Ask A Diabetic Educator Nurse Practitioner

Endocrine

Sep 20

Written By Liz Rohr

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Show notes:

Why can’t diabetes management be like we learned in school? That was complicated enough.

Now you’re on your own, and there are so many questions with your patients to manage diabetes. Symptoms that don’t necessarily follow a straight line. All of the elements of managing diabetes that are beyond your control – patient’s motivation, cost of medications, how realistic a plan may be, how long until they can be seen by the specialist that you referred them to – it gets more complex by the minute.

Spoiler alert: these are not issues faced exclusively by new grads, either; this is the state of play when it comes to working with diabetic patients. And the number of people with diabetes continues to grow; recent estimates show that 1 in 10 people have diagnosed diabetes; over the age of 65, that number is more like 1 in 4.]

Ask A Diabetes Educator Nurse Practitioner – Your Questions, Answered

This week, we have a great interview with Meghan Kavanaugh. She is a Registered Dietitian AND Nurse Practitioner that works exclusively with patients with diabetes. We cover a lot of ground, including:

Taking the stigma out of diabetes and diabetes management
Continuous glucose monitoring – what it is, the double-edged sword that it can sometimes be, and practical tips for patient teaching about it
Tips for the administrative challenge of working with patients with diabetes
Addressing cost for un- and underinsured patients with diabetes
Answers to the questions that YOU submitted

The landscape and tools available for helping patients to manage their diabetes is always changing, and probably always will be. Building a foundation of reduced stigma and improved practicality is a great way to move forward and support your patients with diabetes, and to help them make realistic plans to address their diabetes that will meet their needs – and yours.

Resources mentioned in this episode:

Get your Diabetes Resource Sheet here.

If you liked this post, also check out:

