You know, Paul, I heard the police arrested the world tongue twister champion. Oh god, it's going. Tell me more. I bet they're going to give him a really tough sentence. [Music] All right, that's that's okay. My delivery sucks. I got to work on this. No, don't blame the delivery. The Curbsiders podcast is for entertainment, education and information purposes only and the topics discussed should not be used solely to diagnose, treat, cure, or prevent any diseases or conditions. Furthermore, the views and statements expressed on this podcast are solely those of those hosts and should not be interpreted. Perfect official policy or position of any entity aside from possibly cash like more or possible and affiliate outreach programs if indeed there are any. In fact, there are none. Pretty much we are responsible if you screw up. You should always do your own homework and let us know when we're wrong. Welcome back to the curbsiders. I'm Dr. Matthew Frank here with my great friend and pun hater Dr. Paul Nelson Williams. Paul. Yeah. Hi Matt. Yeah. I don't know. I tried I tried a Demorara sugar pun at a previous episode and it did not go over well. So I have given up on puns for the short term. Yeah. Most of the candy puns when I looked them up too were mint puns which I I used like three on one episode. So I burned through all those. I I should mention that Paul, you are America's PCP. And on this episode, we have a fantastic endocrinologist and your nemesis, Dr. Jeff Coburn, talking about diabetes in special populations. We we go through a couple different cases. We'll tell you about those in a second. Paul, before you introduce our co-host, would you please tell people what is it that we do on Curbsiders? Sure, Matt. As a reminder, we are the internal medicine podcast. We use expert interviews to bring you clinical pearls and practice changing knowledge. As you alluded to and as our astute listeners may have noted, we are joined by a third co-host. We are joined by PA extraordinaire, uh, Isabelle Valdez. How are you, Isabelle? I'm doing great and it's always good to see you guys. Isabelle, it's always great to see you. And, uh, this is another diabetes episode. You've produced several and, uh, I'm glad you're like me. We both we both love diabetes talking about it, learning about it, and this this guest Jeff is is one of the best. So, can you tell us about him and what we talked about? Yeah, we had a really great talk with uh with our favorite endocrinologist, Dr. Jeff Goldberg, who uh he's been our go-to endocrinologist since our very first curbs episode in February, February 17th, 2016. That was not a diabetes uh topic. It was actually um I think it was testosterone replacement therapy. But still we love him for all the work that he does. And I think some of the takehomes that I got is in a nutshell GLP's for the win, uh CGM for the win, but above all insulin for the win in these populations that we're going to see. Dr. Coburn is an academic endocrinologist who is working for the US Department of Veteran Affairs in Virginia. He is an adjunct associate professor for the Virginia Commonwealth University and a nature enthusiast. He has interest in thyroid ultrasounds and bio biopsies and diabetes as we all see tonight. And of course, he also tries to uh include his patients with shared decision- making and leveraging technology to improve and simplify not just the the physician experience but most of all the patients experience. So we had a great talk with him. We had a lot to talk about tonight. So and Isabelle these cases were based in reality. Yes. Yes. Yes. Yes. So uh as we always do we take patient information very very seriously. So everything that we discussed today patients health information has been protected. So we followed HIPPO guidelines. But these are cases that we actually saw in clinic in uh internal medicine. So they inspired these cases. So I think everyone will really enjoy them. Yeah. So we talk about diabetes in an older adult. We talk about gestational diabetes and we talk about uh steroid induced diabetes. So all common things that we see. All right. And a reminder that this and most episodes are available for CME for all health professionals through VCU at curbsiders.vualth.org. Jeff, my good friend and Paul's nemesis. Welcome back. Oh yeah. Thank you. Appreciate it. And it's been a while since we talked. I think last time maybe there was some rock climbing, maybe some swimming, but what are you up to these days? What's a hobby or interest that you're enjoying? So, there's always something active with the kids and usually something outdoors. So, kayaking is the new um interest I have. So, I have four now. One for me, one for the two kids, and one for my wife Juan. And uh the one I have for myself is big, big enough that it can like float 700 lb. So, I sit on it, both kids get on it, and I have both of my dogs on it. And um one is a golden retriever and the other one is like a little six-pound Maltese. So, just imagine going down the local state park like river uh you know, crazy guy with his big round hat and two kids and two dogs. And they pretend that we're a pirate ship. So when other people kayakers are coming along, you know, we're letting them enjoy their peaceful nature time by yelling y and we're we're going to board your ship and with two dogs. I think we're going to need that for the uh social media. Yeah, I think that would make I think that would make probably some good pictures. Um but yeah, that uh it's entertaining I think to the public and uh we're getting exercise and that's good. And now knowing Juan, I could see this. Is she amused by this or is she like kayaking by herself so she can deny that she knows you? Uh she, you know, not with us as often. Sometimes, you know, when we go kaying, I bring a little tow rope and, you know, I get to be the the power for the families. So, but yeah, it's usually me and the kids bothering the public. That sounds that sounds lovely. Well, I'm glad you're enjoying, you know, you moved semi-reently. I'm glad you're enjoying the the new location. Yeah, Virginia is fun. I like it. All right. Well, we have a lot to talk about as always. So, Isabelle, would you start us off with a case from Cashlac? Sure. Uh, we've got Manny, who is a 78-year-old veteran with type 2 diabetes of that was diagnosed 15 years ago, has hypertension and mild cognitive impairment who is brought in by his family for follow-up after an ER visit for a fall. EMS clocked his random glucose at 72 millig mill milligrams per deciliter when they found him and they took him to the ER where his blood pressure was 145 over 63 and just some quick labs that were done. His GFR was 53 and his hemoglobin A1C was 6.3. His daughter and son-in-law managed his medications and noticed that he doesn't always take take them as directed when he's left alone at the at the house. Currently he's on metformin, glamearide, empigloin, loartin tovastatin and tamsyloin. So on first impression, I mean I this is this is like my everyday at least once a day I'll get a patient like Manny. What's your first at first glance what's what do you want to do with him? What's your approach with him? Yeah, so you know the very first things I start to think about because you know usually these um older adults are already on you know they've already been diagnosed. Um you know type 1 and type two diabetes are most common forms of diabetes. You know, whenever we're treating diabetes, we want to be thoughtful about what is the type we're treating. In this instance, most of our older adults, they've had, if they've had type two, have had it long enough that they're often requiring some insulin because the beta cells, they do lose their function across time. So, I think we often understand type two diabetes as resistance. But farther into the course of that disease, the insulin production is lost. And so, many of these individuals are end up on that. This individual is not. So we have to just be aware of the fact that you know we might need to involve that agent. Um so type of diabetes first. Second is going to be goals of therapy. Um so your A1C target comes to mind first. I always think about the ABCs. What's your A1C? Blood pressure and cholesterol targets. So for A1C for older adults uh all of the guideline writing agencies want us to think about relaxing where the A1C is to try to prevent the burden of polyfarm pharmacy to prevent the risk of hypoglycemia are the big ones for patients. Uh and these individuals um they often don't detect hypoglycemia well because of cognitive dysfunction. They can't they're not in tune with how their body is doing. uh they may not be as engaged with testing their blood sugar to know that they're low and then their ability to start a treatment may be may be lesser uh and then they have more risk to fall and to have injuries like fractures. So right up front I'm thinking about those areas um for for my patient. I think the misconception here that I've encountered is some people just they're they're hesitant because they're they're happy that the number is lower maybe that it's been in the past. Yeah. I don't I don't know, Jeff, if you have a way to diffuse that with like the families coming in high-fiving that, you know, their their 78-year-old multimorbid uh parent has like an A1C of less than 6.5. Yeah. They've been beaten over the head for years to get it less than seven and it's finally there. And so the family and them are so happy. And then when you tell them that that's not actually quite good, it it's so confusing. And I can't tell you. Yeah. every day almost in clinic I see someone who they're scratching