Speaker 1:

Welcome to AACE Podcasts. Thanks for tuning in as we elevate clinical endocrinology by taking deep dives into trends and topics that can help us improve our patient care and global health. Find the latest episodes on aace.com/podcasts. And now let's meet the endocrine experts who will be talking with us today.

Maria A. Mogollon, MSN, APRN, FNP-BC:

Hello. Thank you so much for this invitation. My name is Maria Mogollon. I am a family nurse practitioner and I've been working with diabetes for more than 15 years. I'm currently working as a diabetes endocrinology nurse practitioner, and we have today an important topic and very, very interesting topic, which is clinical conversation in diabetes technology podcasts. And we're going to have as a speaker and invite, Dr. Jeff Unger. Please, if you can introduce yourself. Dr. Unger.

Jeff Unger, MD, FAAFP, FACE, DACD:

Yes. Maria, it's great to talk to you and speak on behalf of AACE. I'm Jeff Unger. I'm a family doctor, also a diabetologist, and I actually co-authored the 2021 guidelines on the use of technology in patients with Diabetes. Maria, why is that important? Because every once in a while my office, I show this data to my patients and they start arguing with me. And I say, you cannot argue with me. I actually wrote this stuff. What I'm showing you, I know what I'm talking about. And it's really important for physicians like myself to show patients what this data means and how it benefits them.

Maria A. Mogollon, MSN, APRN, FNP-BC:

Definitely. Definitely. I 100% agree with you, Dr. Unger. I have so much questions for you, Dr. Unger about continuous glucose monitors. I think this is the most popular technology in this years and they're getting more popular and popular over time. But I want to know who do you consider is a good candidate? If we have to choose the great candidates so they can use this continuous glucose monitor, who will you choose?

Jeff Unger, MD, FAAFP, FACE, DACD:

We addressed that in the guidelines that were published back in 2021 and our last day of getting all the authors together, we debated this question, Maria, and here's what we came up with. It's really simple. Anyone with diabetes deserves CGM. And I'll tell you, You're a nurse practitioner, you see these patients all the time. Do you ever have patients that really look forward to pricking their fingers and getting one drop of blood out of it? And remember about five, six years ago, the American Diabetes Association was recommending doing finger sticks 10 times a day for patients with type one diabetes. I don't think anybody does that. We came up with the idea of giving this technology to people, all of them that have diabetes and there's no problem with that. That's a good thing.

Maria A. Mogollon, MSN, APRN, FNP-BC:

Mm-hmm. Okay, sure. Of course the financial burden can be part of the issue that limits the use of continuous glucose monitor. What do you think about that?

Jeff Unger, MD, FAAFP, FACE, DACD:

Well, I'm going to address that because I actually published this a couple years ago. How much does one finger stick cost? Well, if you look at the strip, there's a little bit of gold in the strip and gold is expensive. You know that, everybody listening to this podcast knows that gold is expensive. One finger stick costs $1.15. With the sensors we are able to use today, they monitor blood sugars every minute of every day, which is 1,440 readings in a day over a two-week wear. Some of these sensors monitor the blood sugar 20,160 times. How much does it cost if you're going to do 10 finger sticks a day? It's $15. How much does one CGM reading cost, 0.08 cents.

Maria A. Mogollon, MSN, APRN, FNP-BC:

Wow.

Jeff Unger, MD, FAAFP, FACE, DACD:

It's a lot cheaper to use CGM than it is to use finger sticks. And that's what I tell people. And a lot of these people, it's not a burden to use these things. They get so much more information about using CGM than with finger sticks.

Maria A. Mogollon, MSN, APRN, FNP-BC:

I agree with you. I have a lot of patients that are transitioning to continuous glucose monitor and that even provide that information that it's even cheaper for them to use it and they don't want to go back. That's great. In your practice as a family doctor, do you consider all the primary care physician should be prescribing continuous glucose monitor to their diabetes patient?

Jeff Unger, MD, FAAFP, FACE, DACD:

Absolutely. Maria, you know this, that everybody that has diabetes needs to be on CGM. The word doctor in Latin means teacher. What we need to do is educate our patients on what is going to drive them successfully towards good diabetes management. And I'm going to ask you a question. This is a true or false question. It's really, really simple. That true or false, diabetes is the leading cause of adult blindness, kidney disease, amputations in the United States, true or false?

