The continued advances being made in diabetes technology are exciting, but for some they may also be intimidating. Certified diabetes care and education specialist Dr. Eligio David Soliman Jr. joins The Huddle to talk about lower-tech insulin delivery options, the differences between these options, and how low-tech delivery can benefit the lifestyles of certain people with diabetes.
Jodi Lavin-Tompkins
Hello and welcome to ADCES's podcast, The Huddle, Conversations with the Diabetes Care Team. In each episode, we speak with guests from across the diabetes care space to bring you perspectives, issues and updates that elevate your role, inform your practice and ignite your passion. I'm Jodi Lavin-Tomkins, Director of Accreditation and Content Development at the Association of Diabetes Care and Education Specialists.
My guest today is Dr. Eligio David Soliman. Dr. Soliman is an advanced practice provider with a core focus on endocrinology, diabetes, and metabolism disorders. He completed his doctor of nursing practice from the University of Pennsylvania and is currently a clinical assistant professor at the University of San Diego, teaching in the Doctor of Nursing Practice program. In this episode, we're going to dive into the world of insulin delivery devices for those who prefer non-technological options and how to find options that best meet the needs of those individuals. So David, welcome to The Huddle.
David Soliman
Thank you, Jodi. I'm glad to be here.
Jodi Lavin-Tompkins
Well, before we get into today's discussion, could you tell our audience a bit more about yourself and your work as it relates to today's topic?
David Soliman
Well, in addition to the qualifications you mentioned, I'm also a certified diabetes care and education specialist. This means I wear two hats. One: to educate, investigate and overcome barriers and strategize management in diabetes care. In the other hand, I have the prescriptive authority to start what I think fits best my patients.
Jodi Lavin-Tompkins
And we're looking forward to hearing more. You know, there's many devices out there and there's more coming at us all the time to assist people in managing their diabetes. So can you go over maybe some of the more traditional options and then some more modern options for low tech insulin delivery?
David Soliman
Sure, I'd be happy to. So let's start with the very basic or the traditional. We have the vials and syringes. And step it up a little bit, you'll have the insulin pens. And the techier but low-tech version of these pens are the smart pens. So a little bit about these smart pens. Their system typically works with an app that aid in the correct dosing. So it can customize insulin doses, whether it's for a meal time or for correction or it can be just a way of monitoring dose administration as it logs these insulin doses that are being delivered. The other method would be the non-programmable insulin patches. So there are two that are out in the market right now.
First we have the basal bolus, which covers both long-term and short-term insulin needs. And the other one is the bolus only patch, which only provides the short-term insulin, such as for meals or correction doses. Both patches offer the convenient function of clicking the insulin dose versus injecting it. So each click for either of these devices is set to deliver two units of insulin.
Jodi Lavin-Tompkins
I bet some people with diabetes like hearing that. It's not an injection, it's a click. I imagine that could be a benefit for a lot of people.
David Soliman
Yes, it makes it very simple.
Jodi Lavin-Tompkins
Well, lower tech options tend to be more mechanical, but they can still offer some benefits that make them worth trying, even though they may be lower tech. So can you do an overview of what some of these benefits are with these lower tech devices?
David Soliman
Let's start with the smart pens. So they utilize some technology for connectivity, which enables it to send dose information to a mobile app. So it offers both dose calculations and tracking. So with this benefit, you can take off some of the mental math burden for these patients, because sometimes we as clinicians have a tendency of ordering what we think is a simple insulin dosing, well in fact for our patients it's something really complicated, so it can take away that math burden. The good thing about this too is that the settings are customizable so it can be precise carb ratios, sensitivity factors. Or it can also be pre-programmed fixed doses if that works better for the patient. In my case, the best utility for me is just getting to track objectively all the injections made with the pen and the factors surrounding the dose.
Some smart pens can monitor insulin temperature and monitor injection technique. They can give you some feedback regarding those aspects. Are they checking their blood sugar before injecting the dose? Because the app can actually sync with the glucometer. We can see the dose in relation to the blood sugar reading. So I have this patient who I learned with the pen that he's just doing fixed boluses instead of using the personalized sensitivity factor for his correction scale. And he explains that most of the time he can't really check his finger stick. So this data became a decision point or a discussion point. Would it be better for your workflow if we tried a continuous glucose meter or CGM instead of doing finger sticks all the time? This technology also helps determine inconsistencies with carb information, whether it's under dosing or overdosing with the insulin. This becomes another point of discussion, like I'll ask them, “can you tell me more about this meal you entered as 15 grams of carbs? Because the blood sugar rose to a 300 level despite the insulin coverage that was given before the meal.” So this could even reveal a need for like more nutritional counseling as to how to better approximate carbohydrates or perhaps read labels.
Jodi Lavin-Tompkins
That makes sense.
