Dave Dixon
Welcome to Voices in Pharmacy Innovation, the podcast where we spotlight bold ideas and groundbreaking practices that are transforming pharmacy practice and healthcare care delivery. I'm Dave Dixon, professor and chair at the Virginia Commonwealth University School of Pharmacy and core faculty member of the Center for Pharmacy Practice Innovation. In each episode, we'll sit down with pharmacists, healthcare care leaders, and changemakers who are rethinking how pharmacy can improve patient care and push the boundaries of what's possible in our profession. Together, we'll share stories, explore new models of practice, and amplify the voices driving pharmacy innovation forward. Today, I'm thrilled to have Dr. Diana Isaacs with us on the podcast. Dr. Isaacs is the Director of Education and Training in Diabetes Technology at the Cleveland Clinic. She also co-hosts the podcast Diabetes Dialogue, a monthly podcast on diabetes and the role of technology. Recently, Dr. Isaacs received the Outstanding Educator in Diabetes Award from the American Diabetes Association. She's really a tour de force in the diabetes world, so we're very fortunate to have her join us on the podcast today. Diabetes affects over 40 million Americans, and about 115 million Americans have prediabetes. Historically, diabetes care relied heavily on patient self-monitoring of blood glucose. However, the development of continuous glucose monitoring, also known as CGM and other technologies, has revolutionized diabetes care by providing patients and clinicians with real-time data to optimize glycemic control. Pharmacists are increasingly playing an important role in providing patients access to CGM, interpreting the data, using it to guide treatment decisions. And so today we're going to discuss how this technology came to be, its current state, and what it might look like in the future. And once again, we're just so happy to have Dr. Isaacs on. Diana, thanks so much for joining us and welcome.
Diana Isaacs
Thank you so much for having me. It's so great to be here.
Dave Dixon
So before we jump in, I'd love to learn more about your background. I don't think I know much about kind of how you got into ah diabetes care and particularly into the CGM and the diabetes technology world. So tell our listeners a little bit more about your background.
Diana Isaacs
Sure. Well, you know, it started as a ah pharmacy student. I graduated from Southern Illinois University, Edwardsville, and it was really my great professors who were working in diabetes that really inspired me. And, you know, even as a student, I felt like I could make such an impact at health fairs, educating on glucose monitoring. And so I went on to do residency at the Philadelphia VA, where I specialized in ambulatory care And then my first position after residency was actually in academia teaching at Chicago State University, having a practice site within the Heinz VA in a primary care clinic doing tons of diabetes management. And so in that way, I got to be just like my professors. And I accrued all the hours that I needed to sit for the exams to become a certified diabetes educator, which now has changed to certified diabetes care and education specialist. And then also the board certification in advanced diabetes management. And then I've participated in a lot of great organizations, certainly all of our many pharmacy organizations, but then also the American Diabetes Association, the Association of Diabetes Care and Education Specialists, um ACE, the Clinical Endocrinology Organization. And I've had a lot of great opportunities to work on all kinds of projects and, you know, participate in guidelines. And um yeah, that's kind of what then I ended up where I am now. The last 10 years, I'm at Cleveland Clinic and the Diabetes Center. um And working with a great interprofessional team and really, um you know, organizing a lot of great diabetes programming, specifically with diabetes technology.
Dave Dixon
That's terrific. And the one thing I heard you say is that you did your residency in the VA. I'm also a graduate of a VA residency program. I can't speak highly enough of of those training opportunities I did mine at the Asheville VA.
Diana Isaacs
Yeah. I mean, the VA is so great because pharmacists have the prescribing authority. right And so I felt like it was such a great way. Like i I wanted to be there. The pleasant, surprising thing for me was that when I joined Cleveland Clinic, because Ohio is a pretty progressive state, I continue to have prescriptive authority. But the VA a is like is a phenomenal place to train and and to work.
Dave Dixon
100%. hundred percent All right, so let's jump in and talk about CGM maybe specifically, and then we can talk about ah kind of largely what's going on in the diabetes space as relates to technology. So for listeners who may not routinely work in diabetes care, how does CGM differ from sort of the traditional finger stick glucose monitoring that the especially those of our generation learned in school? And why has it been so transformative?