WEBVTT
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Hey there, welcome to the Real World NP podcast. I'm Liz Rohr, family nurse practitioner, educator,
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and founder of Real World NP, an educational company for nurse practitioners in primary
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care. I'm on a mission to equip and guide new nurse practitioners so that they can
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feel confident, capable, and take the best care of their patients. If you're looking for clinical
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pearls and practice tips without the fluff, you're in the right place. Make sure you subscribe and
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leave a review so you won't miss an episode. Plus you'll find links to all the episodes with
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extra goodies over at realworldnp.com slash podcast. Oh my goodness, I just had the most
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amazing interview. So I interviewed Megan Cavanaugh. She is a nurse practitioner who
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specializes in diabetes care. And we collected questions from the Real World NP community and
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asked some of the heavy hitting questions, things like how to help patients who are not
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adherent with their medications, how to navigate cost challenges when it comes to diabetes care.
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And we also talked all about continuous glucose monitoring, which was just so helpful
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because that's a tricky thing, but it's actually in the guidelines recommended for
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anybody who is approved by insurance, which is something we also talked about.
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We finally talked about the pearls of practice that she had to share for
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nurse practitioners and clinicians in primary care. It was so good and I could literally
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talk to her for hours and hours and hours. And so before we get into the interview,
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I want to let you know that the diabetes, hypertension, and CKD course that we have here
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Real World NP is coming up for re-release oh so soon. And there may be some bonuses in there
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to be able to ask some of your clinical questions for your specific patients when
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it comes to care of those patients. So if you haven't gotten on the wait list already,
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head over to realworldnp.com slash courses. And if you're watching this later than the
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recording time, definitely go check out the same URL and you will find the course there for
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registration. So without further ado, though, I'm going to share my interview with Megan.
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Thank you so much for being here. Can you introduce yourself?
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Yeah. Well, hey, thank you for having me too. I love all your content and thank you for
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what you do for the community for NP's. My name is Megan Cavanaugh. I'm a family
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nurse practitioner. I work in North Louisiana, the clinic that is pretty much diabetes only.
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But we all know it's not just diabetes. We end up treating other things, of course. But
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my original background is nutrition. I'm also a registered dietitian. I finished in 2008 with
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my RD and I finished my master's. I practiced for a few years and kind of got to the point
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of I want to be able to do more. I was in a great position in an outpatient diabetes
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education center, but it was education only and there was no management. So we were really
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limited on what we can do. And I really wanted to get to that point of being able to do more
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for my patients, besides just the education. A few years after that, I decided to go to
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RN school practice for a few years and then just went to NP school. So I've been practicing
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as an NP for about three and a half years. I've been at the clinic that I'm at now for
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almost 10 years. We've been open almost 10 years. So it's been great. I have a feeling
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you're a person who really likes to learn. Yes. Absolutely. I'm a nerd. Don't bother me.
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I read all the time. I read everything. I read formularies for bedtime stories.
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Oh my God. I love it. I love it. That's so awesome. We had so many fantastic questions
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come in from the Real World NP community. You and I, we talked before the recording,
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but tried to narrow it down to some really key highlighted points that are real world applicable,
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tricky. So one of the first really common questions is about continuous glucose monitoring,
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CGM. So I feel like, especially if you're thinking about the place of a new grad or a
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student, can you just talk about what that is and guidance about how to use it and how to
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nationally, there's different rules, but there's different differences. And luckily we're out of
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time now that a lot of insurance formularies are way more generous than what they used to be. So
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when CGMs were first released, it was strictly for type one diabetes. You had to have a
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history of like severe hypoglycemia and awareness, potentially like loss of consciousness
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or causing seizures. It wasn't open initially for like type two diabetes, but now we have
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much more flexibility, thankfully, because it is such a wonderful tool for somebody who's not
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really familiar with the CGM. CGM is a continuous glucose monitor and there's
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several different brands. Probably the top two that you hear about, of course, are Dexcom,
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Dexcom G6 being the newest one, and then the Freestyle Libre. So there is a difference
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with the Dexcom that's a continuous, it's a real time. So for this device, it's Bluetooth to
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a device, usually cell phone for most people. So there's an iPhone app, there's
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Android apps as well, and it's real time data. So it checks sugars every few seconds,
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it averages about every five to six minutes. So I tell people, Mike, you can open your
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phone and look at the app and stare at it and you'll watch it change. So I mean, it's
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real time data. The accuracy over the years has just gotten so much better. I mean, used to,
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we couldn't say, hey, you can make treatment based decisions based off of this number,
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you still had to perform a finger stick. So for somebody on insulin or if they're treating
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a hypoglycemic vent, we couldn't say, hey, trust it, but now you can. So the Dexcom G6
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is factory calibrated. For the Freestyle Libre, that is one that it also now has
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an iPhone app, there's an Android app, both of them, sorry, the Dexcom has a receiver. If
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they don't have a smartphone, the Freestyle Libre, they can have a reader, but that one,
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you have to scan to see what it is. Okay. So instead of opening up Dexcom and saying, oh,
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I can stare at this and see what happens. The other one, you do have to take that extra
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which is not a big deal compared to doing a finger stick glucose. Grab the reader, scan it,
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and then you can see what it is. But the newer versions of the Libres will alert for a low and
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alert for a high, but you have to scan to get that actual data. Oh, so it'll beep if it's low,
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but they just won't tell you what it is. And then you can scan it. Okay. Okay. Correct. Yeah.
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So with one thing too, and I will say this about the Libre because that's one that
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is a decent option cash pay for a patient that if they don't have the insurance coverage,
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or if they're paying an equivalent amount in testing supplies, that might be a great option
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because then they don't have to buy the strips and the lancets and the nucleocometer and
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everything, or they just want to pay for the convenience. So we do have a lot that are like,
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it's worth it. It's worth the 80 bucks a month. Let me just go and purchase that. And
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estimated. Sometimes it goes up to about around here is between like 80 to a hundred dollars cash
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price. And that's generally for two sensors. And each one is one for 14 days discarded.
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A new one's activated after 14 days. So they get two per month. So it's a decent cash
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price option if the insurance doesn't cover it. So with actual insurance coverage, most
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insurance formulas, formularies, at least in our area, require the patient to be taking
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multiple daily injections of insulin. So that could be a basal bolus regimen. If they happen
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to be on like a humulin or U 500, even two times, three times a day of that, that's still
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MDI. Some insurance formularies do require some type of history of hypoglycemia and,
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or hypo unawareness, meaning the person has had enough lows that they just don't feel it anymore,
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which forced a really dangerous situation. So it really helps to justify that need. But
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I will say for this with like the costing coverage, all of these companies have really,
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really good reps that are there to help the clinician and to say, Hey, look, to get this
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covered. I mean, you have to have that documentation in your note of this person's on,
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you know, insulin QID and they're willing to use the technology as intended. They're able to
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use the technology. They have the hypoglycemia and that helps build the case, especially
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if that's for DME, durable medical equipment. Okay. So pharmacy, it's in the cover. So the
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device is considered durable medical equipment. Depends on the formulary. Yes. But more
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it's all great. So many more now is they're covering it under pharmacy. Meaning if you,
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if they have a Walgreens, Walmart, CVS, even a lot of the smaller town pharmacies,
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they can get it and it goes under their prescription formulary. So you send it in
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to the pharmacy just like you would anything else. Yeah. Yeah. That's how it works. How it's,
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how it's typically worked in my clinic. I'm in Massachusetts. Yeah. Yeah. So,
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and then if it does go through DME, then you'd have to go through a supply company,
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you know, but they just, it just depends like in Louisiana or Louisiana Medicaid.
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Thankfully we can get it under pharmacy now for most Medicaid. So that really helps a lot
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in clinic because it's like a, it's just a PA instead of doing a lot of the other paperwork
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and it's easier for the patient because they're not waiting on a supply company to mail them
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supplies. They can go through the Walmart drive-thru and pick it up just as if they're
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picking up their insulin or any other medication. Totally. And just to clarify,
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I remember being a new grad and being like, what is DME? So like what my, and I don't,
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I think this is so state to state, but durable medical equipment is like if you had
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compression stockings, at least this is Massachusetts, but compression stockings,
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walkers, chairs in the shower for people who are at low risk, you have to go through a separate
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company. And this, I always ask the nurses that I worked with, I'm like, how do I order this?
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Yeah. Oh, absolutely. And they were like, this company, this is how you do it. That's,
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that's what that means is that it's going through that process. And then various
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insurances have various coverage of drugs, pharmacy versus durable medical equipment. And
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I will say this too, like I am somebody that's like, it's not a no until it's a real no. So
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I will send it under pharmacy first because it's going to be easier. Our EMR will even if,
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when the insurance information is input by the front desk, we can even search
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and look to see potential costs, various differences if they pick it up local retail
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versus doing express scripts or OptumRx or CVS CareMart. And so then-
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That's in your earmark? You said that's in your earmark? That's amazing.
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Yeah, EMR. EMDs. Oh, interesting.
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Have you heard of that? Yeah. Yeah. So if everything's input correctly, which again,
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it's like, if, and then if, you know, magical, like we think insurance is one thing
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and then they end up with a $5,000 deductible and you're like, okay, whatever, you know,
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that's another problem. But so then it's knowing how to prescribe it. So for example,
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with the Dexcom, there's typically three components. So it's the receiver, which used
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to, and honestly, I would have to double check on this, used to, they would require
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the patient to get the receiver in case the iPhone did not work. Yeah. Yeah. So they would
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have to have something and that might be more under the DME side of it. So you have one
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receiver, which depending on their insurance, they might only be able to get one every two
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five years, whatever it might be. You have the transmitter, which is the little gray
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piece. That's the one that's reused. It's a 90 day battery and that's one for every 90 days.
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So they only have to get that quarterly, right? Cause they reuse it. That's the expensive
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part. Don't throw that away when you change it out. Cause you got to pay cash for the next
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one and lose it. And then the sensors are 10 days each. So you would dispense three for
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30 days. This is Dexcom. Dexcom, correct. For people who are listening or watching,
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this is going to be all written down on a PDF for you to download. And I'll help you
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with that. And then because with certain things like, we probably won't get into like
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insulin pump therapy today. Insulin pump therapy, you can prescribe based off of how
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frequently they change their site based off of their total daily dose of insulin. So if
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have somebody that uses quite a bit more insulin, they might need to change their insulin
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pump site every two days. Okay. So you have some wiggle room. Oh, I see. I see.
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Right. But like Dexcom, correct. So there you have flexibility. Other devices like
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a Dexcom or Freestyle Libre, three for 30 days, two for 28 days for Libre. And
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there's very little wiggle room. So then you make sure to tell the patient, Hey, look,
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there's Dexcom customer support. There's Freestyle Libre customer support. If something
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happens and you know, you're new to the product and number one, maybe one just goes bad and it
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doesn't work. If you wear that sensor for two days, you're going to be eight days short before
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you can get your next one. So you can contact them and they're great about really troubleshooting
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that. So just to kind of think of that too. And so let me get into a little bit of like
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management of it. Because if you look, I was going through all the guidelines and just kind
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of like doing a refresher and I'm like, Oh my gosh, this thing is like a thousand pages long.
