Narrator - Dr. Abel 00:00 Welcome to HelixTalk, an educational podcast for healthcare students and providers, covering real life clinical pearls, professional pharmacy topics and drug therapy discussions. This podcast is Narrator - ? 00:12 provided by pharmacists and faculty members at Rosalind Franklin University, College of Pharmacy. Narrator - Dr. Abel 00:17 This podcast contains general information for educational purposes only. This is not professional advice and should not be used in lieu of obtaining advice from a qualified health care provider. Narrator - ? 00:27 And now on to the show. Dr. Sean Kane 00:31 Welcome to HelixTalk. Episode 164 I'm your co host, Dr. Kane, Dr. Khyati Patel 00:36 and I am Dr. Patel, and today we have Dr. Sneha Srivastava back with us to discuss all the updates in diabetes. Thank you for joining us again today, Dr. Srivastava, Speaker 1 00:48 thanks for having me. It's always wonderful to be on this podcast. Yeah. Dr. Khyati Patel 00:53 So with that diabetes expert joining us, of course, we are going to talk about updates in diabetes. The title of our episode is breaking down the updates, key changes and implications of the 2023 American Diabetes Association guidelines. So here we are kind of talking through some of the important things that are changed as part of this annually changing guidelines. I'll tell you Dr. Kane and Dr. Srivastava. I've had people personally reaching to me and asking me to do this episode. So let's, let's see, this is the most debated episode of the year, and Dr. Patel. Dr. Sean Kane 01:27 Before we get into it, I just want to highlight again how awesome it is that we have annual updates on a guideline from ADA. So kudos to them. And actually, for the listeners, I was actually fairly surprised at some of the recommendations that have come out in terms of this 2023, update. So stay tuned. You're going to see some things that I found somewhat surprising, or, I wouldn't say game changing necessarily, but maybe a little bit game changing in terms of what I learned in school is really falling out of favor in terms of management of patients who have diabetes. So I'm excited for today's episode to educate the listener and what some of those big changes are, Speaker 1 02:02 what's incredible about the world of diabetes is that we're constantly learning, we're learning the different factors that put somebody at risk for diabetes or what causes that hyperglycemia. We're learning different medications and treatment options and how to rethink the treatment options we have. It's very exciting. And I hope that you know, bringing this to the forefront really helps our patients and help optimize their their health outcomes. Dr. Khyati Patel 02:29 One of the cool knit tidbit was that the annual updates, they've been doing it since 1989 so kudos to the team at Ada for doing these updates on a yearly basis, it's really helpful for the clinicians talking about helpful guidance or direction. I think the most important ones, the most commonly cited chapter of this guideline, is the pharmacy recommendation, which is chapter nine. So it makes sense that we start from there. And the changes that were made this time around were to align their recommendation with the easd Ada combined consensus report. Every time I teach this algorithm, I have to look at the updates, and I feel like every year, they're making my job harder, because it's not straightforward. It was never straightforward, and it's kind of becoming a little bit convoluted, but I would say more, more like individualizing based on the patient you have in front of you. So what are some of the changes, or kind of, like the themes we are seeing in this recommendations for pharmacologic therapy, Dr. shavasana, Speaker 1 03:34 so we're really focusing on the patient as a whole and what other medical conditions they have as well. So of course, we want to treat the hyperglycemia, but we're also looking at other comorbidities, including Cardiovascular and Renal comorbidities, and then we're also looking to see what impact these medications have on blood glucose reduction, weight and then other adverse effects as well. And so there's so many different components we're taking into consideration when we're choosing which medication to start with with our patients, Dr. Sean Kane 04:05 one big decision point that it's pretty clear in the kind of the figure from the guidelines that we'll have cited in our show notes, is the main question you're asking initially is, is your goal this cardio renal impact, where you're giving a drug To reduce the risk of future ascvd events or chronic kidney disease as a result of poorly controlled diabetes. And if that's your main goal, because they're at risk for those things, that really does change your management in terms of what drugs you're likely to start with for that patient. Speaker 1 04:35 Yes, for so long, we started with metformin, and that was just unless somebody had a contraindication to it or was not able to tolerate it. That's where we started. And Dr. Patel, where? Where are we at with metformin? Dr. Khyati Patel 04:47 Yeah, you know, every year I feel like Metformin got a little bit of a