Foreign Are you ready to talk about the Advancements in type 2 diabetes well yes Steve but why are you talking like that And I can't see anything out of these Glasses I can't either hey Eric can you Help take clear this up Oh this is so much better it sure is Welcome everybody Dr Tricia Santos Steve Edelman today We're going to talk about revolutionary Treatments for type 2 diabetes and there Are many there are so many and I think You know the point we wanted to make at The very beginning is we have come such A long way with our treatments for type 2 diabetes I mean it used to be all we Had were Stefani areas and some of the Old school insulins and now we have Medications that can actually not only Help our diabetes but give us a lot of Other benefits you know the future of Diabetes treatments is now it really is I mean there's never been a better time To have diabetes All right so we're going to jump right In and the first point we want to make I Think may be one of the most important And that is that two of our newest Classes to treat type 2 diabetes the glp Ones and the sglt2s for those of you That have been around tcode we are Talking about these all the time and the Reason is this they help protect your
Heart and your kidneys and this is Probably the most important point they Do it even if your A1C is already at Goal yeah and the American Diabetes Association that puts out instructions On how to treat patients to doctors they Tell them exactly this that if your Patients have heart disease and kidney Disease it doesn't matter what the A1C Is they still help and that's so Important two of the most important Classes of medication now you said new Glp won since 2005 and sglt2s at least Six seven years now that's true I should Have said newer so there are newer Medications but they've been around Forever now so let's dive in a little Deeper first we'll talk about the sglt2 Inhibitors so these are medications kind Of in the in the short way to say it is They make you pee out your glucose they Make you pee out sugar so they help your Kidney put a bunch of sugar into your Bladder and out into your urine you can See this picture here with all these Sugar cubes in the hand that's the Amount of sugar you're peeing out every Day on average on these type of Medications so you can see that's a lot Of sugar to be getting rid of yeah in The in the very beginning it you know When we treated patients we tested the Urine for sugar and that was bad but This is what we do on purpose so you're
Getting rid of sugar which means you're Getting rid of calories which means your Blood sugars are dropping so your A1C Comes down and people lose a little bit Of weight now I'll just warn you if you Pee on the floor in your bathroom by Accident it'll attract ants Thank you good advice okay All right so let's look at some details With the sglt2 Inhibitors we've kind of Already said this but they help out your Diabetes they lower that A1C they do Cause weight loss because you're Basically peeing out your calories you Pee water with the sugar as well so that Helps lower your blood pressure a little Bit these are great because all by Themselves they don't cause low blood Sugars so they're very safe medication In that regard they protect your heart Now when we're talking about protecting Your heart we're really talking Especially about patients with heart Failure and there's two types of heart Failure these medications protect both Types of heart fails yeah this is really Important because when we say it reduces Heart disease for we're going to get to The little bit of differences with the Glp once but I can tell you that Listening to my Cardiology colleagues That heart failure is the single most Common cardiac abnormality in people of Type 2. once you've had one episode of
Congestive heart failure it it how Should I say this it worsens your Prognosis it gives you a higher chance Of having another episode and another And um you know the ending could may not Be good and I have to tell you you know I work in the hospital and I see a lot Of the heart failure patients in the Hospital and the heart doctors are so Excited about these medications they are Starting them left and right in the Hospital because they are that good yeah And you know when they did the studies Looking at the fake pill Placebo versus One of these sglt2s they're all listed On the top they saw the reduction in Heart failure within weeks of the of the Placebo group so it works pretty fast Too yeah it also this class of Medications protects your kidneys and We're not talking about a little bit We're talking about really life-changing Effects on the kidneys in terms of Protecting your kidneys and kind of Slowing down the progression of diabetic Kidney disease yeah if you have if you Have kidney disease you may not be able To get rid of it completely but slowing It down is of tremendous value you know You're familiar with the egfr and your Chem panel the creatinine your doctor May talk about the amount of protein in Your urine it's been shown to slow it Down and reduce the need for a dialysis
Or transplantation yeah it's amazing So you want to talk about the side Effects yeah you know what I'd like to Say is these medicines in general They're very well tolerated so most People don't have side effects when you Do start putting sugar into the bladder And the genital urinary area you can get More genital infections genital yeast Infections less commonly urinary tract Infections these are not super common But they do happen and then there's a More dangerous side effect but it's very Very very rare especially rare in Patients with type 2 diabetes and that's Called euglycemic diabetic ketoacidosis Which is a big mouthful medical term You're a doctor for you know when Patients can get kind of very sick From not having enough insulin around in Their body but again very very low risk With type 2. and if you're prescribed This drug it's very easy to learn about It we have lectures on our website so And you can also remember you know the Weight loss is not as much as the glp Ones but it is so certainly nice so These drugs are once a day you take it In the morning and the the yeast Infections is primarily in women and if You're a guy that's not circumcised then Your risk may be a little higher too Okay let's talk about the glp-1 receptor Aggregates I'm not even going to tell
You what that stands for because it's Big long complicated word but this is a Slide that I want to spend just a second On to show you how they work first of All the glp-1 are secreted when you eat A meal and then what happens is whoops What happens is it goes down and it Helps promote insulin secretion which is Good it suppresses glucagon Secretion which is very good because Glucagon will raise your blood sugar it Is found to be abnormally high in type 2 Diabetes then it's going to slow down The peristaltic motion of your stomach Now why is that good well the when you Eat food it gets absorbed it gets broken Down in your stomach but does not Contribute to high blood sugar it's only When the stomach propels it into the Rest of the small intestine where it's Absorbed and then your post-meal blood Sugar goes through the roof so if you Can slow that process down it improves Your post-meal blood sugar and then Lastly on the upper right there it Induces satiety what is that it's the Feeling of being full and you don't need To take a class and here talk to a Clinical psychologist about stop eating When you're full it just works and People lose weight and some people lose Significant amount of weight and we're Going to talk about the higher dose glp Ones in a second so these are the four
There's many on the market you know we Have the older by durion then the most Recently trulicity ozembic and these are All once weekly the older baeta Victoza Once a day at lexin you've probably Never heard of and it's important to Point out rebelsas which is a oral glp-1 That you take once a day yeah and I Think you know the all of them besides Robustness are injections but people Need to remember these are not insulin So a lot of people get confused about That and I think sometimes people get Scared about injections but the thing I Like about this is it's literally just The same hormone that our body makes you Know so it's a very safe medication yeah Glp-1 mimics a natural hormone that's Low in people with type 2 diabetes and These these once weekly pens on the left Are easy to use and uh trust us after You do the first one you're going to say Is that all it was I mean it's it's an Impressive class of Agents so this this Laundry list of benefits may look Similar to the glp ones so very big Drops in A1C More significant drops in the weight uh And we have No issues with hypoglycemia because both The sglt2s and this class GOP ones they Do not stimulate the pancreas discrete Insulin in a way that we see with taking Insulin or the sulfoni ureas they do it
In a natural physiologic way especially The glp ones and um it's also been shown To reduce Heart disease more specifically heart Attacks and strokes anything to add to That no I just think you know just to Hit home the point that the sglt2s are Better for heart failure these are Better for heart attacks which is kind Of when you know you have clogged Arteries and that type of heart disease Which is a little bit different yeah and You know what these these two classes Medications are commonly used together Okay just a quick word about the high Dose and you can see that trulicity Started off at 0.75 and 1.5 now you can Go up to three and four point five Milligrams and same with ozembic 0.25 0.5 1.0 and then recently the 2.0 was Approved and then there's a special form Of ozembic it's super high dose well 2.4 And they call that drug a different name Even though it's exactly the same and You get with these higher Dose glp1 side Effects are the same you do have have to Titrate slowly to make sure you don't Have any nausea which is the main side Effect greater A1C reduction greater Weight loss Yeah and you know the one thing I'll say About this the reason there are so many Doses is because if you start at a low
Dose which is what we do the chances of Getting the side effects are much lower And your body once your body kind of Gets used to these medicines the side Effects really don't become an issue Anymore yeah and one trick that we use In clinic is that you don't have to Stick to these standard levels for Example with ozembic some patients are Very sensitive to these drugs and There's like 20 clicks between zero and 0.25 so you click you go up 10 clicks You do it weekly until there's no side Effects and then you can you can go up As slow as you want slow titration is Key and the one thing I do want to say About we Gobi which is the high dose Ozympic and this is really has been Life-changing for us in the diabetes World we go V there's data out about Wegov that it is causing weight loss Similar to bariatric surgery I mean can You imagine that is not having to go Under the knife and getting the same you Know effects on weight loss it's just Really incredible yeah and a friend of Mine's wife is on it and she discovered A Facebook for people on high dose of Zembic and wegovi and they support each Other in learning how to use this drug And my I know this this is not that Unusual but she's lost over 40 pounds Wow just incredible yeah so you know it You have to work on it not only the
