Transcript: Ask A Diabetic Educator Nurse Practitioner

Liz Rohr:
It's just so moving. I'm tearing up a little bit thinking about how powerful that is for people to have so much agency. I feel like I don't know about you, but I feel like when I was a brand new grad, I was keeping my head above water.

Well, hey, there it's Liz Rohr from Real World NP and you are watching the Real World NP YouTube channel. We make weekly episodes to help save you time, frustration and help you take the best care of your patients.

Oh my goodness, I just had the most amazing interview. So I interviewed Megan Kavanaugh. She is a nurse practitioner who specializes in diabetes care, and we collected questions from the Real World NP community and asked some of the heavy-hitting questions. Things like how to help patients who are not adherent with their medications, how to navigate cost challenges when it comes to diabetes care. And we also talked all about continuous glucose monitoring, which was just so helpful, because that's a tricky thing but it's actually in the guidelines recommended for anybody who is approved by insurance, which is something we also talked about.

We finally talked about the pearls of practice that she had to share for nurse practitioners and clinicians in primary care. It was so good and I could literally talk to her for hours and hours and hours. And so before we get into the interview, I want to let you know that the diabetes, hypertension and CKD course that we have here at Real World NP is coming up for re-release oh so soon. And there may be some bonuses in there to be able to ask some of your clinical questions for your specific patients, when it comes to care of those patients. So if you haven't gotten on the waitlist already, head over to a realworldnp.com/courses. And if you're watching this later than the recording time, definitely go check out the same URL and you will find the course there for registration. So without further ado I'm going to share my interview with Megan.

Thank you so much for being here. Can you introduce yourself?

Meghan Kavanaugh:
Yeah. Well, hey, thank you for having me too. I love all your content and thank you for what you do for the community for NPs. My name is Megan Kavanaugh. I'm a family nurse practitioner. I work in North Louisiana the clinic that is pretty much diabetes only, but we all know it's not just diabetes. We end up treating other things of course. My original background is nutrition.

I'm also a registered dietician. I finished in 2008 with my RD and I finished my master's. I practiced for a few years and got to the point of I want to be able to do more. I was in a great position in an outpatient diabetes education center, but it was education only and there was no management. So we were really limited on what we can do, and I really wanted to get to that point of being able to do more for my patients besides just the education. A few years after that I decided to go to RN school, practiced for a few years and then just went to NP school. So I've been practicing as an NP for about three and a half years. I've been at the clinic that I'm at now for almost 10 years. We've been open almost 10 years, so it's been great.

Liz Rohr:
I have a feeling you're a person who really likes to learn.

Meghan Kavanaugh:
Yes, absolutely. I'm a nerd. It doesn't bother me. I read all the time. I read everything. I read formularies for bedtime stories.

Liz Rohr:
Oh my God, I love it. I love it. That's so awesome. We had so many fantastic questions come in from the Real World NP community. You and I we talked before the recording, but try to narrow it down to some really key highlighted points that are real world applicable tricky. So one of the first really common questions is about continuous glucose monitoring, CGM. So I feel like especially if you're thinking about the place of a new grad or a student, almost what... Can you just talk about what that is and guidance about how to use it and how to prescribe it and how to get it covered?

Meghan Kavanaugh:
Sure.

Liz Rohr:
I guess you can because I know you practice in Louisiana and nationally there are different rules.

Meghan Kavanaugh:
There's differences. And luckily we're at a time now that a lot of insurance formularies are way more generous than what they used to be. So when CGMs were first released it was strictly for type one diabetes. You had to have a history of severe hypoglycemia and awareness, potentially loss of consciousness or causing seizures. It wasn't open initially for type two diabetes, but now we have much more flexibility thankfully because it is such a wonderful tool. For somebody who's not really familiar with the CGM, CGM is a continuous glucose monitor and there are several different brands. Probably the top two that you hear about of course are Dexcom, Dexcom G6 being the newest one and then the FreeStyle Libre. So there is a difference with the Dexcom, that's a continuous, it's a real-time. So for this device, it's bluetooth to a device, usually a cellphone for most people. So there's an iPhone app, there are Android apps as well and it's real-time data. So it checks sugars every few seconds, it averages about every five to six minutes. So I tell people I'm like, "You can open your phone and look at the app and stare at it and you'll watch it change." It's just real-time data. The accuracy over the years has just gotten so much better. Used to we couldn't say, "Hey, you can make treatment-based decisions based off of this number," you still had to perform a finger stick. So for somebody on insulin or if they're treating a hypoglycemic vent, we couldn't say, "Hey, trust it," but now you can. So the Dexcom G6 is factory calibrated. For the FreeStyle Libre that is one that it also now has an iPhone app.

There's an Android app both of them, sorry, the Dexcom has a receiver if they don't have a smartphone. The FreeStyle Libre they can have a reader, but that one you have to scan to see what it is. So instead of opening up Dexcom and saying, "Oh, I can stare at this and see what happens." The other one you do have to take that extra step, which is not a big deal compared to doing a finger stick glucose.

Liz Rohr:
For real.

Meghan Kavanaugh:
Grab the reader, scan it and you can see what it is. But the newer versions of the Libres will alert for a low and alert or a high, but you have to scan to get that actual data.

Liz Rohr:
So it'll beep if it's low, but they just won't tell you what it is and then you-

Meghan Kavanaugh:
Correct.

Liz Rohr:
... just scan it.

Meghan Kavanaugh:
Correct. Correct. One thing too I will say this about the Libre because that's one that is a decent option cash pay for a patient that... if they don't have the insurance coverage, or if they're paying an equivalent amount in testing supplies. That might be a great option because then they don't have to buy the strips and the lancets and a new glucometer and everything or they just want to pay for the convenience. So we do have a lot that are like, "It's worth it. It's worth the 80 bucks a month. Let me just go and purchase that and then I don't have to worry about the finger sticks."

Liz Rohr:
Did you say it's 80 bucks a month?

Meghan Kavanaugh:
Estimated. Estimated.

Liz Rohr:
Estimated.

Meghan Kavanaugh:
Sometimes it goes up to about around here it's between 80 to a $100 cash price. And that's generally for two sensors and each one is one for 14 days discard it, a new one's activated after 14 days, so they get two per month. So it's a decent cash price option if the insurance doesn't cover it. So with actual insurance coverage most insurance formularies at least in our area require the patient to be taking multiple daily injections of insulin, so that could be a basal bolus regimen.

If they happen to be on a Humulin R U-500 even two times, three times a day of that, that's still MDI. Some insurance formularies do require some type of history of hypoglycemia and/or hypo unawareness. Meaning the person has had enough lows that they just don't feel it anymore, which of course is really dangerous situation, so it really helps to justify that need. But I will say for this with the cost and coverage, all of these companies have really, really good reps that are there to help the clinician. And to say, hey, look to get this covered you have to have that documentation in your note of this person's on insulin QID, and they're willing to use the technology as intended. They're able to use the technology, they have the hypoglycemia and that helps build the case, especially if that's for DME, durable medical equipment.

Liz Rohr:
It's in the cover. So the actual device is considered durable medical equipment.

Meghan Kavanaugh:
Depends on the formulary.

Liz Rohr:
That's a complication.

Meghan Kavanaugh:
It's all gray. So many more now they're covering it under pharmacy. Meaning if they have a Walgreens, Walmart, CVS, even a lot of the smaller town pharmacies, they can get it and it goes under their prescription formulary. So you send it in to the pharmacy just like you would anything else.

Liz Rohr:
Yeah. That's how it works. How it's typically worked in my clinic. I'm in Massachusetts.

Meghan Kavanaugh:
Yeah. And then if it does go through DME then you'd have to go through a supply company, but it just depends. In Louisiana our Louisiana Medicaid thankfully we can get it under pharmacy now for most Medicaid. So that really helps a lot in clinic because it's just a PA instead of doing a lot of the other paperwork. And it's easier for the patient because they're not waiting on a supply company to mail them supplies, they can go through the Walmart drive through and pick it up just as if they're picking up their insulin or any other medication.

Liz Rohr:
Totally. And just to clarify I remember being a new grad and being like, "What is DME?" I think this is so state to state, but durable medical equipment is if you had compression stockings, at least this is Massachusetts. But compression stockings, walkers, chairs in the shower for people who are a fall risk, you have to go through a separate company. And I always ask the nurses that I worked with I'm like, "Can I order this?"