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It's so long. Cover to cover for the course. Oh my gosh. Yeah. It's unreal. Yeah. So
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what I like to tell patients going into a CGM, because I have some that come in, they're
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like, I want to Libre or I want to Dexcom. I was like, Hey, great. Like let's get you
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diabetes technology. Let's make life easier. Let's get away from these finger sticks.
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What can be so overwhelming for them? Oh, amongst many, many other things,
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when you get a CGM and you have that real time data, or if you're doing the flash and
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you're doing your scanning, all of a sudden that patient is able to see what's going on
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all the time. So it, when you prescribe that, and then if you start it yourself,
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they come back for the education or if they self-start at home and you get a phone call
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within 24 hours and that person's A1C was a nine and they're on meds and all this stuff.
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Oh my gosh, Megan, you know, my sugars are X, Y, and Z. Hey, you know what? You're
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seeing what has been going on. This is not new information for your body. So it's like,
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you're just now able to see in real time what has been going on. And now we can see
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clinically, when you come back, how your meds are working, what's going on with food,
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your different triggers. Is it stress? Is it illness? Is it caffeine that's spiking you in
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the morning with your two cups of coffee? Is it, you know, smoking or dipping or, you know,
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anything like that? But they can see in real time what's going on. So it can be overwhelming.
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It's good information, but it's a lot of information. One of the things we're doing,
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especially with the team on Real World NP and otherwise, is recognizing people's
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way that their brains work, basically. And for some people, they get really into details
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and really obsessed with them. Absolutely. And it might be hard to assess when you're
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starting with a patient, but that might be a helpful question. Do you get really into
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details or not? Do you like data? Yeah. Some people are data nerds, right?
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Absolutely. I guess like a pearl of that is like warning people to start that it can be scary
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to see that. And like, we are comfortable with that as clinicians because we understand that,
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right? We understand what ACF9 means, but they might not. Yeah. And then just talking about
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that. Sorry. Go ahead. Oh yeah. And I would say on the flip side of that too, I can't even
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tell you how many times that this has happened that, you know, we started Libre, even, you
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know, talking about somebody paying cash for a Libre because maybe they're not on insulin and
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it's just, or they're just on metformin and a GLP-1. And they're like, I just want to see
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what's going on. You know, I want to pay out of pocket and do it. Sometimes, or not
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sometimes, a lot of times, once they get that data and they can see, I thought a banana
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wouldn't spike my sugar. I thought this wouldn't spike my sugar. They will come back
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on paper. We'll upload that report. You would have an A1C of this and I have to double
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check. You should anyway, right? Their name and date of birth. And I'm like, are you the
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same person? Because you don't look like this 12A1C. I mean, you're flat as a board.
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And they're like, well, yeah, I could finally see what was going on whenever I ate X, Y,
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and Z. And, you know, as humans, we crave success and you get that instant gratification
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of, oh, wow. Like I did not realize that sweet tea did this to me. Like let me cut that
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back. And then all of a sudden there's a flat line instead of a huge surge. So the data
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is great. And also for the data for the MPs out there, for Dexcom, when they downloaded on
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their app, they had their main app, which is their Dexcom G6. But then there's a second
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one. And I can give you this information called Dexcom Clarity. So that is where you
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get your reports. If there's not a capability in clinic to have like the clinic Dexcom
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account, they can from their app, just email you the data and it's a PDF. So the clinic side
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of it is not anything different than what they would see on their app. So it's not just like,
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hey, put the CG on good luck. You know, you really want to be able to hopefully have the
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capability to go through it with them and be like, oh, what happened here? Like, oh, I had
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COVID and my sugars were sky high after I had to have treatment or just the illness itself.
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So that way you can really look at the data. And then there's also the software for the
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Libre too. So I see that a lot. Like sometimes patients will come in from primary care and
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internal med and they're like, I have this data, but I've never been able to see my
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report before. And then just having that besides the real time, but like the actual like
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And as what's really cool and so rewarding for us to, I mean, like we want to fix people,
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right? Like we just want to fix it is that when they wear each one of these for two weeks at
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a time, you get what's called a GMI, which is a glucose monitoring indicator. They can't call it
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an estimated A1C anymore, but it pretty much is an estimated A1C. And so they see that I'm
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like, oh my goodness, you know, your A1C was X, Y and Z when you came in and now it's down
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to a 6.2 just in the last two weeks. And, you know, again, it's really, really rewarding.
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And also obviously, whenever you see it, and especially patients who are on NDI really helps
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you pinpoint, do they need a different amount of insulin for this trigger food or this situation
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or you can on those two, you can literally watch when like GLP ones kick in, you know,
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when they get to a higher dose, like it's the data on it is fantastic.
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It's just so moving. I'm like kind of tearing up a little bit thinking about how powerful that
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is for people to like have so much agency. Like I feel like, I don't know about you,
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but I feel like when I was a brand new grad, I was like keeping my head above water.
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And I still, you still make an impact from moment one. And even though it's hard for
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a lot of new grads, but I feel like the more time I have as a clinician, it's like,
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I don't know. I just, I just feel like it's so special. It's just like, those are the things
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that are just so special about like really, like the focus is less on keeping your head above
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water. I'm like, Oh my God, what am I supposed to do here? And more on like, how can I empower
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my patients? Absolutely. Keep making that impact, right? Like I said, impact the whole time.
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But like, once you like my frame of reference now is not just all the foundational stuff of
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medicine, but it's like, how can I help people like, yeah, like empower them? So that's just so,
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so special. Oh yeah. And just so much of that, the cause and effect. And we, you know,
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with our clinic, like we're diabetes only, and I've been doing diabetes since
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I wait, I mean, like kind of ages me out, but, but you know, crazy success. Like they
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don't want to have, go pay a copay or pay a deposit on deductible and just get fussed
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and you know, it's like, maybe they just don't have the right tools in the toolbox. Like what,
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let's, let's reevaluate. Like if you need a hammer, a screwdriver is not going to cut it.
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Like let's get him a hammer. Let's get good meds. And I've had people before, like,
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you know, my, even endocrinologist, my endocrinologist, you know, I just see them
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twice a year and they just fuss at me because my A1C is still a nine. Please don't
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fuss at me. And I'm like, do I fuss? Like have I ever fussed? I mean, it's with love.
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If I do, I mean, call it like, you know, something nice and a fuss and then, you know,
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do a little fuss sandwich, but you know, it's, it's with love and it's not demeaning.
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And it's more about empowering that patient and just helping them learn what's going on,
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you know, because they're doing their own management. Most of the time they see me
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for a little tiny blip in the radar and they're in their life span.
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And you use the acronym MDI. Is that, is that we said MDI?
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MDI. Yeah. Multiple daily injections of insulin. Yeah. Yeah. Yeah.
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Awesome. So thank you so much for all of that. I just think you were just a gem
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and such a wealth of knowledge. I, another question, super, super, super common question
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is about adherence and how to help patients when they are non-adherent. And I'm using
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adherence language. We taught in the diabetes CKD hypertension course that I have, I talk about
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language with patients and the way that you talk with them actually does make a difference
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on outcomes. There is research on diabetes. I don't, I'm sure you've seen that, but using
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non-adherence instead of non-compliance. So for patients who are struggling to follow the,
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you know, agreed upon directions that you've talked about, what is, what guidance do you
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have or approach or thoughts? I mean, you kind of mentioned a little bit with like the
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screwdriver, which you told me before, but what are your thoughts about that?
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So I love that you use non-adherence too. I don't say compliance, you know, and I,
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I don't know if y'all use this, but sometimes unfortunately I do have to put
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that ICD-10 code of like the non-compliance, you know, because it, it covers your,
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your rear end, you know, somebody's just literally, you're just at a point and I tell
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them, they're like, Hey, look, I'm sorry, like to cover me, you know, and just did,
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I have to put this in. So it bothers me that that's still not ICD-10, but I use adherence too.
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So, and just forgive me if I'm long-winded. I know everything you're saying is like so
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beautiful. And also like it's, it's a lot, it's a lot of information. And I think I struggle
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with that too. And at least in my teaching is that like, there's so much to say, but
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you're so concise. So go for it. So years ago, this is something that has just stuck with me
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and I probably just need to call this professor and just thank her. When I was in my undergrad,
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my first undergrad program at Louisiana Tech here, and Rustin, one of my favorite nutrition
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professors, she was teaching one of our M&T classes. And one of our big projects was to do
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a project about renal diet, but it's not just, no, renal diet is one of the most difficult
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diets out there. I mean, just, I commend anybody that can follow that diet to a T.
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I know this isn't diabetes, but one of the things she had us do with the project was
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to really put our feet in their shoes and say, okay, she had, it was brilliant. I mean,
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she now granted this is an undergrad nutrition program, but she did use candy, but she,
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for each one of us had different little baggies of all the different meds, what it would
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represent that that person that was on dialysis had to take on a regular basis.
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Then, so we had to keep a diary of what we ate and then track to like how much potassium
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and phosphorus and calcium and, you know, all this in protein and fluids and take your meds.
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Did you miss your binders? Did you miss this? Did you take this? How much fluid? And
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that has stuck with me now, oh my goodness, 15, 18 years, because it's so, when we think
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adherence, it's like, what does that mean? What is your, like, as an NP, like when you're looking,
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okay, what do I expect of this patient? Are you expecting perfection or what's realistic for the
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patient in the season that they're in right now? Okay, so when we get referrals, we don't
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require referrals, but when we do, I mean, it's not a lot of primary care that are sending
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me their A1C patients at the 6.2. It's the one that's so high it won't read and it has
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to be a sick out. So it's a greater than 15 or, you know, whatever, and they're just non-compliant,
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non-compliant, non-compliant. And you really just say, okay, let's think about when that
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person gets the diagnosis and what's their frame of reference of the diagnosis, right?
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Did they have a family member that they saw just suffer and have every complication in the
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world and, you know, they're like absolutely terrified and maybe they're motivated or maybe
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there's a little bit of denial in there. You know, is it, it could be anything, is it they
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just lost a family member, you know, like what is going on with that patient? And it's,
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I try to tell, especially like our ancillary staff this, that when, and I'm going to kind
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of mainly focus on like more difficult regimens, like the MDI, the multiple daily injections.
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And when we recommend, okay, you're going to take Metformin, you're going to do a weekly
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semaglutide. We also need to do a Jordiance, okay? So maybe we can get some combination meds,
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but you know what? You also need a basal insulin and then you need three injections per day.
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You need to do finger sticks because we haven't got your CGM coverage yet.
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And then you literally have a life and you have a family, you have kids.
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By the way, you have a life.
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Like let's exercise too. Like, you know, let's do that. Let's get good sleep. Let's meal prep.
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Let's count on our carbs. And so the ancillary staff too, I'm like, have you ever thought
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about how difficult that is? We have other things to think about than dealing with daily
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chronic illness, right? So we have to recognize and tell that patient, like, I get, I mean,
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this is hard. What you were doing is hard. This is a time commitment. And plus with us,
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we make them keep homework. So they might not have had to write down their meals and snacks
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and try to count their carbs and do all this. We stress the importance of it. Hey,
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do your best. But if we really step back before we just start fussing and we're just
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like, okay, you got to do it. You got to do it. Have we thought about like the time
