Hi everyone my name is Tricia Santos I'm An endocrinologist at UC San Diego and I Work very closely with Dr E and Dr P There so today we're going to give you An advanced session on type 2 diabetes So this is really for people who may Have been around the block for a while Or who have seen some of our tcoad Sessions and kind of know the basics About type 2 we're going to dive a Little bit deeper today So our outline is here first we're going To talk about the latest treatment Algorithm for people with type 2 Diabetes that means kind of how us Healthcare Providers make decisions About diabetes medications I'm going to Tell you about what's new in medications For type 2 diabetes and then we're going To talk about continuous glucose Monitors in kind of the advanced use how To use them in in some more kind of Higher level ways So first I just want to mention that Type 2 diabetes really is a marathon and Not a Sprint so it's not one of these Things where you can kind of you know Get a diagnosis get started on a Medication and then you're one and done And that's very different than maybe how You have your blood pressure controlled Or how you have your cholesterol Controlled where you don't have to think About it too much but really type 2
Diabetes not only is it a progressive Disease but luckily we're getting new Sorts of treatments out all the time and New guidelines and that's why it's so Important for you to be here learning About your diabetes and to stay in touch With tcoid so you can learn what's new When new things come out So first off we're going to take a look At the treatment algorithm from the American Diabetes Association now this Graph to me looks really scary when you First see it it's kind of detailed There's lots of boxes and colors going On but I'm going to simplify it for you And I just want to put this up here Because this is what your Healthcare Providers are using to kind of hopefully Using to guide how they're doing your Treatment for type 2 diabetes So it's this simple first the algorithm Says you should take metformin and still Do lifestyle modification with diet and Exercise Um when you're diagnosed with type 2 Diabetes and then after that You want to ask four simple questions And that helps you determine what to do Next it's really that simple and that Whole big chart so here's the four Questions Number one do you have heart or kidney Disease number two do you need to Minimize hypoglycemia or low blood
Sugars number three do you need to lose Weight I think a lot of people with type 2 diabetes can answer yes to some or all Of these questions and if the answer is Yes to any of these first three Questions then the next medication that You should start would be an sglt2 Inhibitor or a glp-1 receptor Agonist There's also some other options I listed Here if you need to minimize Hypoglycemia but you can see that very Commonly the answer to these questions Is that sglt2 or glp1 the fourth Question is what if cost is an issue Which for many people it is and in that Case depending on your insurance Coverage you may need to start with a Sulfoni urea like Glipizide or a tzd Like Actos because these are more Affordable options Now because the answer to most of these Questions is sglt2 or glp1 these are Classes of medications I want to dive a Little deeper and talk about these Medications So Sglt2s and glp-1s are really the Hot Topic right now because not only do they Help people with diabetes to lower the Blood sugar but they also protect your Heart and your kidneys and one of the Things that these guidelines are telling Us which is kind of a new thing for us Is that even if your A1C is that goal
For you even if your blood sugars are in The target range where they're supposed To be if you have heart disease or if You have kidney disease you should be Taking one of these medications because They have so much benefit on those other Organs that even if you don't need help With your blood sugars you should be on Them so if you're not I want you to Think about talking to your health care Provider about starting one of these Let's look at each of these individually Sglt2 Inhibitors that is a mouthful to Say you can get Tongue Tied just trying To say it This is a class of medications and the Way that they work is they make you pee Out your glucose pee out your blood Sugar so you take all the glucose that Goes into the kidney that's in your Blood and you put it out into the urine Now you can see on the left here this Hand of sugar cubes is about how much Glucose you pee out every day if you're Taking sglt2 Inhibitors this is quite a Bit if you can see it visually there These medications are once a day pills It's kind of one of the nicest things About them they're pretty easy to take You take them all once a day in the Morning I've listed all four that are Available here jardiance Invokana Farsiga and steglatro Let's look at what they do I told you
That they lower A1C levels they do this By dumping that glucose into the urine They also cause weight loss by a number Of factors They improve your blood pressure They don't cause hypoglycemia And importantly like we already Mentioned they protect your heart now This is especially true for people with Heart failure so if your doctor has Listed on your list that you have heart Failure or CHF congestive heart failure You want to be on one of these Medications They also protect your kidneys from Worsening diabetic kidney disease Another good reason to be on these Medications Now they do have some side effects for Most people they're tolerated really Well Um some of the side effects that can Happen are urinary tract infections and Genital yeast infections because as you Can imagine you're putting a bunch of Sugar into the genital area and yeast And bacteria love to kind of feed on That sugar that being said not too Common they can also cause something Called dka or diabetic ketoacidosis and That's a dangerous problem but it's a Very very rare disease and it's even Less common in people with with type 2 Diabetes so us Healthcare Providers