kick to the side. And I feel like this year it, at least it appears to me. And my interpretation of this rubric is that it's not in the. Picture. It is in the picture, but not as a first go to medication, right? And this was a big change. Even some of our students who have learned this in the previous year are coming to wrap their heads around like what Metformin is not like the first thing that you start in a type two diabetes patient, and that's what it is. So what, what you said earlier? They want us to look at patients comorbidities, and if they have these cardiovascular comorbidities, such as they have ascvd or high risk of ascvd, or they have heart failure, then you have certain medications to go to, namely sglt Two inhibitors or GLP one receptor agonist that have that primary evidence. And then for renal issues, we are focusing on CKD, or looking at diabetes, kidney disease and the risk factors, and then using medication such as sglt two ion and GLP one receptor agonist again, so they're kind of like coming up in the limelight, especially when you have these comorbidities. Dr. Sean Kane 06:00 And Dr. Patel, I will mention that something that we'll likely talk about a little bit later is for those patients that either have a CVD or at high risk of ascvd, the first two go tos are your GLP one receptor agonist and or your sglt Two inhibitor. But I see on the chart here that TZDs are listed in this category, and that's surprising to me, because it was my impression, at least, that because of the rosiglitazone fiasco with maybe increasing the risk of heart attacks and the edema that you get, and it may be implicated in terms of worsening heart failure, I thought TZDs were off the map a lot more than what I'm seeing on the document here. Dr. Khyati Patel 06:38 Yeah, they're certainly not recommended the first line, but there is in certain niche population benefit from stroke and heart attack, especially with pioglitazone. And so that's where that recommendation you're referring to is coming from. Speaker 1 06:53 Dr. Kane, we are starting with the risk factors and comorbidities, but not all our patients meet that criteria. So then how do we determine what medications to choose for them? And so when we look at this algorithm, the other side, there's a left side that focuses on the Cardiovascular and Renal risk reduction, and then the right side, looking at it, focuses just on your other overarching goals. And so each of these are really focused on the individual and what their goals may be. And so common goals are efficacy, of course, to achieve their goal, a, 1c, and time and range. We're also looking to see what their weight management goals are, and if patients are presenting with obesity, then we are also considering which agents to choose for patients that are less likely to have a side effect of weight gain. And then, of course, cost is a consideration as well. Dr. Sean Kane 07:50 And one thing that kind of stands out to me on that right side of the chart, when we're looking at higher efficacy of glycemic control and the higher efficacy for weight management, DPP, four inhibitors like Januvia, Sitagliptin as an example. They're pretty low on the totem pole when it comes to reducing your a 1c or you're helping with glycemic control, and also pretty low in terms of not really causing weight they don't cause weight gain, but they also don't really cause weight loss. 510, years ago, these were very popular oral medications, and still are to some degree. So those are not falling out of favor, but a little bit in terms of we're seeing some of these other therapies that are causing weight loss and have more potent glycemic control. So what are some of those other ones? If we're not using our DPP four inhibitor as much, Speaker 1 08:36 that's also where the GLP one RAS come in. We see good weight loss with that class of medications. We also have a newer medication, tirzepatide, and that also has very high efficacy for weight loss. And then if we're not using our GLP ones, or this GLP one, Ra slash, gi P agonist, then we also have our sglt, two inhibitors that are associated with weight loss as well. Yeah. Dr. Khyati Patel 09:07 So I think the way I look at this algorithm again, you know, not easier for students to grapple with, but for clinicians and advanced students to consider, is therapy is highly individualized. You gotta look at a big picture. You know, it's not necessary that these comorbidity patients don't have the need for weight loss or the weight loss patients don't have, you know, any of these comorbidities. You kind of have to, you know, do what best for the patient. That's supported by the evidence. The other thing I noticed, Doctor shavassa, you can chime in on this too, is that they kind of reconfirmed the use of GLP-1 receptor agonist over prandial insulin, you know before, before going the prandial insulin route, absolutely. Speaker 1 09:53 And so, you know what I always tell patients and I tell students, I really think it's important that we start our conversation. Questions with our patients, with the value of insulin. The place of insulin, insulin is truly a lifesaver, and so when you need it to help bring