Medication but it'll change your Lifestyle as well and I I call this a Negative Catch-22 when people start Losing weight they feel better they Start exercising more they they buy a New set of clothes it's like a jump Start you know you know yeah it's a new Start on life it's probably the most Effective uh treatment we have for Obesity I agree Okay and then side effects we talked About Um well we talked about they still Protect against heart attacks and Strokes because just because it's Iridosa means it doesn't protect anymore Um I think this is important to say Briefly we have lectures on our website There's a uh a class of medications we Call fixed ratio combination it's a Typical basal insulin either Lantus or Um deglideck or tresiba mixed together With a glp1 receptor Agonist so the one With Lantus is called uh Adlxin which is one that they don't Typically Market in the U.S separately And the one with tresiba is Victoza and You start off with a low dose you Titrate it very slowly based on the Morning blood sugar kind of like you Would do just basil insulin alone and uh It's amazing that people's A1C comes Down they they lose weight and it's very Easy it is easy I mean who wouldn't want
To take two injections I mean you know Get two injections out of just one Injection It's a combination medication And then the other really important Thing about these medicines is that by And we won't go into the details here There's other lectures on the website But by combining them into one injection We actually decrease the risk of side Effects with both which is a really cool Thing I think yeah you titrate like two Units at a time one unit at a time and Then you you do not experience the Nausea that you would might expect with A glp-1 alone at those set titration Step points but you know what they they Designed this drug to make it easy for People and everyone was saying well it's Good for primary care doctors to Prescribe but you know what I prescribe It a lot I like easy too for sure and is And it's amazing how well A little bit of glp-1 mixed with basal Insulin Works you'd be surprised so keep That on your list of potentials Um okay are you guys ready let's where's The drum roll Eric uh we want a drum Roll here I mean this has got to be the most Exciting Cyber type 2 diabetes so That's a medication called terzapatide Or it's also pronounced monjaro Um which it was literally just recently
Approved by the FDA two weeks a couple Of weeks ago yeah so exciting we've been Hearing about it for a long time so in The doctor world so we're really excited That it's here so this is the first type Of a new class of medication that Combines those glp-1 medications that We're talking about with another Medication called a Gip now you're Probably getting sick of all these Letters that were thrown out there but We'll tell you a little bit more about It so it's a Once weekly medication and It works very similar to the glp ones so If you look at the next slide we have Kind of uh showing you the different Effects that Steve just went over with The glp ones you know that it tells your Brain that you're full sooner it helps Your glucose get go into the fat tissue Like supposed to Um it helps you you know your your Pancreas to treat more insulin and shut Off glucagon which is helpful and then You know Gip basically does almost Everything that glp-1 does it doesn't Delay the gastric emptying as the glp-1 Does but again very very similar but the Idea is you don't kind of have to know All these little details it's basically Like getting kind of two for one and Getting double the effects of each one Um so what they're seeing in the studies With this new medication is that the A1C
Reductions are around two percent to 2.6 Percent from the Baseline this is huge Yeah you guys need to know that when we See a reduction of one percent or one And a half percent it's tremendous and This in some of their studies they're Called the surpassed studies we Summarized a lot of the studies on this Slide up to 2.5 percent drop in your A1C Just imagine that it's huge and and what We know from studies with all Medications is that sometimes when People start out with higher a1cs the Drops even farther yeah um so that's Kind of what we think of as the low end Of the drop right yeah and the studies Are a little bit different because it's Really important like you just said to Know what the Baseline A1C is in these Studies was about 8.5 that's why I use That in this example yeah Um other things that they've seen in Those surpassed studies that you were Talking about is up to 94 percent of Patients that's almost everybody had an A1C less than seven percent at the end Of the study which is really almost Unheard of I can't think of another Study where I've seen that before and up To 62 percent of patients had an A1C Less than 5.7 whoa yeah that is that is I I mean less than 5.7 is normal right Right and we've never seen any data on Any diabetes drug reported at the
Percent of people less than 5.7 because The numbers were so small so the other Thing that's important about that 5.7 is You know back in the day when we used to See a1c's less than 5.7 to me that I Started to get worried about low blood Sugars but this medication does not Cause low blood sugar so we're thinking About getting a1cs that low without any Lows attached to it which is a big deal And then significantly you know the Other thing that they sell with with This medication which is not surprising Is just massive reductions in body Weight up to 22 percent it so that's Like saying if you weigh 250 pounds Going on this medication you could get Down under 200 pounds so 194. that's on Average yeah some people lost more and You know these these drugs have a Natural lipost at that you know they Don't cause people to get anorexia you Know the heavier you are probably the More weight you lose it's it's Impressive it is really impressive yeah Keep your eyes open for that Well we decided that how are you going To remember this name think of Mount Kilimanjaro so it's the last part of Kilimanjaro now the other one is if You're Italian So anyway you got to think of ways to Remember these crazy names okay we Should do these quickly okay so just
