Scott Benner 7/1/24 Scott Benner 7/1/24

#1241 Mannkind CEO Talks Afrezza

In this episode of the Juicebox Podcast, Michael Castagna, CEO of MannKind Corporation, delves into the innovative world of Afrezza, the inhaled insulin. Discover the science behind this breakthrough in diabetes management, its safety profile, and how it compares to traditional insulin methods. Michael addresses common concerns and misconceptions, providing valuable insights into ongoing and future studies. Tune in to learn more about how Afrezza is changing the landscape of diabetes care

You can always listen to the Juicebox Podcast here but the cool kids use: Apple Podcasts/iOS - Spotify - Amazon Music - Google Play/Android - iHeart Radio - Radio Public, Amazon Alexa or wherever they get audio.

+ Click for EPISODE TRANSCRIPT

DISCLAIMER: This text is the output of AI based transcribing from an audio recording. Although the transcription is largely accurate, in some cases it is incomplete or inaccurate due to inaudible passages or transcription errors and should not be treated as an authoritative record. Nothing that you read here constitutes advice medical or otherwise. Always consult with a healthcare professional before making changes to a healthcare plan.

Scott Benner 0:00
Hello friends, welcome to episode 1241 of the Juicebox Podcast.

Today, my guest is Mike Castanea. He is the CEO of the MannKind Corporation better known to you perhaps as the people who make the inhaled insulin a Frezza. 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 or becoming bold with insulin. You can help support type one diabetes research right from your phone right there at home by going to T one D exchange.org/juicebox. and completing the survey join the registry complete the survey the whole thing should take him out 10 minutes and the answers to your simple questions will become part of how things move forward T one D exchange.org/juicebox. The T Wendy exchange is looking for people with type one diabetes and caregivers of people with type one who are US residents. 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 want to save 30% off your entire order at cozy earth.com It's as easy as using the offer code juice box at checkout. This episode of The Juicebox Podcast is sponsored by ever since the ever since CGM is more convenient requiring only one sensor every six months. It offers more flexibility with its easy on Easy Off smart transmitter and allows you to take a break when needed. Ever since cgm.com/juice box. This episode of The Juicebox Podcast is sponsored by us med U S med.com/juice box or call 888721151 for us med is where my daughter gets her diabetes supplies from and you could to use the link or number to get your free benefit check and get started today with us med 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

Michael Castagna 2:28
Podcast got my Castanea the CEO of mankind Corporation.

Scott Benner 2:32
Mike, we have we've been trying to do this for like two years it feels like

Michael Castagna 2:37
it feels like and maybe longer because of COVID The time has just flown by Yeah,

Scott Benner 2:41
really interesting. People always say to me like what are you gonna have someone from mankind on? I was like, I'm trying. Like I'm trying to do my best. I guess you're here today. I'm going to ask you questions about about the inhaled insulin, the Frezza. Am I saying it right? I Frezza? Because you got it right. Nice, okay. And I'm going to kind of pick through how we got to where we are now what your goals are for the future, that kind of thing. So has the patent been sold? Like did this start out at a different company? What's the lineage of it?

Michael Castagna 3:10
Yeah, no, great, great question. never a better time to talk with us. As we get ready for new data coming out here very shortly, your listeners will be even more interested in healthy and inhaled insulin. As we go forward, the technology goes back to 1991. So actually 33 years. And there was several companies that are founder after the man owned, and he was investing in inhaled insulin back in the late 90s. Mainly because he was working on mini med the insulin pump as many your listeners are really familiar with Medtronic. And he realized that the major problem was the input of the insulin. And the everything we're trying to do is manipulate that profile the insulin to increase your ability to control your sugars. But but it was very hard to have that passed on set that he was looking for as an engineer and a physicist, he kind of knew the mechanics and engineering before any of us can even see what CGM look like he had that figured out in the late 90s. When he sold many meds Medtronic, he then stood out to build mankind in 2001 to three of his companies combined them and made mankind. And so the technology has always been within. And we've patented over 1200 patents at this point. And the company has continued to progress since 2001. Till today. And it took I always remind people and they asked me like, why are drugs so expensive. And think about insulin as 100 year old product, it took us 20 years 75 trials and $3 billion to take on your your old product and change route of administration. And you got to think about you know, that's shouldn't be that hard. It shouldn't take that long. But that's how long it took just to bring this innovation to patients. And the good news is, it'll be here for the next 20 to 40 years that I can see. And so we're we're just getting started. I hate to say that because as you know, this product has been around for a while, but we had to redo a lot of the data. And we'll talk about that today. What we're doing now and what's coming.

Scott Benner 4:55
Yeah, I mean, it's interesting because as a layperson when this first popped up in you know this like ice then people are like there's an inhaled insulin. Are you going to let because people look to me, which I don't even know how I got in this position sometimes Mike but like, you know, they looked at me like are you gonna let your daughter use this? And I said, Well, top of my head, I'm going to avoid her inhaling something if I can, only because I don't understand what comes next. And so, I mean, obviously if there's that much money and that much time being put into it, you don't have those concerns, or I'm assuming you diversify somehow. So why? Why shouldn't I be concerned about it?

Michael Castagna 5:32
Yeah, I mean, just use some color, I take the product personally, my family takes it, we're we wouldn't take something we didn't believe or have competence in. Right. And so that could just some confidence that could mean we're not that smart. But I think we're pretty smart. You know, when you when you study drug development, right, you're always looking for toxicities. And so by the time you get FDA approval, you've been through the wringer in trying to show that it's safe and effective, sort of that safety profile was established many, many years ago throughout all the clinical trials. And then people say, Well, this is a lifelong treatment. How do I know when you think about inhaled insulin? You know, in our particular technology case, we bind human insulin, water, and a particle called FTK P. And what happens is when your lot when the particle touches your lung, it releases the insulin directly into your blood. And the FTAAP gets excreted. So think about a car, taking passengers and delivering them and then leaving the FTK P doesn't metabolize doesn't do anything in your body. So what you're really taken as the human, it's on the water. And we know your body likes human insulin, and we know the shows in your body as well. It's not an analog insulin, it's not a modified insulin like Lantis or something like that. And that's what people miss. They think they're putting a novel target in their lungs, and is that going to be safe and effective? And obviously, safety's number one. And so we've studied this and over almost 3000 patients and their long term lung safety study was two years. We've done a lot of trials for six and 12 months at a time. And now we're going into kids. And so that was one of the obviously questions that we asked the FDA is are you comfortable with us going into children, and they were so we started that journey six years ago. And that trial be reading out later this year.

Scott Benner 7:14
So that is that the inhale three study. That's

Michael Castagna 7:17
the inhale one study. So inhale, one was children. And then inhale three was one I funded because I believe the number one alternative choice that people go to his insulin pumps, and we didn't have a lot of data head to head on insulin pumps. And so we wanted to do a bigger study showing usual care which would include insulin pumps or MDI.

Scott Benner 7:35
Ultimately our injection helped me understand the the process. The FDA in the United States, they lean a little more into being aggressive letting people decide what they want to use, but then they'll kind of tack a post marketing study on to you if they think it needs more looking now like the EMA, UK that kind of stuff over there in the EU. What did they say to you like how come you don't have approval in the UK for example? Yeah,

Michael Castagna 7:59
they never said no to us just to be clear, we never filed you know, okay. And so at that time, if you

Scott Benner 8:07
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 vo Capo 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 vo Capo pen before an emergency situation happens. Learn more about why G vo Capo pan 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 For safety information.

Michael Castagna 9:19
When the company launched Pfizer, Sanofi was supposed to file internationally. And when they handed the product back to us, those filings were all stopped. And then mankind honestly was almost out of money. And Helen's almost disappeared, went bankrupt. And so we just didn't have the money to file around the world. We did file in Brazil, we have filed in India, we got approval in Brazil, we're expecting approval momentarily in India. And we know in Europe, they're going to want pediatric data. And so that was one of the things we are waiting for extraordinary funding and pediatric study. And it takes takes about two years to get a drug approved from the time you file and you're better off trying to get one package up front in Europe or Canada or some of these markets because the poor pricing is determined at launch. And so once you launch, if you don't have a full data package or full expectations, you may not be able to have the right price point. And then you're stuck with that. And you may not be able to launch and commercialize the product. And that's really what the holdup has been in Europe is we wanted to get the enail three data show and head to head against insulin pumps. We wanted to get the pediatric study done to show that we can have an expanded population. And we want it to look we're also looking at some other some other areas we'll we'll talk about but but that total package for you're also with the economic analysis will be really important for Europe. And that's really what we're waiting on. So that's, that's coming.

Scott Benner 10:36
Tell me more about how close did the company come to not existing anymore?

Michael Castagna 10:41
For weeks, by really twice? Yeah. When I became CEO, we had less than we were burning about 24 million a quarter to stay alive. And we had about 20 million in the bank. And so I first joined the company, we really were at the same point in 16. And then again in 17. And then at one point, COVID-19, I can remember exactly or fortunately, but we were four weeks away. He was 2018. Actually, we were signing a deal. And it was a rumor I was going we were going bankrupt and everyone's getting fired. And it wasn't true. We were about to announce a major deal. And we were holding out for that pemilik motors get the paperwork done. Now the company has been public company for 20 years, which is good and bad. It gave us the capital to bring innovation to market. But it was also brought evil side of bias. They've been a public company and people that make money by trying to make companies think. So that was a it was a love hate relationship. But I think today we've built good shareholder return over the last seven, eight years and things are going in the right direction. People

Scott Benner 11:38
would never think about that. Right? Most people wouldn't consider that somebody would try to short your stock to make money or something like that. And you're you're better off trying to make insulin and this is all happening. What made you take the job? Where did you come from before mankind?

Michael Castagna 11:51
Yeah, so I'm a pharmacist by training, I chose to want to build a career in the pharmaceutical industry because I thought I can make the biggest difference in the world by doing that versus working in a hospital or running a pharmacy chain. And I feel very good about that choice. And I look back in my career I worked in HIV and helped build the one pill once a day regimen I worked in fertility I worked in rheumatoid arthritis biosimilars growth hormone, and number and growth hormone trying to get a parent to inject their kid, just once a day for three, four years was a nightmare. And I think about now diabetes and insulin, you know, trying to inject them three to five times a day or a pump is equally as difficult when you first go down there life depends on you. And that to me is very stressful just thinking about it. Sitting around Bristol Myers, Novartis came out to California for Amgen. And I was very happy at Amgen. And then when I was a shareholder, mankind until it got approved. And then once I got approved, I sold my stock. And then about a year and a half later, I see I do turn around. That's kind of what I specialize in. It was 20 years. And I saw that inhaled insulin came back from Sanofi and it was in Valencia, California, not being from California, I didn't know where Valencia was. So I had to do a Google search. And there was an hour hour and a half for me. I emailed the CEO and said, Hey, I would love to help you turn this around. I've seen the patient profiles online, I've seen what this drug can do for people to make a difference in their life. And for me, that's what life is about. It's about how do you make someone want to happier everyday? How do you make a tremendous difference in their life. And I actually did not. Some people know this, but I didn't want to work in diabetes, because my father, I didn't know him growing up. By the time I found out who he was, he had passed away from complications of diabetes. So for me, I didn't want to work in a disease every day that I thought about I missed out on this person my life. Yeah, unless I thought I can make a difference. And that's when I saw inhaled insulin is that time Dexcom was barely popular in 2016. But I see these people these incredible time and range profiles and flatlines. And I was like, What are they doing? And how are they doing it? And that's really what convinced me that mankind was something worth taking. And so long story short, how man was supposed to meet him, our founder, and he had passed away on February 25 2016. And the only reason I remember is this my daughter's birthday. And had he not died that day, I probably wouldn't have stepped off the legend to take the risk. But you know, she's your kids are important to you. And that that was an important date. And he chose the day he died. He went and one more wedding anniversary with his wife, I was told. And that was it. He was 91 years old, do everything he could and and he had a great life and did a lot for society.

Scott Benner 14:22
So you said some people in your family use a Frezza? Who

Michael Castagna 14:26
I think for their privacy of your mind. I don't want to answer but I have a lot of family of 40 cousins and

Scott Benner 14:32
and there's type one there. type one and type two. Yeah, my dad,

Michael Castagna 14:35
my dad had seven children and he has lots of grandkids and some of them suffered in diabetes as well. I

Scott Benner 14:41
want to ask questions about using it but I want to get past the like I have listener questions here and they're gonna you know, they say, I hear some people say they have a persistent cough from it or they can't take it or that it hasn't been approved because of concerns about breathing issues or lung cancer. Like can you clear that up for me? Tell me everything you know about have that and then I want to hear about how it works and how people use it day to day. Sure. So

Michael Castagna 15:04
if you have asthma, or COPD, this is probably not the right product for you. Right. And that's because we did a study showing that a kid has me at a higher risk of bronchial spasm. And so we don't disagree with that conclusion. And that's about 10 20% of people in the world that the country that have that underlying disease, and so that's probably not the right product for them. In terms of a lung cancer, you know, you gotta remember there's been over by now 20 30,000 People took a president us there's a bunch of exuberance. So there were some imbalances in the trials of people who smoked, who develop lung cancer. And, you know, unfortunately, we smoke you probably more prone to lung cancer. But I don't think there's ever been a causation that inhale and some causes lung cancer. And so you know, when you study a drug in 4000 people, 3000 people, unfortunately, a subset of them will get cancer on them and other types of cancer, lung cancers, and that, you know, but that rate of cancer was no higher than the general population. That's remind people when you're studying drugs, and sick people, in general, you have side effects that come up, and you got to manage those. Also,

Scott Benner 16:05
the idea is, if you would have followed those people, most of them would have gotten the cancer they got to begin with, it's just you're grabbing a subsection of people and watching them closely. Is that right?