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commitment that it takes to really just do what needs to be done. And we have some
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type A patients that are like, you know what, you just tell me what to do. Tell me what to
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do and I'll do it. I was like, I can't remember the last time I've taken a multivitamin
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daily for an entire week. I'm like a really complicated man. So, you know, and it could
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be to, I mean, we all know the benefits of goal setting. So it might be, Hey, look
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right now. Here's what I want you to focus on. No sugary drinks, except for in the case
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of hypoglycemia. Okay. Let's just work on that. Take your medicines as prescribed
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and check your sugar. I mean, like, you can start with three things before you just like
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start pounding on all these other things. Then guess what? You know, they got to get
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that dialyzer, that eye exam. You got to get the monofilament. You got to do daily
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foot checks. You got to do this, this and this, not to mention if they need a
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nephrology referral, cardiology, whatever. And then they have extra adipose. Yeah. So
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it's a lot. So if you say, I get it. This is hard. This is hard. This is brand new
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information. Let's work on this first, you know, because, you know, I'm in
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Louisiana. We have fantastic, great, fatty, wonderful foods. Like I can work
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with gumbo. I can work with chicken strips. I can work, you know, with a
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with a crawfish boil. I can't work with Coca-Cola. I mean, like I just
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there's, I will dose it if I have to, but there's no place for that. You know,
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like, I love it. I love that. Because you're reading where they're at, you
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know? Yeah, absolutely. So and then you just try to build on that. And
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then once they get that trust, maybe the last few places that they've gone,
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they've just been really kind of talked down to or whatever. And then
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they get that trust with you and know that they're coming like for
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encouragement, but also tough love when needed. You'll see more and more
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adherence if it's not mainly something like a like a cost issue, you know,
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which we'll talk about that in a minute. And also, too, I've had
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patients come in, you probably have too, that, you know, they'll say,
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well, I'm just in denial. I'm just in denial. I'm like, but are
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you in denial? You walked in the door. You came to a diabetes clinic.
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Like, I think you're in denial. I think, you know, let's recognize
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you came in, you made an appointment, you paid your co-pay, you walked in,
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you were here on time, and you're talking to me. I don't think that's
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denial. So it's just like, maybe you just need different tools. And
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that's when, too, you go back to like something like a CGM, you
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know, something that, okay, maybe this person, we can get more data,
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it makes it easier on them. They can trust their med regimen. Maybe
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they were on really old school diabetes meds in the past, and
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they're like, it's the fine areas, and we're dropping out like crazy.
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And maybe they're so terrified of lows. And they're like, I'm
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worried about this SGLT2 causing lows. And then, so maybe it's just
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something like that, where they just need a little bit more education
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on the mechanism of action of the medication. So, but it's just
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like, what does that appearance mean? Like, what are your
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expectations of the patient? And really meet them where they're
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at? Absolutely. Yes, like Pearl should pull out for that,
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because I've heard new grads, I think there's so much,
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because not just new grads listen to the channel and the
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podcast, like there's experienced people too, and people who are
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primary care from another specialty, right? So it's not
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just new grads. But like, when I think about new grads, and I
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think about what I wanted to do, and the people that I work
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with, and what they want to do, there's so much desire to
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do it all right now. And like, having conversations like
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this, like, this takes time, and practice, I feel like the
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first place to start is the non judgmental attitude,
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exactly like you said, of like, I had a similar thing in
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nursing school, where it was not about diabetes, but it was
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about older adults, who have visual impairments, tactile
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impairments, hearing impairments, I wore earbuds, I
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put on these like really hard to see glasses, and I had
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these big things. And like, someone's explaining my med
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regimen to me. And I'm like, I will never forget that.
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Like, that was the problem. And they're saying quickly,
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and I can't, you know, like that whole thing. I think
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that's one thing to start for, especially for newer
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clinicians. It's okay to build on this. And I think
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one other thing I want to pull out about what you said is
376
00:32:25.120 --> 00:32:28.820
like, yeah, just like meeting people where they're at,
377
00:32:29.100 --> 00:32:31.820
because it really is a long game. Because I think
378
00:32:31.820 --> 00:32:33.440
especially, I don't know if you had this when you were a
379
00:32:33.440 --> 00:32:36.100
brand new NP, but you also had so much other clinical
380
00:32:36.100 --> 00:32:38.200
experience before, so maybe it didn't hit you as hard.
381
00:32:38.580 --> 00:32:41.440
But like, it's just like, I felt the pressure of like,
382
00:32:41.440 --> 00:32:44.480
I have to fix it today. And so your diagnosis of
383
00:32:44.480 --> 00:32:47.580
diabetes, I'm like, okay, monofilament, ophthalmology,
384
00:32:47.880 --> 00:32:51.120
it was ridiculous. And I think about it, I'm not saying
385
00:32:51.120 --> 00:32:53.440
ridiculous in a judgmental way to a new grad who is
386
00:32:53.440 --> 00:32:57.680
listening and is doing the same thing. Like in retrospect,
387
00:32:57.780 --> 00:33:01.500
it was like that, that was, people didn't come back,
388
00:33:01.520 --> 00:33:03.720
right? So it's a step-wise approach. It doesn't have to
389
00:33:03.720 --> 00:33:07.580
be done today. And like, the person coming to a visit
390
00:33:07.580 --> 00:33:11.400
who is in denial, like the fact that they arrived is
391
00:33:11.400 --> 00:33:16.240
good enough. We can keep positive intent, like assume
392
00:33:16.240 --> 00:33:18.580
positive intent and assume that everyone is doing the
393
00:33:18.580 --> 00:33:22.080
best that they can all the time. Like, how does that
394
00:33:22.080 --> 00:33:23.700
change the way you approach your patient? It's like,
395
00:33:23.860 --> 00:33:25.880
that's the best that that person can do today.
396
00:33:26.180 --> 00:33:27.700
Come to your clinic and tell you, we're not doing
397
00:33:27.700 --> 00:33:28.580
anything, right?
398
00:33:28.760 --> 00:33:32.500
Oh, yeah, absolutely. Yeah. And you do have to adjust
399
00:33:32.500 --> 00:33:35.440
for where they're at seasonally. And I tell people
400
00:33:35.440 --> 00:33:38.760
too, like, when you're diagnosed with diabetes,
401
00:33:38.920 --> 00:33:42.960
whether that was yesterday or 10 years ago, diabetes is
402
00:33:42.960 --> 00:33:46.380
not like, hey, you got it. I'm going to stay right
403
00:33:46.380 --> 00:33:48.260
here. I'm going to be stagnant. This is the worst
404
00:33:48.260 --> 00:33:51.080
it's going to be. It is progressive. So I mean, like,
405
00:33:51.080 --> 00:33:52.940
I can't remember the stat on like the beta cell
406
00:33:52.940 --> 00:33:55.240
dysfunction and like how much of the beta cells that
407
00:33:55.240 --> 00:33:56.960
you lose by the time pre-diabetes is found,
408
00:33:57.000 --> 00:34:00.580
let alone type two. That destruction is gone and
409
00:34:00.580 --> 00:34:03.500
that's progressive. So like, what used to work
410
00:34:03.500 --> 00:34:06.080
three years ago, that beats just on this little
411
00:34:06.080 --> 00:34:08.560
happy merry way and you got to jump the fits and
412
00:34:08.560 --> 00:34:11.320
you got to get ahead of it, you know, with meds or
413
00:34:11.320 --> 00:34:18.239
weight management or whatever it might be. And it
414
00:34:18.239 --> 00:34:20.780
they have this elevated A1C and newly diagnosed, of
415
00:34:20.780 --> 00:34:23.460
course, you can't fix everything in one visit.
416
00:34:24.739 --> 00:34:26.060
And depending on where you go, of course, I'm
417
00:34:26.060 --> 00:34:28.100
going to be way more aggressive in the treatment
418
00:34:28.100 --> 00:34:31.040
than many other people would be. And, you know,
419
00:34:31.120 --> 00:34:33.520
my boss would be even way more aggressive and
420
00:34:34.060 --> 00:34:36.699
but it's appropriately aggressive. But you have
421
00:34:36.699 --> 00:34:39.219
to tell them to like, hey, look, I recognize
422
00:34:39.219 --> 00:34:41.960
that you're scared or nervous, but you know,
423
00:34:42.000 --> 00:34:43.940
these averages of three hundreds, if I pull
424
00:34:43.940 --> 00:34:46.620
you down the averages of 100 within a week,
425
00:34:46.620 --> 00:34:48.500
you're not going to feel good. You know, like,
426
00:34:48.760 --> 00:34:50.800
I got it. I got a chip away. You know, I've
427
00:34:50.800 --> 00:34:52.400
just got to kind of knock it down a little
428
00:34:52.400 --> 00:34:55.739
bit. And, you know, we can talk about a
429
00:34:55.739 --> 00:34:59.100
little bit with meds and kind of some of
430
00:34:59.100 --> 00:35:01.280
those algorithms and where and we'll go
431
00:35:01.280 --> 00:35:03.360
to the pearls and stuff too. I'm like,
432
00:35:03.440 --> 00:35:06.800
okay, again, people crave success. A lot of
433
00:35:06.800 --> 00:35:08.320
and I know we're focusing mainly on type
434
00:35:08.320 --> 00:35:10.300
two diabetes, but many patients, most
435
00:35:10.300 --> 00:35:14.020
patients with diabetes type two need some
436
00:35:14.020 --> 00:35:16.340
type of weight management, you know, so it
437
00:35:16.340 --> 00:35:19.380
could be, you know what, I know, you know,
438
00:35:19.400 --> 00:35:21.480
an injectable doesn't sound great, but you
439
00:35:21.480 --> 00:35:23.260
know, the smaglotide or the trulicity or
440
00:35:23.260 --> 00:35:25.100
something like that, the weekly injectables,
441
00:35:25.120 --> 00:35:27.120
it's great. Let's get some success. You
442
00:35:27.120 --> 00:35:29.260
can kind of taste that and you build
443
00:35:29.260 --> 00:35:31.760
from there of that compliance. But then
444
00:35:31.760 --> 00:35:33.920
can you imagine, like, let's say that
445
00:35:33.920 --> 00:35:35.780
you're on like a med regimen and
446
00:35:36.520 --> 00:35:38.040
somebody told you, okay, check your blood
447
00:35:38.040 --> 00:35:39.560
sugar two times a day, four times a day,
448
00:35:39.660 --> 00:35:41.640
whatever. And you're checking it. You don't
449
00:35:41.640 --> 00:35:42.900
go back in because they're like, well,
450
00:35:42.900 --> 00:35:44.260
they told me not to come back for like
451
00:35:44.260 --> 00:35:45.660
three months. You're checking your blood
452
00:35:45.660 --> 00:35:47.160
sugar two to four times a day. You're not
453
00:35:47.160 --> 00:35:48.720
seeing it, but you're doing everything
454
00:35:48.720 --> 00:35:50.480
you can with diet and exercise. I kind
455
00:35:50.480 --> 00:35:52.880
of be like, what's the point? Like,
456
00:35:53.760 --> 00:35:55.660
it becomes completely disheartening for
457
00:35:55.660 --> 00:35:57.460
that patient to just be like, well,
458
00:35:57.460 --> 00:35:59.520
I'm not seeing progress. Like, why do
459
00:35:59.520 --> 00:36:01.160
I, why am I still checking twice a
460
00:36:01.160 --> 00:36:02.540
day and I'm seeing nothing but two to
461
00:36:02.540 --> 00:36:04.720
three hundred? So, you know, there's
462
00:36:04.720 --> 00:36:06.860
multiple reasons, but you just think
463
00:36:06.860 --> 00:36:08.840
too, okay, when was the last time I
464
00:36:08.840 --> 00:36:10.740
had to check my blood sugar four
465
00:36:10.740 --> 00:36:11.880
times a day and do finger sticks
466
00:36:11.880 --> 00:36:13.320
and stop what I'm doing and clean off.
467
00:36:13.340 --> 00:36:14.880
And then I need to count my carbs and
468
00:36:14.880 --> 00:36:16.440
make sure it's a low glycemic index
469
00:36:16.440 --> 00:36:17.880
and pair it with protein and fat. And
470
00:36:17.880 --> 00:36:19.780
I need to exercise. Like, can you do
471
00:36:19.780 --> 00:36:22.900
that? Can you do that? I cannot. I
472
00:36:22.900 --> 00:36:24.620
mean, I try really hard to feed
473
00:36:24.620 --> 00:36:26.260
myself well and it's very hard.
474
00:36:26.280 --> 00:36:27.640
Oh my gosh, absolutely. Yeah. And not to
475
00:36:27.640 --> 00:36:29.720
mention your family. Like, it's so
476
00:36:29.720 --> 00:36:32.300
hard. So hard. So, I'd really try
477
00:36:32.300 --> 00:36:33.880
to tell people, like, my main thing
478
00:36:33.880 --> 00:36:35.220
and I'll tell them, like, I
479
00:36:35.220 --> 00:36:37.840
exercise for mental health. My family
480
00:36:37.840 --> 00:36:39.960
history terrifies me, you know, but I
481
00:36:39.960 --> 00:36:42.320
also really like to be able to sit
482
00:36:42.320 --> 00:36:44.540
here and be like, I do exercise five
483
00:36:44.540 --> 00:36:46.080
to seven days a week. I mean, like, I
484
00:36:46.080 --> 00:36:48.240
like to be able to say that. And
485
00:36:48.240 --> 00:36:50.060
then you get what's involved and you
486
00:36:50.060 --> 00:36:52.660
get that. Absolutely. Yeah. And also
487
00:36:52.660 --> 00:36:55.960
too, it's just we're, you know, as
488
00:36:55.960 --> 00:36:57.600
healthcare workers, you know, we have
489
00:36:57.600 --> 00:37:00.020
a certain knowledge base and I always
490
00:37:00.020 --> 00:37:02.080
love and respect people that are just
491
00:37:02.080 --> 00:37:03.800
like, I don't understand. Like, I
492
00:37:03.800 --> 00:37:05.440
call my collaborative MD for stuff
493
00:37:05.440 --> 00:37:06.680
that, I mean, she's always very
494
00:37:06.680 --> 00:37:08.220
assuring, reassuring. She's like,
495
00:37:08.420 --> 00:37:10.260
Megan, no, call me anytime. That's
496
00:37:10.260 --> 00:37:12.060
like, if I don't know something, you
497
00:37:12.060 --> 00:37:16.620
know, that's okay. But we can't assume
498
00:37:16.620 --> 00:37:19.580
that the patient knows what we know.
499
00:37:19.700 --> 00:37:21.980
Like, we can't assume that they know
500
00:37:21.980 --> 00:37:24.360
that maybe fast food twice a day is not
501
00:37:24.360 --> 00:37:27.460
the best option. Maybe sweet tea or a
502
00:37:27.460 --> 00:37:29.780
soda or even half and half tea is
503
00:37:29.780 --> 00:37:32.320
not the best option. So that
504
00:37:32.320 --> 00:37:35.460
sometimes can be helpful because
505
00:37:35.460 --> 00:37:36.980
it's like, just because we know
506
00:37:36.980 --> 00:37:39.120
something doesn't mean, we can't
507
00:37:39.120 --> 00:37:40.580
assume that that patient understands
508
00:37:40.580 --> 00:37:42.480
it to already understand the impact.
509
00:37:42.820 --> 00:37:44.100
Yeah. And I think even when we talk
510
00:37:44.100 --> 00:37:46.720
to patients too, like, if we start
511
00:37:46.720 --> 00:37:48.160
kind of like at the basics,
512
00:37:48.380 --> 00:37:50.700
essentials, most of the time, that's
513
00:37:50.700 --> 00:37:52.900
going to include everybody versus if
514
00:37:52.900 --> 00:37:55.820
we start with not the basics, we're
515
00:37:55.820 --> 00:37:57.360
going to miss those people. But then
516
00:37:57.360 --> 00:37:59.880
also the people who know all that
517
00:37:59.880 --> 00:38:01.140
stuff, they're going to be like, oh,
518
00:38:01.140 --> 00:38:02.360
no, I know. You know what I mean?
519
00:38:02.760 --> 00:38:04.420
Like, yeah, people are quick to
520
00:38:04.420 --> 00:38:05.620
correct you. Like, yeah, I got that.
521
00:38:05.620 --> 00:38:06.920
But if you, if you're kind of like
522
00:38:06.920 --> 00:38:08.140
starting from that foundational place,
523
00:38:08.160 --> 00:38:10.260
you can kind of see the person will
524
00:38:10.260 --> 00:38:12.400
typically volunteer where they're at
525
00:38:12.400 --> 00:38:13.760
in terms of their level. Do you know
526
00:38:13.760 --> 00:38:14.780
what I mean? Like in the conversation.
527
00:38:15.560 --> 00:38:17.800
Right. Right. I would love to go ahead.
528
00:38:17.960 --> 00:38:19.000
I'm sorry. I was going to say one
529
00:38:19.000 --> 00:38:20.420
more thing too about like with
530
00:38:21.520 --> 00:38:23.120
medications, because especially with
531
00:38:23.120 --> 00:38:23.940
something like, I'll give the
532
00:38:23.940 --> 00:38:26.340
example of like a GLP-1. So we
533
00:38:26.340 --> 00:38:27.880
know with those meds that we're
534
00:38:27.880 --> 00:38:28.940
going to see like weight management
535
00:38:28.940 --> 00:38:30.540
and everything. So we, it's like,
536
00:38:30.680 --> 00:38:31.880
what's your approach in communicating
537
00:38:31.880 --> 00:38:33.300
with that patient on how these
538
00:38:33.300 --> 00:38:36.100
medications work? So, you know, yes,
539
00:38:36.100 --> 00:38:39.140
we can say, hey, you know, when you
540
00:38:39.140 --> 00:38:40.600
make this weekly medication, it's
541
00:38:40.600 --> 00:38:41.420
supposed to help with weight loss.
542
00:38:41.480 --> 00:38:42.480
It's going to help your sugars,
543
00:38:42.660 --> 00:38:44.560
you know, whatever you, whatever
544
00:38:44.560 --> 00:38:46.380
your spiel is. But it's like,
545
00:38:46.420 --> 00:38:48.800
let's try to like put it into words
546
00:38:48.800 --> 00:38:50.720
of how it actually works. Okay.
547
00:38:50.720 --> 00:38:53.480
So what I'll say is, okay, so
548
00:38:53.480 --> 00:38:55.580
you're on this GLP-1 and I'll
549
00:38:55.580 --> 00:38:56.600
mention the name of whatever one
550
00:38:56.600 --> 00:38:57.620
it's going to be, whatever we
551
00:38:57.620 --> 00:39:00.160
decide on with the patient. And it's
552
00:39:00.160 --> 00:39:02.000
like, these are intelligent
553
00:39:02.000 --> 00:39:03.720
medications. Okay. These are not
554
00:39:03.720 --> 00:39:06.360
old school grandma's like flip
555
00:39:06.360 --> 00:39:09.300
you know, from 30 years ago, like
556
00:39:09.300 --> 00:39:11.220
these are intelligent meds. So you
557
00:39:11.220 --> 00:39:13.180
take this medicine. So let's say
558
00:39:13.180 --> 00:39:14.620
somebody's worried about lows or
559
00:39:15.300 --> 00:39:16.660
