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0:01:37.850 --> 00:01:45.859Specific Interest Zoom Chair : hello! And welcome to this evening's Webinar safely navigating the management of type. 2 diabetes patients with the Glp. One Ia shortages.1900:01:45.900 --> 00:01:55.319Specific Interest Zoom Chair : You're with Dr. Gary Dee tonight, and my name is Claire Pearson, and i'm the education and Events officer for the specific interest faculty, and i'll be a host for this evening.2000:01:55.540 --> 00:01:59.329Specific Interest Zoom Chair : So just before we start this evening, where is my control panel.2100:01:59.980 --> 00:02:07.520Specific Interest Zoom Chair : So before we begin, i'll just go through a few housekeeping notes in this. So the webinar is being recorded, and it will be made available for you in the coming week2200:02:07.640 --> 00:02:24.230Specific Interest Zoom Chair : and to interact with us. You'll need to use the zoom control panel. So if you cannot see a panel like what is displayed on screen. Hover your cursor over the bottom section of the shared presentation screen, and the panel will appear, and we've got all attendees on mute tonight to ensure that learning will not be disrupted by background noise.2300:02:24.240 --> 00:02:35.290Specific Interest Zoom Chair : And as this is Webinar, we're unable to see you as participants, but you'll still get the chance to interact with your peers using the Q. And a box at the bottom of the screen, and we'll have a dedicated Q. And a. Session at the end of the Webinar.2400:02:35.910 --> 00:02:42.380Specific Interest Zoom Chair : So, introducing your Gp host for this evening, and and I might add, you get 2 Cpd points for tonight's activity.2500:02:42.980 --> 00:03:10.709Specific Interest Zoom Chair : So tonight your Gp host is Dr. Gary deed. So Dr. Gary Deed is a general practitioner with a passionate interest in promoting quality, patient care of diabetes in general practice through education, development of resources, including guidelines, policy, development, research and strategic collaboration. He is the current chair of the Diabetes Specific Interest group for the Rsc. Gp. And a ministerial appointment to the Commonwealth Diabetes Implementation Reference Group for Australia.2600:03:10.890 --> 00:03:26.809Specific Interest Zoom Chair : He is the editor for the general practice management of type 2 diabetes guideline for the Rsc. Gp. And he is an adjunct Senior Research Fellow of Monash University, and helps coordinate the Nh. Mrc. Funded starry statins in reducing events. In the elderly trial2700:03:26.820 --> 00:03:35.560Specific Interest Zoom Chair : he has published peer-reviewed journal articles in diabetes, and is an editor for diabetes therapy and adviser and editor of endocrinology, today.2800:03:35.590 --> 00:03:42.110Specific Interest Zoom Chair : so I will now pass on the presentation to Dr. Gary deed for the presentation tonight, and the acknowledgment of country.2900:03:43.930 --> 00:03:49.900Dr Gary Deed: Thank you, Claire. It's Gary deity and welcome to everyone coming up into this holiday season.3000:03:50.610 --> 00:03:56.879Dr Gary Deed: I do have to acknowledge the traditional owners of the Lancaster, where each of us are joining this Webinar. Today3100:03:57.140 --> 00:04:03.599Dr Gary Deed: i'm on turbul i'm. From where the turmoil people are in the Jaguar country.3200:04:03.870 --> 00:04:08.470Dr Gary Deed: I wish to pay my respects to their elders past present, and emerging.3300:04:13.080 --> 00:04:28.199Dr Gary Deed: Now i'm just going to share my screen, and we're going to go through this. Webinar and During the course of this Webinar, please ask through the Q. And a. Function any questions, and we'll hopefully about to answer those at the end as well.3400:04:28.620 --> 00:04:31.619Dr Gary Deed: And I really thank everyone for taking their time tonight.3500:04:34.260 --> 00:04:45.659Dr Gary Deed: So the agenda for tonight is around the G. L. P. One Receptor, Agnes shortage. And what are these issues A lot of people probably aren't across at all, but i'll try to give you an update as best I can.3600:04:45.710 --> 00:04:54.179Dr Gary Deed: and also that how do guidelines assist us in choosing some of the alternatives around these shortages.3700:04:54.410 --> 00:04:56.260Dr Gary Deed: You're going to