Michael Castagna 16:15
Right. And you're watching them closely, and FTS, is to go back and look in time and sway, go back and look for cancer. And so you found two more people post through trial that got cancer. And so but if you think about the product and the 30, some 1000 people have taken it, we have knock on wood, only had one additional lung cancer recorded, which was in a person who smoked for 40 Pack years, and took the drug for three months and amendments. So So I feel pretty good about the safety profile, the safety and surveillance we've done. I don't see an increased signal, we'll need to work with the FDA on that question. But I always say, you know, we know how sugars, cancer, we know how sugars cause peripheral neuropathy, retinopathy, kidney disease. And so for me, it's it's about avoiding the complications of diabetes and making sure you have really, really good control. And as we know, in this country, that control has not materially changed in 2030 years. So how do we keep giving people the best set of tools that work for them. But the safety profile, this product, I think, is pretty proven at this point after a decade on the market. It's not like it's novel. It's not like it's a new drug. It's human insulin that people take. Yeah, it

Scott Benner 17:24
feels like there's a, we're in a moment here. Because I feel like you're about to tell me that you've got some news about, you know, children and Impreza, I just interviewed a man this morning who had type one, since he was 50s 58. Two and a half years ago, his doctor on a kind of a whim put him on two and a half milligrams a week of Manjaro. And now he doesn't use insulin anymore. And that's not to say that Manjaro cured has type one diabetes, but he 1,000,000% has type one diabetes, got the auto antibodies there. And as I was talking to him, it just becomes abundantly clearly, we don't even know what that GLP completely does get, like, and how long is it gonna take to figure that out? You know what I mean? Like, you need to be interested, when you see stuff like that, you know, like, you need to say, I wonder where we could take this and I feel that way about a Frezza. I think people will say like, I mean, I've had probably, I don't know, maybe five, eight people on the show who have used it, or are users of it. But I see people online who are fervent, they are like, excited to tell people about it, you know, like, where's that excitement coming from like, so for a person who's accustomed to wearing a pump or injecting and they count their carbs and they cover their insulin, they get high? They correct. They get low, they eat some food, like when that's their day to day, like how does that change? If it does with a Frezza?

Michael Castagna 18:43
Well, I think you know, the good thing I can tell you is all the people you see online, all the stories out there are all self driven, meaning we can't pay for these stories. I had someone on Reddit kick one of our patients off saying, Oh, they can't be that good. I'm like, we don't pay people we can't, they'd have to disclose that that's illegal. And so I do want your listeners to first know and he still use the other mankind to not pay to get place they they generally are people sharing their public health, which is actually why I took the job because I saw this wonderful feedback loop in social media that I said, Well, that's amazing. How can I help bring that to life. And what those patients did is a few things that were different than our trials. One, one, they figured out appropriate dosing. And what I mean by that Scott is, you know, the company at the time was developing a product that was more one to one ratio in terms of how label doses to the conversion will be seen over time as patients up to titrate, up to about 1.5 to two times their injectable dose. And so that's the studies we're now doing to show that that increase those gives, you know, more hyperglycemia number one, an equal or better control number to do what you're doing today. So a lot of the new data you'll see coming out will be in that new dosage scheme coming out. Nada and future conferences. The other thing that people ask me like why, what do they feel differently? And then I'm one thing I get is I feel free and the question is, why do you feel free You don't realize how much stress you have on counting carbs, how off you are on the ratio of counting carbs, your insulin sensitivity ratio. People don't realize the temperature of your skin, the angle of injection, pump occlusion sites, you know, back content, we miscalculate all these things. Yeah, right. And they're not that accurate. And so I always joke and say you think you're giving one unit of insulin. But if you change the angle, the injection, it's point 5% off, if your temperature was hotter North pasture, there's all kinds of things that go into batch to batch variability than insulin also happens. When you think about a present, we fill every cartridge to the same, meaning every four unit is identical for units of insulin, there is no variability, because what happens if the batch comes out a little less, we follow the pattern a little bit more. So it's always the same where biologic when you're injecting, you can't change the volume of the biologic. And so every living batch of cells that you produce in biologics, in general, have some variability inherent in the cell organism, and you can't keep in that range. And that's not the case with the present. So you pretty much get this similar dose every single time. But there's all kinds of variability that a patient goes through. And the second part of that variability is timing. And so you're trying to guess the peak of insulin to your peak of food, and those just mismatch by an hour or so. And then the insulin is in your body for four to six hours, FTO. And yet, and so that's really what people you know, we've done enough studies now that I can confidently tell you, the time I Bolus, my insulin, whether it's a pump or a pen, it's generally peaking about 90 minutes later, and it's out my body four to six hours later. And this is why people say, Oh, I got snuck up on a low hyperglycemia is because we're trying to avoid those late and lows. And you're frustrated as a person living with diabetes, that, you know, your sugars aren't coming down, you're seeing them go 200 to 6300. And you're then given another Bolus, and then you're stacking your insulin and you're crashing two hours later. And that whole process is stressful and frustrating. And when you're out at dinner and drinks with your friends and family, you don't know you're gonna have one drink or two, you don't know if you have dessert or not. And that's all you're thinking about as you're talking to somebody. And in the case of a president, it changes that entire equation, reverses that meaning you're in control your sugar, because I inhale, when I eat, when my food shows up, I'm not guessing when my food minute show up, I'm not going to the bathroom to hide, I can inhale in two seconds. And that insulin is now working within five to 10 minutes. And so because it's inhaled what people it's called monomeric versus hexamer. And we make a Frezza. We bind it in an acidic form and monomeric form, which means soon as it goes into the lungs, and it disassociated from Fe KP, it goes right into the blood in its active form at your liver very quickly. And you can show when that's why you want to get the right dose up front, because you really suppress the liver, hepatic production in the liver. And people don't realize that that process when you take injectable insulin, breaks down about 45 minutes later, and then starts to hit the liver and then steps off the signal. And that's why injectable insulin just takes about 90 minutes to kick in. It's nobody's fault. Yeah. And so our patients aren't counting carbs. That's number one, you're taking a four, eight or 12. When you want to take more, you take more, and you could take it as soon as one hour. So if I was doing Hill, and I see my sugar set up to 200, you can take another four, eight within six minutes and bring that control into your range that you're trying to import. So how

Scott Benner 23:11
do they figure out like, the cartridge size that they want to use? Because one of my notes here is just it says dosing confusion. It says like I ask people who are successful with the Frezza how to dose they're like ah, you know, like sometimes I take a four and I take an eight like, like how is that? Like? How do you direct people where to where do they start to learn? I used to hate ordering my daughter's diabetes supplies, and never had a good experience. And it was frustrating. But it hasn't been that way for a while actually for about three years now because that's how long we've been using us med us med.com/juice box or call 888721151 for us med is the number one distributor for FreeStyle Libre systems nationwide. They are the number one specialty distributor for Omni pod dash. The number one fastest growing tandem distributor nationwide, the number one rated distributor index com customer satisfaction surveys. They have served over 1 million people with diabetes since 1996. They always provide 90 days worth of supplies and fast and free shipping. US med carries everything from insulin pumps and diabetes testing supplies to the latest CGM like the libre three and Dexcom G seven. They accept Medicare nationwide and over 800 private insurers. Find out why us med has an A plus rating with the Better Business Bureau at us med.com/juice box or just call them at 888-721-1514 get started right now. And you'll be getting your supplies the same way we do. This episode of The Juicebox Podcast is sponsored by the only six month where implantable CGM on the market, and it's very unique. So you go into an office, it's I've actually seen an insertion done online like a live one like, well, they recorded the entire videos less than eight minutes long and they're talking most of the time, the insertion took no time at all right? So you go into the office, they insert the sensor, now it's in there and working for six months, you go back six months later, they pop out that one put in another one, so two office visits a year to get really accurate and consistent CGM data that's neither here nor there for what I'm trying to say. So this thing's under your skin, right. And you then wear a transmitter over top of it, transmitters got this nice, gentle silicone adhesive that you change daily, so very little chance of having skin irritations. That's a plus. So you put the transmitter on it talks to your phone app tells you your blood sugar, your your alerts, your alarms, etc. But if you want to be discreet, for some reason, you take the transmitter off, just slip comes right off no, like, you know, not like peeling at or having to rub off it. He's just kind of pops right off the silicone stuff really cool. You'll say it. And now you're ready for your big day. Whatever that day is, it could be a prom, or a wedding or just a moment when you don't want something hanging on your arm. The ever sent CGM allows you to do that without wasting a sensor because you just take the transmitter off. And then when you're ready to use it again, you pop it back on, maybe you just want to take a shower without rocking a sensor with a bar of soap. Just remove the transmitter and put it back on when you're ready. Ever since cgm.com/juicebox, you really should check it out.

Michael Castagna 26:38
My doctor asked me the same time every time I get how much and LM can you use? And I said, Well, depends what you mean. It depends on if I have a big meal I take a lot. And if I don't I take a little. And he doesn't well, how do you know? And I said, Well, you kind of get to know the product. It's kind of one of those things like you know how to drive and are you going to 60 or 65 or something like you just learned through the process of experience. And what I tell people is if your sugar's at 200, right, you take a four and you're gonna see how much of four drops you know, think about a four is more like two units of injectable. And you know, tennis generally are going to drop you 160 points, which is where you'd be worried about. So a four unit cartridge, you're going to see does x maybe drops you 30 points, maybe jumps to 50 points. And just know if you're trying to bring your sugar's down, you know, a little bit more, you might take an eight and then see what that does to you. You know, I don't worry about what I eat. I was funny. One time we did an FDA commercial and FDA made us take out food in the commercial because they didn't they said people live in diabetes shouldn't be eating pizza or desserts. But our patients do often live their life and they do take their product. And yes, we don't condone that or endorse that behavior. But the reality is, it's about controlling your sugar, and us giving you the tools, whether it's our product and other products to do that. But I always tell people, you know, like, right now the studies we're doing to to your point, Scott, we're given the first dose in the office, because we give you a shake, and then we give you the president, because no one ever sees their sugars come down on the first hour. And all of a sudden, like, Oh, my God, am I gonna go low? Well, no, because it 40 minutes, 45 minutes, the President had a peak effect. within the first hour, even if you went from 190 to 90, you're pretty much you know where you're going to be at that point. Right. And so that's what people don't understand. Even unfortunately, the Dexcom arrows will still show double down, you're like, oh my god, I'm gonna go low. And I say just wait 35 to 45 minutes and see where you are. Now. Yeah, be safe, have something next if you need it. But the reality is just give yourself 30 to 45 minutes to see how the product works. And then, you know from there, you're going to learn within a couple of days. That's what we see within seven days when you live with type one diabetes. Unfortunately, your your doctor, you know exactly what your body does, you know how to respond to various foods. And you're going to see how this drug works relative to your own experience. The area, I'll give you some, for your listeners, I'm sure a lot of people do try this is a lot of people will use it on top of an insulin pump. And then they'll the Bolus are pumped and they're frustrated. And then they'll take a phrase on top of it, or present does its job it brings down your mealtime control. And then all of a sudden that pumped insulin kicks in two hours later and they go low and they want to blame the president and the reality is that Bolus just takes an hour and a half two hours that wasn't our fault. We did our job we cleared out your sugar your pump finally kicked in because you got tired of waiting for it. I just give people caution right we don't recommend using on top of a pump we know people do that. But that's some of the work that I see people often these tell me Mike price was too powerful. I need to tune a cartridge and I said you must be on an insulin pump. How'd you know because don't whoever asked me for two unit cartridges or didn't generally on insulin pumps. So

Scott Benner 29:30
are people so people generally speaking are shooting Basal insulin like Joseba or something like that. And then using a Frezza for meals were to break high blood sugars,

Michael Castagna 29:40
their meals full time meal meal tolerance. So I look at our population today and half of them have type one roughly and half of them have paid to make juice could be on GRPs basil doesn't matter. They're on all kinds of stuff right? And they add Frezza for their mealtime hives and so that's that's one population. And then that's like one population. I See it in our in our data a couple of different ways. We see some people use a Basal full time and present for meals. We see some people use it just for special occasions or stubborn highs. And we some see some people use their pump for their Basal modulation. And then if present on top, we don't have a lot of data on that third scenario of people just using it. Or on top of their pump, we have some studies we've done, but it's very limited data out there. And the data wasn't good or bad. It just showed it works. But don't show it any better than what you're doing.

Scott Benner 30:27
Yeah, would be interesting to see someone like on loop, for example, but not but not for boluses for meals, and then do that, that would probably be interesting to say, Yep, I found myself confused a second ago. So if if somebody's injecting or using a pump right now, and their insulin sensitivity is one unit moves them 50 carbs, then a two unit cartridges of a Frezza moves them how far our

Michael Castagna 30:53
trials that we're doing. Now there's a conversion table and label series taken zero to four, whatever you just the numbers you just came up came up with with, if that said, you're going to take three units of injectable insulin, our label would say change that to a four unit cartridge. If whatever ratio you just did came out the six units of injectable insulin, our label would say convert to an eight unit cartridge, we have the only comes in for age well. And you can add those up in any four unit combination of the 48. And so we've shown up the 48 units, it's linear. And you can add a two fours to stick to eights, two twelves. It doesn't matter. You pick whatever dose you're trying to get at. And it's a two second inhalation and doesn't you know, some people have like 30 seconds on the you don't need to do that. And some of the people may cough or say it's irritating me, you know, it's really a low you don't breathe really hard. It's two kilopascals, which is very low. And you can see four year olds can do it up to eight year olds can do it. And we've shown that device works. People with lung disease, we use our technology and another disease for hypertension, your lungs. And those patients have compromised lungs and interstitial lung disease and they use our same technology, same active ingredient outside of the insulin. I mean, you have to be an active ingredient. Yeah. And so you know, we know that it doesn't take a lot of inhalation effort to get the right dose into the body. Right.

Scott Benner 32:07
So your inhaler has a patent on it, and you use it with other medications as well. Yes. So

Michael Castagna 32:13
we have a patent on FTTP. We are putting on the halo rear panel manufacturing process to all this

Scott Benner 32:20
is all patented, covered. Are you going to get hit with the the orange book problem that are no,

Michael Castagna 32:26
we're protecting these in the 2030s. So I feel pretty good about the next decade, I would say it would cost somebody about $500 million to duplicate our plan. And it'll probably take them seven years and a couple 100 employees to figure it out. Yeah,

Scott Benner 32:40
maybe not worth their while. Yeah,

Michael Castagna 32:43
it'd be very hard. I won't say impossible, because I think engineering can always figure things out. But it'd be very expensive. And I think with the cost of making the product and marketing and probably everything in cost. It's a very tough business. We lost money for 33 years in those past

Scott Benner 32:58
year. And I was talking specifically about just recently, the FTC told some of those GLP manufacturers, you can't patent the injector and to buy an extra, what is it 30 months on your patent? And that whole thing is playing out right now. But I was but you're but it sounds like your inhaler is specifically designed so that it takes a very low amount of effort to draw in is that the idea?

Michael Castagna 33:25
Yeah, and the inhaler is our platform, it's not an off the shelf platform. And people asked me, I said, look, the inhaler, our powers go together, meaning if I took someone else's powder and put it my inhaler may not fly this time, it may not work is good. And if I took another inhaler and put our powder in it, the same thing would happen. It may not work the same menu different dose. So it's not an easy modification, meaning you know, you'd have to learn how to use FTK P and you have to learn how to manufacture at scale.

Scott Benner 33:50
And my question doesn't fit here, then it sounds like your device is very specific for a reason. I think some of those other companies were just like, hey, say the injectors different. So we can hold on to our patent longer. I

Michael Castagna 34:00
haven't worked on biologics, we'd often change buttons, colors, volumes, all kinds of stuff to kind of just, you know, make the patient's body a little bit easier or a little bit clearer. But yeah, you know, the drug is the drug at the end of the day inside the injector.