they're wanting to do a CGM where
560
00:39:16.660 --> 00:39:18.000
they can like see their patterns
561
00:39:18.000 --> 00:39:20.100
with what's going on. So it's like,
562
00:39:20.160 --> 00:39:21.200
okay, well, you take this weekly
563
00:39:21.200 --> 00:39:22.980
injectable and you take it. It's
564
00:39:22.980 --> 00:39:24.760
like in the background and it's just
565
00:39:24.760 --> 00:39:26.740
waiting on Megan's blood sugars to go
566
00:39:26.740 --> 00:39:28.820
up. It's just waiting for you to eat.
567
00:39:29.020 --> 00:39:31.040
So then you eat that little sausage
568
00:39:31.040 --> 00:39:32.040
biscuit in the morning. What's it
569
00:39:32.040 --> 00:39:33.300
going to do? It's going to come in.
570
00:39:33.300 --> 00:39:34.720
It's going to help. It's going to
571
00:39:34.720 --> 00:39:35.760
help the body release the right
572
00:39:35.760 --> 00:39:37.200
amount of insulin, kind of cover that
573
00:39:37.200 --> 00:39:38.940
a little bit, but not give you too
574
00:39:38.940 --> 00:39:40.120
much where you're going to have this
575
00:39:40.120 --> 00:39:42.160
drop. So it's in the background. It's
576
00:39:42.160 --> 00:39:43.640
kind of waiting, you know, it helps
577
00:39:43.640 --> 00:39:44.840
to decrease your appetite. It's going
578
00:39:44.840 --> 00:39:46.220
to help you feel fuller longer. But
579
00:39:46.220 --> 00:39:48.180
you know what? If you introduce
580
00:39:48.180 --> 00:39:49.960
foods and you eat something that's
581
00:39:49.960 --> 00:39:52.160
going to digest more slowly anyway,
582
00:39:52.320 --> 00:39:54.300
it's baseline chicken strips and
583
00:39:54.300 --> 00:39:55.980
french fries, hamburgers, you know,
584
00:39:56.020 --> 00:39:58.960
anything fatty, anything fried, any
585
00:39:58.960 --> 00:40:00.040
food that's going to slow down
586
00:40:00.040 --> 00:40:01.880
digestion anyway, you put this med on
587
00:40:01.880 --> 00:40:03.560
top of it, you are going to
588
00:40:03.560 --> 00:40:04.720
experience some side effects that
589
00:40:04.720 --> 00:40:06.200
might come back up, you know, so
590
00:40:06.200 --> 00:40:07.500
that's a good deterrent for not
591
00:40:07.500 --> 00:40:08.980
doing that, because they'll come in
592
00:40:08.980 --> 00:40:10.500
and they're like, I have reflux,
593
00:40:10.600 --> 00:40:11.920
I have nausea, you know, I've
594
00:40:11.920 --> 00:40:13.240
been vomiting. It's like, okay,
595
00:40:13.380 --> 00:40:14.680
well, but if they know in
596
00:40:14.680 --> 00:40:16.220
advance, like, oh, you're right,
597
00:40:16.220 --> 00:40:17.680
you know, every time I eat
598
00:40:17.680 --> 00:40:19.620
whatever food, I feel terrible.
599
00:40:19.620 --> 00:40:21.020
So I'm going to feel really bad
600
00:40:21.020 --> 00:40:22.720
with like this medicine on top.
601
00:40:23.060 --> 00:40:24.200
So you kind of give those
602
00:40:24.200 --> 00:40:25.680
besides just like, okay, you
603
00:40:25.680 --> 00:40:26.860
might experience nausea,
604
00:40:26.880 --> 00:40:28.180
vomiting, diarrhea, constipation.
605
00:40:29.500 --> 00:40:31.120
What does that mean?
606
00:40:31.140 --> 00:40:32.140
There's going to be a side effect
607
00:40:32.140 --> 00:40:34.440
for aspirin or, you know, Tylenol,
608
00:40:35.140 --> 00:40:37.820
you have to, but in what, how
609
00:40:37.820 --> 00:40:39.280
can they take that into like
610
00:40:39.280 --> 00:40:40.480
practical knowledge too?
611
00:40:40.840 --> 00:40:42.360
So totally, totally.
612
00:40:42.360 --> 00:40:43.500
It's just a side effect.
613
00:40:43.660 --> 00:40:44.320
I love that.
614
00:40:44.420 --> 00:40:46.000
I love that so much.
615
00:40:46.260 --> 00:40:46.540
Oh, my God.
616
00:40:46.620 --> 00:40:47.900
I can go in a thousand tangents,
617
00:40:47.900 --> 00:40:49.140
so, you know, just.
618
00:40:53.460 --> 00:40:55.240
So I was so grateful.
619
00:40:55.240 --> 00:40:56.800
The way that you and I connected
620
00:40:56.800 --> 00:40:58.060
was I was talking about
621
00:40:58.060 --> 00:40:58.700
one of the things.
622
00:40:58.720 --> 00:40:59.720
So I have this diabetes
623
00:40:59.720 --> 00:41:00.720
hypertension course.
624
00:41:01.100 --> 00:41:02.620
And so I was like the main
625
00:41:02.620 --> 00:41:04.420
thing that I feel less
626
00:41:04.420 --> 00:41:06.760
equipped to answer, like I have
627
00:41:06.760 --> 00:41:08.160
my own anecdotal stuff, but I'm
628
00:41:08.160 --> 00:41:09.860
like in primary care and like
629
00:41:09.860 --> 00:41:11.240
foundationally what I'm teaching
630
00:41:11.240 --> 00:41:12.600
is about like pharmacology
631
00:41:12.600 --> 00:41:13.620
and all that stuff.
632
00:41:13.860 --> 00:41:14.880
But when you talk about
633
00:41:14.880 --> 00:41:16.280
it's the main complaint
634
00:41:16.280 --> 00:41:18.220
that people have as providers.
635
00:41:18.220 --> 00:41:20.140
And like, when I kind of cast
636
00:41:20.140 --> 00:41:21.020
that question out to people,
637
00:41:21.080 --> 00:41:22.980
like, what do you do to manage costs?
638
00:41:23.460 --> 00:41:24.880
You like blew up my dance
639
00:41:24.880 --> 00:41:26.720
in a beautiful way.
640
00:41:26.800 --> 00:41:29.620
I was like, who is this amazing person?
641
00:41:30.460 --> 00:41:31.940
Something I'm very passionate about.
642
00:41:33.700 --> 00:41:35.420
So, so, yeah, I would love
643
00:41:35.420 --> 00:41:37.840
for you to share your your
644
00:41:37.840 --> 00:41:40.020
there are just there are so many ways
645
00:41:40.020 --> 00:41:41.300
to help people with costs.
646
00:41:41.380 --> 00:41:43.140
But what are your thoughts about that?
647
00:41:43.240 --> 00:41:44.480
And also we can like, again,
648
00:41:44.500 --> 00:41:46.360
write down some more stuff.
649
00:41:46.360 --> 00:41:48.660
Yeah, because people listen in the car
650
00:41:48.660 --> 00:41:49.660
and I don't want them to like,
651
00:41:49.900 --> 00:41:50.840
oh, God, I've heard this time.
652
00:41:50.920 --> 00:41:51.880
Oh, yeah, no, no.
653
00:41:52.020 --> 00:41:52.760
Yeah, I'll see.
654
00:41:52.880 --> 00:41:53.700
I'll send you a lot.
655
00:41:53.820 --> 00:41:54.700
So, yeah.
656
00:41:54.860 --> 00:41:56.900
So when I saw that in your
657
00:41:56.900 --> 00:41:58.380
was the Instagram stories, right?
658
00:41:58.640 --> 00:41:59.480
You just presented that.
659
00:41:59.640 --> 00:42:00.820
I was like, oh, my gosh.
660
00:42:00.820 --> 00:42:02.040
I'm here.
661
00:42:03.920 --> 00:42:04.800
Alert alert.
662
00:42:04.940 --> 00:42:05.500
I have resources.
663
00:42:06.140 --> 00:42:08.700
So that is by far.
664
00:42:08.840 --> 00:42:10.540
I mean, we you can have
665
00:42:10.540 --> 00:42:12.380
the best meds in the world,
666
00:42:12.400 --> 00:42:13.860
but if somebody can't afford them,
667
00:42:14.560 --> 00:42:15.760
good job getting them
668
00:42:15.760 --> 00:42:16.360
from the pharmacy.
669
00:42:16.500 --> 00:42:17.880
I mean, like we have the best meds
670
00:42:17.880 --> 00:42:18.720
that nobody can afford.
671
00:42:19.600 --> 00:42:21.380
That group of patients
672
00:42:21.380 --> 00:42:23.700
that are just like in that little window,
673
00:42:24.660 --> 00:42:26.500
people who have these
674
00:42:26.500 --> 00:42:29.080
high deductible medication plans,
675
00:42:29.340 --> 00:42:30.720
you know, so they might
676
00:42:30.720 --> 00:42:31.460
have insurance.
677
00:42:31.680 --> 00:42:33.060
But what if their family deductible
678
00:42:33.060 --> 00:42:34.760
is five to six thousand dollars?
679
00:42:34.980 --> 00:42:36.260
You know, so that's really,
680
00:42:36.260 --> 00:42:36.680
really difficult.
681
00:42:36.740 --> 00:42:37.580
And I know there are
682
00:42:37.580 --> 00:42:38.340
really good questions
683
00:42:38.340 --> 00:42:39.240
from your audience too
684
00:42:39.240 --> 00:42:40.200
about like gap coverage
685
00:42:40.200 --> 00:42:41.240
and everything for Medicare.
686
00:42:42.780 --> 00:42:43.740
Knowing formularies
687
00:42:43.740 --> 00:42:45.320
is super, super important
688
00:42:45.320 --> 00:42:46.540
for a lot of reasons,
689
00:42:46.540 --> 00:42:48.480
but also to it.
690
00:42:48.480 --> 00:42:49.460
It saves a lot of time
691
00:42:49.460 --> 00:42:50.620
for you and your staff
692
00:42:50.620 --> 00:42:52.220
because then you're really
693
00:42:52.220 --> 00:42:53.580
hopefully trying to cut back
694
00:42:53.580 --> 00:42:54.880
on a lot of prior authorizations
695
00:42:54.880 --> 00:42:56.140
and time on the phone pharmacy
696
00:42:56.140 --> 00:42:57.900
and everything and decreases.
697
00:42:59.500 --> 00:42:59.780
All right.
698
00:42:59.780 --> 00:43:00.980
It helps increase access
699
00:43:00.980 --> 00:43:01.980
of medications.
700
00:43:02.720 --> 00:43:03.900
So, of course, you know, like
701
00:43:03.900 --> 00:43:05.580
I was looking back on your stories,
702
00:43:05.660 --> 00:43:06.240
you know, a lot of people
703
00:43:06.240 --> 00:43:07.980
did recommend like the GoodRx.
704
00:43:08.540 --> 00:43:08.600
Okay.
705
00:43:08.720 --> 00:43:10.880
So GoodRx is good
706
00:43:10.880 --> 00:43:11.680
for certain things,
707
00:43:11.700 --> 00:43:13.480
but like really name brand medications.
708
00:43:13.760 --> 00:43:15.980
It doesn't take a lot off
709
00:43:15.980 --> 00:43:17.740
when you still have a med
710
00:43:17.740 --> 00:43:19.760
that can be retail eight hundred dollars
711
00:43:19.760 --> 00:43:21.200
and it's, you know,
712
00:43:21.360 --> 00:43:22.500
a certain amount off.
713
00:43:23.280 --> 00:43:24.180
You're asking somebody
714
00:43:24.180 --> 00:43:25.060
potentially to pay
715
00:43:25.060 --> 00:43:26.060
like two car notes worth
716
00:43:26.060 --> 00:43:27.540
of a medication for just one month.
717
00:43:28.120 --> 00:43:28.900
And, you know, nobody,
718
00:43:28.900 --> 00:43:30.220
even if you can't afford that,
719
00:43:30.480 --> 00:43:32.560
like who really, really wants to do that.
720
00:43:32.660 --> 00:43:33.960
So, and then GoodRx too,
721
00:43:34.000 --> 00:43:35.000
of course, is not insurance.
722
00:43:35.020 --> 00:43:36.360
So if somebody does have
723
00:43:36.360 --> 00:43:37.080
that deductible,
724
00:43:37.120 --> 00:43:38.040
it doesn't hit deductible.
725
00:43:38.100 --> 00:43:40.020
So it doesn't help them
726
00:43:40.020 --> 00:43:42.020
in that aspect except for
727
00:43:42.020 --> 00:43:43.380
if it makes something
728
00:43:43.380 --> 00:43:45.680
that's a generic even cheaper,
729
00:43:45.740 --> 00:43:47.320
you know, that's really, really good.
730
00:43:48.380 --> 00:43:51.640
So all of these big major companies
731
00:43:51.640 --> 00:43:53.140
or I'll say most of them
732
00:43:53.140 --> 00:43:55.620
and I don't work for any of them.
733
00:43:55.760 --> 00:43:57.400
I will blast names.
734
00:43:57.620 --> 00:43:57.900
I don't care.
735
00:43:57.900 --> 00:43:59.120
I don't get compensated
736
00:43:59.120 --> 00:43:59.960
by any of these companies.
737
00:44:00.080 --> 00:44:00.820
Not that I would talking
738
00:44:00.820 --> 00:44:01.900
about patient assistance,
739
00:44:03.680 --> 00:44:06.060
but I would say out of all of them,
740
00:44:06.200 --> 00:44:08.400
the two that are easiest to work with
741
00:44:08.400 --> 00:44:09.800
for patient assistance programs,
742
00:44:10.220 --> 00:44:11.140
Novo Nordisk,
743
00:44:11.640 --> 00:44:13.660
which is Novolog,
744
00:44:14.080 --> 00:44:14.420
Fias,
745
00:44:14.740 --> 00:44:16.720
is a faster acting insulin,
746
00:44:16.880 --> 00:44:18.280
Triseba, Levemir,
747
00:44:18.520 --> 00:44:19.820
Ozempic, Victoza.
748
00:44:19.920 --> 00:44:20.940
You can even, Glucagon.
749
00:44:21.060 --> 00:44:22.440
You can get pin tips on these.
750
00:44:23.460 --> 00:44:24.880
What this, so this is,
751
00:44:25.100 --> 00:44:26.540
there's two different things for Novo.
752
00:44:26.760 --> 00:44:27.160
Okay.
753
00:44:27.160 --> 00:44:29.620
The Novo Nordisk patient assistance program,
754
00:44:30.180 --> 00:44:32.170
that is number one
755
00:44:32.640 --> 00:44:35.360
for patients without any insurance at all.
756
00:44:36.000 --> 00:44:37.940
So if somebody, you know,
757
00:44:37.940 --> 00:44:40.280
it's just they have no insurance whatsoever
758
00:44:40.280 --> 00:44:42.120
and they meet income requirements
759
00:44:42.980 --> 00:44:44.780
and it takes a little bit of time
760
00:44:44.780 --> 00:44:47.080
by you or your staff to fill this out.
761
00:44:47.280 --> 00:44:48.840
Within seven to 10 business days,
762
00:44:48.840 --> 00:44:50.520
you get a yes or a no on it.
763
00:44:50.740 --> 00:44:51.700
And if it's a yes,
764
00:44:51.700 --> 00:44:52.860
if it's non Medicare,
765
00:44:53.160 --> 00:44:55.020
it's a year from that date
766
00:44:55.020 --> 00:44:56.260
that it's approved.
767
00:44:56.260 --> 00:44:59.540
They'll mail four months of medications at a time
768
00:44:59.540 --> 00:45:02.160
and you renew the application.
769
00:45:02.700 --> 00:45:04.500
Now before anybody's like,
770
00:45:04.720 --> 00:45:06.360
you know, oh, what about, you know,
771
00:45:06.920 --> 00:45:08.540
the income requirement?
772
00:45:08.800 --> 00:45:09.000
Okay.
773
00:45:09.180 --> 00:45:10.400
And I was trying to,
774
00:45:10.580 --> 00:45:11.020
I told Liz,
775
00:45:11.680 --> 00:45:13.560
I'm on my husband's Mac
776
00:45:13.560 --> 00:45:16.700
and I don't know how to use it.
777
00:45:17.180 --> 00:45:21.240
See, it's below the 400% poverty level.
778
00:45:21.660 --> 00:45:21.720
Okay.
779
00:45:21.760 --> 00:45:24.480
So this is actually pretty generous.
780
00:45:24.520 --> 00:45:26.100
So this really hits that
781
00:45:26.100 --> 00:45:27.540
middle-class uninsured.
782
00:45:29.600 --> 00:45:30.880
So that, for example,
783
00:45:30.980 --> 00:45:32.200
for a family of three,
784
00:45:33.400 --> 00:45:35.800
it's income below 92,120.
785
00:45:36.100 --> 00:45:39.000
I think for a family of four,
786
00:45:39.320 --> 00:45:40.600
it's below a hundred thousand,
787
00:45:41.160 --> 00:45:42.060
you know,
788
00:45:42.180 --> 00:45:44.160
which that's the definition of,
789
00:45:44.160 --> 00:45:44.800
you know, middle.
790
00:45:45.040 --> 00:45:47.140
So, and then even like family of two,
791
00:45:47.260 --> 00:45:48.980
I think it's like 30 something thousand,
792
00:45:49.040 --> 00:45:49.680
but we can,
793
00:45:49.880 --> 00:45:50.820
I don't have those exact,
794
00:45:50.860 --> 00:45:51.760
they change them too.
795
00:45:51.840 --> 00:45:53.700
So they did change it for inflation.
796
00:45:54.260 --> 00:45:55.160
So that was great.
797
00:45:55.160 --> 00:45:55.660
Yep.
798
00:45:56.340 --> 00:45:59.300
So that is for uninsured patients.
799
00:45:59.900 --> 00:46:01.320
Now, if somebody did,
800
00:46:01.420 --> 00:46:02.740
and I think this is still the case,
801
00:46:02.820 --> 00:46:05.340
if somebody did lose their health coverage
802
00:46:05.340 --> 00:46:06.740
because of COVID,
803
00:46:07.680 --> 00:46:10.720
they're eligible for even getting like 90 days
804
00:46:10.720 --> 00:46:12.180
of their insulin for free,
805
00:46:12.180 --> 00:46:13.500
you know, for it too,
806
00:46:13.520 --> 00:46:15.600
you know, like while there's a gap in coverage potentially.
807
00:46:15.960 --> 00:46:16.180
Okay.
808
00:46:16.180 --> 00:46:17.500
So this is great.
809
00:46:17.780 --> 00:46:18.540
Somebody comes in,
810
00:46:18.540 --> 00:46:20.480
they don't have any health insurance at all.
811
00:46:21.140 --> 00:46:22.420
They do have programs.
812
00:46:22.420 --> 00:46:24.080
We talk about this like the federally funded,
813
00:46:24.080 --> 00:46:26.420
like the FQHC, the 340B.
814
00:46:26.880 --> 00:46:29.500
They might still have a cost associated with that,
815
00:46:29.800 --> 00:46:33.900
but a very, very low cost compared to what it is retail.
816
00:46:34.540 --> 00:46:35.660
But you can get this,
817
00:46:35.700 --> 00:46:37.620
I mean, they can get thousands of dollars
818
00:46:37.620 --> 00:46:38.660
in medications.
819
00:46:40.020 --> 00:46:41.200
I mean, it's tremendous.
820
00:46:41.260 --> 00:46:43.100
You're talking about getting like four pins
821
00:46:43.100 --> 00:46:43.980
of those in fixed,
822
00:46:44.220 --> 00:46:46.260
like that's, I mean, it's incredible.
823
00:46:46.900 --> 00:46:49.540
So when we get this now used to anybody
824
00:46:49.540 --> 00:46:50.800
that's already been enrolled,
825
00:46:51.620 --> 00:46:53.220
I believe it is they still have to mail
826
00:46:53.220 --> 00:46:55.220
the medicine to the prescriber's office.
827
00:46:55.700 --> 00:46:56.780
Now for like new applicants,
828
00:46:57.100 --> 00:46:59.340
I think they just ship it straight to the patient.
829
00:46:59.460 --> 00:47:00.880
So yeah, so it's four months at a time
830
00:47:00.880 --> 00:47:02.460
and they have the patient has to keep up
831
00:47:02.460 --> 00:47:03.220
with their refills.
832
00:47:03.240 --> 00:47:04.820
So they ask them for the, you know,
833
00:47:05.040 --> 00:47:06.720
and then they send a refill request.
834
00:47:06.720 --> 00:47:08.800
So you just have to like kind of stay on top of it.
835
00:47:08.800 --> 00:47:09.900
So it's paperwork.
836
00:47:10.360 --> 00:47:12.580
Sometimes you get patients like free medicines
837
00:47:12.580 --> 00:47:14.320
and free good quality medicines.
838
00:47:14.740 --> 00:47:15.840
They'll be your patient forever.
839
00:47:15.980 --> 00:47:17.500
I mean, like the appreciation
840
00:47:17.500 --> 00:47:19.340
that people have from that is fantastic.
841
00:47:20.500 --> 00:47:22.660
So stick with the same application.
842
00:47:22.660 --> 00:47:26.160
This is also helpful for your Medicare patients too.
843
00:47:26.640 --> 00:47:28.020
Most of our Medicare patients
844
00:47:28.020 --> 00:47:30.420
are on some type of fixed income.
845
00:47:30.480 --> 00:47:33.480
And even if they have like a supplement,
846
00:47:33.560 --> 00:47:35.760
they might not have good Part D coverage
847
00:47:35.760 --> 00:47:37.520
or if they're in the gap coverage,
848
00:47:37.740 --> 00:47:39.080
again, it's income eligible.
849
00:47:39.240 --> 00:47:41.520
A few years ago, it was a little bit harder to get it.
850
00:47:41.920 --> 00:47:45.440
But again, it's not a no until it's like a hard no.
851
00:47:45.560 --> 00:47:47.980
And I would rather them take the time
852
00:47:47.980 --> 00:47:49.800
and bring us that tax return
853
00:47:49.800 --> 00:47:51.720
if they wanted us to submit it from our office
854
00:47:51.720 --> 00:47:53.000
or if they want to do it.
855
00:47:53.340 --> 00:47:55.040
And it's not a no until it's a no.
856
00:47:55.380 --> 00:47:56.500
You know, you just, you get that.
857
00:47:56.500 --> 00:47:58.580
And you get good name brand meds.
858
00:47:58.580 --> 00:48:01.060
You don't have to go for like the cheaper,
859
00:48:01.380 --> 00:48:03.880
less effective options at the pharmacy.
860
00:48:04.500 --> 00:48:07.260
So that's one through Novo Nordis.
861
00:48:07.500 --> 00:48:09.840
The Lilly Company is also a really good one.
862
00:48:09.860 --> 00:48:11.200
That one's an easy one to do.
863
00:48:11.280 --> 00:48:12.780
And I'm just, each one,
864
00:48:13.020 --> 00:48:14.400
like Jordiants has a separate one
865
00:48:14.400 --> 00:48:15.740
for like Jordiants and Sinjardi.
866
00:48:16.180 --> 00:48:18.400
And then Farsego through AstraZeneca has one.
867
00:48:18.500 --> 00:48:20.320
These are the two main ones that I use.
868
00:48:20.320 --> 00:48:22.980
I found in my experience a little bit easier to use
869
00:48:22.980 --> 00:48:24.720
for the patient as well.
870
00:48:25.620 --> 00:48:26.520
So Lilly is another one.
871
00:48:26.540 --> 00:48:28.360
You can get Pumilog through it.
872
00:48:29.620 --> 00:48:32.500
Abesaglar, and they don't do Lantus anymore.
873
00:48:32.860 --> 00:48:35.400
Trulicity, and there's several more even.
874
00:48:35.780 --> 00:48:36.360
And keep this in mind.
875
00:48:36.400 --> 00:48:37.880
This is for Lilly, especially.
876
00:48:38.120 --> 00:48:39.880
It's not just diabetes medications.
877
00:48:40.360 --> 00:48:43.900
So there's different tier beds and they list them.
878
00:48:44.000 --> 00:48:46.220
And on their application, I believe,
879
00:48:46.220 --> 00:48:50.220
it's based off of which, like your income
880
00:48:50.760 --> 00:48:53.080
versus which group of medication it is,
881
00:48:53.140 --> 00:48:55.080
like for the cost, if that makes sense.
882
00:48:55.300 --> 00:48:57.620
So like there's like a variable amount, you know?
883
00:48:57.940 --> 00:49:00.240
So again, three to four months of medication
884
00:49:00.240 --> 00:49:02.280
shipped to the patient, you know,
885
00:49:02.280 --> 00:49:04.140
if they meet that income eligibility.
886
00:49:05.520 --> 00:49:07.420
So then Novo Nordis.
887
00:49:07.600 --> 00:49:09.600
So let's say it's a situation that
888
00:49:09.600 --> 00:49:11.620
you have a patient with type one diabetes
889
00:49:11.620 --> 00:49:15.760
and they have a high deductible plan.
890
00:49:16.540 --> 00:49:19.060
So how much is cash insulin?
891
00:49:19.980 --> 00:49:22.500
Way too much, way, way too much.
892
00:49:22.900 --> 00:49:25.060
The Walmart released the rely on Aspart,
893
00:49:25.160 --> 00:49:27.000
which is the generic noble log.
894
00:49:27.100 --> 00:49:28.360
So that helps out a lot.
895
00:49:28.660 --> 00:49:32.080
But still, if you want somebody to have like good insulin,
896
00:49:32.260 --> 00:49:34.380
not having to do N and R and, you know,
897
00:49:34.540 --> 00:49:37.840
granted that's great for what they can be used for,
