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. Narrator - ? 00:11 This podcast is 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, 179 I'm your co host, Dr. Kane, and I'm Dr. Khyati Patel 00:35 Dr. Patel. And the title of today's episode, to not our surprise, is annual dose of sweetness the 2024 updates from American Diabetes Association guidelines Dr. Sean Kane 00:46 and Dr. Patel. I think this is an amazing episode every year that we do this, because it really highlights the fantastic work that the American Diabetes Association does, where they go through all of this literature and update this really large document in terms of how to best treat patients who have diabetes. Dr. Khyati Patel 01:04 So not only is surprising that, you know, these scholars sit together and review plenty of literature that amounted over the year, because, you know, diabetes is pretty prevalent, and so there's a lot of studies and related literature, but this document is actually a live document, so you download a 2024, standards of care as a PDF, but they might be making some changes as they go along. So it's always a good idea to bookmark the reference and access it through electronically, because they might be making some changes. So they call it the live document, and we do have that included in our show notes. Dr. Sean Kane 01:40 Well, Dr. Patel, if you had to pick one thing from the guidelines, that was one of the bigger updates, what do you think it Dr. Khyati Patel 01:47 would be the biggest updates? Being a pharmacist, I know this is a very well represented interdisciplinary organization, and you know the guidelines are also very reflective of multi pronged approach. And so there was a little bit for everybody. From a pharmacist perspective, I felt that the medication changes, such as, you know, specific inclusion of tirzepatide, when to prescribe glucagon for patients with hypoglycemia, as well as clarification on teplizumab and when to use that. Those were kind of like the bigger highlights of the entire guidelines, and then there are some other medication or intervention related changes, as well as screening changes that are recommended. Dr. Sean Kane 02:28 Why don't we start with tirzepatide? You know, this is one of those medications that is getting hot in the media, just like ozempic in terms of its weight loss potential, and I think most of the lay population doesn't know about it from a diabetes standpoint. So this is munjaro for diabetes, and Zepbound, the brand name for obesity. What did the guidelines say about tirzepatide? Yeah. Dr. Khyati Patel 02:50 So Zepbound was FDA approved as a result of, you know, the SURMOUNT-2 trial back in November of 2023 so that is fairly new, and considering these guidelines were published mid December. They caught this pretty quickly. And so what the guidelines did is they added Zepbound as a weight loss medicine for patients with even type two diabetes in chapter eight. Chapter Eight basically talks about, you know, management of weight in patients with diabetes. And so they included tirzepatide as a comparable medication, along with semaglutide for patients with type two diabetes to use for weight management. Dr. Sean Kane 03:28 Then way back in HelixTalk episode 153 we talked about this already, more for its diabetes potential, but also its weight loss potential in patients who have diabetes, right? Yeah, we did. Dr. Khyati Patel 03:38 And kind of just talking separate arm, which was a weight loss arm. There were, you know, the SURMOUNT-2 trial which led to the approval, but there were four other SURMOUNT trials that tirzepatide was studied against placebo, and they found that mean difference in total body weight loss were 9.6 to 20.8% compared to placebo, leading up to 25 kilogram more weight loss than the placebo. And obviously they looked at, you know, 5% 10% 15% and 20% weight or more weight, and they found that, you know, the tirzepatide actually was better in all of those categories compared to placebo. Dr. Sean Kane 04:15 So then, from management of patients with type two diabetes standpoint, weight loss obviously has cosmetic benefits to it. Is there any reason why something like tirzepatide would be used beyond its weight loss benefit, but for other reasons as well, right? Dr. Khyati Patel 04:30 So tirzepatide is a GLP-1 and GIP receptor agonist, so it does provide pretty significant a1c reduction as well for patients, and the guidelines clarified the place in therapy for this particular agent and said, Hold your horses before you exhaust oral medication and go directly to insulin therapy. Please use either the GLP-1 receptor agonist or the dual GLP-1 and GIP receptor agonist before you move on to the insulin therapy. Now insulin therapy is important if your patient has very high A1c, signs of catabolism and stuff, but for most patients who are kind of gradually progressing, you could intervene with one of these incretin therapies first. Dr. Sean Kane 05:18 And just for clarity, for patients with type one