Maria A. Mogollon, MSN, APRN, FNP-BC:

100% true. 100%.

Jeff Unger, MD, FAAFP, FACE, DACD:

False. False. Really poorly controlled diabetes is the number one cause of these complications. People that are on CGM are very well controlled. We can identify people that are on the rollercoaster, the up and down effect of poor glycemic control. We can identify people before they get hypoglycemic. We can smooth out variability. And you know what? People get very well controlled with CGM. Nobody wants to get complications. And Maria, this is something I tell all of my primary care associates, when a patient comes in to see you that has diabetes for the first time, ask them this question. What scares you the most about having diabetes? And they're all 100% of them going to answer it this way. I don't want to lose my eyes, I don't want to lose my kidneys and I want to lose a leg and oh yeah, I want to watch my daughter walk down the aisle someday. In other words, they don't want to have a heart attack or stroke. You know they're going to answer it this way. And what you tell them is, nothing's going to happen to you on my watch. I've got your back. At that point in time, they will do anything you want. If you want to put a sensor on, go ahead and do it. If you want to use certain medications, go ahead and do it. But they are so scared when they come to see you because they think they're going to end up dead and it's not necessarily going to happen. In fact, it's not going to happen on my watch.

Maria A. Mogollon, MSN, APRN, FNP-BC:

All right. Good. Okay. How difficult and the time-consuming to get on board a patient with this continuous glucose monitor? Because as a provider we struggle a lot with time while we're seeing patients. How difficult is it when we want to start a patient with a continuous glucose monitor?

Jeff Unger, MD, FAAFP, FACE, DACD:

Well, the first part of this question is does the patient want to be on the sensor in the first place? And the answer is, you're going to like this one, Maria. We don't give them a choice. When they come, I don't even ask them, do you want to be on a sensor? I'll bring the sensor into the room and we'll just put it on. I do not believe in informed consent. They come in for diabetes management, they're going to get diabetes management. And they always ask the same question when I'm putting the sensor on there, what are you doing? What are you doing? And I said, do you like doing finger sticks? And they say, no. Good. It's already on. You don't need to do any more finger sticks. Let's show you how this works. Does this take time? Yeah, it takes about a 10th of a second to put the sensor on. It may take about five minutes to onboard them to teach them what it is they're looking for. And what I've done in my practice now, I have my medical assistant and even the receptionist, they both know it how to onboard these things. All I have to do is say put the sensor on Joe in room two. And they pretty much do it like I do as well. And that saves me about five minutes. And then the role of the clinician is to show them how to operate the device. It doesn't take more than a couple minutes.

Maria A. Mogollon, MSN, APRN, FNP-BC:

And I also see the boxes have a number that you can also call. And I have patients calling and they also do the onboarding by phone over the clinicians that they have at the company. It works in case you don't have the time. I've been not that often, but some patients I've done.

Jeff Unger, MD, FAAFP, FACE, DACD:

I prefer, Maria, some of our patients, as you know, are older. They're not really tech-savvy.

Maria A. Mogollon, MSN, APRN, FNP-BC:

Mm-hmm.

Jeff Unger, MD, FAAFP, FACE, DACD:

I want them to know what's going to happen to them when they leave the office. And it's a lot better to do everything in the office than to have them call an 800 number. I don't want them to get confused. I want them to be excited about the experience.

Maria A. Mogollon, MSN, APRN, FNP-BC:

Of course, of course. Have you compare patients with continuous glucose monitor and patients with doing the glucometer finger stick? How long does it take to get glucose control using one or the other?

Jeff Unger, MD, FAAFP, FACE, DACD:

Yeah, I'm glad you asked that question because one of my favorite patients of all time, and I've got a lot of them, but this guy was just amazing. He comes in, he's 52 years old, he's got type two diabetes for 20 years, poorly controlled. His A1C is over 12, but he's been hospitalized not once, not twice, not three times, but four times in the last two months. Why? Because he had symptoms of confusion, disorientation, sweating and passing out. He goes to four different hospitals, he gets 10 MRIs, 10 unfortunately, Maria. Oh my goodness. All 10 of these MRIs are normal. Okay. Nobody asked him about hypoglycemia. No one. The answer to your question is we put him on a sensor, we changed his insulin therapy around, it took 67 days, six, seven to go from time and range, which we're going to explain coming up. Time and range from 0% all the way down to 76%. That's about two months. His A1C dropped from 12 to 7.2, no hypoglycemia. And you know what? The reason that his blood sugars were so bad is he was afraid to use insulin, but nobody told him how to use the insulin. Nobody told him how to do finger sticks. And I even asked him, Chris, how come you're not doing finger sticks and why should I? Nobody looks at the data anyway. 67 days.

