Dhiren Patel, PharmD, CECES, BC-ADM

Dhiren Patel, PharmD, CDE, BC-ADM, BCACP:

 I think what also is helpful and makes it real is seeing how you’ve put all of this that we’ve talked about today into practice. Dr Isaacs, I would love for you to walk us through a patient case. I know this is a patient case of yours, in which KC is a 76-year-old woman with type 2 diabetes. Provide us a little background on KC and then what you did with the patient. Obviously, not everything was done on the first visit, but walk us through where you picked this patient up and how you thought about it and how you were able to introduce diabetes technology for KC.

Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES: 

Yes. She’s a patient who has type 2 diabetes, who was using multiple daily injections of insulin. I introduced the options for her about continuous glucose monitoring and an insulin pump, and subsequently, she opted to start the Omnipod [system] with the Dexcom G6. We trained her, and the training was done virtually as well. That’s something we’ve been able to do, either in person or virtual training. However, I have been working with her, checking in with her, doing virtual appointments each week to continue to tweak the settings because I think when you start someone off from injections to a pump, you want to be conservative. You’d rather them running a little bit higher versus causing all this hypoglycemia. Thus, we started off a little more conservative and tried to home in on everything.

In this most recent report, she’s up to 60% time-in-target range, which is certainly getting closer to our goal of 70%. One of the things we figured out was that now she’s getting 68% of her insulin as basal, and typically we do try for more of a balance, closer to 50/50. It will depend a little on other agents and what the person is eating and everything. She is a little basal heavy, and we noticed that she was having some excursions after eating.

There was one unexplained one where she went up to like 400 [mg/dL], and this is where you have to talk to your patient, not just look at the report because it looked like, oh, she just didn’t bolus, right? But in talking to her, she said she went to a restaurant. She predicted, based on what she was eating, it was 35 g of carbohydrates. However, what we figured out probably happened was, we think her Diet Coke got substituted for a regular Coke because she bolused, she pre-bolused, and she still had this major excursion. Anyway, that was one example. But we did figure that probably her carb ratios needed to be tweaked a little, and so we did intensify those. Another thing we did was we reduced her glucose target because we figured she wasn’t getting enough correction insulin to bring her down when she was going high. Thus, we made those little changes and then we continued to work together, we will continue to do so until she hopefully gets to that 70% or beyond.

 Excellent. I always say to the patients the data don’t lie. Hence, it’s helpful to have those conversations, otherwise you wouldn’t have figured out that specific excursion. Dr Busch, what have some of your experiences been as you see patients coming back? Here was a patient case of KC, and obviously that time in range is excellent. What has your experience been as these patients are on insulin pumps and CGMs [continuous glucose monitors]?

They’re getting their report card. They could see their time in range and know their A1c [HbA2c glycated hemoglobin] even before they come back in, so it’s great positive feedback for the patient. They feel better, they’re not getting hypoglycemic, they can see that they’re in range and they have much better control of things. Own your diabetes. They are owning it. It’s not just every 3 months when they come and get a pat on the back, they can get the pat on the back every day from their own monitoring.

 Yes, absolutely. With that, I’d love any closing sound bites that each of you have as we think about diabetes technology. Today, we reviewed 3 of your big pillars, and there’s additional technology that’s still being introduced. We talked a little about continuous glucose monitors, insulin pens, as well as connected and smart insulin pens. Dr Isaacs, can we get some closing remarks from you on where we are from a diabetes technology standpoint?

Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES:

 Yes, we’re evolving. The whole point of this is it’s supposed to make everyone’s lives easier in terms of seeing what’s happening, making it easier for patients to be able to dose, to give themselves insulin. What I would encourage everyone to do is to attend programs like this. Try to stay up to date on what’s out there, so you can give your patients these options, so they know they have a choice. They don’t just have to use a regular insulin pen. They don’t have to use a regular glucose meter. They have all these options out there, and so they can make an informed choice and have the best quality of life they possibly can.

 I agree. We have terrific drugs available, but also these other monitoring technologies and everything Dr Isaacs talked about. It’s a fun time to practice diabetes as well. As you highlighted, if you have to have diabetes, this is the best time to have it versus what we had years ago. If we look back, and many of us in our careers have looked back, to think that we practiced with NPH [neutral protamine hagedorn], and regular insulin, and urine dipsticks, and we thought we were doing a good job then. Back then, we thought if we divorced the R [Humulin R insulin] from N [Humulin N insulin] at dinner and gave the N at bedtime as the basal. Going from there to the vast array of medications we have now—it’s pretty incredible. That’s why endocrinologists and anyone doing diabetology will always work because it’s too much fun. That’s our hobby, and we can’t wait for the new thing to come out.