diabetes, we don't use these therapies, but for type two diabetes, we do. Are there any patients who have type two diabetes that would be poor candidates for something like a tirzepatide? Yeah. Dr. Khyati Patel 05:31 I mean, we are hearing a lot of things about the gastrointestinal side effects, and so patients who have baseline gastroparesis, not not medication cause, but you know, diabetes in itself, can impact the nervous system around the GI tract, and then causes gastroparesis. So if the patient has confirmed gastroparesis, these agents are probably going to worsen that. And so not a good idea to have patients with confirmed gastroparesis to be on Dr. Sean Kane 05:59 these drugs. So then the next medication that you mentioned, which was a more major update to the 2024 guidelines, was glucagon. I'm familiar with glucagon in the ICU. Every once in a while we might use it for a beta blocker, overdose. It's more commonly used for hypoglycemia. This is an old medication. What is new about glucagon? Dr. Khyati Patel 06:19 The new thing about the organization of the guideline is that chapter six used to just focus on glycemic goals and that's it. But they decided that the information about hypoglycemia, whether it be screening, education, prevention, treatment, it was kind of dispersed throughout all the different chapters. What they did is they pulled it together under this chapter, chapter six. So the new name for this chapter is glycemic goals and hypoglycemia. And so all of these hypoglycemia related content, whether it's screening, education, treatment, prevention, they resides here. The real focus on glucagon now is that historically, the glucagon product was requiring reconstitution. So definitely, when you need it right, our young pediatric patients type one diabetes in the middle of the night, if they are experiencing a hypoglycemia, the parent needs to be ready. And I do remember that red kit that require reconstitution sat in the pharmacy forever until it got expired and we send it back. So yes, History says that because of this reconstitution requirement, you know, the popularity of this particular glucagon product wasn't there. However, in the recent year, we've gotten new products in the market. They're ready to use different formulations. So we have a nasal powder formulation, Baqsimi, we have a ready to inject Gvoke HypoPen, which is basically a pre filled pen. And then we have not necessarily glucagon, but as a desiglucagon prefilled syringe as well as a pen auto injector with the brand name of Zegalogue. And so these have been in the market. And there is a nice table 6.6 in the guide in this chapter that outlines all different products and their cost, and what the guidelines are doing in terms of glucagon product is clarifying when to prescribe, and so the recommendation is prescribing glucagon products to all persons taking insulin or those who are at high risk of hypoglycemia. That is the prescribing clarification. If you look at what patients are indicated for use of glucagon, basically the guidelines are saying it's anybody who is experiencing hypoglycemia but is unable to consume that simple carbohydrate or unwilling to consume the simple carbohydrate. If you look at the PIs for these agents, they're saying that patients experiencing severe hypoglycemia would be able to use this right now, I'm thinking level two, perhaps even level three, hypoglycemia, where patient loses consciousness. It's not really that we are giving this drug to the patient and be like, hey, you know, here's for you to use it, just like naloxone. It's really the family members, the caregivers, maybe for younger kids, it's the school personnel who's gonna keep it, know the location and know how to administer the product. Dr. Sean Kane 09:13 So when I think of glucagon, I think primarily of patients who have type one diabetes, who are taking insulin. Are you also saying that this should be prescribed to patients who have type two diabetes that are on, let's say, a basal insulin only, plus some other medications as well. Yeah. Dr. Khyati Patel 09:29 And I think that's where I'm thinking, where the guideline recommendation is leading to. It clearly says all persons using insulin, so whether they have type one diabetes or type two diabetes, all patients with insulin should be given a prescription for glucagon, as well as those who may not be on insulin. But medications that increases the risk of hypoglycemia, or maybe they have tendencies of not recognizing, you know, what are the symptoms of hypoglycemia are so sulfonylurea comes to mind as another risk factor. Disorder as well as, you know, losing that autonomic response of glucagon where or they don't recognize the symptoms of hypoglycemia, those patients may benefit from glucagon products. Dr. Sean Kane 10:11 And then, Dr. Patel, my second question was, you kind of slipped it in there this other medication that isn't glucagon, but is like glucagon, desiglucagon. Can you just give us though synopsis of what, what exactly is that, and