their head and like doc do you know what you're talking about I I think the thing that helps them hear that we need to make changes is they often know that high blood sugar damages the body but many many have not heard that low blood sugar causes damage and probably the two main things I bring up for damage is one it actually worsens cognition quite a bit so when you look at studies of recurrent hypoglycemia that has a big impact on loss of cognitive function. Um, and so that's the thing this patient's struggling with and that everyone's really afraid of, rightfully so, because once that goes, your self care independence all disintegrates. And so, everybody knows to protect that. And then the second one is falls. Um, and I tell them I'm very worried about that particularly, you know, I have patients that, and I always ask this specifically in my clinic. I say, you know, where is your test supplies? And, you know, what floor of the house do you live on? A lot of times it's the second floor. And I'll ask them, you know, if you're low in the middle of the night, what are you doing? Well, I'm walking downstairs to get something from the fridge. No, see, keep some glucose tablets by the bedside. So, those are some early things I try to discuss. Yeah. Actually, for my patients, I make the family, the caregivers get like a small sugar packets. In fact, the gel caps or the or the tablets. Uh I said, I want one in every room. I want one in bathroom. I want one by the toilet, by the sink. Uh he may he or she may come out of the shower not feeling well. You just never know when it's going to happen. So, you just have them all over the house. Yeah. I like to use the like you'd mentioned the glucose tabs because no one's snacking on those. They don't taste very good because it's just glucose. Sweet tasting things are more like sucrose and you know all the other oses, manos, moltos, fructose, but um like you'd already mentioned uh sugar packets. So, if you go to a diner and get the white sugar packets, not the other colors cuz those are fake sugar, but the white ones, um you actually have to eat four of those to get the um 15 grams of glucose that you need to start elevating the blood sugar. So, yeah, that's I think surprising to most people that you have to consume four of those. So, this is this is our rule of 15 that you taught us on our fanny pack episode, Jeff. It's the you got to carry a fanny pack with glucose tablets and it's uh so 15 grams every 15 minutes. Uh you're going to keep checking the blood sugar every 15 minutes until it rises and if it doesn't rise they they got to go to the ER. Okay. So we're we're talking about this person here. They're on three medications. What medications are you looking out for? Because like if someone's on just metformin and the A1C is 6%. Maybe maybe that's good and actually maybe they should be celebrating that. Uh but for some for this person what would make you think differently? Yeah. So um I think you said it very well. It's not just the A1C we've achieved but it's how we've achieved it. So if you can achieve an A1C less than seven and you're only on agents like maybe metformin and uh maybe epiglyloin is is often a second line. We can talk about some areas that older adults you know increased urination might not be great for them. I reiterate the epigly if they're taking it should be taken towards the morning so the urination is not happening overnight. But those agents are low risk to cause hypoglycemia and so if they're achieving a less than seven with those two agents I'd be happy with that. Um but in our this individual is taking a sophonya glamipperide which is a ATP sensitive potassium channel uh it overrides that. So just to I don't want to nerd out too much but the beta cell it it senses glucose by breaking it down and metabolizing it eventually into ATP and that ATP energy molecule causes the potassium channel to eject the potassium. So the beta cell now has a change in its charge and it will allow calcium to come in to re bring a positive charge in and then insulin gets released. And so this is actually bypass that glucose sensation sensing step that then goes into the metabolism to open the potassium channel. It just opens a potassium channel. And so because the glucose is not being um sensed by the beta cell, the patient's glucose could be quite low and the beta cell will still release all the insulin it can. So if we're achieving these better A1C's with either sophoras involved or meglitonides, which are the weaker cousin of spinoras or with insulin, I'm a little concerned because those agents are more high risk for hypoglycemia. So um and then hopefully that answered your question, Matt. And then Paul was bringing up something and then you uh I think we we stepped over Paul. Paul, what were you going to me actually? Yeah. No, I I did not even Paul I did not even see or hear. I apologize. It's technically my job to compete out for his his uh job here. And I I will just say, you know, at the start of preparing for the episode, Paul told me to use a wireless headphone set. And I was a little skeptical about the wireless headset. I think he was trying to get me fired. sandbag our our recording. No, look, I'll say he's doing a better job of co-hosting than I am. So, I think he tried to get fired. And I I don't know if you can tell, but I got the beard going to try to compete him out there. So, specifically to work on the All right, Paul, what were you going to ask? No, it's along those lines. I just wanted to ask um maybe frame the question a different way. I I think I could probably figure out that I need to deescalate Manny's therapy if he comes in after an emergency department visit for hypoglycemia. Like, I think I'm probably a smart enough clinician. I might be like this optical mearide because I'm a very good doctor. But I guess for seeing you as the expert like what when do you start thinking about deescalating? Like how do we actually prevent this from happening? Like what are the what are your thresholds for tapering down therapy? Are the things that you're watching for that you feel like maybe I need to kind of back off because I think the fear is not just getting to target but the fear if you stop an agent and all of a sudden they'll go screaming into hypoglycemia again. So I would love to hear sort of your broader approach in terms of how you think about these. Yeah, my signposts for that are going to be um as I'm visiting with that patient, you know, I'm curious to know, of course, the A1C and their glucose levels. You know, on a regimen like this, the patient's not on insulin. They may not need to be checking their blood sugar like throughout the day every day. You know, a fasting sugar in the morning may be good. And then I asked them to do at least once a week what I call structured meal testing where they do a before the meal and a 2-hour after the meal just to see how much spike are we getting. Um, generally speaking, the glucose I want to achieve in young adults is 80 to 130 fasting in the morning. But for an adult like this, 100 to 150 is probably more reasonable. So, if we're getting any sugars that are falling below 100, I might want to look to back off. And then postprand um you know, we want uh young adults to have levels that are less than 160 for the most part. Um, for this individual, I might stretch it up to about 180. So, so think about, you know, a lot. So, seeing what their blood sugars are when you do some of that testing and structured meal testing. Uh, again, they don't need tests around the clock, but if you're seeing levels less than 100 or, you know, less than 150 postmeal, you're probably getting kind of too tight, tighter than you need because just keep in mind, an A1C of 150 average is an A1C of a glucose of 150 is a 7 A1C. A glucose of 180 approximately is an 8 A1C. And we want to be between seven to eight for these older adults. I don't think there's a magic number to say someone's like old. Um, but the guidelines would say somebody that is 70 years or older, we start getting thoughtful about the regimen. And Jeff, the the I I think it's it's table 13.2 two and the the ADA diabetes care uh from 2025, they sort of say like based on how healthy the person is and how sick they are, like what the goals become and eventually the A1C target just drops away and it and they they say just avoid hypoglycemia and symptomatic hypoglycemia. How sick does someone have to be in your book to when we get to those are those are our only goals and we're not even thinking about A1C's anymore? Well, yeah. I mean, I I tellalth visited with a person on hospice. I I might not have the person use any insulin. They were on insulin before. Um, if you got a couple of months of lifespan though, you know, if the sugar's allowed to get very high, it actually can cause that patient, even though we're not talking about extending life, they might have a lot of glycosura, a lot of wedding. It can be a lot of um changing for the family. They might sit in that uh, you know, a wet diaper a lot. So I think just trying to prevent significant glycoseria, you know, trying to keep that sugar reasonable, you know, like less than 250, you know, somewhere between like 150 to 250 is probably okay for someone there. Uh, bringing it back to like this older adult, uh, like I had mentioned, you know, trying to shoot for under, you know, between 100 to 200 is probably reasonable for a overall range that we would consider. Um, I will say just since you mentioned the ADA guidelines, you know, they're updated every year and they have specific breakout sections that we're talking about with our populations