 Absolutely. This has been an excellent discussion, and we hope you all found this information valuable. Thank you all for watching this 

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Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES, presents a case study of a patient with type 2 diabetes mellitus, an insulin pump, and a continuous glucose monitor.

Case Study: Insulin Pump for Patient With T2DM 

 I would love your thoughts on how diabetes technology has impacted this past year and a half. I know it hasn’t been easy for us, it hasn’t been easy for our patients, but I really think this diabetes technology allowed us to continue to provide care. When you look at other specialties and you see screenings that are down and routine care that was skipped during this COVID-19 pandemic, you could argue that diabetes in many cases didn’t skip a beat because we had the ability to remotely monitor our patients.

Thus, I would love to learn how you managed COVID-19. What worked, what didn’t work, and what does the new normal look like, if that is even a term now? Dr Busch, we’ll talk about you first. You have a very busy practice, a lot of patients. How did you use some of this diabetes technology to get you through the COVID-19 pandemic, and what is that looking like now as things start to reopen?

Patients were used to the remote monitoring with phone calls, either from us or from a certified educator. Fortunately, because our clinic was not attached to the hospital, patients felt more comfortable coming in versus thinking they’re going to walk in a hospital door and get COVID-19 walking in the entrance. Thus, we weren’t affected as much by that, other than the usual masks and everything else. However, the remote monitoring was extremely helpful, so you could still have continuous visits with your patients without much interruption and have that kind of a visit. Obviously, it was a lot nicer to see the patient in the office and have that personal touch, but that was a great segue. Some people wanted to continue that maybe for every other visit, especially with the educator, so a lot of that was remote with the educator. Obviously, you can’t take their blood pressure remotely. I still want to examine the patients, but it helped a great deal in terms of the monitoring and adjustments.

 What are you seeing now as there is some appetite for remote visits, where some patients still prefer that or they’re hesitant to come back in? What are you seeing now, are you seeing a hybrid model, or are you seeing back to what it was pre-pandemic?

 We have almost 99% back to where it was.

However, I think it is because we’re freestanding and not in a hospital setting, so I don’t know for sure. For my colleagues who work in a hospital, maybe patients are a little more gun-shy walking into a hospital. They think maybe a regular, freestanding office wasn’t touched by COVID-19 and only the hospital was because that’s where the inpatients are. But we’re back to normal, back to normal plus some.

Fascinating. Yes, we are very much a hybrid model, so we were doing virtual care before the pandemic. However, it exploded in terms of the volume. We found patients really like it for the convenience. Even ones who live nearby, just not having to take off work, and the convenience of doing an appointment over lunch. But we also have a number of people far away, in different states, who we’re taking care of. Thus, I would say the virtual care is going to continue to be a hybrid.

Also, with all of this technology, we have connected apps now as well. With the smart pens, with the insulin pumps, with the CGM [continuous glucose monitoring], almost all of them have the connected apps. Furthermore, it’s so much easier now to see the data, and that’s one of the reasons I like putting people on smart pens as well because they can send me the report, or I can log in and look at their report. It makes taking care of them virtually a very smooth process.

 Yes, I would agree. I think we took the best of both worlds. I’m more where you are, Dr Isaacs, where I think it’s going to be a hybrid model. Some patients don’t want to travel the distance. They are thinking, “Hey, this is good, I don’t have to take off a half a day to get the care that I wanted.” Thus, I think it has also helped overcome some of those barriers that we previously saw in receiving care. I think it’s great. I think this technology is going to continue to help patients, for ATPs [assistive technology professionals] and for us to be able to more effectively monitor our patients.

Experts in diabetes discuss the transition to telemedicine during the COVID-19 pandemic and its impact on diabetes care.

Advances in Telehealth for Diabetes Care

 There is one thing I wanted to talk about. I know I’ve had a front row seat to this both on the professional practice side but also on the personal side. As I mentioned, I have a father who has type 2 diabetes who utilizes this technology. Sometimes we’re very hyperfocused on what the clinical trial showed, but I would love to hear some of the warm and fuzzy stories that you’ve heard and seen of how this has improved diabetes management for some of your patients.

