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Our dialogues series got a revamp! Keeping the interesting topics and our amazing guests, our beloved series “The Dialogues” is changing its name to “The T1Dialogues”! To kick off with the brand-new name, we have Saro Arakelians over for a delightful chat. With over 10 years of experience in the pharmaceutical industry, Saro is providing all the insights regarding diabetes, insulin, pumps and CGMs.
Watch the entire video down below:
Hi Saro, Welcome to the dialogues!
Hi Pete, thank you for inviting me.
Well, I’m excited to have you today. So we haven’t had a pharmacist before and I’m really excited to get the perspective of a pharmacist because I think they have a major role in the whole diabetes community and the CGM world. Most of the time patients think about doctors and doctors think about their patients, But I think sometimes the pharmacists’ role gets neglected and doesn’t always kind of get the seat of the table or doesn’t always get the credit for the work that they do for diabetes management, right?
Right. I agree. And I’ll be happy to go over my perspective from a pharmacist’s standpoint.
That’s good, so before beginning today’s discussion, it would be really good for the listeners and the viewers to hear a little bit about you and your background. Please tell us about your credentials and from where your pharmacy career started.
Of course, I went to a Pharmacy School in Northeastern University in Boston. Massachusetts and graduated in 2006. Being a pharmacist for 14 years, I started getting involved in direct patient care for 10 years. I have worked in ambulatory care, pharmacy management, creating programs and managing patients for preventive care, population health, management and now my career has grown from being pharmacist to the vice president of the operations for managing programs like disease management programs, preventive health, population health management programs that are mostly focused on chronic conditions like diabetes, hypertension, heart failure, COPD, and asthma. But these days, we mostly work on diabetes, which is in-turn, connected to hypertension, heart failure, dyslipidemia. Specifically, we see patients as a whole. When we look at the diabetes patients, we manage their blood pressure, lipids, and check for heart failure. So, we look at the patient from a holistic view which is really exciting.
The pharmacists intervene clinically and with medications which are getting more and more common.
Yeah, because that sounds like an expanded, functional role for pharmacists. What I think is that they are perceived to have a role of taking more of a clinical engagement view and handling some of the clinical aspects. Where’s that come from? Has it been that clinicians that are overwhelmed with the amounts of work that they need to do and that actually pass their clinical stuff to the pharmacists that they are capable of doing to actually manage the load across the system?
That’s actually one of the main reasons that the physicians are being bombarded with so many patients and having a whole lot of workload. And they have very little time managing a specific disease. That’s why other healthcare providers, like pharmacies have stepped in, and have been given the permission based on certain guidelines to be able to actually manage these patients. When I say managing patients, it just does not mean checking their blood sugar levels, collecting blood sugar levels rather we actually perform insulin dose adjustments and insulin pump adjustments. So that’s where we have come from since I got involved in 2010 in practice.
Is it require a different level of training for pharmacists, or do they already come equipped with the capabilities to carry out those functions? Those clinical functions are pretty standard across the pharmacy community and Is it in all levels of pharmacy or there are specialized levels of pharmacy where you carry out those functions or they need extra training and so forth?
Yeah, obviously you would need extra training either through an institutional training like residencies or clinical practice, or hands on training. I did my training with endocrinologists and worked to manage basic dosing and then moved on to pump dosing. This training actually helps you to confidently and efficiently Manage these patients basically under supervision and with specific guidelines.
Does that mean you work closely with diabetes nurses, nurse practitioners, or with endocrinologists? Is it a team based approach? Are you having to communicate back to the endocrinologist or Is there a centralized record that you work from?
Yeah, we actually work from the electronic medical records at centralized locations, working with social workers, care managers, diabetes, certified diabetes specialists, nurse practitioners and following up with the provider on our assessment and interventions. So all in all, the coordination of care is done through one platform of care management. This help everyone to be on the same page as to know the progress of the patients and what’s the status of his or her disease.
Amazing, It does seem to make a lot of sense. Indeed, it actually seems to be a positive move to have pharmacists take some of that workload. This helps you to get engaged with the patients a bit more and understand them because you know your call role, which is to help manage medication, understanding the clinical backdrop and these things equip you to help them manage their medications more effectively.