Scott Benner 34:11
It's fascinating how you don't think about these little things like this is apropos of nothing but I know there was one company that they had an injector but when it was all the way drawn out to give yourself a big injection people's thumbs couldn't reach the plunger. And they didn't realize that till they gave them out to people. And then they were like, Oh my God, and then they had to go back and change. It's just it's so crazy. Some of the stuff that has to happen. The answer here is if you try a Frezza it's going to be a little bit of a science experiment for the first week while you figure it out. And but you're going to but it's interesting because when you're like if it says six the eight cartridges is good, I'm not gonna get low then it's just why

Michael Castagna 34:47
well think about your changing the route of administration. So it's something called the bioavailability of the product and what you really want is to get anytime I go from an injection to a patch or an oral pills to a to an injection, those those has always changed because the body breaks down drugs in different ways. And so when you think about a president, we don't have this first pass metabolism that goes through the liver, we get it in the body, and it's active permanent livers. So that, but you lose some of the product in the in the device, you lose some of the product that you know, through your back of your throat. And so we calculate all that in there. So as long as you're inhaling pretty consistently for yourself, you're gonna find that those the doses are pretty much the same, meaning how you inhale every single day, some people will heal very quickly, some people have long, slow, but that those, your body's gonna figure out the right that this is, this is what works for you. And you're gonna say, Okay, it's typically take this much down or 12. And so the inhalation variability, we actually have a Blue Hill device that's called Blue Hill, and it goes on the back of the inhale, and we show you how to properly inhale in the office. And so that's something we can show technique. If you're struggling a little bit, you think you're not doing it, right. Even our best employees who use the product for five years, we show we take into our lab, and we show them how, like, Oh, I've been inhaling wrong, or I've been healing for too long. And it doesn't really matter to you for too long, it's not going to change the kinetics. But it's really if you go too short, that's why I tell people just two seconds, like as long as you because I've seen that, that's not going to be the right the right way. And then

Scott Benner 36:13
you're getting some of it, not all of it right and up in your mouth and then just gone. It's

Michael Castagna 36:17
gone. It's because insulin doesn't work in the gut, right? So the gut deteriorates. That's why we have another drug that we're doing that if you inhale it, you swallow it, it's gonna have some activity from the part that you swallow, it will have some activity that goes directly into the lung, and of blood. And so that's, that's more complicated drug development than insulin, which generally comes in there.

Scott Benner 36:34
So you said the the inhale, one study is almost finished, or is that your your right to present data,

Michael Castagna 36:40
we have two trials coming out, we started inhale one a couple of years ago, that's in kids. That's why it was one. And then the inhale, three study is an adult. And the reason we did three was its receiver of present and Dexcom. So we're trying to say, hey, here's a free tools you need in health rate. And in that study, we wanted to show that you could safely switch off an ad system or a regular pump, or multiple daily injections. And maintain control was the primary goal to study. And so it wasn't to show that it was better It wasn't to to show a better time and range. The main thing is everyone believes, right that AI D is the best system out there for you as a human being, or your child. And we want to show that you could safely choose an alternative and that doctors should be providing more choice to patients. So we've gone head to head against multiple daily injections in our trials, that's really shown behind what people perceive pumps to be a little bit better. And so that's what we wanted to be able to show that were as good as the standard of care that's out there. Kind of how you define it, you may define as multiple injections, you may define it as an ad system. And so we wanted to show you how you could convert from either process to maintain control and hopefully so

Scott Benner 37:50
what is control mean, what what do you mean, if I asked you what a one C and what variability could I maintain with with the Frezza? Do you have like an answer for that.

Michael Castagna 38:01
So our goal was to maintain a onesie. And we also looked at timing ranges, secondary analysis, so you can see, you know, whether you want it whether your goal is below seven 7.4, I think that's something we do in societies, we say, Oh, you need to be below seven. Well, the reality is 75% of people on insulin are not below seven. They may be personally okay with a 7.5, they may be fine with an 8.5. I've interviewed patients who say, Hey, I like my Starbucks every day. I like my food, and that's my life. And that's my choice. And I have to respect that. Right. And I think that's somewhat challenging from a clinical perspective, when else decide because you gotta get the goal. And you're, and you're failing, if you're not, and I think we don't we don't we got to accept people's choices. And so in this trial, can

Scott Benner 38:41
you give me a second, do you think a person who would categorize themselves like that as, hey, I have an eight, five, but I eat the way I eat? Would they do better with a Frezza?

Michael Castagna 38:49
I think if you dose your insulin properly, you can always do better. And I would say that with injectable insulin or inhaled insulin, right? It's about getting your Basal ratio, right. It's about getting your mealtime coverage, right. And, you know, remember, all you have is a deficiency of insulin, a normal healthy person, right, can eat whatever they want, and their body corrects it. So I just believe you got to just give the right insulin dose and it's harder with injectable insulin because it's less predictable, the further you go out. And that's what makes it harder with a president you just get that little bit more near term predictable. Maybe gotta give a second dose of a big meal two or three hours later, because you see your sugars are still 261 to bring them down to 150. So it just gives you a different tool to rethink about how you define control or how you want to be in control.

Scott Benner 39:33
So would it be fair to say that injectable or insulin through a pump is a game you're playing in like this four to six hour window, but with a Frezza. The window is more like 45 minutes to two hours, two hours. And so if I shorten the window, then I can decide if I need more insulin faster and not be worried about like a late and low later. So it's not necessarily that with a Frezza, I'm gonna see fewer spikes or even less spikes if I'm or less aggressive excursions, if I'm using it incorrectly, it's more about how I can come back at it again and again and again, and the profile short and it comes out of my body quickly.

Michael Castagna 40:18
So we would say our data would show you, if you were to use it at the right dose right up front, you would have lower peaks, your glucose excursions might be 40 to 60, instead of 90 to 100. So we would lower the excursion a lot. And we think those peaks have caused a lot of damage. Right. And so we do think reducing those peaks over time. As you know, we haven't been able to show that in clinical trials, nor have we tried in fairness, but but there's data out there talking about that, right. And so we do know, we work roughly 3040 minutes faster, and you can lower your peaks by 3040 20 points.

Scott Benner 40:51
So I still can Pre-Bolus with the President. I should retiming.

Michael Castagna 40:55
Yeah, I mean, why would you just take when your food comes, because what you're trying to do is suppress your endogenous glucose production. And the faster you can do that, and it doesn't really start to until you start smelling the food and everything right, then it starts producing pickoff.

Scott Benner 41:07
Oh, I see. So putting it in 15 minutes early wouldn't help me. No, you shouldn't do that. No, okay. Because

Michael Castagna 41:13
it works fast, right? So if you don't, then God forbid, you don't need for 15 more minutes, then you're gonna go home, be upset and be really soon as your food shows up. That's the most important part. You don't have to worry about guests hurry. You know, people say, Oh, I missed my, I forgot my insulin in my car or something. You know, as soon as you get back to your car, you get your insulin, you can take it no, it's going to kick in an hour. That's important.

Scott Benner 41:33
I feel like I cut you off earlier. I'm sorry. Like, so what's the what's in a one seat goal? Like in your label? What what do you expect that I

Michael Castagna 41:41
was gonna say is in this trial in particular, and then he'll three we lead 25% of the people in the trial, who had less than a seven a one C, which we've never really studied? The people doing the best, right? And could they maintain that control? versus those that aren't doing well? And can you maintain or improve their control? And so you know, that's this is the first time in one of our trials where we took people that were doing fairly pretty well. And the question was, would they stay there? Would they get worse when they get better? That have results aren't out yet. So I can't say too much. But just know when when people do see the results, we went down as low as 6.5 and 6.0. A once these always high as nine and 10. When I think about those people, the people that probably are nine and 10 aren't taking their insulin. And whether they take inhaled insulin ready to take your pump or they take them. Yeah, they're just not complying in many cases. Right. And when some people just don't have the right dosing, right Basal ratio? Yeah, I think that's another thing to pay attention to is, you know, traditionally, in type one, you're told that the percent your insulin units a day should come from basil and roughly 50% should come from bolusing. I think as we get to a Frezza, because of this higher dose conversion, roughly 70% of your Bolus units are going to come from your, your inhaled insulin 30% company or Basal when you get to your titrate try to get those. So I think that's what we're trying to get give you as goalposts, like, Hey, I was talking to a priest once about us, put on a friend and he was struggling. And I think as basil was, like 10%. And I said, I said, I can't tell you what to do. But I can tell you, your ratio is way off, you should go back and talk to your doctor. Right. And and I think that's, that's important. Well,

Scott Benner 43:12
I make a living telling people that it's timing and amount, this podcast is incredibly popular, because all I say about insulin is that if you use the right amount at the right time, and balance it against the impact of your foods, there's actually almost no reason to see an excursion whatsoever, but it's just a difficult thing to do over and over and over again, it takes a lot of effort. Let me ask you this. And I know it's not a label thing or something that companies but do you know anybody personally using a friend who has anyone seen the fives? Oh, yeah, yeah. Oh, you Okay, all right.

Michael Castagna 43:43
No, but I know that many of our best patients right are 545758 they compete. I always tell people look, the data out there less than seven is, you know, whether you're 6.5 5.5 Don't, don't stress yourself out trying to get the lowest a one C. But but stress yourself out trying to get below seven if you can, because that's where the damage is really occurring.

Scott Benner 44:03
Are there other things you're accomplishing that with you personally? Like? Are you on a low carb diet or something like that? No, no,

Michael Castagna 44:09
I mean, if you saw my lifestyle, right, I eat out a lot for work. I travel I have a Starbucks every morning. And so, you know, when I try to express to people, you know, I have my sugars were way out of control, right? I'm sure I eat a lot differently. But I feel like I have tools in my bag that helped me maintain good control. And so I do not stress over what I eat as much. And so that's that's something that I think a lot of people do stress over what they try and maintain low carb diets. So to say all I can't take that too high of a dose. I've seen our data, I mean, people are coming in to whether it's our arm or the control arm, they're coming into these trials 170 Premium 180 pre meal, you're so far from going low, that you have a long ways to go. So I tell people, right and these are patients come in our trials are out of control. And so I think about that, you know, what are you doing to get your Basal dose right, what are you doing to Get your mealtime dose, right? Because you should be coming into meal at 120 100. And whatever you can think about your postprandial spike, let's say you only go 40 points, you're at 110. Well, you're gonna be time and range all day long, right. And instead what happens is people are 170, they're afraid to go low, and to go on to 290. And two hours later before the insulin kicks in, then a good man to take another call center go on the 60. And then they eat a bunch and they go back up to 190 200. And so you're just this Yo yo, all day long. And it's very frustrating when it's out of whack.

Scott Benner 45:28
I'll never forget the first time somebody came to me and said, Look, you know, my blood sugar's 180? Should I still Pre-Bolus? I said, it's not a Pre-Bolus that one ad, it's a correction. And then you have this conversation, right? And this is how I tell people, I'm like, Look, you know, a person over here without diabetes, they're standing here before lunch, their blood sugar is probably 85, it's probably 90, you're 90 points higher to them asking me Do you think I'll go low? If i Pre-Bolus, 10 minutes before I eat up? Like, you should correct the 180 You should Pre-Bolus your food. And you know, like that you're correcting right now and eating at the same time. It's, it's, I mean, I tell people all the time, like if you if you said to me, You have one minute, you're about to leave the planet, what are you going to tell people with type one diabetes, I'd say it's timing and amount, just use the right amounts on the right time. That's it.

Michael Castagna 46:18
And if you look at a president's profile to a natural human insulin profile, we're the closest insulin out there to what your body naturally done. Right? Now, right, it peaks in 30 to 60 minutes, right, and it's out of your body in two hours. And people don't realize that, you know, most meals are cleared within two hours. And so they think, oh, dinner, lunch breakfast, I just looked at all our data, the doses don't actually change too much by breakfast, lunch, and dinner. In fact, what I always tell our patients is the make sure you get your dose right before you go to bed. Meaning if you have a big dinner and you don't take enough, then you're going to bed at 190 200. Now figure out if you can take a foreign aid, whatever is gonna bring you down closer to 100 while you're sleeping, because within your ticket, those are the 30 before you go to bed an hour later, check it to see where you are. Because if you go to bed normal, you wake up normal, you go to bed, how you're waking up, hi, yeah,

Scott Benner 47:08
especially with yours, because once I go to sleep, it's not like I'm gonna go into hell more. Whereas like my daughter, she's an Iaps. Right? Now she goes to bed high, it's gonna keep working her down overnight, what do I do in a high fat meal situation, do I have to a Frezza, wait two hours and then see that next rise from the fat and hit it again,

Michael Castagna 47:28
I said scientifically, we should do is take whatever dose you thought would cover that, that meal you're taking, and, you know, multiply by two and run now, which is what we're doing our trials. And that should cover the whole meal.