I always say I’ve gotten probably the most hugs from my patients for this technology that’s really changed their lives. I’ve seen my father go low while driving, and he takes care of 2 of my kids. Thus, knowing that I can follow his information and that there’s this sense of security, I’m sure you each have hundreds of stories you can probably think of. Maybe globally or to a specific patient, what have you seen on some of the softer metrics, the quality of life, the satisfaction for your patients, as they wear this CGM [continuous glucose monitoring] technology? Dr Busch, we’ll start with you.

That’s a good point. We get a lot more hugs from this, because first of all, it takes away the discomfort of finger sticks. Even though they’re not horribly painful, to take that away is a big game changer, to have the alarms and notify the patient when they are going low. Sometimes the relatives are listening to the high alarm to improve the way that the patient is eating. It’s a great guide. They don’t get an electric shock, but it’s the same kind of thing. It’s Pavlov’s dog, telling them exactly what they should be doing and avoiding some other things like that. Thus, between the right drugs that don’t give you hypoglycemia, and the right monitoring, that even on insulin you don’t get as much hypoglycemia and you get it to control, and you get people whose A1cs [HbA1c glycated hemoglobin levels] are the best they’ve even been without hypoglycemia in between. As a result, it is a major game changer.

Yes. I always say we work with the warm fuzzies because patients are thanking me. They’re so grateful for me starting them on CGM, and I’m fortunate to start lots and lots of people. One story that sticks out from recently is a woman came in with her mother. Her mother was around 75 years old and was struggling with the finger sticks, and she was on multiple injections of insulin. She was worried about her mother going low, and so I started her on real-time CGM, and there’s the mobile app where her daughter could see her readings because they weren’t living together. That gave her daughter so much peace of mind, as well as the mother was now alerted to when she was going low or about to reach low, so they were so grateful. I would say it definitely improved quality of life for both of them.

Those are excellent stories. Like I said, I have a lot that I could probably think of. I see it every day, and I know how beneficial it is. Even some of these features that we may take for granted, such as being able to share these readings or follow someone else’s reading. You think of use cases where someone is going off to college, or an adolescent where a school nurse can also monitor, or a caregiver. Also, you know more and more patients want to age more independently at home. Thus, we still have ways that patients could do this, but you’re not constantly stressed and worried about what’s happening with your loved one. Dr Isaacs, maybe you could talk to us a little about the options out there. I know it’s not as crazy as SGLT2s [sodium-glucose cotransporter-2 inhibitors] and GLP-1s [glucagon-like peptide-1 agonists] where now we have 5 or 6 in a class, but we do have some options here. How do you think of these options, and how do you make sure the right technology goes with the right patient?

 Yes. We have 4 key companies, key options. There’s the FreeStyle Libre, the intermittently scanned CGM, and we have the original 14-day [system] and then the Libre 2. Those are intermittently scanned, so they do require a person to scan to be able to see their glucose readings. But a big difference with the Libre 2 compared to the original 14-day is that there are real-time alerts. The 14-day has a mobile app and the Libre 2 does not, which is one of the reasons some people will continue to use the original 14-day. We also have Dexcom G6, and that is real-time CGM. It does have a mobile app, and it’s a 10-day wear for the sensor compared to Libre, which is a 14-day wear. Another difference is Libre has a disposable transmitter, so everything comes together. Dexcom has a separate transmitter that is reused for 3 months.

We also have Medtronic, the Guardian 3, which goes with their insulin pump, as well as the Guardian Connect, which is a standalone CGM. That is a 7-day sensor wear. It’s also a reusable transmitter that’s good for beyond a year, but it does need to be charged in between use. Then, lastly there’s Eversense, which is the only implantable CGM. It requires an in-office procedure. It’s a 3-month wear, where the sensor is placed in the upper arm for 3 months. There is still an outer transmitter that is taped on over it and does need to be charged, but that sensor you don’t have to worry about inserting it. In the future, it’s expected that there would be a 6-month wear time for that. One key difference between them is in terms of calibrations, like required finger sticks. Both Libre and Dexcom do not require calibrations. Eversense and the Guardian sensors do require 2 or more calibrations per day. Thus, that in a nutshell are the different devices.

That makes sense, and I think the same way that we go through our mental checklist for pharmacotherapy, the same is true here when we talk about technology. There are certain features that may lend itself better because it’s an ecosystem play versus calibration, where this may be something you opt for because there’s an additional integrated benefit that you’re getting. Hence, I think each of them certainly has its place, and the right patient should get the right technology.

Dhiren Patel, PharmD, CDE, BC-ADM, BCACP; Robert Busch, MD; and Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES, provide insight into quality-of-life improvements that have followed advances in diabetes technology and review available continuous glucose monitors.  

