Scott Benner 6/13/24 Scott Benner 6/13/24

#1224 Orange Book Chronicles

Scott Strumello is here to discuss the topic of pharma companies improperly listing patents in the FDA's Orange Book.

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Scott Benner 0:00
Hello friends, and welcome to episode 1224 of the Juicebox Podcast.

Today I'm going to be speaking with longtime diabetes blogger Scott strim. Hello, Scott and I are going to talk a little bit about insulin pricing. But we're going to talk a lot about something called the orange book and how the FTC noticed that maybe some products were on there that shouldn't have been. Now I know that might sound kind of boring and inside baseball, but trust me, this has implications on you and your family. And it's a very interesting look into how things actually work. Please don't forget that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan are becoming bold with insulin. When you place your first order for ag one with my link, you'll get five free travel packs and a free year supply of vitamin D. Drink ag one.com/juice box, use my offer code juice box at checkout at cozy earth.com And you can be wearing the same sweatpants I'm wearing right now except they'll cost you 30% Less cozy earth.com use the offer code juicebox at checkout to save 30% off of your entire order.

US med is sponsoring this episode of The Juicebox Podcast and we've been getting our diabetes supplies from us med for years. You can as well us med.com/juice box or call 888-721-1514 Use the link or the number get your free benefits check it get started today with us med Today's episode is sponsored by Medtronic diabetes, a company that's bringing people together to redefine what it means to live with diabetes. Later in this episode, I'll be speaking with Jalen, he was diagnosed with type one diabetes at 14. He's 29. Now he's going to tell you a little bit about his story. And then later at the end of this episode, you can hear my entire conversation with Jalen to hear more stories with Medtronic champions. Go to Medtronic diabetes.com/juicebox or search the hashtag Medtronic champion on your favorite social media platform. This show is sponsored today by the glucagon that my daughter carries. G voc hypo Penn. Find out more at G voc glucagon.com. Forward slash juicebox. Hi,

Scott Strumello 2:41
my name is Scott Strumello. Some in the diabetes community know me because I have been a longtime blogger. I think I started back in 2005 or so my blog is still out there. It's blog.es romello.com. And I was also very active in social channels, whatever for a long time, not so much that any more are more active these days on threads and LinkedIn. LinkedIn is a little bit more of a professional social media platform. That's the reason I opted to publish my article, which I think we'll probably talk up talk a little bit about, yeah, I'm

Scott Benner 3:22
excited about that. Scott, tell me what is this what you do for a living? Or is this something you do on the side? It's

Scott Strumello 3:27
something I do on the side. But you know, by nature? I'm a very curious person. And, you know, I was curious why, you know, originally it was about biosimilar. insulins back in 2006 or so is of some five 2006. I raised the question, all the patents on these products have expired, why don't we have generics? And I wrote kind of a multi page article on that subject. And there were a whole bunch of reasons why it wasn't happening like it should have. Most of those issues have since been resolved. Most recently, in 2019, when the FDA made a policy decision to recognize any insulin that had been previously approved as a drug under the Federal Food, Drug and Cosmetic Act, which all insulins up until that time had been regulated under they would recognize them as a biologic and therefore they would be eligible for biosimilars for the very first time ever. And with that, you know, companies started pursuing them. And along the way I happened to notice because my interest was in the insulin. All these companies also have biosimilars of the GLP one inhibitor. liraglutide, which was formerly known as Novo Nordisk Victoza, then a couple of years ago after it was introduced, they got an FDA label extension for the indication of obesity without type two diabetes. And they branded that version six, and it's the exact same drug. It's just got a different name, and they're selling it to different people.

Scott Benner 5:18
Okay, so you wrote this article. So listen, let me I'll tell people like I, you and I, we we talked before, we're not sure if we've even ever met maybe once in a blogging conference, you know, 15 years ago or something like that, but we don't know each other. But I follow you on LinkedIn. And I think of you as this curious intelligent person who asks a lot of questions that I find myself asking like, why is this like this? How come that's not cheaper? Why is this not available? Like and I love the way you ask them and then follow up with you know, these are probably the reasons why. And it is a part of life with diabetes that I mean, as the regular layperson does not have time to figure out what's going on here. Right, like so these things happen behind the scenes and you don't know why you're being impacted in your real life. Yeah, go back to the insulin for a second before we move to the GOP. Now that like you know, I'll be a little like, I don't know how this will come off but like you know, in the last year or so, the pharma companies have been saying about insulin like oh don't worry the price is going down I'm like you know the price is going down because you're about to lose hold of it like it's not like you know what I mean like they held a death grip on it till the very last second and then they tried to act magnanimous about it at the end. If you take insulin or sulfonylureas you are at risk for your blood sugar going too low. You need a safety net when it matters most. Be ready with G voc hypo pen. My daughter carries G voc hypo pen everywhere she goes, because it's a ready to use rescue pen for treating very low blood sugar and people with diabetes ages two and above that I trust. Low blood sugar emergencies can happen unexpectedly and they demand quick action. Luckily, G voc hypo pen can be administered in two simple steps even by yourself in certain situations. Show those around you where you store G vo Capo pen and how to use it. They need to know how to use G Bo Capo pen before an emergency situation happens. Learn more about why G vo Capo pen is in Ardens diabetes toolkit at G voc glucagon.com/juicebox. G voc shouldn't be used if you have a tumor in the gland on the top of your kidneys called a pheochromocytoma. Or if you have a tumor in your pancreas called an insulinoma. Visit G voc glucagon.com/risk For safety information.

Scott Strumello 7:43
Yeah, I mean, and there, there is some truth to that, like anything in pharma, it's always a little bit more, you know, it's a little bit more complicated. There's the way I've described my discovery process and how the pharmaceutical industry works. It's kind of like peeling a head of lettuce apart. You peel one leaf, and then there's another one and another one and another one. And you think I'm never gonna get to the frickin answer. And, but eventually you get to the core. And you're like, Okay, that makes sense now, but there were just layers and layers and layers of, you know, weirdness, you know, things that you're like, do businesses really operate this way? And I'm like, yeah, if you're a pharmaceutical company, they do. You know, my, my journey began years ago, back when I began blogging around, I don't know, I guess, like 2005 Maybe I'd have to go back and look at when the first post was. But the good thing is, I was able to find or discover some people that were, I considered very informative on the topic, and I followed them very closely. Lo and behold, they were consistently correct about different things. And, you know, I was like, Okay, so that's why this happens the way it does, it was kind of a fascinating journey of discovery, I guess. But once I once I knew all that, then I could kind of piece together okay. So, this is why insulin is priced the way it is. And most of it is not because Lilly Novo Nordisk, and Sanofi are choosing to price them through the roof. But it's the way that they choose to sell their insolence, the commercialization path, they decided to go for this big PBM rebate contracting sales model, whereby they start with Sky High list prices, and then they give rebates of 90% back, and so it looks like it's generous. But really, the only reason it's generous is because they raised the price so high in the first place that they could discount it all back on the back end. So that's kind of the The story with insulin, can

Scott Benner 10:01
I ask you a question? What's the business benefit of that? Like, why is it presented that way? What does it do for them?

Scott Strumello 10:09
You know, there are a couple reasons, all of them which I feel, which I would say are actually legal. I don't even know if they are legal. But the PBM has basically made a sales pitch to the pharmaceutical industry that said, Look, we represent hundreds of millions of customers, you wouldn't have access to them without us. But guess what, we'll throw you a bone here. We'll keep off your biggest competitors off formulary, they won't be covered. If you pay us a kickback or illegally exempted rebate kickback. And so that was basically how they operated in order to were pharma to avoid truly competing on the products merits. They pay a little bit of extra money to the PBMs to keep their rivals off formulary. And lo and behold, you don't really have to compete on the products merits. Yeah, it's based on the kickbacks that you're paying.

Scott Benner 11:09
Well, that makes sense. Okay. So I'm not sure it does. I mean, it makes sense that that's what they did. Yeah, by me, based on what I saw it because you know, when people's regular life, they'll say all the time, like, Well, my doctor wrote a script for x. And I gave it to my insurance company. They said, we don't cover that, but you can have this. Yeah. And then you go, okay, and that's the end of it. But on the back end, whatever you ended up with, is paying a vague, so that you don't have access to the other thing.

Scott Strumello 11:37
Yeah. And also, there's, you know, there's a little bit more about it, you know, not only are you being told this as our preferred product, but they're saying we're not even covering the non preferred product. If you go back to the early 1990s, when Pharmacy Benefits started to become a thing, because it wasn't until the early 90s, that health plans even had pharmacy benefits. Prior to that it was all like cash out of pocket. Yeah. And so it sort of evolved around the same time. But, you know, keeping your rivals off, formulary became a very powerful pitch and the rebate kickbacks certainly helped help do that. But I think somewhere along the way, I think it probably started happening around 2016 or 17 or so. That's when Novo Nordisk reported to investors via its SEC filings that its US insulin margins had fallen into the negative territory. In other words, they were no longer earning money. They were still earning money, but they weren't. The growth was negative. So in other words, and most of that was because of rebates. They were paying to keep Lilly and Sanofi insulins off formulaire then a couple years later, Lilly decided, you know, we're going to be benevolent here and we're going to, we're going to sell a cheaper version of human log, we'll call it insulin lispro. We'll sell it under the generic name. And that was a good thing because prior to that, either got the heavily remitted kickback driven priced product sold through the P VMs. Or you paid $400 via you know, it was kind of crazy.

Scott Benner 13:28
Can I ask you a question? In retrospect? Was it the right thing for them to do financially? Or did it end up biting them in the ass at the end?

Scott Strumello 13:35
Actually, what happened was when Lilly did this, I think they were a little surprised at the extent to which the unbranded humanoid product sold, like a year after they introduced Lilly insulin lispro injection, it accounted for 1/3 of us human log sales. Like overnight, you know, it's practically they did no marketing of this product. And nearly a third of their sales was the cheaper version. And I think at that point, that was when Lily said wait a minute, we don't need the PBMs to sell insulin at least we can just sell it ourselves and say screw the PBMs we're not paying the kickbacks anymore. So that embolden them to say it to the PBMs Fu, we're not playing your your kickback game anymore. At least for the insulin therapeutic category. We'll just sell it on our own. Our customers are happier. It cost us billions of dollars less money, and we earn more money so it worked out for them. Lilly did it and then like two weeks later, Novo Nordisk did the exact same thing. And then Sanofi was sort of forced to do the same. I don't I'm not sure about Biocon. They're kind of a smaller player right now. But basically, that's kind of the deal with Is that Lily, because they learned that the PVM was were adding no value. And also there, there's another little not so little law that got passed by Congress, which was called the American rescue plan of 2021. The American rescue plan of 2021 contained a little teeny provision that I don't think anybody even paid any attention to at the time, but basically what it said was for Medicaid, not Medicare, or Medicaid, we will no longer allow Medicaid to reimburse more than 100% of the average manufacturer price. And if you charge more than the average manufacturer price, you'll have to pay us Medicaid to get your drug listed on our formulary. And so that really tied Lily noble Novo Nordisk can sign off his hands because these were old, patent expired insulins that were heavily rebated and suddenly they were faced with the prospect that they would actually be forced to pay the federal government in order to get those products listed on the Medicaid formulary. And so the only resolution for that was to slash prices. So without also embolden them a little bit to kind of say, you know, we don't need the PBMs for this, and we'll move on.

