLink for Medtronic is great but the sensor isn’t necessarily as good – maybe the new sensor will be, but I don’t really know at this point in time. I do the Libre quite a lot now, so the Libre is the Abbott, I put it on the back of the arm, the patient wears it for two weeks and they doesn’t see what’s going on. And then we look at their diet records and see how they match up to their glucose profile. And that’s great. The good thing about the first go around with sensing and avoiding the patients seeing the numbers is often patients overreact when they see the numbers. So often I am anxious about a new Dexcom patient because they’re going to see their numbers trending up and they’re not going to realize that the insulin is slow and lagging behind or they’re going to get a low and the Dexcom isn’t going to respond to the treatment of the low, they are going to get another alarm and they are going to overreact and over-treat the lows. Often, it’s better for them not to see the results in the beginning so we can talk later on about “when did you dose the insulin.” I give them sheets that are fairly specific for record keeping, so I know that when they dose their insulin, I download their pump. “When did you dose the insulin, how long did you wait and what did you eat?” And that’s how we look at matching insulin up to food, and it’s not easy, not by any stretch of the imagination, but it’s the way to go because you want to limit the excursions in glycemic control.
Steve: Are you able to get reimbursement for using the blinded CGM from Libre?
Dr. Weiss: Yeah, the reimbursement is not great. I’m not going to buy a new house from it. It’s not great, it’s good – it’s okay, it’s better than not getting paid.
Steve: Do you also get reimbursed from the Dexcom? Same thing?
Dr. Weiss: Same thing. Same billing codes.
Steve: If you had a senior citizen, someone in their late 60s or older, you would prefer the blinded?
Dr. Weiss: For anybody I prefer blinded for the first go-around. So that they can make the mistakes they’ve been making up until the time I see them and intervene, then when I can intervene then I put the Dexcom on them or the Medtronic hopefully as that gets better..then I can put that on them so patients can deal in real time. Real time is hard because everybody expects things to be instant and insulin is slow and food is slow. And that’s trying for the patients because they want to fix that low right away and they want to fix that high right away. With inhaled insulin, we are getting some interesting results on that, but that’s a whole other story.
Steve: I would imagine every endo, even every physician, they do certain things that they think maybe they invented, or what makes their practice different, why they’re successful. They’re certain things that you go over with patients always and you feel that that’s helped you to be more successful with that patient. What are the things that you do, I know you don’t tell patients to watch what you eat and exercise and let them walk out the door, that you don’t do. So what DO you do so that you can be successful with anybody that walks through the door who has type 2 or even type 1 diabetes?
Dr. Weiss: Either way, I talk about diet a lot. I talk about how foods turn to sugar at different rates and how as a type 2 diabetic your insulin is slow, it comes but it’s slow, and as a type 1 you have to match the insulin up to the food so eating a typical American breakfast which would be a cereal or oatmeal all these things that we think are okay, they’re really not that good for diabetics to eat. So, I talk more about eating eggs and protein and having some fat with their meals rather than simple carbohydrates that most people tend to eat especially in the morning because they’re fast and easy. I talk about that and I talk a lot about not eating close to bedtime, that generally applies for everybody. Type 1s it’s almost impossible to match the insulin up to the sugar derived from food when people go to sleep. Either they’re not taking enough most of the time or they’re taking too much and it’s really really hard to hit the ball on the nose when people are eating late at night. Type 2 diabetics also I tell them eating and sleeping is good if you’re a bear and you need to sleep for 3 months, otherwise eating and sleeping is absolutely not a good idea. People work late in New York City and they come home late and then they eat late and then they fall asleep and then they wonder why they’re gaining weight. It’s a huge problem, you know going for a walk after dinner is a very simple approach to diabetes management and controlling the excursions in glucose. I like to tell people over and over again fish and green vegetables that’s kind of my approach to diabetes management. Just to limit the amount of carbohydrates and limit the risk for mistakes. If you’re making a mistake in counting carbohydrates, which everybody does, let’s say it’s a 10% mistake – 15 grams of carbohydrates is not a big mistake. If it’s 100 grams of carbohydrates — a bagel, muffin — you’re making a huge mistake and it’s going to become a major problem if the carbohydrate portions are large for both type 1s and type 2s.
