Podd Avsnitt 23 - Time in Range Podcast

Välkommen till Ett samtal om diabetes.
I det här avsnittet lyssnar vi på en amerikansk podcast om CGM och tid i målområdet med Dr Jeremy Pettus and Dr Steve Edelman. Avsnittet är ungefär 28 minuter.
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Transcript

 Instructions for use: Please note, this supporting file must accompany the podcast audio file and be readily available to any users of the podcast audio file. MAT-GLB-2302068-v1.0 Date of approval: November 2023 Podcast title: The role of continuous glucose monitoring in diabetes care Podcast description In this episode, Dr Jeremy Pettus and Dr Steve Edelman discuss the increasing role of continuous glucose monitoring (CGM) and time-in-range (TIR) in diabetes management. As adult endocrinologists who were both diagnosed with Type 1 diabetes in their teenage years, Dr Pettus and Dr Edelman share personal and clinical perspectives on how CGM has impacted people with diabetes and clinical practice. With reference to their experiences of glucose monitoring over the years, Dr Pettus and Dr Edelman discuss the increasing utilization and potential benefits of CGM and related metrics, such as TIR, in clinical practice. The conversation touches on key clinical targets for diabetes management with CGM, and how CGM-derived data can empower people with diabetes. Dr Pettus and Dr Edelman go on to discuss how the increasing utility of CGM and related metrics is also reflected in the clinical trial space, 1 highlighting the importance of including such metrics as key endpoints in prospective clinical trials. Please note, blood glucose ranges included in the podcast audio are provided in mg/dL. Continuous glucose monitoring targets referenced within the podcast are based on recommendations for adults with Type 1 diabetes (T1D) or Type 2 diabetes (T2D) from the International Consensus on Time in Range.2 Time-in-range (TIR) Time-below-range (TBR) Time-above-range (TAR) Population % of readings Target range % of readings Target range % of readings Target range T1D and T2D >70% 70–180 mg/dL (3.9–10.0 mmol/L) <4% <70 mg/dL (<3.9 mmol/L) <25% >180 mg/dL (>10.0 mmol/L) <1% <54 mg/dL (<3.0 mmol/L) <5% >250 mg/dL (>13.9 mmol/L) Older/highrisk* T1D and T2D >50% 70–180 mg/dL (3.9–10.0 mmol/L) <1% <70 mg/dL (<3.9 mmol/L) <10% >250 mg/dL (>13.9 mmol/L) Pregnancy T1D† >70% 63–140 mg/dL‡ (3.5–7.8 mmol/L) <4% <63 mg/dL‡ (<3.5 mmol/L) <25% >140 mg/dL (>7.8 mmol/L) <1% <54 mg/dL (<3.0 mmol/L) *Includes those with higher risk of complications, comorbid conditions, and those requiring assisted care. †Recommendations for pregnancy T1D are based on limited evidence and further research is required; owing to a lack of evidence on CGM targets for pregnant individuals with T2D or those with gestational diabetes mellitus, percentages of TIR, TBR and TAR were not included in the report. ‡Glucose levels are physiologically lower during pregnancy. Please note, the InRange study referred to in the podcast audio has been provided as an example for the use of CGM metrics as endpoints in a clinical trial setting, and does not constitute an exhaustive list of diabetes studies utilizing CGM metrics. Instructions for use: Please note, this supporting file must accompany the podcast audio file and be readily available to any users of the podcast audio file. MAT-GLB-2302068-v1.0 Date of approval: November 2023 InRange1 was a 12-week, multicenter, randomized, active-controlled, parallel-group, open-label study comparing glucose values and variability using blinded 20-day CGM profiles with Gla-300 (n=172) versus IDeg-100 (n=171). Individuals with T1D (HbA1c 7–10% at screening) who had previously been treated with a once-daily basal insulin analog and rapid-acting insulin analogs for ≥1 year were eligible for inclusion. The primary objective was to demonstrate the non-inferiority of Gla-300 versus IDeg-100 on glycemic control, as assessed by TIR and glycemic variability. Abbreviations: CGM, continuous glucose monitoring; Gla-300, insulin glargine 300 U/mL; IDeg-100, insulin degludec 100 U/mL; SGLT2i, sodium/glucose cotransporter 2 inhibitor; TAR, time-above-range; TBR, time-below-range; TIR, time-in-range; T1D, Type 1 diabetes; T2D, Type 2 diabetes. References 1. Battelino T, et al. Diabetes Obes Metab 2023;25:545–55 2. Battelino T, et al. Diabetes Care 2019;42:1593–603 Instructions for use: Please note, this supporting file must accompany the podcast audio file and be readily available to any users of the podcast audio file. MAT-GLB-2302068-v1.0 Date of approval: November 2023 Podcast transcript SPEAKERS: Jeremy Pettus, Steve Edelman Music Jeremy Pettus Hi everybody, and thanks for listening in. I am one of your hosts, Dr. Jeremy Pettus, I'm joined as always, by my good friend and colleague. Steve Edelman Dr. Steve Edelman. Jeremy Pettus So, if you don't know us, both Steve and I were diagnosed with Type 1 diabetes when we were 15 years old. And now we are both adult endocrinologists, we work at the University of California, San Diego, where we see patients and do research. And we also work for