Scott Benner 16:29
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Scott Strumello 18:08
it was Yeah. But that's very much the product of the PBMs not wanting anyone to know about their little kickback scheme, which by the way is not such a little kickback scheme. It's the last number I had, it was more than a quarter of a trillion dollars a year in rebates across all drugs. So

Scott Benner 18:26
they jack the price up so that they can skim. It's not it's you know, they take a piece of it. And that piece ends up being a quarter of a trillion dollars. Yeah,

Scott Strumello 18:38
it's not just the PBMs. The PBM is our big, big motivator behind it. But a lot of the PBMs which are one in the same with the insurance companies, the United Healthcare optimara civica, Express Scripts and Aetna CVS Caremark they're all one and one together. In other words, they're, they're vertically integrated with these insurance companies. And so they, you know, it hits the bottom line of the insurance company, not the PBM, per se, what they were doing is they were basically saying, We'll give you a discount on your premiums to employers, they were saying, We'll give you a discount on your premiums, we'll call them premium offsets, all that money was coming from PBM rebates that were paid to them. So in other words, to sell more insurance policies of taking money, which is intended for patient relief, and instead giving it to sell more policies. I mean, you couldn't make something up more complex or more convoluted than this. I mean, it's insane. I

Scott Benner 19:47
got a headache thinking about the last time I tried honestly, it's why I appreciate somebody like you who can sit down and just thoughtfully remember it. How much reading Do you think you do on this? These things so I don't

Scott Strumello 19:58
do so much More I used two years ago. And this is, you know, the accumulation of years of reading and knowledge on this topic. You know, after a while, it's just sort of sticks with you.

Scott Benner 20:11
Well, alright, so let's kind of jump ahead to the article you wrote that I saw recently tell me what prompted you to write it and give people an overview of what it's about.

Scott Strumello 20:20
I don't even remember what the title was. It was kind of a long one. Give me a second. I have it here. But basically, the article was basically how the Federal Trade Commission, the FTC, had taken some action on April 30 19, or 2024. I was saying 19 and go back to my blog start here. And basically, the FTC acted, and they basically said, look, to the pharmaceutical companies, they first did it back in November of 2023, for epinephrine pen injectors, and also for asthma inhalers. And basically, what what was happening was the drug industry was listing patents for medical devices. In the Food and Drug Administration's Orange Book, which is a listing of drugs that is voluntary, terribly populated by the drug industry, the FDA doesn't really take a very hands on approach to managing. But what's written in the law is that only the drug or the biologic medicine is permitted to be listed in the FDA Orange Book, not the device. So you may sell an epi pen, for example. But the pen itself can't be listed. Only the epinephrine molecule can be listed. And so last November, they said, We're going to challenge a bunch of these inappropriate patent listings on the food FDA Orange Book, and they were able to do it successfully. And that got them to thinking there's probably other drugs that we can do this floor and wall up. Here we are GLP, one inhibitors being the hot drug of the moment. And a bunch of inappropriate patent listings for those products were listed inappropriately in the FTAs. Orange Book.

Scott Benner 22:22
Let me tell people what the orange book is. And then we'll ask why there an appropriate FDA Orange Book is an authoritative reference that lists all approved drug products providing information on their therapeutic equivalents, patents, and exclusivities. It helps healthcare providers, regulatory authorities and generic manufacturers by detailing when generic versions of drugs can be legally marketed, the book ensures a balance between protecting drug innovation and promoting market competition to make medications more accessible and affordable. Is that something you agree with?

Scott Strumello 22:52
Yeah, absolutely. Okay, a little loan factoid about that is when when drug companies list a list a patent in the orange book, that means that any company that wants to sell a copy of those medicines, has to wait 30 months or two and a half years before they can even be considered, the FDA will not consider the drug application for 30 months. And that's kind of what happened here by inappropriately listing 10 injector devices or the GLP ones. That's not the medication, that's a medical device that's regulated separately.

Scott Benner 23:32
So why did they do that? I know the answer, but it's because the molecules older it's going to run off patent sooner. So they were trying to squeeze more time out of it. Do

Scott Strumello 23:41
you think they were although they did it for their newer their newer ones too, as well, I think and they could kind of argue well, it was a sleight of hand, you know, we sell them in pen format. And so you know, our bad sorry. That was basically what Novo Nordisk would say to the FDA about its inappropriate patent listings for these drugs. But in fact, you know, I think they were consciously doing it trying to get another two and a half years before any generic or biosimilar could come to market, right? Because these GLP medications are forecasted to be huge for some of these companies, right? Yeah. In fact, I just got something the other day that was kind of interesting. It's a fairly new report from the analytics firm known as global data that predicts that sometime in 2020 for the GLP. One inhibitor class of drugs, is poised to become the top selling drug category based upon existing drug sales. The current sales leader is a class of drugs known as PD one inhibitors, which is a type of targeted immunotherapy used in treating certain types of cancers and in my reaction to that as toppling overpriced cancer drugs to become the best seller is no small undertaking. But we can go back to Novo Nordisk earlier FDA label extension for its first generation GLP. One known as liraglutide, which was branded originally as Victoza for type two diabetes. 10 years later, they got an FDA label extension for the indication of obesity without type two diabetes. And they branded that one saxenda. They're the exact same drug. It's just the ones once prescribed for obesity and ones prescribed for type two diabetes. All of those are patent expired. And so what Novo Nordisk did is they, they did make legitimate improvements to them. I mean, it's not these were brand new molecules, in essence, then they took the old products off the market, and they tried to prevent anyone else from selling copies. Oh, really? Of the saxenda? Yeah. Oh, so they had something that worked reasonably well. They improved on it made something that works better, and then went, how did they block people from making the generic of sex ENDA? Well, the first thing they did was they inappropriately listed patents in the FDA Orange Book, which were not for the drug or biologic itself. But were for medical devices, pen injector devices. They were like a whole bunch of them. 36, I think was what the FTC counted, and said, these are all patents for devices. You can't list those in the orange but only the biologic or the drug and be listed in the orange book. So by doing that, Novo Nordisk could have said, well, we was a mistake are bad, you know, but by listing them, they automatically got themselves another 30 months of keeping a biosimilar off the market. So the first thing the FTC, the Federal Trade Commission, did was they disputed all of these inappropriate patent listings, which were not for the medicines, but most were the devices that that the medicines were dosed in. And they said, You can't list these, the statute says, you can only list the drug or biologic not a device. So the FTC went to the Food and Drug Administration and said, We have a long list of patents that we think are inappropriately listed. And we want them to you know, we're calling them into dispute, and we want them removed from the orange book and lo and behold, 36 of Novo Nordisk six patents on various GLP one inhibitors, Victoza? saxenda. And what's the newest on semaglutide? Whenever they're brand new, that

Scott Benner 27:53
was epic. Xebec. Okay,

Scott Strumello 27:55
it was epic. And there we go. They have another one for weego. The Yeah. So all of those products, they listed. patents were the devices. That's a no, no, right. The statute doesn't allow to do that. Yeah.

Scott Benner 28:07
So let me ask two questions here. So first of all, that's not what the orange books for now. Okay. But secondly, let's play devil's advocate for a second be fair to them. There's there's something incredibly special about their injections devices that they'd want to protect. Sure,

Scott Strumello 28:22
but you don't do it, listing it as a drug that automatically gets a 30 month stay. The medical devices are regulated under a different division of the Food and Drug Administration. And they have their own listings.

Scott Benner 28:36
So for clarity for people, if they thought there was something so special about their injection device that they wanted to patent that they would patent that device as a medical device, and not tie it to the medication that was inside of it.

Speaker 1 28:48
Correct. Okay. But they did. And

Scott Benner 28:52
that buys them this two and a half years. Correct. Gotcha. The FTC notices and goes and no, you know, doing that. Exactly.

Do they have the power to stop it?

Scott Strumello 29:03
The FTC has the ability to file a complaint with the Food and Drug Administration saying the following list of patents is inappropriate. And they did it for like 360. So far, it's not just insulin or, or GLP ones. It's not just this company can. But they did it for over 300 patents that were inappropriately listed. And that's probably just scratching the surface. There's probably a lot of others. They

Scott Benner 29:33
went after Lily from Jarno and zap bound pens, did they do it as well? Or did they not do it?

Scott Strumello 29:39
They didn't do it for Lily on Manjaro or zip on. But what they did do is for a former Lilly product, which specifically was the glucagon rescue kit, and I can't remember the name of it's the inhalable

Scott Benner 29:54
one max, max semi now. Yeah,

Scott Strumello 29:57
I think yeah, yeah. So Oh, Lily had listed patents for a drug delivery device for back see me on the orange book. And that's also a no no. However, then

Scott Benner 30:10
it's a little tube that you squeezing it puffs out.

Scott Strumello 30:14
Yeah, yeah. And they're technical specifics in there that are patented.

Scott Benner 30:20
I'm sure it's like,

Scott Strumello 30:21
I'm sure. But anyway, Lilly decided we want to get out of the glucagon business as commoditized. We don't make any money. They sold it to a company called amphastar pharmaceuticals about a year ago. And so now it becomes amphastar problem, even though Lilly was the one that inappropriately listed those patents. But I think what's interesting about amphastar is even though they got slapped on the hands for the back seamy inappropriate patent listings, they on the other hand, got a big gift from the FTC because amphastar pharmaceuticals also happens to have a copy of liraglutide now pending FDA approval. So in other words, their copy of Nova donors sex ENDA or Victoza can come to the market even sooner. So the Lord giveth with one hand and taketh away with the other is kind of the way that I look at it. I suspect that for amphastar, the sales of the biosimilar version of liraglutide probably will make up for any losses they took on vaccine me Yeah,

Scott Benner 31:26
so the reason that this are the article you write catches my, my attention so much is that I mean, besides the fact that at the moment, I have to pay cash for my daughter to use a GLP that she needs. And I'm interviewing people who have type one diabetes, type two diabetes, just for weight loss that are benefiting insanely from this, but they're also talking about having to run around like crackheads looking for this medication and they're paying out of their pocket some $1,200 a month, sometimes I don't pay that much for Arden out of pocket, because she's only using such a tiny little bit of it that we just need one pen to get her through for a while, like that kind of thing. But it's still expensive. I don't want to say that it's not. Yeah, and there are studies coming and going on right now that are going to apply GLP medications to people with type one. And I think that all of this little tic tac bullshit is going to slow down from people getting this medication if they need it. And it sits with me so poorly, that the idea of like, well we can hold off biosimilars by because that's what this really is about, right? Like right now, our big problem is what there's companies who are poised to do this, but they're being held up by the patenting of the injection systems is that right? There. This episode is sponsored by Medtronic, diabetes, Medtronic diabetes.com/juice box. And now we're going to hear from Medtronic champion Jalen.