Maria A. Mogollon, MSN, APRN, FNP-BC:

Wow, impressive. Impressive. Definitely, especially the patients with high risk of hypoglycemia. I'm so afraid of elderly patients with dialysis. Tell me a little bit about that population, patient in dialysis. What's your experience with that?

Jeff Unger, MD, FAAFP, FACE, DACD:

Okay. That's really important that you ask that because what happens with dialysis is the A1C is not reliable. There's rapid turnover of red blood cells. You really don't get very good glycation. You could have somebody with A1C analysis of 5.2, but in reality their A1C is much higher. It could be in the nine or 10 range. A1Cs don't matter. What you've got to do is put these people on sensors because one of the numbers that we look for, Maria, in sensor data is something called a GMI. It's called a glucose monitoring indicator. And this tells us a predictor of what the A1C is going to be. How do we get this number? Well, we're looking at 20,000 glucose readings over a two-week period of time. And there's an algorithm in all these sensors that tell us what the predictor of the A1C is going to be. And that's the A1C. If somebody comes in with a GMI of 7.2, I know that that's what the A1C is going to be. And that's why this is so important for patients with dialysis. Also, as you know, Maria, these people in dialysis can get hypoglycemic. And guess what happens when they're on a sensor? There's an alarm. When the sensor starts detecting the glucose levels are going down, trending below 70, then it's going to alarm. And that alarm is really loud, so it's going to wake you up. No matter where you are, it's going to embarrass you. And it just lets you know that your glucose level is dropping and it's a lot easier to fix glucose levels when you're at 69 than when you're at 49.

Maria A. Mogollon, MSN, APRN, FNP-BC:

100%. This is a question that I've been asked, but I want to ask you. And it's like, who is not a good candidate for a continuous glucose monitor? Who do you consider could not benefit or could be not a good candidate?

Jeff Unger, MD, FAAFP, FACE, DACD:

It's our job to make sure that everybody wears the sensor. I don't know of anybody that's not a good candidate. I think everybody should be a candidate. And we use these a lot in people. This is off-label, but for pre-diabetes, we use that. There's going to be some over-the-counter sensors that are going to be available in the next month that can help people determine if exercise lowers their glucose levels, the effect of lifestyle intervention, the effect of food. I mean when you eat pizza and your blood sugar goes up or Chinese food, your blood sugar goes up and you see this on the sensor, it doesn't mean you have to stop eating this stuff, but it may mean you eat a little bit less or change your dietary habits. Everybody's a candidate and my job is to convince everybody that this is the way it works. And in relation to the question, even if patients don't want to do it, we make them do it anyway. And when they come in, they're thrilled.

Maria A. Mogollon, MSN, APRN, FNP-BC:

I also have, and I ask you this question because in my population of patient, I have patients that they refuse to have any type of device attached maybe because of static, some because of they just don't know how this work and how do you manage those type of patients that they actually, they don't want to use, they don't mind pricking their finger, but they refuse a continuous glucose monitor?

Jeff Unger, MD, FAAFP, FACE, DACD:

If they don't want to do it, then all we could do as providers and clinicians is to do the best we can, Maria. But there could be a little bit of a stigma that I've heard about wearing the sensors out in public. I'm going to tell you something. I was at a beach a couple months ago just walking around and I saw five people wearing sensors. And I walked up to them and said, how do you like this? And universally they said they love this. They'd never go anywhere without it. And there's a couple of patients that had type one diabetes that said, this saved my life. You get all this positive feedback. Everybody wears these sensors as a badge of honor. It's not embarrassing. Even going through TSA at the airport, they don't beep, but they see them and they say, you got a sensor? Good. Go ahead. You're good to go. We're very, very proud of the way that these sensors are being taken up in the general population today.