Diana Isaacs
Yeah, I mean, finger stick was the standard of care. So I mean, finger stick, it's one point in time. So it lets you know what your glucose is right now at the moment. But it's not going to let you know if it went, you know, if it's rising, if it's falling. It's certainly not going to be able to alert you if you're high or low. And then you have to get a drop of blood to do a finger stick test, which, you know, can feel a little bit uncomfortable. In addition, the people that are doing finger sticks, a lot of them don't remember to bring their meter into the visit or they don't remember to bring their log of readings. And so it's a lot harder to know how to adjust their medications or recommend specific lifestyle changes because don't. We don't have that information. And that kind of causes us to then just rely on a hemoglobin A1C test, which is something we're only getting every three months and really is only showing an average. So CGM is going to show you everything. Every one to five minutes, it's updating with a new number. It can alert for highs and lows. And it really provides people with that real time feedback of, OK, well, what's the food, the medication, the activity, the stress? What did it do to their level? And it can cause them to make a lot of changes. And then for a health care professionals, it shows us all the data. So we know what's actually happening and it it better informs treatment changes.
Dave Dixon
Yeah, I tell you, it would be really great if we had something like that for hypertension with blood pressure, right? So some of these surrogate markers that we know fluctuate throughout the day, and that's always been the challenge, like you said, with glucose, and it's the same thing with blood pressure, and and maybe at some point we'll get there with blood pressure. But I certainly am kind of envious of those that do diabetes every day, just having you know, the data available to really understand what's going on, to really optimize glycemic control instead of just throwing drugs at it, hoping that, you know, it it improves and that it's stable, right?
Diana Isaacs
Definitely.
Dave Dixon
So a lot of terms are being thrown around lately in terms of time and range, glucose variability, glucose management indicators. These are all now part of diabetes care, bunch of metrics around CGM. So which of these are most clinically useful? How should we interpret them? What do the guidelines tell us?
Diana Isaacs
Yeah, so I think you know time and range is very useful. This is generally accepted as the time spent between 70 and 180 for non-pregnant individuals with diabetes. And for most people, we are aiming for 70% or more in that target range, which correlates with better outcomes and generally correlates pretty well with the A1C goal of less than 7%. I think the great thing about time and range is that it now is associated with some complications similar to how we we have with A1C. um But also it's just more actionable. um It's really showing the the whole story because unlike an A1C or even, you know, there's the CGM marker of A1C called the GMI, the glucose management indicator, that even still is an average. So yes, it is helpful. Don't get me wrong. It's helpful to kind of see where someone's running. But time and range is really showing you, in addition to what range they're in, it's letting you know how much above, how much hyperglycemia, and then how much below, how much hypoglycemia. And so in that way, it's much more actionable because you could have someone with an A1C of, you know, let's say 8.2. And so you make the assumption, well, we should intensify therapy. Let's go up on insulin. And, you know, it turns out maybe they're having 7% of the time below range and hypoglycemia. So it's really going to change the way that you treat. And then in terms of how we look at this data, we have something called the ambulatory glucose profile report, the AGP report. And that puts all of this information into a one pager because it is a lot of information where you're getting a reading every five minutes. I mean, that's a ton of info over a 14 day period. Right. But this standardizes it. So at the top, you have your time and range. you You do have these other metrics like the GMI and the glucose variability, as you indicated. And then in the middle, you have the visualization, which is great for visual people to see when there's maybe highs and lows. And then at the bottom, you have those last 14 days. So this can be a way when you get good at it, you just you can look at it really quickly and just get the whole picture and kind of know what to do or what to ask the person.
Dave Dixon
I'm very curious from a a patient perspective in your in your clinical experience, what's been the reaction from patients? You kind of alluded to it a little bit in terms of the data, but then also the ah the the visuals. Do you feel like that it has led them to be more, less engaged, overwhelmed? What's been your experience?