Speaker 2 32:53
I was going straight into high school. So it was a summer, getting into high school was that particularly difficult, unimaginable, you know, I missed my entire summer. So I went, I was going to a brand new school, I was around a bunch of new people that I had not been going to school with. So it was hard trying to balance that while also explaining to people what type one diabetes was, my hometown did not have an endocrinologist. So I was traveling over an hour to the nearest endocrinologist for children. So you know, I outside of that I didn't have any type of support in my hometown.

Scott Benner 33:26
Did you try to explain to people or did you find it easier just to stay private? I

Speaker 2 33:31
honestly I just held back I didn't really like talking about it. It was just, it felt like it was just an repeating record where I was saying things and people weren't understanding it. And I also was still in the process of learning it. So I just kept it to myself didn't really talk about it.

Scott Benner 33:46
Did you eventually find people in real life that you could confide in. I

Speaker 2 33:51
never really got the experience until after getting to college. And then once I graduated college, it's all I see, you know, you can easily search Medtronic champions, you see people that pop up, and you're like, wow, look at all this content. And I think that's something that motivates me started embracing more, you know, how I'm able to type one diabetes, Medtronic,

Scott Benner 34:11
diabetes.com/juicebox, to hear more stories from the Medtronic champion community.

Scott Strumello 34:19
Mainly, yes, you know, I didn't look at every single, the FTC letter, you can actually read it and list all the patent numbers, but then you've got a Google patent number, blah, blah, blah. You know, you have to look up each one there's 36 of them. I looked up to just a spot check. And both of them are for pen injector devices. And my only conclusion was, ah, so this is their game. They're inappropriately listing pen injector devices used with the GOP ones to prevent or delay biosimilar competition from coming for two and a half years. And we don't even know if the biosimilars I mean, they're, they're now pending FDA approval, it's possible the FDA may come back and on one or two of them and say, you need to fix this before we approve it. And so you know, they'll get a complete response letter. I can just surmising here. But that's theoretically possible, of things that could happen.

Scott Benner 35:20
Also, I don't know anything, I just don't want stuff standing in the way of people getting what they need. And I don't want to see this whole insulin thing start over again, with a different medication that's going to be important to people with diabetes, you know, like, that's the stuff Listen, my brother has type two diabetes, his a one C went from in the mid sevens to the mid fives, he did nothing different. But shoot ozempic. Yeah. And he doesn't make a lot of money. You know what I mean? Like, his life is being changed. It's being lengthened, it's healthier. And two and a half years. Some people might hear that and go, it's just two and a half years. You go ahead and live within a one see a seven and a half for two and a half years and see if you don't think it's a long time. You know what I mean? So,

Scott Strumello 36:04
I tried coming up with the money, you know, to pay for these things. In the meantime,

Scott Benner 36:09
sure, just pay 28 $29,000 a year so that you don't die.

Scott Strumello 36:13
I mean, you know what, what happened with insulin, the pharmaceutical industry reached sort of a compromise. They said we'll sell a cheaper version of our product. We'll just sell it under the generic drug name. So you have Lilly human log in and Lilly insulin lispro injection, exact same assembly line. They're the exact same drug. It's just one is branded, one is unbranded, the cheaper an unbranded product. It seemed to be the way that the pharmaceutical industry could not piss off the PBMs and sell a cheaper version of their product. My guess is that when these biosimilar products for the GLP one, liraglutide come to market, we probably will see a dual branded unbranded strategy from from them. And by the way, some of the biosimilar companies also white label their products. That's basically private label, they sell it under the stores brand. So let's say you have a company like Lynette company, which is one of them that has liraglutide pending FDA approval. If Lynette company introduces a copy of sex ed up, they will sell one version, the brand at something, and they may sell another one under the Rite Aid, pharmacy brand name. I mean, that's entirely possible. And you wouldn't know it's it's made by Lynette because it carries the Rite Aid pharmacy brand instead. But I think the dual branded unbranded strategy seems to be something that the industry found was workable, invoking the ire of the PBMs. Because the BDMS they're sleazy companies, they, you know, they'll threaten, they'll say, We're gonna keep all your products off off formulary if you if you stop paying us kickbacks, you know, I mean, they do stuff like that. And there's really nobody policing it.

Scott Benner 38:13
I'm super interested to see if I get a cease and desist letter for putting up this episode, actually.

Scott Strumello 38:19
Well, you know, the question is, from whom?

Scott Benner 38:22
Yeah, oh, yeah. I can't even decide who it might be from to be honest with you. Listen, from my perspective, I'm just, I'm the father of a kid with a type with type one. I'm a person who's seeing GLP change their own life and other people's, and I can't I don't have the energy at the end of month, the last third of my life, Scott, I don't have the energy to watch this happen again. And like, Please, look back at the insulin thing, see how it ended up for you. And just don't make the same mistake again. You know, that's kind of how it seems to be. I have a couple of questions for you. I've crafted questions from three perspectives. So I have patient perspective, FTC and pharma perspective. Okay. I want to ask them like this. So let me start with the patient's How do you think the FTC challenge to the orange book listing will impact the affordability accessibility of GLP inhibitors for patients?

Scott Strumello 39:15
So number one, it opens the door to cheaper biosimilar products, admittedly, older products, but still efficacious, so they still work to come to market two and a half years sooner. So that's, that's the first thing. I also think you know, we could see, the essay said that branded and unbranded strategy, the branded is the heavily rebated to PBM. Market, and then the unbranded product will either be sold as the generic drug name or it'll be sold under the pharmacy name. So I do think we will see cheaper biosimilars coming to market and probably by the end of the year or early next year,

Scott Benner 39:57
okay. Can you think of ways that patients will benefit most from that availability. Well,

Scott Strumello 40:02
number one cost, right? Okay. You know, the biosimilar products are going to be a fraction of what the original or the branded products from Lilly and Novo Nordisk sell for. So cost is the big one. And then also, I think, you know, we're hearing stories. I don't know how many of the stories are hyperbolic of shortages of these products. And some of it is because internal production capacity to fill in finish these pen devices is constrained, Novo Nordisk already announced that they were going to stop making the patent expired Basal insulin levels here last year. So they could redeploy that manufacturing capacity to ozempic. And, you know, whatever we go V. Yeah, we go we Yeah, I can't keep them straight anymore.

Scott Benner 40:55
That's a lot. Yeah.

Scott Strumello 40:56
Yeah. You know, assuming they're all approved, and we don't, you know, those are unknowns right now. But what we know, a whole bunch are currently pending FDA approval. Okay.

Scott Benner 41:07
So from the FTC perspective, what do you think the regulatory intent was behind this? Because it's something that's happening, they notice it, but you still gotta get somebody off? They're asked to do something about it. Like, why did they act?

Scott Strumello 41:19
Some of it is just to police. You know, there are regulatory authorities that the FTC has, I should point out that since 2022, the Federal Trade Commission has been studying the pharmacy benefit manager business, their study is currently underway, they expanded it a year later, to include CBM own group purchasing organizations or to POS you know, they're investigating their, their rebate, aggregation processes. So I think the FTC study is going is likely going to uncover a lot of knows, you know, a lot of inappropriate and sometimes illegal behavior. And I think what we could see is either the FTC and or the US Department of Justice may alter when that study concludes. By the way, a couple of weeks ago, the FTC chair, Lena Khan, was at a White House open meeting about CPMs. And she noted that, even though the FTC had sent subpoenas to all of the insurance company owned P VMs, they had not fully complied with those legal subpoenas. So in other words, they're not giving them all the information that they've asked for. And that's a violation of law. So I think FTC is going to have to sue the PBMs. And say, we asked you for this, this, this and this, and you only gave us this, you will owe us a whole bunch of stuff. When that happens, I don't know. But it's holding up the outcome of their six piece study on the PBM. Industry. So we'll say, Well, I'd

Scott Benner 43:07
like to have you back on to talk about that sometime. So what do you think the FTC can do to ensure that, like, this doesn't happen? Like, can we put safeguards in place so that somebody just doesn't find a different loophole? You

Scott Strumello 43:18
know, it's hard to say, I think, because some of it falls under the purview of the Food and Drug Administration, the FDA, and the FDA has taken a very hands off regulatory stance on Orange Book, patent listings. But I think by the FTC stepping in and disputing a whole bunch of them, they're saying, we're noticing what Pharma is doing here. We think it's inappropriate. And we're taking actions which were are within the food, Federal Trade, you know, administration, or commission sorry, FTCS purview. And we're going to take actions to prevent that where we see it, you know, happening. FTC is understaffed, they probably need about 3000 more people to study Orange Book patent listings, if they were to do them all. But I think by by doing this, they have paved a path forward. So that if you're biosimilar company and you're looking to sell a less costly biosimilar, you may say, Well, wait a minute, this is automatically stayed for 30 months. And that's because of the FDA Orange Book. Let me look at all these patents. And so the biosimilar companies can also litigate for inappropriate patent listings. I don't know how good the machinery is to go through them step by step. But I would think if you're going to bring a biosimilar to market, that might be a path that could expedite your approval process.

Scott Benner 44:52
Before I ask the next question. I want to state for everyone listening that I am not nor have I ever been suicidal. So if I ended up suicided somewhere. I just want you all to know that ahead of time, Scott, do you feel suicidal at all? Not currently. Okay, good. So from the pharma perspective, how have you seen the pharma companies react to the FTC challenge?

Scott Strumello 45:13
You know, I think the the drug industry pretends like they didn't do anything wrong. They say, Oh, it was inadvertent, or it was a mistake or you know, sorry, are bad. But because there's really no punishment mechanism in place. They can keep doing it. But by the FTC opening the dispute process, I think you may see, you know, companies that want to make copies or biosimilars or generics, they may look to that and say, you know, we can litigate these things, too. Yeah. You know, the drug industry is basically saying, not our bad, sorry, you know, we have too many patents to worry about. It's a mistake inadvertent, we didn't do it intentionally. I think they did do it intentionally. But with the layers of complexity here. There's really not a lot of safeguards to prevent future similar kinds of abuses. But I think the FTC did open the door to potential disputes that maybe the FDA, because it's voluntarily populated by the pharmaceutical industry. Maybe they should take a closer look at these things. Yeah,

Scott Benner 46:27
listen, I'm a capitalist, and I understand looking for ways to make money and I get all that. And I do wonder if just shining a light on this isn't just going to, like, make darkness somewhere else. And you know, like, get it, they're just going to find another way to like, do the thing. And if that's not just the way things are done, and if you're not going to regulate it enough, and you don't have enough people to pay attention to it and follow it up, then is this all just inevitable? Or is it just a shell game? Right? Are we just moving things around pieces around the board? Or do you think it actually fixes something?