Meghan Kavanaugh:
Yeah. Oh, absolutely.

Liz Rohr:
And he was like, "This company, this is how you do it." That's what that means is going through that process. And then various insurances have various coverage of drugs pharmacy versus durable medical equipment, and it depends on the insurance which one is which for the CGMs at least.

Meghan Kavanaugh:
And I will say this too, I am somebody that's like it's not a no until it's a real no. So I will send it under pharmacy first because that's going to be easier. Our EMR will even when the insurance information is input by the front desk, we can even search and look to see potential costs differences. If they pick it up local retail versus doing express scripts or Optum RX or CVS Caremark and so-

Liz Rohr:
That's in your EMR. You said that's in your EMR that's amazing.

Meghan Kavanaugh:
Yeah EMR. EMDs.

Liz Rohr:
Oh, interesting.

Meghan Kavanaugh:
Have you heard of that? So if everything's input correctly, which again it's like magical, we think insurance is one thing and then they end up with a $5,000 deductible and you're like, "Okay, whatever," that's another problem. So then it's knowing how to prescribe it. So for example with the Dexcom there's typically three components. So it's the receiver which used to, and honestly I would have to double check on this. Used to they would require the patient to get the receiver in case the iPhone-

Liz Rohr:
Oh the bluetooth receiver.

Meghan Kavanaugh:
... did not work. So they would have to have something and that might be more under the DME side of it. So you have one receiver, which depending on their insurance, they might only be able to get one every two years, five years, whatever it might be. You have the transmitter, which is the little gray piece, that's the one that's reused. It's a 90 day battery and that's one for every 90 days. So they only have to get that quarterly because they reuse it, that's the expensive part, I tell them, "Don't throw that away when you change it out." 

Liz Rohr:
Totally.

Meghan Kavanaugh:
... throw it away, because you got to pay cash for the next one if you lose it. And then the sensors are 10 days each, so you would dispense three for 30 days.

Liz Rohr:
This is Dexcom.

Meghan Kavanaugh:
Dexcom. Correct. Correct.

Liz Rohr:
For people who are listening or watching, this is going to be all written down on a PDF for you to download.

Meghan Kavanaugh:
And I'll help you with that if you need help. Because with certain things like we probably won't get into insulin pump therapy today. Insulin pump therapy you can prescribe based off of how frequently they change their site based off of their total daily dose of insulin. So if you have somebody that uses quite a bit more insulin, they might need to change their insulin pump side every two days, so you have some wiggle room.

Liz Rohr:
Oh, oh, oh, I see. I see. Insulin pump, not the monitor.

Meghan Kavanaugh:
Correct. Correct. So there you have flexibility other devices like a Dexcom or Freestyle Libre three for 30 days, two for 28 days for Libre and there's very little wiggle room. So then you make sure to tell the patient, "Hey look, there's Dexcom customer support. There's FreeStyle Libre customer support." If something happens and you're new to the product and number one, maybe one just goes bad and it doesn't work. If you wear that sensor for two days, you're going to be eight days short before you can get your next one so you can contact them. And they're great about really troubleshooting that, so just to kind of think of that too.

Liz Rohr:
Wow.

Meghan Kavanaugh:
And so let me get into a little bit of the management of it. Because if you look, I was going through all the guidelines and just doing a refresher. I'm like, "Oh my gosh, this thing is 1,000 pages long."

Liz Rohr:
It's so long. I read it cover to cover for the course.

Meghan Kavanaugh:
Oh my gosh.

Liz Rohr:
Wild.

Meghan Kavanaugh:
It's unreal. So what I like to tell patients going into a CGM because I have some that come in they're like, "I want a Libre or I want a Dexcom." It's like, "Hey, great. Let's get you some diabetes technology. Let's make life easier. Let's get away from these finger sticks."

Liz Rohr:
100%.

Meghan Kavanaugh:
What can be so overwhelming for them amongst many, many other things. When you get a CGM and you have that realtime data or if you're doing the flash and you're scanning, all of a sudden that patient is able to see what's going on all the time. So when you prescribe that and then if you start it yourself, if they come back for the education or if they self start at home.

And you get a phone call within 24 hours and that person's A1C was a nine and they're on meds and all this stuff and they're like, "Oh my gosh Megan, my sugars are X, Y, and Z. 'Hey, you know what you're seeing what has been going on, this is not new information for your body.'" So it's like you're just now able to see in real time what has been going on. And now we can see clinically when you come back how your meds are working. What's going on with food? Your different triggers, is it stress, is it illness? Is it caffeine that's spiking you in the morning with your two cups of coffee, is it smoking or dipping or anything like that? But they can see in real-time what's going on. So it can be overwhelming, it's good information, but it's a lot of information.

Liz Rohr:
A bit too much for some people. I was going to say Megan one of the things I've been doing, especially the team on Real World NP and otherwise is recognizing people the way their brains work basically. And for some people they get really into details and really obsessed with them and then-

Meghan Kavanaugh:
Absolutely.

Liz Rohr:
... others are like, "I don't care."

Meghan Kavanaugh:
I hear you.

Liz Rohr:
And that might be hard to assess when you're starting with a patient, but that might be a helpful question of, "Do get really into details or not?"

Meghan Kavanaugh:
Do you like data?

Liz Rohr:
Some people are data nerds, right?

Meghan Kavanaugh:
Absolutely. Absolutely.

Liz Rohr:
Yeah. I guess a pearl of that is warning people to start that it can be scary to see that. And we are comfortable with that as clinicians because we understand that. We understand what an A1C of nine means, but they might not and then just talking about that, sorry, go ahead.

Meghan Kavanaugh:
Oh yeah. And I would say on the flip side of that too, I can't even tell you how many times that this has happened. Even talking about somebody paying cash for a Libre, because maybe they're not on insulin or they're on Metformin in a GLP-1 and they're like, "I just want to see what's going on." I want to pay out of pocket and do it. Sometimes or not sometimes a lot of times once they get that data and they can see, "I thought a banana wouldn't spike my sugar. I thought this wouldn't spike my sugar." They will come back on paper we'll upload that report, "You would have an A1C of this." And I have to double-check you should anyway their name and date of birth. And I'm like, "Are you the same person because you don't look like this 12 A1C. You're flat as a board."

And they're like, "Well, I could finally see what was going on whenever I ate X, Y, and Z." And as humans, we crave success and you get that instant gratification of, "Oh wow. I did not realize that sweet tea did this to me, let me cut that back." And then all of a sudden there's a flat line instead of a huge surge, so the data is great. And also for the data for the NPs out there, for Dexcom when they download it on their app, they have their main app which is their Dexcom G6. But then there's a second one and I can give you this information called Dexcom Clarity, that is where you get your reports. If there's not a capability in clinic to have the Clinic Dexcom account, they can from their app just email you the data and it's a PDF.

And so the clinic side of it is not anything different than what they would see on their app. So it's not just like, "Hey, put the CGM on. Good luck." You really want to hopefully have the capability to go through it with them and be like, "Oh, what happened here? 'Oh, I had COVID and my sugars were sky high after I had to have treatment or just the illness itself.'" So that way you can really look at the data and then there's also the software for the Libre too, so I see that a lot. Sometimes patients will come in from primary care and internal med and they're like, "I had this data, but I've never been able to see my report before." And then just having that besides the real-time, the actual summary. What's really cool and so rewarding for us too we want to fix people, we just want to fix it.

Is that when they wear each one of these for two weeks at a time, you get what's called a GMI, which is a glucose monitoring indicator. They can't call it an estimated A1C anymore, but it pretty much is an estimated A1C. And so they see that and I'm like, "Oh my goodness, your A1C was X, Y and Z when you came in and look now it's down to a 6.2 just in the last two weeks." And again, it's really, really rewarding and also to obviously whenever you see it and especially patients who are on MDI. Really helps you pinpoint do they need a different amount of insulin for this trigger food or this situation. On those two you can literally watch when GLP-1s kick in when they get to a higher dose, the data on it is fantastic.