today. They have a whole section on older adults. And uh, one thing that's new, I haven't seen this in the um, previous editions, they have this what they are calling the 4 M framework. And so they talk about mentation, they talk about medications, they talk about mobility and what matters most. And so when you think about your older adult with mentation, we want to know, you know, what is their ability to do self-care? You know, can they detect hypoglycemia, respond to it? You know, for medications, are we in a zone of polyfarm pharmacy? I mean, are we actually being effective with the agents that are using? And you know, what are the end organ disease and complications that we are need to worry about? You know, patients with renal failure, we have to be very careful with mobility. We're looking at foot complications, risk for falls, um, frailty and sarcopenia. So, you know, our we like our GLP1 agonists, but you know, your older, frail, thin patient does not afford to lose weight and some of the weight loss with GLP1 agonist can be muscular weight. So, you need to be careful there and then what matters most. So honestly you know the idea of shared decision-making trying to understand with the patient and a lot of times for for a cognitively changed patient the family uh what is their expectations of lifespan and symptoms and and how they're doing because again with my the patient I spoke with he has this wonderful spouse who's very concerned about the diabetes affecting him and it's hard to pull people out of that and I was like you know he can if he can take a little taste of ice cream let's be realistic about what we're doing. So this is the whole conversation. Exactly. Uh we've started to do a series with uh Penn the geriatrics group and uh we talked about the five M's. The only M that was missing from this Jeff was multicomplexity which is you know what other coorbidities are in play which we we sort of talked about as we were as we were talking about how to how to size up our patients. So you know I I it's very much in line with this. I mean they're all the otherwise all the M's are the same. So this is a I think it's it's a great framework to apply to to I mean people of any age really but it it works very well for geriatrics. Yep. So Isabelle I think we were going to switch up the case a little bit, right? Uh so is this person going to be on insulin? What do you want to do? Where do you want to take this? Yeah because and actually we've started to talk about this already like what if if let's say he could not have been on any of the meds. He wasn't on glperide metformin or empagloin. So he was on glargine 50 units and aspart 15 units before meals and he was since he was taking it by himself anytime like once or twice a day depending on when he would remember and he's always done 15 units that's why that's why they stuck to that number. So what should our approach be in this patient now that we're seeing the hypoglycemia that led to the fall. Yeah. So, this is great because it brings back that idea that the longer you've had diabetes, the more likely it is you're going to need insulin just because the beta cells have failed. So, sometimes you you're going to have to have insulin. Um, for an individual, the more shots they're doing, the more complex it is. I've noticed many times in my clinic, um, some of these older patients, they are very differential to the doctor and they oftent times will not tell you or admit or may not remember that they're missing doses. And so sometimes I'll see these pretty heavy doses of insulin piled onto an older kind of thinner person and I start to think that dose of insulin seems you know pretty big like largene 50 that's a pretty solid dose and aspart 15 that's a pretty solid dose for these doses and um I don't recall if we have his body weight but I would just say I would start to scrutinize and sometimes what I do is I'll go back to say let me like maybe realize he's not injecting all of it focus on just the once a day insulin, try to achieve some reasonable glucose in this in this person and maybe hold the meal time. Um, and sometimes you do that and sometimes I'll have to go back to considering, you know, doing something like 2.3 units per kilogram versus whatever the stated doses may be. So, just be careful. I've seen that quite a bit. Um, I try to simplify the regimen by maybe you can reduce the meal time to just the biggest meal he eats. You know, sometimes people have a big spike because they eat a big dinner or they eat a big breakfast. These individuals might not be good at doing correction. Um, so if you have your basil, your glaring plus bololis, your meal time aspart, and many younger adults, we may also consider what's called correction insulin where they'll look at, oh, I'm fine 150 to 200, I'll add a unit, 200 to 250, I'll add two, so on and so forth. This sort of person that might not be in their ability. I think the we have to be careful and and I often if I'm going to have someone follow a correction scale or ask them to use different doses in the day, I I do what's called a teachback. So I'll say, "Okay, I've explained what I think your regimen should be. Tell me what are you going to do?" And I'll give them scenarios. I'll say, "Okay, if I'm doing a correction scale, I'll say, "Okay, you're going into dinner. Tell and your glucose is 300 based on this stuff I've written out for you and what we talked about, what are you going to do?" And if they can't give back to me an appropriate um reasonable, you know, mathematics on that correction scale, I'm I'm probably not going to do it because I worry that, you know, if you flub that up, you can really hurt the patient. So, anyhow, those are my initial thoughts. I think try to simplify if they you know, go to once a day insulin if you can with the glaragene, maybe drop the number of meals they use their aspart for. And I would these doses here on this patient, they just seem like too much for an older person. I I would worry, are they actually getting it all? Well, I did that on purpose a little bit, right? The over basilization that we talked about before uh already this patient's on 50 uh at at 6.3 A1C uh maybe we don't need that much gargene reduce that for him. Yeah. Just we're not doing 80 to 130 which is for young adults fasting in the morning. We want something that maybe 100 to 150, you know, we want to relax that and so backing off the insulin uh to be reasonable I think is very smart. Yep. Jeeoff, I want to recap a little bit and then I want to ask uh some specific medication type questions. So, we said that uh for our patients, first we want to make sure we know what type of diabetes they have, type 1, type two. Then we want to talk about targets, A1C, blood pressure, cholesterol. Older adults have may have poor hypoglycemic awareness and they might have worsening cognitive function or even falls more likely if they're having low blood sugars. Those can be some of our bargaining chips when we're talking to patients and families about we might need to deescalate the medication, de-intensify it. And that are uh you said our prerandial or fasting 100 to 150 and then our postrandial less than 180. Yep. And we talked about how insulin we might just do just a long acting largene and see if we can get away with that. Then add maybe with their largest meal of the day one dose of insulin. And I I can say personally since I've started doing that for patients, it has really it works very well. And when patients have a CGM, it's it can be very easy to identify the time of day that they actually need to have that. And we've also started doing that since we talked to you. Paul, I don't know if you have any comments about that if that is that something are you using many CGMs these days or Oh, yeah. Yeah. I mean, if someone's on an injectable medication, they're they're by and large using a CGM. So, it's it really has been gamechanging in terms of figuring out Yeah. the medications. Agree with above, Dr. Wat. Yeah. And I'll second your comments. I think one of the best things for these uh some older adults could be a CGM. And um Medicare, Medicaid, if long as you're on insulin, it doesn't have to be a multiple day injection. and they don't have to prove that they're doing the finger sticks like they used to. Um, they'll cover the the the CGM. And I know we have an episode so I won't go too much into that deeply, but I will say most of them have a receiver um which is pretty easy to connect with the sensor on the arm. And these are pretty small. They usually worn for 10 or 14 days for the ones out there. Or you can connect it to the cell phone. And the advantage of the cell phone is two things. One, the data can be clouded to the clinic. And two, some of them, well, actually all of them, the there are follow-on apps where the family can kind of spy, I call it spying on the patient to kind of check in how it's going and get alerts. And um, you know, honestly, once you set the cell phone up, uh, and I've been surprised, I don't want to say anything agist. I I guess just internally we think, oh, you know, older people, they don't use cell phones. I have patients that are 90 95 years old. they're whipping through their cell phone just fine and they don't need to know how to do complex computer stuff with it. It's just, you know, you can uh we actually at our clinic we help people get the download done, connect it and then once things are connected it kind of sets it's pretty good and the family usually will help the patient. So anyhow, I just want people to realize, you know, don't discount a person's te technology ability on the CGMs because