898
00:49:37.840 --> 00:49:40.740
but that's really going to be the last option for me.
899
00:49:41.260 --> 00:49:42.000
Which one is?
900
00:49:42.080 --> 00:49:44.960
Because I want N and R, NVH and regular.
901
00:49:45.600 --> 00:49:46.340
NVH and regular.
902
00:49:46.880 --> 00:49:47.160
Yeah.
903
00:49:47.540 --> 00:49:49.700
So meaning they can go to Walmart and pay $25
904
00:49:49.700 --> 00:49:51.860
and get a bottle over the counter without a prescription.
905
00:49:52.120 --> 00:49:55.960
That's my, that's the last, you know, on the list.
906
00:49:57.280 --> 00:49:59.200
So Novo Nordis, you just Google it.
907
00:49:59.480 --> 00:50:01.740
It's My9999.
908
00:50:02.360 --> 00:50:05.360
And that is a copay card that you print out.
909
00:50:05.560 --> 00:50:08.220
It's, you just, you can do it in office
910
00:50:08.220 --> 00:50:12.020
and it's a mix and match for two,
911
00:50:12.020 --> 00:50:14.940
up to two different brands of insulin, not a GLP one.
912
00:50:14.960 --> 00:50:17.540
So you can get like Tristeva and Fias,
913
00:50:17.640 --> 00:50:22.460
like a box of each or a certain amount of vials of each for $99 a month.
914
00:50:23.200 --> 00:50:26.140
So considering the actual cash price on that,
915
00:50:26.420 --> 00:50:30.320
the vial of insulin is like $3, $330 per vial
916
00:50:30.320 --> 00:50:34.020
and they can get three or four vials.
917
00:50:34.080 --> 00:50:34.920
I'm going off memory here,
918
00:50:34.920 --> 00:50:39.020
but I'll send you all the applications for it for $99.
919
00:50:39.500 --> 00:50:40.880
So that's a fantastic program.
920
00:50:41.220 --> 00:50:43.580
So that they can have commercial insurance
921
00:50:43.580 --> 00:50:45.800
and like a high deductible plan,
922
00:50:45.940 --> 00:50:48.480
or they just, you know, don't have great coverage,
923
00:50:48.540 --> 00:50:49.600
even with the copay cards,
924
00:50:49.640 --> 00:50:52.240
if it doesn't reduce enough off of it,
925
00:50:52.420 --> 00:50:54.580
because you always want to utilize copay cards and stuff too,
926
00:50:54.580 --> 00:50:57.140
but it might only buy it down like a certain, okay?
927
00:50:57.440 --> 00:50:59.020
So that's, that's another one.
928
00:50:59.340 --> 00:51:02.240
Then in our area too, and I looked online
929
00:51:02.240 --> 00:51:04.000
because you can search by your area.
930
00:51:05.240 --> 00:51:06.880
One of our new, and this is newer to me,
931
00:51:06.880 --> 00:51:08.100
so I'm still learning about it,
932
00:51:08.600 --> 00:51:12.100
but the different programs available like in the rural areas,
933
00:51:12.100 --> 00:51:18.000
like the FQHC clinics and then the 340B insulin,
934
00:51:18.680 --> 00:51:19.940
340B clinics as well.
935
00:51:19.980 --> 00:51:21.680
So they use them for primary care
936
00:51:21.680 --> 00:51:23.000
and they have their pharmacies.
937
00:51:23.240 --> 00:51:24.940
Those, some of these GLP ones,
938
00:51:25.100 --> 00:51:27.940
depending on which they get in stock,
939
00:51:28.040 --> 00:51:30.680
you can get Mozambique for $10 a box.
940
00:51:31.220 --> 00:51:34.260
You know, you can get, and the price just went up.
941
00:51:34.400 --> 00:51:36.180
What's retail price with Mozambique?
942
00:51:37.180 --> 00:51:38.100
Oh, $800, $900.
943
00:51:38.620 --> 00:51:39.000
Okay.
944
00:51:39.000 --> 00:51:39.080
Okay.
945
00:51:39.080 --> 00:51:40.220
Just for context, especially-
946
00:51:40.220 --> 00:51:40.980
Oh yeah, for context.
947
00:51:42.420 --> 00:51:45.360
Yeah, because you can, oh, Zempic's great,
948
00:51:45.640 --> 00:51:48.220
but I don't know if I want to pay that much for it.
949
00:51:48.300 --> 00:51:50.540
So the same thing with insulin,
950
00:51:50.540 --> 00:51:52.120
and it just depends on the brand
951
00:51:52.120 --> 00:51:53.720
of what they have available in the pharmacy,
952
00:51:54.220 --> 00:51:55.860
the SGLT2 inhibitors,
953
00:51:55.860 --> 00:51:59.120
depending on which one they have available
954
00:51:59.120 --> 00:52:00.500
and also the strength.
955
00:52:00.580 --> 00:52:02.720
So sometimes they might not have a max though strength
956
00:52:02.720 --> 00:52:06.800
that again, it's like between eight and $10 in my area.
957
00:52:06.860 --> 00:52:09.540
So it just depends, but all that information is online.
958
00:52:09.540 --> 00:52:12.480
If you search for 340B or FUHC,
959
00:52:12.480 --> 00:52:13.780
you know, like in your area
960
00:52:13.780 --> 00:52:15.480
to help refer those patients to.
961
00:52:15.980 --> 00:52:19.560
So those are like my big ones.
962
00:52:19.680 --> 00:52:20.720
Yeah, for sure.
963
00:52:20.980 --> 00:52:24.680
And then there's also, so Genuvia,
964
00:52:25.500 --> 00:52:28.260
it was, I think was supposed to go generic last year.
965
00:52:28.340 --> 00:52:29.340
Didn't go generic.
966
00:52:29.840 --> 00:52:30.700
I can't believe it.
967
00:52:31.660 --> 00:52:34.800
I've been working long enough to remember when it was.
968
00:52:35.680 --> 00:52:36.820
I did not know that.
969
00:52:36.820 --> 00:52:37.760
I didn't realize that.
970
00:52:37.860 --> 00:52:38.380
Wow.
971
00:52:38.380 --> 00:52:39.820
It was supposed to go generic,
972
00:52:39.840 --> 00:52:42.220
but I think it got pushed to maybe spring of next year.
973
00:52:42.220 --> 00:52:44.640
So don't quote me on that spring of 2023.
974
00:52:45.360 --> 00:52:48.640
So that will be a great option too for DPP4 inhibitor,
975
00:52:49.160 --> 00:52:52.100
not my go-to, you know, for diabetes management,
976
00:52:52.120 --> 00:52:53.780
but a good option.
977
00:52:54.140 --> 00:52:56.480
And then also too, unless this has changed recently,
978
00:52:56.660 --> 00:52:59.300
the SGLT2, that's the Glotro
979
00:52:59.300 --> 00:53:01.900
has a really great copay card, right?
980
00:53:01.920 --> 00:53:02.940
The Glotro.
981
00:53:03.180 --> 00:53:03.920
I don't know.
982
00:53:05.240 --> 00:53:05.720
Okay.
983
00:53:06.260 --> 00:53:06.660
Yeah.
984
00:53:07.040 --> 00:53:08.740
And it also comes in a combination
985
00:53:08.740 --> 00:53:10.520
with Extended Release Metformins.
986
00:53:10.580 --> 00:53:12.360
It's called Sigluro-Met.
987
00:53:12.740 --> 00:53:14.040
And there's a combination
988
00:53:14.040 --> 00:53:16.840
SGLT2 with Genuvia called Siglujan.
989
00:53:17.640 --> 00:53:19.760
I think they make these names up just to,
990
00:53:19.760 --> 00:53:20.860
you know, make fun of us.
991
00:53:21.220 --> 00:53:23.720
But so it has a really good copay card
992
00:53:23.720 --> 00:53:25.560
that buys it down to zero dollars.
993
00:53:26.660 --> 00:53:27.460
Then AstraZeneca.
994
00:53:28.160 --> 00:53:30.460
I mean, so you have to kind of know these little nuances, right?
995
00:53:30.500 --> 00:53:32.040
So you got to talk to your reps and be like,
996
00:53:32.040 --> 00:53:33.940
hey, look, the Sigduo.
997
00:53:34.080 --> 00:53:37.660
So Sigduo, just to not assume anybody knows,
998
00:53:38.120 --> 00:53:39.440
because I'll just pretend like y'all don't know,
999
00:53:39.860 --> 00:53:42.180
Sigduo is for Ciga and Metformin put together.
1000
00:53:42.400 --> 00:53:42.760
Okay.
1001
00:53:42.760 --> 00:53:46.880
So it comes in, oh, a 10,500,
1002
00:53:47.180 --> 00:53:51.420
a 5, 1000, a 10, 1000, I think a 2.5, 1000.
1003
00:53:51.880 --> 00:53:54.160
At the first of this year, unless it's changed,
1004
00:53:54.260 --> 00:53:55.720
if somebody has a high deductible,
1005
00:53:55.720 --> 00:54:03.240
their copay card will buy down the 5, 1000 Sigduo to zero dollars.
1006
00:54:03.400 --> 00:54:07.420
But if you do two of the 5, 1000s and just spend 60,
1007
00:54:07.420 --> 00:54:08.740
they might have an out of pocket.
1008
00:54:09.280 --> 00:54:11.660
So you might not get the max effect of the medication
1009
00:54:11.660 --> 00:54:14.140
if you can't get them on a full 10 milligram
1010
00:54:14.140 --> 00:54:15.520
of the Ciga equivalent,
1011
00:54:15.620 --> 00:54:17.400
but you can always max out the Metformin,
1012
00:54:18.640 --> 00:54:19.340
if that makes sense.
1013
00:54:19.340 --> 00:54:22.420
So you could do a 5, 1000 and two of the 500 Metformin
1014
00:54:22.420 --> 00:54:24.680
extended release generic for real cheap.
1015
00:54:24.680 --> 00:54:28.480
And get that cost down to zero dollars and get a great, great med.
1016
00:54:28.740 --> 00:54:29.820
It's so fancy.
1017
00:54:30.100 --> 00:54:32.380
And I guess I just want to pause here and say,
1018
00:54:33.220 --> 00:54:38.400
I just want to normalize that I anticipate the people
1019
00:54:38.400 --> 00:54:40.660
and what they're going to say and what they think too.
1020
00:54:41.440 --> 00:54:45.880
And it just really demonstrates how frustrating insurance can be.
1021
00:54:48.280 --> 00:54:51.620
Number two is that I feel like my approach,
1022
00:54:51.620 --> 00:54:56.000
I can hear the new grads being like, what?
1023
00:54:57.840 --> 00:54:59.540
But I feel like the thing is,
1024
00:54:59.600 --> 00:55:03.220
it's almost like a dedicated project, right?
1025
00:55:03.260 --> 00:55:06.840
Where instead of a communication course about whatever,
1026
00:55:07.680 --> 00:55:10.340
it's taking aside that time of almost like
1027
00:55:10.340 --> 00:55:13.120
a continued education course of what is on,
1028
00:55:13.440 --> 00:55:15.020
but it's like a whole thing, right?
1029
00:55:15.140 --> 00:55:17.360
It's like, what are the options and getting familiar with that
1030
00:55:17.360 --> 00:55:19.080
and then you can use it.
1031
00:55:19.080 --> 00:55:21.140
And also I think one other thing,
1032
00:55:21.400 --> 00:55:24.480
especially in the lens of primary care that can be bonkers crazy
1033
00:55:24.480 --> 00:55:28.100
with patients who have more things than just diabetes is like,
1034
00:55:28.260 --> 00:55:31.060
I just came up on Instagram.
1035
00:55:31.760 --> 00:55:33.560
Another account was talking about this,
1036
00:55:33.600 --> 00:55:37.140
about how they documented their time in their clinic
1037
00:55:37.800 --> 00:55:41.340
to show to their leadership, which like evidence of like,
1038
00:55:41.340 --> 00:55:42.920
you know what, when I work five days a week,
1039
00:55:43.200 --> 00:55:45.000
I do this much overtime,
1040
00:55:45.340 --> 00:55:48.620
which was a negotiating tool for them to go to four, 10 hour shifts.
1041
00:55:48.620 --> 00:55:51.460
And so I feel like in the same lens,
1042
00:55:52.160 --> 00:55:53.740
again, this is not really for a brand new grad
1043
00:55:53.740 --> 00:55:55.540
because you're kind of just keeping your head above water.
1044
00:55:55.780 --> 00:55:58.060
But if you think about like documenting
1045
00:55:58.060 --> 00:56:00.220
all of the time it takes to, like you said,
1046
00:56:00.280 --> 00:56:02.900
like do the great work of like applying
1047
00:56:02.900 --> 00:56:06.340
for these applications and all these other pieces.
1048
00:56:06.880 --> 00:56:09.680
And you also have results about how it goes down,
1049
00:56:09.720 --> 00:56:11.880
like it's helped your patients A1C go down.
1050
00:56:12.120 --> 00:56:14.880
Like that's motivating for your clinic to allow you
1051
00:56:14.880 --> 00:56:16.620
to either have more time to work on that,
1052
00:56:16.620 --> 00:56:19.080
bring in a part-time staff member to help you
1053
00:56:19.640 --> 00:56:21.200
be a diabetes liaison, right?
1054
00:56:21.260 --> 00:56:23.800
We have community educators.
1055
00:56:24.280 --> 00:56:25.520
Like if you don't have that resource,
1056
00:56:25.920 --> 00:56:29.300
like the way you get resources to support those moving parts
1057
00:56:29.300 --> 00:56:31.520
is to document it, present a case,
1058
00:56:31.520 --> 00:56:33.040
and then you get more support.
1059
00:56:33.420 --> 00:56:34.600
Either more clinic time,
1060
00:56:34.760 --> 00:56:36.760
either like less clinic time for you to work on,
1061
00:56:36.840 --> 00:56:38.200
like more admin time for you,
1062
00:56:38.260 --> 00:56:40.260
or a support staff member who's going to help
1063
00:56:40.260 --> 00:56:42.180
be educated in all these pieces
1064
00:56:42.180 --> 00:56:43.800
and then go forward from there,
1065
00:56:44.040 --> 00:56:46.440
which I know is like a lot to think about.
1066
00:56:46.980 --> 00:56:48.900
Not really for a new grad necessarily
1067
00:56:48.900 --> 00:56:50.300
because you're just keeping your head above water,
1068
00:56:50.500 --> 00:56:53.960
but like there are ways to do this in primary care
1069
00:56:53.960 --> 00:56:55.700
because I can just hear people being like,
1070
00:56:55.700 --> 00:56:57.080
there's no way I'm ever going to do that
1071
00:56:57.080 --> 00:56:59.220
because that's so involved and there's so much time.
1072
00:56:59.400 --> 00:57:01.000
But I just want to like advocate for,
1073
00:57:01.100 --> 00:57:02.400
like as you expand in your practice,
1074
00:57:02.440 --> 00:57:04.060
like we can do stuff like that
1075
00:57:04.060 --> 00:57:06.040
because our clinics are also motivated.
1076
00:57:06.360 --> 00:57:08.580
They get at least an FQHC setting.
1077
00:57:08.840 --> 00:57:10.000
If you have an A1C of 9%,
1078
00:57:11.080 --> 00:57:12.580
they're looking at the numbers of patients
1079
00:57:12.580 --> 00:57:14.860
with A1C of 9% or higher, right?
1080
00:57:14.860 --> 00:57:16.720
That's actually like, it's again,
1081
00:57:16.720 --> 00:57:18.280
we all care about patient care,
1082
00:57:18.280 --> 00:57:20.340
but when it comes to the business of primary care,
1083
00:57:20.540 --> 00:57:22.960
they need to see return on investment, right?
1084
00:57:23.020 --> 00:57:24.320
And so if you can document,
1085
00:57:24.400 --> 00:57:27.100
if you have like a way to do that, right?
1086
00:57:27.220 --> 00:57:28.820
Anyway, that's just like a very side note,
1087
00:57:28.820 --> 00:57:29.640
but like I just,
1088
00:57:30.200 --> 00:57:31.740
I think that's a real barrier for people
1089
00:57:31.740 --> 00:57:33.320
in terms of the confidence is like,
1090
00:57:33.320 --> 00:57:34.400
there's just so much to know
1091
00:57:34.400 --> 00:57:35.660
and so much to do with it.
1092
00:57:36.420 --> 00:57:39.260
Right. And also too, I'm really,
1093
00:57:40.180 --> 00:57:41.260
I'm one of those, it's just like,
1094
00:57:41.260 --> 00:57:43.220
if I can streamline something,
1095
00:57:43.220 --> 00:57:45.040
if I can make my day easier,
1096
00:57:45.160 --> 00:57:46.620
the patient's day easier, my MA,
1097
00:57:46.720 --> 00:57:49.900
like I'm not trying to add a thousand tasks
1098
00:57:49.900 --> 00:57:51.580
to her back that she already has
1099
00:57:51.580 --> 00:57:52.860
because we filled, of course,
1100
00:57:53.100 --> 00:57:54.380
we all filled a lot of phone calls,
1101
00:57:54.440 --> 00:57:56.360
a lot of issues with pharmacy and whatever, okay?
1102
00:57:56.360 --> 00:57:59.240
So just something as basic as this, okay?
1103
00:57:59.240 --> 00:58:00.660
So it doesn't sound like this big of a deal
1104
00:58:00.660 --> 00:58:03.540
saves minutes upon minutes upon minutes,
1105
00:58:03.580 --> 00:58:04.440
which are precious.
1106
00:58:05.320 --> 00:58:08.060
So how our clinic works,
1107
00:58:08.060 --> 00:58:14.200
each room, patient room has a remote desktop, okay?
1108
00:58:14.200 --> 00:58:16.020
So like we remote into the server
1109
00:58:16.020 --> 00:58:17.400
and then that's how we do it.
1110
00:58:17.740 --> 00:58:20.500
So I have in every single one of my patient rooms,
1111
00:58:20.720 --> 00:58:22.980
a folder saved on my desktop
1112
00:58:22.980 --> 00:58:26.220
that has every single one of these forms
1113
00:58:26.220 --> 00:58:29.120
already saved, pre-filled out
1114
00:58:29.120 --> 00:58:30.780
with the prescriber information,
1115
00:58:31.260 --> 00:58:33.060
the NPI number, everything,
1116
00:58:33.380 --> 00:58:35.000
facts, contact information, whatever.
1117
00:58:35.640 --> 00:58:37.660
And it's updated every year
1118
00:58:37.660 --> 00:58:38.780
when the new applications come out
1119
00:58:38.780 --> 00:58:40.400
because there'll be little things
1120
00:58:40.400 --> 00:58:41.920
that they'll just change here and there.
1121
00:58:42.080 --> 00:58:43.840
And it's like I'm talking to the patient
1122
00:58:43.840 --> 00:58:44.800
and I'm like, oh, okay,
1123
00:58:44.980 --> 00:58:46.440
we know cost is always an issue.
1124
00:58:46.460 --> 00:58:48.120
And I'll tell you this too,
1125
00:58:49.420 --> 00:58:52.280
even if a Medicare patient comes in
1126
00:58:52.280 --> 00:58:53.560
and I'm talking to them and they're like,
1127
00:58:53.560 --> 00:58:55.620
you know what, I can pay X, Y, and Z
1128
00:58:55.620 --> 00:58:56.600
for my medications.
1129
00:58:57.240 --> 00:58:58.580
Even if they say that,
1130
00:58:58.740 --> 00:59:00.340
it's like, why not try?
1131
00:59:00.500 --> 00:59:02.160
Why not try to help them out
1132
00:59:02.160 --> 00:59:03.160
to get rid of that copay?
1133
00:59:03.220 --> 00:59:05.140
Because you know what happens is,
1134
00:59:05.320 --> 00:59:07.040
let's say they're on an Eloquist,
1135
00:59:07.040 --> 00:59:08.180
which is a high dollar med
1136
00:59:08.180 --> 00:59:10.780
or something for RA in a high dollar med.
1137
00:59:11.140 --> 00:59:12.340
Those high dollar meds
1138
00:59:12.340 --> 00:59:12.920
are going to push them
1139
00:59:12.920 --> 00:59:14.580
into that gap coverage sooner,
1140
00:59:14.700 --> 00:59:15.980
which means they're going to be out
1141
00:59:15.980 --> 00:59:17.360
that 25% out of pocket
1142
00:59:17.360 --> 00:59:18.560
for those medications.
1143
00:59:18.720 --> 00:59:20.620
Why can't I do my part
1144
00:59:20.620 --> 00:59:22.640
to help them stay out of the gap coverage
1145
00:59:22.640 --> 00:59:24.280
to keep the coverage for the other meds?
1146
00:59:24.860 --> 00:59:27.100
Okay, so rant for that.
1147
00:59:27.900 --> 00:59:30.320
But I have the little folder ready to go.
1148
00:59:30.400 --> 00:59:31.460
I print it out.
1149
00:59:31.600 --> 00:59:32.620
All I have to do
1150
00:59:32.620 --> 00:59:35.020
is just put the SIG for the meds
1151
00:59:35.020 --> 00:59:35.860
and all that stuff.
1152
00:59:35.860 --> 00:59:38.460
And then you've learned really quickly
1153
00:59:38.460 --> 00:59:39.340
what you have to attach.
1154
00:59:39.540 --> 00:59:41.080
And it's on them to bring
1155
00:59:41.080 --> 00:59:42.280
either take the application,
1156
00:59:42.400 --> 00:59:43.080
complete it at home
1157
00:59:43.080 --> 00:59:44.620
with their tax information, whatever.
1158
00:59:45.260 --> 00:59:46.200
I usually, and I tell them like,
1159
00:59:46.280 --> 00:59:47.540
it's not to get into your business.
1160
00:59:47.720 --> 00:59:48.300
You know, it's not,
1161
00:59:48.460 --> 00:59:49.460
I don't care how much money you make.
1162
00:59:49.540 --> 00:59:51.780
I just want you to have great meds
1163
00:59:51.780 --> 00:59:53.820
at little to no cost if that's possible.
1164
00:59:54.360 --> 00:59:55.840
So then they, it's like,
1165
00:59:55.900 --> 00:59:56.880
okay, just bring that back.
1166
00:59:56.900 --> 00:59:57.780
We can have it on file.
1167
00:59:57.820 --> 00:59:59.200
And then we fax it in.
1168
00:59:59.280 --> 01:00:00.820
And then seven to 10 business days they have.
1169
01:00:00.940 --> 01:00:02.840
So it doesn't like, just me,
1170
01:00:02.840 --> 01:00:04.660
the day that that clicked in my head,
1171
01:00:04.660 --> 01:00:06.760
why didn't I think about this five years?
1172
01:00:06.960 --> 01:00:09.100
You know, like, I can just have this form
1173
01:00:09.100 --> 01:00:11.240
already filled out with my NPI and my contact.
1174
01:00:11.280 --> 01:00:13.460
And it saves so much time
1175
01:00:13.460 --> 01:00:14.500
because I just print it out
1176
01:00:14.500 --> 01:00:16.180
and it may keep stuff with it.
1177
01:00:16.300 --> 01:00:17.100
I fill it out.
1178
01:00:17.200 --> 01:00:18.220
For the most part, she'll help me.
1179
01:00:18.720 --> 01:00:21.480
And then even things like the,
1180
01:00:21.720 --> 01:00:23.060
let's say you work with a population
1181
01:00:23.060 --> 01:00:24.400
that would need something like
1182
01:00:24.400 --> 01:00:26.680
the My99 one through Novo Nordis.
1183
01:00:27.080 --> 01:00:27.540
And by the way,
1184
01:00:27.640 --> 01:00:29.000
Lilly does have something.
1185
01:00:29.160 --> 01:00:31.120
It's called Lilly Cares, I think.
1186
01:00:31.480 --> 01:00:33.160
So if it's more of like
1187
01:00:33.160 --> 01:00:35.220
Humalog preferred, you know,
1188
01:00:35.280 --> 01:00:37.020
then they have something very similar to it too.
1189
01:00:37.040 --> 01:00:38.020
So I'm not.
1190
01:00:39.100 --> 01:00:40.420
And again, it's differentiating
1191
01:00:40.420 --> 01:00:42.520
no insurance versus hyperductable.
1192
01:00:42.540 --> 01:00:44.180
So you've got to learn insurance.
1193
01:00:44.480 --> 01:00:47.000
Okay. So those My99 ones,
1194
01:00:48.720 --> 01:00:51.700
excuse me, those are kind of like
1195
01:00:51.700 --> 01:00:54.120
any other savings card
1196
01:00:54.120 --> 01:00:55.920
that it has its own like prescriptions and number.
1197
01:00:56.000 --> 01:00:57.700
So it's not like you do one
1198
01:00:57.700 --> 01:00:59.420
and make 20 copies of it.
1199
01:00:59.620 --> 01:01:01.380
Sometimes if it's kind of a season,
1200
01:01:01.380 --> 01:01:03.340
I'm like going through these a lot.
1201
01:01:03.820 --> 01:01:05.880
I'll activate print, activate a new one, print,
1202
01:01:05.980 --> 01:01:06.620
activate a new one.
1203
01:01:06.720 --> 01:01:08.760