Scott Benner 47:40
So I can put in enough for the carbs and the fat rise in one shot, you could

Michael Castagna 47:46
take it right up front, okay, and you know, make it up. Because normally your body would just release more insulin on that on that bigger meal, right? Sure. And so you would take more insulin up front. And then when you do that, if present has a longer curve, right, the more you take, the higher goes the longer it list. And so you know, for I'll make it up as they all work about the same speed, they come out of your body at different times, right. So for you, it'll be done in about 35 minutes at 12pm Peak effect in 45 minutes, that's out of your body within 180. So if you're going to have this big meal, you're going to be 16 to 20 units a meal. And that's just going to cover you for the full 234 hours. Now I'll say that's the science, the reality as a human is, I'm going to worry the whole time and I'm probably going to underdose. And therefore I just say see, we're sugars aren't one hour, and those again, if you need to, or two hours, okay? And but the bigger dose you give up front, the better, you're going to shut down that endogenous glucose production. And that's what people don't quite understand. Because injected ones that just doesn't do that that fast. But if you can shut down that liver, you're shutting down the signaling pathway that's causing this huge rise, I say and the faster you do that, the better control you have. Because

Scott Benner 48:49
you're working with type twos. Will Will there be us that I'm spending your money over here? But Will there be a study with people using GRPs? I

Michael Castagna 48:57
don't know. I mean, we redirected our focus to type one diabetes. That's why you've seen us in kids with adults, pumps, you know, this is what we're focused on going forward, we are looking to bring your presence to the rest of the population around the world. So we will hopefully be in India by next year, Brazil, and us that's about a third of the world's diabetes population. And then we're gonna be going to Europe, China, and Asia and Australia. So we think that over time, you're gonna see it now be global, which is great for society, the GLP has worked pretty well. And so that doesn't mean that they're not delaying the use of insulin or you still need insulin I do think we're going to see in the long run, but everyone can tolerate GLP or eventually they were and you were talking about long term safety earlier about these things. It's funny because I I I tried to Olympic at one point and I just did not feel well. I started wondering like, Okay, what's the date on these things long term? So I called one of the manufacturers I won't say who? And they said oh, we haven't studied to be on two years. What do you mean you want me to take this for the rest of my life? So what will happen when a person stopped taking and what did they wants to do with their waking go back? We don't have any that they don't people discontinue we only people do. After the trial and followed up, so there is no when we asked me what inhaled insulin I can tell you, we studied it for two years non stop, we looked at I think they only have one year data on this one drug. And I'm like, and so now it's been in the market 10 years. So we feel pretty good about our profile. We're GLP is are still, you know, they've been around 20 years in fairness. Yeah. But using them for long term weight loss. And these other things. I think once

Scott Benner 50:22
they're really popular right now, we're thinking about like, the Stata. Right, right. Exactly the stuff that the you're shooting every day at one point right now it's all a crapshoot, I, I've lost 47 pounds on a GLP in the last 14 months. And thank you fundamentally changed my life. That's fantastic. My daughter's using it, it decreased her. I, my math tells me that my daughter will use 16,000 fewer units of insulin over the next year, because of a small dose of a GLP. Like, that's crazy, right? But I'm just I'm wondering about that. Because as you're talking, I'm thinking, there's obviously is obviously a population for inhaled insulin, like, obviously, and so you're gonna make it available for children. At some point, FDA is gonna say yes, it sounds like and then that's going to be another group of people who can try it. Now we're looking at people who might inject basil, do the inhaled, etc. so on then, but then people are going to hack it along the way. There's already people micro dosing GLP is, and like, so like, you're gonna I just was wondering, like, what happens once you really lower my insulin need, with a GLP, I have Basal insulin running in the background, and then I hit a meal with this, like, it's just, it's gonna be interesting to see what people do with it, and what doctors prescribe it. To

Michael Castagna 51:45
your point, you know, the kids, they don't will, this trial is fully enrolled. So the pace less patient will pull here in September, October timeframe will crunch the data in the fall. So we'll know on pediatrics very shortly. And hopefully, it looks good. And we'll file that with FDA next year, the inhale three results will we'll try to get will debate whether it goes up to now or later to try to change some things in the label around the conversion chart. But otherwise, to your point, you know, our job is to make people aware of the science, the safety and efficacy of the product. And we didn't have much money in the last seven years to fund a lot of that stuff. Now we have, okay, and so that's what I think you'll start to see nothing but new data. Now we got 30, we trial 17 weeks, primary endpoint 30 weeks of follow up coming out next year, you're gonna have keys, which will be a 52 week study and 26 weeks as a primary endpoint. And then we're just approving a gestational study that we'll look at friends use and gestational diabetes, and PK PD and make sure women can inhale properly, their diaphragm and all that you're seeing us invest more as we go forward. And we're not backing down from where we've been. I think this is a useful tool. And to your point. GLP has definitely reduced the need for insulin. But I can tell you looking at the National insulin statistics, the market stopped growing, but it's not shrinking. You know, more people have diabetes in the future, more people need insulin, you always know there's a seven to 10 year delay in type two now, maybe 11, or 12. Who knows? Eventually, we're gonna need insulin for patients. And honestly, if we can lose weight and use less insulin in society better off health wise, we're all federal, right? Yeah.

Scott Benner 53:16
So that's faster. It's fantastic. I appreciate you coming on doing this with me. I really do. I have to jump off. I apologize. I'm short on time, which is not usually what happens because I make a podcast that usually just I'm like I can keep talking. Maybe we can get back together and and learn some more again, I actually have some of your users like lined up this year to be guests. People are very excited to talk about it. So there'll be some of that there. But I really do appreciate you taking the time. Real quickly am I going to see problems getting it covered by my insurance? If I have type one, just

Michael Castagna 53:49
about say a scar? Don't let me leave it I'll talk about access. So generally, if you're type one, you're in a better position, then type two is because the insurance company wants to know you tried and failed their preferred agent. And failed means you could have hypo means you could anyone see could be 7.2. Right? So the failure definition is quite broad. And we've created a program that as long as you go through our pharmacy and reimbursement support, if it's not approved, for whatever reason we charge $99 a month, or $3 a day. So I've tried to take the excess burden off of society and say, people should have access to insulin. We think $3 A day less than a Starbucks these days with inflation is a fair price. Or it can I guess most states, and so that's where we are as a company. That's our position our policy and if anyone has any problems, they can feel free to reach out to me and I'll make sure we take care of them. But we want as many people have access to the product. We will work with insurance companies to make this happen.

Scott Benner 54:40
And it's fantastic. Thank you very much. Thank you

a huge thank you to one of today's sponsors, G voc glucagon, find out more about Chivo Capo pen at G voc glucagon.com Ford slash Juicebox Podcast spell that GVOKEGLUC AG o n.com. Forward slash juicebox. I want to thank the ever since CGM for sponsoring this episode of The Juicebox Podcast and invite you to go to ever since cgm.com/juicebox. To learn more about this terrific device, you can head over now and just absorb everything that the website has to offer. And that way you'll know if ever sense feels right for you. Ever since cgm.com/juice box Arden has been getting her diabetes supplies from us med for three years, you can as well us med.com/juice box or call 888-721-1514 My thanks to us med for sponsoring this episode. And for being longtime sponsors of the Juicebox Podcast. There are links in the show notes and links at juicebox podcast.com to us Med and all of the sponsors. If you are a loved one was just diagnosed with type one diabetes, and you're looking for some fresh perspective. The bold beginning series from the Juicebox Podcast is a terrific place to start. That series is with myself and Jenny Smith. Jenny is a CDC es a registered dietitian 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. The 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. 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. The episode you just heard was professionally edited by wrong way recording. Wrong way recording.com. 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.

#1240 Weekly News 6/29/24

Diabetes News for 6/29/24

+ Click for EPISODE TRANSCRIPT

Scott Benner 0:00
Hello friends and welcome to episode 1240 of the Juicebox Podcast

I'm back with another News episode and other type one diabetes informative little what's going on in the world 15 minute podcast episode just for you while you're listening to it, please remember 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. In just a moment, Scotty is going to read you the news. 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 Hey guys, T one D exchange.org/juice box head over there. Now take the survey we're looking for type ones and the caregivers of type ones who are US residents to spend 10 minutes completing the survey to help type one diabetes research T one D exchange.org/juicebox. If you're looking for community around type one diabetes, check out the Juicebox Podcast private Facebook group Juicebox Podcast type one diabetes. I'm introducing a new advertiser today, hold on one second to learn more.

Your kids mean everything to you, and you do anything for them, especially if they're at risk. So when it comes to type one diabetes, screen it like you mean it because if even just one person in your family has type one, your child is up to 15 times more likely to get it. But just one blood test can help you spot it early. So don't wait. Talk to your doctor about screening. Tap now or visit screened for type one.com To get more info. This episode of The Juicebox Podcast is sponsored by screen it like you mean it.com Everybody seemed to enjoy when I read the news last week and a short episode. So I'm going to do it again this week with a twist. This week I'm going to tell you a little bit about stuff. I've heard a little bit about stuff I've read and we're going to let chat GPT tell us a little bit. Let's start with the old chatter GPT or I asked it for a brief synopsis of some of the latest type one diabetes news and it broke it down into five different areas. First area was vertex pharmaceuticals. Stem cell therapy, says that positive results had been reported from a trial where participants with type one diabetes were able to produce their own insulin following treatment derived from stem cells. And then I said to chat GPT break that down for me with some easy bullet points and it did positive trial results. Vertex pharmaceuticals reported successful outcomes from a stem cell trial for type one, participants in the trial were able to produce significant participants in the trial were able to produce sufficient insulin on their own after receiving the stem cell therapy says that the therapy mechanism is that the treatment involves using stem cells to regenerate insulin producing cells in the pancreas. This therapy offers significant hope for more effective and long term treatments for type one impact on patients. It says the ability to produce insulin independently blah, blah, blah research significance. Yeah, but was this a human trial? Or mice? Let's see if it knows it's looking on the interweb boopity boopity boopity Boop it's looking at clinical trials sense.com. Let's see here the key points recent advancements, I guess of action, safety and tolerability, clinical trial details global expansion. The stem cell therapy VX 880 is currently undergoing a phase one slash to clinical in trial on human so that's cool. Participants in the trial have shown significant improvement with some achieving insulin independence. For example, one patient achieved insulin independence at day 270 With an HPA once they have 5.2 v x eight ad involves the infusion of stem cell derived fully differentiated isolated cells into the hepatic paddock excuse me, portal vein. These cells are designed to restore pancreatic isolate cell function enable glucose responsive insulin production is very cool. You got to ask yourself though, couldn't your autoimmune issue just go get those cells too but sure we're getting to that. They say the therapy has been well tolerated with most adverse events being mild to moderate no serious adverse events related to the treatment have been reported. Clinical Trial details. The trial is multi centered, single arm and open label designed to evaluate the safety and efficacy of VX 880. It includes multiple parts with approximately 17 patients expected to be in one rolled. All right. That's pretty cool. Thank you chat GPT Overlord, that was lovely. Let's go to the next thing it told us about. The FDA has approved land teacher the first donor cell therapy specifically for type one diabetes patients with severe and reoccurring low blood sugar. Clinical trials showed that many participants lived without external insulin for up to five years post therapy that's led tindora has an FDA approval. Let's find out more about that, shall we? I'll say to the Overlord, tell me more about the Latendresse approval. From the very beginning, your kids mean everything to you. That means you do anything for them, especially if they're at risk. So when it comes to type one diabetes, screen it like you mean it because even if just one person in the family has it, your child is up to 15 times more likely to get it to screen it like you mean it. Because type one diabetes can develop at any age. And once you get results, you can get prepared for your child's future. So screen it like you mean it type one starts long before there are symptoms, but one blood test could help you to spot it early, before they need insulin, and could lower the risk of serious complications like diabetic ketoacidosis or DKA. Talk to your doctor about how to screen for type one diabetes, because the more you know, the more you can do. So don't wait. Tap now or visit screened for type one.com. To learn more. Again, that screen for type one.com screen it like you mean it give me some bullet points. Boop boop, boop, boop doesn't make that noise. It's actually very high tech. It's already typing here. Here's some key points about the FDA approval. The tindora is the first ever approved cell therapy for type one diabetes patients with severe and reoccurring but while we already read that, it involves the infusion of ice blood cells from deceased donors into the patient's liver, enabling the production of insulin with the body. In trials 21 of 30 participants did not need insulin for at least one year after receiving the therapy. 11 participants remained insulin dependent independent excuse me for one to five years and 10 participants. For more than five years, five participants required external insulin after the therapy and did not achieve insulin independence. There were serious adverse events including two deaths during the trial, one from multi organ failure and sepsis and another from progressive confusion and global atrophy. These events were associated with unnecessary Amin Oh, immunosuppressant therapy that goes with it. So they're given you the cells but you gotta get the your immune system suppressed. Ah, okay. This is this, this treatment is aimed at patients with a type one diabetes experiencing recurrent severe hyperglycemia and those with hypoglycemia unawareness, making it a crucial option for those who cannot maintain stable glucose levels through current methods into the liver. Okay, so All right, well, this is I mean, it's interesting stuff you don't I mean, it's just I don't think it's ready to be on your Walgreens counter just yet. How about this CRISPR therapeutics and vitae site have received Health Canada approval to begin trials for VCT x 210 and CRISPR edited stem cell therapy aiming to replace insulin production beta cells without the need for immune Oh, suppression. Hold up a second. Let's let let's let him tell me more in bullet points, because Scotty doesn't wanna have to break down a paragraph. Therapy overview VC T X 210 is a CRISPR edited system stem cell therapy designed to replace insulin producing beta cells and patients with type one. The therapy uses CRISPR cast nine gene editing technology to modify stem cells making them capable of evading the immune system and eliminating the need for immuno suppression. Now we're talking Health Canada let's see the clinical trial application has been approved by Health Canada making it the first gene edited therapy for diabetes to approach clinical trials. Hey, Health Canada. Lovely. The mechanism of therapy V CT X to 10 involves editing donor derived stem cells to create insulin producing beta cells that are implement implanted, excuse me into the patient. These cells are engineered to avoid immune detection and destruction. I would like to maybe do that with some other cells too. About the ones can I could we fix people's thyroid? Could we who wait a minute, there's a lot here isn't there? The phase one trial will evaluate the safety tolerability and immune evasion of VCT x 210 and type one patients oh god bless you. I hope this goes well. therapy is a joint effort between CRISPR therapeutics and vitae site via site. Hey, if anybody wants to come on and talk about this, I'd love to hear more about this from one of these entities and I will reach out and see what I can figure out. Hey, this chat GPT tells us what's going on segment is pretty freakin great. And inhaled insulin study the new data presented at the ADL at fourth Scientific Sessions indicates that inhaled insulin are present safe and effective for improving glycemic control and HPA once the levels and type one patients. I'm actually going to have an episode about this with Dr. Blevins coming up in a couple of weeks. You know Dr. Blevins from the GLP episodes, and he's going to be talking to us about Frezza and something else. I don't want to give it everything away right now but stuff is coming. All right. Well, there's