how is that different than glucagon? Dr. Khyati Patel 10:23 Yeah, that was actually a learning moment for me as well. That's probably the newest glucagon product that's been out in the market with the brand name of Zegalogue, and it's very analogous to body's own glucagon. So we have those 29 amino acids, but in order to improve water solubility of glucagon, they changed seven of these amino acids, so now you have this glucagon in an aqueous solution ready to use has better stability and potency, just like native glucagon or the body's own glucagon. Very cool. Dr. Sean Kane 10:59 Speaking of newer medications, the third one that you mentioned that I'm honestly not familiar with is tepilizumab. What medication is this and why have I not heard of it? Dr. Khyati Patel 11:09 Right? I was very intrigued when I found out about tepizumab sometime last year. Apparently, it's been approved by FDA since 2022 but the ADA guidelines are inching their way to make clinicians ready where they're diagnosing patients because it needs to be used in a certain patient population. The brand name is Tzield, and as the name suggests, it's a mAb. So it's a monoclonal antibody. It's against the CD 30 surface antigen on the T lymphocytes. And basically its job is to deactivate those auto reactive T lymphocytes against pancreatic beta cells. The approval by FDA is to prevent progression of stage two, type one diabetes to stage three type one diabetes, and it was just a year ago, Dr. Kane, I tell you that I realized that there are stages of type one diabetes as well. Apparently there are, and this is trying to catch patients early before they have a full blown type one diabetes where they would have a DKA and would end up in the hospital. And so it is actually approved for patients eight years and older who have stage two type one diabetes. Dr. Sean Kane 12:25 So more for the listeners who maybe are less familiar with type one diabetes. Type one diabetes is an autoimmune condition where your body has attacked its own beta cells, which produce insulin. What you're saying is that this medication halts or slows down some of that autoimmune attack of the beta cells so that you don't progress as quickly through these stages that I'm also not familiar with of type one diabetes to this later stage, which is a more severe version of that autoimmune condition. Dr. Khyati Patel 12:54 That's a that's an exactly and very good summary. And so what is stage two diabetes? The the definition of stage two diabetes is that clinically, if you check patients auto antibodies, you'll find at least two auto antibodies positive. One example is islet cell antibodies, or auto insulin antibodies, or gad 65 antibodies. So you will do you know some of these antibody testing you have to have two of them positive, and the patient would also do a 75 gram oral glucose tolerance test, which is basically a perennial test to check, you know, how high your sugars go. And they would fail the test, but they wouldn't have overt hyperglycemia where they're having DK and they're in the hospital. These are the patients that are defined as having stage two. You have to meet this requirements in order to use this medication, because, as we will discuss, some of the risks that come with the medication are also pretty significant. Dr. Sean Kane 13:54 So those risks are things like neutropenia, lymphopenia, rash, headache, nausea, diarrhea, more severe would be something like a cytokine release syndrome, where you're going to have an increase in LFTs, and, you know, this is blocking part of your immune system, right? So we're worried about risk of infection, and then it's a monoclonal antibody, so also risk of an allergic reaction to the monoclonal antibody itself, right? Dr. Khyati Patel 14:17 So it's given over 14 days. It's a 30 minute like IV infusion, you know, you you take it for 14 days. For the first five days, they're recommending to pre medicate because of the, you know, the reaction for the infusion, and then the doses based on body surface area. And so basically, the guideline is saying, Yeah, go ahead and use it for your stage two type one patients, but make sure it's done in a facility that knows how to handle the medication and the clinicians are trained to be able to use the medication. Dr. Sean Kane 14:53 Well, those are kind of the three or four medication updates, but there's obviously a ton of other updates that are out there. What do you want to. Talk about next Tech. Dr. Khyati Patel 15:01 So what I want to talk about is that nice table in chapter nine that kind of delineates the algorithm for diabetes management, and it's based on comorbidity. So you look at your patient with diabetes, look at their cardiovascular risk, whether they have heart failure or CKD or not. So look at their cardio renal risk. If they don't have it, then the recommendation is not just to focus on A1c reduction, but also focus on weight reduction, right if they need weight management. And so the emphasis in this guideline has been, yes, do