Selected Podcast
Diabetes Technology
Henry Zelada MD discusses how diabetes treatment has changed over the last decade and patient selection criteria for starting CGM. He shares when it is important to consider starting an insulin pump and offers his recommendations to primary care physicians about using diabetes technology in their primary care practices.
Featuring:
Henry Zelada, MD
Henry Zelada, MD is an Assistant Professor of Medicine.Learn more about Henry Zelada, MD
Release Date: October 13, 2021
Expiration Date: October 12, 2024
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Speaker:
Henry Zelada, MD
Assistant Professor in Endocrinology
Dr. Zelada has no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity.
Release Date: October 13, 2021
Expiration Date: October 12, 2024
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Speaker:
Henry Zelada, MD
Assistant Professor in Endocrinology
Dr. Zelada has no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity.
Transcription:
Melanie: Welcome to UAB MedCast. I'm Melanie Cole. And today, we're discussing how diabetes treatment has changed over the last decade. We're talking about patient selection criteria for starting them on CGM or an insulin pump and recommendations to primary care physicians about using diabetes technology in their primary care practices.
Joining me is Dr. Henry Zelada. He's an Assistant Professor of Medicine and an endocrinologist specializing in diabetes, metabolic and hormonal imbalances at UAB Medicine. Dr. Zelada, it's a pleasure to have you join us today. So tell us a little bit about the trends that you've been seeing in diabetes and how treatment has changed over the last decade.
Dr Henry Zelada: Thank you very much for having me today. The treatment of diabetes has changed in a positive way over the last decade. There are new insulin and also non-insulin medications now to choose, depending on our patient's needs. The use of GLP-1 agonists on SGLT2 inhibitors for sure have changed the approach of the diabetes management as they are now considered the second line of therapy after metformin in patients who have or those who are at risk to develop atherosclerotic cardiovascular disease.
In addition to that, the use of CGMs, continuous glucose monitoring, insulin bands, and also the use of more advanced technologies such as integrated hybrid closed loop systems are options now available for our patients.
Melanie: Well, it's certainly an exciting time in your field. And as an exercise physiologist myself, I've been seeing all of these things develop. So we're going to talk about CGM and insulin pumps. But before we do, Dr. Zelada, how much do healthcare providers rely on patient-provided data when it comes to managing diabetes? I'd like you to speak about some of the barriers to the use of self-monitored blood glucose and, you know, lack of timely, regular feedback, whatever you'd like to say and what you've been seeing as far as the technology that is available to patients today.
Dr Henry Zelada: Absolutely. The technology is there on the market. Unfortunately, not every patient qualifies to get CGMs. In the past, there was a misconception that CGMs were mainly used for patients with type 1 diabetes. However, there is research upcoming that suggest that CGMs are also indicated for patients with type 2 diabetes and the results are promising.
I do believe that the conversation about starting a CGM should be initiated in the primary care setting. Of course, we're always happy to receive any kind of referral and every referrals are the best. But starting a conversation about the benefits of CGMs from the primary care setting, it's for sure a class for the patient.
Melanie: Well, then speak about patient selection just a bit. For other providers, what patients do you consider starting on CGM?
Dr Henry Zelada: Yeah. That's a great question. So just to understand a little better what CGM is, CGM in simple words are glucose sensors. They measure the glucose from the interstitial fluid every one to five minutes, depending on the type of CGM. So a CGM has three parts, a sensor that measures the interstitial glucose levels, a transmitter that transmits the information from the sensor to a receiver and the receiver, which is a device that receives the glucose data from the transmitter for viewing interpretation. Most lately, patients use their phones as a reader.
In regards of what patients should we consider to start a CGM, I believe that's a great question and a very common question that is around. So there is a common misconception to think that CGMs are only indicated for patients with type 1 diabetes as I just said. There is a recent randomized clinical trial. The name of this trial is called the MOBILE study. This trial is interesting because it was done in primary care settings in 15 hospitals in the United States on patients with type 2 diabetes who were on just basal insulin and oral antidiabetic medications.
They compare two groups of these patients, patient who checked his sugars using glucometers, two patients who use CGMs. The aim of this study was to see if there were any changes in their A1c after eight months. The group that used CGMs had an A1c drop by 0.4% compared to the group that use glucometers. So this study along with others have suggested that patients who use CGMs become more conscious about their diabetes and what they eat when they are using a CGM. For example, if a patient is about to eat and his or her sugars are in the 300s, they will be more cautious what to eat. And that's something that has been shown and this is evidence-based how CGM by itself controls an A1c by 0.4% to 0.5% just by wearing it. So I do believe that CGM should be offered to any patients with diabetes who takes at least one shot of insulin per day.