they're pretty user friendly nowadays. Jeff the specific medication question I wanted to ask I guess I guess there's two maybe you can so first do you have any favorite sulfano uras if you're forced to use them and then second I've been seeing the endocrinologists and maybe this is just a local practice pattern using like the gleanides like nagglanide or rapaglinide yeah and those are meds that I was never really necessarily trained to use so I don't know if you think they have a place for certain people but uh if you could just comment on those insulin secrets. Yeah. No, you're very right. So the meglitenides are the weaker cousin to the sophonoras. They work at the same place. They work on the um ATP sensitive potassium channel on the beta cell. So again they are going to override glucose sensing and so there's a potential that um the person can have lower sugars happen but they have a shorter duration of action and so the hypoglycemia risks are lesser. Weight gains usually lesser. These would be kind of your sphineria for an older person and I agree in my intro medicine training I never heard about them until I got into fellowship and um I don't use them a lot but I will say the older patient is the person I look for them. They potentially are a little bit more expensive. I feel like um they're getable. Uh I haven't had too many struggles to try to get them achieve them for a person especially if you explain to the insurance that you know this older person the surferas are probably not great. As far as between the spineras, I can't say that there's a standout that's better for an older person. I would try the mglitinides. Um I do think um and you've mentioned it in your script here that the DPP4 inhibitors cited for example is one example of that is um a group of medications that is it has a small A1C drop. It's you know point4 to.5% but they come with very minimal side effect profile. um they are renally dosed, but I will say most experts will say that um it's mostly be careful with initiation and then you can actually bring the dose up as long as it's tolerated. Um it's probably, you know, it's not that it's like a toxic scary concern when they're on a a dose. I mean, I will say, you know, follow the renal dosing be appropriate, but this is not something where if someone's like right at the cut point, I'm like, "Oh no, I better drop it." No, no, you're safe. If you're above the GFR cut point, you're totally safe there. Um, but that's another kind of easy one to try. But the intolerance is that similar to what you see with the GLP1s, but sort of milder. That's what I would expect. I much milder. Yeah. So the Exactly, Paul. I think the side effect profile that you would see listed on the insert would be similar because basically DPP4 is DPVP4 is the enzyme that our body uses to break down our own body's GLP-1. So our intestinal cells make GLP1 after we eat and DPP4 is the enzyme that degrades that. So, if you can block the DPP4 enzyme, you can increase your own body's GLP-1. So, it's not going to go up as high as when you inject GLP-1, but um you could foreseeably see a side effect profile that might be very minimally or mild like a GLP1, though. Yeah, that's a good thought. Yeah, I I find those medications that they have a very narrow use case for me because they're they're expensive still. I there is just this weird formulary thing sometimes if you can get metformin paired with one and it's like tier one on a formulary and I'm just like all right sure why why not I'll we'll use it kind of a freebie y that's like one of the few times I use it yeah I'm not driving for it like you say it's expensive but if you can get it like cheap for some reason it's kind of a freebie low risk and it it might help a little bit enough to stop using a higher risk agent for me it's almost like a psychological medication like it's for the the patient who's really obsessed with the A1C and just wants a little bit better and like I don't I don't have a real horse in this race. I'm not too worried about like all right if they can afford it we can throw this in the mix and sort of see how they do. There's one more to touch on quick. Um and Isabelle actually did a good job bringing this one up which was pioglitazone. So your um TZDs are a class of agents that have really been dragged through the mud. Um you know pioglitazone is really your only one on the market. Raziglitazone and troglyazone are no longer out there. um these agents back in the day, you know, more than 10-15 years ago were thought to maybe increase the risk of heart disease and heart events. And so actually diabetes agents coming to market are required by the FDA to do cardiovascular outcomes trials because of these agents and um pyogglyone was absolved of the concern for causing heart disease. Uh if anything, they actually might reduce it, but it does cause fluid retention. So your patients with heart disease and CHF heart failure should not get them because they are have problems with fluid retention. So that being said, pyogglitazone um it is uh you know it has a you know A1C lowering effect of maybe up to one. Pyoggly glitzone is dosed at 1530 or 45 milligrams taken once a day. Other than uh fluid retention, patients may have some increase in abdominal circumference which for an older frail patient may not be a problem so much but also there is concerns for bone loss and osteoporosis which affects this population less so for males. You know if you have a normal bone mineral density in a male I'm not that concerned maybe with that agent. I will say these agents uh in the Iris trial were shown to reduce the risk of stroke. Um and so uh this could be another and actually there's some good evidence to show that they might reduce or delay the onset of cognitive loss. And so in addition to being an agent that gets visceral fat out of the liver and it mobilizes it to the subcutaneous space. So you know you might have some liver benefit for those MASH patients. Um you've got a a couple of interesting things that are useful here and it's a low risk for hypoglycemia. So that's the reason I bring it up in this case is that it could be another agent to consider. He's a male. Unless he has thin bones, it could be reasonable. He doesn't have heart failure. It might actually help quite a bit. And I use this actually quite a bit in these patients that are not right for intensive insulin and maybe not safe for sofaras. Okay. So our our our first patient here, we we're going to back off the glimeride, I imagine. And then if if if we were giving him the case where he was on the insulin, we would have cut down on the basil insulin because he was over basled. Um, anything else you wanted to talk about before we move on to the second case? I think we can move on. That was a great case with our with Manny, but now we're going to talk about Penelope. Uh, she is a 32-year-old healthy female who is 26 weeks pregnant with her second child. She was diagnosed with gestational diabetes at 24 weeks after an abnormal glucose tolerance test. Otherwise, she's had no complications so far and with her first pregnancy, no complications either. So, what are the targets for pregnant patients? What should we be thinking about with her? Because it's not a population I see a whole lot of, but every time I every now and then I get I get the one patient that comes in and we still see them. We got to help them. So, what's your approach here? Yeah. So, it is interesting. I think as internists, we often think, oh, well, I'm not going to have to deal with this. But just realize that um we have to be preparing our patients for when they're getting ready to be pregnant. Um it is it's it's known that the dislycemia even in the leadup to a pregnancy can affect the pregnancy. Um so there's some concern there even in that that those early days of pregnancy and then truly the patient may not know that they're pregnant. So, we have to make sure that they're trying to control their diabetes if they have it as they are fertile and if they're not using effective contraception. So, young women that have fertility potential should be consistently counseledled um by their physician to either use appropriate contraception well and to and to have their diabetes well controlled. The other reality too is that um when that person does become pregnant and is aware of that you're going to be initiating therapy and you need to know what drugs to potentially stop or start to help that person before they can get in with a OB/GYN or MFM which could be a little bit and so we have to know what we're doing at least at the start and it probably will transition to a specialist um during the pregnancy I would think. So to go back to your question directly, the A1C target for patients that are pregnant is lower during pregnancy. So it's less than 6%. And the reason is that because of increased red blood cell turnover and and higher intravascular fluid amounts uh uh uh fluid volume, the A1C reads um uh artifactually low. And so they're they're kind of cheating. And so the the A1C less than seven for most other people um is easier to achieve for them. So we can't let them cheat. Um just because you got pregnant, you're not allowed to cheat. I know that's a that's you got a gold star, but no cheating. So um the glucose targets and I honestly often have to look this up to refer to it because I just don't see enough patients, but um so I am honestly reading from a table for you. Um although I'll just say the concept if you can remember is going to be that it's lower than for people that are just healthy on adults. So for gestational well and I should back up once. So people