Liz Rohr:
It's just so moving. I'm kind of tearing up a little bit thinking about how powerful that is for people to have so much agency. I don't know about you, but I feel like when I was a brand new grad I was keeping my head above water. And you still make an impact from moment one and even though it's hard for a lot of new grads. But I feel like the more time I have as a clinician it's like, "I don't know. I just feel like it's so special." Those are the things that are just so special about really... The focus is less on keeping your head above water, I'm like, "Oh my God, what am I supposed to do here?" And more on, "How can I empower my patients?"

Meghan Kavanaugh:
Absolutely

Liz Rohr:
Keep making that impact like I said you make the impact the whole time... My frame of reference now is not just all the foundational stuff of medicine, but it's like, "How can I help people empower them?" So that's so, so special.

Meghan Kavanaugh:
Oh yeah. And just so much of the cause and effect. With our clinic like I said we're diabetes only and I've been doing diabetes since '08, it kind of ages me out. People crave success. They don't want to go pay a copay or pay a deposit on a deductible and just get fussed at. And it's like maybe they just don't have the right tools in the toolbox. Let's reevaluate. If you need a hammer a screwdriver's not going to cut it. Let's get them a hammer. Let's get good meds.

And I've had people before who were like, even endocrinologists, "My endocrinologist I just see them twice a year and they just fuss at me because my A1C is still a nine, please don't fuss at me." And I'm like, "Do I fuss, have I ever fussed?" It's with love if I do. Call it something nice than a fuss, do a little fuss sandwich, but it's with love and it's not demeaning. And it's more about empowering that patient and just helping them learn what's going on because they're doing their own management most of the time, they see me for a little tiny blip in the radar in their life span.

Liz Rohr:
Really. You use the acronym MDI, is that what you said MDI?

Meghan Kavanaugh:
MDI. Multiple daily injections-

Liz Rohr:
Multiple daily injections.

Meghan Kavanaugh:
... of insulin.

Liz Rohr:
Awesome. So thank you so much for all of that. You are just a gem and such a wealth of knowledge. Another question super, super, super common question is about adherence and how to help patients when they are nonadherent. And I'm using the adherence language. In the diabetes CKD hypertension course that I have I talk about language with patients, and the way that you talk with them actually does make a difference on outcomes.

Meghan Kavanaugh:
Absolutely.

Liz Rohr:
There is research on that  diabetes, I'm sure you've seen that, but using non-adherence instead of non-compliance. So for patients who are struggling to follow the agreed upon directions that you've talked about, what guidance do you have or approach or thoughts? You kind of mentioned a little bit with the hammer and the screwdriver, which you had told me before but what are your thoughts about that?

Meghan Kavanaugh:
So I love that you use non-adherence too. I don't say compliant. And I don't know if y'all use this, but sometimes unfortunately I do have to put that ICD-10 code of the non-compliance because-

Liz Rohr:
I know i.

Meghan Kavanaugh:
... it covers your rear end. Somebody's just literally, you're just at a point and I tell them that, "Hey look, I'm sorry to cover me I have to put this in." So it bothers me that that's still in the ICD-10, but I use adherence too. And just forgive me if I'm long-winded

Liz Rohr:
Everything you're saying is so beautiful. And also it's a lot of information and I think I struggle with that too. At least in my teaching is that there's so much to say, but you're so concise, so go for it.

Meghan Kavanaugh:
So years ago, this is something that has just stuck with me and I probably just need to call this professor and just thank her. When I was in my first undergrad program at Louisiana TechCare in Ruston, one of my favorite nutrition professors she was teaching one of our MNT classes. And one of our big projects was to do a project about renal diet, but it's not just... No renal diet is one of the most difficult diets out there. I commend anybody that can follow that diet to a T, I know this isn't diabetes. But one of the things she had us do with the project was to really put our feet in their shoes and say, "Okay-" It was brilliant. Now granted this is an undergrad nutrition program, but she did use candy. For each one of us had different little baggies of all the different meds, what it would represent that that person that was on dialysis had to take on a regular basis.

So we had to keep a diary of what we ate and then track too how much potassium and phosphorus and calcium and all this and protein and fluids and, "Take your meds. Did you miss your binders? Did you miss this? Did you take this? How much fluid?" And that has stuck with me now oh my goodness 15, 18 years. When we think about adherence it's like what does that mean as a NP when you're looking, what do I expect of this patient? Are you expecting perfection or what's realistic for the patient in the season that they're in right now. So when we get referrals, we don't require referrals, but when we do it's not a lot of primary care that are sending me their A1C patients of a 6.2. It's the one that's so high it won't read.

So it's a greater than 15 or whatever and they're just non-compliant, non-compliant, non-compliant. And you really just say, "Okay. Let's think about when that person gets the diagnosis." And what's their frame of reference of the diagnosis. Did they have a family member that they saw just suffer and have every complication in the world? And they're absolutely terrified and maybe they're motivated or maybe there's a little bit of denial in there. It could be anything, is it they just lost a family member. What is going on with that patient?

And I try to tell especially our ancillary staff this, and I'm going to mainly focus on more difficult regimens like the MDI, the multiple daily injections. And when we recommend, "Okay, you're going to take Metformin, you're going to do a weekly semaglutide. We also need to do a Jardiance, so maybe we can get some combination meds. But you know what you also need a basal insulin and then you need three injections per day. You need to do finger sticks because we haven't got your CGM coverage yet. And then you literally have a life and you have a family and you have kids."

Liz Rohr:
By the way you have a life.

Meghan Kavanaugh:
"Let's exercise too. Let's do that. Let's get good sleep. Let's meal prep. Let's count our carbs." And so the ancillary stuff too I'm like have you ever thought about how difficult that is? We have other things to think about than dealing with daily chronic illness. So we have to recognize and tell that patient, "This is hard. What you were doing is hard, this is a time commitment." And plus with us we make them keep homework. So they might not have had to write down their meals and snacks and try to count their carbs and do all this. We stress the importance of it, it's like, "Hey, do your best." But if we really step back before we just start fussing and were just like, "Okay. You got to do it. You got to do it." Have we thought about the time commitment that it takes to really just do what needs to be done? And we have some type A patients that are like, "You know what, you just tell me what to do. Tell me what to do-

Liz Rohr:
Oh really.

Meghan Kavanaugh:
... and I'll do it."

Liz Rohr:
Totally.

Meghan Kavanaugh:
I was like, "I can't remember the last time I've taken a multivitamin daily for an entire week. A really complicated med regimen." We all know the benefits of goal setting, so it might be, "Hey, look right now here's what I want you to focus on. No sugary drinks except for in the case of hypoglycemia. Let's just work on that. Take your medicines as prescribed and check your sugar." You can start with three things before you just start pounding on all these other things and then guess what? They got to get that dilated eye exam, you got to get them on a filament, you got to do daily foot checks. You got to do this, this and this. Not to mention if they need a nephrology referral, cardiology whatever-

Meghan Kavanaugh:
... and then they have extra out pocket... Yeah.

Liz Rohr:
Totally.

Meghan Kavanaugh:
It's a lot, so if you say, "I get it this is hard. This is hard. This is brand new information. Let's work on this first." I'm in Louisiana we have fantastic, great fatty, wonderful foods. I can work with gumbo. I can work with chicken strips. I can work with a crawfish boil. I can't work with Coca-Cola. I just can't. I will dose it if I have to, but there's no place for that.

Liz Rohr:
They love it. I love that because you're meeting them where they're at.

Meghan Kavanaugh:
Yeah. Absolutely. And then you just try to build on that. And then once they get that trust, maybe the last few places that they've gone they've just been really talked down to or whatever. And then they get that trust with you and know that they're coming for encouragement, but also tough love when needed. You'll see more and more adherence if it's not mainly something like a cost issue, which we'll talk about that in a minute. And also too I've had patients come in, you probably have too, that they'll say, "Well, I'm just in denial. I'm just in denial." I'm like, "But are you in denial you walked in the door, you came to a diabetes clinic. I don't think you're in denial. Let's recognize that you came in, you made an appointment, you paid your copay, you walked in, you were here on time and you're talking to me. I don't think that's denial."