So this is the part that intrigues me. Believe it or not, we are able to see 100 diabetes patients a day, make insulin dose adjustments a few times a week and we do enough adjustments to get their A1Cs for and timing range under control within two months from lets say 10 to 8, or 14 to 10 in 2 to 3 months. Though we’re not doing any magic, we are just following these patients instead of putting the patients on 10 years of regiment. Likewise we continue seeing them again in six months. We do the dose adjustments so often such as three times a week, twice a week. so this intense dose adjustment gets you the guaranteed results. You get it under control, especially if the patient is compliant.
We also add the nutrition aspect in collaboration with diabetes educators to know What foods the patient has access to and what they can eat on the excess as part of their routine. We were able to spend time teaching the patients about insulin like what it is and how it works and taking them on insulin therapy. So this is something that we can help providers so that they can focus more on other diseases while we’re managing the diabetes party.
What does that look like to you? Is that you see patients in a clinic like face to face on a daily basis? do they come to you and sit in a room with you?
So we have experienced that for sure and we definitely prefer the patients to see them face to face for the first time. But due to COVID we have opted for virtual collaboration. However, we still prefer to see face to face if virtual call is not possible, then after a few virtual sittings or face to face ones, we go on to having phone calls reviewing their blood sugar levels, the current dosing, hyperglycemia symptoms, their trends (ups & down) and how the patient feels and adjusting medications or insulin on regular basis over the phone.
Are you helping them in managing their insulin, or are they actually patients across the full spectrum since their diagnosis?
We have combinations of new and old patients at the point of starting their insulin therapy and we have patients that have been on insulin but not maximally tolerated dose which is not beneficial for them. Besides, we also have patients with compliance issues so they need to follow up and encouragement. Basically, we help them to reduce their medications and insulin with exercise, routine, and nutrition management, and in some cases we actually take them off of instruments.
Just thinking about type 1 diabetics What are some of the bigger challenges that you face while helping them?
According to recent data from the United States each year we have about 40,000 new type 1 diabetes patients who get diagnosed. Likewise, type 1 diabetes among the pediatric population is also increasing, So, managing these patients is a challenge. Similarly, managing noncompliant patients who cannot follow the schedule due to certain reasons requires a lot of effort. So with those patients, we get more instances of hypoglycemia and urgent care visits, therefore we try to work with them on the best options of the insulin therapy management and their diet management, evaluating them for their eligibility for pump usage.
Do you guys prescribe pumps?
Yeah, as part of the program, we initiate the pumps and we recommend them to our patients if they qualify for it on the basis of certain criteria. We check whether they have previously been on insulin, do they have understanding about how to do the injections and their compliance status because they should have to be compliant to some extent. Then we recommend pumps to the patients including various pumps based on their needs and with the endocrinologist’s help. After that, we follow up on the programming and dose adjustments on the pump.
I would like to jump on the CGM stuff soon because I think that’s an area of your expertise and I’m really keen to hear from you about that. Just before we jump onto that tell us a bit more on the pumps like how many different pumps are available in the US at the moment?
Currently, we have Medtronic, OmniPod, Viggo and we have several other pumps too but the majority of patients use medtronic pumps. Either they get prescribed or they get referred to us, we have seen these three types of pumps used by our patients.
I have type 1 diabetes for the past 15 years odd years but currently I’m not on a pump. When I talked to people from pump companies, they all said that I should be on a pump. My HBA!C is around 6.9 and I’m not too unhappy with that at the moment. But like certainly the idea of a pump is in the back of my mind. And maybe eventually, I’ll get there when I can’t manage anymore and when it starts creeping up after doing all the things that I could do like manually injecting, So then I’ll opt for it. I would like to ask what’s your general view that when should people be looking at getting onto a pump?
We see the majority of pediatric patients getting on pumps just for the ease of getting less injections, especially in school. Like If they’re not home, the pump does the work for them. Many children and adults with type 1 are not able to manage their diabetes because of hypos, or other side effects. They’re not able to regularly follow insulin injection routines.Hence, they are the good candidates for pump. Now with this, you can program the pump like getting small doses per hour or half hour and they get a lot of benefits from the auto injection. This helps their A1Cs to get under control.
So do you initiate Pumps to adult patients?
Yes we do!