there's the chat GVT effort. diatribe came back with a little little recap of stuff. They heard about pumps. They talked about tide pool being at Ada with their new twist AI D system, which of course is tide pool loop and this new twist pump. That Dexcom stello will be available in August. This is already something we've talked about on the podcast before Dexcom stello. Of course, the CGM is designed to be worn on the back of the arm. Though people with diabetes tend to get creative with placement says the author for up to 15 days and the readings are displayed directly using a smartphone app spokesperson said pricing will be announced closer to the launch date. This is like no. This is for type twos that don't use insulin. You won't need a prescription for this. This will be a walk in and buy thing. By the way. This article was written by Paul Helsel for diatribe. Paul, thank you very much for letting us read your article. What else does Paul say? There's some study results from tandem Medtronic and insolate. At the ADA conference tandem highlighted at small mobi pumps. Citing a recent study conducted by the Barbara Davis Center for diabetes the University of Colorado, which showed time and range improved without an increase in time below range using control IQ. The device integrates with iPhone Babaji 67, Medtronic offered data showing that its mini med seven ADG AI D system reduces sleep interruptions and improve time and range during sleep cool. The system's ability to deliver small bonuses every five minutes company said also helped reduce the dawn phenomenon rate from 12.2% to 4.5. And slightly increased the time and range from 12 to 6am. It's insolate. Excuse me, insula which is Omni pod presented a study at Ada showing its Omnipod five system could benefit people with type two diabetes who use insulin participating participants excuse me who were previously using injections or pump therapy saw improvement, they wouldn't see reduced blood sugar spikes and hyperglycemia. The company said as well, time and range improved by 20%. And overall insulin was used by overall insulin was reduced by 23 units a day. That's really great. Thank you diatribe. Thank you, Paul. Lovely, lovely. Lovely. Like I said, I'm gonna have Dr. Blevins on to talk about a Frezza. And actually, he's gonna come on and talk about some other stuff too. Maybe we'll I don't want to give it away. Again, I look at me, I'm teasing myself. I shouldn't do that. This ain't bad. This is not bad for a little bit of news this week. Hmm. Looks like there are people out there working with stem cells, people working on automated insulin delivery systems to get them working better and to cover more people. Dexcom is going to be helping out with type two diabetes with their new product. So all in all, a good week at Ada. I got a lot of reports back from Ada, my, my people were everywhere telling me the good and the bad and sometimes the ugly. And I'll tell you what made me think maybe I'll go to ADA set up a little booth and do a little Juicebox Podcast thing at the 85th annual EDA. So Scott he's looking into that there's little news for me to you. I don't need other people running around talking about me. I can talk about myself. What else we got here, kids, anything anything else you want to know? Oh, July 2, the juicebox cruise goes on sale. Head into the private Facebook group or the public Facebook page. We are doing a cruise for Juicebox Podcast listeners. You can get all the details there that goes on sale July 2 in the Facebook group. First we want to make sure that everybody who is a Facebook group member has an opportunity to get a cabin before we go wider with the offering. So go check that out. We want to get a bunch of Juicebox Podcast listeners together family, adults, anybody who's interested in coming, be a great five day trip. We're going to make a couple of ports of call in Mexico all the details of the details will be in the post. And there'll be a private Facebook group for people who put down a deposit so you guys can meet each other and really get to know each other before the cruise embarks on June 14 and 2025 I'll add a little bit of my own news. A group of coders have split a branch of IEPs off to something called trio. It's in beta right now. Arden's running it loving the loving the branch very much. If you're a DIY looper and you've ever thought about looking into IEPs I might look at trio instead. For me to you, I think that's worth looking into. Alright, so I guess that's the end of Scott reads the internet today. I wish you were here to say no Scott s this of the chat GPT overlord. But I don't I don't have anything else. Although you know what, hold on. What's that new Canadian insulin that once weekly, we're going to be just seeing if Chechi here is what I'm talking about. We talked about a genuine Yeah, it's called a weekly. I will say again, Novo Nordisk Whoever named it genius. Aw, IQ li a weekly. Health Canada approved a weekly on March 12 2020. Ford is set to become available across Canada starting June 30th. Geez, that's like right now. 2024. Weekly is a Basal insulin designed to be administered once a week. It works through a time release mechanism gradually releasing insulin over the course of a week. Clinical trials included both type one and type two patients, but the therapy is expected to be most beneficial for those with type two diabetes. type one diabetes patients will still require additional fast acting insulin injections at mealtimes. Well, yeah, but that that might just be Chachi Beatty, not quite understanding. I mean, if it's a once weekly Basal, then that's valuable for everybody. The most common side effects included hypoglycemia, and injection site reactions with bruising, pain and swelling that's from Yahoo Finance. A weekly aims to improve glycemic control with fewer injections, potentially increasing adherence to insulin therapy and reducing the risk of diabetes related complications, etc. and so on. Hey, if somebody in Canada ends up using a weekly I'd love for you to come on and tell me about it. That'd be absolutely wonderful. But I guess that's gonna be it for now. I will. I will see you again soon. Let me know if we should keep doing this little news thing. I'm up for this. I like this a lot. But if you guys hate it, like I'm not gonna You don't I mean, send me an email.

Did you know if just one person in your family has type one diabetes, you're up to 15 times more likely to get it to screen it like you mean it. One blood test can spot type one diabetes early. Tap now, talk to a doctor or visit screened for type one.com For more info. If you're looking for community around type one diabetes, check out the Juicebox Podcast private Facebook group Juicebox Podcast type one diabetes, but everybody is welcome. Type one type two gestational loved ones. It doesn't matter to me. If you're impacted by diabetes, and you're looking for support, comfort or community check out Juicebox Podcast type one diabetes on Facebook. The diabetes variable series from the Juicebox Podcast goes over all the little things that affect your diabetes that you might not think about travel and exercise to hydration and even trampolines. juicebox podcast.com. Go up in the menu and click on diabetes variables. 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.

#1239 Ask Scott and Jenny: Chapter Twenty-Four

Scott and Jenny Smith, CDE answer your diabetes questions.

• What are the methods to help support an elderly parent who has type 1?

• At what point is it justified for me to ask for u200 insulin?

• What do I tweak first and last to smooth out these highs followed by lows? Do I look at my insulin timing first, my basal, my correction factor, my carb ratio?

• How do I extend a bolus like a pro?

• How do you eyeball carbs?

• With all the automated systems, is getting your meal bolus exactly right going to be as important moving forward as it is now?

• How would you go about putting a pump on your child if they are dead set against wearing a pump?

• What is new in insulin choices and how do they work with pumps?

• How do you handle refrigeration of insulin?

• What about hot tubs? Do you get into a hot tub with your pod on? Could your insulin start to deteriorate?

+ Click for EPISODE TRANSCRIPT

Scott Benner 0:00
Hello friends and welcome to episode 1239 of the Juicebox Podcast

Jenny's back everybody and we're doing another episode of Ask Scott and Jenny. That's pretty much it. Although Jenny loses power like 20 minutes into it. So there's a whole kerfuffle. 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. We're always complaining we want things to move forward. We want better research, but they need to know what to research and what people think. And that's where you come in. T one D exchange.org/juicebox. complete the survey help people who are trying to help people by answering simple questions that you know the answers to I promise. T one D exchange.org/juice. Box takes about 10 minutes to complete the survey they're looking for people living with type one diabetes where US residents and people who are caregivers, T one D exchange.org/juice box be part of the solution. 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

Today's episode is sponsored by Medtronic diabetes, a company that's bringing together people who are redefining what it means to live with diabetes. Later in this episode, I'll be speaking with Mark he was diagnosed with type one diabetes at 28. He's 47. Now he's going to tell you a little bit about his story. To hear more stories from the Medtronic champion community or to share your own story. Visit Medtronic diabetes.com/juice box and check out the Medtronic champion hashtag on social media. This show is sponsored today by the glucagon that my daughter carries G voc hypo penne Find out more at G voc glucagon.com. Forward slash juicebox. This episode of The Juicebox Podcast is sponsored by the ever since CGM. Ever since it's gonna let you break away from some of the CGM norms you may be accustomed to no more weekly or bi weekly hassles of sensor changes. Never again will you be able to accidentally bump your sensor off. You won't have to carry around CGM supplies and worrying about your adhesive lasting. Well, that's the thing of the past. Ever since cgm.com/juicebox. Jenny, we are going to do a ask Scott and Jenny episode today. All right, I have questions. You have answers. Let's get started.

Jennifer Smith, CDE 2:52
I might hopefully have answers.

Scott Benner 2:56
This first one I know is a near and dear problem to your heart. So I'm going to start with this. I would be interested in methods to help support an elderly parent who has type one. They have a CGM and Ron MDI, they're 95 years old. Wow. Yeah, that's awesome. Yeah, great. Yeah, that's awesome. Yeah, but you talked about this all the time that the devices aren't really designed for people with slower motor skills, eyesight, stuff like that. And obviously, at some point, this woman got back to MDI, but do you have any thoughts about how to help somebody with this?

Jennifer Smith, CDE 3:35
Yeah, without any of the details, you know, there's, there's got to be a lot of assumption this person is helping their parent did you say it is right for an elderly parent, an elderly parent, if the person is living with them, you know, an automated system may be very good to consider. Because at least at that point, you've got some protection from both the end zones that you're trying to aim to stay away from the highs and the lows, you can also navigate some targets that are even a little bit more conservative, if you're really worried. It may give some ability to have them have some time on their own, while you may go to work, or do the things that you need to do. And so you don't always have to be there for you know, things like bolusing, right? There's a whole host of other things to consider if you're looking at nursing home and those types of care situations, which are very difficult, difficult to navigate with any type of technology. But if you're the main caregiver for an aging or an elderly, you know, parent, or loved one, some of it can be a little bit easier with some of the newer technology that we have because you have visibility then to what's going on. Are

Scott Benner 4:49
you thinking islet? Are you thinking like Omnipod five what is your

Jennifer Smith, CDE 4:54
islet could be the easiest again, depending on what I mean this person is older Are the 95 years old, if clearly had I what I'm assuming is a long time with type one, depending on where they are in their ability to consider things appropriately like mental status, you know, if they're already knowledgeable about carbohydrates, then something like maybe Omnipod five, where they could truly just Bolus for their meal and go about it right might be easier than, you know, I start starts to kind of fail and drawing up a syringe or even dialing up a pen and having the dexterity to be able to push the end of the pen in appropriately. All those things are considerations as we age. So a pump may be easier in terms of button pushing, I would say that the eyelet for somebody who has a little bit less ability to count would be a really nice potential option.

Scott Benner 5:53
You might also think if you've known some older people, they don't eat a ton anymore, either. There's not a lot of food being taken in, you know, maybe that like small meal or snack button on the island would help or, or even, you know, there's part of me wants to say like, what about one of those patch pumps that you just squeeze it and give you two units? But I don't even know maybe two units is way too much? There? No it? Yeah.

Jennifer Smith, CDE 6:15
And or because it's squeezable, again, from a dexterity standpoint, not be able to do it might not be able to do it. Or maybe they can't acknowledge how many pushes they've given I, ya know what I mean? I mean, these are all the things to definitely explore.

Scott Benner 6:32
I interviewed in the cold wind series. So it was an anonymous person who was a nurse in a facility for older people. And if you end up in one of those situations, what's going to be is that they're going to come, they're going to give you a predetermined amount of insulin. And they'll check your blood sugar three hours later, and maybe they'll give you some more if it's high enough. And that's pretty much it. Yeah,

Jennifer Smith, CDE 6:55
you will be in most cases, not all, but in most cases of those living situations for the elderly. Typically, technology is not, is not allowed anymore. Yeah, I've had a couple of rare cases where the family members were close enough. And they would be the ones that came in and did the pump site change, or they were the ones that came in and did the sensor change or whatever. But even there is something happens at two o'clock in the morning. Nobody on staff knows what to do with the system kind of left until your family member can get there. Yeah, and there are a lot of rules and regulations and things that have to be put into place. So it is it's a I've told my boys don't bother me at all. They're way too young to even understand you know what that is. But

Scott Benner 7:51
while you it would be nice if one of you didn't get married, and just hung around with mommy, we'll flip a coin later and figure out who it's gonna

Jennifer Smith, CDE 8:00
be nice if one of you has a basement room that's furnish really lovely, and I promise I won't eat very,

Scott Benner 8:07
mommy's writing this five and a half a one c out till the end. Dammit. Right. Okay, well, I mean, it's, listen, it's a tough thing that hopefully we're all going to have to figure out how to deal with and I don't know that it's going to be an easy answer.

Jennifer Smith, CDE 8:21
Right. And I think you know, for this woman, obviously 95 years old, has lived a long, full, hopefully very wonderful life with what sounds like really wonderful family members who want the best to open. And my hope is that, you know, for the younger people with diabetes and technology use that technology just keeps getting better. And at the point that you may need some type of care, it'll be to the degree that there's not much that you really have to do to use it.

Scott Benner 8:52
So that'd be nice. Alright, let's move on to at what point is it justified for me to ask for you 200 insulin, my 11 year old daughter routinely uses over 100 units of you 100 Novolog every day. And she is already on two Metformin pills a day, the large dose of insulin hurts going in especially the long acting to SIBO. On days we go untethered, could switch into a different type of insulin have a difference as to the kids getting such a large Bolus under the skin to that even that isn't is unpleasant. Yeah. Okay. What

Jennifer Smith, CDE 9:28
do you think, in this 100%? Correct, they should be asking for you 200 insulin, also kind of questioning. They're great that the Metformin is in the picture already. I would actually recommend them ask their clinician, how much of an impact do you think this is actually having? Right? Because and that would take some comparison, which sometimes in kids is harder to do because they are growing and so insulin needs will naturally increase as kids To grow anyway. But from pre use to current use of metformin, has insulin really not shifted much? Maybe it's not doing much. And maybe there are other things that could be considered along with you 200 insulin, that'll take care of the volume at the site. Yeah.

Scott Benner 10:20
What else do you think would help? Well,

Jennifer Smith, CDE 10:22
again, things that are being considered in use things like GLP ones. Yeah. I mean, they're, they're, they're, you know, certainly not as tested in the youth. They're certainly something that I have heard and seen being used off label. It really takes an endo team to consider use for something like that. You know, the other consideration, and this is something that's also very near to what I navigate with people every day is evaluating food intake. Right? Yeah.

Scott Benner 10:59
Yeah. You don't know. Because it's not in the question. They didn't say, they didn't say she's using 100 units, and we're eating 300 carbs a day, this could be right. This could be 50 carbs, and and this problem, which would indicate that it might not matter how low carb you go correctly? Are there knowable, physiological reasons why this happens to some people? Or do you just have to say it happens to some people?

Jennifer Smith, CDE 11:25
I think it's easier to say that it just happens to some people, you know, when you're considering type one was never included, or I guess, resistance was never included, along with type one, until maybe 510 years ago, let's say, in general, where we really started to see the potential that someone with type one diagnosed type one, right, could potentially have resistance along with that, not necessarily relative to lifestyle factors or whatever. more prevalent from a woman perspective, especially once they get puberty and they get into, you know, their adulthood where things like PCOS might be in the picture, polycystic ovarian syndrome, right, that definitely impacts resistance, regardless of type one. You know, I think that there are people that are more resistant, there is a reason for it. I don't think that there is a nailed down conclusive, this person with type one is very likely to also have resistance to insulin, right. Thus, we should consider these types of inclusive, sort of, let's call it alternative medications or management, you know, therapies along with just the insulin. Yeah,

Scott Benner 12:44
well, so I mean, people have heard me say it enough, probably. But I will add that, you know, I just paid cash for a GLP bed for Arden today. So it helps her immensely. She was not up to 100 units a day. But truth be told, like in three days, she could use a whole pod. You know, she could use 200 units in three days. And, you know, I've said before that I expect Arden to use 16,000 fewer units of insulin this year because of GLP. A lot less Yeah,

Jennifer Smith, CDE 13:17
it is And didn't you? I can't remember the age of the child. But you didn't you interview a mother?