the notfor-profit organisation Taking Control of Your Diabetes, which is all about empowering, educating people to take control of their diabetes. So, thanks for listening to our Sanofisponsored podcast. And today's podcast, we'll be discussing the evolution of CGM, and time in range, which is a CGM derived metric over the past century, how patients are using it, how we're using it in clinic, and now how we're using it in clinical trials. Steve Edelman Yeah, what's great about the metrics, and the verbiage around these continuous glucose monitoring issues is that it's the same verbiage as we, as patients speak to us. So, like, when we talk time in range, they understand that, we talk time below range, we, we explained standard deviation. And that's what we do at our not-for-profit Taking Control of Your Diabetes. So, it's the same language. And I do think it brings providers closer to their patients, when they can get engaged in a really good conversation about their download that you might print up or show on a computer. Jeremy Pettus Yeah, and I think just off the top, you know, Steve, you and I both have said many, many times, I think you coined the, the quote first, and now I've adopted it, that continuous glucose monitoring is truly the greatest advance in history of diabetes since the discovery of insulin. And that is not over selling it or over blowing it. It's just a fact. Steve Edelman Thanks, Jeremy. I love when people quote my famous quotes. But when you think about it, right now, in you know, 2023, it's a standard of care for patients with Type 1. But you and I are strong believers that every patient with diabetes, no matter what time they get diagnosed, you know what type of therapy they're on, including Type 2’s, would definitely benefit from having a continuous glucose monitoring, getting engaged in their numbers, and knowing what they mean and using that to improve their diabetes control, whether it's adjusting their medication or lifestyle. Jeremy Pettus Absolutely. So, let's talk a little bit then about kind of the evolution of CGM, because guess what, we didn't always have it. So, we're gonna take a little bit of a trip down kind of memory Instructions for use: Please note, this supporting file must accompany the podcast audio file and be readily available to any users of the podcast audio file. MAT-GLB-2302068-v1.0 Date of approval: November 2023 lane. And Steve is, you know, handful of years older than me. So even though we got diabetes, when we were both 15, you got it in the 70s, and I got it, you know, in the early 90s. So, talk to us a little bit what you know, testing, quote, unquote, your blood sugar, was when you were diagnosed. Steve Edelman Yes, well, I'll make it brief because there's not much to say other than there was no fingerstick tests. There was no CGM obviously, there was no pumps, there was no insulin pens, I had to urinate in a cup, and use a little dropper take 10 drops water, five drops urine, and then put a little glucose pill in there and that would fizz turn 1000 colours. And I would hold it up to a chart and dark blue meant four plus when you are high, that's all you had, you know, you really, you were high and that was it. And then if it was orange, it was good. And that's what you put in your logbook. Jeremy Pettus And how often did you do that, every day? Steve Edelman Well, I was supposed to do it two, three times a day. But for our younger Doctor listeners or healthcare professionals, whatever is in your urine was in your blood three hours ago. So theoretically, in the morning, you had to void the first sample and then try to pee again. And in those days, I was on insulin because I was a Type 1 and we never adjusted our insulin. Jeremy Pettus So it's like why am I even doing this? Steve Edelman Yeah Jeremy Pettus It's not helpful information. You know, it’s high, low, I don't change it. I remember you know; you always said you were on one shot of regular NPH a day, which just doesn't last all day. So of course, your blood sugars were all over the place. Steve Edelman Yeah and I didn't know any better, my parents didn't know any better. So, it was the Dark Ages. And then eventually, you take it up with finger sticks. Jeremy Pettus Yeah, so you know, I was diagnosed '94 I think 1994, and, you know, classic symptoms, went to the hospital in DKA. And when I was in the hospital, they showed me my first blood sugar meter. And I didn't realise that this was kind of like a newer thing. You know, to me, it was always kind of the way that you know, we did it. I didn't know urine testing. And then you know, you had to prick your finger and of course that hurts. And we always say that that actually is the most painful thing about diabetes, like pricking your finger is way worse than taking injections. And it took a minute to get a result and a lot of it was this huge drop of blood you had to put on the device. And a lot of times after a minute it would say error. And so at least I had a blood sugar meter. But you know, I was a 15 year old kid. And I had to lug this pretty big thing to class in high school