Quickly we do want to mention for those Of you with type 2 who are on hundreds Of units of insulin per day or really Really high doses of insulin which is Not uncommon if you have type 2. so Don't worry about it but the cool thing About these newer basal insulins is that They're concentrated so we have two Types of concentrated Basils to Jo which Is concentrated Lantus essentially and Traceba which is a newer insulin all in Of itself but these pens hold a ton of Insulin so for those of you that used to Be on kind of the regular concentration Pens you would kind of go through pens Very quickly throughout the week and now We have a pen that holds up to you know 900 units 600 units and you can even do Those higher units at a time yeah the Insulin itself is concentrated so you Don't get a big glob of liquid insulin In your thigh or wherever you inject it No you got to be careful not to take a Syringe and suck it out of the pen Because your your insulin syringes Aren't meant for those units but it Really is meant to waste less insulin Waste less pens and and make it Convenient for people for sure okay We also have newer rapid acting insulins Or Meal Time insulin if you think of Them so for those of you that are Interested we have fiasp and lumjev These are two faster acting
Humalog and novolog and essentially you Know there are lectures on our websites About this if you're interested but you Know just be aware of them and if you're Interested go on our website and watch Some more lectures about how these work Absolutely And another fast acting insulin is is Inhaled insulin do you want to talk About that yeah just a little bit this Is a picture of the inhaled insulin Device we don't want to spend too much Time on this but there are extensive Lectures on our website by Dr Pettis uh Dr Pettis and I both have type 1 we use A fresa and the key issue is that it Gets in your system quickly and it gets Out quickly better post meal blood Sugars and less delayed hypoglycemia and For a lot of people with type 2 what They like about it is it's easy and they Don't have to take an injection at a Restaurant or and it also works better So this medication is approved for type 1 and type 2 diabetes and it may be Helpful for you okay You know we also want to give you some Idea of kind of what's coming obviously There's a lot of cool stuff here right Now but many people don't know that in The works is once weekly basal insulin That is mind-blowing to me yeah yeah um So you know usually patients that are on Basal insulin they have to take it once
A day but now um there are some really Good studies showing that I think this Is going to work and and be approved in The in the near future yeah and even Combining it with one of the glp-1 drugs Kind of like the fixed ratio Combinations which are daily injections So everything's meant to be effective Safe uh and and easy to implement for Yourself Yeah so speaking of making your life Easier Um if you guys are living in a cave and You're using one of these goofy dog kits Any type two on insulin even a sulfonia Like Glipizide Glyburide should think About having an emergency glucagon kit Yeah and this is the old one we're not Going to go into detail about it but it Was really a pain to use you see the Picture you gotta mix in the diluting Fluid suck it out while the your your Loved one's doing the fried egg and the Seizure uh so now we have Um much much easier options for newer Glucagon you know we have Auto injectors That are kind of like an EpiPen Essentially just very easy to use we Have a nasal spray glucagon also very Easy to use so for those of you who are On insulin please ask your you know Healthcare provider about one of these Yeah especially those on insulin for Sure
And then the other point we just want to Make while we're talking about low blood Sugars is when you're treating a low Blood sugar you want to make sure that You're eating pure sugar to treat that If you're awake and you don't need to Take glucagon you're just going to eat Or drink something right so you want to Drink pure juice or soda regular soda Candy corn you know is a picture here Starburst Skittles a lot of people like Avoid like Snickers and chocolate bars Because that's slower you know how many Uh Kettle corns you need to treat a low Eight bags you know it's a joke I have No clue but when you start you cannot Stop yeah Okay well let's end our session with Talking about probably one of the most Significant advances in terms of Technology for type twos because Continuous glucose monitoring those type Ones those son of a they've been Hogging them all for years and people Are finally realizing that hey they can Be really be helpful people type 2. now Trisha and I believe they could be Helpful to anybody with type 2 no matter What you're treated with currently a lot Of times you won't get you won't get it Paid for unless you're on three shots a Day but let me just go over briefly the Major ones which is you know we have the
Freestyle Libre which you see the sensor On the arm and you swipe a monitor over It on the upper right we have the Dexcom G6 and then in the middle bottom we have Called the eversense where you have a Little sensor implanted under your skin And it stays there for six months now so Um it's it's a personal choice Um and we on the website we have so much About CGM but remember if you're a type 2 this could really be helpful not only Behavior modification but to see how Your medication is working also it'll Help you decide what to eat how much to Eat you'll see the benefits of exercise We've seen people just turn around like You can't believe just by putting on the Device and them seeing their numbers Yeah and the way I think about it as a Doctor is I think about it like a Medication I mean essentially when I put A patient on a continuous glucose Monitor it's like improving their A1C Without having to give them another Medicine it works that well because People just automatically kind of can See what's happening and adjust their Behavior yeah we're gonna end this talk With some of the advancements in these Devices so why don't we just go through This Trisha yeah just quickly to review The way that continuous glucose monitors Work is there's a little sensor it's Like a little tiny wire it looks like a