So it's just like maybe you just need different tools and that's when too you go back to something like a CGM. Something that, okay, maybe this person we can get more data makes it easier on them, they can trust their med regimen. Maybe they were on really old school diabetes meds in the past SIMPONI ARIAs and they're dropping out like crazy. And maybe they're so terrified of lows and they're like, "I'm worried about this SGLT2 causing lows." So maybe it's just something like that where they just need a little bit more education on the mechanism, the action of the medication. But it's just what are your expectations of the patient and really meet them where they're at.

Liz Rohr:
Absolutely. There are a couple of pearls to pull out for that. Because I feel like new grads I think there's so much... because not just new grads listen to the channel and the podcast. There's experienced people too and people who are entering primary care from another specialty, so it's not just new grads. But when I think about new grads and I think about what I wanted to do and the people that I work with and what they want to do, there's so much desire to do it all right now.

Meghan Kavanaugh:
Absolutely.

Liz Rohr:
And having conversations like this, this takes time and practice. I feel like the first place to start is the non-judgmental attitude. Exactly like you said of I had a similar thing in nursing school where it was not about diabetes, but it was about older adults who have visual impairments, tactile impairments, hearing impairments. I wore earbuds. I put on these really hard-to-see glasses and I had these big things and someone's explaining my med regimen to me and I'm like I will never forget that, that was uncomfortable.

And they're saying it quickly, that whole thing. I think that's one thing to start for especially for newer clinicians. It's okay to build on this. And then I think one other thing I wanted to pull out about what you said is just meeting people where they're at, because it really is a long game. Because I think, especially, I don't know if you had this when you were a brand new NP, but you also had so much other clinical experience before so maybe it didn't hit you as hard. But it's just I felt the pressure of, "I have to fix it today." And so the diagnosis of diabetes I'd be like, "Okay. Monofilament, ophthalmology... It was ridiculous." I'm not saying ridiculous in a judgment way too, a new grad who is listening and is doing the same thing. In retrospect it was like... people didn't come back. So it's a stepwise approach, it doesn't have to be done today. The person coming to a visit who is in denial, the fact that they arrived is good enough.

Meghan Kavanaugh:
Absolutely.

Liz Rohr:
If we can keep positive intent, assume positive intent and assume that everyone is doing the best that they can all the time. How does that change the way you approach a patient is like that's the best that person can do today. Come to your clinic and tell your patient, "We're not doing anything."

Meghan Kavanaugh:
Absolutely. And you do have to adjust for where they're at seasonally. And I tell people too when you're diagnosed with diabetes, whether that was yesterday or 10 years ago, diabetes is not like, "Hey, you got it. I'm going to stay right here. I'm going to be stagnant. This is the worst it's going to be." It is progressive. So I can't remember the stat on the beta cell dysfunction and how much of the beta cells that you lose by the time prediabetes let alone type two, that destruction is gone and that's progressive. So what used to work three years ago, diabetes is just on this little happy merry way and you got to jump the fence and you got to get ahead of it with meds or weight management or whatever it might be. And it might be talking about if they had this elevated A1C and newly diagnosed, of course, you can't fix everything in one visit.

Of course, I'm going to be way more aggressive in the treatment than many other people would be. And my boss would be even way more aggressive, but it's appropriately aggressive. But you have to tell them too, "Hey look, I recognize that you're scared or nervous, but these averages of 300s. If I pull you down to averages of 100 within a week you're not going to feel good. I got to chip away. I just got to knock it down a little bit." And we can talk about a little bit with meds and some of those algorithms and we'll go to pearls and stuff too of, again, people crave success. And I know we're focusing mainly on type two diabetes, but many patients, most patients with diabetes type two needs some type of weight management. So it could be you know what I know an injectable doesn't sound great, but the semaglutide or the Trulicity or something like that, the weekly injectables it's great.

Let's get some success. You can taste that and you build from there of that compliance. Can you imagine let's say that you're on a med regimen and somebody's told you, "Okay. Check your blood sugar two times a day, four times a day," whatever and you're checking it. You don't go back in because they're like, "Well, they told me not to come back for three months." You're checking your blood sugar two to four times a day. You're not seeing it budge. You're doing everything you can with diet and exercise. I kind of be like, "What's the point?"

Liz Rohr:
Exactly.

Meghan Kavanaugh:
It becomes completely disheartening for that patient to just be like, "Well, I'm not seeing progress. Why am I still checking a day and I'm seeing nothing but two to 300." So there's multiple reasons but you just think too, "When was the last time I had to check my blood sugar four times a day and do finger sticks and stop what I'm doing and clean off. And then I need to count my carbs and make sure it's a low glycemic index and pair it with protein and fat and I need to exercise." Can you do that? Can you do that?

Liz Rohr:
I cannot. I cannot. I try really hard to feed myself well and it's very hard.

Meghan Kavanaugh:
Oh my gosh, absolutely. Not to mention your family it's so hard, it's so hard. So I really try to tell people my main thing and I'll tell them, "I exercise for mental health." My family history terrifies me. But I also really like to be able to sit here and be like, "I do exercise five to seven days a week." I like to be able to say that and then-

Liz Rohr:
Because you get what's involved and you get the-

Meghan Kavanaugh:
Absolutely. And also too it's we're as healthcare workers, we have a certain knowledge base and I always love and respect people that are just like, "I don't understand." I call my collaborative MD for stuff that... she's always very reassuring and she's like, "Meg you know call me anytime." And it's like if I don't know something that's okay, but we can't assume that the patient knows what we know. We can't assume that they know that maybe fast food twice a day is not the best option, maybe sweet tea or a soda or even half and half tea is not the best option, that sometimes can be helpful. Because it's like well just because we know something doesn't mean... we can't assume that that patient understands it too or understand the impact.

Liz Rohr:
And I think even when we talk to patients too, if we start at the basics, essentials, most of the time that's going to include everybody. Versus if we start with not the basics we're going to miss those people. But then also the people who know all that stuff they're going to be like, "Oh no, I know." You know what I mean?

People are quick to correct you of, "Yeah. I got that." But if you're starting from that foundational place, you can see the person will typically volunteer where they're at in terms of their level. Do you know what I mean in those conversations too. Go ahead.

Meghan Kavanaugh:
I'm sorry I was going to say one more thing too about with medications, because especially with something I'll give the example of a GLP-1. So we know with those meds that we're going to see weight management and everything. So it's like what's your approach in communicating with that patient on how these medications work? So yes we can say, "Hey, when you take this weekly medication, it's supposed to help with weight loss, it's going to help your sugars," whatever your spiel is. But it's like let's try to put it into words of how it actually works. So what I'll say is, "Okay. So you're on this GLP-1." And I'll mention the name of whatever one it's going to be, whatever we decide on with the patient. And it's like, "These are intelligent medications. These are not old school grandmas glipizide from 30 years ago, these are intelligent meds. So you take this medicine-"

So let's say it's something that's worried about lows or they're wanting to do a CGM where they can see their patterns with what's going on. So it's like, "Okay. Well, you take this weekly injectable and you take it and it's in the background and it's just waiting on Megan's blood sugars to go up. It's just waiting for you to eat. So then you eat that little sausage biscuit in the morning, what's it going to do? It's going to come in, it's going to help. It's going to help the body release the right amount of insulin. Cover that a little bit, but not give you too much where you're going to have this drop.

So it's in the background, it's kind of waiting. It helps to decrease your appetite. It's going to help you feel fuller longer. But you know what, if you introduce foods and you eat something that's going to digest more slowly anyways as a baseline chicken strips and french fries, hamburgers, anything fatty, anything fried, any food that's going to slow down digestion anyway, you put this med on top of it you are going to experience some side effects that might come back up. So it's a good deterrent for not doing that."

Because they'll come in they're like, "I have reflux. I have nausea. I've been vomiting." But if they know in advance like, "Oh, you're right. Every time I eat whatever food I feel terrible, so I'm going to feel really bad with this medicine on top." So you kind of give those besides just like, "Okay, you might experience nausea, vomiting, diarrhea, constipation." Because people are just like, "Well, what does that mean?" There's going to be a side effect for aspirin or Tylenol-

Liz Rohr:
Totally.

Meghan Kavanaugh:
... but how can they take that into practical knowledge too?

Liz Rohr:
Totally. Totally.

Meghan Kavanaugh:
That's just a side.

Liz Rohr:
I love that. I love that so much. Oh my God.

Meghan Kavanaugh:
I could go on 1,000 tangents.