Scott Strumello 46:57
I think it's a good question. And to some extent, it is kind of like whack a mole, you hit one and another one pops up someplace else. On the other hand, I do think by taking these actions, and this that had never been done before, and some other government agency, the Federal Trade Commission stepped in and said to the FDA, you got all these patents listed. And they're not for the drugs, the medicines, they're for devices. We don't think these have a place in the orange book. And FDA said, You know what, you're right, are bad, we should have paid closer attention. We didn't. But thank you for bringing it to our attention. They are now removed from the orange book. Because it's never been done before. I think it opens the possibility that perhaps in the pharmaceutical industry, you may see something else to sue about in the future.

Scott Benner 47:53
And you're gonna Well, listen, it's also not lost on me that, that pharmaceutical companies are large organizations that pay people have a significant amount of money. There are a lot of smart people working in pharma companies, and they they get a big salary. And we're asking him to do these things. I'm using the GLP medication. I'm incredibly grateful for it. I'm you know, so is there a way for them to protect innovation, and allow them to make, you know, as much money as they can, like without like, like, you don't I mean, like, is there a way to do this where they benefit? And so do we, and nobody gets screwed? Like, you

Scott Strumello 48:30
know, I don't think Pharma is losing here, what they're losing is three, you know, two and a half years of extra noncompetition that they weren't entitled to in the first place, they already have patent protection on these products. And by the way, the patents on biologics is longer than it is on small molecule drugs. That was something that many people thought was inappropriate when it happened. Lo and behold, they got it, you know, an extra like five years for him. I think the patent system is in place, and it will protect farmers interest, their legitimate interests. They're not so legitimate interests. Nobody has to protect that stuff.

Scott Benner 49:13
Yeah, I would imagine they'd make the argument about the extra five years for the biosimilar stuff, that the biologic stuff that they just be like, Look, this is new science, we it might not bear fruit for a while it is probably going to help mankind in the long run, you got to you got to make it so that I can put the money into it to find out if this works or not. I would guess I mean, that's the argument I'd make if I was them. That's

Scott Strumello 49:34
what they said when you know when the decision was made to to pass that, you know, the patent on biologics as opposed to small molecule drugs. That's exactly the argument they made and they got what they wanted. Again, the patent system is giving them the, you know, that exclusivity and they're getting longer for it on the biosimilar and the biologic medicines than they are in the smaller guilds. rods here. I think they get the pharmaceutical industry has exactly what it wants and should have. I think what is happening right now is things are being taken away from them that they weren't entitled to in the first place. Okay. So

Scott Benner 50:16
you know, we didn't even say this when we started Scapa, you have type one diabetes, how long have you had it?

Scott Strumello 50:21
I will be eligible for a Jocelyn 50 year metal in 2026. Jesus, how old are you? I am 55. Wow,

Scott Benner 50:32
you were diagnosed in your five

Scott Strumello 50:35
sevens delayed? did this wrong? I'd let it done the math wrong. I have to do it on the calculator. Now I can't keep drawing. My

Scott Benner 50:43
daughter was two. She just turned two. She's 20. Now. Yeah, crazy, you know,

Scott Strumello 50:48
times zooms by and you don't even realize that it's gone already.

Scott Benner 50:52
Let me ask I have two more questions for you. So the first one is, why do you do this? If it's not your job? And you see this happening in the world? I saw what you said on LinkedIn. But I want you to tell people about it. Like, I feel like you were saying, Why is no one paying attention to this? Like, why am I not seeing this on the news? Why am I writing about this? I felt like is what you were asking. Yeah,

Scott Strumello 51:16
I do think that's exactly. And I opted to self publish it because I felt like it was a vital story that needed to be told, and nobody was telling it. And, you know, look, I I kind of, you know, complained to, you know, the media alerts. But I figured it's not worth my effort. I you know, I can I can write this in a short coherent format. And hopefully, people will go to the the article and read it because I think the story is worth telling. We can't really rely on corporate media to do this stuff. The media is, you know, they, they're sort of struggling with, how do we make money, you know, and do we do clicks? Or do we do you know, that the media outlets, financial advertising driven revenues have changed a lot over the last 10 years. And they have their own issues. They rely primarily on freelance art, you know, authors, not so many paid staff anymore.

Scott Benner 52:24
And not someone like you who's been picking through this for years. Yeah,

Scott Strumello 52:28
I mean, this was stuff I wrote literally in like, 45 minutes. It was not. Yeah, truth be told, I did write i, for me, the research part is the interesting part. So I wrote like a long ass article. And then what I ended up doing is turning to AI and said, cut this down so that it's more digestible. And so I happen to use Google Bard or Gemini, I guess, is what they rebranded. I entrusted the AI to edit it for me, I did that I then reread it made a few tweaks, and then it's two things I thought needed to be in there. And so that's kind of what I ended up with. But it started out with my work, you know, wasn't like generated by the computer, I did the research, you know, I just used it for an editorial function. I

Scott Benner 53:20
don't think that it's reasonable for us to expect everyday people to believe care, or look into the idea that a patent that doesn't belong on a plastic injector might stand in the way of them getting something for extra two and a half years, you know, like that. I don't know how we're supposed to all keep up with that stuff. You know what I mean? It's

Scott Strumello 53:40
crazy. And, you know, this is because it is such a complicated and highly regulated industry in the first place. The drug industry is is not for wimps, you know? But on the other hand, you know, it also it doesn't mean you can be, you know, a vulture capitalist and break the law. Yeah, you know, you might consider it a sleight of hand, but in fact, it impacts real world people. In this instance, the FTC stepping in, really helped open the door for it. But there could be other conditions that have similar issues. You just have to roll up your sleeves and do the research and figure out why it's happening and then find the root cause. I think one of the issues on insulin that we discovered was the, for a long time. What we were told was the reason prices are high was because the pharmaceutical industry prices them out. That wasn't really true. What was happening was the PBMs were, you know, doing stuff behind the scenes, they were acting in anti competitive fashion. And nobody was noticing it. They were doing it because they didn't have to tell anybody about it. Yeah. Now, I think you know, I spent many years kind of uncovering what how things have happened. And it was fascinating journey along the way. But the bottom line is, you know, this is stuff that I consider myself pretty knowledgeable about these days. And hopefully, you know, someday when there's some other drug that I need when I'm dying of cancer or something, I may be able to do something there. Yeah, that's

Scott Benner 55:20
my thought, as you're talking about, you know, like, when you said like, oh, somebody probably just thought they had some business sleight of hand great idea got themselves a little extra bonus, their boss liked them a little bit. And meanwhile, there are people out there not getting insulin. Yeah. And you know, and to say, Oh, don't worry, it's gonna come off patent in this much time. Well, there's a lot of people who get hurt between now and whenever that happens. And then it could be too late for those people at that point to you know, it just there's some things. Listen, I'm, I'm with you, like, people can't be vultures about it. But I'm alright, with people making money and innovating and running businesses. All that makes sense to me. But at some point, you do have to step back and look at the human impact of what's happening here and say, This has to be part of the equation to some degree, you know, you can't just let a lawyer make this decision. Like somebody's got to actually, you know, many times I've spoken to somebody who works at a pharma company or device manufacturer or something like that, they don't have diabetes, when you start talking to him about it, they don't even understand what it means. Like, they don't know what it's like to live with it. They don't even know what they're doing to you, or helping you with even sometimes, like even the good things they're doing. They don't have an appreciation for why it's valuable for you. Yeah. And, you know, so you can't put that decision on a bean counter when it's got real world implications at the

Scott Strumello 56:38
end. Yeah, I mean, I do think there, you know, like, on the insulin case, in particular, I think JDRF stepped in and kind of helped bankroll a nonprofit drug company to bring biosimilars of the three best selling insulins to market. Those are now pending FDA approval, by the way, they have insulin pens, when you

Scott Benner 56:59
say JDRF do you mean breakthrough tea one day breakthrough tea,

Scott Strumello 57:03
Wendy, as of yesterday? Yes. It'll take me a while to get used to that. But yeah, but you know, there, again, nonprofit sector really played a role in enabling that to happen, you know, on the obesity issue. I don't know who their advocacy organization is, but presumably there is one? And if not, maybe somebody wants to start one.

Scott Benner 57:26
Yeah, they should. Let me let me ask you to I guess I said two more what I meant three more. Let me say this to you. It's not a question. If you sit down and put together a thoughtful list of PBM style interviews, I'll do as many of them with you as you want. If you'd like to lay out what they really explain to people what they are and how they work and where it hurts them. I would be fascinated by that. It's no pressure. But but that would be amazing. And then my last question is, do you have any idea about this new Mark Cuban led, online pharmacy, and what impacts that might have for people with diabetes? And

Scott Strumello 58:01
the PBM thing? I'll I'll shelve that. For now. I think there's there if you could even get them to talk to you, which is highly unlikely. There would be a boatload of questions. But I'm not confident that whatever happened,

Scott Benner 58:15
I have a series called cold wind where we take out people's names and change their voices. So if anybody has recently retired, incredibly wealthy from a PBM, and once the unburden their soul, please give me a call. Well,

Scott Strumello 58:26
here, here's something you could turn to, and that is that the civica nonprofit drug company civica script is its consumer facing you. And the CEO of the civica script operating unit happens to be a former optim r x executive. And she did a whole interesting podcast on you know, like, how her PBM experience really helped her in the role. And so I would defer on that one. What was the you mentioned something else? Mark Cuban? I

Scott Benner 58:57
think once you What do you see impact for people with type one from Cubans new pharmacy? Yes,

Scott Strumello 59:05
I do. I think whether anyone cares to admit it or not, Mark Cuban's cost plus pharmacy has had a very big impact and will continue to have a growing impact. And there's a lot of reasons for it. But introducing transparency is kind of a key that he's doing. And Alex Ashby outski, who's the founder and president of hospice drugs, who works for Mark Cuban, he has type one himself, so he he knows this stuff inside now, but I do think we will see cos FOSS drug company, for example, may be selling a GLP one inhibitor, one of the many that are now pending FDA approval. I would not be surprised to see one or more of those coming from them. They're gonna give you an honest So, you know, 15% markup, the prices are probably going to be better than you're gonna get from your PBM. From your insurance companies. So look to them, I think they, it's definitely on their radar, and it's coming. Great. And by the way, one other thing that I think cost plus drugs is doing that's kind of interesting that is a little under the radar is the team cubing card initiative that they've launched, which is basically they have a network of local pharmacies around the country that will sell their drugs at cost plus drug prices. But you can just go into a local pharmacy and do it. That's kind of a cool thing. Because for things that need to be temperature controlled, like insulin and GLP ones, you might not want to do it mail order, but you might be willing to walk into a local pharmacy and buy it.