Diana Isaacs
Yeah. So I would say most people love love the CGM. I mean, they love it because at least they don't have to poke their fingers, but also they love it because they're getting real-time data and they're getting real-time feedback. So I would say the average person, the way they utilize it is you know they're wearing it. They're able to check in on their numbers. They're able to see what what did this food do to me? What was the effect of taking my medication or you know This really good night of sleep, did that impact? Am i running lower today? That's how the average person looks at it. The AGP report can be a bit technical. And especially if you dive into some of the other pages, like it can be a bit much. So i my approach is just at least introducing this concept of time and range and And that we're trying to see if we can get to 70% or more. So I really, i try to keep it simple and not focus on like all the other things, like the variability and the GMI and the average and this and that, just like focusing on day to day and and time and range.
Dave Dixon
Yeah, that's very helpful. So on the clinician side, ah what are some common mistakes that maybe clinicians could make when trying to interpret CGM data? What are some of the mistakes that you've seen happen in practice?
Diana Isaacs
Oh, I can tell you the mistakes I've made. So, you know, one thing which which seems like simple, but it's honestly, it's the date of the report. And I know that sounds like crazy. Like what when you look at the date, like shouldn't it be the most current date? But not always. I've definitely run into scenarios where um maybe someone's not still wearing the sensor and it pulls up the most recent data. And so, yeah. ah if if they weren't wearing it the last two months, what you're going to see is the data from two months ago. I've also seen where people went in and made a second account for whatever reason, and you pull the data and you happen to pull their first account, which ended whatever number of months ago or years ago. And it's really easy to just overlook the date and start looking at that data and make your decisions off of that data, which is not the current data. So I think like i I just always look at it and we have like we have medical assistants that pull the reports and sometimes, you know, you know, mistakes happen, right? It's just not the most recent. um Also, make sure it's the right patient. um You know, we should we should always be checking for that. Right. Beyond that, within the reports themselves, um you you do want to make sure you have enough data to make conclusions, right? The recommendation is to have about 70% of the data over 14 days. Sometimes for various reasons, people don't have all the data. because I've seen where someone only had it for like 12 hours out of a 14 day period, but those 12 hours were 100% in range. And then you look at it and it's like, it looks like they're 100% in range and you know you're making assumptions off of that, right? So you really wanna make sure you're looking at everything, you're seeing the last 14 days, what's happening. um The other thing is, You know, i I love to focus on the day where there's the most time and range and, you know, see what patterns, like what things a person did to lead up to that. And often it can be a really motivating strategy, right? But sometimes you do that and it turns out, They were in range. They had no you know no spikes that day because they were sick and they were in bed all day, right? So it's really like we want to have a conversation. We don't want to make assumptions about the data. So I think you know those are some of the really critical things. And then I think you know hypoglycemia is always, it's a safety concern. So it really should be our our priority. um So make sure you ask about it. And sometimes there can be errors with sensors where, you know, you you get a compression low. So for example, it's, it's on the back of the arm. Someone sleets on the arm. It looks like they're running low all night. So definitely asking about that um if the lows are real lows, if a person is confirming. um The other thing on the flip side of it is it could look like someone has no hypoglycemia. But you should still ask because I've had people that tell me they're chugging juice all day long. And so, yeah, it's showing zero percent below 70, but they're chugging juice all day long. Right. So it's like you still there's the whole human piece of this, which it should be a conversation starter. You still have to ask the person to kind of fill in all the answers. Yeah.
Dave Dixon
That last statement is a great segue to the next question as it relates to the role of pharmacists, such as yourself and and many others that are engaged in this space. So what's been your experience? You know, where do you see pharmacists kind of adding the greatest value in CGM care? i know you've mentioned that in your model, there are MAs or medical assistants that help. Um, You know, is it related to kind of improving access to CGM, how to select a device, educating patients? We already talked about interpreting the reports, but kind of where do you see the pharmacist role kind of fitting here in this space?