Impact of Technology on Diabetes and Quality of Life 

When we think about metrics associated with diabetes care, we tend to think about A1c [HbA1c glycated hemoglobin]. I know we’re all out there telling folks to be mindful of comorbid conditions, and we shouldn’t live and die by the A1c. When we think about CGMs [continuous glucose monitors], we have other terminology that gets introduced. How have you talked to your peers, primary care providers you work with, in explaining to them time in range, coefficient of variation? Sometimes everyone associates technology with being more complicated but it’s not necessarily more complicated; we’re just now dealing with different metrics and different ways to look at it.

 We talk about variability and how the patient with an A1c could be having a good A1c. You could have 300s average with 50s [mg/dL], so your A1c looks good; you have variability like that or smooth control. Obviously, the smooth control is a lot better for the patient and probably has less vascular disease by doing that versus significant peaks and valleys. The other thing is that time in target, you become like a seer with the patient to predict what their A1c is when you look at their time in target. As we know, if your time in target of 70 to 180 [mg/dL] is 70% or more, your A1c is going to be below 7%. Hence, it’s very nice to predict even before you make the phone call for their A1c, what their A1c is going to be.

It’s almost like when you put someone on a statin and you know what the statin efficacy is, you can predict what their LDL [low-density lipoprotein] will be based on what you know. Time in target, most people can understand that, and they can understand variability. Some people use the analogy of if you’re on a plane, would you like the plane to go smooth, or would you like to go up and down? You can still get to your destination the same way.

Yes, that’s a great analogy that I might tuck away for later. Dr Isaacs, what are your thoughts on this? I tell folks you read a couple AGP [ambulatory glucose profile] reports, and you get them under your belt. They’re very visual, color coordinated, and then everyone has their own nuances about where they would like to go and view and drill down into. However, overall, it’s very easy to use. How have you talked to your peers regarding not just the AGP reports but time in range, the coefficient of variation?

 I think there are so many limitations to A1c, and the big one is that it doesn’t tell us anything about glucose variability. Thus, that’s where time spent in that target range as well as the other CGM key metrics come in, where there’s one for glucose variability, that coefficient of variation. I think people are busy. We don’t have time to be sifting through 20 pages of data.

 You could if you really wanted to, but there’s no need for that. Thus, we have the AGP report, which is 1 page and it has everything, and this has been standardized by the international consensus on time in range. At the top of the report, you have your CGM key metrics like time in range, the percentage of time the CGM was worn, as well as that coefficient of variation. Then, in the middle of that report you have that AGP itself, which is that nice visualization where you can see, are there certain times of the day where the person may be spiking higher or experiencing hypoglycemia? Then, at the bottom of that report has those last 14 days, so you can see those day-by-day variations. Consequently, that has everything and yes, I agree, once you’ve looked at a few of them, you become very comfortable and can do it very quickly and efficiently.

Robert Busch, MD, and Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES, discuss metrics to evaluate diabetes control, including time in range and coefficient of variation.

Improved Metrics for Evaluating Glucose Control in Diabetes 

 We’ve talked about insulin pens, insulin pumps, and a couple of different ways insulin can be delivered. However, continuous glucose monitors [CGMs] have revolutionized the field, and we’ve seen quite a bit of uptake not only from primary care providers but also from patients. I know this is something that comes up a lot in conversations, especially with some of my patients, where they tend to bring in a magazine clipping and say, “Hey, I want to go on this,” or they’ve seen a commercial that says, “I don’t want to check my blood sugars anymore.” Let’s talk about some of these challenges of self-monitoring blood glucose and the stories that you’re hearing from your patients. Also, how do you think the use of CGMs can help our patients with type 1 diabetes? I don’t want to discount the impact of this technology in that cohort, but a lot of it has been available to them early and its slowly making its way to our patients with type 2 diabetes as well. Dr Busch, you’ve seen that progression from when you were doing the urine [tests], but let’s pick up from the self-monitoring to the CGM technology.

That also has been a major game changer. The dietary compliance…“Please eat this, not that,” and the patient sees what they think is the same caloric load but very different glycemic excursions. The great part is you can download it in front of the patient and tell them, “This is your conscience. We can spy on you.” Not only can we check what meds they fill from [other providers], but [we can also say], “These are your readings. What happened this day?” Also, for the patient that tells me they are adjusting their basal between the 90 to 110 range, I can see their average is 130 and they have no lows in between. To be able to look at that with the patient there is incredible.