do a case study.3800:04:56.820 --> 00:05:10.250Dr Gary Deed: and then we're also going to move through also about insulin, because I think it's important to think about that as part of the choices, and how general practice is really aligned to be able to make those choices, and then we'll summarize with the Q. And a. Session.3900:05:13.040 --> 00:05:24.869Dr Gary Deed: This is these are my disclosures. I work in a general practice, and I do clinical care as well as other activities, including educational activities and research.4000:05:24.880 --> 00:05:35.150Dr Gary Deed: And I don't have any conflicts of interest, particularly around the contents of this talk, although I've done educational development for most of those pharmaceutical companies listed.4100:05:37.250 --> 00:05:56.240Dr Gary Deed: Now glp one receptor, Agnes. hopefully in we'll talk a little bit about them. They're in in in injectable therapies. Used to help manage diabetes. This is a a hormone release from the intestinal cells. Once food is ingested.4200:05:56.250 --> 00:06:07.230Dr Gary Deed: and it goes from the intestine through the portal circulation to the pancreas, and stimulates inch on the release and suppresses Glucagon from the Alpha cells.4300:06:07.670 --> 00:06:17.760Dr Gary Deed: Thus it links food to glucose-dependent insulin release so that you get an equivalent Reduction of the glucose as it starts to absorb.4400:06:18.370 --> 00:06:24.140Dr Gary Deed: However, this hormone has other aspects of its action. It can then also circulate4500:06:24.410 --> 00:06:33.489Dr Gary Deed: either through general circulation or through Vegas nerve inputs and change some of the appetite centers in the in the4600:06:33.620 --> 00:06:41.759Dr Gary Deed: areas of the brain that control appetite, for instance. So They've been known to also be involved in management of obesity.4700:06:41.870 --> 00:06:45.209Dr Gary Deed: both not only with diabetes, but independent of diabetes.4800:06:46.190 --> 00:07:02.980Dr Gary Deed: so quite potent, injectable agents at the present time they've been altered, so that the the normal G Lp. One that you have in your body lasts a few minutes and broken down by Dpb: 4 enzymes that line the portal circulation, and also in the pancreas.4900:07:03.090 --> 00:07:14.899Dr Gary Deed: but because of alteration in the structure, these now G. L. P. One receptor that there are daily, but also now weekly. G. L. P. One receptors which have prolonged action because they are resistant to degradation.5000:07:15.650 --> 00:07:30.030Dr Gary Deed: The shortages really are focused around both classes, in fact. but the weekly G. L. P one receptor Agnes commonly known as semi-glutide one of which is used for diabetes called Osmpic as a trade name.5100:07:30.040 --> 00:07:37.779Dr Gary Deed: and there's also I hope they spot the right way. Jovi which is semi-gluty, which is used for obesity.5200:07:37.960 --> 00:07:48.630Dr Gary Deed: they are not the same. They are the same chemical, but they are not the same device and the same dosages. Why, Jovi has not been released here in Australia, so there's no stock available.5300:07:48.790 --> 00:08:01.260Dr Gary Deed: semi-glutite as in the diabetes, so zempic because of international shortages there will be no stock until at least April 2,023. At this present time it may change, but we doubt it.5400:08:02.220 --> 00:08:16.239Dr Gary Deed: The alternative. One is Dula glutide which is a weekly injectable, called trilicity, and there is variable stock availability, and we expect that also to be a problem right into early 2,023 as well.5500:08:16.250 --> 00:08:30.529Dr Gary Deed: So basically if you're being using the weekly gop. One recept, Agnes the availability is about zilch at the present time, both for diabetes, but also, if it's been off label used in in obesity. There's also not the availability.5600:08:31.200 --> 00:08:48.389Dr Gary Deed: So there are the older Daily. G. L. P. One receptor, Agnes, some there's lyraglotide which is with diabetes. It's called Viktosa. it's a trade name. It is still available, but it's remember it's non-pbs, and can be quite expensive as a daily injection. So if you're trying to switch from5700:08:48.400 --> 00:08:55.219Dr Gary Deed: duller glue tide, semi-guly tied to leraglotide patients may not be able to afford it5800:08:55.640 --> 