blood glucose levels to goal, then we use it. But with the addition of these newer medications and these newer mechanisms of action, what we found is specifically with GLP one Ra, we can impact prandial glucose so we don't need to start our mealtime insulin in our patients as early as maybe we needed to in certain patients with type two diabetes. And these GLP one RAs, help with lowering blood glucose, the prandial levels, and they are also less likely to cause hypoglycemia and less likely to cause weight gain. In fact, they, you know, help promote weight loss. And so the combination of using a basal insulin in patients that need it, and then a GLP, instead of like a meal time, insulin is really the way to go for many of our patients with type two diabetes. Dr. Khyati Patel 11:00 So with us painting that larger picture, maybe we can dive down to some of these comorbidities and where the recommendations have been updated. So kind of honing on to the left side, you know, going through the cardiovascular risk. I think one thing that they did for us, which is a good thing, and this is always a topic is defining what they say hypertension, right? We know that there was one point the SBP goal was regarded as, you know, less than 120 because, you know, other trials that didn't include diabetes patients looked at that however. They stuck to their 140 over 80 goal, and now they've kind of said, Okay, we want to be in consensus with all the other cardiovascular guideline bodies and say that hypertension is when systolic blood pressure is 130 or above and diastolic blood pressure is Speaker 1 11:57 80 or above. And then to keep in line. Our goal is to have patients reach a blood pressure goal of less than 130, over 80. And so that's nice, because having all these different numbers to try to remember, depending on which guideline you're following, could be confusing. Dr. Khyati Patel 12:16 Yeah, and with that, they are saying, you know, you could definitely do medication therapy for reducing blood pressure when you are above that systolic or diastolic blood pressure. Some of the other changes I noticed were in terms of dyslipidemia therapy, and this is aligned with, you know, reducing the cardiovascular risk reduction. What were some of the updates there? Dr. shivaswa, Speaker 1 12:40 so in patients with diabetes, and then a high ascvd risk score. So they're defining that as greater than 20% we want to use a high intensity statin to help lower LDL by 50% from baseline or get to a goal of LDL of less than 70. They also discuss the role of ezetimibe or PCSK9 inhibitors as well adding it to maximum tolerated statin. So Dr. Kane, do you want to talk a little bit about that? Dr. Sean Kane 13:08 Yeah, so this is kind of in line with what we would traditionally have for patients who had a history of ascvd, where they would get a high intensity statin, and then the data for ezetimibe or PCSK9 inhibitors, primarily was in people who had a heart attack, for example, and they would drive that LDL even lower. So it's interesting here that it's for primary prevention in the setting that potentially they're suggesting Zetia might I think people don't get too worked up about but those PCS canine inhibitors are injectables, and they cost a lot of money. So it is interesting that the guidelines are suggesting that as an option for people who are at very high risk but haven't yet had an ascvd event. Yeah. Dr. Khyati Patel 13:46 And I think if you're talking about goal based therapy in patients with diabetes and existing cardiovascular history or ascvd, they are aiming for LDL goal of less than 55 and I was, you know, and as we discussed earlier, to Dr. Kane, this is a little bit of a surprising goal. First of all, we don't go after LDL goals unless a patient has presence of ascvd. And then to that, even we aim it to less than 70 this less than 55 goal was very interesting. And from what I gathered, there's not a whole lot of discussion about why they came up with these goals, but what I gathered is that their rationale for coming up with a certain goal is because they're thinking it's difficult for patients to obtain that baseline LDL because usually when we apply a high intensity therapy, we're aiming for 50% or more LDL reduction from the baseline. But when you have patients, you're treating where we don't have the baseline levels, it's rather than comparing that reduction, it's easier to just go for that. You know, we're going to keep your LDL below this level. When it comes to that stricter goal, it's based on couple of meta analysis which are not relatively new, and a few of the randomized. Control trials that are also not relatively new. Dr. Sean Kane 15:03 And another thing that came up that really is not a surprise to me at all is the recommendation that sglt Two inhibitors should be used in patients who have diabetes who have either reduced ejection fraction heart failure or preserved ejection fraction heart failure. And we've covered this on the podcast several times, but these sglt, two inhibitors are effective in treating heart failure, both types of heart failure, whether a patient has diabetes or not, and the effect is actually