what you need to do in order to control the cardio renal risk, but don't ignore the weight impact. You know, the reduction that can bring and improve the blood glucose management for these patients. So as we talked about earlier, chose hepatitis one of the other occasion that's been added to chapter eight. However, they're saying if patients are not meeting the goal, you look at both blood glucose and weight as kind of parallel goals and not just blood glucose goal reduction. Dr. Sean Kane 16:07 And I think historically, weight was seen as something that was just cosmetic in nature, but we've come to realize that you lose weight, your blood pressure gets better, your lipids get better, your glucose gets better, your insulin resistance gets better. There's a lot of physiologic reasons why that weight loss is important, Dr. Khyati Patel 16:22 yeah, and that is the reason, and perhaps ADA loves to do that, to kind of provide that guideline support, because a lot of Payers are looking at to see, are these guidelines, you know, recommending medications, should we include that in our formulary or not? Right? And so, as we know, you know, weight loss is considered cosmetic by a lot of payers, not by a lot of organizations, and, you know, healthcare providers. And so paying for these medications could, you know, be a little bit of an hassle as well, but not only the medication, I think supporting proper weight management. ADA guidelines are also saying, just don't stop at the medication. Please support their lifestyle interventions that would promote weight loss. If patient is appropriate to receive Metabolic Surgery for weight loss, those efforts should also be supported, and so it's their way of telling the payers that these interventions are helpful in overall care for diabetes patients. Dr. Sean Kane 17:23 Another big update was clarifying the role of regular insulin versus some of our rapid acting insulins. So what was new with that? Dr. Khyati Patel 17:31 So we've known that the human insulins, such as NPH or regular insulin, tend to have a little bit more risk of hypoglycemia. And analogs, which is the rapid acting insulins, or our basal insulins, they tend to mimic our body's physiologic insulin release very close to what it should be. And so we've known that analogs have less hypoglycemia compared to our human insulins. Interestingly enough, in this recommendation, they put inhaled insulin in the parentheses and said, Don't forget about the inhaled insulins when you're thinking about analogs, they're just as good as the analog insulins that are out there. I found that very interesting. And I don't know if somebody from you know the inhaled insulin industry or supporter who's like voicing this here, because in my clinic, we haven't really seen a whole lot of patient getting dispensed inhale insulin. I would agree. Dr. Sean Kane 18:31 It's interesting that they included that, but it kind of begs the question, then, why do we have regular insulin, if it's a non or less preferred when would a patient potentially be using regular insulin, or why would we encounter a patient on humulin R when we know that it's a less preferred therapy? Dr. Khyati Patel 18:47 Yeah, I think the coverage for insulin has been addressed by politicians as well as you know, lawmakers, and thankfully, due to that, those policy changes, insulin is a little bit more affordable Now, prior to that, our patients struggle. You know, I serve. I work at an underserved clinic here, run by Boston Franklin University, and one of the rate limiting stuff why we can't help our patients, we have to refer them out as if we can't provide insulin. Our patients are not able to afford it. So the R and the n are the insulins that are, I like to call it BTC, behind the counter, products that you can get without prescription for your pet, you know, Friends, if they if they need it, but also great for patients. And those are, those are vial and syringe and you know, about 29 $30 a while, so patients who have cost issues. Can afford these medications. They're not ideal from the safety profile, but if you need insulin therapy over no insulin therapy, I think something's better than nothing good Dr. Sean Kane 19:51 to know. You know, another recommendation is the suggestion of using early combination therapy for type two diabetes management to basically get to your a 1c goal. Quick. Group, which I think sounds pretty reasonable to me. Yeah, I Dr. Khyati Patel 20:02 think this is just going with their, you know, recommendation on please prevent the clinical inertia. And so that's a perfect recommendation. Dr. Sean Kane 20:10 Then we also had recommendations focusing on comorbidities, right? So heart failure plus diabetes, CKD plus diabetes, ascvd risk with diabetes. What did they talk about with those comorbidities? Dr. Khyati Patel 20:23 Yeah, so no drastic changes in the recommendation. What they did is just they delineated those separately as additional recommendation so you can find, like, a quick line item, an executive