00:09:05.690Dr Gary Deed: there's also sack centre which is in a different injective device, and also different dosage is used for obesity. It is still available, but also it's non-pbs.5900:09:06.740 --> 00:09:13.079Dr Gary Deed: Unfortunately, the twice daily Bioter was Xenotide6000:09:15.320 --> 00:09:20.789Dr Gary Deed: going to be withdrawn from the market So it's actually not a clinical choice that we should be utilizing.6100:09:23.950 --> 00:09:32.969Dr Gary Deed: Let's go to these characteristics of these G. L. P. One with Sept. Agnes. So then, if we know the characteristics, we can then make sensible choices as we move through alternatives.6200:09:33.480 --> 00:09:35.750Dr Gary Deed: we another injectable once weekly.6300:09:35.950 --> 00:09:53.200Dr Gary Deed: The only other injectable currently for diabetes. Outside of this class, of course, is insulin, which there's no weekly injectable insulin. In fact, there's daily and also multiple daily injections of different types, the dally, of course, as we call basal insulin.6400:09:53.210 --> 00:10:05.230Dr Gary Deed: and the multiple daily ones come as either meal time insulin or combined, in some with basil and meal time insulin combined, called Premix or co-formulated insulin6500:10:06.100 --> 00:10:19.429Dr Gary Deed: back to the weekly Gel P. One recept Agnes they're either a single use. One dose device, which is a jeweler glue tide trilicity by name, or the tight tradable multi-use device, which is semi-glotide by osmpic6600:10:20.410 --> 00:10:28.960Dr Gary Deed: as I mentioned, the other G. L. P. One Receptorgnus, a daily lyraglatide, or twice stalling Xenoty, but that's not no longer available. Their acclatide remains6700:10:29.680 --> 00:10:44.789Dr Gary Deed: characteristically they've got actually quite potent hemoglobin a one C lowering not a lot of head to head studies, but there are head-to-head studies against, for instance, the Dp. Before class, and they certainly are more potent in hemoglobin, a one, c. Lorry6800:10:44.810 --> 00:10:54.289Dr Gary Deed: again, dependent on starting hemoglobin a one, c. And they do have a low risk of hypoglycemia unless they're used with sulfon areas or insulin which increases that risk6900:10:55.100 --> 00:10:58.930Dr Gary Deed: when combined with metformin. There is a very low risk of hypoglycemia7000:10:59.710 --> 00:11:18.920Dr Gary Deed: of course I mentioned about the aspects of acting on a central nervous system. control centers for appetite and weight management. They also slow gastric empting so nausea, even vomiting another g gastron. Tesl upsets are a risk, and can be significant in some patients.7100:11:19.460 --> 00:11:31.800Dr Gary Deed: Very rarely. are we concerned about gallbladder and Pancreas Titus issues with this class, so one would be just cautious if there is a history of uncontrolled gallbladder disease, and certainly pancreas7200:11:32.740 --> 00:11:44.790Dr Gary Deed: very notably. They are synergistic with insulin, and can help what we call insulin dose sparing that is, they can reduce the need for higher dose Eventually, when combined with insulin.7300:11:47.410 --> 00:11:57.469Dr Gary Deed: But very importantly, there are Pbs prescribing issues which do not apply to the alternatives in that you're going to be thinking about in class.7400:11:58.250 --> 00:12:12.209Dr Gary Deed: but I want to just say to you that the Tda rules for all Australian College of General Practitioners and the Strand Diabetes Society advise you not to initiate any new prescriptions of the weekly G. L. P. One receptor agents of this stage7500:12:12.230 --> 00:12:22.310Dr Gary Deed: there's no stock available, and it'll end up causing patient grief and also problems with the mansion of their diabetes. So we need to seek alternatives.7600:12:23.630 --> 00:12:47.799Dr Gary Deed: Remember going back to the Gop one Sept. Agnes, particularly the weekly ones, have restricted Pbs Axis access, and they were initially and were clearly to be combined with met form and all, and or a softened area unless the cell phone area was contradicated. So it's a little bit restricted in the fact that we couldn't combine, for instance, then with the Dpp 4 inhibitor7700:12:48.300 --> 00:13:04.310Dr Gary Deed: on the Pbs. Or the S. L. T. 2 inhibitor, the D. P. 4, because of the contradication they're working on