Scott Benner 1:00:52
Okay, that's interesting. This is usually the point where I say, is there anything I didn't think, to ask you that I should have?

Scott Strumello 1:00:59
No, just what I would ask is just share the link to my article. When you post this, I think others might like to get to read it. And I think it's an interesting article to say,

Scott Benner 1:01:10
I agree. And Scott, I'd be happy to share the link to it. I'd be happy to repost it if you want me to you just let me know what you'd like. Yeah,

Scott Strumello 1:01:16
I mean, when you post this the show, just include the article link with it. I think that's, that's relevant.

Scott Benner 1:01:24
I'd also like to put your blog up there, because I think people should see some of the other things you've been thinking about and talking about as well. You can welcome to do it. Let me ask you this last little bit at the end. How did the South Park GLP episode strike you?

Scott Strumello 1:01:40
Well, truth be told, I'm not a paramount plus subscribers. So I watched the I watched a summary of it. And I watched the trailer for the episode that struck me is sort of very indicative of off label marketing. And I'll leave it at that. That stuff that farm is not supposed to do, but somebody thought it was an interesting idea. And they did it. You know, interestingly, they talked about semaglutide semaglutide semaglutide. They mentioned that their drug name, like over and over and over in that episode, so it was

Scott Benner 1:02:14
interesting, there's something sinister with the South Park episode. You believe that it's a marketing tool.

Scott Strumello 1:02:19
I believe they're they're making they're depicting the drugs as not legitimate medicines, but as mainly these drugs. You know, they

Scott Benner 1:02:30
never really spoke I watched it didn't really speak about diabetes at all. No, yeah. Yeah. And it listen, it was the first third of it was oddly accurate. And like, you know, and funny, but like it was, but it was obviously overblown in cartoon eyes, which is, but I would expect, right at the end, when you know, machine gun wielding moms are double fist injecting, you know, GLP and then attacking trucks with DLP medication inside of it, trying to find their their stash. I mean, it got into very ridiculous at the end. It was interesting. It never occurred to me that I never looked to see who who funded it. So I you

Scott Strumello 1:03:08
know, I don't necessarily think I don't think you can point a straight line to Novo Nordisk and say that, and truth be told, there was a clip in there were, they said, both, like ozempic and Manjaro, which are two competing products from two different companies. That didn't hold that closely to it, but, but I do, it did strike me as sort of, kind of weird off label marketing for these products. I will tell you this intentional or not, even satirically,

Scott Benner 1:03:41
it was pretty on point. So

Scott Strumello 1:03:45
you know, the thing I found most funny about it was when they go into the dark room behind where the actual insurance like person worked, and it's like this dark closet with an old typewriter and a fax machine guys

Scott Benner 1:03:57
going very slowly, and then he picks up the phone and he says, he doesn't say anything. You don't hear anything on the phone. He hangs it up. He goes, medical director said no. I was like, yeah, yeah, at some point, he actually said the line like something about like, we always say no, so that then you have to go out there and battle the healthcare system. It was interesting, because it's, it was very satirically. correct on that part of living with like, you know, an illness where you're constantly fighting and arguing with people and, and running in circles feels like you're on a hamster wheel to come back to here. Now again, to just try to find another perspective to one day someone just goes okay,

Scott Strumello 1:04:36
the thing is, the thing I find funniest about it was because there was probably more truth to it than fiction.

Scott Benner 1:04:44
I thought, alright. Anyway, I would say I'd lend you my Paramount plus login, but I don't want to get in trouble. Scott, thank you very much. I appreciate your time. Can you hold on for one second for me?

Scott Strumello 1:04:54
Sure. Thanks.

Scott Benner 1:05:00
A huge thank you to one of today's sponsors. G voc glucagon. Find out more about Chivo Capo pen at G Vogue glucagon.com forward slash juicebox you spell that GVOKEGL You see ag o n.com. Forward slash juicebox. A huge thanks to us med for sponsoring this episode of The Juicebox Podcast. Don't forget us med.com/juice box this is where we get our diabetes supplies from you can as well use the link or call 887211514 Use the link or call the number get your free benefits check so that you can start getting your diabetes supplies the way we do from us med. Jaylen is an incredible example of what so many experience living with diabetes, you show up for yourself and others every day, never letting diabetes to find you. And that is what the Medtronic champion community is all about. Each of us is strong and together we're even stronger. To hear more stories from the Medtronic champion community or to share your own story visit Medtronic diabetes.com/juice box and look out online for the hashtag Medtronic champion. To read Scott's blog, go to blog dot s s t r u m e l l o.com blog.ss t r u m e ll o.com. I know that Facebook has a bad reputation. But please give the private Facebook group for the Juicebox Podcast. A healthy once over Juicebox Podcast type one diabetes. The group now has 47,000 members in it, it gets 150 new members a day. It is completely free. And at the very least you can watch other people talk about diabetes. And everybody is welcome type one type two gestational loved ones, everyone is welcome. Go up into the feature tab of the private Facebook group. And there you'll see lists upon lists of all of the management series that are available to you for free in the Juicebox Podcast, becoming a member of that group. I really think it will help you it will at least give you community you'll be able to kind of lurk around see what people are talking about. Pick up some tips and tricks. Maybe you can ask a question or offer some help Juicebox Podcast type one diabetes on Facebook once there was a time when I just told people if you want a low and stable a one C just listen to the Juicebox Podcast. But as the years went on, and the podcast episodes grew, it became more and more difficult for people to listen to everyone. So I made the diabetes Pro Tip series. This series is with me and Jenny Smith. Jenny is a Certified diabetes Care and Education Specialist. She's also a registered and licensed dietitian and a type one herself for over 30 years and I of course am the father of a child who was diagnosed at age two in 2006. The Pro Tip series begins at episode 210 with an episode called newly diagnosed or starting over and from there all about MDI Pre-Bolus thing insulin pumping, pumping and nudging variables exercise illness, injury surgeries glucagon long term health bumping and nudging how to explain type one to your family. Postpartum honeymoon transitioning all about insulin Temp Basal. These are all different episodes, setting your Basal insulin, fat and protein pregnancy, the glycemic index and load and so much more like female hormones and weight loss. Head now to juicebox podcast.com. Go up in the menu at the top and click on diabetes pro tip. Or if you're in the private Facebook group, there's a list of these episodes right in the feature tab. Find out how I helped keep my daughter's a one C between five two and six two for the last 10 years without diet restrictions juicebox podcast.com Start listening today. It's absolutely free. If you're not already subscribed or following in your favorite audio app, please take the time now to do that. It really helps the show and get those automatic downloads set up so you never miss an episode. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. The episode you just heard was professionally edited by wrong way recording. Wrong way recording.com

#1223 Trust Issues

Laurie talks about mistrust, pressure and stress. She is the mother of a child with type 1.

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COMING SOON

#1222 Bold Beginnings: Injected Wrong Insulin

Bold Beginnings will answer the questions that most people have after a type 1 diabetes diagnosis.

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Scott Benner 0:00
Hello friends and welcome to episode 1222 of the Juicebox Podcast.

Today, Jenny Smith and I are going to talk about one topic. That topic is What do I do if I inject the wrong insulin? Now basically what that means is you're about to inject your Basal insulin and you do it you know, what do you get like 2030 units of basil a day, whatever your number is, and you won't put it in and whoopsie daisies I put in my mealtime insulin. What do you do? Nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan. If you or a loved one was just diagnosed with type one diabetes, and you're looking for some fresh perspective, the bowl beginning series from the Juicebox Podcast is a terrific place to start. That series is with myself and Jenny Smith. Jenny is a CDC as a registered dietician, and a type one for over 35 years. And in the bowl beginning series, Jenny and I are going to answer the questions that most people have after a type one diabetes diagnosis. This series begins at episode 698 In your podcast player, or you can go to juicebox podcast.com. And click on bold beginnings in the menu. This episode of The Juicebox Podcast is sponsored by the Dexcom G seven dexcom.com/juice box. And by the way, Dexcom now pairs with your Apple Watch. Check it out dexcom.com/juice Box. Today's episode of The Juicebox Podcast is sponsored by the contour next gen blood glucose meter. This is the meter that my daughter has on her person right now. It is incredibly accurate and waiting for you at contour next one.com/juice box. This show is sponsored today by the glucagon that my daughter carries. G voc hypo Penn. Find out more at G voc glucagon.com. Forward slash juicebox. Jenny I thought today we could talk about what to do. Like I want to have a nice, small, all in one episode about what do I do if I inject the wrong insulin? Oh, that's a good one. Yeah, it happens to people and the time to start thinking about it isn't when it's happening. So I'd like people to know ahead of time what to do. So good. I was gonna say

Jennifer Smith, CDE 2:41
I think something else that goes along with it too. Although most, most pumps now have a protection feature to dosing too much even have the right insulin right one unit versus oh my gosh, I took 10 units because I didn't realize what buttons I was pushing. Right? Yeah, but I think it's part of the same,

Scott Benner 2:58
it's still happening. Also, I have a story that I'll tell during this that will. I didn't know what I was gonna say there. I always think of every time I think of saying something that will shock somebody I think of the line from the Julia Roberts movie, where she's famous. And Hugh Grant owns a bookstore. What is that movie? Do you know what I mean? I know they fall in love. And there's a crazy roommate of Hugh Grant. Anyway, he says, I'm going to tell you a story that will shrink your balls to the size of raisins. And I think of that every time I think of this and I have a story like that about somebody getting too much insulin, which I will tell awesome later, let

Jennifer Smith, CDE 3:34
me just say no, the roommate is always in his underwear. Yeah, I don't know the name of the movie. But he's like a crazy and he's British, and he's got the most horrible t

Scott Benner 3:43
this is ridiculous at the end are on the park bench. She's pregnant, it's happy. I'm an art. If that doesn't come to us, we'll look it up at the end for all the people who are yelling at their headphones right now and already know the answer. Okay, so here's what could happen. And now listen, if you're not MDI, like Jenny just said, Hold tight, this applies to you as well. But moreover, what ends up happening normally is that people at the end of the day or in the early morning, when they're tired, grab their fast acting insulin or mealtime insulin instead of their basil or their slow acting insulin and inject a lot of fast acting insulin instead of basil. So yes, yeah.

Jennifer Smith, CDE 4:20
And I would say that's correct in terms of the majority of MIS used insulin type. That's it is somebody meant to take their basil, and instead they took their rapid acting, it's not common that I find the other way around. Yeah,

Scott Benner 4:37
and if that happened, you just be like, Oh, well, whatever.