and try to hide under my desk and sit there and look at this go 47, 46, 45, it seemed like an eternity. And then finally you get a reading. But Instructions for use: Please note, this supporting file must accompany the podcast audio file and be readily available to any users of the podcast audio file. MAT-GLB-2302068-v1.0 Date of approval: November 2023 you know, at least that I knew what my blood sugars were so that was a huge advance. But really, between when you were diagnosed the 70s and in the 90s that was kind of the biggest advance, we went to blood sugar metres, and thank God for them, but they certainly weren't like the end all be all. Steve Edelman Yeah but you know what, you know, what amazes me is that all the doctors out there that are resistant to change, they were against people seeing the results of their own glucose meter. They said, "Oh, they won't know what to do with it, that it'll cause you know, dangerous situations though, overdose insulin." And that sort of philosophy or thinking came out when CGM first came out. So I mean, change is difficult, and doctors are stubborn. It really is the greatest single advance since the discovery of insulin. Music to connect two segments Jeremy Pettus Okay, so then going through time, so you know, my first meter was called The OneTouch Basic. And then a couple years later, I got the OneTouch Basic Two, and then eventually the meters got smaller, and they needed a little less blood, and they needed less time. And so that was great. But that was literally like over a decade, you know, from, let's say, 94 to 2004. That's kind of all that had happened in blood sugar monitoring. And it wasn't for me until 2010 that I got on my first continuous glucose monitor. So now we're gonna talk a little bit about kind of the CGM appearing on the scene. And we actually filmed a video here at TCOYD, reenacting the moment that I went on a CGM, because it was actually the moment that I met you, Steve. I was in my medical training as a resident. And I heard there was this legendary doctor named Steve Edelman that I had to go and meet. And I went and met you and I wanted to talk about research or something like that. And as soon as you found out that I was a Type 1, you started talking about CGM, and pretty much ridiculed me that I never heard of it or that I wasn't on it, and sent me away. And I literally got on my first CGM the next day. So, tell us a little bit about that system, Steve. Steve Edelman Well, first of all, the first part is exaggerated tremendously that I helped you get your first CGM. I was shocked that you had not heard about it. But anyway, the systems back then were, were pretty archaic when I think about how they work now, you know, they had longer warmup times, they didn't last as long they weren't as accurate. The subcutaneous sensor that went under the skin did not have an auto inserter. And as you mentioned, you know, the different companies that make CGM have come on with the newer advances, newer models, up until the current time, and we got some pretty good choices now. Jeremy Pettus So I would say even by today's so by today's standard, that initial device that you and I were on was, was not great, we just like you said it was not as accurate and etc. However, it was still a godsend, you know, going from even if I was checking my blood sugar 10 times a day, which is a lot, to all sudden seeing my numbers, you know, every, all the time essentially. So I remember just like feeling like the blindfold have been taken off. But now I can see where I am all the time, I felt safer. Having these alerts and alarms that would go off when I was high or low. You know, I always tell a story of when I was, you know, checking my blood sugar. I would wake up every morning and check my blood sugar. And literally put my hand over my eyes because I just like, was fearful of what is this number going to be? I have no idea what Instructions for use: Please note, this supporting file must accompany the podcast audio file and be readily available to any users of the podcast audio file. MAT-GLB-2302068-v1.0 Date of approval: November 2023 happened overnight. Sometimes it was 300. Sometimes it was 80. So just being on a CGM and having that taken away where there's no more surprises, really, you can kind of see where your blood sugars are going, feeling safer. It was it was a huge, huge win. Steve Edelman Yeah, I totally agree. And what opens up the conversation for the rest of our podcast is at that time, Jeremy in 2010 for you, we didn't really talk about CGM metrics. We didn't have the download. We never talked about time in range. So, it's a relatively new phenomenon. So, I'm, I'm excited to get into it. Music to connect two segments Jeremy Pettus So, you know, that brings us to our next section on kind of, CGM derived metrics. So, first of all, it's important to realise that there's really kind of two big broad categories that CGM can do. It's the real time information for the patient living with diabetes, so we can look at our CGM right now Steve, see if what our blood sugar is where it's going, if