the same pathways, and then S. L. T. 2 receptor Sorry. St. L. T. 2 inhibitors, because the Pbs. Did not subsidize that funding.7800:13:04.870 --> 00:13:05.470Okay.7900:13:05.610 --> 00:13:12.139Dr Gary Deed: they can can be combined with insulin. But you must be using netform and an insulin with the G. Lp. One or Sept. Agnes, when you are using them.8000:13:12.410 --> 00:13:19.950Dr Gary Deed: But as I mentioned, the alternative choices may not have as much restriction in the Pbs access and combinations that are available.8100:13:22.300 --> 00:13:28.540Dr Gary Deed: So what are the decision makings If the G Lp. One recept records are not available.8200:13:29.190 --> 00:13:39.019Dr Gary Deed: Review your patients. You know. What what you need to do is, you know, use it as an opportunity to audit those Prescribe the Glp. One recept, Agnes, it's a plan. Do see, act.8300:13:39.100 --> 00:13:42.000Dr Gary Deed: process don't just necessarily. Just leave it.8400:13:42.280 --> 00:13:48.139Dr Gary Deed: You might want to go through your database and see who is prescribed, and if they need some help to look at alternatives8500:13:49.370 --> 00:13:54.219Dr Gary Deed: just stopping the glp. One receptor. This may not be the optimal thing to do.8600:13:54.330 --> 00:14:03.129Dr Gary Deed: but sometimes patients. Some are at goal, and you know deprescribing is part of that. But most patients probably need advice on lifestyle and weight management.8700:14:03.830 --> 00:14:13.609Dr Gary Deed: and also look at adherence and assess clinical parameters, and a one, c. As it recently done. All of those things just are really good to do. A clinical review.8800:14:14.940 --> 00:14:28.180Dr Gary Deed: You know what other additional weight management support can be provided for the patient Do they need a team care, plan to help them assist the the whole process Again, I think that's important, and think about a Dietitian, and certainly a credential diabetes. Educator.8900:14:28.850 --> 00:14:36.020Dr Gary Deed: I emphasize again. Do not initiate any new prescribing of the weekly glp one. Accept, Agnes until further notice9000:14:36.690 --> 00:14:45.230Dr Gary Deed: and replacement options, you know, are there because it's a. G. Lp. One for a subtract. This may not be available for some months.9100:14:49.550 --> 00:14:57.760Dr Gary Deed: so i'm going to go back to some clinical guidelines that will help you. understand what sort of choices we have.9200:15:00.220 --> 00:15:09.349Dr Gary Deed: This is the Australian type, 2 diabetes Glycemic management. Algorithm it's available on the Rcgp website, and also from the Australian Diabetes Society9300:15:09.600 --> 00:15:17.980Dr Gary Deed: and really whack bang at the start of it. It's about looking at weight, loss, and often that's why we use the glp. One receptor, Agnes, to help assist9400:15:22.440 --> 00:15:25.319Dr Gary Deed: in the chat function. You'll see a link to that.9500:15:25.340 --> 00:15:43.629Dr Gary Deed: However, when we move through to beyond lifestyle and weight management focus we look at choices, and of course, metformin is a conditionally recommended. First choice, let's say soft on areas. Insulin is available for very severely decompensated diabetes with elevated9600:15:43.640 --> 00:15:58.659Dr Gary Deed: glycaemia and metabolic compromise but certainly the other agents are less commonly used, or are not Pbs subsidized only archibos, as Pbs reimburse for monotherapy, and not very commonly used due to side effects on the gut9700:15:59.540 --> 00:16:15.880Dr Gary Deed: then beyond mid-formant you can see the G. L. P. One receptacles were a recommendation for the addition to metformin, but, in fact, the Sgl t 2 inhibitors, as oral therapy, are considered to be one of the first choices to add to met Forman as you progress through.9800:16:16.020 --> 00:16:32.919Dr Gary Deed: and if you were on a. G. L. P. One recept Agnes, and adhering to the Pbs. Maybe you weren't using a Sgl. T. 2 inhibitor because of the restrictions. So now so time to think that the S. L. T. 2 inhibitors the Green Dots suggest they're highly recommended for many reasons which i'll get to in a moment9900:16:32.930 --> 00:16:36.139Dr Gary Deed: might be another choice. Your first choice to consider10000:16:36.260 --> 00:16:46.519Dr Gary Deed: sending the D. P. 4 inhibitors as an oral