Jennifer Smith, CDE 4:41
Maybe I don't have to inject you know, rapid today because I've got so much basil in the background, right, but it could just eat all day,

Scott Benner 4:48
but it doesn't feel as like immediate Yeah, like it has to happen right now because it does because, listen, even if you're a if you're a kid, even you know and you inject for Five units of Novolog, let's say when you meant for it to be, I don't know, 11 meter or transceiver or something like that that's a significant thing because most people know for their kids, five units is a ton. And then when you get into adults, they could be using 2025 30 units of Basal insulin. And now all of a sudden, you've got 25 units of fast acting insulin, but let's pick round numbers. So we can do this well, okay. Okay. Let's say you meant to inject, I don't know 10 units of basil. And instead you injected 10 units of fast acting. And your insulin to carb ratio is one unit covers 10 carbs. This is a nice way to conversationally, very easy math, right? So I've seen people panic. I've seen people call 911. I've seen them drive to the emergency room. I very frequently wonder why people don't just think, Well, I wonder what my carb ratio is here. How much would I have to eat to counteract this?

Jennifer Smith, CDE 6:00
Right. And that should be a it should be a first thought. But I also think, as you said, it's a Oh, my goodness, what did I just do and panic sets in. And you think that was a lot of insulin and especially for? I think from a clarification, as you said, already, kiddos, many little kids are very sensitive to insulin. So a whopping 10 units of rapid insulin, when it shouldn't have been, could have been a lot of extra insulin versus an adult who maybe could actually cover that pretty easily with some simple food,

Scott Benner 6:37
right? And maybe wouldn't be a crazy amount for them to begin with as a meal Bolus. But just to keep your head about you. If one unit is 10 carbs for you, and you put in 10 units, you need to eat 100 carbs. Yes, not that much. But

Jennifer Smith, CDE 6:57
But I think the timing there of putting it in. Thankfully, we have CGM where you not only took the amount of insulin now you've got it? You're okay. Okay, I've got this. I know how much I took. Let's put all the pieces together. Where is my blood sugar? Where is it heading? Is it stable? Is it rising? Is it already falling and lower to begin with? So those are all parts in the decision of starting to put food in to cover this excess?

Scott Benner 7:26
Right? What kind of food is that? Because of digestion absorption? Am I going to cover the 10 units in time? So if you panicked, for example, and said, I don't know, see, I guess this is the problem. Like I like doing this in real time. Because what food would I go grab? And like? Do you start thinking a hundreds of big numbers, so I have to get something that's like a lot or like instead of thinking like, let me put in some fast acting sugar and then go get something that digests a little slower.

Jennifer Smith, CDE 7:59
You're right. And that's where you're now thinking as someone should be thinking, Okay, where's my blood sugar? Is it in target? Is it dropping? If it is you're looking at that 10 units now, probably a little bit more simple carb upfront, to really stabilize out whatever drop was happening already before the 10 units right. And then once you've got stability, then again, action of rapid insulin is about let's call it four hours, it's three to five hours, but on average about three to four hours so you still have you still have a timeline of its action to cover that 100 grams doesn't need to be eaten in 15 minutes. If

Scott Benner 8:42
you take insulin or sulfonylureas you are at risk for your blood sugar going too low. You need a safety net when it matters most. Be ready with G voc hypo pen. My daughter carries G voc hypo pen everywhere she goes because it's a ready to use rescue pen for treating very low blood sugar and people with diabetes ages two and above that I trust. Low blood sugar emergencies can happen unexpectedly and they demand quick action. Luckily Jeeva Capo pen can be administered in two simple steps even by yourself and certain situations. Show those around you where you storage evoke hypo pen and how to use it. They need to know how to use Tchibo Capo pen before an emergency situation happens. Learn more about YG vo Capo pen is in Ardens diabetes toolkit at G voc glucagon.com/juicebox. G voc shouldn't be used if you have a tumor in the gland on the top of your kidneys called a pheochromocytoma. Or if you have a tumor in your pancreas called an insulinoma. Visit GE voc glucagon.com/risk First, right? You get out of it. Right? So stop the initial drop from crashing you with Some food buoy and a little bit, if you will, like you know, hold it up a little and then go a little slower eating forward, watch the clock, watch your CGM or test if you start drifting in the wrong, like drifting up, you think maybe, oh, maybe I got this now. Right,

Jennifer Smith, CDE 10:15
and then you let the drift happen at that point, you definitely still have insulin Now let the drift happen. Yeah, I mean, you don't like high blood sugars. But this is a different scenario of a high you were trying to prevent what you didn't plan to do to begin.

Scott Benner 10:28
We're also trying to go without saying it. And maybe we should just say it here like you're trying to prevent, like dying is what you're trying to prevent? Yeah. Yeah, let's run the risk of having a high blood sugar for a few hours until we're sure that insulin is gone. Right? I do see people at times, they run to juice. And they start panicking and trying to get all the carbs and the juice, but I want to I want to tell you, you can get what I call juice sick. If you do that, like you're like your stomach, and then you're in trouble. Because if you vomit, or you can't eat anymore, and you still need more, you're going to be in trouble there as well. If you're trying just to cover with correct with

Jennifer Smith, CDE 11:05
food, right? Which is again, the reason for some of the timing of intake, right? If your timing that out giving a portion upfront watching the CGM, you know, watch it every 15 to 20 minutes digestive Lee you have to get get some time going for that food to move in, really get absorbed. If you want to speed some absorption because you were dropping already, you may do some warm liquid along with the simple carbs, because that does speed up absorption and the rate of kind of digestion. So it gets things moving a little faster to stabilize things out. And then eventually with stability, you know, okay, well, I covered this much already, there's still this much, let's say five units was still uncovered. As long as you've got stability, you may start putting in the rest of the food to cover that five extra units in a little bit more complex food. So that, you know, so that it doesn't really cause a big spike and then drop you off yet again,

Scott Benner 12:02
because of digestion. So I'll say this, if you haven't listened to the Pro Tip series, I think if you listen to the Pro Tip series, when this happened, you would just do what Jenny and I are saying kind of naturally, right? Because you you'd have a concept of timing, and amount, right? And so but if you haven't fair enough, what did you just say about the warm liquid? What does that do that helps your body pull up the sugar?

Jennifer Smith, CDE 12:28
Yeah, so warm liquid actually speeds the rate of digestive to a degree and so that it increases the ability for your body to digestive ly absorb that food or that carbohydrate, especially faster, so that you're you know, you get a little bit quicker response. You know, again, if you were dropping honey in warm water is lovely. It five grams per teaspoon, it works pretty quickly. You're getting it into your system, it's also not volume, you're talking about juice sickness. There's only so much liquid you can put in before you start feeling yuck right to teeny tiny amounts, maple syrup or honey, even a teaspoon of like regular sugar can be easy to get in and it's not this large volume of

Scott Benner 13:14
food. That's a good point. Like even the juice boxes that aren't and still carries to this day for Lowe's are very tiny. But we I mean, I guess I did a lot of juice box research at one point in my life, right? Like, how can I get her the least volume of liquid that she still is okay with the taste of that will get her the most carbs because we're not using them for pleasure. You know, we're not using them to drink we're using them to combat a low blood sugar. You know, I have to say, I sent her off to college six months ago with juice boxes. And I was like, Look, when you run out of them, you'll have to buy more. And she hasn't had to buy more. That's awesome. So exciting. Yeah, it's such a little thing. But like I love throwing juice boxes away when I pick her up at college. I'm like, Oh my God, you didn't use these like, it's fantastic. Yay. Let us go into digestion just Just a minute. So you can't just grab anything. The amount of people I see are like I have a little blood sugar in there. Like they have chocolate. I'm like that is not not an option. Not chocolate. Yeah, like I know because they think sweet or sugary, which is nice, but it's fatty and not absorbable being slow. Yeah. So simple sugars to stop the, I guess the way you have to think of it as you've just put in way too much insulin. And reasonably speaking, insulin does not work faster or slower. Because you've used more of it like inlet until you start getting into really bigger numbers. Yeah, value like if you start I mean if you put in, let's say 150 units instead of one and a half units, which by the way, hint hint is the story I'm going to tell you in a minute. So it let's say that happened, then yes, it's going to start dropping more quickly. But if you put in 10 And, and you know your normal Bolus is like for usually the, it's not like your blood sugar is going to drop 12 seconds later. Correct. So you have a little time. Now we're going to put in some fast acting easily absorbed stuff like juice like honey and warm water, that kind of stuff to basically start shooting your blood sugar up so that when that insulin starts to hit, it's fighting against the rise already. Yeah, kind of the opposite of Pre-Bolus for a meal, instead of causing a drop, that your food just kind of hold steady, you're gonna put in enough food that even if the drops happening, it can't overwhelm, right? Yes, right? Yep. Now you've got yourself saved for a minute, I'll take a breath. Right? And now do the do the math. How many more carbs do I have to cover here. But we're not going to do that with pizza, for example, because now your digestion slows way down. And the insulin has time to overpower the simple sugar that you took to initially. And now the pizzas not digesting. So now the insulin is there. And nothing's combating it. If you explain how to Bolus for pizza right now, that will solidify my example. Would you do that for me?

Unknown Speaker 16:12
How to Bolus for pizza? How

Scott Benner 16:15
do you Bolus for pizza? Sure,

Jennifer Smith, CDE 16:17
so pizza has a lot of carb, right. But it also has a lot of fat and potentially a lot of protein, which is going to draw out an impact. So you're going to do is you're going to give some upfront with Pre-Bolus, maybe 50%, let's call it. And then if you're doing multiple daily injections, you may do a split Bolus technique, a Bolus some up front you Bolus some maybe right after the meal or some maybe 30 to 60 minutes after the meal to catch the end effect. If you have a pump that does something like an extended Bolus can do some upfront and extend from that point the rest of it over a period of one to three hours, for example. So essentially, you're getting some, and then you're ticking in the rest as the food digests more slowly on the back end.

Scott Benner 16:59
So for those of you who have ever Bolus for pizza and thinking like, oh, there's 30 carbs, and every one of these slices, I'm gonna have three slices, here's 90 carbs. And the next thing you know, you're super low. It's because the insulin is working, the food hasn't started digesting enough for your body to pick it up. And to combat it. Understanding how to Bolus for pizza explains why you wouldn't use something like pizza in this example, like so I thought maybe that would be a good thing to

Jennifer Smith, CDE 17:25
absolutely make sense. I you know, and I think in terms of the technology we have today, I think another piece that should really help to decrease the panic in that scenario is you don't have to do a finger stick every single five minutes, right, you've got to CGM to be able to follow. The other really awesome thing is that in today's world, we have multiple options for glucagon. And if you really were worried, and you really didn't see movement on that glucose graph, and you did finger sticks, and they were verifying that the CGM is correct and your blood sugar is not rising, and you're worried. You have glucagon. Yeah, you could use it. Absolutely.