summary before the chapter starts, you'll you'll see all of those comorbidity related recommendations listed out Dr. Sean Kane 20:41 separately, kind of related to that with within the ascvd realm, they now are talking about bempedoic acid. What's the buzz with Dr. Khyati Patel 20:48 this one? Yeah. So their chapter 10 focuses on cardiovascular risk management in patients with diabetes, and they created a section, a separate section altogether, for patients who are statin intolerant obviously, statins are still the primary therapy, but there are quite a few patients that I work with in the clinic can't tolerate statins. They've tried many different statins. What do we do for them? bempedoic acid has shown some CV risk reduction in recent trials, and so they are recommending for primary prevention, we could use bempedoic acid in patients who are statin intolerance, and then for secondary prevention, they're kind of put neck to neck with your PCSK9 inhibitors. So either you use your PCSK9 inhibitor therapy or bempedoic acid therapy in patients who are statin intolerance, PCSK9 monoclonal antibodies, injections, expensive compared to bempedoic acid, a pill taken once daily available. You know, easily don't have to do whole Specialty Pharmacy thing. Dr. Sean Kane 21:50 And just out of curiosity, do they mention Zetta mite as part of those different options? Dr. Khyati Patel 21:56 Yeah, the recommendation for use of ezetimibe in patients who need additional LDL lowering, if statin therapy wasn't enough, it still remains the same, perfect Dr. Sean Kane 22:07 in terms of SGLT2 inhibitors. What is the new evidence or new guideline recommendations regarding those guys? Dr. Khyati Patel 22:13 Yeah, so nothing changed in terms of SGLT2 inhibitors, but the sotagliflozin (Inpefa) is our SGLT1/2 inhibitor. So they kind of just added that along with SGLT2 inhibitor, saying in patients who have heart failure or, you know, CKD, those patients should be able to prioritize these medication looking up in PEFA, which I was not very familiar with. I have not seen it in practice. It was approved mid 2023, and the particular trial that showed this risk reduction was a SCORED trial and showed that patients had decrease in death from CV causes, obviously hospitalizations from heart failure, as well as additional hospital visits in patients who had diabetes, CKD, as well as increased cardiovascular risk. Dr. Sean Kane 23:06 So kind of a new drug class, but not really SGLT1/2 at this point. Do the guidelines say that that's better than any of the existing SGLT2 inhibitors? Or time will tell, because we don't know. Dr. Khyati Patel 23:18 This SCORED trial was not done in head to head comparison with another SGLT2 inhibitor, so it's hard to tell yet if it's better than the already out SGLT2 inhibitors, but compared to placebo, the SCORED trial did have benefits, and so they're kind of putting in both together in the same line. Dr. Sean Kane 23:38 So another update was education about ketoacidosis, checking ketones, if a patient is ketosis prone and or those that like the keto diet, especially in patients that take SGLT2 inhibitors. So what's the deal with SGLT2 inhibitors, specifically in this ketoacidosis section, right? Dr. Khyati Patel 23:57 So as we know, the risk of euglycemic ketoacidosis is there. We know it from SGLT2 inhibitors in general, and in patients who are ketosis prone or using keto diet or paleo diet, that's high fat diet, there is an increased risk. And so recommendation is to provide patients with ketone monitoring strips so they can monitor their ketone body levels Dr. Sean Kane 24:23 appropriately, and then kind of a smaller update in children and adolescents that are 10 years and above. What's the story in terms of using or not using Metformin? Dr. Khyati Patel 24:32 Patients who are using Metformin, with or without insulin? If that therapy is not enough, then the recommendation is to move on to one of the GLP ones that is approved for this younger age population, or empagliflozin. So I think the new thing is that empagliflozin is kind of being put along with the GLP one when we are thinking about therapy escalation in this patient population. And. Dr. Sean Kane 25:00 Is a section on inpatient glycemic management, and here we see the continued emphasis of using insulin, which is level a recommendation, and then other therapies, Level B recommendation, that can be either started or just intensified for glucose values more than 180 in terms of those other therapies, what did the guidelines say about those other therapies? Dr. Khyati Patel 25:23 For the other therapies, the recommendation was level B, that they could be started or intensified. And that made me started thinking, right? Like we have patients using a GLP one, but we don't have it in our hospital formulary, so a lot of the time, patient are not given that medication. And maybe this is a way of the guidelines saying, Please, you know, support the use of those medication, not just the insulin, as long as they're