therapy can be also added to met formant, or even later on as a combination with the S. L. T. 2 inhibitors met forming together.10100:16:46.710 --> 00:16:49.130Dr Gary Deed: or even with cellphon. Here is, etc.10200:16:50.110 --> 00:17:01.979Dr Gary Deed: Normally we reserve the Sulfon arrears carefully for patients, because there's a conditional recommendation against the use, because they are a risk of severe hypoglycemia. When you utilize those10300:17:02.480 --> 00:17:15.580Dr Gary Deed: insulin is available there's no recommendation for or against insulin in the current guidelines, and it requires a bit of skill and a lot of up regulation around education. We'll get to that later in the talk.10400:17:15.619 --> 00:17:17.890Dr Gary Deed: as I mentioned metforman.10500:17:18.089 --> 00:17:21.840Dr Gary Deed: probably conditionally recommended S. Lt. 2. Certainly10600:17:21.859 --> 00:17:25.859Dr Gary Deed: our Dpp. Force possibly issues10700:17:25.960 --> 00:17:35.760Dr Gary Deed: think about it. But then the combination. Beyond that, if you've got a met form, an Sgl. T 2, and the next combination may be a. D. P. 4 inhibitor before moving on to inchland.10800:17:39.990 --> 00:17:52.280Dr Gary Deed: This is Just try to explain the living evidence and diabetes guidelines which allocates those dots that I mentioned a little bit before.10900:17:52.620 --> 00:18:02.789Dr Gary Deed: So metformin is considered the first line monotherapy, particularly if the patient has cardiovascular disease existing, or multiple cardiovascular risk factors11000:18:03.200 --> 00:18:23.019Dr Gary Deed: and or kidney disease, or a combination of those risk factors, Some, considered at high risk, are men aged over 55 women over 60, with diabetes, but also other factors, such as high blood pressure, dyslemodemia, or smoking. So there's a lot of patients where this preferred left-hand column is the way to go.11100:18:23.670 --> 00:18:38.959Dr Gary Deed: You consider an s G L. T 2 inhibitor as the first combination. If the a. G. L. P. One receptor actness is not being used, but also I just want to go back to these guidelines. So you actually recommend the S. G. L. T. 2 should be considered with metform, and11200:18:39.190 --> 00:18:46.879Dr Gary Deed: added, You should have added a glp, one receptor, and if the Sglt 2 inhibitor was contrindicated or not tolerated.11300:18:46.960 --> 00:18:47.860Dr Gary Deed: interesting.11400:18:48.260 --> 00:18:58.109Dr Gary Deed: And then, if the Glp, one receptor, Agnes and the Sgt. 2 are not tolerated or contradicated, then you'd consider a Dpp forward meant form.11500:18:59.380 --> 00:19:06.189Dr Gary Deed: If the patient did not have any cardiovascular disease, do not have those multiple risk factors which are listed on the slide11600:19:06.290 --> 00:19:15.229Dr Gary Deed: and or kidney disease, and was unable to achieve goals for the glycaemia. You could have added each of those agents, including the injectable G Lp. One of subdirectness.11700:19:15.250 --> 00:19:23.989Dr Gary Deed: They don't highlight one or the other. There, again, the issues are in the living evidence, natural national health and research.11800:19:26.860 --> 00:19:32.789Dr Gary Deed: Council Recommendations not to consider an S. Lt. 2 as first choice, because of the risk of11900:19:32.850 --> 00:19:36.059Dr Gary Deed: of severe hypoglycemia.12000:19:38.490 --> 00:19:39.350Dr Gary Deed: So12100:19:40.260 --> 00:19:42.280Dr Gary Deed: let's talk about what we're going to do12200:19:42.400 --> 00:19:52.359Dr Gary Deed: based on those guidelines. We're going to maximize our all therapy if we've looked at lifestyle and physical activity and and dietary approaches, and had our good team-based support.12300:19:53.100 --> 00:19:57.950Dr Gary Deed: But we also need to adjust doses, for, according to our clinical assessment of each patient.12400:19:58.430 --> 00:20:07.869Dr Gary Deed: go back and look at that form, and if appropriate to renal function that you can do an optimal as 2 grams of the Xrad. If they're not on that, maybe you need to up regulate that at this stage12500:20:07.980 --> 00:20:13.890Dr Gary Deed: you may have to reduce it. If there's a falling renal function, especially below I'm. 60, and certainly below 30.12600:20:15.280 --> 00:20:28.759Dr Gary Deed: Think about the Sgl. T. 2 class, and