David Soliman
It gives you insight on timing. Sometimes I see the dose is always given when the blood sugar has reached the peak. So one patient developed this habit of giving the insulin dose after meals, because she was scared of low blood sugars. Because of the data I had, I was able to explain to her the concept of mealtime dosing and the importance of correct timing. I explained to her that intentionally giving your insulin late is like having the money to pay for your mortgage, but choosing to pay for it a day after it is due and you do this every month.
Jodi Lavin-Tompkins
Ah, I love that analogy, that's great.
David Soliman
The late insulin doses have penalty if you let your blood sugar rise, you develop a certain insulin resistance that a 10-unit dose would have maintained within goal range if it was done at the correct timing. These smart pens can help reinforce these kind of learning together with the paired blood sugar readings.
For the patches, we have two, as I mentioned earlier, one is basal bolus and the other is bolus only. For the basal bolus patch, it can cover both the long-term and short-term insulin needs and it can replace all injections provided that the insulin requirements fit in the patch. It does have that convenient click function to give extra doses of insulin. And this modality is a very good match for someone who needs at least 20 units of long-acting insulin and meal time and correction coverage. This may not be the best option for someone needing less basal insulin, lower than 20 units, or someone who may have variable basal insulin need because of the risk of hypoglycemia. And this patch is changed daily.
The other patch, the bolus only, covers mealtime or correction requirements. It also offers the convenient click function to give the insulin. This is typically preferred in my practice because the patch is replaced every three days instead of daily. This will be a good fit for someone who needs lower dose basal insulin, or as I mentioned, someone with variable basal insulin need.
I have had great success in consistency of insulin dosing with the patches, especially with busy patients on the go who tend to forget their insulin or their activities are just so fast-paced. One example I have is a patient who is a business contractor. So he could be out in the field the first part of his day, attending a meeting, being in office, and then off buying materials randomly all throughout the day. He has no issue giving his nighttime long-acting insulin, but during the day, he's lucky if he can get one injection in. So for some people, injection becomes a burden or sometimes impossible to do. The patch can be clicked from under the garment and go on with your meal. So if the patient needs multi injections per day, I will always consider a patch and see if my patient will see it as an alternative that would make more sense.
So if you convert one injection, whether it's a pen or a vial, if you will enumerate the steps, it would be a minimum of 12 steps, depending of how ideal you want to be. The patch can do these 12 steps in one click.
Jodi Lavin-Tompkins
Wow.
David Soliman
So I have seen night and day difference in the time in range for my patients. And in the long run, it improves the A1C levels.
Jodi Lavin-Tompkins
Yeah, it does sound a lot more convenient and easier to do. Well, David, since there are different levels of tech to choose from, what are the reasons that some people may not want such a high-tech option and go for some of these lower tech devices?
David Soliman
So first of all, from my practice, it's intimidation with technology. And you might not believe it, but I have patients who do not even have emails or smartphones. They still have the flip phones and landlines in their homes.
Jodi Lavin-Tompkins
Oh boy.
David Soliman
So anything remotely related to an app or software, they shy away from immediately. In some cases, I have people who may not like change regardless of their tech savviness. So they got used to a certain way of doing it, they want to do it that way. And for some people, the lower tech version fits better with their lifestyle versus the high-tech versions of it.
So like one patient I have who has type 1 diabetes, he cannot use a pump or a CGM because of his line of work. He works in the national parks and he gets deployed in an area for a few weeks at a time, completely off the grid. And another patient I have is a firefighter. So he's exposed to extreme or potentially extreme temperature. Same thing is true with industrial pipe workers. So the higher tech versions are always not even a potential option for them. So in these situations, the lower tech options may benefit them more or may be the only alternative in terms of delivering insulin.
Jodi Lavin-Tompkins
Yeah, I remember working with a forestry worker in my past who had the same challenges. All right, so we've covered what the devices are, some of the lower tech options, what the benefits might be. You've even given us some examples of people who might find these especially useful for managing their diabetes considering their work. So how can a healthcare professional figure out a person's comfort level and help them decide on the level of technology that would be most helpful for them in your experience?
David Soliman
My philosophy is always begin with the patient. Communicate what kind of treatment is needed and present the options in which the recommended treatment can come in. So if a low-tech option is one of them, you can assess savviness in navigating the potential product, such as exploring available resources to ensure the success if they are placed on this particular device. Vendor support, are there trainers available, are there family members who can be trained together with the patient as additional support. Many times the patient will welcome the idea, then shy away because of the barriers they perceive. Each patient encounter is a journey for me, and it's so fulfilling to overcome each barrier with a patient.
Jodi Lavin-Tompkins
Yes, I had the same experience. You can make such a difference in their life. It's really rewarding. So because of this, is it important for us, all of us out there who care for people with diabetes, to really understand these devices and be able to tailor the choice of the device to that person's comfort level?