Diana Isaacs
So I think pharmacists can do so much. They can do all of the above, any of the above. And I think it depends a little bit on your environment and how CGM is currently being utilized or not utilized. So I think it's been challenging um adopting CGM in some settings, especially in primary care settings where it's not just diabetes, it's multiple disease states. And CGM, to get the data, right, you, well, you need to prescribe it, but then you also need to make sure you've got a portal that someone can connect their data to. You've got to connect that data. um And then, right, you want to pull up that report and figure out the efficient way to do that. And then someone's got to go through that and figure out how to, you know, what may need to be adjusted based on that interpretation. So I think depending on where a practice is currently at might be where the pharmacist gets involved. So if the issue is there's just no uptake like people have you you've got all these all these patients are on insulin. They clearly would have coverage. for CGM, but it's like there's just been this barrier to even getting started. So maybe it's it's helping to identify the patients and coming up with a process to get them started. And it could even be providing some of that initial education to patients. Like, this is how you you use it. I think especially in community pharmacies, pharmacists, you know, there's a lot of un unlocked potential to really support people in this way. I think there also can be troubleshooting with devices like questions come up all the time. Like my sensor fell off early or why is my finger stick 20 points different than than this? Or why when I eat, is it going up and my finger stick is different? you know like the lag time, like there's all these these things that can come up. um And I think we also can do a lot to educate the health care professionals around us. um because the tech is changing so fast. And so it's really fun to kind of stay you know stay on top of it. And then we can be a resource to others in terms of what devices are available. How do you educate people? What are some best practices? So there's really, there's like a ton of things that that we can do. And then of course, just the whole medication management piece for those of us that have collaborative practice agreements and We can use this data and make meta adjustments. And it makes it so much easier to make adjustments when you have this rich data to look at.
Dave Dixon
Yeah, it really resonated with me when you mentioned sort of, you know, folks that aren't directly engaged in either diabetes care or CGMs still having a role. I know in my preventive cardiology clinic, we don't do a lot of direct diabetes management, but I can can't tell you how many times I've had patients come in asking questions about their CGM or it fell off, like you said, and what do I do or how do I put this back on? And um So I think it's definitely, ah you know, really important that for for pharmacists to to be aware of CGM ah in some of the issues around it because it's the use has really just increased. But I know that access can still be an issue for some patients. So what barriers still exist that kind of prevent patients from obtaining or successfully using CGM?
Diana Isaacs
Yeah, well, the coverage in the whole landscape has changed pretty, you know, pretty quickly. So sometimes people, you know, they remember from years ago, i couldn't get it. It was too expensive. Insurance didn't cover it. And sometimes you have health care providers and and patients that just kind of assume that they can't get it when actually the coverage has gotten a lot better. um In terms of right now, Medicare covers for any insulin user. And then other insurance plans, they often follow Medicare, but many are actually covering even for people not on insulin. So it definitely varies a little bit. um But one of the mistakes that I see happen sometimes is that it's a question of, well, can you send the prescription to the pharmacy or does it need to go to DME, durable medical equipment? And in the case of Medicare, ah most plans do require going through a DME as opposed to just sending it directly to the pharmacy. And the problem is, know, it's certainly easier to just e-scribe it and send it to the pharmacy. So when it's not done correctly, the person goes to the pharmacy and is told they're going to need to pay a lot of money. It's not covered. And they kind of get demoralized. So i think it's really about kind of coming up with a workflow, Medicare, like knowing what It goes to DME. And there's a lot of solutions out there. There's things like Parachute, which is a kind of a portal to make the process smoother. There's ways to set up so you can prescribe DME in your EHR, your electronic health record. um And then it's also kind of just staying up to date in your area. what like What is the coverage for the common plans? what can go through the pharmacy. We are seeing like more and more can go to the pharmacy. And then it's just a matter of knowing like how many sensors someone needs and making sure they're getting the right amount. So many of our products now are 15 day wear. Yeah. So that's going to be two sensors a month versus if it's a 10 day where they need three sensors a month. so it's just making sure they're getting the right amount. And then the other thing I'll say is that it is a common thing that a sensor falls off early. That's just like that is a fact of life. Right. But the insurance is not going to cover additional sensors. So that is where we really try to educate people. Call the company. They are great about sending a replacement, but it has to come from the company. It it won't come from the pharmacy.
Dave Dixon
That's good to know. That's a great tip. um So there are a couple of, I guess, somewhat controversial areas that I wanted to touch on. um And one being there's CGM devices are being and used increasingly among individuals without diabetes. And I'm curious from your perspective, is there a meaningful clinical value in that use or are we at risk of just generating data without a clear purpose?