that are going to become pregnant may have type 1 diabetes, type two diabetes, um pre-existing prior to becoming pregnant and then there's some people that don't have either of those become pregnant and develop dislycemia and we call that gestational diabetes. So all three of those can happen uh in a person that becomes pregnant. So that's just fair to say that. So gestational diabetes, the treatment targets are 70 to 95 fasting. Um, and just remember that for uh young adults that aren't pregnant, it's 90 to 130. And for your I want you to focus on the 2-hour postprandial, the target for uh women that are pregnant that have diabetes is 100 to 120. Um, and so with those targets in mind, quite a bit more stringent. Um, and we have to try to achieve those to benefit the baby as the as the main target we're talking about. And this is table 15.2 in the diabetes care like the most recent version of those. So, yes. Yeah. And I would say, you know, refer to that. Uh, certainly um we all refer to things uh that we don't do every day. I would say if you're not familiar, take a peek there and you can offer that to your patient to say, "Hey, this is what we're supposed to try to hit." Um, realizing it's tight and it and it can take some work to get there. Yeah. They they even have in the guidelines uh for people that wear a continuous glucose monitor like uh if they have type 1 diabetes, they even have like the goal sensor ranges and everything too. So it has some really specific stuff in there. Yeah. And just to say it, it's and I'm looking at it 63 to 140. Now the time and range uh time and range is usually 70 to 180. Um I don't know that that plays the same in this because that upper part of the time and range is just too high actually for these people. So, I think you have to really go with the glucose range, not the time and range percentage. I would probably use the actual straight glucose. Uh because you don't want them over 140 like at all, um is the target. Yeah. Okay. So, so we're talking about like preconception counseling here and we just talked about like where we want their sugar to be, but how are you talking to people that let's say they have diabetes already and they're taking medication? like what what do they need to be thinking about if they're going to be getting pregnant? Uh I mean just as far as diabetes agents goes, you know, if so we were we were talking in pre-recording someone's on now simaglletide, tepatide, those those kind of agents, any of the ones we were talking about before any specific diabetes meds that that would be a no-go in pregnancy? Yeah. And so GLP-1 agonists are going to be a do not use in the pre-preg. Once the person becomes pregnant, it needs to be discontinued. And your SLT2 inhibitors are similar. Those can be used but are discontinued immediately at the onset of a pregnancy discovery. Um and so um some of the specific concerns so GLP1 agonists, you know, they in induce a lot of weight loss and they're not well studied during pregnancy. They can also potentially increase the risk for retinopathy which pregnancy is a and that's that is a we're not quite sure what that association is. We're seeing a non-eskeemic uh uh um optic neuropathy happening uh during uh use of GLP1s. We're not sure what is the path of fizz of that but uh there's some retinopathy concerns with them. So pregnancy um patients that have diabetes and are young fertile females need to have regular routine dilated eye exams to evaluate the retina every year and um when they're pregnant in the first trimester and if there's any concerns there every trimester during that pregnancy because that's a time when retinopathy can really take off. um macular edema can happen uh which will cause blindness um and that can happen in the person during the pregnancy and so we're talking about some acute changes in vision that are high risk and Jeeoff this is specifically with the GLP-1 agonist or is this for just anybody any uh woman with diabetes who's of like childbearing age and yeah any woman with diabetes we have to be watchful on the eyes yeah and the GLP ones I think especially we have to watch we have to be a little careful of with the recent um advice from from the FDA and other advisory uh bodies that are telling us that there's some signal that we need to investigate further with the literature to understand what the relationship might be. But yeah, any young person and female and during pregnancy with diabetes needs close monitoring. Um other medications um you know we used to have a sweetheart um for metformin and sophonoras. Those were the standards for treating young women with pregnancies and diabetes. We actually thought oh these are safer than insulin and we've come completely around on that different. So metformin and sophinaas are are not firstline agents for patients that have pregnancy and the rationale is that these agents later on in the life of the child. So usually not seeing high level complications during the pregnancy but after those children are born and during their young uh child and later adult life they have higher rates of metabolic dysfunction that are thought related to to that fetal exposure to those medications. They both cross the placenta. Um and so uh insulin is the preferred agent for a uh pregnant female. Yeah, that's that's kind of wild. like it was the the summary of it was something like yeah they they cause these metabolic metabolic problems weight problems later in life but like like maybe even small for gestational age like if they're taken during pregnancy. So it just seemed just just what you don't want there. So is it so right now and and maybe we're jump jumping too far ahead, but so the which which meds are on the table during pregnancy as as our as our drugs we can think of as safe or considered safe? Yeah, I would say top of the list of course we'd mention insulin. So going back remember treating diabetes we always start with what's the type. Um type 1 diabetes absolutely insulin. Pregnancy can come with an increased risk of DKA um because there are some uh pregnancy comes with more insulin resistance. If you are in your first trimester and you're having a lot of nausea, vomiting, you can have dehydration which can prompt EKA. It can be uh more risky. But type 1 diabetes of course is insulin. Type two diabetes, if the person's on other agents to treat their glucose once they become pregnant, we actually want to switch them to uh just insulin. Um and we used to have some preference about which insulins to use. Um those were kind of debated quite a bit. We've moved towards thinking that um they're all considered reasonable. Uh although there's not controlled trials to understand which insulin is superior or safer. It's actually well accepted now that um all of the insulins are reasonable. If you think about you know what is the difference between let's say for example glargene and aspart they're both insulin. The shape of them has to both fit into the insulin receptor. The only difference is the types of substances that are included in the insulin to slow or speed their absorption and their effect. And those usually aren't things those substances are not things that are usually going to pass the placent or affect the baby. So it's you know insulin's insulin that's your primary tool. And then for gestational diabetes um it's thought that many of those cases can be treated with lifestyle. And so going back to getting them with nutrition counseling, getting them with regular moderate exercise is the first line treatment for gestational diabetes. And then if that's not uh substantial enough, uh insulin, one last one I will just say that we often don't think about, but uh folic acid supplementation uh is critical to prevent neural tube defects. Uh it is recommended at 400 to 800 micrograms per day. Uh that should be part of the thinking that we all have as well. Yeah, those are my those are my brief thoughts. And there has to be some nuance to this. I I would suggest but I'm just imagining a world like because we have so many options now and because type two diabetes is happening at early and earlier ages. I can envision someone who had a pretty bad not bad but an LB1C that then we're treating efficiently or effectively with GLP1 agonist and metformin and then we find out that this person has become pregnant and then we have to stop those medications and start insulin. So, this is my long-winded way of asking because I've had I've had trainees enter their second year of internal medicine residency training without having to initiate insulin. Yeah. And so, I guess my question is is does your because for someone who's not pregnant, I I'm a little bit less aggressive with in like I true truth be told, I'm not starting insulin a lot of pregnant patients. This is not part of my day today. But in general, when I'm starting insulin, I'm not super duper aggressive just because I want patients to get used to the idea and make sure I don't make them hypoglycemic. But here, it seems like there's a little bit more urgency. This is my long-winded way of asking sort of what does initiation look like? Does it differ for someone who's newly pregnant versus someone that you're just normally initiating insulin for in other circumstances? Paul, that's a great question. I think the initiation can be the same as with your other patients, but the difference is going to be on how quickly they get the followup. Uh, honestly, and it's very hard for us in the style of the way visits work. you know, you're I don't know how often you can get a patient right back in your clinic, but this is where I think if you have a nurse, nurse