And then each room you have a few of them.
1204
01:01:08.920 --> 01:01:10.860
It's like take this to the pharmacy
1205
01:01:10.860 --> 01:01:12.960
and get thousands of dollars of insulin for $99.
1206
01:01:13.320 --> 01:01:14.700
And they're like, oh, that's incredible.
1207
01:01:15.320 --> 01:01:18.020
So you just do a few little prep things
1208
01:01:18.020 --> 01:01:22.360
and it doesn't have to be this big whole ordeal.
1209
01:01:22.800 --> 01:01:23.860
So absolutely.
1210
01:01:24.420 --> 01:01:26.000
Yeah. And I really feel like I love it.
1211
01:01:26.000 --> 01:01:26.720
It's worth it.
1212
01:01:26.940 --> 01:01:29.580
Yeah. I love that you have a process oriented.
1213
01:01:29.580 --> 01:01:31.820
I think that saves me in primary care
1214
01:01:31.820 --> 01:01:34.180
is I do the same thing in the same way every time,
1215
01:01:34.400 --> 01:01:35.520
obviously customized for patient,
1216
01:01:35.580 --> 01:01:36.980
but my process is the same.
1217
01:01:37.300 --> 01:01:38.980
So I just, I really, I really love that.
1218
01:01:38.980 --> 01:01:40.600
And I really do want to stress that like
1219
01:01:40.600 --> 01:01:41.660
it really sounds like,
1220
01:01:41.700 --> 01:01:42.580
because I'm not even familiar
1221
01:01:42.580 --> 01:01:43.760
with all of these things, right?
1222
01:01:44.000 --> 01:01:45.440
Like my plan is I'm going to sit down,
1223
01:01:45.440 --> 01:01:46.560
I'm going to read about them
1224
01:01:46.560 --> 01:01:47.720
and I'm going to get my baseline
1225
01:01:47.720 --> 01:01:48.780
understanding familiarity.
1226
01:01:48.780 --> 01:01:50.400
And then I'm going to say like, okay,
1227
01:01:50.400 --> 01:01:52.380
like what is my process to make this easier
1228
01:01:53.280 --> 01:01:55.840
worth the time and of initial learning
1229
01:01:55.840 --> 01:01:58.520
and then it will become more rote for people.
1230
01:01:58.520 --> 01:02:01.040
Well, I do, I'm sorry, go ahead.
1231
01:02:01.200 --> 01:02:02.380
Oh, I was going to say one more thing
1232
01:02:02.380 --> 01:02:06.500
about the GLP ones for the, like the costs by far,
1233
01:02:06.500 --> 01:02:08.520
I find that that's the most difficult one
1234
01:02:08.520 --> 01:02:09.960
to get at a good price.
1235
01:02:10.000 --> 01:02:12.220
If it's a deductible issue, especially,
1236
01:02:12.320 --> 01:02:13.540
or if it's like a cash payment,
1237
01:02:13.660 --> 01:02:17.200
if they don't especially qualify
1238
01:02:17.200 --> 01:02:19.760
for like the free one based off of income.
1239
01:02:20.420 --> 01:02:22.360
But the, and I think we're going to talk
1240
01:02:22.360 --> 01:02:25.120
if we have time about the newer medicines
1241
01:02:25.120 --> 01:02:26.980
like that are on the market,
1242
01:02:26.980 --> 01:02:29.520
you know, it's not on formulary yet.
1243
01:02:29.880 --> 01:02:31.640
And that's a really, really great option
1244
01:02:31.640 --> 01:02:33.400
that like, regardless of insurance coverage
1245
01:02:33.400 --> 01:02:35.460
or deductible, when you talk to the reps
1246
01:02:35.460 --> 01:02:37.240
and at least here, and I'm assuming
1247
01:02:37.240 --> 01:02:38.660
it would be the same nationally,
1248
01:02:39.100 --> 01:02:42.800
you get 90 days of a great new meta GLP,
1249
01:02:42.800 --> 01:02:45.340
GLP one that's new on the market for $25.
1250
01:02:45.960 --> 01:02:48.320
So it's like some of these newer meds
1251
01:02:48.320 --> 01:02:50.220
when Ribelsis first came out,
1252
01:02:50.420 --> 01:02:52.040
yeah, insurance, you could get it
1253
01:02:52.040 --> 01:02:54.200
for $10 or 25 or something like that.
1254
01:02:54.200 --> 01:02:56.200
And now once it was on formulary,
1255
01:02:56.200 --> 01:02:57.900
I had these patients on Ribelsis
1256
01:02:57.900 --> 01:03:00.180
and we had to figure out a plan B for that.
1257
01:03:00.420 --> 01:03:01.940
But it's like, at least in the interim,
1258
01:03:01.940 --> 01:03:03.100
because you never know if that person
1259
01:03:03.100 --> 01:03:04.560
gets a new job change or whatever,
1260
01:03:04.560 --> 01:03:07.660
you still want to advocate for like the best meds
1261
01:03:07.660 --> 01:03:09.880
at the best price possible.
1262
01:03:10.660 --> 01:03:11.580
Yeah, I love that.
1263
01:03:11.800 --> 01:03:13.260
Well, yeah, I do want to be mindful of time.
1264
01:03:13.480 --> 01:03:16.140
I think, I think a great closing place would be
1265
01:03:16.140 --> 01:03:18.940
is, even though I have like a thousand
1266
01:03:18.940 --> 01:03:20.180
more questions I could ask,
1267
01:03:21.560 --> 01:03:23.220
is like what like pearls,
1268
01:03:23.220 --> 01:03:27.000
like, like whatever feels best for people,
1269
01:03:27.120 --> 01:03:29.340
like what pearls do you have for primary care?
1270
01:03:29.780 --> 01:03:31.500
Like another way to think about that
1271
01:03:31.500 --> 01:03:32.280
or look at that is like,
1272
01:03:32.300 --> 01:03:34.300
what do you wish primary care providers knew?
1273
01:03:34.580 --> 01:03:37.200
But either side of that point of that question,
1274
01:03:37.240 --> 01:03:38.620
like whatever you want to share
1275
01:03:38.620 --> 01:03:41.080
for pearls and practice and all that.
1276
01:03:42.600 --> 01:03:43.720
There's, there's several.
1277
01:03:44.100 --> 01:03:46.780
And I love primary care.
1278
01:03:47.220 --> 01:03:48.060
I love primary care.
1279
01:03:48.440 --> 01:03:50.040
I'm like, go back to primary care.
1280
01:03:50.180 --> 01:03:51.020
We love primary care.
1281
01:03:51.120 --> 01:03:52.940
I'm not your primary care provider.
1282
01:03:53.660 --> 01:03:55.080
Please go back to them.
1283
01:03:55.080 --> 01:03:56.840
Like, yeah, if you're not seeing them for six months
1284
01:03:56.840 --> 01:03:59.000
and your lipids are crazy and, you know,
1285
01:03:59.100 --> 01:04:01.140
blood pressure out, absolutely adjust meds
1286
01:04:01.140 --> 01:04:03.380
and prescribe hypertensive and hyperlipidemic meds.
1287
01:04:03.900 --> 01:04:05.560
But it's just, please go back to primary care.
1288
01:04:05.560 --> 01:04:06.600
So thank you for what you'll do.
1289
01:04:06.740 --> 01:04:07.140
Thank you.
1290
01:04:09.760 --> 01:04:14.040
So one of the things that I would really make sure,
1291
01:04:14.120 --> 01:04:15.540
especially in this is getting back
1292
01:04:15.540 --> 01:04:17.880
to like the language of how we talk to people
1293
01:04:17.880 --> 01:04:19.680
and everything, we have,
1294
01:04:19.680 --> 01:04:21.420
and I think that I really feel like
1295
01:04:21.420 --> 01:04:22.960
this has gotten better over time.
1296
01:04:23.220 --> 01:04:25.040
But we have got to get away
1297
01:04:25.040 --> 01:04:27.600
of thinking that insulin is a punishment.
1298
01:04:28.260 --> 01:04:29.260
Insulin is not a punishment.
1299
01:04:29.580 --> 01:04:30.800
Insulin is not a four-letter word.
1300
01:04:31.080 --> 01:04:34.960
It is not, it is not you're being a bad diabetic.
1301
01:04:35.460 --> 01:04:36.300
Like, first of all, you know,
1302
01:04:36.360 --> 01:04:38.680
talking about being, saying like non-compliant,
1303
01:04:38.700 --> 01:04:40.380
like we don't say you're a diabetic.
1304
01:04:40.600 --> 01:04:43.380
I mean, to me, no, no, you have diabetes.
1305
01:04:43.520 --> 01:04:44.740
It's not like you have this.
1306
01:04:44.920 --> 01:04:45.240
Yeah.
1307
01:04:45.420 --> 01:04:47.000
So, no, you're not brittle.
1308
01:04:47.160 --> 01:04:48.960
You don't have, you're not a bad diabetic.
1309
01:04:49.000 --> 01:04:51.840
If you need insulin, again, it's the tool in the toolbox.
1310
01:04:51.840 --> 01:04:55.300
So we don't want to use that even as like a threat.
1311
01:04:55.720 --> 01:04:58.180
Like if you don't come in three months,
1312
01:04:58.180 --> 01:05:00.200
if you come back and your A1C is still elevated,
1313
01:05:00.240 --> 01:05:01.760
I'm going to have to put you on insulin.
1314
01:05:02.100 --> 01:05:03.620
And then so they might come see me.
1315
01:05:03.640 --> 01:05:05.000
I'm like, let's do it today.
1316
01:05:05.240 --> 01:05:07.320
It's not, it's not, it's not a punishment.
1317
01:05:07.380 --> 01:05:09.820
It's a way that I can get you safe
1318
01:05:09.820 --> 01:05:11.480
in a relatively quickly manner.
1319
01:05:11.820 --> 01:05:14.400
That's a variable amount that can be adjusted
1320
01:05:14.400 --> 01:05:15.980
based off of what your needs are
1321
01:05:15.980 --> 01:05:18.120
that might not even be permanent, right?
1322
01:05:18.200 --> 01:05:19.400
So it's not something that,
1323
01:05:19.400 --> 01:05:21.660
that's like my favorite pastime
1324
01:05:21.660 --> 01:05:22.600
is taking people off insulin.
1325
01:05:22.680 --> 01:05:23.640
Like it's so much fun.
1326
01:05:24.300 --> 01:05:25.080
So that's one thing.
1327
01:05:25.180 --> 01:05:25.680
So great, really?
1328
01:05:26.400 --> 01:05:27.700
Yeah, take people off of meds.
1329
01:05:27.700 --> 01:05:28.620
Don't just add meds.
1330
01:05:28.940 --> 01:05:29.940
So that's one thing.
1331
01:05:30.020 --> 01:05:32.080
It's like, let's not use insulin as a punishment.
1332
01:05:32.600 --> 01:05:36.560
I will say too, and this is just kind of my practice
1333
01:05:36.560 --> 01:05:38.740
on like when you're looking at the algorithms
1334
01:05:38.740 --> 01:05:40.780
and everything and I was looking back
1335
01:05:40.780 --> 01:05:42.140
at some of your old YouTube videos
1336
01:05:42.580 --> 01:05:45.240
and I love that you referenced the ACE guidelines.
1337
01:05:46.040 --> 01:05:46.580
I like ACE.
1338
01:05:47.420 --> 01:05:48.420
I love ACE.
1339
01:05:48.420 --> 01:05:50.200
Their algorithm is so pretty.
1340
01:05:50.360 --> 01:05:52.020
Like we need to make sure that everyone has like,
1341
01:05:52.240 --> 01:05:52.880
it's so pretty.
1342
01:05:53.040 --> 01:05:54.280
It's so beautifully done.
1343
01:05:55.100 --> 01:05:56.900
And it's very easy to follow.
1344
01:05:57.280 --> 01:05:58.260
So easy to follow.
1345
01:05:58.560 --> 01:06:00.440
And one of the things that is down below this video.
1346
01:06:01.240 --> 01:06:04.220
There is also a way to get those
1347
01:06:06.160 --> 01:06:07.920
like laminated pocket size
1348
01:06:07.920 --> 01:06:10.680
and I think you can get them from ACE, I think.
1349
01:06:10.780 --> 01:06:12.200
So that's really handy too.
1350
01:06:12.200 --> 01:06:12.940
I'm going to look at that.
1351
01:06:12.940 --> 01:06:13.960
So they're like really small
1352
01:06:13.960 --> 01:06:15.520
because there's also one for hypertension
1353
01:06:15.520 --> 01:06:16.400
and hyperlipidemia.
1354
01:06:16.400 --> 01:06:18.840
So I love the ACE guidelines.
1355
01:06:19.360 --> 01:06:24.640
But when you look at it, obviously with med management,
1356
01:06:25.340 --> 01:06:26.800
like on the big, there's a big part
1357
01:06:26.800 --> 01:06:28.920
since like regardless of A1C control,
1358
01:06:29.000 --> 01:06:33.360
if there's the ASDVD risk or CKD or heart failure,
1359
01:06:33.680 --> 01:06:35.680
you have somebody on like on the SGLT too.
1360
01:06:35.920 --> 01:06:36.200
Okay.
1361
01:06:36.260 --> 01:06:38.400
So for patients, I'm sorry,
1362
01:06:38.500 --> 01:06:40.440
for your MPs that aren't quite as familiar,
1363
01:06:40.840 --> 01:06:42.460
that's Giardia and Sparsiga.
1364
01:06:42.640 --> 01:06:44.920
You know, Sigotra was just one we talked about earlier.
1365
01:06:44.920 --> 01:06:48.600
But how, sometimes what happens is
1366
01:06:49.240 --> 01:06:51.080
the patient might come in
1367
01:06:51.080 --> 01:06:53.820
and maybe they're like new to primary care
1368
01:06:53.820 --> 01:06:55.460
or just somebody that's kind of hit or miss.
1369
01:06:55.860 --> 01:06:57.300
They might be like on, you know,
1370
01:06:57.420 --> 01:06:59.160
mid-range or maxed out metformin
1371
01:06:59.160 --> 01:07:00.900
and an old school like sulfonylurea.
1372
01:07:01.060 --> 01:07:02.140
Maybe we still have a lot
1373
01:07:02.140 --> 01:07:04.240
that are on like piaglitazone like Actose.
1374
01:07:04.580 --> 01:07:07.020
And so maybe it's a cost issue or something.
1375
01:07:07.120 --> 01:07:08.700
I was going to say that's one of the cheaper options.
1376
01:07:09.100 --> 01:07:11.140
So sulfonylurea in that class, yeah.
1377
01:07:11.420 --> 01:07:12.220
Oh yeah, for sure.
1378
01:07:12.580 --> 01:07:13.920
So those are strong meds.
1379
01:07:13.920 --> 01:07:16.440
Those are strong meds
1380
01:07:16.440 --> 01:07:20.060
and they're not like the newer, more intuitive ones.
1381
01:07:20.660 --> 01:07:22.500
But so sometimes patients will come in.
1382
01:07:22.580 --> 01:07:23.900
They'll be like, well, I was on Giardia,
1383
01:07:23.900 --> 01:07:25.220
but it didn't work for me.
1384
01:07:25.260 --> 01:07:27.440
Like, okay, well, what else happened at that time
1385
01:07:27.440 --> 01:07:28.980
that Giardia was prescribed?
1386
01:07:29.340 --> 01:07:32.100
Like, oh, well, they took me off of cliposide and Actose.
1387
01:07:32.480 --> 01:07:34.800
Well, if you have somebody like on a max dose
1388
01:07:34.800 --> 01:07:39.700
of a sulfonylurea, that being as strong as it is
1389
01:07:39.700 --> 01:07:41.440
stimulating that insulin production,
1390
01:07:41.620 --> 01:07:43.580
assuming that they still have beta cell function,
1391
01:07:44.460 --> 01:07:46.100
that is hard to get off of.
1392
01:07:46.260 --> 01:07:49.000
If you take, you have to titrate slowly off of that.
1393
01:07:49.340 --> 01:07:51.100
So if somebody comes in and you're like,
1394
01:07:51.100 --> 01:07:53.700
I'm going to add, add, but then you take away,
1395
01:07:54.720 --> 01:07:55.780
those sugars are going to go up,
1396
01:07:55.860 --> 01:07:57.880
especially if you're titrating up the GLP-1.
1397
01:07:58.260 --> 01:08:00.240
So if you have somebody that's on cliposide,
1398
01:08:00.440 --> 01:08:03.040
extended release and they're on 20 milligrams a day total,
1399
01:08:03.860 --> 01:08:06.720
sometimes that or even higher can be the equivalent.
1400
01:08:06.740 --> 01:08:08.540
And this is just what we see clinically,
1401
01:08:08.760 --> 01:08:09.640
not necessarily in literature,
1402
01:08:10.120 --> 01:08:13.100
like 20 to 30 units for some people of insulin.
1403
01:08:13.100 --> 01:08:15.720
That's how strong it is though.
1404
01:08:16.000 --> 01:08:17.580
There's like this, yeah.
1405
01:08:17.740 --> 01:08:19.520
So it's like, okay, well, you know what?
1406
01:08:19.760 --> 01:08:21.979
Your A1C is a nine or an eight or whatever.
1407
01:08:22.040 --> 01:08:22.939
These meds aren't working.
1408
01:08:23.060 --> 01:08:24.340
Let me take you off of them.
1409
01:08:24.380 --> 01:08:26.319
Which yeah, that would be the goal
1410
01:08:26.319 --> 01:08:28.200
while you're adding and titrating up
1411
01:08:28.200 --> 01:08:29.380
on some other ones.
1412
01:08:30.700 --> 01:08:33.500
But their sugars are going to, for a lot of people, go higher.
1413
01:08:33.960 --> 01:08:35.620
So we want to think of that too,
1414
01:08:35.779 --> 01:08:39.680
is like, are you just like adding on the therapy
1415
01:08:39.680 --> 01:08:42.340
while decreasing slowly?
1416
01:08:42.340 --> 01:08:44.260
Really think about the mechanism of action
1417
01:08:44.260 --> 01:08:47.560
of these medications and how strong, how potent they are.
1418
01:08:48.120 --> 01:08:49.819
Because yes, you're going to get great results
1419
01:08:49.819 --> 01:08:51.620
with the SGLT-2 and GLP-1,
1420
01:08:51.720 --> 01:08:54.819
but if you take away max doses of others at the same time,
1421
01:08:55.460 --> 01:08:57.939
you're not going to see much success on there too.
1422
01:08:58.560 --> 01:09:03.260
And just another thing that this is kind of what I try to think of,
1423
01:09:03.260 --> 01:09:04.880
and I educate the patient too,
1424
01:09:05.760 --> 01:09:08.500
I like my go-to, of course, Metformin.
1425
01:09:08.720 --> 01:09:09.880
Yeah, Metformin, okay.
1426
01:09:09.880 --> 01:09:14.000
GLP-1, love a GLP-1 at first, especially if they're high.
1427
01:09:15.040 --> 01:09:17.300
If I have somebody come in,
1428
01:09:17.500 --> 01:09:19.979
and we do a baseline UA when they come in,
1429
01:09:20.300 --> 01:09:22.779
and they're not on the SGLT-2, okay,
1430
01:09:22.880 --> 01:09:24.800
I know I need to put them on one,
1431
01:09:25.000 --> 01:09:29.120
but if they already have three plus glucose in their urine
1432
01:09:29.120 --> 01:09:33.260
and you have the higher incidence adding SGLT-2
1433
01:09:33.260 --> 01:09:36.340
with the yeast infection or urinary tract infection,
1434
01:09:36.800 --> 01:09:39.300
do I want to add something at that point
1435
01:09:39.300 --> 01:09:41.859
that can potentially precipitate it and increase it,
1436
01:09:41.859 --> 01:09:43.660
knowing that I can add it later, right?
1437
01:09:44.040 --> 01:09:45.920
So if somebody's coming in, they're real high,
1438
01:09:46.040 --> 01:09:48.840
what I'll do too, I don't want to start a med
1439
01:09:48.840 --> 01:09:53.319
that gives them such a potential side effect or issue
1440
01:09:53.319 --> 01:09:56.140
that that puts a bad taste in their mouth and their brain.
1441
01:09:56.560 --> 01:09:57.580
Oh, can't do that.
1442
01:09:57.620 --> 01:10:00.260
They gave me that jar dance, gave me yeast infections.
1443
01:10:00.700 --> 01:10:03.120
Well, your sugar was also average of 300,
1444
01:10:03.120 --> 01:10:05.040
and you were drinking like five sodas a day.
1445
01:10:05.560 --> 01:10:07.020
Was it really the jar dance?
1446
01:10:07.020 --> 01:10:10.480
But if that happens, who wants to be on the med again
1447
01:10:10.480 --> 01:10:12.940
that gave them a terrible yeast infection?
1448
01:10:13.460 --> 01:10:15.700
So a lot of times we'll pull them down
1449
01:10:15.700 --> 01:10:17.940
and they'll be like, I want to add this med.
1450
01:10:18.200 --> 01:10:20.160
It has the CKD, I don't want to say CKD,
1451
01:10:20.200 --> 01:10:22.140
but it has, helps your kidneys, helps your heart.
1452
01:10:22.240 --> 01:10:24.740
You have this, but I really don't want you
1453
01:10:24.740 --> 01:10:26.220
to have X, Y, and Z happen.
1454
01:10:26.260 --> 01:10:28.480
So let me pull you down and then I'll add it on later.
1455
01:10:28.660 --> 01:10:31.140
So that's kind of just another little pearl too.
1456
01:10:32.520 --> 01:10:35.020
And then one more, let's see, I had written down a few,
1457
01:10:35.020 --> 01:10:37.120
is with insulin.
1458
01:10:37.540 --> 01:10:39.240
One of the questions when we were first talking,
1459
01:10:39.740 --> 01:10:41.020
I think you had presented like,
1460
01:10:41.140 --> 01:10:42.500
is there like a max dose of insulin?
1461
01:10:43.060 --> 01:10:43.860
Yes, that's a great question.
1462
01:10:44.260 --> 01:10:45.200
Yeah, I love that.
1463
01:10:46.280 --> 01:10:48.120
So insulin, I mean, we're all taught in nursing school,
1464
01:10:48.180 --> 01:10:49.300
it's a critical med, right?
1465
01:10:49.400 --> 01:10:51.520
So two people check off on it and all this,
1466
01:10:51.900 --> 01:10:52.920
and you're like in the hospital
1467
01:10:52.920 --> 01:10:55.680
and you're checking off like two units of humulin R,
1468
01:10:55.680 --> 01:10:57.720
and I'm not disrespecting that at all.
1469
01:10:58.060 --> 01:10:59.180
And then you have, you know,
1470
01:10:59.180 --> 01:11:02.360
I have people on U500 insulin that's five times concentrated
1471
01:11:02.360 --> 01:11:04.480
and it's on 300, 400 units per day.
1472
01:11:04.480 --> 01:11:07.560
So, you know, you still have the respectful fear, right?
1473
01:11:08.140 --> 01:11:10.100
But you're trying to think too,
1474
01:11:10.300 --> 01:11:11.600
it's like when you have,
1475
01:11:11.740 --> 01:11:14.720
or let's say you have like the CGM data in front of you,
1476
01:11:15.020 --> 01:11:16.100
like, what do you think about,
1477
01:11:16.100 --> 01:11:17.640
what am I trying to fix, right?
1478
01:11:17.640 --> 01:11:18.440
What am I trying to fix?
1479
01:11:18.580 --> 01:11:22.200
If we say, hey, your A1C is a nine,
1480
01:11:22.380 --> 01:11:24.420
but what if they come back and they're like,
1481
01:11:24.740 --> 01:11:27.600
you know what, and let's say they're not on the CGM.
1482
01:11:27.780 --> 01:11:32.240
Well, my fastings are like between 90 and 120, you know?
1483
01:11:32.800 --> 01:11:35.620
So is the answer to just keep increasing the basal insulin.
1484
01:11:36.240 --> 01:11:37.880
Now, number one, the answer might be
1485
01:11:37.880 --> 01:11:39.060
changing the basal insulin,
1486
01:11:39.180 --> 01:11:40.720
get out of the glargine and denomere
1487
01:11:40.720 --> 01:11:44.180
and do more of like a longer, long-acting insulin,
1488
01:11:44.640 --> 01:11:46.780
like I'm not disrespecting that, 42-hour.
1489
01:11:46.880 --> 01:11:48.160
You know, like it's fantastic.
1490
01:11:48.480 --> 01:11:50.860
It's just, it's beautiful and it's more comfortable.
1491
01:11:51.220 --> 01:11:54.160
But is that answer to just increase basal,
1492
01:11:54.200 --> 01:11:56.500
because what's going to happen to this number, right?
1493
01:11:56.500 --> 01:11:57.580
So they're just going to go lower.
1494
01:11:58.140 --> 01:12:00.900
We have to remember that, sorry, this went out.
1495
01:12:02.760 --> 01:12:05.100
Most of, I can't remember the percentage,
1496
01:12:05.540 --> 01:12:10.680
most of an elevated A1C is due to like post-spring deal surges.
1497
01:12:11.160 --> 01:12:13.760
Okay, so you get the GLP one on the board, you know,
1498
01:12:13.760 --> 01:12:16.260