Liz Rohr:
Seriously, I could literally be sitting here all day.

Liz Rohr:
I want to touch on the class, so I was so grateful-

Meghan Kavanaugh:
Absolutely.

Liz Rohr:
... the way that you and I connected was I was talking about one of the things... So I have this diabetes hypertension CDK course and so I feel less equipped to answer. I have my own anecdotal stuff, but I'm in primary care and foundationally what I'm teaching is about pharmacology and all that stuff. The main complaint that people have is providers and when I kind of cast that question out to people, "What do you do to manage costs?" You blew up my DMs in the most beautiful way I was like, "Who is this amazing person?"

Meghan Kavanaugh:
Something I'm very passionate about.

Liz Rohr:
So I would love for you to share. There are so many ways to help people with costs, but what are your thoughts about that? And also we can, again, write down some more detail stuff.

Meghan Kavanaugh:
I'll send you links and everything.

Liz Rohr:
For people listening in the car and I don't want them to be like, "Oh God, I have to write this down."

Meghan Kavanaugh:
Oh yeah, no, no I'll send you a lot. So when I saw that in your was it Instagram stories you just presented that, I was like, "Oh my gosh, I got to blow her up."

Liz Rohr:
I'm here.

Meghan Kavanaugh:
Alert, alert, I have resources, so that is by far... You could have the best meds in the world, but if somebody can't afford them good job getting them from the pharmacy. We have the best meds that nobody can afford. That group of patients that are just in that little window, people who have these high deductible medication plans. So they might have insurance, but what if their family deductible is five to $6,000? So that's really, really difficult. And I know there are really good questions from your audience too, about gap coverage and everything from Medicare. Knowing formularies is super, super important for a lot of reasons, but also too it saves a lot of time for you and your staff, because then you're really hopefully trying to cut back on a lot of prior authorizations and time on the phone pharmacy and everything and decreases... or it helps increase access of medications.

So of course I was looking back on your stories. A lot of people did recommend the GoodRX, so good RX is good for certain things. But really name brand medications it doesn't take a lot off when you still have a med that can be retail $800. And it's a certain amount off, you're asking somebody potentially to pay two car notes worth of a medication for just one month. Even if you can afford that who really, really wants to do that. And then GoodRx too of course is not insurance. So if somebody does have that deductible, it doesn't hit deductible. So it doesn't help them in that aspect, except for if it makes something that's a generic even cheaper, that's really, really good. So all of these big major companies, or I'll say most of them and I don't work for any of them, I will blast names I don't care.

I don't get compensated by any of these companies, not that I would talking about patient assistance. But I would say out of all of them, the two that are easiest to work with for patient assistance programs is Nova Nordisk, which is Novolog, Fiasp is a faster acting insulin. Tresiba, Levemir, Ozempic, Victoza you can even get glucagon, you can get pen tips on these. There's two different things for Novo. So the Novo Nordisk patient assistance program, that is number one for patients without any insurance at all. So if somebody is just they have no insurance whatsoever and they meet income requirements and it takes a little bit of time by you or your staff to fill this out, within seven to 10 business days you get a yes or a no on it.

And if it's a yes if it's non-Medicare a year from that date that it's approved, they'll mail four months of medications at a time and you renew the application. Now before anybody's like, "Oh, what about the income requirement." I told Liz I'm on my husband's Mac and I don't know how to use it. Lets see it's below the 400% poverty level, so this is actually pretty generous, so this really hits that middle class, uninsured. For example, for a family of three it's income below 92,120. I think for a family of four it's below a 100,000, which that's the definition of middle. And then even family of two I think it's like 30 something thousand, I don't have those exact... they change them too, so they did change them for inflation, so that was great.

Liz Rohr:
Cool.

Meghan Kavanaugh:
So that is for uninsured patients. And I think this is still the case, if somebody did lose their health coverage because of COVID, they're eligible for even getting 90 days of their insulin for free for it too... while there's a gap in coverage, potentially. So this is great, somebody comes in they don't have any health insurance at all.

They do have programs when you talk about this like the federally funded, the FQHC, the 340B, they might still have a cost associated with that, but a very, very low cost compared to what it is retail. But you can get this, they can get thousands of dollars in medications for... it's tremendous. You talk about getting four pins of Ozempic, it's incredible. Anybody that's already been enrolled, I believe it is they still have to mail the medicine to the prescriber's office. Now for new applicants I think they just ship it straight to the patient. So it's four months at a time and the patient has to keep up with their refills, so they ask them for the refill... and then they send a refill request. So you just have to kind of stay on top of it.

So it's paperwork, you get patients like free medicines and free good quality medicines, they'll be your patient forever. The appreciation that people have from that is fantastic. So stick with the same application, this is also helpful for your Medicare patients too. Most of our Medicare patients are on a fixed income. And even if they have a supplement they might not have part good Part D coverage. Or if they're in the gap coverage, again, it's income eligible a few years ago is a little bit harder to get it. But again, it's not a no until it's a hard no and I would rather them take the time and bring us that tax return if they wanted us to submit it from our office or if they want to do it and it's not a no until it's a no. And you get good name brand meds, you don't have to go for the cheaper less effective options at the pharmacy, so that's one through Nova Nordisk.

The Lilly company is also a really good one, that was an easy one to do. Each one like Jardiance has a separate one for Jardiance and Synjardy, and then FARXIGA through AstraZeneca has one. These are the two main ones that I use, I found in my experience a little bit easier to use for the patient as well. So Lily is another one you can get Humalog through it, Basaglar and they don't Lantus more. Trulicity, and there's several more even.. keep this in mind for Lilly especially it's not just diabetes medications, so there's different tier beds and they list them. And on their application I believe it's based off of your income versus which group of medication it is for the cost.

Liz Rohr:
That makes sense.

Meghan Kavanaugh:
So there's a variable amount. So again, three to four months medication shipped to the patient, if they meet that income eligibility. So then Novo Nordisk, so let's say it's a situation that you have a patient with type one diabetes and they have a high deductible plan, so how much is cash insulin? Way too much, way, way too much. The Walmart release the ReliOn aspart, which is the generic Novolog, so that helps out a lot. But still if you want somebody to have good insulin, not having to do N&R and granted that's great for what they can be used for, but that's really going to be the last option for me.

Liz Rohr:
Which one is?

Meghan Kavanaugh:
N&R, NPH and regular.

Liz Rohr:
NPH and regular.

Meghan Kavanaugh:
So meaning they can go to Walmart and pay $25 and get a vial over the counter without a prescription, that's the last on the list. So Novo Nordisk you just Google it it's my99, 9-9. And that is a copay card that you print out, you can do it in office. And it's a mix and match for up to two different brands of insulin, not a GLP-1. So you can get Tresiba and Fiasp a box of each or a certain amount of vials of each for $99 a month. So considering the actual cash price on that of what the vial of instance like three, $330 per vial, and they can get three or four vials. I'm going off memory here, but I'll send you the applications for it for $99, so that's a fantastic program.

So that they can have commercial insurance and a high deductible plan, or they just don't have great coverage even with the copay cards. If it doesn't reduce enough off of it because you always want to utilize copay cards and stuff too, but it might only buy it down a certain... so that's another one. Then in our area too and I looked online because you can search by your area, and this is newer to me so I'm still learning about it. But the different programs available in the rural areas like the FQHC clinics and then the 340B clinics as well. So they use them for primary care and they have their pharmacies, some of these GLP-1s depending on which they get in stock, you can get Ozempic for $10 a box and the price just went up.

Liz Rohr:
What's retail price for Ozempic?

Meghan Kavanaugh:
800, $900.

Liz Rohr:
Okay. Just for context especially for newer

Meghan Kavanaugh:
Oh yeah, for context.

Liz Rohr:
$10. Whoo.

Meghan Kavanaugh:
Ozempic's great, but I don't know if I want to pay that much for it. The same thing with insulin and it just depends on the brand of what they have available in the pharmacy, the SGLT2 inhibitors depending on which one they have available and also the strength. So sometimes they might not have a max dose strength that, again, it's like between eight and $10 in my area, so it just depends. But all that information is online if you search for 340B or FQHC in your area to help refer those patients too, so those are my big ones. For sure. And then there's also so JANUVIA I think was supposed to go generic last year, didn't go generic. I've been working long enough to remember when it was.