Scott Benner 13:23
She's 15 Yeah. I just heard from her again. They're moving her basil down again. So I told you she was at seven units and no boluses On we go v. And I'm going to scroll up to her extra me. So she says she was a little bit older. She's definitely 15 Yeah, she sent me another graph. It is I would say with the exception of three excursions that go to 151 40 and 150. She is stable around 85 or 90, and never gets under her low alarm, which looks like it's set at maybe 460 at now, if I'm guessing, because I can't see the I can't see where the alarm setup. Wait, here's the rest 95% range, standard deviation 15 Oh, excuse me. 100% and range range 65 to 180. Average glucose 95 standard deviation 15. Scott, I thought you might want to see this. We're going to be dropping Basal from seven, down to six, it might go as low as five that's from 70 total units of insulin a day before the week before the week OB so

Jennifer Smith, CDE 14:41
and other considerations to which this you know, this parent doesn't necessarily post but as thyroid be evaluated, and or has it been managed? Well, if there is already a known issue in the picture, all of that can influence insulin sensitivity as well.

Scott Benner 14:57
So I forgot to say that actually A Thank you. Yeah, yeah, TSH mat, if you have thyroid issue, make sure they're managing your TSH under like 2.1. If your TSH is you know above that and somebody's telling you don't worry, it's in range, we're looking at it, you have symptoms, that I think those symptoms need to be medicated and some of those symptoms could be could be what Jenny's talking about here, which is insulin not working correctly. Okay, you have something else on that. Are you good?

Jennifer Smith, CDE 15:27
I don't know the thyroid was the only thing that I really wanted to add

Scott Benner 15:32
to that. Yeah. Okay. All right. Here's one this is going to be this might take up the rest of the time. What do I tweak first? And what do I tweak last? In order of operation to smooth out these highs followed by lows? How do I look at my insulin timing first my Basal like my correction factor, I carb ratio, what do I look at first when I'm seeing eyes, followed by lows. 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 vo 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 For safety information.

Jennifer Smith, CDE 17:12
What do we always start with? We always start first with basil. Basil in the right place. And if you're again, we don't know anything about these the system being used here, right? If it's a manual pumping system or MDI, look at the base Basal which you have adjustment, you know, to? If not, then look at where there is stability in a Basal only time period with an algorithm? And is it holding things in a pretty stable place? Maybe it's holding it a little higher than you want, but at least it's pretty stable. The expectation then is the Basal probably not the piece that's the most off. So then you could absolutely go to the factors that you can adjust which are insulin to carb correction factor, maybe active insulin time. Yeah. You know all of those things. But when you're seeing graphs, I think it's also important to make note of where did the Bolus go in? When did the food start to be taken in? What was the content of the meal? Right? Do you need a longer Pre-Bolus? Do you need a shorter? Do you need none? Do you need an extended Bolus? So there are steps to it, which is what they're asking. But if you're using the right carb count as precise as possible, I don't think everything is 100%. But as much as possible, you're doing your Pre-Bolus Strategy, you're getting high and you get stuck high and you have to correct that it's very likely that it's an insulin to carb ratio problem. You started in a great place it went up never came back down, which is the goal of the right amount of insulin for food is to get it down if that's not happening. The insulin to carb. Yeah, if you're starting at a normal place it goes up higher than you want comes down. But you get to target it's not the Bolus then it's the timing right yeah. And then from a correction factor which I always feel like it's sort of like it's like the stepchild in the corners forgot

Scott Benner 19:16
about their correction factor that

Jennifer Smith, CDE 19:18
a lot of a lot of people don't and I think actually they don't mainly because it's also less adjusted by most clinicians it's the factor that's not often shifted enough unless there's a very visible Oh yes, you corrected and it never brought your blood sugar down. Great. Let's shift this but a good visual love you test it you you find out oh, my insulin to CARB is great. It was the it's timing. Okay, well what happens if you start that meal with a higher blood sugar? You take the right amount of insulin, you time it and your blood sugar does come down but it never lands you at Target. Okay, you knew your insulin to carb was right because when you started with a target blood sugar and you Bolus right He brought you to target. This time you're starting high, and it never gets you down. That's your correction factor.

Scott Benner 20:07
Nice. Okay. That's a nice way to think I said nice because it's a clearer way to describe it. Yeah. Yeah. I mean, when I see this question, my first thought if the person was in front of me, I would probably first say, is this been like this forever? Or was this not happening, and now suddenly, it is happening. If suddenly it is happening, then I'm thinking your insulin needs have obviously changed. And I'm always with Jenny basil. First, make sure your basil is keeping you at the level you want. Also, that's a lot to consider too, because your comfort for Where does your blood sugar sit stable, and somebody else's might be different. If you know Arden's blood sugar is held stable at 90 overnight, then when we go to Bolus for something, she's got that consideration of basil happening constantly. But if you're a person who's like, oh, I want my blood sugar to be at 130 overnight, then the truth is, is you're deficient in basil, not a ton, obviously, because you found stability, but it's still not as much as your body really needs, or your or your blood sugar would be lower. And now you have to, so that's okay, if you want to do that overnight, like good on you, like whatever you want to do is fine with me. But then you have to consider that when you're looking at correction factor insulin to carb ratio, all the other implications because you're already late on Basal Correct, yeah, yes. So

Jennifer Smith, CDE 21:26
if you are thinking that way, it's actually great that you brought it up, because if you're thinking, I feel safe and healthy at 130, floating in overnight, coming into breakfast, and then you're frustrated, because during the day, your Bolus is aren't pulling you down to 100. Basil this week, it's likely that your basil is the deficit there, right.

Scott Benner 21:49
The way I've always said it, you'll hear me say it and like the Pro Tip series is that if your Basal supposed to be one unit an hour and you're using point seven, then every hour of the day, you're deficient point three. So after one hour, you're down point nine, you know, or after three hours down point nine and for six hours you down two units almost. And then you go along and you Bolus for something that your carb ratio says it only needs three units. Well, that's great, except in the last six hours, you're you're deficient two units of basil, you make a three unit Bolus for the meal. You're all you've done is replace the basil. And there you go, you're the blood sugar is off to the races. So I mean, Basil first, because I think nothing works. Well. If your basil is wrong, then I try another meal. If and then just like Jenny said, does it shoot up and then come back down? Maybe your Pre-Bolus was too short, you know, does it go up and stay up? Maybe it's not enough insulin, you know, does it take a while and then go up? Maybe there's no fat or protein in your meal? It's pushing you up? You're not considering there's a you know, keep messing with it. You'll figure it out? Well,

Jennifer Smith, CDE 22:53
and I think in this train of thought when you are trying to figure it out, I think it's beneficial to actually truly try to cover a meal that's not necessarily void of fats and proteins, but not terribly heavy in it either. Because if you're really trying to get a handle on, is it the insulin to carb ratio, then really what does our rapid insulin What's it formed to cover?

Scott Benner 23:18
How many times have you thought it's time to change my CGM? I just changed it. And then you look and realize I got it's been 14 days already a week, week and a half. Feels like I just did this. Well, you'll never feel like that with the Eversense CGM. Because ever since is the only long term CGM with six months of real time glucose readings giving you more convenience confidence and flexibility. So if you're one of those people who has that thought that I just did this, didn't I? Why well I don't have to do this again right now. If you don't like that feeling, give ever sent to try because we've ever since you'll replace the sensor just once every six months via a simple in office visit ever since cgm.com/juice box to learn more and get started today. Would you like to take a break? Take a shower you can with ever since without wasting a sensor. don't want anybody to know for your big day. Take it off. No one has to know have your sensor has been failing before 10 or 14 days. That won't happen with ever since. Have you ever had a sensor get torn off while you're pulling off your shirt? That won't happen with ever since. So no sensor to get knocked off. It's as discreet as you want it to be. It's incredibly accurate. And you only have to change it once every six months ever since cgm.com/juice box. Right now we're going to hear from a member of the Medtronic champion community. This episode of The Juicebox Podcast is sponsored by Medtronic diabetes. And this is Mark.

David 24:53
I use injections for about six months and then my endocrinologist at nav recommended a pump

Scott Benner 24:59
Hello Have you been in the Navy? Eight years up to that point? I've interviewed a number of people who have been diagnosed during service. And most of the time they're discharged. What happened to you?

David 25:09
I was medically discharged. Yeah, six months after my diagnosis. Was

Scott Benner 25:13
it your goal to stay in the Navy for your whole life? Your career was?

David 25:17
Yeah, yeah. In fact, I think a few months before my diagnosis, my wife and I had that discussion about, you know, staying in for the long term. And, you know, we made the decision, despite all the hardships and time away from home, that was what we

Scott Benner 25:29
loved the most, was the Navy, like a lifetime goal of yours?

David 25:34
lifetime goal. I mean, as my earliest childhood memories, were flying, being a fighter pilot,

Scott Benner 25:39
how did your diagnosis impact your lifelong dream?

David 25:42
It was devastating. Everything I had done in life, everything I'd worked up to up to that point was just taken away in an instant, I was not prepared for that at all. What does your support system look like? friends, your family caregivers, you know, for me to Medtronic, champions, community, you know, all those resources that are out there to help guide away but then help keep abreast on you know, the new things that are coming down the pipe and to give you hope for eventually, that we can find a cure.

Scott Benner 26:08
Test it with a meal you've been good at in the past. Yeah, it's very countable links so that you're not guessing at the carbs. And then you'll get a good idea of whether or not your ratio is decent or not. And then you can start adding considerations for you know, higher fats and stuff like that down the road. Right. All right. Well, this next one will just kind of like piggyback right on to this, how do I extend a Bolus? Like a Pro? That was the question? Oh,

Jennifer Smith, CDE 26:35
like a pro,

Scott Benner 26:36
just live with diabetes for a long time and keep trying to extend Bolus this

Jennifer Smith, CDE 26:41
is gonna say lots of experimentation.

Scott Benner 26:44
I mean, I'll start by saying that I used to use a lot of extended Bolus is when Arvind was in school. And I would use them in creative places. The first way I use them that I don't think people would think to use is as a way to Pre-Bolus a meal at school. So Arden would we Bolus in her classroom, she and I together. But you know, you wanted a 10 or 15 minute Pre-Bolus. But at the same time, you're pumping insulin into this kid sitting in the classroom, she's not going to the nurse, she's gonna is she gonna go right to the cafeteria, she's gonna mess around is there going to be a line like, I don't know what's going on. So I wanted some insulin on my side. But I didn't have the nerve to just put it all in. Because what if you know all the what ifs. So what I would do is I Pre-Bolus the time, but I would do something like now, remember, Arden uses Omni pod. So this is kind of like language from their thing. But you can apply it to your own, I would do something like that I'd put in all the carbs or 70 carbs in this meal. And it would say, you know, however much it was gonna give her and I'd say Okay, put 30% of it in now, and the rest of it over a half an hour. So let's say it was a 10 unit Bolus, it wouldn't have been, but let's just say it was three units goes in, that's my Pre-Bolus. This last seven units is getting squeezed in real fast over the next 30 minutes, you get the initial pull from the first three units. And then as you get there, and you sit down, you start eating the rest of that seven units is in there starting to fire up. And that's one way I would use one, you can apply that to anything, just have to reverse engineering, you just have to say, I'm gonna have, you know, a high fat meal. And I know that my blood sugar is going to try to go up 45 minutes after I start eating. So how do I line up these extended pieces of this Bolus to combat the impact of the carbs? And that's to me, that's the whole thing. Like it's just, it's basically an extended Bolus is Pre-Bolus thing, a bunch of different variables through a meal. If that makes sense. That is how I think about it. But you might say it differently. Jenny, you're frozen? I thought you disagreed with me. That's hilarious. Hold on a second. All right. She'll be back in a second. She made such a face. Like as she froze. There wasn't like a real face. It just froze in a weird spot. Keep in mind, Jenny is from a Nordic state. Anything could have happened here. massive snowstorm out of nowhere. She could have been eaten by a Yeti. She's pretty close to Canada. She said, okay, all the power my house just shut off. She just texted me. Hold on. I'm gonna pause. Okay, hey, Tony, what's up? Not much. How are you? Good. So I just listened back to the last couple of minutes of this conversation. We're going to leave the part in that indicates that you lost power at your house. So first of all, let's take a second before we go back to where we were to talk about Will you will you share with people what you said afterwards, like when your power went out?

Jennifer Smith, CDE 29:47
What I share Yeah, embarrassing. My embarrassing

Scott Benner 29:51
information. Yeah, so the embarrassing thing that happened but the other thing too, were like, so Alright, so Jenny's power goes out, and she's texting with me. Oh, yeah, and I'm gonna tell you from my perspective, I thought gosh, I hope I'm not miss reading this but she seems scared I'm gonna offer to call her. But you're Listen, you're an adult, you have children a home, a husband, get car, you know, a job, people know you as thoughtful and like level headed, but tell people your fear.

Jennifer Smith, CDE 30:24
I fear is that, you know, like, all the scary people hiding, like, potentially in the dark room that you like, and I think I texted you when you texted you know, are you okay? You seem kind of scared. I was like, so yeah, I was the teenage kid who sat in the kitchen with my friend's parents talking to them, rather than watching the Friday the 13th movie that all my friends were watching, because I was too scared to watch it. So and I've still never seen any of those movies. So I have would have had to have my power goes out, right? Like, okay, check the power box, is it just mine, right. But in the meantime, I like have to go into the dark, dark room in my basement in order to see. And it's not like around the corner in the dark room. It's like across the room in the dark room against the firewall where the spiders live. And all those things, right? So it means I have to open the box, and maybe somebody's hiding it. I know that this is all gonna think oh my god, Jenny is a crazy person. I really not a crazy person. I'm old enough to not have this be the case in my brain anymore.

Scott Benner 31:34
So I call her because I'm like, I really think she's scared. And I'm like, we know each other really? Well. I got Oh, wait you to be scared. You know, it's like so we're on the phone. And then I immediately like I slip into who I am. So I'm like Jane, listen, go head over to the fuse box. I'll stay on the phone with you. And when this guy attacks, you do your best to describe him so I can tell the cops later. She's like, Oh, great. Thanks.

Jennifer Smith, CDE 31:58
And I did I was brave enough. Yeah, I take the flash went into the room. I'm like, yep, none of the fuses are blown. It's all good. And then I texted our neighbor. And it was like a power outage or a car had hit a pole or whatever. And it was out for a good number of hours. But yes, God saved me in my I have to go into the dark room.

Scott Benner 32:16
I did feel that no. Okay, so now we'll, I'll tell you what, we'll pick up where we left off. And at the end of this, we'll tell the people about the embarrassing thing that happened to you after that.

Jennifer Smith, CDE 32:27
Are you sure? Really because that's kind of embarrassed? No, I

Scott Benner 32:30
know, but we don't want to pile on right now. So we're just gonna say this. I don't know where we left off. We were talking about extended Bolus isn't like how to extend a Bolus, like a pro. So yes, like, I gotta be honest with you. Like, I don't know what we talked about. So if you all feel like we didn't do a good job of that, send me a note. And we'll do extended bonuses again, sometimes, but it's gonna be too disjointed to go back and try to figure out where we are and come in.