it's high or low. We get alerts in real time. But then for providers, what we can do, is we download the information, and you can set it that you want to look, we usually say in clinic the last two weeks, that gives you a good picture of what's been going on. And you get all these metrics. So, the first one you get is just what somebody's average blood sugar is. So over the last two weeks, they can see your average blood sugar's 140, 150, whatever. And that's an average from a number taken every five minutes for two weeks. So, I don't know Steve, do that math real quick. Steve Edelman Several 1000. But you know, Jeremy, the next step, and Jeremy and I teach patients and providers how to read their CGM is the GMI, the glucose management indicator, which is the basically the estimated A1C and to spare all of you my diatribe on how inaccurate the laboratory based A1C is, the average glucose goes into the calculation. So the GMI is a more accurate measurement of the A1C than actually the lab. Jeremy Pettus And so, real quick, you can get an estimate of how this person's overall control is, what their average blood sugar is, what their estimated A1C is, boom, you get that in two seconds. And this is really how we go through it. We look at that kind of first and then the next thing we look at are these time in range buckets. So what is time in range? What is time above range, time below range? Well, we as a diabetes community have agreed that the area that we want to try to keep people in is a blood sugar between 70 and 180 milligrams per deciliter, so that’s not, you know, 80 and 120, we're not aiming for euglycemia we are aiming to keep these people in an area that we know is safe, that the data supports that the more people have time in range, the less complications they get. So, we look at what percent of the time is somebody in that range between 70 and 180. And we say, so what is their time in range. And our goal is to keep that above.... Steve Edelman 70%, which is 17 and a half hours per day. And it's, it's such an important number, because it really represents what, what the A1C would be, the higher your time in range means the less you're above range. And then you're going to get to it in a second, which will be the time below range, which is another important value. And of course, the time in range has different Instructions for use: Please note, this supporting file must accompany the podcast audio file and be readily available to any users of the podcast audio file. MAT-GLB-2302068-v1.0 Date of approval: November 2023 goals. If you're a pregnant woman, they should, they shoot for a little bit tighter. If you're older with the risk factors for severe hypo, they might say 50% is what we want, but no hypoglycemia. So, there are different categories, but 70 to 180 is the range. And last thing I'll say is, they didn't just pick these numbers out of a hat, they, they had a big consensus conference, all the big mucky mucks, you and I were not invited. And basically, that's the range where people should be in general before and after eating. So, it does include a typical day, but we know that no one can stay in that range 100% for more than one or two days. Jeremy Pettus Yeah I always tell patients that even people without diabetes will go up to 140, 150. So we're not aiming for you know, 100 all day long. But I also like what you said at the top of our programme, Steve is that time in range means something to providers, and to patients. So, for us, we're thinking about 70%, they're avoiding complications. For patients, it's just time that they're safe, and that their diabetes is leaving them alone, they're not low and having to eat a bunch of food and just feeling crappy. They're not high and having to take you know, insulin or medications, they're in a safe range or just kind of cruising. So, it's language that we can all understand. Versus like, what is an A1C, you know, like, that doesn't really kind of make sense to people off the top of their head. But hey, the amount of time I'm in a safe range does. So time in range 70–180 that's the kind of main bucket we look at. The next thing I would say we look at is time below range. And that's basically the amount of time somebody is hypoglycemic. And this is put into two categories. So, the first would be kind of a mild hypoglycemia, if you will, which is a blood sugar between 70 and 55. And then the category below that is more of a severe low blood sugar below 55. And our goals for that is that we want that overall to be less than 4%. And then the sorry, in the kind of mild low less than 4%, and the severe low less than 1%. So, 4% is our metric, but 4% is an hour a day. So, I honestly think that's too much that I want to get people to be you know, 2–1% or less than really minimise their lows, maximise their time in range. Steve Edelman Yes, you repeat the fact that 1% is 15 minutes. So, you're right, when someone comes into the office and their, their time below range is 10%, they're basically below 70, two and a half hours a day. So, during the length of that download, you know, when you