Liz Rohr:
I did not know that, I didn't realize that. Wow.

Meghan Kavanaugh:
It was supposed to go generic, but I think it got pushed to maybe spring of next year. So don't quote me on that that's spring of 2023. So that will be a great option too, for a DPP4 inhibitor, not my go to for diabetes management, but a good option. And then also too unless this has changed recently the SGLT2, the STEGLATRO has a really great-

Liz Rohr:
Who?

Meghan Kavanaugh:
... copay card. STEGLATRO.

Liz Rohr:
I don't know.

Meghan Kavanaugh:
Not that one.

Liz Rohr:
Okay.

Meghan Kavanaugh:
And it also comes in a combination with extended-release Metformin called SEGLUROMET and there's a combination STEGLATRO with JANUVIA called STEGLUJAN. I think they make these names up just to make fun of us. So it has a really good copay card that buys it down to $0, then AstraZeneca. You have to know these little nuances, so you got to talk to your reps and be like, "Hey look, so Xigduo-" Just not assume anybody knows, so I should pretend like y'all don't know.

Liz Rohr:
Yeah. Yeah.

Meghan Kavanaugh:
Xigduo is FARXIGA and Metformin put together. So it comes in a 10/500, a 5/1000, a 10/1000, I think a 2.5/1000. At the first of this year unless it's changed if somebody has a high deductible, their copay card will buy down the 5/1000 Xigduo to $0. But if you do two of the 5/1000 and just spend 60 they might have an out of pocket. So you might not get the max effect of the medication if you can't get them on a full 10 milligram of the FARXIGA equivalent, but you can always max out the Metformin if that makes sense. So you could do a 5/1000 and then two of 500 Metformin extended release generic for real cheap and get that cost down to $0 and get a great, great med.

Liz Rohr:
It's so fancy and I just want to pause here and say I just want to normalize that it can.... I anticipate the people and what they're going to say and what they think too. And it just really demonstrates how frustrating insurance can be and the medical world can be. And number two is that I feel like my approach to... I can hear the new grads, my mentees being like, "What?"

But I feel like the thing is it's almost a dedicated project where it's instead of a continuing education course about whatever. It's taking aside that time of almost a continuing education course of what is on, but it's a whole thing. It's like what are the options and getting familiar with that, and then you can use it. And also I think one other thing especially in the lens of primary care, that can be bonkers crazy with patients who have more things than just diabetes is I just came up on Instagram.

Another account was talking about this about how they documented their time in their clinic to show to their leadership evidence of, "You know what, when I work five days a week I do this much overtime." Which was a negotiating tool for them to go to four 10 hour shifts. And so I feel like in the same lens, again, this is not really for brand new grad because you're just keeping your head above water. But if you think about documenting all of the time it takes to like you said do the great work of applying for these applications and all these other pieces. And you also have results about how it's helped your patients A1C go down. That's motivating for your clinic to allow you to either have more time to work on that, bring in a part-time staff member to help you be a diabetes liaison. We have community groups, we have-

Meghan Kavanaugh:
Absolutely.

Liz Rohr:
... diabetes educators. If you don't have that resource the way you get resources to support those moving parts is to document it, present a case and then you get more support. Either less clinic time for you to work on like more admin time for you, or a support staff member who's going to help be educated in all these pieces and then go forward from there. Which I know it's a lot to think about, again, not really for a new grad necessarily because you're just keeping your head of above water. But there are ways to do this in primary care, because I can just hear people being like, "There's no way I'm ever going to do that because that's so involved and there's so much time." But I just want to advocate for as you expand in your practice, we can do stuff like that because our clinics are also motivated they get at least in the FQHC setting, if you have an A1C of 9%, they're looking at the numbers of patients with A1C 15% or higher.

Meghan Kavanaugh:
Absolutely.

Liz Rohr:
It's again, we all care about patient care, but when it comes to the business of primary care they need to see return on investment. And so if you can document, if you have a way to do that. Anyway, that's just a very side note. I think that's a real barrier for people in terms of the is there's just so much to know and so much to do with it.

Meghan Kavanaugh:
Right. And also too I'm one of those it's just like if I can streamline something. If I can make my day easier, the patient's day easier, my MA. I'm not trying to add a 1,000 tasks to her back that she already has. Of course, we all filled a lot of phone calls, a lot of issues with pharmacy and whatever.

So just something as basic as this, so it doesn't sound like this big of a deal saves minutes, upon minutes, upon minutes, which are precious. So how our clinic works each patient room has a remote desktop, so we remote into the server and then that's how we do it. So I have in every single one of my patient rooms a folder saved on my desktop that has every single one of these forms already saved, pre-filled out with the prescriber information, the NPI number, everything, fax, contact information, whatever.

I update it every year when the new applications come out, because there'll be little things et they'll just change here and there. And it's like I'm talking to the patient and I'm like, "Oh, okay, well, cost is always an issue." And I'll tell you this too... if a Medicare patient comes in and I'm talking to them and they're like, "You know what, I can pay X, Y, and Z for my medications." Even if they say that it's like, why not try? Why not try to help them out to get rid of that copay. Because you know what happens is let's say if they're on an ELIQUIS, which is a high dollar med or something for RA, a high dollar med. Those high dollar meds are going to push them into that gap coverage sooner, which means they're going to be out that 25% out of pocket for those medications.

Why can't I do my part to help them stay out of the gap coverage to keep the coverage for the other meds, rent for that. But I have the little folder ready to go. I print it out. All I have to do is just put the Xig for the meds and all that stuff. And then you learned really quickly what you have to attach and it's on them to either take the application, complete it at home with their tax information, whatever. And I tell them, "It's not to get into your business. I don't care how much money you make. I just want you to have great meds at little to no cost if that's possible." So then it's like, "Okay. Just bring that back. We can have it on file." And then we fax it in and then seven to 10 business days they have it.
The day that that clicked in my head of, "Why didn't I think about this five years... I can just have this form already filled out with my NPI and my contact." And it saves so much time because I just print it out and my MA keeps up with it. I fill it out for the most part she'll help me. And then even things like the... Let's say you work with a population that would need something like the my99 one through Nova Nordisk. And by the way Lilly does have something it's called Lilly Cares I think. So it's more of a Humalog preferred, they have something very similar to it too. And again it's differentiating no insurance versus high deductible, so you get insurance.

So those my 99 ones, excuse me, those are like any other savings card that it has its own prescription BIN number, so it's not like you do one and make 20 copies of it. Sometimes if it's kind of a season I'm like, "Man, I'm really going through these a lot." I'll activate, print, activate a new one, print, activate a new one. And then in each room you have a few of them it's like, "Take this to the pharmacy and get thousands of dollars of insulin for $99." And they're like, "Oh, that's incredible." And you just do a few little prep things-

Liz Rohr:
So good.

Meghan Kavanaugh:
... and it doesn't have to be good this big whole ordeal.

Liz Rohr:
Absolutely. And I really feel like I love that-

Meghan Kavanaugh:
It's worth it.

Liz Rohr:
Yeah. I love that you have a process-oriented... I think the thing that saves me in primary care is I do the same thing, the same way every time, obviously customized for a patient but my process is the same. So I really love that and I really do want to stress that it really sounds like because I'm not even familiar with all of these things. My plan is I'm going to sit down, I'm going to read about them and I'm going to get my baseline understanding familiarity. And then I'm going to say, "Okay, what is my process to make this easier?" It's worth the time and of initial learning and then it will become more rote for people. I'm sorry. Go ahead.

Meghan Kavanaugh:
Oh, I was going to say one more thing about the GLP ones for the cost by far I find that that's the most difficult one to get at a good price if it's a deductible issue especially or if it's a cash pay, if they don't especially qualify for the free one based off of income. And I think we're going to talk if we have time about the newer medicines that are on the market, the new Mounjaro it's not on formulary yet. And that's a really, really great option that regardless of insurance coverage or deductible, when you talk to the reps and at least here and I'm assuming it would be the same nationally, you can get 90 days of a great new med a GLP-1 that's new on the market for $25.

Liz Rohr:
Wow.