Diana Isaacs
So this is very timely because I just gave a talk on this topic on over-the-counter use of CGM. um And it I think the title was Data for All or Clinical Chaos. um So I think, you know, yes, they are available now. We have at least two over-the-counter sensors that people can just, you know, go online and they can purchase and anyone can take a look at their data. I am overall hopeful because 38% U.S. adults live with prediabetes. And I would say like half of them don't even know that they live with prediabetes. So in my mind, if someone starts monitoring and you know they discover that they have some dysglycemia or maybe they have undiagnosed type 2 diabetes that they weren't aware of, I think overall that is a positive thing. And that can be useful. And even, um you know, there's data supporting that people, for example, with obesity may have some dysglycemia, even though they don't have a diagnosis of prediabetes or type two diabetes. When we look at their time in range and especially their time in tighter range, 70 to 140, like we see differences. So in my mind, that could be helpful, right? You see that you ate I don't know, you ate two cups of rice and what it did. And then maybe the next day you try to just eat one cup of rice or you switch to brown rice. Like, right. That can be helpful. I think that there is a concern for some data overload, especially is i I kind of dug into the the information with exercise. So there's some fascinating data with CGM and like what happens with athletes, even football players and how, you know, it go can go up above 180. Sometimes it's going below 70. It's not clear to me, though, how that might translate into outcomes. Like, I don't know. Like, actually, when I go to Orange Theory, my glucose can go over 180. I don't have diabetes. Is that bad? Am I working too hard? I mean, I think these are the questions we don't know. So like, yeah, we're getting data. It may not all be useful. um But I think overall, my sense of it is the positives outweigh the negatives.
Dave Dixon
I like that. That's a good summary. And and I agree that ah anything that can help improve awareness of prediabetes and diabetes, or like you said, even just any degree of dysglycemia is is is probably a good thing for most. so um Another area that, you know, is constantly evolving, of course, is around AI, artificial intelligence. So i'm I'm curious for your thoughts on how artificial intelligence, and I know there's other technologies related to automated insulin delivery, connected pins, um using predictive analytics, you know, What does the future of all of that lead us to eventually in terms of CGM and and diabetes technology? I guess, you know looking in your crystal ball, what what does this look like in five to 10 years?
Diana Isaacs
Well, I think it's really exciting. We are starting to see some AI be embedded into different apps. And, you know, one example is with our CGM apps now, you can take pictures of of food and the AI is able to pretty accurately identify the food.
Dave Dixon
Wow.
Diana Isaacs
Some apps. Yeah. I mean, it's really it's it's like very detailed. It's very impressive. um And some, depending on the platform, like it will even be able to identify the carbohydrates and the macronutrients. um And so we're seeing AI be able to identify patterns. And so when it comes to other technologies like insulin pumps and automated insulin delivery, Many of these have you know several settings and there's companies now that will look at the data and basically they can recommend setting changes based on the patterns. And so I have no doubt that there'll be a day where either the algorithms get so much better because of ai and these predictive analytics, um Or, you know, there'll be some tool that will just be able to take it and be like, do this, do that. Right. And I'm OK with that because i think anything we can do to improve outcomes, in my mind, there will always be something else to do. um So if it's not changing someone's settings all the time, i will find something else. I do think, though, that there is this whole human component and human connection That AI obviously cannot replicate. And I think that there is always the every person has a story, right? There's a story behind the data. And if you just make assumptions based on the data without getting that story, you can really come up with the wrong conclusions. And so that's why I believe AI needs to be supervised by humans. And if we can partner and work well together, we can get the best outcomes.
Dave Dixon
I agree wholeheartedly. That was very well said. Very well put.
Diana Isaacs
Thank you.
Dave Dixon
So we'll kind of wrap up here with some of our reflective questions. So what resources have you found most influential in your own thinking about innovation as it relates to obviously diabetes and technology or pharmacy practice?
Diana Isaacs
Yeah. You know, thinking about this is such a good question and it's hard. I don't think it's not like I have like this one resource or like there was this magical book that just changed my thinking. i I think it actually comes down to talking to people and surrounding yourself by the right people and people that you know spark this good discussion where you can generate ideas. I also think it's taking time to do it, to be creative. Innovation is so important, but if you're constantly putting out fires and just running from one thing to the next, there is no time for innovation. It is only survival. um And I think humans are really good at innovating and being creative. Right. So I think it's important to take that time and be around the right people. And then you get the innovative ideas and you can do new things. And yeah, we can change the world.