What kind of results are you seeing? Like, what’s the impact in general? What common things that you commonly experience in managing those adult patients on pumps?
Well, to be quite honest, we’re actually gathering the data right now to work on a study for us to see before and after using various pumps for the number of patients that we have. But what we see right now are several things; A1C improvement, patients being more compliant with insulin and its impact on being happier, better quality of life, less injections they have to deal with, and to get their desired results (with the help of a pump). So it gives that extra assistance especially if the patient is busy or in case of children, It gives them that extra help and motivation. Basically we have two things; A1C improvement and compliance that goes much higher with diabetes control.
Do we have enough real-world data for pumps and CGMs in terms of improvements in whatever measure we’re talking about, whether it’s A1Cs, time in range, etc. I mean, I know there would be randomized controlled trials available for example, for the libre or the medtronic or dexcom that shows an impact on A1Cs but do we have the real world data that can help to conclusively say that community data mirrors the findings of the randomized control trials and we will definitely see these improvements. Do we have that ability to look at real world data for pumps and or CGMs?
We have more data on reducing hospitalizations and emergency visits with CGM devices. So right now, there is no study or data available that could randomize the results and you could translate it to the whole population in the world to show reduction in hospitalization and about blood sugar improvement. But several randomized control trials on libre, dexcom and other CGMs show A1C improvement forsure, reducing the emergency care visits, improving the patient’s compliance. That’s the exciting part for so many CGM patients for being able to be compliant on their own for the first time.
Indeed, It’s really exciting to have such innovative tools at our fingertips and we are really lucky for that. In addition, the best part is having clinicians, pharmacists and other care providers to be integrated for patient care in an era when we have this technology and these tools available to help us manage it, So we feel quite lucky to better manage this disease.
Yeah, it’s definitely true. I was looking up some information like we got the first blood glucose test strips in 1908, first blood glucose monitor in 1970 and the first CGM In 1999 and it got modified and improved like now we have Medtronic, Libere, Dexcom. This is a revolutionary change that has come from the 30-40 years since we got our first glucose monitor. Fortunately, now we have different versions of CGMs available. I mean, we went from dexcom G4 to G7 which is coming soon, Libre to libere 2 and libre 3. So as you said, we’re in a lucky time as the technological advances have provided the patients with way more options to manage their disease and it’s no more a hassle for them.
Absolutely. I’m really keen to know I think it would be really useful for our listeners to get to know an unbiased perspective on CGM’s, as if the differences between each and the gamut of details across this CGM spectrum. We would like to know your perspective on the CGM’s and the pros and cons for each.
Yeah, We definitely see patients on libre, dexcom and medtronic. Also we have patients who transit between the two, and we also have seen patients from going back to libre from dexcom or vice versa. The aspect that excites me is the fact that it opens up the patient’s eyes to the technology that helps us to test 4 to 6 times every day for as long as 90 days, On the contrary, if you’ve been manually testing your blood sugar levels like every day, four times a day then it’s a big hassle. You cannot understand your trends, ups and downs. That’s the part that really excites me. The downside I see right now is it’s not approved yet in the United States for all patients. So they have to meet certain criteria to opt for it.
Yeah, it’s not cheap. Like I am on Libre and the Australian government reimburses for under 18 (not sure) and also for high risk patients like pregnancy. So 10 boxes of Libre cost me a few thousand dollars that I can use for 20 weeks so It’s definitely one of the big expenses that I have to bear.
Yeah, that’s definitely one of the unfortunate parts we see right now. I mean, we’re in a lucky time to have this technology but also unfortunate that everyone does not have access to it. But we have some of the patients on the health plan which covers their sensors and transmitters almost completely. However, the benefit of CGMs is much more like It brings a different life to these patients, And just like you said, it’s $1000 extra for you but I mean testing four times a day or six times a day is extremely inconvenient. As we move forward, I hope that CGMs become more affordable enough that everyone can get them.
When do you think we’ll see the full reimbursement for all patients for CGMs? When do you think we’ll see a broader reimbursement from insurers and governments for CGMs? When will the realization be there? Will it be when the cost comes down or when the huge impact will be seen on long term health care spending?