appropriate. Dr. Sean Kane 25:49 And we've seen a shift towards sglt, two inhibitors more for CKD and heart failure patients. And the question of, one, should you continue it if they're already on it? The answer is yes. And then two, if they're not on it yet, is that part of your gdmt for their heart failure, for example, to start it while they're still in the hospital, for that clinical inertia that you talked about, Dr. Khyati Patel 26:10 interesting that you mentioned it, because the guidelines did say that you should, whenever appropriate, initiate SGLT2 inhibitor therapy for patients with diabetes who are in the hospital coming in with concurrent CKD issues or heart failure issues, if they haven't been already started Dr. Sean Kane 26:27 on it. So certainly, the guidelines say you should do something if they're inpatient and their glucose is more than 180 for the critically ill patient, the recommendation is a goal of about 140 to 180 super controversial. There's a lot of evidence behind that, and it's kind of, we're not exactly sure, but that sounds like a good range, and then a potential for a strict goal of 110 to 140 for certain individuals, if you can do it without causing hypoglycemia, which it really depends on the critically ill patient, but hypoglycemia risk, especially a medical ICU patient, is a very concerning risk. I would imagine a lot of this focus is more on that cardiovascular surgery patient, where some of the original data for tighter glycemic control came from, and that population also tends to have a lower hypoglycemic risk. Dr. Khyati Patel 27:16 Yeah, that was definitely surprising that they are going as tight as 110 to 140 Yeah, Dr. Sean Kane 27:22 well, then why don't we transition a little bit to digital health and some of the technology updates with diabetes? This is a very hot area right now. Dr. Khyati Patel 27:30 Yeah, it's actually very exciting too. And this is not only evidence based, but also putting it in the recommendation. The hope from ADA is that the payers will recognize this, right? And so people who have type one diabetes, the recommendation is to start CGM early, like, don't delay the use of CGM. Same thing with a ID products, which is automated insulin delivery or pump products. They're actually, again, supporting early use of that in all patients with type one diabetes. What's been happening is a patient gets diagnosed with type one diabetes. Usually they'll get started with multiple daily injection, basal and bolus. They'll assess the comfort of the patient and then say, Okay, we'll transition you to pump if you can't meet your blood glucose control. The guidelines are saying, Don't do that. You know, start them on pumps. Start them on those smart pens, if need be, because they're connected to CGMS. And then everything is connected in the app. And then you can see better management, better goals and data. Dr. Sean Kane 28:36 So then another recommendation is to continue personal CGMS, continuous glucose monitors and those allowing for automated insulin delivery devices, as long as a patient is appropriately able to use it, so that they're aware, you know, and cognitively able to do it, yeah, to continue those while they're in the inpatient setting, Dr. Khyati Patel 28:54 I can kind of see this bring a lot of headache to a pharmacy department, right? Because they need to verify what insulin is in the pump, and you know, what is your basal rate, for example, and what you're getting and stuff. So there needs to be a lot of talk before it can actually happen in clinical practice. But that's at least what the recommendations are right now and then, when it comes to CGM use, you know, they they are highlighting the use of CGM in patients who are at high risk for hypoglycemia, because Multiple studies have shown in type one patient, type two patient, or patients with gestational diabetes as well, that it has reduced the risk of hypoglycemia. And talking about our patients who are not really gestational diabetes patients, but they're type one patients who then become pregnant. They are recommending to continue the CGM use, they may have to still do the finger pricking, because that's a recommendation during pregnancy, but CGM use in clinical studies have shown to improve neonatal outcomes such as macrosomia as well as neonatal hypoglycemia. Dr. Sean Kane 30:00 Them important. So then moving on to screening and monitoring. Screening recommendation is for pre symptomatic patients with type one diabetes that they need at least two auto antibody tests that are positive. What's going on with this? Dr. Khyati Patel 30:15 So this recommendation is really just gearing up the clinicians for the use of teplizumab as the patient use criteria is that they have to have the stage two type one diabetes that is recognized by presence of at least two auto antibodies, and they have to fail basically that 75 gram oral glucose tolerance test showing dysglycemia. And so I think this recommendation really comes to get people ready so they could