similar, which is really interesting. So again, not a surprise, the heart failure guidelines already support this, but it's nice to see that the ADA guidelines have also gotten in line with that same recommendation. Dr. Khyati Patel 15:40 Yeah, and then the recommendations for use of sglt two eyes in terms of cardiovascular morbidity, mortality, was already there. What they added is a few others trials that looked into specific parameters, such as improvement of the symptoms. How are patients feeling right? It's a quality of life, and whether adding this medication had improvement in, like, some of the physical limitations, or not. And so because, you know, ADA guidelines updates are pretty evidence based, they kind of added this as an additional recommendation that you're not just doing it to reduce cardiovascular risk, you're really making patients feel better by adding these meds on topic. And that's Speaker 1 16:18 important to have those discussions with their patients, right? Because some of those cardio renal risk reductions you're not necessarily seeing that day to day, but I am certainly seeing how I feel day to day. And so having those conversations that kind of wrap both sides of that is really helpful, and we have evidence to back that up, too. And so speaking of sglt, two inhibitors, they are also recommended in patients with chronic kidney disease. And so when we think about our patients with type two diabetes and chronic kidney disease with albuminuria, they should be treated with ACE inhibitors or or ARBs. And then we have a newer medication on the market now that also may have a role. Dr. Khyati Patel 16:57 Yeah, this one to me, it came up a little bit as a surprise, but what they're recommending is that in patients with type two diabetes and CKD with albuminuria, who are on maximum tolerated doses of ACE or ARB, they're recommending adding a mineral corticoid receptor antagonist called phenomenon. The brand name is corundia, and this is based on a couple different trials, Fidelio DkD and then Figueroa DkD trial results. Dr. Sean Kane 17:25 So one of the trials is called the Fidelio DkD trial. This was a trial that looked at renal outcomes in people who had diabetes who also had CKD. They gave them phenerinone versus placebo. What they found was in a composite endpoint that basically captured progression of chronic kidney disease, they reduced the progression by about 18% so the hazard ratio was point eight two. Taking phenerinone helped the kidney and a separate trial called the Figaro DkD trial, they looked at a cardiovascular endpoint and a fairly similar patient population, and they had a composite cardiovascular endpoint that included things like cardiovascular death and my stroke and heart failure hospitalization. And they did show a reduction in that composite, a 13% reduction, but interestingly, that was primarily driven by a reduction in heart failure, hospitalization. Now this is interesting for two reasons. One, it doesn't appear that it really changes the risk of heart attacks, strokes and cardiovascular death. It was primarily reducing heart failure exacerbations, but two, we already have mineralocorticoid receptor antagonists that are used for heart failure treatment, not for prevention, but for treatment. We already know that they're effective for that. So it is interesting that this is more of a preventative strategy in a high risk group, as opposed to treating heart failure. But we do have other agents already on the market that have just been studied in a different way, not specifically in patients with diabetes, either. Dr. Khyati Patel 18:51 And the other update in the CKD world, which is a tiny bit update in favor of sglt two I use, is that the cut off for benefit was the EGFR of 25 or above, but then we have data from the Emperor heart failure trials for patients with EGFR as low as 20 were included, and they benefited from Adrenal outcomes as well. And so now they are saying that you could use sglt twos as the EGFR as low as 20, and then a micron in ratio of 200 or above to get that renal benefit. Speaker 1 19:31 And then we know with diabetes complications, we also have the risk of microvascular complications. And neuropathies are one of the more common ones, and there can be everything peripheral neuropathy to gastroparesis, to erectile dysfunction, to many more. And so the consideration of treating these microvascular complications with appropriate medications is also highlighted. And so that might be SNRIs, your. Or TCA sodium channel blockers, depending on what type of neuropathy a patient's having. Dr. Khyati Patel 20:06 Yeah, in the past, the evidence, or the, quote, unquote, the initial therapy was like the go to therapies were gabapentinoids and the duloxetine as one of the SNRIs. The surprising fact is that they're adding some other SNRIs, like when the facts seen that spin the vaccine, as well as the TCAS, like amitriptyline as well as sodium channel blockers, like Lamotrigine, glosamide, oxcarbazepine and valproic acid as initial therapies, as opposed to it, kind of opened up with the list of possibilities that you can have for the patients. I think Dr. Sean Kane 20:39 that's