practitioner, someone who's like set up to have a, you know, every 3day kind of quick call with the patient um as part of a routine to titrate that insulin quickly. That that can be really key. These are such high-risisk uh situations that we really want to get those targets like you'd mentioned under wraps. Uh if I didn't have that resource, it would be one of the ones I would say is worth the spend of your couple of minutes to just grab a call for that patient. Hey, where are we at with the sugar today? Okay, great. Let's do this change and then hang up because that's worth it. Um I think for for this situation, but I think my initiation would be similar to other patients. You know, I would start them on a basil insulin like largene. I will just give one exception to that. This is pregnancy, type two diabetes and even gestational, probably more so justational will seem to have some pretty big spikes of glucose after meals or from meals compared with the elevation in fasting glucose as opposed to kind of other adults that have obesity and have diabetes. And this is the one time where I might actually start fast acting insulin first to to just tackle the big meal jumps before I start a basil. And so I would say if you could could throw a professional version CGM or get a CGM on the person or at least get them just for three days to check their sugar um fasting pre and post breakfast, pre and post lunch, pre and post dinner to kind of see, okay, what is the profile? Okay, do I have to tackle that fasting or are those meal times blowing up? That that actually could be something to consider. So that would be the only difference between this and another kind of adult. Um, but it could look similar starting basil 0.2 units per kilogram. Um, you know, so that's going to be something between like 15 to 20 units of glorine once a day usually. Um, or maybe it needs to be meal time. So I I deposit to that to you to say that yeah, you want to look at the profile and consider. Okay. And because I want to make sure we have time to get to the last case, let's just uh let's ask about just postpartum anything specifically for our patient. Let's say we're give she had we gave her gestational diabetes and she did okay with just lifestyle modifications. So fortunately she wasn't messing around with the CGM and the insulin. Um but what about postpartum? What what should we tell her there? Yeah. So she had gestational diabetes. There is a 50% chance that she will develop type 2 diabetes in the next 5 years. And so we really have to get um concerned about this person's uh risk in the near future for type two diabetes. What happens during the gestation is the placenta and the fetus and mom's hormones are all um uh sending out growth hormones, growth factors which create a lot of insulin resistance and it's unmasking some underlying metabolic dysfunction in that woman. And so that's a big signal that we really need to get uh helping this person in uh usually a weight loss process. Now most medications are going to be concerning for during the breastfeeding time and so I would avoid most medicine you know continue the insulin until breastfeeding concludes and try to avoid other agents. Um but once that concludes um you know helping that person with weight loss either with medications and or lifestyle I think is a is an important uh thing to do. One medication I will say that often is used for weight loss that is a big big big nogo is topamate that is absolutely stratogenic uh cannot be used in these patients but um they're expensive and so unggetable but GLP1 agonists are probably your best safest agents for weight loss effective um it's just they're so expensive now we're just need to wait for that uh situation to improve okay before we move on metformins and sulfon uras are out. Many patients if they just have gestational diabetes can get by with lifestyle changes, but insulin is is preferred for as the first line agent. And you said that getting either a CGM or just 3 days of pre and postprandial try to figure out do they need just meal time or do they need uh basil and meal time insulin or just basil what have you. Uh that's what we would decide and uh we just have to have frequent follow-ups to titrate that in a safe way. Um, and that's about it. So, uh, let's get on, Isabelle, to our last case. Yeah, our last case is Vanessa. She is a 53 year old female with lupus, CKD, hypertension, obesity with a BMI of 33, and type 2 diabetes. And she's coming in today for follow-up after she saw rheumatology who increased her to prednazone 20 milligrams daily after a recent hospitalization for cellulitis and AKI. Her labs at discharge from the hospital are an A1C of 9.2 2 and GFR 43. Since she's been discharged, her blood sugars have been labile and labile to high with uh 350s to 400s according to her uh like just her um her CGM. And also she's reporting nocturnal hypoglycemia. In fact, it happened just a couple nights ago. Right now she's currently on 40 units uh twice a day of glarine aspart 15 before meals ulmasartin methtoresate folic acid prennazone 20 which was just up increased alurol and fioamide. So again her approach with this one because she's coming into us rheumatology said you need all the prennazone and then she's coming to me with I have all the high sugars but then she's got she's got these hypos at night. I know this is something that we've talked about before. So how how should we approach this? Yeah. So, you know, they're this individual is at high risk to begin with because their A1C is elevated, which means that they probably had a uh uncontrolled set of diabetes glucose even before those steroids got on board. Uh, of course, I think many of us are very familiar that corticosteroids are going to raise the glucose levels for the patient. It's interesting. it it will raise it throughout the day. But if you were to focus on either it being fasting morning sugars or postprandial glucose, the the most dramatic effect is actually on the postprandial glucose and it has to do with glucose disposal and the effect of corticosteroids on the insulin sensitive um glute receptors. Um, and so, uh, muscle and liver, um, and fat are your main places that will be taking glucose out of the blood and and disposing of it, if you will. And steroids dramatically affect that. And so, you can get some very high postprandial spikes. You know, we're benefited by having first of all, sugar information. Um, and so I always go back to thinking, what's the type of diabetes this person's type two? And then you need the data. uh um having a continuous glucose monitor to say that again would really help uh in this situation to see what the profile is. Um now this person luckily is already on insulin which is great. Um many people that aren't need to like in short order learn how to do an injection and and manage insulin. So we're already I think a little step ahead of the game. One thing you might consider is trying to um look at the profile and see if to start with you can adjust the insulins they're already using. I would say in general this person might be able to get away with just dialing up the aspart and so if you're seeing that it's just big-time meal bumps for the duration of time that we expect this person to stay on the predinazone the only thing we might have to do would be to dial up that aspart for the duration of the time they're on the predinazone and then they may be able to bring that back down now how much to go up by I usually start changing insulin by 10 or 20% based upon if there's hypoglycemia. 20% being if wow there's a lot of hypoglycemia. Um so I'd probably do a 20% increase for this person. You know that'd be you know somewhere between 3 to five units more already up front. So um with each meal and then assessing response and then uh going up further their A1C is high to begin with. So I might actually go up a little bit more maybe five or six units on top of what they're doing for the meals just to begin with. Um I will say we have to you've added the lovely concern of acute kidney injury. So not not only are we piling on the insulin but this person has some renal dysfunction. Uh just to bring that concept to the four insulin is renally cleared. Um and if we have a person with declining renal function you can have hypoglycemia in you know when the insulin when it's lasting too long longer than you think and it's stacking. So those are some initial thoughts I have um on how to maybe manage this person. But should we keep her then? I mean we've t we just mentioned over basilization in our last patient and she has a BMI of I think BMI of 33 and she's taking a total of of 80 units of glargene a day. So would this be overilization? Should we how should we affect how should how should we adjust the glargene or should we even stay on it considering that we're just going to go up on the aspart? Yeah, the basil I agree with you is probably going to not do as much in the face of this problem u because of the acute rise around the meal times. So that basil um like I'd said if your first um attempt with a patient is to just dial up what they already have that's probably the best first step. However, I think your your point is actually very apt and saying, you know, the basil is not helping as much in this type of scenario. Are there any other tools in the toolbox and there are and you can use an intermediate acting basil insulin that also contributes to meal time coverage? And this is an older insulin which many of us have probably forgotten or maybe never used, but that would be neutral protein hagadorn insulin or NPH. NPH insulin is kind of interesting. um it has a