Piece of hair I mean just tiny inserted Under the Skin there's a little Transmitter that sits on top of it that Transmits the data to whatever the Receiver is that you have and that can Be a smartphone in some cases a smart Watch a little you know device that they Give you there's many options and again I just want to stress we have so many Lectures that Focus just on CGM on the Website if you're interested but the big Deal about this is it not only gives you The data about the glucose it can help You change your decision about what You're going to do like gosh maybe I'll Go for a walk around the block or maybe I'll change my medication dosing or Maybe I will eat half of that piece of Cake next time and then it also not only Gives you the glucose number it tells You where it's going which I think is Really cool especially for people on Insulin it can kind of tell you that Your blood sugar is heading down quickly Um and they're going up or going up Quickly and it has alerts and alarms on There too which can you know really is a Safety issue yeah and remember alerts And alarms are your friends there's a Whole thing about alarm fatigue but We're not going to get into that now Now one of the things that's a little Bit of a shift in the way we're thinking In diabetes is we're really getting away
From the hemoglobin A1c as kind of our Target and moving towards what we call Time in range that's what TIR stands for On this slide and time and range means How much of the day are you spending With a blood sugar between 70 and 180 And the goal is about 70 of your day and That's about 17 and a half hours in Ideal range and then the other area That's important is the time below range We don't like hypo that we want the Percent of time between 55 and 70 less Than four percent yeah and then below 55 Less than one percent and if you're Older and have lots of other health Issues you got to really get your hypos Down to almost zero and the time and Range we don't worry about that much we Just want you to be over 50. so this is A typical download everyone should get The app and go over these numbers with Their doctor you see this is a page Patient whose average glucose is 151 Gold is less than 155. standard Deviation means how much you're bouncing Around we want that minimal at least Less than 50. then there's a thing Called GMI it's the estimated A1C this Person is not doing too shabby at all And there's their percent time and range And as Trisha mentioned it should be Over 70 percent so everybody needs to be Familiar with these this terminology It's the same as the terminology that
The doctors use there's the 55 to 70 Should be less than four percent below 55 less than one percent Um this is a 24-hour uh profile the Midnight is to the left and you know in Two seconds as a provider and two Seconds as person living with diabetes When you see your own numbers you could Say that's the biggest problem part of The day I don't know what you're doing At night but I don't even want to ask But that's the area that we can focus in On during our clinical visit and if You're looking at these numbers yourself You can say yeah that nighttime snacking Isn't good you know so um and this is One last clinical example of a patient With type 2 Um on basal insulin you know Lantus Levimir and we got the download and the A1C was just a little high and we Realized right away that the biggest and Only major problem during the day is Bounces up too high after dinner so you Can try everything you want you can try You know reducing your carbs exercise After eating and we ended up adding one Shot of fast acting insulin right at Dinner time and I wish I had the post One to show you but it's awesome All right so we'll end with kind of Where CGM is going you know it's Constantly evolving so these are the Three systems that that we use
Frequently and kind of what's happening In the future the freestyle Libre the One that you know Steve talked about Swiping on the arm the newest freestyle Libre that will be coming out is the Freestyle Libre 3. it's smaller it's About the size of a penny ish Um and the nice thing costs more Costs more than a penny the nice thing Is you don't have to swipe it anymore It's just going to constantly give you Readings like the Dexcom and the Eversense do which is going to be really Nice I think Um the ever since three that we E3 that We've talked about it's a quick office Procedure where they they put the little Sensor underneath the arm six months can You imagine not having to put on a new Sensor for six months and then not Dealing with refills yes yes that's a Big one Um and then the Dexcom G7 we also expect To come out soon which is going to be Much much smaller than the prior Dexcom It has a shorter warm-up time and then I Think one of the biggest things is you Don't have to save the transmitter for Those of you who know about the Dexcom It's going to be combined and you can Kind of just rip it off and throw it in The trash like the Libre yeah it's Combined in there so um we talk quickly So that way when you look at this later
You can put it on slow motion yeah and Stop it and see this picture about the Future of diabetes you know where I got This picture Where Google image That was it thanks everybody thanks Thanks Trisha