Meghan Kavanaugh:
So it's like some of these newer meds when RYBELSUS first came out with insurance you could get it for $10 or 25 or something like that. And now once it was on formulary I had these patients on RYBELSUS and we had to figure out a plan B for that. But it's at least in the interim because you never know if that person gets a new job change or whatever. You still want to advocate for the best meds at the best price possible.

Liz Rohr:
I love that. Well, I do want to be mindful of time. I think a great closing place would be is even though I have a thousand more questions I could ask you right now. Whatever feels best for people, but what pearls do you have for primary care? Another way to think about that or look at that is what do you wish primary care providers knew, but either side of that coin of that question, whatever you want to share for pearls and practice and all that,

Meghan Kavanaugh:
There's several and I love primary care. I love primary care. I'm like go back to primary care. We love primary care. I'm not your primary care provider. Please go back to them. Again, if you're not seeing them for six months and your lipids are crazy and blood pressure up. Absolutely, I adjust meds and prescribe hyperlipidemic meds, but it's just please go back to primary, so thank you for what y'all do. Thank you. So one of the things that I would really make sure, especially this is getting back to the language of how we talk to people and everything. And I really feel like this has gotten better over time, but we have got to get away of thinking that insulin is a punishment. Insulin is not a punishment. Insulin is not a four letter word. It is not you're being a bad diabetic. Talking about saying non-compliant we don't say, "You're a diabetic."

No, no you have diabetes it's also like, "You have this." So no you're not brittle, you're not a bad diabetic if you need insulin. Again, it's the tool in the toolbox. So we don't want to use that even as a threat, "If in three months if you come back and your A1C is still elevated, I'm going to have to put you on insulin." So they might come see me and I'm like, "Let's do it today." It's not a punishment. It's a way that I can get you safe in a relatively quickly manner that's a variable amount, that can be adjusted based off of what your needs are that might not even be permanent. That's my favorite pastime is taking people off insulin, it's so much fun.

Liz Rohr:
So great, it really is, it's amazing.

Meghan Kavanaugh:
I keep people off meds, so I'm just an admin. So that's one thing is let's not use insulin as a punishment. I will say too and this is just my practice on when you're looking at the algorithms and everything. I was looking back at some of your old YouTube videos and I love that you referenced the AACE guidelines.

Liz Rohr:
I like AACE.

Meghan Kavanaugh:
I love AACE. Their algorithm is so pretty. We need to make sure that everybody has a link. It's so pretty. It's so beautifully done and it's-

Liz Rohr:
So easy to follow.

Meghan Kavanaugh:
Very easy to follow. So easy to follow. And one of the things-

Liz Rohr:
I'll put that down below this video too. People can link to it.

Meghan Kavanaugh:
There is also a way to get those laminated pocket size and I think you can get them from AACE I think, so that's really handy too.

Liz Rohr:
I'm going to look at that.

Meghan Kavanaugh:
So they're really small because there's also one for hypertension and hyperlipidemia, so I love the AACE guidelines. But when you look at it, obviously, with med management, there's a big part that says regardless of A1C control, if there's the ASCVD risk or CKD or heart failure, you have somebody on the SGLT2. I'm sorry for your NPs, that aren't quite as familiar. That's Jardiance, FARXIGA, STEGLATRO was just one we talked about earlier. Sometimes what happens is the patient might come in and maybe they're new to primary care or it's just somebody that's hit or miss. They might be on mid-range or maxed out Metformin and an old school like SIMPONI ARIA. We still have a lot that are on pioglitazone, like ACTOS, maybe it's a cost issue or something.

Liz Rohr:
Yeah. I was going to say that's one of the cheaper options SIMPONI ARIA  and that class.

Meghan Kavanaugh:
Oh yeah, for sure. So those are strong meds. Those are strong meds and they're not the newer more intuitive ones. But sometimes patients will come in they'll be like, "Well I was on Jardiance, but it didn't work for me. 'Okay. Well, what else happened at that time that Jardiance was prescribed?' Like oh well they took me off of Glipizide and ACTOS." If you have somebody on a max dose of a SIMPONI ARIA, that being as strong as it is stimulating that insulin production assuming that they still have beta cell function, that is hard to get off of.

You have to titrate slowly off of that. So if somebody comes in and you're like, "I'm going to add, add," but then you take away those sugars are going to go up, especially if you're titrating up the GLP-1. So if you have somebody on that's on glipizide extend release and they're on 20 milligrams a day total, sometimes that or even higher can be the equivalent. And this is just what we see clinically, not necessarily in literature. 20 to 30 units for some people of insulin, that's how strong it is.

Meghan Kavanaugh:
It's like, "Okay, well, you know what? Your A1C is a nine or an eight or whatever these meds aren't working let me take you off of them." Which that would be the goal while you're adding and titrating up on some other ones, but their sugars are going to for a lot of people go higher. So we want to think of that too as are you just adding on to therapy while decreasing slowly, really think about the mechanism action of these medications and how strong and how potent they are. Because yes you're going to get great results with this, SGLT2, GLP-1, but if you take away max doses of others at the same time you're not going to see much success on there too. And just another thing that this is what I try to think of... And I educate the patient too is I like my go-to of course is Metformin. Metformin. GLP-1, love a GLP-1 at first, especially if they're high.

Liz Rohr:
Yes.

Meghan Kavanaugh:
If I have somebody come in and we do a baseline UA when they come in and they're not on SGLT2. I know I need to put them on one, but if they already have three plus glucose in their urine, and you have the higher incidence adding a SGLT2 with the yeast infection or urinary tract infection. Do I want to add something at that point that can potentially precipitate it and increase it, knowing that I can add it later? So if somebody's coming in and they're real high what I'll do too... I don't want to start a med that gives them such a potential side effect or issue, that that puts a bad taste in their mouth and their brain is like-

Liz Rohr:
Can't do that.

Meghan Kavanaugh:
it's giving me yeast infections." It's like, "Well, your sugar was also average of 300 and you were drinking five sodas a day." Was it really the Jardiance? But if that happens, who wants to be on that again that gave them a terrible yeast infection. So I'll a lot of times will pull them down and then be like, "I want to add this med it has the CKD-" I don't say CKD, "But it has helped your kidneys, helped your heart, you have this, but I really don't want you to have X, Y, and Z happen." So let me pull you down and then I'll add it on later, so that's just another little pearl too.

Liz Rohr:
Love that.

Meghan Kavanaugh:
And then one more. Let's see, I had written down a few is with insulin. One of the questions when you were first talking, I think you had presented is there a max dose of insulin, which I know you did.

Liz Rohr:
Yes, that's a great question. I love that.

Meghan Kavanaugh:
So insulin, we're all taught in nursing school it's a critical med. So two people check off on it and all this, and you're in the hospital and you're checking off two units of Humulin R and I'm not disrespecting that at all. And then I have people on U-500 insulin that's five times concentrated and some 400 units per day. You still have the respectful fear, but you're trying to think too... Let's say you have the CGM data in front of you... think about what am I trying to fix? What am I trying to fix? If we say, "Hey, your A1C is a nine." But what if they come back and let's say they're not on the CGM.

They're like, "Well, my fastings are between 90 and 120." So is the answer to just keep increasing the basal insulin?" Now, number one, the answer might be changing the basal insulin, get out of the glargine and detemir and do more of a longer, long acting insulin like Tresiba 42 hour, it's fantastic, it's beautiful and it's more comfortable. But is that answer to just increased Baal? Because what's going to happen to the, so their just going to go lower. We have to remember that sorry my earpiece went out. I can't remember the percentage, most of an elevated A1C is due to post prandial surges. So you get the GLP-1 on board, but the answer is not just to increase, increase, increase, increase basal. At some point you need to be like, "Okay, you're at 0.5 units per kilo on this, that's too much it's time to add in a mealtime insulin."

Now a lot of facilities don't do sliding scales, we do obviously, we do heart ratios, sensitivity factors and stuff. And then we always want to say prevent the problem, don't just treat the problem. So if they're 90 here and you're like, "Okay. Well, how about this check two hours after you eat breakfast. And if you're 25 take three to five units or whatever the scale." What's going to pull them down. How do you prevent the 250? You're still not getting ahead of it. You want to get of everything, so that's when you need to really start to that prandial insulin. And then once they get on those higher doses start considering doing the concentrated insulins too.