The major problem we have is the coverage because, in general, for type 2 [diabetics], at least in New York, they have to be testing 3 or 4 times a day and taking 4 doses of insulin a day. You almost want to give someone a prescription for Humalog so they can be testing or taking insulin 4 times a day, just so they could afford the CGM. Sometimes CGM is covered on plans, but other people are willing to pay out of pocket to do it.

Putting the Freestyle Libre [sensor] on is easy enough for the doctor to do—even I can do that and incorporate it in the visit. Then, the 2-week follow-up is with my educator, so they get to see the readings, take the [sensor] off for the first time and review it with the patient. It’s a real eye-opener.

Absolutely. The ease of use—you would think that technology is going to be complicated for patients to do. I deal with a geriatric population, and I tell them, “If you can put on a Band-Aid, you can put on a sensor”. It’s very easy. Dr Isaacs, can you talk about the role of CGM in patients with type 1 and type 2 [diabetes] and how it impacts disease management? Recently, CMS [Centers for Medicare and Medicaid Services] came down and there were a few wins there, so we know coverage seems to be pretty good.

 Yes. Every person with type 1 diabetes should have access to CGM, there’s no question about it. Fortunately, we’ve seen coverage to be pretty good with people with type 1 diabetes. With type 2 diabetes or anyone who’s taking multiple injections of insulin, or even a basal insulin, there’s no question, [they should also have access to CGM]. Recently, the MOBILE study came out and showed the benefits in people with type 2 diabetes just taking basal insulin. More and more studies are showing benefits of CGM for people with type 2 diabetes, just like we see in the real world. Certainly, anyone that’s on any medication that could cause hypoglycemia, like a secretagogue or insulin, [should have access to CGM]. Guidelines are advocating for that, too. If you look at the ADA [American Diabetes Association] standards of care, [specifically concerning] their recommendations for CGM, they keep type 1 and type 2 diabetes together because they’re trying to say that people with diabetes benefit from CGM. It’s not separating out type 1 vs type 2. AACE [American Association of Clinical Endocrinology] also recently put out a guideline with technology and advocates for the type 2 population. You also mentioned CMS, and yes, that was a big win that they finally removed that 4-times finger stick.

 Which was kind of crazy because it was like people had to earn their right to CGM, and they would only get coverage for 3 finger sticks a day, but somehow they had to do 4 to earn their CGM. Hopefully we will continue to see coverage expand. Ideally, we would also get rid of the recommendations for having to be on all these injections, because people benefit from seeing their data, they learn in the moment.

Another thing, too, is the arrows. If someone checks their glucose before they go to bed and it’s 150, they may say, “OK, it’s safe to go to sleep.” But what if it’s 150, double arrows going down, and they’re dropping? A CGM can tell them that, or it can alert them in the middle of the night. With regular blood glucose monitoring, what are they going to do? They’re going to wake up in a sweat, if they do wake up. That’s scary, so, for sure, there are so many benefits to CGM.

 Yes, absolutely. As the body of evidence continues to grow, payer coverage is going to improve. Usually when CMS makes a change, a lot of folks point to it for good or for bad, but hopefully we’ll see a trickle-down effect.

A panel of experts discuss the impact of continuous glucose monitoring (CGM) on individualized patient care plans for patients with type 1 and type 2 diabetes.

Continuous Glucose Monitors in Type 1 and Type 2 Diabetes

 Diana, I know you do a lot of the nitty-gritty with the pumps. Dr Busch, you recommend it and you have a team that helps you make sure all the settings are correct on it. If each of you could talk to me about when you recommend an insulin pump, some of the benefits that you’ve seen, and how you work through that process as you see a patient. Dr Busch, we’ll start with you, then we’ll go to Dr Isaacs.

 Yes. [For example, say] my patient is on basal insulin and they tune up the basal to the fasting sugar. If they’re bottoming out before lunch or dinner and you see that’s not their rapid acting that they’re taking at mealtime, but the basal is too much during the day because of their activity, even though it was fine overnight—that’s someone who wants a variable basal and that’s where I’d recommend the pump. For someone who’s on multiple bolus doses and forgets to take their insulin with them to work, there’s the convenience of having the pump. Of course, you must get over that you’re wearing something, and some people don’t want to do that. But [this is] where you need a variable basal, [and to make sure] that your basal isn’t fixed to the morning reading. Also, if you’re bottoming out at lunch or dinner, or high pre-lunch to high pre-dinner and you need higher basal, how do you do that if you’re tuning up your basal to the fasting sugar?

