Diabetes nation

Over 30 million Americans have diabetes, which is almost 10 percent of the population. Another 84 million have prediabetes, a condition that often leads to type 2 diabetes within five years if not treated.

We talked about the state of diabetes with Ira Hirsch, the UW’s Diabetes Treatment and Teaching Chair. Hirsh is a UW professor of Metabolism, Endocrinology and Nutrition, as well as a board-certified physician at the Endocrine and Diabetes Care Center.

What’s new and exciting in type 1 diabetes care?

There are many companies that are working toward an artificial pancreas. We are getting closer every year. We are going to be working on a study with (Boston University professor) Ed Damiano funded by the National Institutes of Health. Damiano has developed a biohormonal pancreas that uses insulin to bring blood glucose levels down, and glucagon to raise it. A sensor keeps blood sugar levels stable no matter if sleeping, eating, or exercising.

While the technology is going forward, the cost of insulin is going skyward. Retail insulin can cost $300 per vial, and most patients require at least 2 vials per month. Obviously, many can’t afford this without insurance.

What about type 2 diabetes?

From a public health point-of-view, the problem is type 2 people who don’t know they have the disease. According to the CDC there are now 7.2 million Americans with undiagnosed type 2 diabetes.

How is it possible to have type 2 diabetes and not know it?

You can have it and have no symptoms, that’s how. Ideally high-risk people are screened (risk factors include obesity, family history of type 2 diabetes, sedentary lifestyle, hypertension, and history of gestational diabetes) with blood glucose testing. But there are other problems. There are new, effective medications that many physicians don’t know about and payers (insurance companies) don’t understand.

As just one example, some insurers cover Jardiance, which drastically reduces cardiovascular events, but other payers don’t. And another drug in the same class as Jardiance, called Invokana, has a warning from the Food and Drug Association about the potential for lower-extremity amputations. Jardiance doesn’t have this warning. Why would I put a patient on Invocana if they are at risk for an amputation, and not Jardiance, especially since Jardiance has the cardiovascular protection? This isn’t new, esoteric research—this information is now on the labels of these agents—yet the payers don’t seem to understand this yet.

Should all patients be on a continuous glucose monitor?

It’s the standard of care for type 1. There is no reason not to. Medicare started covering them in 2017. Washington state will cover them now for type 1 for Medicaid patients.

There is a new monitor that just came to U.S. in December called the Freestyle Libre; it’s been available in Europe for four years. It’s a system that has a handheld reader and a sensor worn on the back of the arm. Instead of a finger stick, you have a little reader you can see. Most people can cover the cost. For a month of wearing this sensor, cash price at Walmart is $120. No fingersticks are required for calibration, but for Medicare coverage you have to document fingersticks four times per day, and also be taking mealtime insulin.

Or there is Dexcom. Most insurance covers it. In Washington State, Medicaid covers both the Dexcom and the Libre. We’ve had the Dexcom since 2008. It’s a very different technology. It alarms you if your blood sugar is high or low, but this June it will be factory-calibrated to alarm before you get low. It has a share app. For one person wearing this technology you can share with five different people.

You look at your sugars on your phone. If you are a kid with it, or if you have a spouse and you are traveling to the East Coast, as long as you have internet you can automatically have the same blood sugar information they have. It’s great because even if you aren’t in the same country, or if you have a kid in bed at night, you know right away.

I have people wearing it who share with me when they are admitted to the hospital so I can be sure their blood sugar is OK.

So, these monitors are a good thing?

Just now I saw a patient who is pretty far advanced with his diabetes, but it’s the first time I have seen him since he started wearing a continuous glucose monitor. They see how everything they eat, and how their stress, impacts their blood sugar.

One patient said wearing the monitor is more effective than a nutritionist, because he can see how every piece of food affects his blood.

You have type 1 diabetes and so does your brother, James Hirsch. He wrote Cheating Destiny, about his son Garrett being diagnosed at age three. How is Garrett now?

Well, he’s 17 and he’s doing great. He plays high school football. My wish for him in college is that he will not play football.