remember that ambergly flows and has 2 doses available, 10 milligrams, but you can increase it to 25 milligrams if they are not a target. So you got that little bit of dose variability there.12700:20:28.810 --> 00:20:32.220Dr Gary Deed: Dapper glide flows in the sea. Alternative only has a single dose12800:20:33.520 --> 00:20:39.149Dr Gary Deed: remember fixed those combinations. I'm going to unpack this a little bit really do help patients.12900:20:39.650 --> 00:20:48.279Dr Gary Deed: Remember that. When you combine Sgl. T. 2 S. And particular D. P. 4 inhibitors together, such as empogly flows in the Lineaglypton13000:20:48.390 --> 00:20:52.980Dr Gary Deed: or dappoglow flows, and and saxophone, for instance.13100:20:52.990 --> 00:21:09.160Dr Gary Deed: you get a greater hemoglobin, a one c. lowering than each used individually as soul therapy. So there's a bit of patch there, but also I mean it promotes Adherence is less patient medication less cost.13200:21:11.440 --> 00:21:29.859Dr Gary Deed: So this unpacked fish fixed those combinations, and often overlooked, which is a real problem in our Perhaps I saw a patient today. Even I was prescribing it, and I needed to go back and actually update because this man was on, and Linda Lipton and Emperor like Flosen, and I hadn't thought of it. So it's a really good reminder as part of this process13300:21:30.540 --> 00:21:34.850Dr Gary Deed: as said, improves adherence, convenience, and cost-saving13400:21:35.380 --> 00:21:39.280Dr Gary Deed: so you can have an sglt 2 with met Forman to reduce13500:21:39.450 --> 00:21:40.680Dr Gary Deed: the Pilgrim.13600:21:40.800 --> 00:21:51.069Dr Gary Deed: hempic, Glyphos and Macforman Jard Emmett, dap a glowflow in a met form called zig-juo, and the alternative sgl t 2 there's a very good flows in, and Netflix13700:21:51.300 --> 00:21:53.500Dr Gary Deed: say, blue room it.13800:21:55.590 --> 00:22:06.200Dr Gary Deed: But then there's also S. G. L. T, 2 s and D. D. P. Fours combined, so you can work out which is the most efficient for the patient, ambergly flows and l and gript and complexambi13900:22:06.310 --> 00:22:14.840Dr Gary Deed: dappa glyphos in a sex Eglypton called Q-turn and Herticola flows in the city. Clipping cords are staggered. It's deadly, Jan.14000:22:16.020 --> 00:22:30.960Dr Gary Deed: and down the bottom is D. P. 4 inhibitors and matteform and combination. So you see there's all these choices. Lineage Lipton in met foreman, called Trigentovit Saxolypt, in a met forming called comic lies and citiglipt in a met form could genuine14100:22:31.650 --> 00:22:47.830Dr Gary Deed: so as you're moving through. Remember, I said, you know, maybe met Forman. I had an S. G. L. T. 2 of the G. L. P. One receptac. It's no longer available, and then you can move to an additional Dp. 4 inhibitor, so you can pick and choose between these how you can combine those often when you get to triple therapy, for instance.14200:22:50.550 --> 00:23:01.950Dr Gary Deed: So this is to show you so you can do, an S. G. L t 2 with the D. P. 4, and add met formin as a separate tablet or s shel t 2, and met formin, and add a D. P. 4 as a separate table.14300:23:02.300 --> 00:23:12.899Dr Gary Deed: or you can do a. D. Pv. 4 in met form, and an S. L. T. 2 is September, so i'm just trying to help you. It's a really good reminder of the flexibility that fixed dose combinations allow you.14400:23:14.970 --> 00:23:17.989Dr Gary Deed: However, when you're making a choice, you14500:23:18.280 --> 00:23:20.439Dr Gary Deed: going back to those guidelines.14600:23:20.580 --> 00:23:29.499Dr Gary Deed: it's not just making a choice based on random things. It's based on guidelines. And now we're not just talking about glycemic14700:23:29.540 --> 00:23:47.369Dr Gary Deed: efficacy. But some of those choices were labeled because there there are non glycemic benefits. When are choosing, going back to that living evidence Guideline those patients with cardiovascular disease, those with cardiovascular risk factors existing heartfare and or chronic kidney disease.14800:23:47.420 --> 00:23:50.299Dr Gary Deed: Some of the agents have additional benefits.14900:23:50.850 --> 00:24:01.059Dr Gary Deed: so the S. L. T. 2 S. Are indicated for diabetes, but also for the non glycemic benefits in hardfare, with reduced ejection, fraction.15000:24:01.220 --> 