Steve: You talk about nutrition. Because that’s probably maybe 90% of what causes their blood sugar to go up. What do you tell them about physical activity?
Dr. Weiss: Walking is good, the longer you walk the longer you live. I say that over and over again. There are lots of different ways of describing it but it’s fairly individualized. Exercise up to about 45 minutes or an hour may not lower blood sugar all that much right away, but different people respond in different ways, so that’s where CGM comes into play. You put the Libre on or get them to wear a Dexcom or buy one, then we can really see how they respond as an individual to exercise. Some people drop right away, other people drop the following morning, and you just have to figure it out. Basketball played for fun will likely drop the blood sugar; basketball played in a competitive way will probably raise the blood sugar. Again, individual variability, so sensing is really, really, really the most important thing.
Steve: What do you teach your patients about exposure to Vitamin D and Vitamin D levels and the use of sunscreen?
Dr. Weiss: Vitamin D has been kicked around a lot in terms of its role in diabetes. Vitamin D Deficiency has been linked to diabetes. I think it might be all part of the same lifestyle, in other words, people who are eating and sitting around and not doing any physical activity, that will lead you to diabetes. Obesity leads you to diabetes. On the other hand, people who are physically active, who are outside running are going to have less diabetes. The sun exposure is important without sunscreen to make Vitamin D, once you put sunscreen on you don’t get Vitamin D at all. 15 minutes of sun exposure during peak hours is really all you need – your arms, your legs and your face – and that should adequately raise your Vitamin D into a reasonable range. Again, the link between Vitamin D deficiency and diabetes as causal is controversial thing. I’m not really sure that I’m 100% certain, but I do believe that Vitamin D deficiency is a marker for lifestyle that is consistent with the development of diabetes.
Steve: Do you do a Vitamin D test?
Dr. Weiss: I used to do it all the time, but now I just tell my patients they need 15 minutes of sun without sunscreen during peak hours of the day. I think there’s a rough rule, though I don’t know how valid it is, if your shadow is shorter than you, the sun’s hitting you at the right angle to get adequate Vitamin D. If your shadow is longer than you are tall then the sun is probably not at the right angle to make Vitamin D. I also know that studies done a long time ago show that from March to November in the Northeast – it was done on the roof of Mass General Hospital by Dr. Hollick – if the sun’s hitting you at the right angle to make Vitamin D…if you’re not getting that kind of exposure, then you won’t get Vitamin D from the sun.
Steve: I want to thank you for your time. I thought it was very informative. It’s always great to talk to physicians that know what they’re doing when it comes to diabetes, because most of the GPs out there are having a difficult time.
Dr. Weiss: The GPs need to learn a lot. They need to learn to start early and not wait until the A1C is 6.5 before treating their patients.
Steve: What would you say if a person walks into your office and they have an A1c of 5.8%, 5.9% just below 6%, do you just tell them to diet and exercise?
Dr. Weiss: Well, I don’t just say diet and exercise. That’s very easy. A lot of people kneejerk diet and exercise as an expression. But really, I have them do the same thing, I send them home with sheets to write down everything they eat and I have them check their blood sugar post-prandial. Post-prandial blood sugars can be high well before the A1C is going to be elevated and it’s the first indication of a problem, also high triglycerides, the post-prandial numbers are high, that’s what we need to address
Steve: At what point do you put them on medication? Or do you wait until they hit 6.5%?
Dr. Weiss: I beat them over the head about diet a lot, and I have a lot of success with it. I hear people say that after 6 months people fall off their diets and after a year they’ve regained all their weight and their sugars are just bad again. I keep calling my patients back on a 3-month basis to reinforce or have them meet with the educators to reinforce the need for that. If, however, they’re slipping that’s when I think a DPP4/Metformin combination early on.
Steve: Even before 6.5?
Dr. Weiss: Even before 6.5, if they have a strong family history of type 2 diabetes and they’re headed that way, then absolutely.
Steve: Even though technically that’s off label?
Dr. Weiss: It’s off label, yes.
Steve: You’re one of the few physicians…I guess you can do that in a private practice, but you couldn’t do that if you were working for a large company because you have to follow their standards of care.
Dr. Weiss: Well, yeah. Not a big fan of standards of care. (laughter)