Dave Dixon
Love it. um So you mentioned your ah career kind of you had a a phase in academia. So I'd love to hear your thoughts on how pharmacy education and maybe our training programs should evolve to prepare students and maybe residents for practicing and in this landscape.
Diana Isaacs
Well, I have an update. I'm actually joining academia again. um yeah I just took a shared but I'm still at Cleveland Clinic, but I took a shared role where now I'm at Northeast Ohio Medical University. So I will be teaching.
Dave Dixon
This is our first like breaking news segment here on the podcast. how It just happened. ah Congratulations.
Diana Isaacs
Thank you. Thank you. So, yeah, I'm coming back to my roots of of teaching pharmacy students. And I think we are, you know, we're in such a different era because really information is at our fingertips. I mean, I can go to open evidence and put whatever question I want in there and get an answer. um So I think it is really important that we take time to think critically and not just like read information because it's when I think back to like my own pharmacy school experience, I don't really know how much I remember from the lectures. Right. I mean, and also the information changes like, OK, the pharmacology is probably mostly the same, but like the clinical, how much has it changed over the years? Like every guideline comes out, it changes what it was before. So it's not the regurgitation of the facts. It's like how you think about it and how you apply it. And so I think that's what's going to be so important. Like that critical thinking, that case-based application. And I still think, I really feel the best way to do that is through experiential, like through being at the practice sites. Like you see the person in front of you. Now you are faced with this person. What do you do? So I think that's critical. I'm glad the programs continue to have, you know, the year of APPEs and all the introductory experiences. And I think like that's the key and working with good preceptors who care and who love what they do. um i think that's yeah, that that's what works well.
Dave Dixon
Great. Well, congrats again.
Diana Isaacs
Thank you.
Dave Dixon
um What's something you're looking forward to in the next six to 12 months? This could be personally or professionally, obviously career wise, you just mentioned the the change there, but anything else?
Diana Isaacs
Well, I actually, there was new data that was ah that was shared at the American Diabetes Association Psy Sessions, which I know you were at as well presenting. um But the CONNECT study is really a landmark trial that utilized, it was a randomized controlled trial with CGM in people with type 2 diabetes not taking insulin. And it showed, I'll just give you the punchline, it showed that there was a 0.9% improvement favoring the group on CGM. And this is really a landmark study because when I think back, the mobile study, which was a similar setup, but it was in people that were on just a basal insulin, that is what got Medicare to cover CGM for people on just a basal insulin. Prior to that, you needed to be on mealtime insulin. And so I am really hopeful this data, you know, it's going to get adopted into the new guidelines, which ADA comes out every year. December, we get the new ones for the next year. And I'm hopeful that will increase coverage and increase access for my patients. So that is something I'm very, very excited about.
Dave Dixon
Yeah, I think that's something you should be excited about. We should all be. That's fantastic. um Well, thank you so much, Diana, for educating us on all things related to diabetes and technology. i think it's clear that pharmacists play a huge role in helping patients not only access the technology, and use it appropriately, but also how to make therapy adjustments to improve outcomes. Please let our listeners know where they can connect with you to learn more about your work.
Diana Isaacs
Yeah, well, I have a podcast, as you mentioned in the beginning, Diabetes Dialogue. So if you look that up in my name on any podcast platform, you should be able to find it. um Also, I have a website that I need to update, but it's diabetes-pharmacist.com. And then I'm on social media, Instagram, X, at Diana M. Isaacs. And then you can always find me on LinkedIn as well.
Dave Dixon
Great. Thank you to our listeners for tuning in to this episode of Voices in Pharmacy Innovation. If you enjoyed today's episode, please subscribe, share it with a colleague, and join us next time as we continue to spotlight the innovators that are shaping the future of pharmacy practice in healthcare. care Thank you for listening to today's episode. Voices in Pharmacy Innovation is published monthly. You can listen on Apple Podcasts, Spotify, or by visiting our website linked in the show notes. If you have any questions or comments, you can contact us through our email cppi at vcu.edu. We appreciate your engagement and look forward to having you join us next month.