David Soliman
Definitely, and I think this is true not just with insulin but in all matters that relate to medication taking. There tends to be a cookie cutter approach in deciding treatment for diabetes, and this is a natural phenomenon for clinicians in general. We tend to gravitate around options within our own comfort level. So if the clinician is not comfortable with multiple insulin dosing, we can end up over titrating a basal insulin, which may lead to what we call overbasalization. We see this quite often. A patient would have very high dose of a long acting insulin with no meal time or correction coverage. And their blood sugar will be randomly dropping at night or during the day while consistently spiking after meals. Or the other end of the extreme, if a clinician is very apprehensive with low blood sugars, they can come up with very intricate correction scale, which the patient may have a hard time following. So with these low-tech options, you can adapt a multi-dose insulin plan in a more simplistic approach, which would increase success and consistency with mealtime dosing, which leads to better health outcomes.
Jodi Lavin-Tompkins
Yeah, and it's good that we have some of those extra optional tools in our tool belt to offer those people.
So David, can you share with our audience any tips for ensuring that the people who do select these lower tech devices are successful and have good outcomes that you mentioned?
David Soliman
So the vital point would be helping patients understand why they need insulin. Many patients are averse to taking insulin in the first place. How do we overcome that psychological insulin resistance? So I investigate, and you will be amazed at the reasons that they will give you why they don't like to take insulin. So one of the most common stories I've heard is that they know someone personally who died shortly after insulin was started. It could be a relative or an immediate family member. So I explain that many times for these cases that mortality followed shortly after insulin was started, insulin was started too late. I introduce the concept of pancreatic exhaustion. So I blame the tired pancreas for the high blood sugars. And the tired pancreas cannot produce insulin adequately. Then connect the destructive effects of sugar within the bloodstream. In this way, I can introduce insulin as the “good guy”, a companion for their health, versus perceiving it as a death sentence.
Jodi Lavin-Tompkins
That is so important, and I love your use of analogy again in teaching people, I think that's really effective.
David Soliman
If a low-tech device is chosen, clinicians should be knowledgeable on the device function and resources available to ensure their success. I always look at the availability of family for support. That way, there's always a second person that could be a backup learner for these new devices that they're going to be trained on.
As a clinician, one of the greatest challenges is getting this approved through the payer system or the insurance. For this particular barrier, I use the manufacturer resources, you know, the vendors, our reps that are very helpful that can help us get through the process. Sometimes there is a preferred pharmacy that actually works on the paperwork without having the clinic staff work on this or labor on this tedious approval process. Is there a specific way of writing the prescription? One time I have a prescription that got denied because instead of ordering 30 pieces for the non-programmable patches, I was actually ordering 30 boxes per month. So my patient could have been a local distributor of the product if he ended up filling it.
Jodi Lavin-Tompkins
Ooh. Ha ha ha. Well, that's okay. We all make mistakes, but you learn from them and move on, right?
David Soliman
Yes.
Jodi Lavin-Tompkins
Well, thank you so much for this comprehensive look at low-tech insulin delivery devices and sharing your experience. You have a lot of great tips that I hope our listeners can take advantage of. So do you have any other closing thoughts or tips for our listeners?
David Soliman
I always say this, and it's, I think, one of the most important driving principles in my practice is that there is no cookie cutter approach in diabetes care. And as clinicians, we are trained in clinical practice guidelines. While this is important, we must start with our patients and their needs, and then present the options that you can mutually agree on based on the clinical guidelines. Not enforcing the clinical guidelines because it's written it has to be executed for some reason, but start with the patient and how the clinical guidelines will actually fit for that specific patient that you're treating.
If a patient hasn't met with a certified diabetes care education specialist, make that your top priority. Almost all of the patients I was able to lead successfully in their diabetes journey is because of the skills I have as a certified diabetes care and education specialist. It is a mouthful, but it's a mouthful for a reason. They would exclaim and say, I have been treated for diabetes for the past 30 years, and nobody has explained to me the way you did in just 15 minutes. So partner with a CDCES in your practice or get certified yourself.
Jodi Lavin-Tompkins
Wonderful. I agree completely.
Well, David, thank you so much for taking the time to join us for this episode of The Huddle and for sharing your knowledge and experience on the use of lower tech devices to help people with insulin delivery be as successful as possible in managing their diabetes, because that is our goal. And your insights should help other clinicians who need to know about these options for making life with diabetes just a bit easier for the people they work with.
David Soliman
It has been my pleasure and I'm glad to be here and share the experience I've had, success stories as well as the barriers. So I'm glad to be here.
Jodi Lavin-Tompkins
Thank you all for listening to this week's episode of The Huddle. Make sure to download the resources discussed in today's episode. You can find them linked in the show notes at diabeteseducator.org forward slash podcast. And remember, ADCES membership gets you free access to resources, education and networking that improve your practice and optimize outcomes for your clients. Learn more about what ADCES can do for you at diabeteseducator.org forward slash join.
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