Unfortunately,the reality is a lot of people with type 2 diabetes end up progressing to multiple daily injections. Of course, we try to optimize their SGLT-2 [sodium-glucose cotransporter-2] inhibitors and GLP-1 [glucagonlike peptide-1] agonists, but people are developing type 2 diabetes earlier in life. When you’ve had it for 40 years or 50 years, it’s not surprising that eventually insulin may be needed to achieve those glucose targets. For me, any person that is requiring multiple injections a day can be a candidate for insulin pump therapy. I find there’s a lot of misconceptions about a pump. People think, “Oh, that means you have the bad kind of diabetes,” or, “It must be serious,” and, “I failed at my diabetes management.” None of those things are true. It is just another method to deliver insulin, and often a much more convenient method. We’ve got pumps that have tubing. We also have pumps that don’t have tubing. It’s a convenient way to deliver insulin, so it’s something I share with my patients, and many people with type 2 diabetes are eligible through insurance coverage to be able to utilize [a] pump.

 Absolutely. Sometimes we paint everything with a broad stroke when we think about who those candidates are, but also when we talk about the category of insulin pumps. Dr Isaacs, while you have the mic, can you walk us through some of the options that are available from the more common manufacturers and how you filter through them for your patients?

Yes. We currently have 3 companies that have FDA-approved products, starting with Omnipod, which is a tubeless pump. A lot of people like that feature. It does hold a bit less insulin than the other 2 options, it holds 200 units instead of 300 [units], so that can sometimes be an issue for people who are on higher doses, but the tubeless feature makes it convenient. What’s exciting is that the Omnipod 5 is in the pipeline, which will have integration with Dexcom G6 to automate insulin delivery. We’re expecting that to become available in the second half of 2021.

We also have Medtronic. With Medtronic, the 630G is FDA approved for type 2 diabetes and that does integrate with their Medtronic Guardian Sensor to be able to suspend insulin delivery if someone is predicted to go below their low threshold. We also have other hybrid closed loop pump options with Medtronic, the 670G and the 770G, and those are FDA approved for type 1 diabetes. However, we know many times, in the real world, these are used off-label in people with type 2 diabetes that still experience a lot of benefit. And what’s in the pipeline for Medtronic is the 780G, which is approved in Europe and is a more sophisticated algorithm. It’s going to have an updated sensor, the Guardian 4, which will be more efficient and not have all those calibration requirements, so that’s exciting.

The final player we have is Tandem. The Tandem [t:slim] X2 [insulin pump] integrates with Dexcom G6. There is Basal-IQ [technology] where insulin is suspended if it’s predicted to go below 80, and then Control-IQ [technology], which is a hybrid closed loop that regulates insulin delivery and gives automatic correction doses every hour as needed to achieve the glucose targets. This is an exciting area and it’s continuing to rapidly evolve, but those are our current options and things that I like to share and go through with my patients.

 That’s excellent. Dr Busch, Diana just did a fabulous job of [describing] what our options are. When you step back and look at the big picture as we talk about automated insulin delivery and some other things, what excites you the most? What’s possible here for your patients as we think about this connectivity? Yes, you’ve been using insulin pumps for quite some time, but you’re now starting to see some of these integrations and interconnectivity that Diana mentioned. How does that affect the care that you provide?

 It’s customizing the care so the patient can own their diabetes. I know Diana and others are doing basal bolus pumps and connective pumps—that’s the term they tend to use—and I like that you can customize it or do precision diabetes management. I’m spoiled, so I get to work with someone like Diana, but she knows all that stuff while I’m busy with the cardiovascular outcome studies, the renal outcome studies, and that kind of stuff. I’m doing the rest of their diabetes, but my pump specialist keeps track of all those options, and we share the patients. I might see the patients every 6 months, she sees the patients every 6 months, so they’re being seen every 3 months, but they have the expertise of the pump [specialist] who knows all that [information], and then I’m doing their lipids, their blood pressure, and [handling] the other noninsulin drugs on top of what they’re on. It works out.

 We’re all fortunate to be in multidisciplinary practices where we have resources and we can share some of the work because it’s not easy. I always say it takes a village to take care of a patient with diabetes, so we’re all fortunate that we have a lot of different folks that can help on the care team.

Robert Busch, MD, and Diana Issacs, PharmD, BCPS, BCACP, BC-ADM, CDCES, provide insight into the use of insulin pumps in type 2 diabetes and describe currently available smart pumps. 