Jennifer Smith, CDE 32:53
And I think that we had, I mean, we did something about how to do extended why I think we're talking about scenarios as to why you do an extended Bolus. And even some of our algorithms today that don't even allow an extended Bolus and unless you choose to go back into manual mode to utilize that for what you know what you need to write.

Scott Benner 33:12
Okay, so let's just go on to the next question, which is, what to do if you really don't like to count carbs, and you just want to eyeball it, but your guesses are always right. Laugh out loud. I'm just trying to think of things because honestly, you have answered so many of my questions that I've elicited. Okay, so she wants to know, how do you eyeball carbs? I guess is the is the overarching question. Yeah, you really count. Like do you look on boxes and weigh things

Jennifer Smith, CDE 33:39
I would say a lot more of mine is eyeballing. And also, if there is a packaged item, I don't buy packaged items that I haven't purchased before we're really in what we bring into our house, we're careful about a lot of ingredient stuff. So I tend to buy the same things over and over because I know that they work and because I've done that I already know like how many crackers is this particular brand, so I don't really look at it anymore. I just know it from previous use. But other things you know, like fruits and vegetables and stuff that don't come with a label on them. Those become more of an eyeball and there are some things that I use a food scale for to use carb factors and get a more precise count things that I don't eat all the time and that my guesstimate I'd rather have a little more precision like a sweet potato in winter or something like that. But a lot more of my I would say a lot more of my meals are they're intelligent estimates because it's I've been doing it long enough that it works yeah.

Scott Benner 34:44
Or you can just look at a plate and go this is usually about when I have meatloaf it's usually about 50 carbs because I have potatoes with it and there's carrots here some gravy

Jennifer Smith, CDE 34:52
and or that I've made the recipe before and the recipe had nutrition information. And I can all again it's like a mess. Emory component,

Scott Benner 35:01
I should say that I don't mean that the the, I'm guessing, like, oh my gosh, there's definitely 50 carbs here. I think of it more as like, well, there's the insulin that 50 carbs and the pump will give me his worth of impact from food here. I know that sounds weird, right? Like, I don't actually guess the carbs so much. Although I do count sometimes. But it's more like, like if like, you know, if you had hunks of chicken in there were breading on it. And french fries as an example, I would basically just count the french fries and go, you know, 246-810-1215 1820, and then 510 1520, like here for the nuggets. And then I look and go is their sauce, their sauce five more, you know, is this greasy? Maybe another 10%? Here we go. Like, you know, that might be how I would do it.

Jennifer Smith, CDE 35:46
And that's kind of along the lines of when we do more like advanced estimate counting kind of information for people. They're easy tools, like a woman's fist is about the size of a one cup portion. So again, you're not going to carry measuring cups in your purse, but you do have your hand attached to your body. Yeah,

Scott Benner 36:06
I right hand, I was just wondering how big my fist is, like,

Jennifer Smith, CDE 36:09
it's a woman's fist, not a man's fist. A woman's fist is about a cup. So if you know how much from measuring things like pasta, or rice or other carbs worth a cup portion, and you're out in a restaurant, you can say, well, it looks like they're three of my fists of pasta on this plate, you can estimate that a little bit more precisely based on known factors you've had before. Right? I'm

Scott Benner 36:33
gonna ask a question to kind of piggyback onto this one. Now, I want to say before I start, there are times when I ask questions, because I know the answer to them. And I want to have the conversation. This one I don't know the answer to and I may be pulling this out of my butt. And I might not be right. I'm starting to wonder if with all these automated systems, if getting your meal Bolus, exactly right is going to be it's going to sound crazy, but as important moving forward as it is now. Because if I'm having 50 carbs, and I guess 45, and I start heading up, the algorithms gonna start pushing insulin pretty quickly, right?

Jennifer Smith, CDE 37:07
Correct. Depending on the algorithm, some are more aggressive than others, some will turn that around faster, and you won't have to adjust with extra insulin, some are a little slower, and you just have to wait for enough give to get in the picture to make a difference there. But in the case of looking at that data, then somebody who doesn't really just want to rely on the system catching the five gram difference, or the off count or whatever. Some people are great with that, and others are gonna say, Okay, I'm gonna look at my data, I'm gonna say, well, it looks like the system is always giving a lot after my breakfast meal, I probably need to either count more with precision, or maybe my ratio isn't quite right. So I think there are two ways to think about if people want a little more precision in their dose settings. And then other people were, if the system is going to help them, and they're okay with this part, this type of a Rise Fall, they just let it happen. And then, you know, until the system isn't containing it the way that they were used to, and a setting then may need to be shifted for them because something has changed.

Scott Benner 38:16
If you count the carbs get it right, and then it doesn't work, then your settings might be off. Correct, right, or you're getting some impact from food that you're not giving its full weight to.

Jennifer Smith, CDE 38:28
And I think with and on the same like line of thought I think with depending on the do it yourself systems, right, that are now in heavy use. They are leaning to the adaptation of settings in a way that's much more aggressive than the other adaptive systems that are on the approved list here. Right? So settings are going to adapt based on total daily insulin, or a set of data that says it looks like you're trending to needing a little more coverage, it looks like you're trending to needing a little bit less. And some people have found that they don't even Bolus with some of these systems. Yeah, right. They don't even announce anything. And depending on the system they're using, the system may use this particular piece of the algorithm versus this beta based on the rate of change, and the other settings that they have told it to work with,

Scott Benner 39:25
right? So like if on the pod five, for example, sees like a bigger use of insulin over two days. Then on that third day, it may just start being more aggressive because it expects that's what you need. Also, Arden who's wearing IPS which I think she's going to switch from soon to another branch of it. But that one has dynamic, everything. It's dynamic, Basal dynamic, insulin sensitivity, dynamic card ratio, I have it all turned on and it works pretty well. Okay, and you know what, let me just tack on to the end of this. The other idea about Being on the algorithm is an algorithm is let's say your basil is a unit an hour. If you miss your Bolus a unit heavy, there's a world where the algorithm can still make up for that by just keeping the basil off longer after the Bolus co said, like almost like five units were further food. And oops, I put in six units. I'll just keep the basil off an hour longer and make up the difference there. Basically, I Pre-Bolus the next hours worth of basil with the over Bolus of the food, the mistaken overhauls to the food, there's a lot of different ways to think about timing. Once the algorithms involved, it's giving and it's taking away. Right.

Jennifer Smith, CDE 40:39
And I think that's the it's the more automated use of eons ago, the the term coined by John Walsh was the super Bolus option, right, where you give a lot more upfront, and then you would manually set a temporary Basal decrease or suspend assuming the upfront coverage was to stop a quick rise on the back end, you took away what you added in the front. But now our automated systems can absolutely do without you even exactly

Scott Benner 41:07
what it's doing. Yeah. Okay, this one's not going to be easy. So we'll just jump right into it. Because there's a lot of has a lot of just opinion here, but how would you go about putting a pump on your daughter when she's seven years old, and she's dead set against wearing a pump. I know what the right approach is, she's eight months into new diagnosis. I co parent, our daughter is split 5050. Between me and my ex, he told her, it will be up to her when she wants to wear one. And she's sticking to that. And as you can imagine, that's messed up my plan pretty good. So this is interesting, because I just had a conversation on the podcast the other day, I interviewed a physician whose child has type one. And she shared with me. She said, I agree with you, Scott, I've heard you say this on the podcast before I don't let kids make medical decisions. And I'm like, okay, and she goes on, I get the other part of the conversation too, with autonomy and body positivity and like those other concerns. And she's like, but from my perspective, after she wore it for a little while she was okay. And the getting over the hump is what she thought was the problem. And I was like, it's interesting, because I feel both sides of that. I do too. Yeah, you know what I mean? Like, I wouldn't want to make anybody do what they don't want to do. But you also me how many stories you hear about like kids like, no, no, no, no, no. And five days later, like, this is fantastic. I haven't used the needle in five days. So, you know, I don't know, what do you think about that?

Jennifer Smith, CDE 42:41
I do very much agree with the doctor you talk to, in general, the adult brain isn't really completely adult until like to age 25. So we talk about kids, they're really, they're under informed in a way that they're that it's also because they're not at the level of understanding the depth that an adult truly has in understanding benefits here reach bar. Yeah, kids also, you know, have kids with diabetes who have caregivers who are navigating it with and for them pretty much they can't understand or grasp the gravity of what their parents are doing for them. Right. And some of the navigation as that sounds like this parent is kind of emphasizing is they need some life back to they need some assistance with dosing that can be a lot more precise, and potentially offsetting feeding insulin because it doesn't have to be there in such imprecise doses. Right. And so I also agree in the fact that many times kids adapt pretty quickly. They may really dislike it to begin with, maybe it's a week worth of complaining and annoying. But as you said, less injections, man, for the most part goes over pretty darn well. Yeah,

Scott Benner 44:10
I think there's going to be outliers, obviously. And there's yes, there's a spectrum here of of how the response is going to be for sure. Now, if my kid was having a complete meltdown, and you know, like, running into walls and screaming, I'd be like, okay, hold on, like, let's wait, but, but just the kid who's like, I don't want to do that. Well, of course, they don't. I mean, any you put on a pump every day, if I gave you the choice, would you want to do that? Like, you know what I mean? Like nobody wants to do that. Like, it's hard because you get this diagnosis. And, you know, we're very much fans and telling people like you're going to live a perfectly normal life. I think that's true. It's not gonna stop you from doing anything. I think that can be true. But, you know, most people don't walk around with a couple of things stuck to their arm or their hip or their belly or something like that. Right? There's an adjustment to be made there and a Um, acceptance that has to come. Right? You know what I mean? So I'm not, I wouldn't be a fan of just looking at a kid one day and being like blurting out, like, Hey, we're getting the CGM for you, you're doing it, I don't care what you think. Yeah, I think you gotta like, you gotta parent your way through it and support them. And like, there's got to be love there and compassion. And we're gonna do this together, and I know you're wearing it, but I'm gonna be here. And, you know, I wouldn't be I'm not a fan of just like, do it. But I'm also not a fan of letting an eight year old make a decision about their

Jennifer Smith, CDE 45:33
health. Yeah. And I also think that there is a way of discussing that piece that you want to bring in, in a way that makes sense at their level, at their age level, at their education level, you find the things that are really important to them that maybe they've had an issue with, because they always have to check in, because they have to take an injection, or they, you know, are taking more time out of class, and having to always go to the nurse versus push a couple of buttons and text, right. So there are some things on their level that you, you could explain to the extent that you've complained about this, if we did this, it could take this down a notch, it could improve this, we wouldn't have to get up at two o'clock in the morning and do an injection. If that was something that was in the pit, you know what I mean, you also

Scott Benner 46:28
have to be ready for when they're, I mean, there's downsides of everything. So when a downside of a pump comes up, you have to be ready to deal with that to not just act like it's surprising you like one day, it's gonna get ripped off, like your site will get ripped out, or it's an omni pod, or they'll get popped off or your Dexcom is gonna hit a door jamb or something like that. You don't want to be ill prepared for when something like that does happen, because otherwise the kids going to be like, See, now this is a hassle. And you're going to be left by going like that. I think you have to tell them upfront, like it's not going to be perfect, but Right. We'll try to measure our wins here and see if they're not greater than the ones we're having right now. Right? And then you know, half joking. Money always helps to you can just

Unknown Speaker 47:09
grease the skids crazy. bribery. Yeah.

Scott Benner 47:12
How would you like a Lego at a pump?

Jennifer Smith, CDE 47:16
Really big $600 Star Trek or whatever, right?

Scott Benner 47:19
Do you think a new baseball glove and a CGM would go over. I mean, I very famously, and one of my episodes, older kid wasn't Pre-Bolus in his meals. And he was almost out of high school if I'm remembering the conversation correctly. And he wanted to start a business of chopping trees when he got out of high school and needed a chainsaw. And I said, the mom was like, you know, I'm going to end up having to buy the chainsaw initially, because the kid doesn't have any money. And I do want to help them. He's got a truck gonna get off on this thing. I said, Why don't you sell Pre-Bolus for $1? Like in a jar, and tell him look for the first 600 Pre-Bolus says, I'll pay you $1 For each one of them get to 600 I'm done paying, you can buy your chainsaw. And I don't know if they ever did it or not. But I felt like a genius that day. That's a great idea. Right? Like, everybody gets something you got something to work towards you feel like you're doing something for yourself. Yeah, the moms being supportive, because they were just stuck in a battle. The kid wasn't gonna do it. And, you know, I mean, I'm not saying you should bribe people. But I think what I'm saying is, is you can like wave shiny things in front of kids and make them forget what they care about sometimes. And maybe this is one of those situations if it is now if you have again, some over and above problem. sensory issues. Like you know, I'm not I'm not certainly saying just be like, screw you take the pump. You

Jennifer Smith, CDE 48:40
know what I also in this situation, it is a hard one because it seems like parental they're not really on the same page. It's almost like a give from one parent. I think it was the dad who was like, Yeah, whenever you are ready, whatever kind of again, the you make the decisions child right? Where the mom's like, you know what, this is going to be better most of the time, it's going to help much more of the time. It's going to make things easier, more of the time. And it's hard because they're completely on opposite.

Scott Benner 49:15
Yeah. Listen, I'm over 50 So I'm going to sound old, but in the entire time I was growing up no one ever wants to ask me what I wanted ever in my whole life. Oh, yes. Didn't ask me what I wanted for dinner. They didn't ask me. I would buy like you got shoes that somebody was like hear these? You didn't get to go. Oh, no, thank you. I prefer they Oh, no. Here's your shit.

Jennifer Smith, CDE 49:37
Absolutely. That's so funny because I thought of that the other day when I was making dinner, and we were talking about it. My older son and I and then I thought about it. I was like When did my parents ever asked me like never know ever. It was just presented. This is what you get to eat tonight.

Scott Benner 49:58
I've had 25 minute Converse. patients sitting in our car outside of our house trying to decide what restaurant to drive to with for people where I didn't think we were gonna come to an agreement, I thought we're gonna have to go back inside. If I was lucky enough to go to a restaurant as a child, I certainly didn't get a say into which one it was.

Jennifer Smith, CDE 50:14
No, we were taken wherever we were going to be taken. And then that was it.