um pharmacocinetic profile that is actually pretty similar to the way the steroid would affect the patient. This is in particular for hydrocortisone, predinazone, prednisolone and methyl predinazone. Um those are your short and intermediate acting steroids and the impact that they have on the blood glucose uh due to their duration of activity is very similar to the pharmacocinetic profile of NPH. NPH has an onset of 2 to four hours. It has a time to peak of 4 to 10 hours and it has a duration of up to 18 hours. And so um NPH it does have instead of glargine which is very flat. NPH has a duration that is fairly long but it also has a bump to it a peak that occurs with it that can help pull it can go up and grab and pull down some of those um spiking sugars. And so that might be actually an ideal item to stop their basil insulin. Um, convert that to NPH and then usually I will take 2/3 of the dose. So like let's say they're on 80 of Oh boy, Paul help me with the math. What's 2/3 of 80? So Oh, that's going to be what? Let's make it 90. Let's say they're on 90 of Okay, 60. Okay, make it easy for me. Um, so 60 I can do that. 60 uh with the um with the morning uh like usually they'll get the steroids in the morning. So 60 along with the steroids and then give the other one/3 towards like the dinner time which will serve as their dinner and their rest of the basil for going through the nighttime hours. So 30 towards the night time. I might make that change. Maybe add a few units or maybe just change it direct unit to unit and then maybe go up on I would leave them on the aspart and use that as well to cover those meal times. Um but it's a tool that I think many haven't heard of. There's um a great paper that I think we're going to link by Dr. Chloran uh that talks about using uh for an insulin naive patient. So this person's already on insulin but using 0.1 units per kilogram for persons starting predinazone 10 u2 units per kilogram for 20.3 for 30 point4 for 40 units per kilogram um of NPH and that given at the time of the steroid. Uh one last thing not that I've thrown enough numbers to dizzy people's heads out there a little bit but is to think about um just when we're talking about those numbers it's all predinazone equivalent. Um, and so like for example, hydrocortisone is um, uh, 20 to one for predinazone equivalent. I'm sorry, 20 to five. Yeah, I'm going to mess you all up, aren't I? Methyl predinisolone is about equal to predinazone. Dexamethasone is a big different one. Dexamethasone, um, it's approximately 1 to five and so it's much stronger. The problem with dexamethasone is it has a very long acting flat profile. So actually the dialing up the glargene or using the glargene might be better for dexamethasone. So anyhow I've thrown a lot of information at where did I confuse you? Well it's not not confusing. It's just with the uh I just wanted to say so for and we can this table that uh Jeff is referring to from one of the papers uh we can we can link for people but essentially it based on how much predinazone they're taking. So for every in increments of 10, so if it goes 10, 20, 30 or 40 or higher, they would take a different number of units of insulin per kilogram body weight. So it's it becomes a math equation. And there's calculators that you can use to do this or any of the AI programs now, if you type in, you know, they will they will calculate these kind of things for you. But they cap it, Jeff, at 0.4 units per kilogram, right, for anyone that's on 40 or more. Yeah. So you don't go past that generally just because you're starting to get some big numbers and we want to start seeing assess the response before we start dialing up too high. And even the example here, you know, th those numbers start to sc like someone that's on 80 of a day, you know, we were talking about let's say you have your average 100 kilogram person, you know, they're already on more than 0.5 units per kilogram. So that's like we talked about that over basilization. Like that's where I would start to think like is there too much basil insulin here for this person? like do they really need all all 80 of that? And so when you're switching over to the NPH like those those big numbers that just scares me, but I you know I know what the math says. It's just uh a lot of NPH that sometimes you're calculating for these people. Yeah. And sorry I probably misstated his name. It's Dr. John Cllor and he's actually a VCU graduate and it was a VCU F. I haven't run into him. I work in Virginia. Okay. Yeah. And Jeeoff, so I I've seen some people if they're on a steady dose of Gargginine and meal time insulin and let's say you're in the hospital and they're getting predinazone every morning, 20, 30, 40 milligrams, someone would just give them just an a little bit of NPH just at the same time they get the steroid and just leave their leave their same almost like somebody that's on like pain meds outside the hospital. you continue their regular pain meds and then you give them a little more if they have pain on top of it. I I thought of it as the same way with this NPH. Do you do some people do it that way too? Absolutely. I definitely do. So, I'll have individuals where they're going to start it and I just throw the NPH on top on top just like you'd mentioned. I probably only do that in the hospital though because when you send someone home on three different insulins, it can get really tricky. Oh, yeah. Um but but that's why I mention it the way I'm trying to make replacements. But in the hospital definitely. I just I and I think again a lot of um our audience may not really have used or be familiar with NPH. Maybe I'm wrong in that because it it is one that is maybe cheaper and so maybe more accessible to folks that don't work in a place that can get the other insulins. But yeah, it is a good tool to throw in your toolbox. I would not be afraid of it. Um it's a it's a good tool for this type of instance. Yep. Okay. I feel like I'm missing something in the stem here, but is there a reason after like once everything is sort of settled down post hospitalization, this person would not be on a JLP1 agonist like that, this is a person with obesity who has fairly high it looks like in some requirements as is like is that would that be a reasonable just kind of have floating around in the background? Yeah, honestly, um the only because the glucose that we're going to talk about is going to be just surging so high so fast now the insulin becomes the agent that we think is going to be the most powerful titratable agent to get this tackled. But Paul, I like where your mind is going is that if this is going to be maybe a more longer course process, absolutely the GLP1 because the GLP-1 focuses on treating and improving the glucose that's postprandial, which is where the steroids have their biggest impact. So if you can line up those impacts, that's great. Um the other one that might help you a lot is casual 2 inhibitor because a lot of these I see this person's already on ferosomide. So they're probably getting some help in preventing um edema because steroids can often have some of these people gain some fluid weight. An SGLT2 inhibitor. This person has renal dysfunction. I wouldn't start that you like right in a good around the time of an acute kidney injury. You know, I think we'd let things heal and settle out. But if they have chronic kidney disease, that could be another really good agent to consider in this individual to help prevent fluid onloading and to um help manage the sugar. And they really do good about the higher the sugar is past that renal threshold of 180 milligrams per deciliter, the more effective they can be at offloading sugar. So it's another really good agent to bring it down to consider too. So it's not just insulin that can help. Uh Paul, that's a great point. Think about your other agents that might help too. Okay. So, so we've talked about our options like if if they're going to be on steroids for a while and we we might replace their their glargene, you could replace it with NPH insulin dose kind of 2/3 in the morning, 1/3 in the evening with their evening meal and that would replace the glargine in a 1:1 ratio. And then if they're in the hospital, we could keep their home regimen and we could just give them NPH in the morning with the predinazone and we would use that formula we were talking about um based on their weight and how how much predinazone equivalence they're getting. Yep. I think that that respects the ideas that we want to give the patient insulin they're familiar with if you can. We want to titrate up especially around the meal times. um Isabelle's comment of over basilization that very high basil is not going to help as much in the situation. So getting NPH may be involved as the basil or Matt like you mentioned um just adding the NPH on top of the regimen at the time of the steroid um that's given. So you just time them right together. Um all of those are valid. And then I guess the third option you had mentioned uh and you I just recalled was that you could just go up if they're really just having these really high postprandial excursions and they're taking prennazone you might just go up on their prenial insulin and just give them go up by 10 to 20% just to give them a little extra coverage. Yes. And they might need a lot more than that but I think it's a good place to start. Um, and uh, again, these are people that need uh some some some close titration um, because it might do nothing to to bring that down. Uh, so you really need to to drive those numbers up uh, in quick succession. Otherwise, they're going to just be very hypoglycemic. So, you