Dace Trence 2018 Transcript

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Freed: This is Steve Freed with Diabetes in Control and we’re here at AACE 2018 in Boston. And we have a special guest with us today. And that’s Dace, is it? [Freed to Trence]

Trence: Dace. Dace.

Freed: Trence. And kind of a unique person. I have a list of everything that you’re involved in. And I just — we’d be here all day if I had to list everything, so I’m just going to let you tell us a little bit about yourself and how you practice.

Trence: Well, I’m at the University of Washington in Seattle at this time. And I’m part of the Division of Metabolism, Endocrine, and Diabetes Nutrition and have a number of hats that I wear. I have the fellowship program, so I see a lot of trainees. I certainly see patients, so I’m a clinician. And do a bit of administrative work, so a couple of different hats.

Freed: And what caused you to become an endo out of all the choices that you have when you started out?

Trence: Oh, it’s a fascinating area. I mean, it’s an area of thinking. It’s an area that challenges one to really think literally outside the box to be able to address issues that patients have.

Freed: So, let me just start off with the question that’s changed diabetes probably more than anything else, and that’s CGMs. It’s a newer technology. How does the CGM impact diabetes per se?

Trence: I think it’s really a tool that has allowed people to see something evolve. It isn’t a point in time when we did urines, fortunately decades ago, it gave you the answer of what was happening, perhaps, four hours ago.

Freed: Yeah.

Trence: Very helpful, isn’t that? Four hours ago. And we all were just dramatically enthusiastic when finger-stick glucoses became available, because now suddenly you had at least something that was right there. But then if you think about it, that’s the result of one second, of one minute, of one hour, of one day. Does it tell you, are you going to have ups or downs on your blood sugar profile? Are you going to be staying stable? It doesn’t give you a sense of what’s happening over time. And that’s exactly what CGMs, Continuous Glucose Monitor Sensors, actually now do. And so, it gives people a sense of what is it that’s happening when I choose to do something. So, if I choose to eat this, what’s it going to do to my blood sugar in two or three hours? Or if I choose to go out and exercise, what’s going to happen to my blood sugar? What if I take only half of my medication, what’s going to happen? What if I delay my medication? So, it gives a lot of answers to individuals right away. You don’t have to wait until your next three months’ appointment to discuss what was happening. You know right away what’s happening.

Freed: And we learn a lot. And what do we do with that information if it’s just to look and see what that number is? It doesn’t improve our condition. So, how do we use that?

Trence: I think that’s a good point, because that’s a point that has been made with the finger-stick checks. That if you just tell someone, “Go ahead, check your blood sugar by doing a finger-stick,” and you get a value, you don’t know. Is this a good value? Is this a poor value? Should I be doing better? Should I not worry about it? I think those were questions that people had that weren’t always answered. And so, the literature really wasn’t very positive. The finger-sticks helped people really advance and better manage their diabetes. With the continuous sensors, it’s a little different because you can see immediately, “Well, I had two servings of spaghetti. Oh, that’s not such a good idea. Maybe I should just try one.” You don’t need to have a lot of sophistication to be able to kind of know that that’s a change I can make. There actually is a study that has looked at just that. Looking at individuals with type 2 diabetes and actually, looking — do you need to do a lot of education? It seemed that you really did not. But people could pick up very easily because they could see immediately the feedback of a choice that was made.

Freed: Now, let’s talk about A1C. I always thought that was the gold standard. When I would sit down with a patient, first thing I did before I did anything, I did an A1C test. I knew exactly — and I used the home test, so I knew exactly where I was, how much work was going to be involved. They would say, “Steve, what do you charge for your services?” I’d say, “Well, depends on your A1C. If your A1C is eight and above, it’s $475 an hour. If your A1C is below five, my services are free.” So, let’s work to get your A1C down, so my services are free. And just from that number, they weren’t lying; I can tell if they were lying, that they’re eating all the right foods and everything. So, the A1C had its day and its time. But what I discovered was that with the CGM that it’s not all about A1C, because that’s a 90-day average. We need to have the information on a daily or hourly basis. And because of the variability, now we have studies that show the variability of your blood sugar is just as important as the final number. So, what are you thoughts when it comes to the A1C test? Is there another test that you like better than the A1C?