prescribe teplizumab as appropriate. Dr. Sean Kane 30:47 And then in terms of heart failure screening, the guidelines talk about screening for BNP, or NC pro BNP, which is the hormone in the blood that becomes elevated in some situations in patients with heart failure. And they recommend this in patients who are at risk of structure or function or or symptomatic heart failure. So that's stages B and C. And really, the point here is to recognize it earlier so you can start some of the therapies that would be indicated for these patients. Dr. Khyati Patel 31:14 Yeah, and I thought about this recommendation, you know, as a somebody who treats patients with diabetes and primary care. I wouldn't think about throwing a pro BNP or, you know, BNP lab, but I think the guideline is trying to encourage clinicians so we can diagnose if they have heart failure, you know, early stages, or prevent the progression, put them on appropriate medication early on, if need be. Dr. Sean Kane 31:37 And then another one, Dr. Patel, that kind of caught me off guard, was screening for bone fractures. Where did this come from? Dr. Khyati Patel 31:44 Yeah, that was interesting that they emphasize the screening for bone fractures. Now we know the inherent differences when it comes to decreased bone mass and bone fractures when it comes to type one diabetes versus type two diabetes. Type one diabetes patients tend to have a little bit more risk over type two diabetes, but then knowing that, that's why they're recommending to kind of align with the American Society for bone and mineral research, recommendation on make sure you are testing patients appropriately using DEXA, make sure you're appropriately managing other risk factors, such as medications that could decrease bone mass. And there are some diabetes medications that can do that, such as the, you know, thiazolin and diones, or clinical fosin. And also avoid medications that could cause hypoglycemia, because hypoglycemia can lead to fall. Fall can lead to fractures and Dr. Sean Kane 32:36 things like that. And then the recommendation is there for daily vitamin D and calcium for all patients with diabetes. Is this for anyone or those that are at risk for osteoporosis, Dr. Khyati Patel 32:49 they're saying in all patients with diabetes, there's they should have optimal daily intake of vitamin D and calcium, yep, yep. Dr. Sean Kane 32:56 So it may not be that they supplement, but they should, at least from a dietary standpoint, get those Dr. Khyati Patel 33:01 Yes, absolutely. When it comes to supplementation, dietary intake is definitely better than taking a pill. Dr. Sean Kane 33:10 And then, of course, if their T score is too low, or they've had a fracture, any of the therapies that we normally think about for osteoporosis would be appropriate for these patients as well, right? Dr. Khyati Patel 33:21 The T-score of, you know, negative 2.5 or below is considered osteoporosis, and that's where usually we try to bring this anti resorptive or anabolic therapy. They're recommending it a little bit earlier. So score of negative two and less, that's where they're recommending to bring on these medications. Dr. Sean Kane 33:41 And then the guidelines also address psychosocial screening for diabetes, distress, depression, fear of hypoglycemia. There's a lot to take on when a patient is diagnosed with diabetes, and I'm sure that the psychosocial aspects need to be addressed, just like the A 1c Dr. Khyati Patel 33:56 does, right? And I think this is emphasized because we're forgetting about this. You know, fair too often we focus on cardiovascular risk reduction and, you know, you know, renal risk reduction and stuff, but we forget that this is very real. I actually have a patient who I'm working with right now has a very rational fear of hypoglycemia, and there are other social things that are compounding this fear and their ability to appropriately use medication as well. And so yeah, these things are very real and need to be addressed. Dr. Sean Kane 34:31 And then we mentioned weight management earlier, and a lot of weight management focuses on weight reduction, but just to identify someone who needs that weight reduction? They talk about using other body measures, not just BMI or Dr. Khyati Patel 34:45 body weight, yeah, so don't forget about your waist circumference, right? waist-to-hip ratio, waist-to-height ratio, etc. This is still an expert opinion, but I think people in the metabolic disease world agree that BMI is just not a very accurate representation of body fat. Dr. Sean Kane 35:05 And again, there's all sorts of diseases that are present in these guidelines. We've focused on CKD, heart failure, acvd risk. What about pad, peripheral arterial disease? What did they have to say about that? Dr. Khyati Patel 35:17 Right? So this was interesting. You know, we normally talk about ped in context of that comprehensive foot exam. You know, foot care is important, yada yada yada, they realized that the screening for PED was not occurring like