when you download someone's CGM, you have to look at the timeframe, you know, last month, last two weeks and, and people have apps that they can look at the last 90 days. Now the other thing I was going to mention, Jeremy, I'm not sure if you were going to, was the standard deviation or the glycemic variability. And that's important too, because even if someone's high all day, if there's, if they're not bouncing around, that's easier to fix. And then, the last thing that we look at, I believe is we look at the 24 hour glucose profile. And literally, when you start getting good at looking at the CGM downloads, doesn't take a rocket scientist either. Even though I am one of those. Jeremy Pettus You are. You are. Steve Edelman In literally 30 seconds, you could really hone in on the single biggest problem your patient has. And Jeremy and I did a programme called Rapid interpretation of CGM download. And basically, with within 30 seconds, you can say, okay, this is what we need to focus on. It helps the providers spend the most efficient use of their time. Instructions for use: Please note, this supporting file must accompany the podcast audio file and be readily available to any users of the podcast audio file. MAT-GLB-2302068-v1.0 Date of approval: November 2023 Jeremy Pettus Yeah, and one other point again, I wanted to make on the patient side of it, is that, again, patients can see this information on their phone kind of all the time. So, as an example, I have my personal daily time in range goal set at 80%. I want to push myself a little bit. So, every day I get a text, and it'll say, hey, you reached your goal yesterday of, you know, above 80%. And then every Sunday, I get a text that says hey, your time in range for the last week was, you know, 80% or whatever, that's, a 3% increase or decrease from last week. So, patients are getting this information, they can set their goals, they can come in with to see you a little bit more informed. So, it's not like that every three months, get my A1C and like, you know, like, again, kind of closing your eyes. So, you know, but getting back to what you're talking about as using this in the clinic. That is so important. And having this information just makes the clinic visits just so much more fruitful. I honestly just don't know what to do with patients when I don't have CGM information, because it's just, you know, you go from kind of a sea of plenty to nothing. And it's also been so important in this kind of digital world. Like, especially when you know, when, when the world of COVID when we couldn't physically see patients, but we can have them send us their CGM information. And so, we're still really well equipped that you know, the clinics could get the information the day before so we could look at it, see the patient virtually, go over their CGM together. And thank God we had that or otherwise well, you know, what will we have done? Steve Edelman Yeah, it really emphasises the point that the A1C is obsolete. It just tells you an average doesn't tell you how much variability, doesn't tell you how much time below range, and it could lull you into a false sense of security. You see a patient their A1C is 6.5. You go awesome, but then you put a CGM on and then they're getting low at night for a long period of time. And you know, that's an issue. Jeremy Pettus Well, you know, it's a good point, because I've seen a number of patients recently that will come in, their A1C is 5.8, 6.2, and they're saying, you know, I'm kicking butt, right? I'm doing a great job, but their time below range is 10–20% and that scares me. So, you're right, that a lot of times providers will say, Oh, your A1C is 5.8, you're my best patient. Like you got to teach all my other patients with diabetes, how to do it. And I'm thinking No, this is the person I'm most worried about. Steve Edelman Yes Jeremy Pettus But I wouldn't know that unless I had this kind of CGM information. Music to connect two segments Jeremy Pettus Alright, so, clearly in clinical care CGM is of paramount importance, for patients day-to-day CGM is of paramount importance. But now, you know, we're getting into the world of using it in clinical trials, which has honestly been like a little delayed, and but it's just now starting to happen more using CGM and clinical trials. So maybe, Steve, talk to us a little bit about the, the evolution there. Instructions for use: Please note, this supporting file must accompany the podcast audio file and be readily available to any users of the podcast audio file. MAT-GLB-2302068-v1.0 Date of approval: November 2023 Steve Edelman Yes, well, the evolution has been extremely slow. And the A1C had been so ingrained as the gold standard. It's been very tough to change their mindset. But we are breaking through that, there have been a couple of studies, the one that I was intimately involved with for five years through COVID was called the InRange study. And for the first time ever, they used time in range as the primary endpoint, because it's always A1C, and then there might be time in range might be a secondary endpoint. And