If you would have asked me this question two years ago, I would have said in the next 5-10 years, but I see in the last two years more health plans covering it in the United States. More health plans even provide full coverage for CGMs. So with the clinical trials data showing A1Cs improvement is a huge quality of life improvements. Also, it’s cost effective for the patients and hospitals. I think that this sense has started to develop and we expect to get more of such benefits for our benefits.
Yeah, it’s good that more and more data is mounting up which says that If we invest in these things now, there’ll be a benefit to society and in decreasing health care budget or resources.. This will make a difference as it will save a lot of money that can be redirected towards more preventative measures.
Exactly,this part really interests me and this is why I’m involved in diabetes care. Note that diabetes is preventable, fixable, and manageable. If you don’t have diabetes, you may be able to prevent it. If you have diabetes, it’s manageable and fixable. So the good news is that and the part that really excites the pharmacy is telling them that type one or type two diabetes is not the end of the world and you’re not dying, it’s very easy to fix. You just have to get used to a new schedule. You can control it whether with CGM, insulin, test strips, exercise or nutrition, it’s a disease that you can handle. You know it’s one of those diseases that you can actually get better as compared to hypertension, heart failure etc. that get worse as you age because of the associated organ damage.
It’s absolutely exciting. I believe that no one is closer to insulin than a patient and a pharmacist. What’s your opinion about the state of affairs around the fact that there are individuals out there who can’t afford healthcare, for insurance, insulin either sparing their insulin or they’re not getting insulin. And individuals are actually dying in a Western country because of an inability to afford. I mean, is this an accurate perspective that I’ve got in mind? Or am I misunderstanding it? Is it more due to the patients who are not able to manage it well? Or is it actually a real system issue that people cannot freely have better access to get insulin?
It’s definitely more on the system issue and affordability concern because It’s still expensive. Though, It’s still covered by many insurances, but it’s not as cheap as oral medications and it costs some co-pay for the patients. We have patients not being able to receive their insulin due to affordability issues. However, we’re seeing more assistant programs coming into play to help such patients that can’t afford their insulin. We are hoping to see more help and assistance coming to these patients in the near future.
How might insulin b’more accessible to people who have problems finances? I think you made a point about the causes that exist, and that’s great. But how do you think we get to a point on this? I know that in the US this problem cannot be fixed but I think we could probably do it in other parts of the world like sub sub Saharan Africa etc. So, how can you fix it elsewhere, like and What’s your view on it?
I mean, it’s getting better with time since I started managing the diabetic patients in the last five years. So, It has gotten much better than before. I believe that with more insulins in the market, more they will become generic and more competition will be there which will eventually decrease the prices. Hence, making them affordable for everyone. Same goes with CGM’s. I think we’re getting to a point that in the next few years we will have much less affordability problems for insulin and CGMs.
I’m really grateful to have you with us today and I’m really happy that we’ve had a perspective from a pharmacist on this interview series that we’re running, so thank you for your time. Before we wrap up, is there anything you wanna say about the work that you’re doing within your organization that you are working at?
I would like to say to our audience that diabetes is easily manageable. It is also easy to manage or control the A1Cs and blood sugar levels. It’s just a matter of focused attention on nutrition, exercise, and daily routine. I have seen patients managing their diabetes themselves with the help of the pharmacists, and health care providers. It’s a disease that has a huge hope for these patients, that they can stay under control for the rest of their lives. So do not worry about it.
The part that really excites me is the fact that It is a manageable disease that I’ve seen people participating in marathons. So I believe that it’s doable. You do not have to be scary about it; rather with focused management, with the help of the pharmacists and health care providers, we can manage it.
Yeah, I think that’s a really good message to end on, right? It’s not just a responsibility of a doctor, nurse or a pharmacist rather a patient’s own responsibility to self manage it. If you do not do it then it’s gonna be very hard for a health care provider to really support you. You know, I’m an advocate for personal responsibility when it comes to this, and there’s no shortage of really high performing individuals out there and professional athletes with type 1 diabetes, right? There are many bodily challenges that we have to face like your body’s reaction to exercise etc. But definitely, it’s not a scary disease and you can go out and do really whatever you wanna do from being an explorer to a professional football player. I mean, there aren’t any reasons to be held back.
Exactly, just just get the help and manage your routine.
Thanks Saro. It was awesome to chat with you. I really appreciate your time.
Thanks very much, Pete.