Scott Benner 50:19
Also, while I sat at that restaurant, my father smokes cigarettes at the table. So like, the world's gonna come a long way. But I don't know, listen, this is a tough one, like being a parent. You know? I mean, I think my answer is compassionately act like an adult and bring them into the conversation as much as humanly possible. But get them to where you think, you know,

Jennifer Smith, CDE 50:41
and also expose them, right? It's a concept that's very odd to think about. It's, it's not something that they've maybe touched or felt they might have heard adult level talking about it. They might have heard about it in their endocrine visit. But nobody's let them touch it, see it interact with it. You know, from a mom standpoint, check with check with the pediatric that you that you work with? Do they have a pump exploration day? Would you go there? Because you're also then going to probably see other kids who already have a pump? Yep. And that visibility makes it a lot easier for a child to be like, Oh, I guess I'm not the only one considering this.

Scott Benner 51:25
I can't tell you how many can you show me your pump? posts go up on Facebook that can somebody please show my daughter like this? Or that? Like I've actually I've contacted Arvind recently, and I was like, Can I put a picture of you up with your pump on like this little kid, you know, and then I got a nice note back like, oh my god, like, you know, thank you. She's, she thought Arden was pretty and now she'll do it. Like, you know what I mean? Just like that. Yeah, that's simple, you know, make a difference. Yeah, absolutely. Does. What is new in insulin choices? And how do they work with pumps? Um, there's nothing new that's on now is there like is loom jab and fiasco are the newest and there are a few years old with

Jennifer Smith, CDE 52:01
pretty much the newest and they're just considered more, I guess, ultra rapid acting right. And most people see a difference that use them. Not everybody does. And some people see wider variability. But yeah, I mean, in terms of insulin, they're the more rapid acting I would say the next would probably be the inhalable insulin.

Scott Benner 52:26
A Frezza. Okay, yeah. That's pumped, though. But yeah, that's new, right? That's new. You just said something I'm gonna like, because there's not much to say here like the insulin is what it is right now. There's nothing new they work in there. As far as working in pumps. There's one right a pizza doesn't work in a

Jennifer Smith, CDE 52:44
pizza you cannot use in the tandem, tandem one right tandem.

Scott Benner 52:48
And they'll tell you, you can't use it an omni pod. But Arden's been using an omni pod for like eight years. So. But that aside, you just said something really interesting. Like, don't don't let me lose my thought here. We see people some have luck with it, some don't. At what point do we wonder? Is it the insulin? Or the people's knowledge of how to use the insulin? Like why do we so easily say, oh, that works? For some people, it doesn't work for other people. And we say your diabetes may vary and all that stuff. But what if what's really happening is like you're using it wrong, or your settings are way off. And then you tell me a Novolog doesn't work? Well, if your Basal should have been a unit an hour, and it's a half unit of hour, I could see where you would say but because you see that all the time with like, human algorithm pumps, like, right, this thing doesn't work. And then you look at their settings, and they're so whacked, it would have no chance to work. We never really talked about that. I think out of kindness, really. But you know, all those stories you hear in the space about this thing's better than that thing like says you. And how do I know you use that correctly? Here? Is that a thing you think about while you're helping people?

Jennifer Smith, CDE 53:55
That is interesting. And I think in terms of looking at somebody who is trying one of the newest, more rapid acting, whether it's be asked for loom Jahve, who has been appropriately using the just regular rapid acting insulins, whether it's a pee draw, or Nova log or human law or Novo rapid or whatever, right? They've been appropriately using it, but like they're at the point where that Pre-Bolus is becoming for whatever lifestyle reasons, it's hard for them to maintain that. And I think on many levels, whether it's a kid level, a team level, or even a really busy, you know, adult level in a job that doesn't really give them a long time for a break or whatever, right? And so if they're already trying their best, one scenario that it is working to their advantage is that now that they're using it, we can see the difference in their post meal, blood sugar, even some people who may not have much ability from a previous standpoint, if the medication is going to work for them, we're definitely going to see that that again, that post meal or post food intake is much better contained than it was using the other. Yeah, insulin,

Scott Benner 55:13
I come to that question a lot, because I see people online, and they're at wit's end, and I need a cure this look, this happens to me every day. And I think I think if I was there, I could fix this. Like you don't I mean, like, I know, I can't do it remotely, because you're too far spun off center, and you've got too many preconceived notions about what you think is happening. But I really think there's an answer here that I recognize that person might not be able to get to. But I do think sometimes, like, I think if I was there, I could figure this out. And I might be wrong on some of them. But like, I think in a great number of them, it just is I hate to say, I don't mean user error, but it's the quickest way to make the point, you know, so

Jennifer Smith, CDE 55:55
right. I can give my n of one with fiasco specifically. And honestly, with loom job, yes. worked beautifully for me for about five months. Yeah. And then all of a sudden, I was changing settings to the degree that I had never seen that type of insulin, what I was assuming was resistance. And knowing a little bit, it was pretty soon after fiasco came to market where there was some information essentially, about, it seems to work for some people. For some people, it has a little bit of a waning effect, et cetera. And I was one of those. Yeah, I went back to my long term, used human log, and had to dial everything back back. Why do I insulin right away, it was within 24 hours, I was low and having to dial things back down. loom Jeff just didn't. It was variable like variability. I had never, I'd never seen variability like that before. It was almost like it didn't have the upfront quickness for me. But as soon as it got going, it trashed my blood sugar.

Scott Benner 57:01
Okay, it was bizarre a long time to get going. Then it was like turbo after that.

Jennifer Smith, CDE 57:05
And then it was really, really, really fast for me. So I just stick with my human login, select what works.

Scott Benner 57:13
Alright, let's stick with insulin for one more question. Yeah. How do you handle I'm just going to ask you, I'm not going to I'm not going to read the question. How do you handle refrigeration of insulin? So obviously, you keep it refrigerated when you're not using it. But once you open it, do you keep the open vial refrigerated? Yes. Okay. I do too. Do you have to?

Jennifer Smith, CDE 57:36
Technically no, you have, again, based on what the package insert that nobody reads says 28 to 30 days and then a vial at room temperature should be thrown away. That's what they say. Right. Now, I have long term because that's what I learned to do. Long term, insulin was just kept in the fridge, you took it out when you needed to use it, you put it back in the refrigerator. I travelled for years and years with a ice pack specific bag for my insulin to go in and go places and whatever. And to this day, I still use some type of like insulated pack. The only time I haven't is when we hiked the Inca Trail. And there was no ice ash, there's nothing you could do. There's nothing I could do so but I use the frill. And that worked well because I could get water and at least it kept it cool enough room temperature is what they say. Right? But in general at home or in you know, I keep it in the refrigerator or take it out fill my filled syringe, put that on the counter to get to room temperature and my vials back in the fridge.

Scott Benner 58:41
Have you seen people sharing that article that says that insulin lasts longer than 28 days on refrigerated?

Jennifer Smith, CDE 58:46
I haven't read that article, but I didn't know people are sharing. Oh, yeah.

Scott Benner 58:50
So you but you've seen it as well. Right? Yeah. It wasn't an actual study, wasn't it? I believe it was yes. So I'll just say this. Like, we keep our insulin refrigerated. If we didn't, our house is pretty consistently around 70 degrees, like winter summer, like it's about around where we keep it right. So if we left it out, it wouldn't see any harsh conditions. And there have been stretches of Arden's time where we've done that to like just been like, Oh, it doesn't need to go back in there. And it sits out. I use insulin until it's gone. I don't track how many days it's been open if I'm being honest. So and there's no way you use a vial in 28 days. Right? Right. Yeah. Okay. So you keep using it.

Jennifer Smith, CDE 59:34
How often do you change your Landsat? That's the same question.

Scott Benner 59:38
Like so if you want to follow the rules, God bless you, you should follow the rules. And if you want to try some other stuff, I mean, I think it's up to you you have autonomy, you should you should do some experimenting and see what's my other question around insulin I was gonna

Jennifer Smith, CDE 59:54
say and I think that the reason that I also feel confident in going I'm going beyond that 28 days. And really, I also I mean, I suck all of that insulin. Like down to the last little nibble, right? But I feel confident doing it that way, because I have kept it refrigerated. Okay. If I travel in this is just my strategy when I travel and it has been in like a Freo or something like that when I get home, and thankfully I have I have access to enough insulin that you can do it. Yeah, I just get rid of that vial and I started a new one.

Scott Benner 1:00:31
That's the same for us. We have access to insulin, and I would do the exact same thing. We've gone on like Island vacations where eventually like, a weekend or you're like I couldn't get this thing into ice anymore. And but it keeps working fine while you're there. And then you get home and you're like grommet open and no one yes. Yeah, I mean, okay, what about hot tubs? You get into a hot tub with your pot on? I do. And it's okay afterwards. These are all the things people worry about.

Jennifer Smith, CDE 1:00:57
There all the things people worry about. And when people ask, you know, my best is, what is your blood sugar look like hours after? Is it doing what you expect it to do? You know? And if it is, then that didn't have an impact. If you're rising, or if you Bolus for a meal, and you're not getting the response that you typically should expect? Then change it out. Right? Yeah, it's it's less of a, what should I do? Should I you know, whatever. I mean, hot tubs are hot. You're not going to technically be boiling your insulin, right, but exposed to extreme temperature like that. And if you're completely submerged for a really long time in a hot tub. Sure, it could start to impact. Yeah, absolutely.

Scott Benner 1:01:45
But if you were in there, I mean, Arlen gets in a hot tub. Sometimes she's in there for half hour an hour. I don't think anything of

Jennifer Smith, CDE 1:01:51
it. Like I don't even think I've ever sat in a hot tub for an entire like an hour like I Yes.

Scott Benner 1:01:56
Because you're not a young person. Yeah, kids, you got other things to do. Right? I guess I'm not. Because after 15 minutes, you like, this was nice. I have things I gotta do. My feet up, what is that? Also, you know that a summer, it can be 90 degrees outside, and you can be outside for hours and hours of your pump on or you're not pod on. And the insolence still 98 degrees and you leave it on for days. So Right. All right. Okay.

Jennifer Smith, CDE 1:02:25
I mean, I have I have a lot of questions that come that way, too. You know, we've been, we're going on a beach vacation, or we're going here and it's gonna be really hot and really humid. We're going to be outside. Okay, I can't tell you exactly what's going to happen. Could your insulin start to deteriorate? It could? Sure. Is it going to happen every time? No. What do you do you watch your blood sugars and the response that you would typically expect? And if it looks odd, just change it out?

Scott Benner 1:02:52
Yeah. Yeah. And by the way, are you one day going to get, I don't know dehydrated, your insulin is not going to be as effective. And then you're gonna think Oh, my God, the insolence bed. And like, you know, like, it's gonna happen to you like along the way, the best thing I can say to people is that a lot of the things you're worried about, much like in the rest of life, eventually you won't be worried about them anymore. But you have to go through them enough times to see it happen so that you can kind of leave the fear behind and go, this is just how this works. It's fine. If I leave it out, or I don't leave it out. Now listen, if I didn't air conditioning my house in the summer, and it was always 90 degrees in here. I wouldn't leave insulin out of the refrigerator. I just go back. That's not that mean, just common sense. has to come into play at some point. All right. You know what? I think if I'm not mistaken, we are down to one last question on this list. About that. We've actually gotten through this list. That's That's incredible.

Jennifer Smith, CDE 1:03:49
Yay. Is it a long question? I've got about five minutes.

Scott Benner 1:03:55
Yeah, we're not doing it then. No, you're done. Okay. All right. Yeah, so instead Jedi see you just and let me say, We're gonna delete this out. Yeah, just yourself. Okay. And here's why. Because now instead of we're going to tell the story about what happened. So Jenny's power went out. And then she had to take the kids were,

Jennifer Smith, CDE 1:04:14
oh, I had to go pick them up. At the end of my day, I have to go get it to get the kids from school. Right. And power is still out clearly. And I do have to like preface by saying, I'm still in the state of my, my power is out. I had to totally stop this podcast. I had a whole bunch of emails I still had to respond to in detail. So I'm in this a little bit of like, annoyed, flustered. I go in the garage, and I hit the garage door button and then like, cried I'm locked into the garage because it's the electricity doesn't work. So I tech Scott, and I'm like, Oh, my God, my garage door won't open. He's like, Yeah, pull the string. I'm like, oh my god I'm

Scott Benner 1:04:57
so first of all, she texts me and I was like, oh my I got like, I'm really in this with Jenny Now, like it but it's a first of all your terminology is fantastic because you're like, I'm locked in the garage and I'm like, No, she's not. And then I'm like, Okay, I'm like, oh, Mike, okay, find the the motor and pull the cord down. It'll click, and then you can push the door up on its own. And like, I explained how it all works and everything. But that's not really where the embarrassment is. Right? That's just the thing you never bumped into in your life. Where's the embarrassment?

Jennifer Smith, CDE 1:05:24
Or the embarrassment is the fact that so I tell and I got to school a little bit like, late it was like, two or three minutes later, right? And telling the kids why I'm a little bit late. And my youngest.

Scott Benner 1:05:37
That's your oldest kid, your youngest kid.

Jennifer Smith, CDE 1:05:40
How old are young? My youngest kid who is seven, your seven year old? Go ahead. I seven year old? Yes. Before I even told them. How I actually got out of the garage or what I had to do. I was telling him I'm locked in the garage, bla bla bla. And my little guy is like, well, mommy, did you just have to pull that cord? Oh my god, where were you? 20 minutes ago, when I was panicking. My

Scott Benner 1:06:05
favorite part of the story is but later Jimmy says to me, my kid knew how to do that. Good times.

Jennifer Smith, CDE 1:06:12
I think it was frustration because I have maybe if I had looked around in the garage, I'd have been like, oh, look, there's hard to pull here but

Scott Benner 1:06:22
just I want all you people to remember you're getting your diabetes information from a lady who felt like she was locked in her garage because the power

Jennifer Smith, CDE 1:06:30
thank you for making me feel very,

Scott Benner 1:06:32
you're the one that said you had a couple of minutes left that you could have easily said I had to go. Cool. Thank you.

Mark is an incredible example of what so many experience living with diabetes. You show up for yourself and others every day, never letting diabetes define 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 where to share your own story. Visit Medtronic diabetes.com/juice box. A huge thank you to ever since CGM for sponsoring this episode of the podcast. Are you tired of having to change your sensor every seven to 14 days with the ever sent CGM? You just replace it once every six months via a simple in office visit. Learn more and get started today at ever since cgm.com/juice. Box. A huge thank you to one of today's sponsors G voc glucagon, find out more about Chivo Capo pen at je Vogue glucagon.com Ford slash juicebox. you spell that GVOKEGLUC? Ag o n.com. Ford slash juice box? You have questions Scott and Jenny have answers. There are now 19 ask Scott and Jenny episodes. That's where Jenny Smith and I answer questions from the audience. If you'd like to see a list of them, go to juicebox podcast.com up into the menu and click on Ask Scott and Jenny. 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 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 a 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, the episode you just heard was professionally edited by wrong way recording. Wrong way recording.com 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.