Trence: Well, certainly A1Cs are the gold standard. We all know that. It’s in the literature. We’re all familiar with it. There’s been a lot of average energy, really trying to make that a recognizable number that everyone should know about and everyone should be able to interpret. So, clearly I like your charges, although I’m not sure I’d agree with them but I do like the charges. But again, as you mentioned, it’s on average. And it’s an average that you could get —  let’s say, I’m gonna make up a number. Let’s say you have an A1C of 10, so that’s an average of 1 and 20, 1 and 20, 1 and 20. That’s also an average of 8 and 12, 8 and 12, and an average of 9 and 11, 9 and 11. Now, what does that tell you about the control if you’re trying to say — again, if you say the variability versus the tightness of the range? So, if you think about it, isn’t the range more important? And I think this is where, again, with the continuous glucose sensors, we’re moving into interpretation of time and range that has a lot more meaning. It tells you how much time am I spending and where I really want to be. And you can argue that the range may be X, Y or Z, but by definition it’s still within a tighter amount of lower and higher blood sugar. And even more importantly, it tells you how much time am I spending where I don’t want to spend time, which is the super lows or lows, or the super highs. And an average won’t tell you that.

Freed: You know when it comes to type 2 — well, first of all, I remember the first CGM which was the GlucoWatch, which I had one and it wasn’t very accurate. The thing would conk out on me, I mean every time I went for a walk and I had a little bit of sweat, so it was difficult. Never really went anywhere. But from that, they developed the newer technology which I find to be very educational. And do you see using it in a type 2? Well, we know that people who take insulin, it’s very effective. What about the people that are not on insulin, that are on other oral drugs, or even GLPs type of thing? Do you use that for those type of patients? Because I don’t — insurance won’t pay for it per se at this point in time. But I think eventually they will because I think that’s the best education in the world. You sit down, you have a piece of chocolate cake, and you look an hour later or 20 minutes later, you see it’s 800 or whatever the case may be, you’re not going to do that anymore. Have you seen it being used in type 2s and what is the end result?.

Trence: There is — I just actually reviewed the literature and there really is not much data outside the insulin program for people with diabetes. But there’s that in both types 2s and type 1s but they’re all on insulin, even the basal insulin minimally. So, I think your point is well made that we still need studies to really support that the use is proven scientifically. But with now the lesser expensive CGM that has been available in the market in the past couple of months, people are buying it on their own. You don’t need to go through an insurance company, so it’s very easily accessible. Or you talk to your friends or coworkers that are in the European countries or outside the US, where the device has been available basically by going to a drugstore, picking it up. So, people have gotten this and are using this irrespective of whether they’re insulin users or pill users. And I think it goes really to show how universally applicable we all feel this tool is. I actually happen to give a presentation to a community in our state, it’s an Indian community, that feel so strongly about this that they’re going to make the most recent sensor available to every type 2 individual in their particular community. And in speaking to one of my older senior citizens about this, and it’s a person who is on insulin but lives in a senior housing and we’ve talked about this. And he said, “Oh, that patch one? I can’t tell you how many people are around that congregate dining table that show me their patch. I know all about it. You don’t need to tell me anything about this. I know how to use this. Just give me the prescription for this.” (Laugh) So, I think that eventually it will become a tool that really will replace finger-sticks completely, just like finger-sticks replaced urine.

Freed: What are the barriers to the CGM sensor?

Trence: Right now? Well, one of the major barriers is expense because not all of them are inexpensive by any means and still require some insurance coverage for people that want to use it on an ongoing basis. I think that will change over time. I think the other big issue is the accuracy issue. They’re getting better and better, and better, and better. Are they prefect? Are they as accurate as we would like in all conditions? Not maybe quite yet, but it’s coming. And I think the last part is that many of them still require calibration. Again, that’s changing to where there will be no calibration or at least not the need to do finger-sticks unless something is odd. As I tell some of my patients that I see or if you see that that says your blood sugar [is] 500, you say, “(Laughs) I don’t think so. I don’t feel like I’m at 500.” Well, we still need the finger-stick to kind of calibrate or corroborate if you want to say that this is really the glucose that it should be at.