Really feel that the benefits far Outweigh the risks in most people What about those glp ones this is the Other class of medication that's Commonly recommended now so it turns out Glp-1 is actually a hormone that we make In our gut already This hormone works very similar to the Way that the glp-1 medications work so When food is ingested the gut secretes The hormone glp1 and that has a number Of different effects it makes your Pancreas secrete more insulin which is a Good thing if you have diabetes It tells your brain that you're full Sooner so when you're eating your brain Will think you're full even when maybe Normally you wouldn't so it decreases Your appetite a little bit It also decreases the amount of sugar That your liver makes and then it slows Down your stomach from emptying the food Too quickly and by doing that it keeps You full longer so patience on glp-1 Medications will lose weight and the Most common side effect by far with These medications is a little bit of Nausea because the food is just kind of Hanging out in the stomach a little too Long Um that nausea usually goes away after Patients have been on the medication for A little bit so it's not something that Usually requires people to stop the
Medication Now these are the various glp-1 receptor Agonists or glp-1 medications that are Currently available Most of them are injectable medications And some people get confused and think That it's insulin these are not insulin It's a non-insulin injectable medication Some of them come in a once a week Formulation that you can see here on the Left some of them come in a once a day Injection and then we even have an oral Pill glp1 now that's once a day called Rebelsus over here on the right Like the sglt tube Inhibitors these Medications lower A1C levels they're Even a little bit stronger at doing that Than the sglt2 medications they cause Weight loss because remember I said they Slow down that emptying of the stomach They make you have a lower appetite than Usual They don't cause hypoglycemia And they protect us against heart Disease particularly heart attacks and Strokes so patients on the sglt2 Inhibitors commonly will be protected by Heart failure but if you have heart Attacks then the glp-1 receptor agonists Are the way to go Okay I'm going to move on from those Sglt2 Inhibitors and glp-1 receptor Agnes but I just want to remind you Again that if you have harder kidney
Disease or if you need to lose weight You really should be on one of those Medications Now if you're interested in being on a Glp-1 medication and let's say you're Also on insulin or you should be on Insulin once a day we also have these That I want to introduce to you which Are it's a big kind of long name here Fixed ratio combination medications and What that is is it's the glp-1 Medication with all those benefits that We just discussed and a basal insulin That's the long-acting insulin in a once A day injection so you're getting two Medications for one injection which is Pretty cool I think we have two of these Available selequa which is insulin Glargine and the glp-1 Lexi xenotide and Then we have zoltify which is insulin Deglidec and the glp-1 the raglatide so If you're interested in those Talk to your health care provider They're also really interesting because By combining the medications you can Also decrease the side effects of each Of them so they have a little bit less Nausea a little less hypoglycemia when Used together than when they're used Alone Now I want to tell you about some of the Newer insulins that are available so This is the cool thing I was saying About type 2 diabetes you may think
You've got it down and then there's Always some new cool medications or Devices or things that are coming out So we have newer I say newer because now They've been out for a few years now Basal insulins which are the long-acting Once a day insulins and we have two of Those to Jo and tresiba So those of you who are on the older Basal insulins like Lantus Um levimir and pH you may want to ask Your healthcare provider about these Because they're longer acting than those Older Basils they're associated with Less hypoglycemia and less weight gain Additionally we have newer fast acting Insulins so those people that are taking Insulin with meals we have faster aspart And faster lispro so fiasp and Loom jev We also have inhaled insulin called a Fresa that's Ultra rapid acting and These are all really nice because Instead of having to take your mealtime Insulin you know really far before You're eating you can take it closer to Your meal that you're you know right at The start of your meal time which is Much more convenient And lastly on our new medication list is Newer forms of glucagon so any of you Who are on insulin should really also Have a prescription for glucagon in an Emergency to raise your blood sugar if You can't eat
The older glucagon pen was this big red Box and it was in a powder formulation And you would have to mix it and do all These things it was really cumbersome Now we have all different sorts of Glucagons available that are in an easy Nasal spray and easy pre-filled syringe And even auto injector pens like epipens Okay now I want to spend the next Several minutes talking about continuous Glucose monitors and this is a big part Of this talk because this is really kind Of the wave of the future for people With type 2 diabetes We've talked about these a lot here at Tcoid so those of you in this Advanced Session have probably heard about them In other sessions and I have some shown Here the freestyle Libre The Dexcom G6 and the eversense E3 which Is now FDA approved to be implanted have An implanted continuous glucose monitor For 180 days that's six months where you Don't have to think about putting a new One in so let's talk about these in a Little bit more detail I want to review the various parts of a CGM so that you can understand what's Going on and you have a nice review In a continuous glucose monitor there's A small sensor that's inserted Under the Skin and on the upper right here you can See for the traditional glucose monitors Those are that's usually just a little