Melanie: That's so interesting, Dr. Zelada. I didn't know that. So thank you for sharing how that really responds and gets the patient to realize what's going on with their glucose. So when do you consider starting an insulin pump?
Dr Henry Zelada: It's interesting to see many patients who come to our diabetes clinic with uncontrolled diabetes and thinks that an insulin pump is what's going to solve their problems. And that's a misconception in general population. We use mainly insulin pumps in patients with type 1 diabetes. And the reason is because these patients require small changes in their insulin doses that are only possible to be made using an insulin pump. That's one indication.
The other possible consideration is when we want to start using something that is called hybrid closed loop system. A hybrid closed loop system is a system that comes with three parts, a CGM, a glucose sensor; then an insulin pump, and also a computer program called algorithm that takes data from the pump and CGM and adjust the pump's insulin delivery automatically. Today, we have two hybrid closed loop system. One is called Control-IQ and the other is the hybrid closed loop system from the Medtronic pump.
However, it's also important to remember and consider that some patients with type 2 diabetes could also be candidates for insulin pumps. There is new evidence that suggest that Omnipod insulin pump, that's another type of pump, could be considered on these patients. So the decision should be made with a patient, their needs and their expectations.
Melanie: Well, it certainly is an interesting discussion to have between patient and provider. And as lifestyle management remains very basic to long-term diabetes management and control, and there's no one-size-really-fits-all, Dr. Zelada, what are the latest recommendations on diabetes lifestyle management? Anything you'd like to add to this discussion?
Dr Henry Zelada: Yeah, absolutely. Lifestyle management helps a lot to control diabetes along with exercises and a good diabetic plan for the patients. And again, the treatment should be individualized. Every single patient with diabetes have different goals and actually have different needs. So the endocrinologist or primary care should identify what's the goal in order to choose the right medications for the patients.
Melanie: Well, there are so many options available today. And you discussed medications earlier in the podcast. As we wrap up, what do you recommend to primary care physicians about using diabetes technology in their primary care practices? And what you'd like to take-away message to be on this podcast today?
Dr Henry Zelada: I do believe that starting a conversation with their patients about using CGMs in the primary care clinics should be considered. I do not expect that a hybrid closed loop system is initiated in a primary care setting. But starting a CGM, a glucose sensor, should be considered, because of all the benefits that we have just discussed.
Also an early referrals is also very well appreciated by us when the diabetes remains under control and also when they suspect atypical forms of diabetes. We need to understand that diabetes is more complicated than type 1 versus type 2. There is a full spectrum of atypical forms of diabetes that needs to be identified and needs to be addressed properly. So I do believe that primary care physicians who suspect atypical forms of diabetes should refer their patients to the diabetes clinic.
Melanie: Great information, Dr. Zelada. Thank you so much for joining us today. A physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST or by visiting our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. Please remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole.
Melanie: Welcome to UAB MedCast. I'm Melanie Cole. And today, we're discussing how diabetes treatment has changed over the last decade. We're talking about patient selection criteria for starting them on CGM or an insulin pump and recommendations to primary care physicians about using diabetes technology in their primary care practices.
Joining me is Dr. Henry Zelada. He's an Assistant Professor of Medicine and an endocrinologist specializing in diabetes, metabolic and hormonal imbalances at UAB Medicine. Dr. Zelada, it's a pleasure to have you join us today. So tell us a little bit about the trends that you've been seeing in diabetes and how treatment has changed over the last decade.
Dr Henry Zelada: Thank you very much for having me today. The treatment of diabetes has changed in a positive way over the last decade. There are new insulin and also non-insulin medications now to choose, depending on our patient's needs. The use of GLP-1 agonists on SGLT2 inhibitors for sure have changed the approach of the diabetes management as they are now considered the second line of therapy after metformin in patients who have or those who are at risk to develop atherosclerotic cardiovascular disease.
In addition to that, the use of CGMs, continuous glucose monitoring, insulin bands, and also the use of more advanced technologies such as integrated hybrid closed loop systems are options now available for our patients.
Melanie: Well, it's certainly an exciting time in your field. And as an exercise physiologist myself, I've been seeing all of these things develop. So we're going to talk about CGM and insulin pumps. But before we do, Dr. Zelada, how much do healthcare providers rely on patient-provided data when it comes to managing diabetes? I'd like you to speak about some of the barriers to the use of self-monitored blood glucose and, you know, lack of timely, regular feedback, whatever you'd like to say and what you've been seeing as far as the technology that is available to patients today.
Dr Henry Zelada: Absolutely. The technology is there on the market. Unfortunately, not every patient qualifies to get CGMs. In the past, there was a misconception that CGMs were mainly used for patients with type 1 diabetes. However, there is research upcoming that suggest that CGMs are also indicated for patients with type 2 diabetes and the results are promising.