Freed: What needs have CGM shown us that were not recognized previously?

Trence: Well, I think certainly the ability to respond to someone immediately. I mean, CGM tells you, “I just did this and I got this result in my blood sugar.” So, how can I approach this? How can I do better? And I think one of the things that we’re recognizing is that we need the ability to respond very quickly to situations. Not wait until the appointment in a week or a month or three months when totally forgotten like, “What was it that I did?” I think we need to be able to get tools that allows the ability to really respond much, much more promptly to issues that require some kind of a discourse between the clinician and the patient. .

Freed: And what do you think the next biggest breakthrough is going to be in the field of diabetes and cardiovascular disease?

Trence: Well, you added cardiovascular disease. If you told me just diabetes alone, I would certainly say the movement towards having the synchrony between a sensor and an insulin delivery device. So, that really takes you, the person, out of the decision making process. Certainly we have one such system now that has come out very recently, but I think we’re going to see more and more of these where that really kind of takes over. And perhaps even to the point that you may have a sensor on the dashboard of the car, so that you’re watching your blood sugar as you’re driving. Heaven forbid, not consistently watching it but it’s there recording or at least giving you a signal if it’s wrong or something is going awry. So, I think technology is going to increasingly address the issue of spontaneity, knowing what to do. Also, we’ll have a better idea of what should our targets really be. I mean, if we’re really still thinking that blood sugars are related to cardiovascular disease, and I think we still have some thought not totally band-aiding that, what is it about the blood sugar that it’s critical? Is it the certain level? Is it less variability or is it both? I mean, do you have to achieve a certain level with a certain degree of lower variability to really be able to impact on cardiovascular disease?

Freed: And coming up, the ADA, is there anything that you think that is going to be important coming out of this year’s meeting?

Trence: Everything.

Freed: Nothing in particular?

Trence: Well, I think we’re hoping that there’ll be some studies reported that will give us some more insight in to drugs that can give us additional cardiovascular benefit. I think there’s a lot of movement in that direction, so I think that will be very helpful. We’re certainly looking at the tools that we do have already. Perhaps looking at some of the older tools that we’ve had and thought that, “Well, maybe we should abandon them.” The old insulins, unfortunately have one big benefit and that is, it’s less cost. You don’t necessarily need to have a prescription to get a few of these. How do you make them work in the era where people are a little strapped for money?

Freed: Give me one of the biggest changes, especially for endocrinologists who are specialists in the treatment of diabetes. Is that — was, it was always about blood sugars? That we never had any drugs to treat cardiovascular situations. And all of a sudden now–

Trence: Well, we did separately.

Freed: Right.

Trence: And we did separately, so we attended to blood pressure, lipids, the aspirin, the plavix, things like that.

Freed: But now, because we have these drugs that do both–

Trence: Yes.

Freed: –how has that changed the way you treat patients?

Trence: I think, first of all, it’s made it easier to get some of these drugs because insurances are recognizing that they have additional value beyond just glucose lowering. That’s been a big change because they’re still expensive, but the door is a little bit more open in terms of who can get these. So, it isn’t quite, “Nope, the FDA approves it for this and that’s all we’re going to do.” Of course FDA now has also been a little bit more liberal too in their additional benefits and indications. But I think it’s added some additional thought processes to in this particular person, “What might be the best regimen to help control the blood sugar?” So, it’s a different layer than just looking at blood sugar and it goes beyond cardiovascular. There’s also the renal benefits we’re seeing from of these drugs. So, they’re additional benefits that you can actually begin to tailor a regiment towards a particular person. It’s moving in the air of what many people are calling precision medicine. So, it’s not just calling, “Okay. Step one, you do this. Step three, you do this. Step five, you do this type of thing.” It’s really, “Okay. I have this individual in front of me. What medication regimens can I really prescribe or suggest to this person that really have the most benefit?”

Freed: Well, I don’t want to take any more of your time. I really appreciate you coming down here.

Trence: Thank you.

Freed: Enjoy the rest of your stay here in Boston. And like everybody else, we’ll be looking forward to ADA and some exciting results coming out of some of these studies. Well, thanks again!

Trence: Thank you!