important to highlight, because if you think about the range of possibilities Dr. Patel that you just mentioned for neuropathic pain, right, there is a lot of different pros and cons to Gabapentin versus an SNRI versus TCA versus something like Lamotrigine, right? So again, kind of getting back to the idea that really a lot of this is very patient specific, in terms of the values of the patient cost, the perceived side effect, drug interactions. There's a lot going on here, and I love that that really highlights the potential role of a pharmacist here, and that, you know, we are the drug experts. We know a lot about Lamotrigine and lecoins and things like that, to help educate providers who may be less familiar with these other options that they're choosing those because they're trying to avoid the sedative quality of gabapentin, for example, or the sexual dysfunction of SNRIs. You know, there's a lot going on here that really highlights patient specific, individualized therapy, 100% Dr. Khyati Patel 21:35 and then kind of, you know, taking the turn from our main comorbidities with diabetes going along with some other comorbidities that we don't get to hear or talk about much, and that's the non alcoholic fatty liver disease, or Nash Dr. Shrivastava. Can you orient the audience? Just really quickly as to what these acronyms are, and you know what is its impact in patients with diabetes. Speaker 1 22:01 Currently, there aren't any medications approved to treat Nash, and so when we think about Nash and NAFLD, NAFLD is more of the global universal term, and then Nash is a more severe complication, or under non alcoholic fatty liver disease, and there are no current treatment options to treat Nashville. What we really need to do is address the what's associated with it. And so patients with hyperglycemia and patients with obesity, especially if there's fibrosis present, have more negative outcomes, and there's a higher risk of progressing to liver related mortality, and so we really need to focus on treating that hyperglycemia and obesity, you know, in general, but specifically with patients that are either diagnosed with NAFLD or at our risk Dr. Khyati Patel 22:54 of it, and this untreated fibrosis then kind of leads to that cirrhosis, right? That's where, kind of, like, the negative outcomes and liver related mortality comes in play. Dr. Sean Kane 23:03 What's interesting about this is, in my head, when I think about poorly controlled diabetes care, I think about micro and macro vascular complications, which we've kind of highlighted. Actually, was not that familiar with Nash or cirrhosis being associated with diabetes care. Is this a common thing in terms of patients who have type two diabetes developing Nash or an AFLD, Speaker 1 23:26 10 to 15% of people with type two diabetes also have Nash with significant fibrosis. Dr. Sean Kane 23:34 So that's pretty substantial number. And I'm going to go out on a limb here and assume that GLP one receptor agonists have a role here, given how they reduce weight. And we love these new medications, and they're amazing, and they're first line for all sorts of patients, yeah. Dr. Khyati Patel 23:48 And so highlighting that, Dr. Kane, you know, the importance of lifestyle changes, especially weight loss, is highlighted for the treatment of the umbrella and AFLD, or the Nash in general. And they're actually saying, you know, use obesity pharmacotherapy. There is a chapter, chapter eight in the guideline that outlines obesity and diabetes and then possible pharmacotherapy. But you're absolutely right. They're now highlighting GLP one, Ras, and not just any, but there's couple that have randomized control trials done so talking about these GLP ones, we have two that are studied specifically in this patient population. The liraglutide study was a little bit smaller, and it showed that there were some features of Nash that was improved as well as it delayed the fibrosis progression, which is kind of like the parameter, the outcome that we look at in this patient population. So semaglutide, however, had a relatively larger study. They looked at outcomes such as, you know, resolution of Theo hepatitis, which is like that fat induced inflammation that happens in the liver that ends up increasing some of your liver enzymes. They also. Looked at 72 week study was 72 weeks about progression of fibrosis. And what they found in both of these parameters, that the higher doses of somacotite they studied different doses did lead to resolution of steatohepatitis, 59% in the highest semaglutide dose group, versus 17% in the placebo group. And this was statistically significant. And then when it came to looking at my progression of fibrosis, it was 4.9% versus 18.8% in the placebo group, and this was also statistically significant. Dr. Sean Kane 25:34 So kind of interesting. You know, this is not a disease state that has been commonly looked at historically in patients who have diabetes. So it's kind of exciting one that we have some data. Have some data, and two, that we have a drug that might be effective for that, and even if it wasn't effective, to be honest with you, we probably would still use GLP, one