Maria A. Mogollon, MSN, APRN, FNP-BC:

I agree. I agree. And in terms of cases, like for example, I think you mentioned having a patient that she's a 32-year-old patient, type one. And tell me a little bit about that story because it's very interesting to hear what happened and how did you manage that?

Jeff Unger, MD, FAAFP, FACE, DACD:

Yeah. Type one diabetes, you've got a soccer mom, 32 years old and it is 2:00 in the afternoon, Maria. She ate two hours before she checked her blood sugar. She ate at noon. 2:00, her blood sugar is 112. Now remember, this is a type one patient that used rapid acting insulin at noon. Her blood sugar out of finger stick is 112. She's loading up her van, putting all these kids in the car, they're going to drive 20 miles to soccer practice. Maria, is this patient safe to drive?

Maria A. Mogollon, MSN, APRN, FNP-BC:

No.

Jeff Unger, MD, FAAFP, FACE, DACD:

Right. We don't know because when you use a finger stick, that's what it is in that moment in time. However, the truth is that if you use rapid acting insulin two hours after you inject it or bolus it, you still have 60% of that insulin on board. Her blood sugar is likely to be dropping. The patient may be reassured 112, that's a pretty good number. If you put her on a sensor, the sensor is going to detect if the glucose level is trending up, down or there's no trend, it's going straight across. You see the importance here of knowing what your blood sugar's trends are? And that's what people really, really like about using CGM.

Maria A. Mogollon, MSN, APRN, FNP-BC:

Perfect. Now let's talk about the report. What's the first thing you look at when you have the report, if it's [inaudible 00:17:45] or Freestyle, any type of continuous glucose monitor report? What is the first thing you focus on?

Jeff Unger, MD, FAAFP, FACE, DACD:

Well, about six years ago, I think it was six years ago, I may have lost track, but a group of very intelligent doctors, I don't know why they didn't invite you and me, but they went to a meeting and they developed something called an ambulatory glucose profile. The AGP report is used by all these companies that make the sensors. It's a one-page document that doctors and patients alone as well can look at to see how they're doing. It gives you a lot of information. The first thing we look at is time and range, also known as time and target. We want to get this value in the range of 70 to 180 70% of the time. Why? Well, it turns out Maria, if you're 70% of the time in the green zone or in the safe zone, that means your A1C is going to be close to 7%. The next thing we'll look at is time below range. We want this hypoglycemia range, which is anything under 70, to be less than 4%. The ADA is going to be changing their guidelines pretty soon, but right now AACE says 4%. That can be reduced to 2% if you've got somebody that's elderly, frail, has heart disease and has diabetes as well. That's what we look at at the AGP report. The next thing we look at I already mentioned is the GMI. Then we look at something called glucose variability or the GV. What we're looking at here, and I tell this to patients, is we're looking at the roller coaster ride of diabetes. The flatter the line, the better it is. The trend line, when it goes up and down like a roller coaster, can increase the risk of not only getting complications of diabetes, but could also increase your risk for hypoglycemia. The bottom line with this GV is we want it less than-three percent. If you're under 33%, good for you. If you're 50%, that means you're on the roller coaster ride. Now this is very important to the listeners. Diabetologists like flat lines, very, very important. What do cardiologists do when they see a flat line? Well, they get really nervous and they're going to come by and they're going to shock the person back to life. What about a neurologist? If a neurologist, Maria, sees a flat line, what are they going to do? Nothing. The patient's dead, donate the pancreas, but we as clinicians in the field of diabetes want flat lines. That's pretty much what we look at at the AGP report. We can see a lot of other data as well. We can see trends over several weeks or months. But you know what? Patients see the same thing and they know how to interpret the data. It's a lot easier to look at this stuff than it is to look at an EKG. It's easy.

Maria A. Mogollon, MSN, APRN, FNP-BC:

I agree. I agree. And another benefit I think is that I know it takes some time to analyze the data and it takes time from our visit and I understand is an item that we can bill on. What is your recommendation to all the primary care physician and endocrinologist, dermatologist in terms of billing this type of time or procedure that we are doing at the visit?