it's supposed to. So they particularly called it out and said patient has diabetes that they're, you know, 50 years or old or above, has had any, any micro vascular complication. So it could be a renal complication, foot complication. They have any an organ damage, they should be screened using an ankle brachial index with toe pressures. That's an additional recommendation that was separate, but eventually you need to do the Ankle Brachial Index with toe pressures. And this highlights the importance of you know, if you as a primary care can't do it, refer them to a podiatrist, right? Do the interdisciplinary collaboration. Dr. Sean Kane 36:10 And again, in someone who has even asymptomatic pad, there are therapies that we would give to that patient that we wouldn't necessarily give to someone who doesn't have pad. So you have to monitor it and screen for it to be able to know that they need these therapies, right? Dr. Khyati Patel 36:24 And talking about another microvascular issue, retinopathy. This was, this caught my eye. Apparently, there are FDA approved AI algorithms that would screen retinopathy, and they wanted to highlight that. And this is kind of going with technology update is the ADA guidelines. Are looking at all of these different research and bringing what's important and what's working and what's evidence based. Very cool. Dr. Sean Kane 36:52 So Dr. Patel, the last big section that we were going to talk about is lifestyle. So this is kind of things related to diet and exercise, primarily when it comes to food, what are some recommendations, either new or continued, about food intake for people who have diabetes? Dr. Khyati Patel 37:07 Yeah, I think they kind of expanded their definition of nutrition principle. So before, it used to include, like, plenty of fruits and vegetables, non starchy vegetables, whole grains, etc. Now they're saying minimize the consumption of meat, so they're kind of calling that out, particularly calling out the refined grains, as well as Ultra processed foods, particularly so those should also be kind of paid attention to, and patients should be educated regarding avoiding those foods. Dr. Sean Kane 37:39 And then they also emphasize Mediterranean diet, style, dietary intake, and this is where we think about mufas and PUFAs. What exactly is that? Dr. Khyati Patel 37:49 Yeah, we knew about mufas and PUFAs. And, you know, it's, it's one thing to say it clinically, and then one thing to explain it to people, what they what they entail, what they did is they kind of explain what these different fat types are, and so they're now including, okay, that means you got to eat more fatty fish. You got to eat more nuts and seeds and avocado and olives like those are the examples of the mufas and PUFAs. Now they're including that in their Dr. Sean Kane 38:16 recommendation, and just for the audience, MUFA stands for monounsaturated fatty acid. PUFA is polyunsaturated fatty acids. So are these good fats that we want our patients to have or not? Dr. Khyati Patel 38:26 Yeah, absolutely. These are your unsaturated fats. Which are good fats you want to avoid all your saturated fats? Yep. Dr. Sean Kane 38:32 And then what about religious fasting? This is an area that I wouldn't have expected the guidelines to weigh in on. Dr. Khyati Patel 38:39 Yeah, the highlight of the update in the 2024 guideline is inclusivity and patient first language. And you know, honoring and respecting patient practices, one of that is religious fasting. So the examples are Ramadan fasting or Yom Kippur fasting, some of these different fasting practices basically are acknowledged. And for clinicians who are not as familiar, but who have patients doing these practices, resources are provided. They've also kind of identified and provided more information about Chrono nutrition. So this is where people say you got to eat with your circadian rhythm. You know, don't eat it too much at night, and then timing of eating. All of those details are kind of expanded. I wouldn't say there is a recommendation one is stronger than the other is just more information is included. Dr. Sean Kane 39:32 Well, Dr, tell this is a wonderful review of a very comprehensive document for the listeners. We have some show notes where we've kind of highlighted some of our key points that's available at HelixTalk.com Again, this is episode 179 we also have a link to the ADA 2024, guideline update. So you're you're able to kind of go through these different chapters and read for yourself what some of the new and improved recommendations are from those guidelines. So with that, for the listeners, we love the five star reviews and iTunes keep. Is coming. We also have a mailing list and receive an email when new episodes come out. So with that, I'm Dr. Kane. Dr. Khyati Patel 40:05 I'm Dr. Patel. I can't wait for the 2025 updates, but until then, study hard. Narrator - Dr. Abel 40:12 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 - ? 40:23 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.