time below range might be another one. So, it wasn't until the last, I would say, two or three years that we started to see companies use it as a primary endpoint and it is so important, and it tells us so much more information than the A1C. Jeremy Pettus And thankfully, that's catching on a little bit now, and we have other studies that are doing the same. But I would say you just simply cannot do a diabetes trial now, where you're looking at glycemic control without at least including continuous glucose monitoring. I mean, maybe it's not the primary endpoint, but you need it there, because it gives you such a robust data set to look at, you know, time in range, time below range, because hypoglycemia is just notoriously underreported in clinical trials or in clinical care in general. So, you know, I do a lot of clinical trials and people will come in and we'll say, over the last two weeks, you know, did you have any low blood sugars? No. And then, you know, so we say no, but then we look at their own personal CGM, and they're low all the time. So, having that data is just critical. Steve Edelman Yeah. And you know what, you know, in your studies, you know, the protocol called for blinded CGM, you know, so that's what we do in clinical trials, never in real life. It's amazing how much data it will tell you about what that medication, what that therapy is doing. And there is just a consistent body of literature that shows CGM does all these positive things with really no negative issues, it just less highs, less lows, you know, it gives providers confidence and gives them ideas on a change therapy, gives patients confidence, as you mentioned earlier, so it's really a body of literature that is consistently similar and positive. Jeremy Pettus Yeah. And so, and thankfully, again, with these clinical trials, I think now having some things with primary endpoints and using them more, hopefully, the FDA and other kind of regulatory bodies will start accepting these as outcomes and using it kind of more and more. And as you also mentioned that just recently here in the United States that we can use it for people with Type 2 diabetes on just basal insulin. So, we're just going to be using it more and more in clinical practice, hopefully, eventually, for people not on insulin, just people with prediabetes, as these devices get cheaper. So, I would say when they first kind of came out, there was a lot of resistance. I remember just people thinking that was a kind of a whiz bang tool or fun toy for people to look at. And it's taken a long time to win people over. I have to say, Steve, you're one of the pioneers and got me on board early. And now people are always like, well, you know, I was always on board. And this, of course, is where it's at. But thankfully, people are coming around one way or another. Steve Edelman Well, I'm so sorry I, I upset you that first day I met you, but it came from a place of love. Instructions for use: Please note, this supporting file must accompany the podcast audio file and be readily available to any users of the podcast audio file. MAT-GLB-2302068-v1.0 Date of approval: November 2023 Jeremy Pettus So Steve, obviously, you and I are big fans of continuous glucose monitoring, but they do have some challenges. I would say overall, these challenges are getting much less, meaning when they were first on the scene, it was really difficult to get it covered for patients. And you mentioned some of the issues with the accuracy and falling off. You know, so how have you seen things improve and what are some challenges that still exists with CGM? Steve Edelman Yeah, I think the challenges that still exist is there's still a lot of ignorance about CGM, both on the cut side of providers as well as people living with diabetes. So there has to be education around this. Jeremy Pettus When you say ignorance, what do you mean? Steve Edelman Well, they don't exactly know how they work. They don't know how they're going to help their patients, they don't know time in range, they don't know how to deal with the glycemic variability, they don't know, they don't have enough knowledge to help patients set their upper and lower limits. And so, education, I think, is key. And that's why you and I spent so much time at Taking Control of Your Diabetes, which has a healthcare, professional wing. The second is still a big issue was access. You know, we know that Type 1 diabetes, all of those patients should have one, but it's easier said than done. And so, I think that's extremely important to help those patients get one, especially if we know it's going to help them live a longer and healthy life. So, after, you know, after getting it, then of course, we talked about educating how to use it and dealing with the fact that there are a lot of little tricks to the trade for people to be successful. And then you mentioned several times, how they should teach them how to analyse their own numbers to get engaged, it is all about engagement. Jeremy Pettus And I would say the last one that again is getting better but it's the inner connectability between the CGM and other devices, particularly with pumps. So, you know, certain CGMs only work with certain pumps. And as new CGM products become, you know, available they might not integrate right away with pumps, so these things can be kind of like, out of phase. But, you know, again, it's getting a little bit better. Steve Edelman Yeah, we're at we're at the infancy actually, so, you know, eventually we'll have a totally closed artificial pancreas. So, you know, we are, you would agree that the advancements in CGM are exponentially going on. Jeremy Pettus Oh my gosh, yeah. And just like, like we mentioned going from three days to now 10 days. And, you know, we didn't even mention the part that is accurate enough now that you don't have to do finger sticks. And that was huge. When CGM was first kind of invented, if you will, you still had to calibrate it twice a day, and that's gone away and that was amazing. So, I always tell the story now about people that I see are newly diagnosed with Type 1 diabetes in the hospital. You put a CGM on them, and they may literally never check their blood sugars, which is crazy. Instructions for use: Please note, this supporting file must accompany the podcast audio file and be readily available to any users of the podcast audio file. MAT-GLB-2302068-v1.0 Date of approval: November 2023 Steve Edelman Yeah, well, don't forget, we have an implantable. Jeremy Pettus Thank you for taking off your shirt to show me on your arm. Steve Edelman I was showing you. Jeremy Pettus The listeners can't see it. Steve Edelman We have different, different form factors, and we have an implantable CGM, as well, and people are working on all different types of, of, you know, technology. So, it's, I was trying to remind you to say and say it, but I guess I said it myself. Yeah, it's it's amazing field. And when we talk to younger doctors thinking about going into endocrinology, it's one of the things that excite them the most when they hang out with us in clinic. Jeremy Pettus Well, so thanks for going through this with me, Steve. So, you know, when we're talking about kind of key takeaways from the discussion, what do you want to, you know, some points you want to leave our listeners with? Steve Edelman Yeah, I would say this that if you're someone that is not using a lot of CGM, I hope we opened your eyes to the benefits that will not only help your patients, but also help you be a more efficient and effective healthcare provider. And I think the other thing is that it's the language that we've mentioned several times is the same between provider and patient. And it does take a little bit of time on your side, or maybe if you have an educator to get your patients engaged in looking at their CGM, understanding the numbers, because a lot of times you and I have had patients where we put a CGM on them and they don't seem to get much better because they don't look at the values. So, it takes a little bit of engagement and education. And you know, where you set your upper and lower limits, there's a whole bunch of things that all of your listeners can go to our website and go into the video vault and also look at, listen to some of our prior podcasts. But I do think that the benefits are tremendous. Jeremy Pettus I would say, yeah, if you're listening, and you think this is all overwhelming, you know, time in range and the systems, I don't know how to prescribe it, or, or interpret the results, please still offer it to your patients, because you should not be the gatekeeper of this technology that people do so much better with. And even if you never look at their data or help them with it, people are safer, they generally do better. As soon as you put these devices on, they start learning. It's a fantastic, you know, standard of care for people with diabetes. And when it comes to kind of the research and clinical trials, it's just going to be kind of more and more there that these metrics are going to report it. It's just the way that think diabetes is going thankfully, so God bless CGM, you know, it continues to evolve, the devices keep getting, you know, better, more sophisticated, so, it's a really kind of a cool time to be practising diabetes. And for you and I to see this as patients of gosh, how it's changed our lives in a Instructions for use: Please note, this supporting file must accompany the podcast audio file and be readily available to any users of the podcast audio file. MAT-GLB-2302068-v1.0 Date of approval: November 2023 very positive way to just feel safe and in control with this disease that can, a lot of times be the opposite of that. Steve Edelman Yeah. And I think it's the first time in my career where I might have a whole clinic of patients with really good A1Cs, but also very low hypoglycemia, and that was just unheard of before. Jeremy Pettus Well, that's usually the patients I see, and then once I like, fix them, I send them to you to make you feel good. Anyways, well, thanks everybody for listening. Steve, as always, been a great joy doing this with you and I hope you all enjoyed listening. Music fades out