Jeff Unger, MD, FAAFP, FACE, DACD:

Well, this is very important. We're working really hard for the benefit of our patient and insurance companies, third-party payers know this. If you onboard a patient with the sensor, you get to bill for that. There's specific codes you can ask your reps about those codes. And then once a month you could download the data. You could actually do this remotely as well. See if they have telemedicine visits, Maria, you could download the data. It could be presented to you on the computer or right at your side where the computer is. Either way. But if you do this once a month, you can get compensated for that as well. You could do it once a month. Onboarding is once a year I believe. But this is the way that we could be compensated for our time. We're not doing this for nothing. We're doing this for the benefit of the patient and in exchange for our time, we can bill for it.

Maria A. Mogollon, MSN, APRN, FNP-BC:

All right. I think this is a lot of good and important information for this podcast. I also have new information for myself. Is there any other comment that you want to share with us, Dr. Unger, or any recommendations for our listeners?

Jeff Unger, MD, FAAFP, FACE, DACD:

I'm going to tell you about a patient by the name of Bob. I'm going to end with Bob. Bob is amazing. This guy is really, really smart. He's a real live rocket scientist, Maria. He works out in Pasadena at the JPL, which is 35 minutes from my office. He designed the Mars Rover. He also works with artificial intelligence. He designed NASA's AI computers, but Bob also has type two diabetes. He comes to see me. As usual, as I told you, I don't give anybody an option. They're going to get a sensor. Put the sensor on, and then I said, come back in two weeks. Let's see what's going on. Bob couldn't wait. He comes back in one week later and he knocks on my door and he said, I got to see Dr. Unger right now. I've got to see him. I got to see him. And I said, Bob, what are you doing here? You okay? He said, I've got something to show you. And he pulls out reams of data. I mean, Maria, he put something on my desk that was six feet tall that came out of this NASA computer. And I said, Bob, what are you showing me? And it was all different colors and shapes and sizes and bar graphs and lines and P values. I said, what is this? He said, he was very serious. Did you know that when you exercise your blood sugar goes down?

Maria A. Mogollon, MSN, APRN, FNP-BC:

Oh my God.

Jeff Unger, MD, FAAFP, FACE, DACD:

No, Bob, I didn't know that. He said, look, it's right here. You should publish this. I'll be the second author. The point is, look how excited people are, Maria, with this technology and look how we could stimulate them to do the right thing. Okay. Is Bob non-compliant? No, he just comes to us for guidance. We put these sensors on and their lives change. And then there's one more. His name is David. David comes in with an attitude and he's got type two diabetes. His A1C is 11.4, so obviously not under control. He's a big time executive. And we put the sensor on and the sensor warm up is about maybe 30 minutes. After we put it on, it warms up, he goes out to the front desk to make his next appointment. All of a sudden he gets an alert saying, your sensor warm up is done. He looks at his phone and his blood sugar is 246. And he starts screaming, look at this. I'm 246. Now, you know that's not a good number, but this is the first time this patient realized what's going on with his blood sugars without a finger stick. And then five minutes later, he's leaving the office, he's going out the front door. He said, well, now it's 249. What do you know about that? We've just given this patient excitement in managing their diabetes. This is how we make people successful. Nobody wants to be treated to failure. We don't need to do that. We have the drugs, we have the technology, we have the techniques, we have the knowledge. We have the ability to help these people not only survive, but do it in the right way. I'm so excited to have spoken today, Maria, and thank you for what you do. And thank you, AACE, for allowing me to be on this podcast and next time you invite me, remind me because I'm on 12 cups of coffee right now and I've had 16 Diet Cokes. I'm a little bit manic, but I hope I got my points across.

Maria A. Mogollon, MSN, APRN, FNP-BC:

Oh, thank you so much, Dr. Unger. We learned so much from you. I have your book and I love it. And every time I want to review something, I go and look for my book and I know you have so much knowledge and it's a pleasure and honor to have this conversation with you. So much information in this short period of time that is valuable for, and especially I know the listeners are going to enjoy it a lot. Thank you so much.

Jeff Unger, MD, FAAFP, FACE, DACD:

Thank you. Thank you to AACE as well, Maria.

Maria A. Mogollon, MSN, APRN, FNP-BC:

Thank you at AACE. Yes.

Speaker 1:

Thanks for listening to another great AACE podcast. Join us for another episode at aace.com/podcasts and help us in our mission to elevate clinical endocrinology. Together, we are AACE.