receptor agonist, because of all of the other benefits that we get from a weight loss and a cardiovascular perspective, the thing that kind of stuck out to me Dr. Patel was pioglitazone, so Actos, this is one of those thiazolidine diones or TZDs that, again, I thought that these were way off the map in terms of ever being recommended, but I'm seeing here that they're now recommended in patients who have this, an AFLD or a Nash cirrhosis, as a way to delay the progression of that liver disease. And there's some data for pioglitazone and treating steato hepatitis, so in that fibrosis and maybe even decreasing the cardiovascular risk as well. Dr. Khyati Patel 26:31 Yeah, and this is really coming from pioglitazones ability to reduce that insulin resistance and impact on lipid metabolism. These two are like that underlying pathophysiology that causes, you know, fat deposit into the hepatocytes and leading to NAFLD type picture. So that's where the mechanism appears that its own comes in handy. You know, we were highlighting the importance of weight loss and GLP one. Dr. Srivastava, what were the updates in the obesity and weight management world when we are considering type two diabetes treatment, Speaker 1 27:04 and I am so glad that there is a chapter that focuses on this. And Dr. Kenn and I were just talking yesterday about this as well, how it's taken a long time, but slow strides are being made to truly recognize obesity as a chronic disease. You know, it's not just something that that's just there or it's a person's fault. And so, yes, absolutely reinforcing the obesity is a chronic disease, and that even with smaller and larger weight loss, like some smaller end, like 5% or higher, like 10 to 15% we see positive health outcomes that lead to disease modifying effects diabetes remission and long term cardiovascular outcomes and improvement. And we have medications that we know help with the weight loss, like our GLP-1 RAs. And then we started talking about our new medication, tirzepatide. Dr. Khyati Patel 28:21 Technically, this is, as you described earlier. It's a GI P, GLP, one agonist, molecule, dual molecule. It's technically not approved by FDA for weight loss. However, a recent phase three trial did show significant weight loss data compared to an active comparator, not placebo. The active comparator was somagotide, and we've talked about this in Episode 153 when we discussed trip zapitite. So listen to that episode for more details. However, in general, those are the reasons why tridzapatide Now merits its place in this Dr. Sean Kane 28:54 chapter for therapy. I think just for the listeners benefit, it might be a good idea to just cover some of the brand names, because some of these GLP one receptor agonists have a brand name for the diabetes indication and then a separate brand name for an obesity indication. And patients may not realize that they are getting the diabetes version of the medication or the obesity version of the medication, but it truly is the same molecule, typically a different dose, though, Speaker 1 29:20 absolutely, that's a great point. So with semaglutide, it's ozempic, and that's the diabetes indication, and we go V for the weight loss and with laratide, we have Victoza with the diabetes indication, and then sex Senda for the weight loss indication. Dr. Sean Kane 29:34 And then in terms of special populations, so it looks like there's some updates in the 2023 guidelines with respect to special populations. One area I know is older individuals. What? What's new or different with the older patient population who have diabetes? Speaker 1 29:51 We can combine this conversation with the use of technology. You know, when CGM came out, we weren't exactly sure where we saw some evidence of who would benefit. Bit most from it. But what we're finding is that many people with type one and type two diabetes for similar reasons and differing reasons, benefit so specifically in older individuals, the use of CGMS has been emphasized for people with both type one and type two diabetes to reduce that risk of hypoglycemia. We're also considering other types of technology, like automated insulin delivery systems and connected pens as well to help reduce that hypoglycemia risk. Dr. Khyati Patel 30:31 And I think I kind of thought about this and thought about why this was specifically added, and I think it's for twofold, because our older patients are at risk of hypoglycemia, so why not use the technology that's proven to reduce the risk of hypoglycemia? And then secondly, we've kind of viewed our older patients as, oh, they're not going to use the technology, or technology as a learning curve and stuff. And ADA wants to just come out and say, that's not the case. Use it, because we have the evidence people who are willing to learn the technology and we can improve outcomes here absolutely. Speaker 1 31:04 And maybe this is where a little bit of biases and implicit biases come into play. And you know, somebody who's getting older, I would like to think that I'm going to embrace technology and all the new things that are out there to help improve my outcomes, and I want my parents to use it, and my grandparents