but the answer is not just to increase, increase,
1499
01:12:16.260 --> 01:12:17.560
increase, increase basal.
1500
01:12:17.780 --> 01:12:19.220
At some point you need to be like, okay,
1501
01:12:19.260 --> 01:12:21.200
you're at 0.5 units per kilo on this.
1502
01:12:21.500 --> 01:12:22.420
Like that's too much.
1503
01:12:22.900 --> 01:12:25.880
It's time to add in a mealtime insulin.
1504
01:12:26.120 --> 01:12:28.220
At that point too, now a lot of facilities
1505
01:12:28.220 --> 01:12:29.180
don't do sliding scales.
1506
01:12:29.200 --> 01:12:30.420
We do, obviously, you know,
1507
01:12:31.360 --> 01:12:32.580
sensitivity factors and stuff.
1508
01:12:32.700 --> 01:12:35.020
And then we always want to say, prevent the problem.
1509
01:12:35.160 --> 01:12:36.220
Don't just treat the problem.
1510
01:12:36.480 --> 01:12:38.520
So if they're 90 here and you're like, okay,
1511
01:12:38.600 --> 01:12:39.200
well, how about this?
1512
01:12:39.240 --> 01:12:40.840
Check two hours after you eat breakfast.
1513
01:12:40.840 --> 01:12:44.080
And if you're 250, take three to five units
1514
01:12:44.080 --> 01:12:45.220
or whatever the scale.
1515
01:12:45.560 --> 01:12:46.900
Okay, well, it's going to pull them down.
1516
01:12:46.960 --> 01:12:48.660
How do you prevent the 250, right?
1517
01:12:48.680 --> 01:12:50.000
You're still not getting ahead of it.
1518
01:12:50.280 --> 01:12:53.980
So you're all, you want to get ahead of everything.
1519
01:12:54.040 --> 01:12:55.920
So that's when you need to really start going
1520
01:12:55.920 --> 01:12:57.500
to that cranial insulin.
1521
01:12:57.500 --> 01:13:00.580
And then once I get on those higher doses,
1522
01:13:00.600 --> 01:13:02.940
start considering doing the concentrated insulin too.
1523
01:13:03.580 --> 01:13:05.680
Yeah, and just for people, like I just,
1524
01:13:05.680 --> 01:13:08.340
I'm just going to head deep in all of this.
1525
01:13:08.980 --> 01:13:10.260
And so I'm like, yes, yes, yes.
1526
01:13:10.420 --> 01:13:12.000
But I'm just thinking about some new grads
1527
01:13:12.000 --> 01:13:12.840
who are like, what?
1528
01:13:13.460 --> 01:13:15.160
For some of the parts, not that,
1529
01:13:15.160 --> 01:13:16.120
I feel like that was very clear,
1530
01:13:16.400 --> 01:13:18.580
but recently I've gotten more comfortable
1531
01:13:18.580 --> 01:13:20.380
with the more concentrated long-acting one.
1532
01:13:20.720 --> 01:13:22.100
And so just to pull that piece out,
1533
01:13:22.300 --> 01:13:25.460
you have Semgly, Basical-R, Atlantis.
1534
01:13:25.540 --> 01:13:26.880
Those are like the brand names.
1535
01:13:26.880 --> 01:13:28.220
Yeah, those are not the generics.
1536
01:13:28.800 --> 01:13:30.740
And then you've got Traseba.
1537
01:13:31.360 --> 01:13:32.260
Again, I have not affiliated
1538
01:13:32.260 --> 01:13:33.860
with any pharmaceutical companies either.
1539
01:13:34.800 --> 01:13:35.980
But Traseba is the long,
1540
01:13:35.980 --> 01:13:38.340
it's basically the long, long-acting insulin.
1541
01:13:38.980 --> 01:13:42.340
And then you also have concentrated,
1542
01:13:43.220 --> 01:13:45.140
certain medicines have certain concentrations
1543
01:13:45.140 --> 01:13:45.960
that are higher.
1544
01:13:46.640 --> 01:13:48.100
So like you're saying, U500,
1545
01:13:48.340 --> 01:13:50.320
are you talking about regular U500 or?
1546
01:13:51.100 --> 01:13:52.220
Yes, yeah.
1547
01:13:52.220 --> 01:13:56.880
So U500 is its own kind of thing.
1548
01:13:57.100 --> 01:13:58.820
It replaces basal and bolus.
1549
01:13:59.120 --> 01:14:00.720
Okay, so if you have,
1550
01:14:01.120 --> 01:14:02.400
let's say you have somebody on,
1551
01:14:04.540 --> 01:14:06.920
let's say like Atlantis, okay.
1552
01:14:08.140 --> 01:14:09.260
Atlantis burns.
1553
01:14:09.360 --> 01:14:10.260
Glaregine burns.
1554
01:14:10.260 --> 01:14:10.760
Oh, really?
1555
01:14:11.400 --> 01:14:13.100
Yeah, so like that's not a very
1556
01:14:13.100 --> 01:14:13.780
comfortable injection.
1557
01:14:14.160 --> 01:14:16.480
And I always ask patients about that.
1558
01:14:16.820 --> 01:14:17.640
Like, you know, nobody loves
1559
01:14:17.640 --> 01:14:19.100
to get themselves an injection anyway.
1560
01:14:19.440 --> 01:14:20.460
I'm like, do you feel that?
1561
01:14:20.620 --> 01:14:20.960
Does it burn?
1562
01:14:20.960 --> 01:14:22.440
Oh my gosh, it burns so bad.
1563
01:14:22.480 --> 01:14:23.460
Like it feels like a beast thing
1564
01:14:23.460 --> 01:14:24.240
for a lot of people.
1565
01:14:24.900 --> 01:14:26.240
So then you want to try to get somebody
1566
01:14:26.240 --> 01:14:28.120
on a more comfortable injection.
1567
01:14:28.160 --> 01:14:29.380
That's usually why I go
1568
01:14:29.380 --> 01:14:30.980
with Traseba for most people.
1569
01:14:31.760 --> 01:14:33.380
Yeah, but then think to,
1570
01:14:34.340 --> 01:14:37.540
okay, so you have like a large dose of Atlantis.
1571
01:14:37.860 --> 01:14:39.480
You know, so if you dialed up that 10
1572
01:14:39.480 --> 01:14:40.760
and it was like 80 units
1573
01:14:40.760 --> 01:14:41.660
and you square it out,
1574
01:14:41.760 --> 01:14:44.240
it's like how much liquid comes out
1575
01:14:44.240 --> 01:14:45.720
to be sub-Q, right?
1576
01:14:45.920 --> 01:14:46.740
So that's a lot.
1577
01:14:47.220 --> 01:14:48.360
So at that point,
1578
01:14:48.700 --> 01:14:49.620
you know, if it's starting
1579
01:14:49.620 --> 01:14:50.820
to get uncomfortable for them
1580
01:14:50.820 --> 01:14:52.160
or if you're even considering having
1581
01:14:52.160 --> 01:14:54.700
to do like twice daily long-acting insulin,
1582
01:14:55.080 --> 01:14:56.980
that's when it definitely go for like a Traseba
1583
01:14:56.980 --> 01:14:58.660
because it's on formularies for a lot.
1584
01:14:58.800 --> 01:15:01.520
And then also Tugeo is a U300.
1585
01:15:01.880 --> 01:15:04.660
I don't know if you've, yeah, yeah, yeah, yeah.
1586
01:15:04.720 --> 01:15:06.540
So Tugeo is U300.
1587
01:15:06.700 --> 01:15:08.800
So the smaller pin has the equivalent
1588
01:15:08.800 --> 01:15:10.540
of 450 units.
1589
01:15:10.680 --> 01:15:12.400
The larger pin has 900.
1590
01:15:12.960 --> 01:15:16.460
The three mil pin of the Traseba U200
1591
01:15:16.460 --> 01:15:18.460
has 600 units in it.
1592
01:15:18.500 --> 01:15:19.960
So you do have to convert it
1593
01:15:19.960 --> 01:15:24.040
to the pharmacy, safety, safety, safety, safety
1594
01:15:24.040 --> 01:15:26.840
on this is just, okay.
1595
01:15:26.900 --> 01:15:29.240
So there's warnings on the hairdryer
1596
01:15:29.240 --> 01:15:30.620
to don't take a bath
1597
01:15:30.620 --> 01:15:31.480
while you're blow-drying your hair.
1598
01:15:31.660 --> 01:15:32.580
I mean, somebody did it, right?
1599
01:15:32.960 --> 01:15:35.620
Okay, so most of these,
1600
01:15:35.660 --> 01:15:37.580
because there's also a Humalog U200
1601
01:15:37.580 --> 01:15:39.020
and then there's a Lumegeb,
1602
01:15:39.020 --> 01:15:41.000
which is a faster version
1603
01:15:41.000 --> 01:15:43.020
of the Humalog U200.
1604
01:15:43.260 --> 01:15:45.060
And on those, there's like these little,
1605
01:15:45.060 --> 01:15:46.700
they're yellow stickers.
1606
01:15:46.720 --> 01:15:49.200
It says, do not draw out with a syringe
1607
01:15:49.200 --> 01:15:51.900
because sometimes patients do run out of pin tips,
1608
01:15:52.100 --> 01:15:53.120
the little twisty pin tips.
1609
01:15:53.140 --> 01:15:54.140
Oh, I see, I see.
1610
01:15:54.280 --> 01:15:54.580
Yeah.
1611
01:15:54.900 --> 01:15:57.420
So if they, this is converted down by volume.
1612
01:15:57.500 --> 01:15:59.040
So you're not changing the unit.
1613
01:15:59.200 --> 01:16:00.860
The pin changes the volume.
1614
01:16:00.860 --> 01:16:03.880
So if they're on 80 of Traseba
1615
01:16:03.880 --> 01:16:06.100
and you put them on the U200,
1616
01:16:06.820 --> 01:16:07.920
if you compared it,
1617
01:16:07.920 --> 01:16:10.080
it's gonna look like 40 units by volume.
1618
01:16:10.400 --> 01:16:10.700
That makes sense.
1619
01:16:10.740 --> 01:16:11.800
So you're not saying,
1620
01:16:12.580 --> 01:16:14.320
so each one is, yeah.
1621
01:16:14.340 --> 01:16:16.100
So it's half of the volume
1622
01:16:16.100 --> 01:16:16.960
because it's concentrated.
1623
01:16:17.240 --> 01:16:17.600
Yeah.
1624
01:16:17.600 --> 01:16:17.960
Okay.
1625
01:16:17.960 --> 01:16:20.780
So if they're like, oh, I ran out of pin tips
1626
01:16:20.780 --> 01:16:22.200
and they get a little insulin syringe
1627
01:16:22.200 --> 01:16:24.080
and they're like, oh, let me just pull this out
1628
01:16:24.080 --> 01:16:25.340
and they pull out 80,
1629
01:16:25.440 --> 01:16:26.740
they're getting double the 160
1630
01:16:26.740 --> 01:16:28.240
because it's by volume.
1631
01:16:28.500 --> 01:16:28.760
Yeah.
1632
01:16:28.940 --> 01:16:31.260
So that's the safety part on that.
1633
01:16:31.400 --> 01:16:31.980
They're fantastic.
1634
01:16:32.000 --> 01:16:33.600
I don't want that to like scare people
1635
01:16:33.600 --> 01:16:34.420
from not using it
1636
01:16:34.420 --> 01:16:36.580
because it's such a more comfortable injection.
1637
01:16:36.620 --> 01:16:40.720
They're not getting as much of that volume sub-Q.
1638
01:16:41.000 --> 01:16:41.400
Yeah.
1639
01:16:42.020 --> 01:16:44.000
And then total,
1640
01:16:44.200 --> 01:16:45.900
I'll touch on that U500 a little bit.
1641
01:16:47.460 --> 01:16:49.620
When our clinic first opened,
1642
01:16:50.400 --> 01:16:52.660
again, the U500 was on the market
1643
01:16:52.660 --> 01:16:54.960
but we had to convert it down by volume
1644
01:16:54.960 --> 01:16:57.940
either in a TB syringe or an insulin syringe.
1645
01:16:58.540 --> 01:17:01.940
But now the U500, it's a teal pin
1646
01:17:01.940 --> 01:17:03.820
and I will say on their website
1647
01:17:03.820 --> 01:17:05.100
and I double checked last night
1648
01:17:05.100 --> 01:17:07.620
to make sure that the prescribing information is there.
1649
01:17:08.000 --> 01:17:11.560
There are two or three great tables
1650
01:17:11.560 --> 01:17:12.940
on the prescribing of this.
1651
01:17:13.220 --> 01:17:13.420
Okay.
1652
01:17:13.420 --> 01:17:15.060
So this is typically used
1653
01:17:15.060 --> 01:17:17.420
whenever the total amount of insulin per day
1654
01:17:17.420 --> 01:17:19.540
is 200 units or greater.
1655
01:17:20.520 --> 01:17:22.900
So meaning if they're on 10 units
1656
01:17:22.900 --> 01:17:25.200
or 20 units of Humalog a few times a day
1657
01:17:25.200 --> 01:17:26.600
plus a lot of basal insulin
1658
01:17:26.600 --> 01:17:28.320
and it equals 200 or more.
1659
01:17:28.560 --> 01:17:30.740
This is a great, great, great insulin
1660
01:17:30.740 --> 01:17:34.920
to help with just reducing the amount of injections
1661
01:17:34.920 --> 01:17:36.980
because you can start at VID dosing.
1662
01:17:36.980 --> 01:17:40.040
So you can go from potentially two Lantus per day
1663
01:17:40.040 --> 01:17:41.600
if they're on a split regimen
1664
01:17:41.600 --> 01:17:44.400
and three Mealtime to two times per day.
1665
01:17:44.400 --> 01:17:45.820
So you reduce things.
1666
01:17:46.220 --> 01:17:48.040
So you get rid of the pre-trial and the long-acting
1667
01:17:48.040 --> 01:17:49.320
and just replace it with this one.
1668
01:17:49.760 --> 01:17:50.060
Cool.
1669
01:17:50.340 --> 01:17:51.340
And it's not a mixed insulin.
1670
01:17:51.440 --> 01:17:53.660
So the U500 has a much longer duration
1671
01:17:54.240 --> 01:17:55.560
but then you can reconvert it
1672
01:17:55.560 --> 01:17:56.800
but there are really good tables
1673
01:17:56.800 --> 01:17:58.600
on the prescribing of it.
1674
01:17:58.620 --> 01:18:01.100
But what's scary is I did an example
1675
01:18:01.100 --> 01:18:01.980
I'm just trying to find it
1676
01:18:01.980 --> 01:18:03.260
because then you're like, oh.
1677
01:18:03.880 --> 01:18:05.900
It's so I took it as
1678
01:18:05.900 --> 01:18:07.460
because it's a straight conversion
1679
01:18:07.460 --> 01:18:08.620
if they're A1C is over eight
1680
01:18:08.620 --> 01:18:10.580
and that's when you're like, that's a lot of insulin.
1681
01:18:10.580 --> 01:18:15.220
So if they're on a straight 200 units per day
1682
01:18:15.220 --> 01:18:17.640
and you want to start with an easier regimen
1683
01:18:17.640 --> 01:18:20.280
and they again, they give you the dosing on it.
1684
01:18:20.280 --> 01:18:21.980
So it's 60% in the morning
1685
01:18:21.980 --> 01:18:23.800
40% at night to kind of start.
1686
01:18:24.780 --> 01:18:27.700
60% of 200 is 120 units
1687
01:18:27.700 --> 01:18:29.660
that you would dose that person at one time
1688
01:18:29.660 --> 01:18:31.280
and then 80 in the evening.
1689
01:18:31.480 --> 01:18:35.360
So you look at that and you're like, oh wow.
1690
01:18:35.800 --> 01:18:38.020
But it is and I remember the first time
1691
01:18:38.020 --> 01:18:39.840
I had to put my name on a prescription of that
1692
01:18:40.400 --> 01:18:42.160
please make sure I did this math right.
1693
01:18:42.720 --> 01:18:43.420
And it's right.
1694
01:18:43.520 --> 01:18:44.640
I mean, it's to the T
1695
01:18:44.640 --> 01:18:47.840
and so that too, especially things like this
1696
01:18:47.840 --> 01:18:48.900
you want to think of, you know
1697
01:18:48.900 --> 01:18:50.640
if somebody is practicing in a rural area
1698
01:18:50.640 --> 01:18:53.000
that they don't have access to endocrinology
1699
01:18:53.000 --> 01:18:54.440
or they don't have, you know
1700
01:18:54.440 --> 01:18:56.720
you need to know how to do this
1701
01:18:57.720 --> 01:18:59.600
because but then they have that
1702
01:18:59.600 --> 01:19:00.640
again, really, really tables.
1703
01:19:00.940 --> 01:19:03.360
I have put screenshots on my phone
1704
01:19:03.360 --> 01:19:07.020
and I have like a saved photo album for it
1705
01:19:07.020 --> 01:19:08.020
of just because there's
1706
01:19:08.580 --> 01:19:09.860
they tell you, hey
1707
01:19:09.860 --> 01:19:12.380
if the average fasting is below or above
1708
01:19:12.380 --> 01:19:14.400
this is the dose that you increase
1709
01:19:14.400 --> 01:19:15.540
and then by what percent
1710
01:19:15.540 --> 01:19:18.240
so they give it to you like stuff like that.
1711
01:19:18.500 --> 01:19:19.940
And I guess I just want to pause and say
1712
01:19:19.940 --> 01:19:20.800
well two things.
1713
01:19:20.880 --> 01:19:26.640
One is that most insulins are 100 per ml
1714
01:19:26.640 --> 01:19:28.580
the concentration is 100 per 1 ml
1715
01:19:28.580 --> 01:19:31.640
and so when you overuse the U200, U300, U500
1716
01:19:31.640 --> 01:19:34.360
it's just 500 units per ml, correct?
1717
01:19:34.420 --> 01:19:34.780
Correct.
1718
01:19:34.900 --> 01:19:36.700
And then something happens
1719
01:19:36.700 --> 01:19:39.160
when you have more concentrated insulins
1720
01:19:39.160 --> 01:19:42.520
that it changes the pharmacokinetics
1721
01:19:42.520 --> 01:19:44.120
because both because of the volume
1722
01:19:44.120 --> 01:19:45.360
and because of the concentration
1723
01:19:45.360 --> 01:19:46.100
and that very
1724
01:19:46.940 --> 01:19:48.380
before I actually say any more
1725
01:19:48.380 --> 01:19:50.240
I want to normalize for students
1726
01:19:50.240 --> 01:19:50.920
and newer grads
1727
01:19:50.920 --> 01:19:52.200
and people just switching into primary care.
1728
01:19:52.260 --> 01:19:54.680
This is advanced diabetes management.
1729
01:19:54.680 --> 01:19:55.220
Oh yeah, sorry.
1730
01:19:56.660 --> 01:19:57.800
It's beautiful, right?
1731
01:19:57.800 --> 01:19:58.760
It's not just new grads
1732
01:19:58.760 --> 01:20:00.100
that are watching and listening
1733
01:20:00.100 --> 01:20:01.640
and it's so helpful for me.
1734
01:20:01.760 --> 01:20:02.320
I love this.
1735
01:20:02.640 --> 01:20:03.420
But like you're
1736
01:20:03.420 --> 01:20:05.780
unless you are a passionate diabetes person
1737
01:20:06.520 --> 01:20:09.300
and also you have more years of practice
1738
01:20:09.300 --> 01:20:11.740
you're probably going to like ease into this
1739
01:20:11.740 --> 01:20:13.260
but like yeah
1740
01:20:13.260 --> 01:20:14.540
like there is
1741
01:20:14.540 --> 01:20:17.080
the concentrated longer acting ones
1742
01:20:17.080 --> 01:20:18.400
are just wonderful
1743
01:20:18.400 --> 01:20:21.360
and it's Humalog is U500
1744
01:20:21.360 --> 01:20:22.520
that's the right name.
1745
01:20:22.640 --> 01:20:23.740
I'm saying that right, correct?
1746
01:20:24.200 --> 01:20:25.840
It's Humulin R U500.
1747
01:20:25.960 --> 01:20:27.800
Oh, Humulin R U500.
1748
01:20:28.520 --> 01:20:30.480
There is a Humalog U200.
1749
01:20:30.960 --> 01:20:31.920
Okay, okay.
1750
01:20:32.380 --> 01:20:33.200
Yeah, so that's
1751
01:20:33.200 --> 01:20:34.440
it's like a shorter one
1752
01:20:34.440 --> 01:20:35.480
but when you put it
1753
01:20:35.480 --> 01:20:36.980
in that hyper concentrated formula
1754
01:20:36.980 --> 01:20:38.640
the pharmacokinetics are different.
1755
01:20:38.820 --> 01:20:39.340
Is that correct?
1756
01:20:39.500 --> 01:20:39.860
Right.
1757
01:20:39.900 --> 01:20:42.080
Yeah, because I was reading even about it too
1758
01:20:42.080 --> 01:20:42.940
because it's like
1759
01:20:42.940 --> 01:20:44.220
it's almost like misleading
1760
01:20:44.220 --> 01:20:45.060
because you look at it
1761
01:20:45.060 --> 01:20:46.640
and it's like, okay, Humulin R
1762
01:20:46.640 --> 01:20:48.180
but it's just a concentrated
1763
01:20:48.180 --> 01:20:49.920
so is it a concentrated regular?
1764
01:20:50.480 --> 01:20:50.620
Exactly.
1765
01:20:51.220 --> 01:20:53.880
Yeah, so it's a long tail.
1766
01:20:54.040 --> 01:20:56.220
I mean long, long tail on it.
1767
01:20:56.420 --> 01:20:57.180
Yeah, that you can see.
1768
01:20:57.500 --> 01:20:58.840
Yeah, that's really good to know.
1769
01:20:59.220 --> 01:21:00.920
So I think for students
1770
01:21:00.920 --> 01:21:03.660
newer grads ask for help before you do that
1771
01:21:04.440 --> 01:21:06.020
if you have more practice
1772
01:21:06.020 --> 01:21:08.120
or you're really passionate about diabetes.
1773
01:21:08.440 --> 01:21:09.280
It's beautiful.
1774
01:21:09.300 --> 01:21:10.520
This is really, really helpful
1775
01:21:10.520 --> 01:21:11.580
because again, like
1776
01:21:11.580 --> 01:21:13.100
I have many years of practice at this point
1777
01:21:13.100 --> 01:21:13.660
and I'm like
1778
01:21:13.660 --> 01:21:15.080
I'm interested in expanding more
1779
01:21:15.080 --> 01:21:16.240
of my diabetes care
1780
01:21:16.740 --> 01:21:18.020
and it's such a good point
1781
01:21:18.020 --> 01:21:19.260
you said about rural medicine
1782
01:21:19.260 --> 01:21:21.140
because so many clinicians say
1783
01:21:21.140 --> 01:21:23.460
like I just can't get people to a specialist.
1784
01:21:23.700 --> 01:21:24.300
What am I supposed to do?
1785
01:21:24.300 --> 01:21:24.680
Oh, absolutely.
1786
01:21:25.160 --> 01:21:26.580
And I think safety first
1787
01:21:26.580 --> 01:21:29.100
is that like if you're a new grad
1788
01:21:29.100 --> 01:21:29.940
you're still a new grad
1789
01:21:29.940 --> 01:21:31.320
even if you practice some rural medicine
1790
01:21:31.320 --> 01:21:33.040
you probably still need support
1791
01:21:33.040 --> 01:21:34.640
and also you're probably going
1792
01:21:34.640 --> 01:21:35.780
to expand your practice
1793
01:21:35.780 --> 01:21:38.480
to a place that is really serving people
1794
01:21:38.480 --> 01:21:40.300
to that maximum level of your license
1795
01:21:40.300 --> 01:21:41.880
but it's going to take a little bit of time.
1796
01:21:42.240 --> 01:21:42.920
So all of this stuff
1797
01:21:42.920 --> 01:21:44.080
is just so beautiful to share.
1798
01:21:44.160 --> 01:21:45.240
Thank you so much.
1799
01:21:46.020 --> 01:21:47.700
So many other questions
1800
01:21:47.700 --> 01:21:49.300
but we'll wrap up this interview
1801
01:21:49.300 --> 01:21:50.690
and perhaps there'll be a part two
1802
01:21:51.500 --> 01:21:54.040
but yeah, thank you so, so much.
1803
01:21:54.880 --> 01:21:55.500
Yeah, oh yeah.
1804
01:21:55.540 --> 01:21:56.560
Thank you so much for having me.
1805
01:21:56.660 --> 01:21:57.460
It was great.
1806
01:21:58.080 --> 01:21:58.780
Love it.
1807
01:22:04.030 --> 01:22:05.890
That's our episode for today.
1808
01:22:05.890 --> 01:22:07.790
Thank you so much for listening.
1809
01:22:08.130 --> 01:22:09.530
Make sure you subscribe,
1810
01:22:09.770 --> 01:22:10.490
leave a review
1811
01:22:10.490 --> 01:22:12.410
and tell all your NP friends
1812
01:22:12.410 --> 01:22:13.850
so together we can help
1813
01:22:13.850 --> 01:22:16.190
as many nurse practitioners as possible
1814
01:22:16.190 --> 01:22:18.110
give the best care to their patients.
1815
01:22:18.530 --> 01:22:20.010
If you haven't gotten your copy
1816
01:22:20.010 --> 01:22:21.470
of the ultimate resource guide
1817
01:22:21.470 --> 01:22:22.650
for the new NP
1818
01:22:22.650 --> 01:22:25.250
head over to realworldnp.com
1819
01:22:25.250 --> 01:22:26.150
slash guide.
1820
01:22:26.470 --> 01:22:27.870
You'll get these episodes
1821
01:22:27.870 --> 01:22:29.750
sent straight to your inbox every week
1822
01:22:29.750 --> 01:22:31.210
with notes from me,
1823
01:22:31.510 --> 01:22:32.050
patient stories
1824
01:22:32.050 --> 01:22:33.250
and extra bonuses
1825
01:22:33.250 --> 01:22:35.370
I really just don't share anywhere else.
1826
01:22:35.370 --> 01:22:37.330
Thank you so much again for listening.
1827
01:22:37.490 --> 01:22:38.730
Take care and talk soon.

Podcast

Liz Rohr