Wire that sits under the skin you can't Feel it when it's in there for the Implantable ever sense that would just Be inserted under the skin in a very Simple office procedure and that sensor Measures the glucose every five minutes Then there's a transmitter that's going To send the glucose mono the glucose Values that you're getting to whatever Device it is that you're using and those Devices can be some sort of receiver Sometimes it's a device that the company Will give you that looks almost like a Meter sometimes it can be your Smartphone or even a smart watch and That's where you can kind of view the Glucose values Now continuous glucose monitors give you Much more information than your A1C or Your glucose meter so you know back in The day the way we used to do it is you Would get an A1C every three months and Kind of call it a day if if your A1C Looked good but what we realize is these Continuous glucose monitors are giving Us data about what's happening all day Long so we can really change kind of Decisions that you're making throughout The day like what kind of foods you're Putting in your mouth how often you're Going to exercise the way you may dose Your medication It also gives you a trend Arrow so if You see up here in this freestyle Libre
Picture you can see on the right it says That your glucose value is 112. but There's also a little arrow there that Shows not only is it 112 but it's on its Way up so you can imagine let's say your Blood sugar is you know 70 and it shows The arrow is on its way down then you May decide to eat something whereas if It's 70 and it's on its way up you don't Have to eat anything so those Trend Arrows can really give us information About what to do and help us make Decisions It also has alerts and alarms for both High and low glucose levels which again Can be very helpful and and protective Honestly you know keeping you safe And something that we're going to go Over today is that there's glycemic Reports for your healthcare provider and For you so these reports and this data That people are looking at on continuous Glucose monitors you know initially People kind of waited till they saw Their health care provider and then let Them look at all the data but what we Want to teach you how to do is how you Can look at the data yourself and make Some decisions about how to maybe change What you're doing for your diabetes so Let's look at that now you may say well How do I look at the data all I see is That little glucose level on the Receiver that I'm getting it turns out
That all of the different systems that Are available for continuous glucose Monitors have an app that you can Download that can show you your data and Not only does it show you to it to you But it can analyze it a little bit for You as well so let's look at that in a Little more detail This is an example of a mobile app for a Continuous glucose monitor and this is Kind of busy and you can see it's a lot Of data but you know just by pulling This up on your phone you can get over Here on the left this little color bar Which is a time in range which we're Going to talk about in a little bit more Detail you can get an estimated A1C you Can even see how much of the day you Spent in in a you know safe glucose Range every day of the week over here on The right so there's lots of different Data that you can look at Now I want to walk you through how to Look at your data so that you can make Informed decisions about how to care for Your diabetes So this is called an ambulatory glucose Profile or an AGP report and the nice Thing is every CGM on the market has This type of report that you can look at An AGP report it's a standardized report That gives us a lot of information about What's happening with your diabetes Over here on the left you can see
Something called the glucose statistics And targets there's a few things I like To look at here number one is how many Days it's analyzing so in this example You can see 13 days You can also see the average glucose the Standard deviation or the variability of The glucose and the glucose management Indicator which is the estimated A1c In this box here you can see the time And range and I'm going to talk about This in the next slide in a little bit More detail what that means Right here on the right is our Ambulatory glucose profile this is what Shows you kind of what's Happening by Various times of day so you're looking At an entire 24 hours here on the far Left you can see 12 am and it goes all The way on the far right to 12 a.m the Next day so you're looking at 24 hours You can kind of see by time of day where The highs and lows are occurring and Then lastly the daily glucose profiles If you want to see you know what Happened on February 2nd you can look Back and see what happened that day and See kind of daily patterns Now I want to look at kind of how steps To how you're going to review your CGM Data so first you're going to look at Your average glucose and your glucose Management indicator the glucose Management indicator or GMI is your
Predicted A1C so if you kept that Average for 90 days that would be your A1C so it's nice you can kind of pull up Your own A1C anytime you want It also helps is helpful to look at the Standard deviation so our goal for that Is less than 50 or the coefficient of Variation the CV the goal is less than 36. this is looking at how much your Glucose is varying throughout the day Are you you know between 70 and 200 most Of the time or you swinging between 40 And 400. You want to look at the time and range Time and range means how much time You're spending between 70 glucose of 70 And 180. so you want to look at the time You're in hypoglycemia and then look at The time that you're in range which I'll Show you in a second you want to look at That 24-hour profile to see what time of Day your highs and lows are occurring And then look at the individual days to Find kind of you know nitty-gritty Problem areas and also you can look at Your alerts when are you setting your Low alert or high alert to kind of Notify you that your blood sugar is out Of range you want to try avoid alarm Fatigue meaning getting too many alarms Where you stop paying attention to them Okay here's getting oriented with our Report so this is just an example Dexcom Report here you can see the first thing