and my older patients. So I think we really think about what are the best options for our patients? Dr. Khyati Patel 31:24 A new recommendation for one of the other special population that was added, and this is interesting, is breastfeeding. They're recommending breastfeeding to reduce the risk of maternal type two diabetes, and especially in patients who've had previous instances of gestational diabetes. And so there's some meta analysis. One meta analysis that looked at 17 different trials where it showed benefit. They are still looking and more studies are need to be done in terms of whether a cardio metabolic risk of the offspring was improved or not. The data is a little bit weak, but it seems like the data for the mothers for the answers of type two diabetes, it's a little bit stronger, and therefore this new recommendation is added. Dr. Sean Kane 32:10 No one's kind of interesting for a couple of reasons. One, generally, breastfeeding is recommended for infant health anyway, but then two, it does make you wonder if some of the benefit is from a weight loss perspective of losing calories by breastfeeding, or if there's some other effect at play here as well. Then in my neck of the woods, it looks like they made an update for inpatient glycemic control care. And, you know, historically and still, there, they make the recommendation that a general glucose target for non critically ill hospitalized patients is 140 to 180 but they said a new recommendation is the option of a more stringent goal, like 110 to 140 or 100 to 180 would be acceptable in patients who have new hyperglycemia or those with known diabetes. This one caught me a little bit off guard, because for the most part, most of the stringent data for glycemic control has not been in the acutely ill patient. It's been the critically ill patient, and there's a whole like bag of worms opening up with respect to that. So this one caught me off guard a little bit in terms of why they were opening up to a somewhat more stringent goal, especially in a non critically ill patient population, Dr. Khyati Patel 33:22 yeah, definitely a different one. I try to look into again, what evidence they have. And if you look at the discussion portion of it, it says it's more of an expert consensus. There are no new trials in the non critically ill patient but from what I can see, they're drawing conclusions from those critically ill patient trials that did show benefit with stricter control. Dr. shavastava, you mentioned technology earlier, and I know there's tons and tons of updates in technology coming up. Were there any specific updates in the technology chapter, which is chapter seven? Speaker 1 33:54 Yes, we can definitely go through that. And if I'm remembering correctly, Wasn't there an episode that you all did on that that was their first CE episode, Dr. Sean Kane 34:02 yes, so episode 162 for the audience, if you still want, you can get a one hour of CE credit for episode 162 cost $5 but that's pretty cheap for a one hour CE. So that's available at our website, helix tech com. Speaker 1 34:17 You know, rather than the word cheap, I'd like to say it's inexpensive and it's worth your time and effort for it. So some of the things that were highlighted in this chapter was with people taking basal insulin real time. CGM has a higher level of recommendation versus intermittent scanning. That being said, as the technology is changing, our CGMS mostly will be real time. Also, they are recommending uninterrupted access to CGMS for all patients with diabetes, because they have seen that interruption in this access can worsen outcomes. We also know certain. Substances interfere with the readings. And so they highlighted that. Dr. Patel, would you want to talk more about that? Dr. Khyati Patel 35:07 Yeah, I know we knew about different substances that can interfere with different systems. They just did a nice job of putting a table together for the audience to know what those substances are. You know, we've covered those in that CE episode, if you want to listen more to Speaker 1 35:21 it, and then glucose targets. And so we are continuing to look at a 1c and they do mention the types of a 1c tests that we should be using in our patients. Of course, those that are FDA approved and making sure trained personnel are using the appropriate point of care a 1c test. And then the second thing that we're looking at is time and range. And so time and range for many of our patients, the magic number we kind of think about, is 70% but in certain patients, especially at those that have a higher risk of low blood glucose, we can loosen that time and range goal a little bit to greater than 50% and really focus on having people at this higher risk of hypoglycemia to spend as minimal time as possible, but less than 1% below range, Dr. Sean Kane 36:12 and this is somewhat in line with previous guideline recommendations in terms of a slightly more liberal a 1c goal For that frail or elderly patient, is that correct? Absolutely. Speaker 1 36:23 And I think you know, just thinking of it as well like going beyond age and kind of looking at that patient holistically when we're determining what their