Scott Benner 18:05
And I just want people to understand how to manage it without it. But I'm not saying don't use it. If you get sick to your stomach, if you panic, if you like just better off alive with a high blood sugar. And we'll start over again, then that not I don't want to see a passing out. I also don't want to see what I hear happen sometimes. Once the panic goes through. People will put themselves in the car sometimes to go to the hospital. And I'm like, No, I don't want you driving. Your blood sugar's falling rapidly. You don't know when it's gonna tank out like putting, but I've seen it happen, like, yeah, there's a panic, then there's a froze, they freeze. Some people will go to the internet helped me I just did this, all I can think is there's five minutes there to open your phone to put up the posts or somebody sees it like, time is wasted. And then they're like, I don't have anything in the house, or I don't have this right. I can't make up that much. I don't feel well. I'm gonna go to the hospital. And I'm like, by yourself. Call my

Unknown Speaker 19:07
purpose of 911. Yeah,

Scott Benner 19:08
we don't want you to driving during the situation. But I think what happens is, is that any reasonable person who would not do something like that, in a normal situation, when the panic hits them, and they run out of options, they just go to what's left. And you know, if you really thought if you really thought you were about to pass out in your home, and you had enough insulin in you that it was going to do you in then trying to drive to the emergency room doesn't seem crazy. All of a sudden, you don't I mean, right? Anyway, I've just seen so many people have these experiences that I'm aware of where they go upside down at times. With all that said, you have to have this stuff in your house, obviously like if you have type one diabetes, and you don't have this stuff in your house. There's got to be an emergency stash somewhere of stuff Correct? Yes, you need to understand that simple sugar absorbs well through your cheeks, like inside of your cheeks. You You can rub like glucose gel in there. You can try tablets, you know, but yeah, use your use your glucagon if, if if you can't figure the rest of it out or if you're panicking because we don't want anything bad to happen. Oh,

Speaker 1 20:11
you know what? Good thought of the movie name.

Scott Benner 20:15
Wait. Oh now I feel weird. So, wait, we wait. So she's a very famous like in

Jennifer Smith, CDE 20:22
the back of my brain thinking while we've been talking about like, I know that

Scott Benner 20:26
she's super famous She's an American actress she comes to England to make a movie falls in love with a guy from a bookstore. They have a bit of a romance they break up again, Alec Baldwin shows up at some point. I know the entire goddamn movie. But what is it called?

Unknown Speaker 20:42
Can I give you a letter?

Unknown Speaker 20:44
I guess so go

Unknown Speaker 20:45
ahead. Ah, in this is in the second word. Second word. It's a two word name.

Scott Benner 20:55
I'm gonna be so embarrassed. I also let me tell you this. I've seen this movie like five times because my wife watches it all the time.

Jennifer Smith, CDE 21:02
Oh, really? I don't think I've only seen it like watched Oh, no,

Scott Benner 21:05
I could pretty much walk you through the script right now if I needed to at one point, she's making kind of like a bridgerton type show. And he shows up there and puts a headset on here's her talking to another actor about him. I know the whole thing. What? Don't tell me. Just okay. Okay. Let's keep talking. Okay. Okay, so be good.

Jennifer Smith, CDE 21:26
I was gonna say another component that I do think of it for those who are on pumps, this wouldn't apply for MDI. But it would apply for pumps, you do have the opportunity to subtract some of your Basal over the next couple of hours. Right, you could technically replace knowing again, insulin action is going to be a couple of hours of this bigger dose than you expected to take. And if you've got an insulin, you know, Basal rate that's like one unit an hour, you could technically for the next two hours just set us a zero Basal or a suspend, which could prevent that Basal from building behind this large dose, allowing some of that Bolus to just be replaced.

Scott Benner 22:08
Yeah, I would say that, like if your blood sugar was 130, and it was super stable for hours, you never any act of insulin at all. That contour next gen blood glucose meter is the meter that we use here. Arden has one with her at all times. I have one downstairs in the kitchen, just in case I want to check my blood sugar. And Arden has been at school, they're everywhere that she is contour next one.com/juice box test strips. And the meters themselves may be less expensive for you in cash out of your pocket than you're paying currently through your insurance for another meter. You can find out about that and much more at my link contour next one.com/juice box contour makes a number of fantastic inaccurate meters. And their second chance test strips are absolutely my favorite part. What does that mean? If you go to get some blood and maybe you touch it and I don't know stumble with your hand and like slip off and go back. It doesn't impact the quality or accuracy of the test so you can hit the blood not good enough, come back get the rest without impacting the accuracy of the test. That's right, you can touch the blood come back and get the rest and you're gonna get an absolutely accurate test. I think that's important because we all stumble and fumble at times. That's not a good reason to have to waste a test trip and with a contour next gen. You won't have to contour next one.com forward slash juicebox you're gonna get a great reading without having to be perfect. Today's episode of the podcast is sponsored by Dexcom and I'd like to take this opportunity to tell you a little bit about the continuous glucose monitor that my daughter wears the Dexcom G seven the Dexcom G seven is small. It is accurate and it is easy to use. And where Arden has been wearing a Dexcom G seven since almost day one of when they came out and she's having a fantastic experience with it. We love the G six but man is the G seven small the profile so much closer to your body the weight, you can't really feel it and that's coming from me and I've worn one I've worn a G six I've worn a G seven I found both of the experiences to be lovely. But my gosh is that g7 Tiny and the accuracy has been fantastic Arden's Awan C's are right where we expect them to be. And we actually use the Dexcom clarity app to keep track of those things. That app is built right in to Arden's Dexcom G seven app on her iPhone. Oh, did you not know about that? You can use an iPhone or an Android device to see your Dexcom data. If you have a compatible phone, your Dexcom goes right to the Dexcom app. You don't have to carry the receiver but if you don't want to use the phone, that's fine. Use the Dexcom receiver it's up to you. Choice Is yours with Dexcom dexcom.com/juicebox. Like if your blood sugar was 130, and it was super stable for hours, you never any active insulin at all, and your Basal rate was one unit per hour. If you just Bolus two units, and then shut your basil off for two hours, you'd be very possible you wouldn't notice anything happened. Right? Right, like so those are those kinds of ideas that you need to apply in this situation for certain. Okay, so we've injected the wrong insulin or pump in more than we've meant to, these are ways to handle that. What if I do the wrong dose of? So here, these are actually questions from people. So what do I do when folks inject the wrong insulin? Like their fast acting versus their long acting? What do I do be aware of what's the next few hours? Like? What's the math behind it? I feel like we've covered all that, what to do if you take a double dose of long acting by accident, so that so I shoot my Basal insulin, and an hour later, I can't believe this does happen. Like I do it again. I go, Oh, my God, I Oh, my God. Now I have 20 units of my long acting going. It's almost, I mean, it's a completely different game now. Right? Like, because it's not, yeah, it would be

Jennifer Smith, CDE 26:17
a completely different. And again, depending on the time of day, if you're a Basal dose, at night, or, you know, in the evening, it's very, very likely, the best recommendation would be to have an uncovered snack before you go to bed, because you now have twice the amount of Basal insulin. And while we do you know, the newer insulins like true Siba, they tend to be much more flat. In effect, they don't really have a rise and then kind of a dip down at the end. Lantus is fairly flat, but it still does have a little bit of a surge in action and kind of like a petering out at the end. But in all, the best option there is again, to aim for a little bit higher blood sugar, especially overnight than what you would typically aim for, let's see for the overnight and uncovered snack, some good protein content to it, so that it has some sort of stability behind everything. The next day, though, and this is for those who might do their Basal insulin in the morning, now you've got double coverage. And as I sort of said earlier, it's very likely your doses for meals are probably going to need a downplayed dose, because now you have a lot of basil. The other potential is that you have to have a meal. And you may have to have some uncovered snacks between because again, there's a much higher amount of Basal insulin there than you wanted to have.

Scott Benner 27:43
So if your Basal is dialed in perfectly, and you're one unit an hour, you know, it's let's say it's 24, you should 24 units a day, because you're about one unit an hour. Now suddenly, you've put it in twice, now you have 48, if your stability is at 90 on the 24 units, with 48, your blood sugar is just going to constantly want to be low. So you're basically going to have to feed that insulin until it's out or until it starts to wane. And the newer ones don't wane the way the older ones though. So you might be 24 hours if you did this with the receiver, for example. Correct. Versus if you did it with Lantus or levemir, which would probably start to change around like 1820 hours, I'll tell you, yeah, okay. super interesting. Now, here's your story. So this is an interview that won't be out for a number of months here on the podcast. But this seven year old girl leaves in the morning, she's an omni pod user, but leaves her phone behind in her car when she goes to school. So the mother calls the school and says, Hey, you know, you're gonna have to go to the backup plan, let's we'll use MDI until I can get back to the school and drop off the phone, which I'll be able to do pretty soon. But you know, there's a thing coming up, you know, whatever it comes up, you know, go to the MDI, 504 plan, etc, has us covered for that. So the mom does some stuff, she gets to the school. And just as she gets to the school, she comes to the nurse's office, because that's where the kid is, the kid just got insulin for something. And the moms think so I'll go to the nurse's office and drop off the controller, the phone, whatever, and I'll be on my way and she sees the little girl who for some reason has two syringe marks inner instead of one like it just interesting, too, that she could see the syringe and she could see these two little syringe marks on a kid and she goes, Wow, how can we have like two little like, you know, how can we get poked twice? And the nurse says all the insulin didn't fit in just one syringe. Yep. And here you go. Johnny, take a minute to take it in. You'll want to catch this when it comes out because it's just me cursing a lot for for an hour.

Jennifer Smith, CDE 29:55
So the woman thought that literally all the insulin in the vial was a dose and had to go in.

Scott Benner 30:01
She wanted to give her a unit and a half and gave her 150 units of insulin. A seven year old. So the mom, as you'll hear in the Yeah, Yeah, no kidding, like really absorb it for a second. So when we talked about the if you put in enough insulin and a smaller about you know, in a body, it'll it started acting pretty sure on the kid right? So

Jennifer Smith, CDE 30:22
well and is going to last for quite a while because when you talk about volume, that volume of let's call it a unit and a half may take a little time to get moving like normal are Pre-Bolus. But then it's gone in a normal amount of time because that pocket of insulin into the skin is it's almost like a styrofoam ball instead of a Super Bowl ball. Right, that compact turning on rubbery. That's a large dose of insulin. And now despite having a three to five hour active insulin window, now you've got a tightly packed insulin that's inside of that ball of injected and that's going to take

Scott Benner 30:59
forever. Yeah, well, what it took was eight hours on a on a dexterous drip in the ER, yeah. So anyway, I won't ruin the whole story. Or the things I said I would do to the school nurse. But my God, but anyway, the mom, she first just she just tries to find a way that it didn't happen. Are you sure that's what you did like? So there's a couple of minutes spent in the office doing that. They live very close to the house where they live. And so she's fixed the kid in the car is at the house in two minutes. leaves the kid in the car runs the house grabs glucagon I'm not sure why glucagon wasn't at the school. But anyway, I bet she does. Now she hits the kid with the glucagon. But the kids already depan like I'm sure yeah, like she's she's her lights are going out. Right like so the she hits her with the glucagon, which pushes her blood sugar to like 74 long enough for her to drive her to the emergency room. Anyway, I she told me that story. I couldn't decide if I was gonna cry or scream when she was saying it. It was insane. Like, wait, did you hear her tell the story? That's

Unknown Speaker 32:08
like, I don't usually I have words for most things.