We look at is the glucose management Indicator or estimated A1C so here at 6.6 with an average glucose of 139 The standard deviation is 46 which is Good we like it to be less than 50 and Then this colored time and range bar I Want to blow this up for you so you can See it the green is where your blood Sugar is in a safe range from 70 to 180. And the goal there is that it's in that Range over 70 percent of the time the Red is where you're in hypoglycemia and The yellow is hyper or high blood sugars So here's the goal these are the time And range targets for most people for People who are elderly or who are Pregnant you'll have different time and Range goals so you want to go over this With your provider The green again is the time and range We're going to be talking about this a Lot in the various tcoid Sessions so time and range is defined as A blood sugar between 70 and 180 and you Want to try and be in there over 75 Percent of the time You want to be hypoglycemia or in the Red less than five percent of the time And then hyperglycemia less than 30 Percent of the time in the yellow Okay these are the other things you can Look at at the report you can look at The 24-hour modal day which can give you Kind of your overall sense of patterns
You can look at the spaghetti graph I Love this one because it shows me each Line is a different day and I can see What's happening over an entire week Um and then you can look at individual Days if you want to see what happened on A particular day All right so the last couple minutes I Want to do some practice looking at These reports this is a 72 year old Person with type 2 diabetes who has Heart and kidney disease as well as Retinopathy and they take a long-acting Insulin 10 to 25 units at night and 10 To 15 units of a short-acting insulin Humalog with meals but they missed their Dose frequently so let's take a look Here The glucose statistics this is um Sedata looking at 28 days you can see The average glucose is 207 The predicted A1C or GMI is 8.3 percent And the variability is pretty good right At 36 percent we like it to be 36 or Less Now let's look at that time and range Color graph the time in range is 39 Remember we want that green range to be Above 70 percent they're not having a Lot of lows it's less than one percent Lows and then most of the time they're Spending above 180 in hyperglycemia Now if you kind of look at this Ambulatory glucose profile or AGP you
Can kind of find out well what time of Day are those High numbers occurring What you can see here overnight is kind Of 4 a.m 6 a.m 8 A.M the blood sugar Averages on the top of this graph here Are in a pretty good range you know 140s 150s 180s and then right after breakfast Is when things start to go high so the Way that this can change the way you're Taking care of your diabetes is if You're this person you might say gosh I Can see that I really do need to take This insulin with every meal or gosh Maybe I'm gonna change the way that I'm Eating at these meals so I don't get Highs because it seems like the highs Are really starting after I eat and then It stays High throughout the day while I'm eating Let's take a look at one more case this Is a 54 year old with type 2 diabetes For 20 years with kidney disease who's On a long-acting insulin once a day and Farsiga the pill sglt2 inhibitor So this report is looking at 14 days of Data the average glucose wow impressive 155 and that corresponds to an A1C or a GMI of seven percent with very low Variability at 23 percent When we look at that time and range we See really this person is at goal Everywhere so zero percent hypoglycemia 77 time in range which is outstanding It's above that goal of 70 percent and
Whoops and less than 20 or less than 30 Percent highs Now by time of day you can See from 12 a.m to 12 a.m these blood Sugars are in range between these gray Bars of 70 180 most of the time and Honestly it's kind of silly to even be Evaluating this person because their Numbers look so great and their time and Range is excellent but if they were Worried about highs by looking at this Report you can see exactly what time of Day those Highs are occurring they're Occurring in the evening after dinner So you may evaluate this report and Think you know these types of things you May say gosh maybe this data was able to Show me the most important problem area Again this person was really in range Most of the time so this is being really Nitpicky Um but for lots of our patients with Type 2 diabetes one shot of fast acting Insulin with a single meal can help and If they were higher than you know if Their time in range was not so good I Would think about starting something Maybe just with dinner Um or maybe you're going to limit your Carbohydrate intake at meals to kind of Offset those numbers so it can really Help change your management All right we're already out of time so Much to cover for type 2 diabetes exam Advanced session but I just want to say
You know with type 2 diabetes sometimes If you're doing everything right This disease will still continue to Progress so give yourself a break Continue to learn so that you can be up On all the latest and greatest for type 2 diabetes and you know tcoid is here to Help you take control of your diabetes Be sure to see our video evolved if you Want to in-depth look at some of these Topics that we covered today