Liz Rohr:
And just for people, I've just been head deep in all of this and so I'm like, "Yes, yes, yes." But I'm just thinking about some new grads who are like, "What?" For some of the parts I feel like that was very clear. Recently I'm getting more comfortable with the more concentrated long acting one. And so just to pull that piece out, you have Semglee, Basaglar, Lantus those are the brand names, those are not the generics. And then you've got Tresiba, again, I'm not affiliated with any pharmaceutical companies either. But Tresiba, it's basically the long, long acting insulin. And then you also have concentrated... certain medicines have certain concentrations that are higher. So like you're saying U-500, are you talking about regular U-500 or...

Meghan Kavanaugh:
Yes. So U-500 is its own kind of thing, it replaces basal and bolus. Let's say you have somebody on let's say like Lantus. LAntus burns, glargine burns-

Liz Rohr:
Oh really.

Meghan Kavanaugh:
... it's acidic. So that's not a very comfortable injection. And I always ask patients about that. Nobody loves to give themselves an injection anyway. I'm like, "Do you feel that? Does it burn?" They'll be like, "Oh my gosh, it burns so bad." It feels like a bee sting for a lot of people. So then you want to try to get somebody on a more comfortable injection, that's usually why I go the Tresiba route or for most people it's-

Meghan Kavanaugh:
So you have a large dose of Lantus. So if you dialed up that pen and it was 80 units and you squirt it out, it's like how much liquid comes out to be subq, so that's a lot. So At that point, if it's starting to get uncomfortable for them or if you're even considering having to do twice daily, long-acting insulin, that's when definitely I go for a Tresiba because it's on formularies for a lot. And then also Toujeo was a U-300. I don't know if you've-

Liz Rohr:
Yeah. Yeah. Yeah.

Meghan Kavanaugh:
So Toujeo is U-300, so the smaller pen has the equivalent of 450 units. The larger pen has 900. So 3 ml of the Tresiba U-200 has 600 units in it. So you do have to convert it the pharmacy. Safety, safety, safety, safety on this is just... So there's warnings on the hair dryer, don't take a bath while you're blow drying your hair.

Liz Rohr:
Yes.

Meghan Kavanaugh:
Somebody did it. Because there's also a Humalog U-200 and then there's a Lyumjev, which is a faster version of the Humalog a U-200. And on those there's these little like the yellow stickers it says do not draw out with a syringe. Because sometimes patients do run out of pen tips, the little twisty pen tips.

Liz Rohr:
Oh, I see. I see.

Meghan Kavanaugh:
This is converted down by volume, so you're not changing the unit, the pen changes the volume. So if they're on 80 of Tresiba and you put them on the U-200, if you compared it's going to look like 40 units of volume if that makes sense.

Liz Rohr:
Oh, that's so bad.

Meghan Kavanaugh:
So it's half of the volume because it's concentrated. So if they're like, "Oh, I ran out of pen tips." And they get a little insulin syringe and they're like, "Ooh, let me just pull this out." And they pull out 80, they're getting double, they're getting 160-

Liz Rohr:
Oh my goodness.

Meghan Kavanaugh:
... because it's by volume. So that's the safety part on that. They're fantastic I don't want that to scare people from not using it because it's such a more comfortable injection, they're not getting as much of that volume subq. And then total I'll touch on that U-500 a little bit. When our clinic first opened again the U-500 was on the market, but we had to convert it down by volume either in a TV syringe or an insulin syringe.

Liz Rohr:
Wow.

Meghan Kavanaugh:
But now the U-500 it's a teal pen. And I will say on their website and I double checked last night to make sure that the prescribing information is there, there are two or three great tables on the prescribing of this. So this is typically used whenever the total amount of insulin per day is 200 units or greater. So meaning if they're on 10 units or 20 units of Humalog a few times a day, plus a lot of basal insulin and it equals 200 or more. It's a great, great insulin to help with just reducing the amount of injections, because you can start at BID dosing. So you can go from potentially two Lantus per day if they're on a split regimen, and three meal time to two times per day. So you reduce six-

Liz Rohr:
So you get rid of the pre-fill and the long acting and just replace it with this one.

Meghan Kavanaugh:
Right.

Liz Rohr:
Cool.

Meghan Kavanaugh:
And it's not a mix insulin, so it's a U-500 it has a much longer duration, but then you can reconvert it, but there are really good tables on the prescribing of it. But what's scary is I did an example let me see if I can find it because then you are like, "Ooh." So I took it as because it's a straight conversion if their A1C is over eight and that's when you're like, "That's a lot of insulin." So if they're on a straight 200 unit per day and you want to start with an easier regimen of, and again they give you the dosing on it. So it's 60% in the morning, 40% at night to kind of start. 60% of 200 is a 120 units that you would dose that person at one time and then 80 in the evening. So you look at that and you're like...

Liz Rohr:
Okay.

Meghan Kavanaugh:
Oh wow. And I remember the first time I had to put my name on a prescription of that, I'm like, "Oh my gosh, please make sure I did this math right."

Liz Rohr:
Please.

Meghan Kavanaugh:
And it's right, it's to the T. So that too especially things like this you want to think of, if somebody's practicing in a rural area that they don't have access to endocrinology or they don't have... You need to know how to do this.

Liz Rohr:
Exactly. Exactly.

Meghan Kavanaugh:
But then they have that again really, really good tables. I have put screenshots on my phone and I have a saved photo album for it because they tell you, "Hey, if the average fasting is below or above this is the dose that you increase," and then by what percent, so they give it to you.

Liz Rohr:
Step by step. And I just want to pause and say, well, two things one is that most insulins are 100 per ml. The concentration is the 100 units per 1 ml. And so when you ever say U-200, U-300, U-500, it's just 500 units per ml, correct?

Meghan Kavanaugh:
Correct. Correct.

Liz Rohr:
And then something happens when you have more concentrated insulins, that it changes the pharmacokinetics both because of the volume and because of the concentration... Before I actually say anymore I want to normalize for students and newer grads and people just switching into primary care, this is advanced the diabetes management.

Meghan Kavanaugh:
Oh yeah. Sorry.

Liz Rohr:
That's okay. No, it's beautiful because it's not just new grads that are watching and listening and it's so helpful for me I love this. Unless you are a passionate diabetes person and also you have more years of practice, you're probably going to ease into this. The concentrated longer acting ones are just wonderful. And Humalog is U-500, that's the right name, I'm saying that right, correct?

Meghan Kavanaugh:
It's Humulin R U-500.

Liz Rohr:
Oh, Humulin R U-500.

Meghan Kavanaugh:
U-500. There is a Humalog U-200.

Liz Rohr:
Okay. Okay. It's like a shorter form but when you put it in that hyper-concentrated formula, the pharmacokinetics are different is that correct?

Meghan Kavanaugh:
Right. Because I was reading even about it too, because it's almost misleading because you look at it and it's like, "Okay. Humulin R." But it's just a concentrated. So is it a concentrated regular?

Liz Rohr:
Exactly.

Meghan Kavanaugh:
It's a long tail. I mean long, long tail on it that you can see.

Liz Rohr:
Yeah. That's really good to know. So I think for students, newer grads ask for help before you do that, once you have more practice-

Meghan Kavanaugh:
100%.

Liz Rohr:
... and/or you are really passionate about diabetes. It's beautiful, this is really, really helpful. Because again, I have many years of practice at this point and I'm like, "I'm interested in expanding more of my diabetes care." And it's such a good point you said about rural medicine because so many clinicians say, "I just can't get people to a specialist. What am I supposed to do?"

Meghan Kavanaugh:
Oh, absolutely.

Liz Rohr:
And I think safety first is that if you're a new grad, you're still a new grad even if you practice in rural medicine you probably still need support. And also you're probably going to expand your practice to a place that is really serving people to that maximum level of your license, but it's going to take a little bit of time. So all of this stuff is just so beautiful to share. Thank you so much.

Meghan Kavanaugh:
Oh yeah. Absolutely.

Liz Rohr:
I have so many other questions, but we'll wrap up this interview and perhaps there'll be a part two. But thank you so ,so much. Really appreciate it.

Meghan Kavanaugh:
Oh yeah. Thank you so much for having me. It was great. Love it.

Liz Rohr:
Great. Totally.