a 1c or a time and range goal should be, Dr. Khyati Patel 36:34 and all of these changes and outcomes and positive impact on diabetes control can't come about until we implement some behavioral changes too, right? So there is a nice chapter on Implementing Behavioral changes. They kind of change the in the true fashion of being positive and inclusive in the language. They change the name of the chapter as well, but kind of highlighting, again, weight loss and its benefit in efficacy of up to 15% weight loss has been highlighted. So as we discuss some of those medications, GLP, one combined. GLP, one. Gip, don't, don't be afraid to use it, because we know that that promotes better outcomes. Speaker 1 37:17 And then when we just think about all the other components of health. It's no different when it comes to a person with diabetes, really focusing on sleep, we know the negative health outcomes associated with poor sleep, and then also focusing on just psychosocial care and foreign patients that we may need to to mental and behavioral health professionals. And then a new section that's one of my favorites in this new standards of care, is a discussion on how we can support positive health behaviors. And so we, of course, know any of these health behaviors, whether it is, you know, we talked about what medications, but medication taking is a health behavior that patients may choose to do or not do, or changing lifestyle like sleep or exercise or healthy eating. All of that is healthy behavior changes that a patient needs to make. And so we have this important role of supporting that. And so that might be things such as motivational interviewing, seeing where our patients at and their willingness or desire to participate in what their goals are, helping with goal setting. You know, we always want to put a goal like, I'm going to lose 40 pounds in this next month, and then are really disappointed, right? And so working with our patients to see what their overarching goals are, and then help them create ones that, you know, maybe it is 40 pounds, but that's over the next year and a half. And like, what can we do in the meantime? Discussing problem solving. They may be going on a trip and worried about their insulin or GLP, and where do they stop? Store that and working with them. Dr. Khyati Patel 38:57 And that's really important, Dr. Srivastava, because this is a condition that the patients live with day in and day out, and we need to kind of take that chronic approach and make sure that they're meeting their goals, they're sticking to their goals, they're being supported in their goals time after and again to reach good health outcomes and to just kind of wrap up the conversation on some of the other updates that the guidelines included is kind of focusing more on the person first language, inclusive language, right, making people feel included in their care in a in a more respective manner, language that is free of stigma, that invite change and discussion and shared decision making are included and promoted some of the other good changes they're focusing on or emphasizing on, our community change agents. These are our community health workers using their help going out and reaching people using different forms of digital health, like tele. Health, and then kind of focusing on special population need, and not, not special in sense of their disease states or their age, but especially in case of, you know, culturally, where they come from, right? So patients who are of migrant communities, who come here for maybe seasonal agriculture workers, they're kind of reaching out, branching out, and focusing on all of these people and how to improve care in them. Dr. Sean Kane 40:27 Well, Dr. Patel and Dr. Srivastava. Thank you so much for your time today. You know, this is an area that I don't see as much of, and it's always interesting to see the annual updates. And what's new for me, one clear thing is the emphasis of obesity management, the love of GLP one receptor agonists, and I'm still shocked to see pioglitazone on a list anywhere. So that was a big deal for me to see that as well. For the audience, we'll have some show notes and a link to the 2023 American Diabetes Association standards of care guidelines, where you can look at those beautiful charts and graphs and things like that that's at our website, at HelixTalk.com Again, this is episode 164 so with that, I'm Dr. Kane and Dr. Khyati Patel 41:09 I'm Dr. Patel and Dr. Shava. Thank you so much for joining us and providing your wisdom in the care that we provide for our patients with diabetes. Speaker 1 41:16 Thank you. Thank you for having me. It was a pleasure to be here Dr. Khyati Patel 41:19 and to our audience. Study hard. Narrator - Dr. Abel 41:22 If you enjoyed the show, please help us climb the iTunes rankings for medical podcasts by giving us a five star review in the iTunes Store. Search for HelixTalk and place your review there Narrator - ? 41:33 to suggest an episode or contact us. We're online at HelixTalk.com thank you for listening to this episode of HelixTalk. This is an educational production copyright Rosalind Franklin University of Medicine and Science.