Jennifer Smith, CDE 32:14
But I don't have words like I don't even I wouldn't even have words in the moment. I wouldn't have wasted words on the nurse I would have, I would have moved with my child. And the words would have come later. Oh,

Scott Benner 32:26
I told her I said I said if that was me, I would have been shooting glucagon with one hand at choking that lady with my other one. And for clarity, because you definitely go find the story somewhere, wherever it isn't a podcast and good luck. I probably ended up naming it something stupid. You'll never find it. But a nurse in her 60s She was a nurse for 40 years and

Jennifer Smith, CDE 32:43
should have no mean insulin has been around that long drying up insulin. You can't tell me this wasn't the first child she's given.

Scott Benner 32:52
Right? But it goes to prove like what we were talking about a little like to come down on the side of the nurse for a second, right? Like what we talked about before, like, I don't know, how do you shoot 24 units of basil and then do it again. An hour later. He's because sometimes you just you get flummoxed and you just don't think of things. My real like sticking point was? Why would a needle manufacturer make a needle that doesn't hold enough insulin for an average seven year old to Bolus for a sticky snack? Like Like, right? Like, do you really think people are hitting themselves with multiple needles every time they eat? And that's where no common sense got involved at all. It didn't stop her. She just she gave the kid 150 units of fast acting insulin. Even like holding the vial. Wouldn't you say to yourself, oh my god, I wonder how many of these she must use hundreds of these vials of insulin every month. Like right? Like none of that kind of like common sense stuff. God tour, the kid knew. The kid threw up a flag when the nurse said oh, it just doesn't fit. I mean, she was seven. She was like, Oh, right on like, and she just sort of went with it.

Jennifer Smith, CDE 33:54
Right. You know what my my inclination would be in terms of how the mom could see that? There were two. I bet the nurse put band aids. Oh, I bet there were two band aids that I mean, because those injection spots. You can't rip. That would be my thing is that there were two little band aids and mom was like, Why do you have to bandys It's going

Scott Benner 34:16
on right now. Yeah. What's going on right now? Just the timing of it, Jenny? Yeah. If the mom gets held up for 10 minutes and doesn't show up at that moment, they send that kid back to class and she just dies in a room. You know what I mean? Isn't that terrible? Like anyway, so I'm sorry, I was just it was so upsetting, you should see. But anyway, if you hear the episode, I just at any point in the episode, start cursing and I get upset.

Unknown Speaker 34:42
It does happen, oh my god. But

Scott Benner 34:44
nevertheless, you are at some point in this game, you're going to end up with the wrong amount of insulin one way or the other. And knowing how to like deal with those situations is I mean, it's probably not going to Be 150 units when you meant to do a unit and a half, but you are going to make a Bolus one day and get sick in the middle of it not want to eat, or the the restaurant is going to come back 20 minutes later and go, Oh, we didn't have what you ordered? Would you like to order something else? And you're going to be like, Oh, wait, what now? Right? So this is gonna happen at some point. Yeah.

Jennifer Smith, CDE 35:21
And even in terms of, you know, sometimes get more emergent emails that are, you know, Susie just throw up threw up and we just gave her her dose for her dinner. Now, what do we do? It's kind of the same, it really is. Same idea. Really just covering it a little bit different way, obviously, if there's a stomach bug or something else in the picture, right. But yeah, it is. I mean, everybody makes mistakes. I have done this, that between basil and rapid, but I've done it because I was not. I was not paying as close attention to what I was dosing. And I took more than I was supposed to take because I was busy doing other things with my kids. And I went and I entered. And then I looked at my iob. And I was like, Ha, I shouldn't have this much. I'll be there.

Scott Benner 36:08
You know what I know that's happening with a pump what I see happen to people more frequently than anything else. It's not like saying to yourself, like, Oh, I'm gonna give myself five and giving yourself 10. It's saying to yourself, I'm having 30 carbs. And you're a one to three, you're a one to 10 for example, right? And instead of giving yourself three units, giving yourself 30 units because the the number 30 sticks in your head while you're dialing it up and you're paying attention to something else that is literally that's the way I see it happened with pumps more often than not correct

Jennifer Smith, CDE 36:40
absolutely or distraction. Again, mine was I mean, this is honestly in my memory is the only time that I've ever done it in terms of like that absent minded and I was supposed to take a unit and I took 10 units. And that's a lot of insulin for me, but I just enjoyed the attitude. Like I know how to take care of the cane

Scott Benner 37:04
while we were eating for real today.

Jennifer Smith, CDE 37:08
We are not taking a bike ride today.

Scott Benner 37:11
Listen, listen, have a meal or snack consume fast I think carbs monitor your blood sugar. Stay with someone avoid activity, contact your healthcare provider carry glucagon adjust your Basal insulin. These are things you can do. Yep, I never did it. But I almost did it. I drew it up. And I had it my hand. And I don't know what happened. But my brain was like that vial was the wrong color. That made you second thing thought me just long enough. And then when I went back, because they're both in the refrigerator. I don't know what I did. So I just I threw the syringe away. And I just started over again. Yep, I don't know. I get never I never made it all the way to the injection. But I've I've done that. I mean, I've also miscalculated carbs given too much insulin like that. I mean, it's gonna happen a lot of different ways. But listen, again, I just want to say at the end, if all else fails, glucagon, 911. Yes, absolutely. No, like, let's not have what what did my son's outfield coach tell him when he was when he was in Little League? Don't turn a mistake into a disaster. That's a yeah, yes. He cursed a lot while he said it. So it wasn't that nice. But that's what he meant. What he meant was just a bit. Yeah, you're gonna make a mistake. It's cool. Don't keep making them after that. And anyway, I hope this is helpful for people. I hope you hear it before you need it. That's my goal and making this one because like I said, the Facebook group. I'm gonna say monthly. Oh, my God, guys, what do I do? Yeah, I mean, so. And

Jennifer Smith, CDE 38:47
I think it goes along with just kind of in my circumstance, too. It's like the busyness of life, right? It is and you think you've gotten into such a routine that you're not going to make that mistake. It's a mistake. We are human. We will make a mistake at some point. And beating yourself up about it in that moment is not going to be helpful. So you just move forward. Okay, what do I have to do now?

Scott Benner 39:11
Try to keep your head about you the best you can. Yeah. All right now, Jenny, let's do something. I'll just embarrass my I'm you know what? I'm married. I'm not embarrassed by this. Okay. I've seen a lot of Julia Roberts movies. I don't think I've seen one of them on purpose. Or because I wanted to, but I have let's go through all the Julia Roberts movies. I know. She was in Mystic Pizza.

Unknown Speaker 39:31
Oh, that's one of my favorites. Okay.

Scott Benner 39:33
There's the one where she's the hooker. That one's called. Pretty, pretty woman. Okay, let's see if I can come up with them. There's that one where she's helps the lawyer. Erin Brockovich.

Jennifer Smith, CDE 39:45
Err. Oh, that's another thing I didn't like I like I have to say that. I really

Scott Benner 39:48
like can I tell you something. Erin Brockovich, the first movie we ever took call to Kelly, breastfed Cole in Erin Brockovich because we were so we had to get out of the house like so badly. had to get out of the house. Julia Roberts has been in those movies now she's been in a ton of movies. She was in that movie, where she had type one diabetes. And that one's called she

Speaker 1 40:12
the Southern 100 Steel Magnolia magnolia. That's an old Shelby.

Scott Benner 40:19
Remember that one? That one by the way, my wife's favorite movie till Arden got type one diabetes, and now we don't watch it anymore. And then, of course, there's what other movies has Aaron Brock. I just called her Erin Brockovich been in. Julia Roberts.

Jennifer Smith, CDE 40:36
Oh my gosh, well, and I know the one that you're trying to think of, but I'm not gonna say it until you can think about it.

Scott Benner 40:41
I literally could tell you that entire movie front to back. Why can I not?

Jennifer Smith, CDE 40:46
It's a she's also in my best friend's wedding. My best friend's wedding. There you go. Which is not this one.

Scott Benner 40:54
She's been in seven movies where her and George Clooney are almost dating. So there's all those I don't know the names of them.

Jennifer Smith, CDE 41:01
Oh, she's also I used to be a really big, a really big John Grisham. I used to love his novels. In Pelican Brief.

Scott Benner 41:09
Thank you. Right we're like they're on the house and it's raining and the crazy guy once the killer or something like that, right? Yeah. Hold on. Oh,

Jennifer Smith, CDE 41:18
you know the one that I really like it was a book is Eat Pray Love.

Scott Benner 41:22
Okay. I've never seen that. Really? That's a flex for my part. But okay.

Jennifer Smith, CDE 41:28
Yes, I'm I am. I'd be surprised if your wife Oh, I

Scott Benner 41:31
somehow got out of it is what I'm thinking right now. But the movie, by the way, here's the crazy thing about the movie I can't think of at the end of the movie. There's a montage where they like have their life together. And the and the song sheet is sung. Like I even know that. But I don't know what in the hell the movies called. And when you tell me I'm gonna bang my head on the desk. I'm gonna be so frustrated. I'm gonna go Of course. That's what it's called. It's called.

Unknown Speaker 41:58
Alright, tell me. Sure.

Scott Benner 42:02
I'm so upset with myself. All right, we have to go just told me.

Unknown Speaker 42:07
Notting Hill

Scott Benner 42:13
I'm so pissed.

Jennifer Smith, CDE 42:14
I love you. We won't tell we won't tell your wife.

Scott Benner 42:18
My wife has two rainy day movies. Notting Hill was one of them. Oh, the other ones Twister. Loves Twister. When like when the weather's bad. She puts Twister on the remaking Twister. She seems very excited.

Jennifer Smith, CDE 42:32
I don't like remakes. I'll tell you I think remakes are I

Scott Benner 42:36
might be an update. I don't know when it's gonna be but I saw Kelly. She's like, Oh, more twisters. She seemed pretty excited. Yeah. All right. Notting Hill. God dammit. That's really upsetting. You

Jennifer Smith, CDE 42:48
know, something I like about her as an actress too. For the most part. She does a lot of different like she doesn't get typecast. I guess. She's got a lot of variety in what she does. Like I really liked her in that they're kind of I consider them sort of gangster II The ocean's movies. Ocean's

Scott Benner 43:05
1111 Yeah, yeah, I

Jennifer Smith, CDE 43:09
think she was into two of them at George

Scott Benner 43:11
was there she's there. You understand? Yeah, they they seem to come off. Yeah. Hey, I can't call this episode drink your juice Shelby can i because people will get upset but that would be a really perfect title for this episode. It's I think it's great talk to you. Okay. All right. I'm gonna pull people in the Facebook group before I do that because I don't want Alright, thank you. Hold on. Yeah.

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