really might need some of these individuals need a lot more insulin. It's hard to know. So, just day by day, a continuous glucose monitor would help a lot. Um, I know we keep saying that, but you got to have the data to treat. Yeah. And if if we had a different patient that just they didn't have like baseline diabetes, but now they're their A1C is 7 8% and they they're on steroids for something like polymyalgia rheumatica where they're going to be on steroids for a while. Do you have a way to handle that? I I know that changes this case totally, but that does come up fairly often. I don't know, Paul, if that's something you're you've dealt with before, but it seems to come up. Yeah, I mean PMR doses, I mean I've seen some of them get predinizone 80. I mean some really high and then they're going to titrate that down across like six months and so um yeah in they probably need to be friends with insulin if they're not on insulin already. So just because the the glucose is potential to really rise very quickly and they're going to need some actual effective controlling uh treatment. So even though the other agents may be helpful, just realize that GLP1 doesn't start working for several weeks until that dose comes up. They have to titrate up slowly. So you really need insulin um to start in that patient and at least just start glaring and then you can start adding in the other insulins like we do for other patients, but they need to start glaring and then you can add the other ones as they go forward. Okay, Paul, uh any questions about this this topic? No. Do you think we're getting towards take-home points? I think. Yeah. No, I I think it's we've I am filled to the brim with diabetes at this point now. I'm not sure my brain could hold any more information. Okay. Yeah, I think I'm ready for takehome. All right, Jeff. Well, our time is coming to an end here, but let's let's give the audience a couple take-home points uh from from our discussion tonight. Yeah. So, I think um with our patients that are of advanced age, we need to really be careful of um causing hypoglycemia. These individuals don't detect it very well in themselves. usually maybe due to cognitive dysfunction. Um symptoms of hypoglycemia may not be as um apparent to them and then their ability to quickly access uh carbs and treat that may be impaired. Uh they can fall and and lows can cause worsening cognitive dysfunction which again just complicates their ability to take care of themsel even more. And so the A1C targets and glucose targets are softer. Um we try to prioritize ensuring that the medication regimen is not uh too aggressive and and and um too burdensome for the patient and seek what the patients preferences and and values for their life are uh including what acknowledgement of what the lifespan is. In our second case we talked about a patient that has uh pregnancy related diabetes and we mentioned that people with type 1, type two or then develop new diabetes during the pregnancy we're going to have to take care of. uh we mentioned their A1C target is below six because they are cheating by being pregnant and that their overall glucose targets are much lower to achieve that insulin is the primary agent uh and mixtures of insulins to treat patients uh whereas before metformin and sophonoras uh were our primary agents. Those are okay to have on the patient before the pregnancy, but we discontinue those uh during uh pregnancy and favor insulin, which is kind of a new uh uh paradigm, but that is the accepted approach uh for safety of the fetus. We want to be careful with their retinal uh health uh with pre-preg counseling. That includes making sure their eyes are looked at yearly if they're a young woman that could become pregnant, ensuring they're using effective contraceptive if they're not ready to be pregnant, if their glucose levels aren't good, um, and they and they're not ready for pregnancy, and uh, checking their eyes uh, throughout and early in the pregnancy. In our third case of steroid induced hypoglycemia and diabetes, um, we mentioned that insulin is a powerful agent that is highly titratable. So, that's usually your go-to. And we talked about trying to use what the insulins are that the patient already has and and working with them to see if you can achieve a response that's acceptable. And then also knowing that new trick of knowing that you've got NPH in your tool bag and you can use 0.1 units per kilogram for predinazone equivalent of 10 milligrams and 2 for 20.3 for 30 and so forth. Uh delivered at the time of the steroid delivery. Um, and that can be added to their entire regimen to help cover glucose. Or you can convert their basil to NPH because it has that peak effect and and also acts as a basil. Although again, NPH has to be used twice a day. Um, and even though it's used twice a day, the patient is actually recommended to eat three times a day because that peak at the middle part of the day might cause a low if they skip that lunch. We did mention throughout all of the talk that um, GLP-1 agonists are probably great agents. we all realize are very expensive but can help with um older patients uh maybe that don't have sarcopenia or thin uh but the the light alternative of the GLP1 is a DPP4 inhibitor we mentioned that would be like GLP-1 light uh cheaper agent post pregnancy GLP1s may be reasonable to get that weight loss to prevent the gestational patient from progressing to type two and then steroid induced GLP-1s TD2s probably do a good job of the postprandial elevations and can be added there as I mean, so we touched on a lot of things. And oh, the last one I'll say is that CGM's probably help everywhere in this. Yeah, that's yeah, that's a good that's a good summary. Anything you'd like to plug, Jeff? Yeah. And so I'm going to plug very briefly. Um, so you didn't ask a book recommendation and the last time that you did I felt um I was terrible cuz I mentioned my book recommendation was a book that I recommended before and Matt was like, "Oh, hey Jeeoff, you recommended that when you were on last time like last year." I was like, "Okay, I guess I haven't really advanced myself." And truly, I was rereading it. It wasn't just because I hadn't read a book in a year. So, but I know Paul was like, "Oh, yeah, Jeff's totally not getting my job." Because he's just recommending the same book over and over. So, I have three quick ones. And so, I'm going to actually recommend um three books that I'll plug that are from my mentor, Jack Louie. Uh I don't know, Matt, if you remember Jack, endocrinologists. He's actually now uh an author and he's authored a couple of books. Be Well, is one you can get on Amazon. Um you can get print or or paperback, and it's a compendium of um kind of inspirational and thought-provoking quotes. A good one I'll give you is the universe is change. Our life is what our thoughts make it. Uh that's from Marcus Aurelius and he has other kind of ones in there as well. Um his second authored book is Keys to Better Health, a guide for patients and health care professionals. Um so again, oops, sorry, by Jack Louie. And uh this one is a discussion of how uh this is actually good for patients. It tells patients like what they're going to experience with their doctor visits and how to prepare themselves. So there's resources here for patients. And the last one is rooted in wellness. um exploring the health benefits of trees. So, and this one uh there's lots of studies that talk about how trees improve your health, including one from um people uh at Walter Reed, the the base there going to Uniform Service University that either had to walk through the woods or walk near the road to work every day. And they took surveys of their wellness and found that if you walk through the woods going to work, you did better. So, anyhow, I'm plugging my mentor and good friend um because now I'll be better than plugging the same book I I was going to ask. So, Jeff, I don't know if you've read it yet, but I feel like uh Roma Sabrosa would be right up your alley. Oh my god. I've not read that in a while. Paul, as usual, the digs, man. I I tell you, I he tried to get me to use a wireless headset and get me kicked. I I told him no. I thought Isabelle said it had to be wired. And I'm glad I listen to Isabelle because I know what his plots [Music] are. This has been another episode of the Curbsiders, bringing you a little knowledge food for your brain hole. Yummy, yummy. Still hungry for more? Join our Patreon and get all of our episodes ad free, plus twice monthly bonus episodes at patreon.com/curbsiders. You can find our show notes at the curbsiders.com and sign up for our mailing list to get our weekly show notes in your inbox. This includes our curbsiders digest, which recaps the latest practice changing articles, guidelines, and news in internal medicine. and we're committed to highv value practice changing knowledge and we want your feedback. So email us at [email protected]. A reminder that this and most episodes are available for all health professionals for CME through vcualth at curbsiders.vualth.org. A special thanks to our writer and producer for this episode, Isabelle Valdez, and I believe we have some help from Zoya Serrani as well. Our technical production is done by the team at Podpace. Elizabeth Proto does our social media. Jen Wadd runs our Patreon. Chris the Chu Manchu moderates our Discord. Steuart Brigham composed our theme music. And with all that, until next time, I've been Dr. Matthew Frank Wad. And I am the curbsider PA, Isabelle Valdez. And as always, I remain Dr. Paul Nelson Williams. Thank you and goodbye. [Music] [Applause]