I do believe that the conversation about starting a CGM should be initiated in the primary care setting. Of course, we're always happy to receive any kind of referral and every referrals are the best. But starting a conversation about the benefits of CGMs from the primary care setting, it's for sure a class for the patient.
Melanie: Well, then speak about patient selection just a bit. For other providers, what patients do you consider starting on CGM?
Dr Henry Zelada: Yeah. That's a great question. So just to understand a little better what CGM is, CGM in simple words are glucose sensors. They measure the glucose from the interstitial fluid every one to five minutes, depending on the type of CGM. So a CGM has three parts, a sensor that measures the interstitial glucose levels, a transmitter that transmits the information from the sensor to a receiver and the receiver, which is a device that receives the glucose data from the transmitter for viewing interpretation. Most lately, patients use their phones as a reader.
In regards of what patients should we consider to start a CGM, I believe that's a great question and a very common question that is around. So there is a common misconception to think that CGMs are only indicated for patients with type 1 diabetes as I just said. There is a recent randomized clinical trial. The name of this trial is called the MOBILE study. This trial is interesting because it was done in primary care settings in 15 hospitals in the United States on patients with type 2 diabetes who were on just basal insulin and oral antidiabetic medications.
They compare two groups of these patients, patient who checked his sugars using glucometers, two patients who use CGMs. The aim of this study was to see if there were any changes in their A1c after eight months. The group that used CGMs had an A1c drop by 0.4% compared to the group that use glucometers. So this study along with others have suggested that patients who use CGMs become more conscious about their diabetes and what they eat when they are using a CGM. For example, if a patient is about to eat and his or her sugars are in the 300s, they will be more cautious what to eat. And that's something that has been shown and this is evidence-based how CGM by itself controls an A1c by 0.4% to 0.5% just by wearing it. So I do believe that CGM should be offered to any patients with diabetes who takes at least one shot of insulin per day.
Melanie: That's so interesting, Dr. Zelada. I didn't know that. So thank you for sharing how that really responds and gets the patient to realize what's going on with their glucose. So when do you consider starting an insulin pump?
Dr Henry Zelada: It's interesting to see many patients who come to our diabetes clinic with uncontrolled diabetes and thinks that an insulin pump is what's going to solve their problems. And that's a misconception in general population. We use mainly insulin pumps in patients with type 1 diabetes. And the reason is because these patients require small changes in their insulin doses that are only possible to be made using an insulin pump. That's one indication.
The other possible consideration is when we want to start using something that is called hybrid closed loop system. A hybrid closed loop system is a system that comes with three parts, a CGM, a glucose sensor; then an insulin pump, and also a computer program called algorithm that takes data from the pump and CGM and adjust the pump's insulin delivery automatically. Today, we have two hybrid closed loop system. One is called Control-IQ and the other is the hybrid closed loop system from the Medtronic pump.
However, it's also important to remember and consider that some patients with type 2 diabetes could also be candidates for insulin pumps. There is new evidence that suggest that Omnipod insulin pump, that's another type of pump, could be considered on these patients. So the decision should be made with a patient, their needs and their expectations.
Melanie: Well, it certainly is an interesting discussion to have between patient and provider. And as lifestyle management remains very basic to long-term diabetes management and control, and there's no one-size-really-fits-all, Dr. Zelada, what are the latest recommendations on diabetes lifestyle management? Anything you'd like to add to this discussion?
Dr Henry Zelada: Yeah, absolutely. Lifestyle management helps a lot to control diabetes along with exercises and a good diabetic plan for the patients. And again, the treatment should be individualized. Every single patient with diabetes have different goals and actually have different needs. So the endocrinologist or primary care should identify what's the goal in order to choose the right medications for the patients.
Melanie: Well, there are so many options available today. And you discussed medications earlier in the podcast. As we wrap up, what do you recommend to primary care physicians about using diabetes technology in their primary care practices? And what you'd like to take-away message to be on this podcast today?
Dr Henry Zelada: I do believe that starting a conversation with their patients about using CGMs in the primary care clinics should be considered. I do not expect that a hybrid closed loop system is initiated in a primary care setting. But starting a CGM, a glucose sensor, should be considered, because of all the benefits that we have just discussed.
Also an early referrals is also very well appreciated by us when the diabetes remains under control and also when they suspect atypical forms of diabetes. We need to understand that diabetes is more complicated than type 1 versus type 2. There is a full spectrum of atypical forms of diabetes that needs to be identified and needs to be addressed properly. So I do believe that primary care physicians who suspect atypical forms of diabetes should refer their patients to the diabetes clinic.
Melanie: Great information, Dr. Zelada. Thank you so much for joining us today. A physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST or by visiting our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. Please remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole.