บทถอดความฉบับเต็มของ Rethinking Insulin in Long-Term Care: Safer Strategies for an Aging Population | Episode7

back to this, this episode, ⁓ there's a lot to discuss isn't there, Caitlin? Caitlin Little: Ha ⁓ yeah. Yup. ⁓ yes, a lot. It's my favorite topic. Scott Stewart: Yeah. And before we get started on this, some of the things that will remind all of you listening in, if you're part of a long-term care facility, don't forget to take out a Sharpie and date your insulin pins when you take them out of the fridge. Yeah. Do not keep all of them out of the fridge either at one time. Make sure that you only pull the pin that you need for that resident. Don't share insulin pins with other residents. It's a no-no. Don't reuse needles. Caitlin Little: Please. Scott Stewart: that are on there again and again for the same patient. If there are safety needles, you won't be able to do that. They're blocked after one use. But lots of little reminders there that we see when we're doing the cart audits out there. And that can be a really costly error if you pull all the insulin out and you leave it in your cart versus just using one pen at a time. But if they're not dated, then you have to kind of destroy it based on the dispensed state. And they're oftentimes a month back so you end up having to destroy lots of pins. But with that being said, let's talk about control. ⁓ Caitlin of somebody like our age and older perhaps that has diabetes. What will we see maybe out in the community based setting and then we'll move into the long term cure space. Caitlin Little: Yeah. Mm-hmm. Yeah, so in the community and more of the middle age group, we would see a little bit more aggressive control. So our main goal of therapy is going to be to try to slow down the progression of the disease state. And we all know that diabetes causes other disease states like renal issues, eye issues, neuropathy, and those types of things, cardiovascular events. So. And that's what makes kind of diabetes also complicated, because we're not just treating blood sugar. We're also treating and trying to prevent other disease states from happening from high blood sugar. So we will see a little bit more aggressiveness with a more aggressive A1C goal. We'll see more, you know, insulin usage in the community. We'll see ⁓ more, you know, more than one non-insulin therapy. ⁓ Also more blood sugar checks. now whether the patients are compliant to it or not, think that in the community, that's really a barrier because we're very active. Like this, this is the age group of active, you know, busy day we're working and checking our blood, blood sugar is kind of very difficult for compliance and staying on top of that. So leaning on a one C's is, is it more of a lab that they will use to kind of fill in the blanks. of what is reported by the patient of their blood sugars. So you'll see more weight on those A1Cs being done every three months ⁓ versus what you may see in the elderly community. ⁓ And also ⁓ active exercise, non-pharmacological, ⁓ more non-pharmacological interventions of diet and things like that. We

definitely want to do that in long-term care, but that is very heavily pushed in the community setting. of those non-pharmacological interventions. So we can, once again, that end goal is to try to slow down the progression of that disease and it affecting other organ systems. Scott Stewart: Yeah, and I think then we move kind of into the long-term care space. And in long-term care, we have these residents that are in their 60s, 70s, 80s and older. And the treatment modality, the goals that are going to be coming along with that age range is not as aggressive of treatment. because a lot of the target organ damage has already occurred in a lot of instances. We're now changing the direction that we are trying to go with those residents. And Kayla and I were talking about this before you guys joined us here, but in a lot of, I remember I've been practicing in long-term care from the time I graduated from the College of Pharmacy and got my license. And back then, You saw, we've seen all different types of regimens for treating a diabetic resident. Even back then, I think the American Diabetes Association and some other groups out there were recommending pretty aggressive control, like seven less than seven A1Cs, like Caitlin was mentioning. Now we're seeing that change. And as we move into this segment, when we're going to talk about aggressive treatment in the long-term care space and some of the, cons of that. That's no longer the goal that American Diabetes Association, American Geriatric Society, a bunch of other groups out there have recommended. It's now less than 8.5%, but even more so, it's just prevention of hypoglycemia. Hyper or hypoglycemia is the primary goals, end goals for a long-term care resident. So you can kind of see from like what Caitlin was talking about, in a more community-based setting, we're going to be more aggressive. We're going to use a lot of different treatment methods to bring A1C down to, of course, they'll be checking blood glucose and stuff routinely, but a lot of times looking at A1C goals, keeping them low so that that person is more aggressively treated. The target organ damage is reduced greatly, the quality of life, all that kind of stuff goes into consideration. Not that all that goes out the window when you get into long-term care, but aggressive treatment is not always needed in the long-term care space because the goals that we have for them are different than somebody that's in the community setting. And I think sometimes that's really hard for clinicians. It's hard for pharmacists. It's hard for nursing staff. It's hard for, you know, admins, everybody else in the buildings out there in long-term care space or any type of long-term care setting you're in. to remember that that person that we're treating, we're treating the person, not numbers, and we're trying to prevent hospitalizations, we're trying to prevent hypoglycemic events. And so I think when we move into this aggressive treatment, ⁓ the reason why this is so important to know in this setting is that our residents are frail, they are ⁓ very complex, oftentimes very vulnerable, and they're at high risk. Caitlin mentioned this already, that as you have target organ damage, for example, your kidneys, your renal function, cognitive status, heart related issues, a lot of the residents that we're taking care of are there. They're having those problems because maybe diabetes wasn't controlled well going into that setting, up into that point in time, maybe they... were treated and it just they didn't stay compliant to the regimens that they were being treated with. I mean, we're pharmacists and we act like we're perfect, but we're probably the world's worst at staying on task with antibiotics and everything else that we're supposed to do. We think we know better. But you see all these things that what we would be trying to prevent in the community setting we're seeing now in the long-term care space. And so this aggressive treatment Caitlin Little: Yeah, yeah. Scott Stewart: isn't needed as much as the reduction of hypoglycemia reduction of hyperglycemia. And there's a lot of reasons why it hypoglycemia is not just well, their blood glucose is low. I mean, that's that's true. That is very true. That's that's the definition of it. But it's what happens when a person goes hypoglycemic. That is what you're trying to prevent. The person could fall. there could be a hospitalization that happens with that. And we're trying to prevent, I mean, delirium, you name it. Well, we did a case study the other, this is a couple months back at one of the organizations I attended. And in the case study, it was a diabetic resident that had a hypoglycemic event, had suffered delirium when they went in the ER setting, came out of that on more aggressive treatment for diabetes, everything else along that line, but also came out on antipsychotics and things for the delirium. So you can see that that person, we really want to keep him out of the hospital. We really want to keep him from falling. We want to do things that are going to help them be safe and use treatments and regimens that are going to keep them safe. One of the things that we see, which we'll spend a little bit of time talking on now, and then you'll hear it throughout this. our good friends, the sliding skill insulin orders and how they really don't treat anything. They treat numbers and it's all retroactive. after the fact on those, it's not trying to be more proactive on regimens, but we see a lot of sliding skill in this setting. Huge risk, huge risk. ⁓ things that you guys don't even probably think about and Caitlin, you can bring some up here. You can be thinking some, Caitlin Little: Yep. Scott Stewart: on when I'm like demoing this, but there I've got this pen right here in front of me. This thing I've got the safety needle already engaged. I injected it in this little pad next to my desk here. But when you're priming your insulin and I

don't know if you saw that, but it just flung some more of that fluid out of there. So now my office smells even stronger than it did. But when you're priming this and you do your two units or whatever, if you don't see it come out, Caitlin Little: Mm-hmm. Scott Stewart: There's an issue with like the pin needle at the end of it. And you just keep priming and priming and priming without switching the pin needle. It builds up extra volume in there. Things like that that you don't really even think of when then when you go and inject that person, they get more insulin in them. A lot of times that happens with like the sliding scale stuff because you're giving them more insulin or there's more exposure to it. But it doesn't really do anything for the overall resident other than bring a number down. It also opens you up to giving the wrong amount of insulin. We've seen that before. Misreading the order. So maybe, and I've never understood this, like 150 to 200 to get one unit of insulin. Not sure what a unit does, but one unit of insulin. So you misread the order and you don't give the unit of insulin. That opens you up to med errors and other issues there, not following orders. So sliding skills are really becoming more and more a thing that's used, yes, in a hospital setting, absolutely, for more of acute care aspect of it, but there's a reason behind that. In our setting, in the outpatient setting, sliding skill is not really a standard of practice at all anymore. And so if you're listening in on here, you're like, well, I've got a lot of sliding skill in my building. There's a lot of reason to talk with your prescribers, ⁓ your physicians, your nurse practitioners, et cetera, PAs that are in your buildings about why that's the case. And perhaps there's some changes that you can make there, but that's just one example of an area where you can see a really aggressive way of treating diabetes by putting these aggressive sliding skills on that do increase the risk of med errors of not giving insulin correctly or of, you know, again, harming that person by just too much insulin or over aggressive treatment. What else, Caitlin? What are some other things that we see in the long-term care space with aggressive treatment? Caitlin Little: high dose long acting insulin. That one. Scott Stewart: Yeah, what they, they call that over basal ization of insulin. Yeah. Caitlin Little: Yes, yeah. And I think that's, you know, part of that transition from the community coming into long-term care. And I think it's important to note that hypoglycemia is very dangerous. It is more dangerous than hyper. So hyper causes damage over time of uncontrolled. Hypo is pretty instant of damage to the organ systems, cardiovascular patients can code, Darren hypo. ⁓ So with long acting insulin, is like exactly where my mind goes. If this person stops eating for a second or they get up and start walking more and burning more sugar because exercise burns sugar or there's any variable losing weight can cause them to respond better to long acting insulin. So when we're at 45 units of Lantus and something shifts that scale, that hypoglycemic event can be very severe and their bodies are so sometimes overloaded anyways, they have other disease states that are going on. So their ability to compensate or overcompensate for that hypoglycemic event in their cardiovascular system is not as strong as somebody in the community. They don't bounce back as quick from that. It prolongs the hospitalization stay. It makes it more difficult for them to regain strength after that event. So those episodes are more traumatic for our residents in long-term care. And the long acting insulin and short acting, but the long acting, because once it's in, it's in. And I have seen residents try to eat in front of it. I have seen nurses try to give. the glucose tablets or give the emergency glucagon to try to stay in front of it. But when that dose is so high, it's almost on the line of impossible to stay in front of. So it's incredibly dangerous. ⁓ That is one thing with my diabetic residents that are type two is really targeting the sliding scales, but also high doses of basal insulin. And typically you'll see that when we're not utilizing non-insulin therapies. So we want to try to use those non-insulin therapies as our staple and our backbone. They do come with lower risk. They also manage their other disease states and have additional properties that will help cardiovascular or decline in the progression of neuropathy and things like that. So that's where I kind of target for me too, is those basal insulins. They scare me. I have had a phone call from a D.O.M. that said, need you here tomorrow. We had somebody code and we almost were not able to bring him back. And we have to do something because my patients are bottoming out every other day to the point where the nurses were refusing to give the long acting insulin. It happens. They change and things change in their bodies and their diets. Scott Stewart: Yeah. Caitlin Little: their other disease states and it can happen very, very quickly. Scott Stewart: Yeah. And, and that's a really good point. I think sometimes they, there's this thought that the long acting insulins are less risky. ⁓ and if you're listening in, you may not remember really the reason for each insulin type, but your long acting mimics your body's, way of handling glucose in your, in your body when you're eating and things like that. It's kind of this baseline. level of insulin in your system that offsets and make sure it kind of like equilibrates everything. And then that's when you see things like the short acting, the rapid acting given before meals. That's because when you eat, you have a spike of glucose when you eat. And so those help bring that overall average down, just like the low, like the basal insulin that doesn't necessarily peak brings your overall average down. And so the goal there is, is again, you can

use them and they are a great insulin therapy. They're one of the mainstays for sure in this setting, but you can use too much of them. And that's what Caitlin is talking about that sometimes I think it's easy for us to say, well, we don't want to do a meal time insulin or anything along those lines because that's more risky, more chance of somebody not eating. And then what do do with that? And so they, just see the basal insulin. Continuing to increase I think even sometimes as pharmacists were like well, that's just the easiest way to go Like we'll just increase their basal insulin but not necessarily we need to look at the person and not the numbers for that What we mentioned earlier I think is also so important with aggressive treatment. What are the goals that you have for that? Specific resident and you have you care plan that there a once he's gonna be less than seven. That's a really aggressive A1c goal range. Remember again, American Diabetes Association, other organizations out there, they've widened that up maybe 8.5. I think that's somewhere in the, and I don't know if it's exactly right, but around the 200 blood glucose range. We'll just say give or take 20 or 30 years. So 10, 10 to there. don't know. Somewhere in that ballpark range. I think it's 200 ish. And so that's kind of Caitlin Little: you Scott Stewart: gives you an idea of reference. So if you're taking finger sticks on those residents, which we'll continue to talk a little bit about as we move into how do you de-intensify, how do you lessen the risks for your diabetic patients that are on insulin, the residents that are on insulin, that if they've got this really strict goal, they don't need that strict of a goal in this setting. Really, we were trying to prevent the hypoglycemia that Caitlin and I have been talking about, hyperglycemia as well. We're just trying to prevent those in this this setting. And that's why reassessing the resident, making sure that the care plan is accurate for what that resident really needs in terms of their care, which leads us into the second segment. We want to talk about de intensifying when less is more. Sometimes you don't need as much insulin. so Caitlin, let's talk about how would you know, when, what are some residents that perhaps are listeners that are, you know, keying in on this topic, what would they be looking for? How would they know who might be a candidate for de-intensification of insulin? Caitlin Little: Well, the first thing you'll want to look at in the facility or in the residence chart is the glucose sugars. I mean, that's, that's a given and how often. So, you know, sometimes you can look at those and they may just be the fasting or if they are truly the fasting, you have to look at what time that is. If it's 5 a.m. more than likely that's the true fasting. You have to look at the time of which they're taken. You have to look at the frequency of which they're taken. And then you have to look at. the A1C. If I see that

a resident has got several glucose monitoring, let's say three times a day, I can go through probably two to three months of that data and be able to tell, okay, well, we're running really low in the morning or we're running little way high in the afternoon. And that gives you that many frequent glucose checks will kind of give you a picture of like what their sugars are looking out through the day. And that will kind of lean you towards, well, are we doing too much of long acting insulin? Are we bottoming out first time in the morning? Are we bottoming out in the evening? You're going to look for those low sugars. There are times where I may see just the blood sugars being checked once a day and I may go to their A1C and see it's a 5.5 and I'm like, Ooh. And they're waking up in the morning at 16. I'm like, Ooh. Well, we might need to deep, we might need to kind of come down on some of their, their therapy doses, ⁓ to just really, it depends on the resonance. So your A1C sometimes can, can lead you in that direction because if you look at their sugars and you see a bunch of high, but their A1C is a 5.5, then you could probably say that they're bottoming out sometime during the day because that's how they got that average of 5.5. The A1C is an average, right? So if they have a bunch of highs and they're at like a really low A1C, well, they're probably bottoming out. There's some lows to bring that average down, right? So that will kind of clue you in. ⁓ Their weight gain or loss will help you. That does help. So if somebody is ⁓ constantly like trying to stay in front of high dose insulins, they're going to gain weight. They're not going to be as mobile. So that will help you lean towards, ⁓ we have weight management issues here. We really want them to try to get up and be more mobile. We might want to decrease long acting, start something like Trulicity that has better overall, you know, options and manageable. you know, they're not side effects, but you know, targets for their disease state, like with the, the weight management and controlling their blood sugar. So it really kind of, for me, depends. And the whole picture will tell me, like, I'll look at their regimen that will sometimes clue me in of what we're doing there. Like our prescribing pattern, or we just on mono insulin regimen, like it's just all insulin and they're type two diabetic. And they may be controlled. mean, I have some residents that are at 7 % and their blood sugars look great, but they're on 50 units of long acting insulin twice a day and meal replacement insulin. I'm like, this, this is a very aggressive regimen and is dangerous. Even though everything looks pretty, one day it may not be pretty for this resident and it will happen faster than we can probably fix it. So that will help clue you in of the regimen itself and how it's structured of whether they need to lean off of the insulin more and deescalate that and put more safer alternatives in that regimen to pick up the weight of controlling those blood sugars. Scott Stewart: Yeah, I think you mentioned something that's really important. And if you guys listening and heard that it's that like any of us where that resident is right now is likely not going to be where they are in three, six months, nine months, a year. We're all changing in this setting. The unfortunate reality is, is a lot of those residents, this is the end of their life, right? Their life expectancy. is however many years that would be in that setting, their functional level is likely to decline and weight fluctuations, all the things that Caitlin mentioned are all areas that if you see that happening, you would want to key in, okay, well, that person may not need as high of doses as they were getting. They quit eating all their meals all the time. I mean, I'm convinced I'm probably going to need a lot of insulin because like I'm to be drinking Dr. Pepper and eating like candy all the time. ⁓ I had a resident one time and I was like, man, I don't understand how they're, they're so uncontrolled and the homes they look here and we went by the room and their family had brought them Taco Bell for like all three meals that day with like pop and soda and all, all sorts of stuff there with them. ⁓ that'll likely be me cause I really liked Dr. Pepper if you don't know that. Caitlin Little: You I know, I do too. I love root beer and Dr. Pepper. Yeah. Scott Stewart: ⁓ yeah, this is why we get along so well. Those are my two favorites right there. But you might be wondering, okay, well, what if you find a resident that does kind of fit that bill and you think to yourself, well, I think maybe we need to de-intensify. What exactly does that mean? Well, we've kind of like teed you up for this one because we've talked about what over an aggressive treatment looks like where you're using sliding scale, we're using high doses of basal insulin. De-intensifying is getting rid of those or reducing those down. So yeah, you might be sitting out there and saying, yes, carefully. Something that you might be saying to yourself is, well, my doctor or whatever is never going to get rid of those sliding scales. We hear that a lot. Caitlin Little: Carefully, carefully, carefully. Scott Stewart: That doesn't mean that they always have to stay exactly how they are right now. What I mean by that is, for example, we make some adjustments, we use some of these non-insulin options in there, we de-intensify their insulin regimen. That resident may not need that 150 to 200, 200 to 250, whatever reading sliding skill anymore. They may not need that. You may reserve the sliding scale for more at the high end where if they were, again, we're trying to prevent hyperglycemia as well. So maybe we want to reserve that for the high end of that regimen. And so that provides a method by which the doctor has a treatment in place. They're not going to necessarily get notified right then and there. If it's really high, they will get

notified. Almost every sliding scale order says that. They go beyond a certain point, but that's, Caitlin Little: ⁓ huh. Scott Stewart: Option that you could do it doesn't mean that the sliding skill is completely gone But it does lower the risk of giving too much insulin on the other two times that you might have given it when it was lower readings that the resident really didn't need to begin with and and If their overall regimen can support it, that's one area you can do that in Caitlin's mentioned this several several times reducing that basal dose Caitlin Little: Mm-hmm. Scott Stewart: A lot of times there's no need for them to be on these gigantic doses of basal insulin. Maybe isn't really benefiting them at all to be on that and all it's doing is opening up risk associated with that. Caitlin Little: And honestly, if you think about it and the beauty of this, just starting to decrease in basal and start non-insulin therapies, right? It kind of takes care of itself in a way because the type 2s, not just type 2s, not type 1s, but type 2s are resistant to insulin, including manufactured insulin. Scott Stewart: Right, yeah. Caitlin Little: So when you start non-insulin therapies and their body starts responding and utilizing what insulin they are producing, which we know at the latter end of type two diabetes, the pancreas is not as productive in producing insulin anymore. And they're more on the line of a type one, but we always want to maximize our body's response to what it is still producing. And you'll find that once you start. playing on this line of transitioning out of these insulins and high dose insulins that they start responding better. Not only to the insulin that they're being given, but whatever insulin they still are producing. And that's what I mean by like careful. So when we do this transition from insulin to non-insulin therapies, we have to be really mindful of that and really careful during that transitional stage, but it will kind of. show itself and take care of itself in the sense of like, okay, well now we can go up on Metformin to a thousand milligrams twice daily. Then you max that out and you're like, ⁓ my gosh, their sugars are, okay, we're gonna have to decrease this. And it kind of does it on its own. And you'll be able to establish the lowest most effective dose of insulin needed with less risk. Scott Stewart: which goes right along with everything else in the elderly population. want lowest effective dose. Heard that with psychotropics, every drug known to man. Yeah, lowest effective dose and simplification of regimens. Really the goal that we're trying here is, and if you're a nurse listening in and you've had a resident with a very complex regimen, lots of insulin, lots of sliding scale, Caitlin Little: Everything else. Everything else. Lowest effective dose. There it is. Yep. Yep. Yeah. Mm-hmm. Scott Stewart: That's just opening up for problems. know, there's not only, we're not necessarily talking about just overall med pass burden, although that does absolutely increase your med pass burden and chances for error, but just the overall care. I mean, you've got all these residents that you're trying to take care of. You've got them coming up to you. I mean, we see you. We see you as consultant pharmacist. We want you to know that. And we see how often Caitlin Little: him. It does. Yeah. Scott Stewart: Those residents trust you guys, but they come up to you and they bombard you with lots of things that they're needing and you're drawing up insulin or you're dialing up insulin on the insulin pen, right? And it's easy to get sidetracked. know ⁓ cognitively, I think we did a YouTube short, a med short on this, where if you get interrupted, it takes the average person up to 15 minutes to get back on task. And so those kinds of things can increase the risk. Caitlin Little: Yeah. Scott Stewart: for problems, de-intensification or de-intensifying the insulin regimen, simplifying it perhaps even to once daily insulin plus some of these non-insulin therapies lowers that overall risk there as well. And so that would be another thing that you see. We've mentioned a lot of ⁓ times these non-insulin options. And so Caitlin and I wanna talk next. Caitlin Little: Mm-hmm. Scott Stewart: on this next segment about that, about the, what are the non-insulin options that we're seeing? What are the ones that are rising? And of course, some of these you're going to have heard about from a weight loss perspective, but we're going to be talking about them from the insulin and diabetes management perspective. But we're going to start off with one of the big guns. And this thing has been out for a long, long time. And it's still one of my favorite drugs because I, it's, there are very few diabetic meds out there that can lower blood glucose and A1C like the powerhouse that is Metformin. Metformin is just a beast and probably I just think, I just find it amazing. I don't know, Caitlin, if you found that the same way, but like it's been out for so long and yet all these things have been trying to come out and rival Metformin in terms of like the effectiveness, not that they're necessarily competing, but want to be as effective as Metformin and many of them Caitlin Little: Mm-hmm. Yeah. Right. Mm-hmm. No, they can't. They can't. No. Mm-mm. Scott Stewart: still can't even get close to metformin effectiveness. So I just find it to be such a cool drug, but metformin is one of the big guns and we see that one used. In fact, yes, EGFR renal function is very important with metformin. I think we're going to see a lot of studies coming out and continue to come out with relation to diabetic management. I even read a study one time where they gave metformin to people with very poor renal function and they were just fine. you know, so I think we're going to see a lot of that too, but, but Caitlin and I know this all too well, that when you have lower renal function, metformin is supposed

to be dose suggested. And that is something that sometimes is forgotten or not even started to begin with. But when you can use metformin, it's so, it's just such a powerful drug and really Caitlin Little: And they were fun. Yep. I've seen that too. Okay. Yeah. Scott Stewart: I mean, correct me if I'm wrong, Caitlin, very like no hypoglycemia risk or very little hypoglycemia risk and none and hardly any side effects. Like incredible. Caitlin Little: None. None. About none. Very little. It got a bad rat for the lactic acid. And that was a long time ago. And since then, we have so many studies showing that that isn't so rare. Even with risk factors, it's incredibly rare. It's of no reason to withhold this therapy from a type two diabetic. Metformin... Scott Stewart: Yeah, like acidosis or whatever. Mm-hmm. Yeah, super rare. Caitlin Little: is the only one other than Actos. But Actos has such limitations when it comes to contraindications with, you know, disease states. But Metformin increases insulin sensitivity. And that is what we need in type 2s, right? They're resistant. So we want them to respond once again to their own insulin. And it does that. And it received the best benefit at that 2000 milligrams max daily. I have had a prescriber bump it to Scott Stewart: Right. Yeah, it's huge. Caitlin Little: 200 and 2,500. I was like, I don't, I don't know. But he, but, but they were super excited about the drug. And I'm like, me too. love it, but I'm not sure. Um, it, it is a great drug for type twos. And I, I feel like sometimes I'm very repetitive in my recommendations. Cause I'm like, please have met for me, please have met Foreman. Like, please it's, it's the lowest risk. It's the safest alternative and it's Scott Stewart: It's a load of that for me. Yeah. Caitlin Little: of the most effective? Like what else could you ask for? Scott Stewart: Yeah. Crazy, crazy cool drug. think, ⁓ just such a, a wonderful agent course. Yeah. I mean, as you get into the higher doses, like what Caitlin was saying, you might see more of the side effects, but in general, very, a very low risk drug, ⁓ assuming the renal function is fine. And so if you're working with your consultant pharmacist, whether that be us or another company in your home, ⁓ we want it to be us by the way, but if you're working with us, Caitlin Little: Yeah. Scott Stewart: and you see those recommendations for metformin. ⁓ That's why, because we're looking at their profile and we're saying, well, renal function's good, everything looks fine. This is a non-insulin ⁓ alternative agent that we want to give, but even more important, metformin along with insulin therapy has been shown to vastly improve type 2 diabetic residents immensely. and that's in long-term care outside of long-term care. So the drug itself is huge. Caitlin, take our next class of drugs. ⁓ Caitlin Little: Mm-hmm. ⁓ yay. Yeah. Okay. So these, so it's the DPP4 inhibitors. I don't use them a whole lot or recommend them a whole lot, but they do have their little niche of when I feel like they come in handy in today's time. I think our market for non-insulin therapies has expanded so much since these came on the market. ⁓ but They do have once daily dosing. So they're really great for simplifying regimens. They have very low hypoglycemic risk. So that's always a plus. They're weight neutral. I like to see the weight loss part because a lot of our residents are not very mobile, but they at least don't cause weight gain. And the big part where that niche I'm talking about that I might use it or really see it place in long-term care is in decline renal function. when we have to take them off metformin, when we have to take them off other agents, even Farcega has a limit as to how in the GFR, how low we can go and still continuing to use it. This medication can come in and carry some of that load and help with the control of those blood sugars in those instances of the last stage of renal failure and really you know, defer having to just use insulin. Scott Stewart: Yeah. And so those are our DPP fours. next two are the newer classes that have gained immense momentum. You guys will know one of them instantaneously from the weight loss perspective. And those are our GLP one receptor intact or agonist. And those are your semiglutide, et cetera, that are out there and very effective medications. We know them in the public eye for weight loss. So that's something to keep in the back of our mind because we're dealing with a population that may not always be overweight or may just be average weight or whatever. And like Caitlin and I've talked about up to now, weight loss can impact insulin amounts, ⁓ ways that we treat their overall disease state. Caitlin Little: Yes. Mm-hmm. Scott Stewart: the aggressiveness or de-intensification of their insulin regimens, all that kind of stuff can depend on their weight. So these, we often are dealing with frail elderly patients. They got that name for a reason. And so that's something we need to keep in the back of our mind is that, yes, these are very, very effective. ⁓ However, if they're really small patients, residents, then not a great option if they're already struggling to maintain weight, things like that. They do have side effects. And although, you hear GLP ones like the best thing since sliced bread, but they have tons of GI side effects with them and other issues that we see with GLP ones. And as we've seen this kind of like widespread ⁓ movement and utilization of GLP's, I think we'll see that continue to come out as we get more market research and more utilization of it means more people taking i.e. more people giving us information on what side effects they're experiencing and then updating the monographs to support those. But that's our GLP ones. You're likely to see those things. Keep in mind too that GLP ones are so sought after in the space of weight loss that You might not think about diversion, but diversion could be

something that can happen. And you may need to lock them up in your fridge lock box area if you're having that occur, or you may think that that's a potential or possibility because GLPs are expensive. ⁓ There's much more expensive things out there, but they are a very expensive drug. And that would save people money to divert those and utilize those or sell them. Caitlin Little: Mm-hmm. Yep. Scott Stewart: That's something that you can see in this setting as well. And Caitlin will take our last class that we see as alternative agents. This one also has gained a lot of momentum over the last five, however much years they've been out. And that is what class Caitlin. Caitlin Little: Hmm. That is the SGL2 inhibitors. I love this class. I'm not going to lie. ⁓ I see Farsega and Jordiance used a lot. Those are typically the two that ⁓ prescribers will go with. And it's probably, you know, for insurance reasons, but mainly those two. So it's always like between the two. So recently with studies coming out, they do show cardiovascular protective properties. We see more of that in Giardians. So when we're picking between Giardians and Farcega, we see a little bit more cardiovascular, a little bit more secondary prevention of MI's in Giardians. Heart failure, same, a little bit more in Giardians. Farcega kind of comes in with ⁓ chronic kidney disease. We see a protection property of farcega with slowing down the progression of chronic kidney disease. So slowing that decline in the, the GFR to the point to where it is now FDA approved for just kidney disease, not just, you don't have to be a diabetic to have it. You can have chronic kidney disease and it being used specifically for reserving your GFR. ⁓ The things to watch with this class with long-term care is going to be urinary tract infections. And we know that in long-term care where our residents are very susceptible to urinary tract infections, they are, ⁓ that's a huge high risk. And I just really recommend watching that. ⁓ And sometimes even if I don't see that they are on those medications or on, you know, antibiotics, I'll still put a comment in there and saying, Hey, watch out for this because this could be an issue down the road. Also dehydration. They really need to stay hydrated. ⁓ these, these drugs are filtered through the kidneys and then watching their blood pressure that can, that these drugs can decrease blood pressure. So if we're having an issue with hypotension, we might just want to be careful. not that they can't take it, but kind of start it on a low dose and see how that affects their blood pressure. So those are things that we really want to be careful with with these medications. But as far as their load on blood sugar control, they do an excellent job. They actually can bring that A1C down anywhere from 0.8 to one. So they can carry a good load of controlling that blood sugar. they are good non... insulin therapy option to add on. Scott Stewart: Yeah. And like you were saying, ⁓ I think the Pagaflosen just went generic and still expensive, but yet great drugs and the UTI ⁓ side effect or increased risk for UTI is a negative of them, but there's a lot of positives that I think, and depending on the resident may offset that risk along with the fall and dehydration and all those risks. And so Caitlin Little: Mm-hmm. Scott Stewart: Those are some of your mainstays, some of the backbone for what you could use to treat a resident, to kind of de-intensify, to give them more non-insulin drug therapies that can overall lower their insulin need, or potentially get it down to once daily or something along those lines. So we wanna give you guys, in these next two parts here, some practical... strategies and steps that you guys can take that we can take with you as we are all part of this overall healthcare team taking care of your resident population. The first thing is, and I think this is important before you get into all these other things that we're going to talk about that are more patient specific, I would highly recommend a hypoglycemic protocol. to be in place in your facility. And the reason why is as you're working through these things, there are likely residents that are going to have hypoglycemic events. Knowing what to treat and how to treat them is so important. If you've ever worked in an ER setting when somebody's coding or anything along those lines, trying to think logically and all of that is not everybody's strong suit. in that more of an emergent situation. And so when you have a hypoglycemic protocol in place, you're not waiting on the doctor to get a response to what you need to do. You're able to go and treat that resident. Highly recommend that if you, you you're going to have some type of hypoglycemic protocol, your consultant pharmacist can work with you on that. I think it's really important when you look at the different guidelines that are out there that a resident can be unwilling and or unable to take a hypoglycemic treatment by mouth or an injection or whatever. think that's really important to include in there because sometimes they're unwilling. Mrs. Smith doesn't want to eat her food all the time and you think you're going to get 18 glucose tablets down her ingestos? Probably not, right? So that's really important to be a little bit patient specific with that and use some of that terminology there. But then making sure that you have glucagon in place for those residents. that are dipping down, doesn't need to be every resident, but those residents that are dipping down and they are getting closer to the hypoglycemia range, very effective. Definitely recommend the ready to use options. There's been multiple studies out there where if you try to do the reconstitution, glucagon, 70 % of the time it's given correctly versus like 99 % of the time with a ready to use option. So in an emergent situation, the less amount of things you're having to do, the better. to be able to take care of that

resident and take care of them in a good way. So that's number one that I would definitely recommend. Put that in place, protect yourself, protect your residents, reassess your goals for those residents. We've mentioned this multiple times. A1C, sure, I mean, you can definitely get A1C levels on your residents and that's okay, that's good, but it is an average. So you've got high and low values, it averages out. And that is what you see when you look at that sheet of paper. I think more often than not, looking at blood glucose values, trying to manage that side of it, not having too many finger sticks, but enough to manage that resident is the more kind of important thing. We talked about this already, but eliminating sliding skills when you can, huge help there. Basal, lowering basal dosing. including one of these other options that are non insulin therapies in there as well. And then just looking again at your residents as a resident, not a number, and really looking to see are they trending in either one of those directions where they're hyper or they're hypo and how can we manage that person effectively to help have their control not be too aggressive. but also to be appropriate for that resident to minimize all the side effects as well as to improve their quality of life. What are some other things, that they can take away from this? Caitlin Little: Just, we always say this in every podcast, it's the individual. You have to look at the individual overall and everybody's story is going to look different. And just really educating, having these conversations with the nurses, with the facility administrators, even with the medical director. And just really understanding, you know, what you and your facilities can do to work together to have safety protocols in place. Like Scott was mentioning, you know, what is the burden of these residents? Is it the finger sticks? Is it the long acting insulin? Do you have a lot of hypoglycemia? Because every facility is different. You know, that one facility had a lot of hypos. I have another facility that's like, we're monitoring too much. Like we're hurting their fingers and their you know, blistering up and, and they don't even want to check it anymore. So those conversations of what target needs to be addressed is going to be different, but just having those conversations and really, you know, coming into the team and, know, addressing that and opening this conversation up will go a very long way. Scott Stewart: Yeah. So we hope that this has been very helpful for you. I know it's always a great review for us. We were really excited to do this one because of the fact that insulin does comprise a lot of our patient population, a lot of the resident population we service, lots of residents on it. We on the consultant pharmacist in want to help you and be a part of that care team for your residents. So please reach out to your consultant pharmacist. Let them take a look at the residents that you might have some concerns over, ⁓ specifically those residents that are dipping down or that are very high or that have a lot of finger sticks or that have sliding scale or all the things that we talked about on the podcast today. We want to help you in doing all these things, working together. It's obviously primarily for the resident. We want their quality of life to be there. We don't want them to go to the hospital. We want them to stay in the facility. The other advantageous things that you see with this topic is obviously by making sure they're not going to the hospital. We got quality measures that are affected by that. There's survey results that are affected by that. Your star ratings, all that kind of thing, all fall under this as being a part of those. How this factors in can be in a big way. So we want to make sure that we're not just protecting the resident, doing what's best for the resident, but they're also protecting and doing what's best for you and your facilities with regards to their their control of the diabetic population. I think the big thing that we want to leave you guys with because we've given you some really good topics and things to consider in your facility what was going to work best for you and your resident population. But just remember that tight control is not always thoughtful control. So we want you to always focus like Caitlin said, like I've said on that sweet resident, not on a number, not on what you read in some magazine, but what is working for that resident and what their family wants for them as goals, what they want for them as goals. This whole idea of being age friendly, we'll talk more about that on the podcast, but taking into consideration what that resident wants, what their family wants for their life, what is best for them, not a number, not an A1C, but what is best for them. And so, I believe that if we all do that, Caitlin, myself, all of our consultant pharmacists, all of you guys at the facility level, we're going to create such an amazing environment for our resident population and a safe and healthy environment for them. So with that, Caitlin and I are signing off and we appreciate you tuning into this episode of our Med Talk RX podcast. And we look forward to seeing you guys next time.