00:24:05.559Dr Gary Deed: or progenureic chronic kidney disease. So15100:24:05.650 --> 00:24:14.890Dr Gary Deed: that's why this darker the heavier lines are showing. Probably our preferred choices when choosing when the glp one is not available, go back to the Sglt.15200:24:14.950 --> 00:24:20.940Dr Gary Deed: remember the combination with met formative, appropriate, or a. D. P. 4 inhibitor, if appropriate.15300:24:21.640 --> 00:24:30.230Dr Gary Deed: make sure maximize the dose, remember implied flows, and as the 2 doses range 10 milligrams, 25. Look at the met form and dose and optimize that.15400:24:30.760 --> 00:24:39.819Dr Gary Deed: But also remember that there's additional indications that some people with heart failure without diabetes can also get an Sglt. 2 inhibitor15500:24:39.950 --> 00:24:51.230Dr Gary Deed: and people with chronic kidney disease without diabetes are also able to get. dappigly flows in the current time. So it's really interesting. So these are challenging our paradigms.15600:24:51.840 --> 00:24:59.180Dr Gary Deed: We know the dp before inhibitors have cardiovascular safety. There is a concern, though, with saxophone and a risk of heart failure.15700:24:59.270 --> 00:25:08.999Dr Gary Deed: So when you're choosing fixed those combinations is that an issue I think it's something to think about. the sulfur sulfon. You have no clear cardiovascular benefit.15800:25:09.180 --> 00:25:11.910Dr Gary Deed: There is a risk of hypoglycemia and weight gain.15900:25:12.130 --> 00:25:15.819Dr Gary Deed: So that's why greened those preferred16000:25:16.070 --> 00:25:20.660Dr Gary Deed: thought Bubbles, in joining and making combinations available.16100:25:22.920 --> 00:25:35.289Dr Gary Deed: Everyone asks what about renal impairments So these are direct quotes from the Tga I haven't altered them, and of course they've got the trade names, unfortunately. But this is directly from the product. Information16200:25:35.660 --> 00:25:38.749Dr Gary Deed: with Amberg life flows and a patient with renal impairment.16300:25:39.270 --> 00:25:43.359Dr Gary Deed: Please assess renal function prior to initiation, and periodically16400:25:44.270 --> 00:25:56.250Dr Gary Deed: for Glycemic control and notice that it is also for the prevention of cardiovascular depth is one indication that's the unique to ampag by Flosen. That embalo flows in is contrindicated16500:25:56.370 --> 00:26:02.460Dr Gary Deed: for diabetes glucose management. If the Egfr drops below 3016600:26:03.310 --> 00:26:06.280Dr Gary Deed: but you don't have to dose adjust if patients are above them.16700:26:06.420 --> 00:26:08.539Dr Gary Deed: But if you're treating for heart for you.16800:26:09.830 --> 00:26:16.610Dr Gary Deed: you can commence, or it's recommended. If the Egfr is above 20, it's a different cut off.16900:26:17.300 --> 00:26:24.609Dr Gary Deed: All right. So just remember 30 for diabetes alone for Glycaemia. But for the heart fail you can go a bit lower.17000:26:24.990 --> 00:26:26.000Dr Gary Deed: Okay.17100:26:26.870 --> 00:26:32.920Dr Gary Deed: Dapogly flows in no dose. Adjustment is required based on renal functions. 10 milligrams a day17200:26:33.210 --> 00:26:41.939Dr Gary Deed: but one would be cautious in initiating dappogy inflation in patients with E. G. Far less than 25.17300:26:42.400 --> 00:26:46.500Dr Gary Deed: However, when you're treating just for glucose lowering17400:26:46.650 --> 00:26:54.199Dr Gary Deed: duplicate flows in efficacy, falls when the Egf. Is below 45, as mentioned there.17500:26:54.490 --> 00:27:10.590Dr Gary Deed: Therefore, if the 2 far falls below 45, you may need additional glucose, lowering treatment. When you're treating people with diabetes, if you're treating for heart failure or chronic kidney disease that cut off does not necessarily apply. You can do it down to an eigenfunction of 2517600:27:11.140 --> 00:27:12.760Dr Gary Deed: hope that makes sense.17700:27:16.200 --> 00:27:22.370Dr Gary Deed: I wanted to bring you up to date with a recently published guideline in the Medical Journal of Australia. The consensus17800:27:22.390 --> 00:27:30.690Dr Gary Deed: on the Pharmacological prevention management of heart failure just released by my friend and colleague, Andrew Sindoni at Tel.17900:27:31.120 --> 00:27:39.559Dr Gary Deed: And you notice that there are now 4 pillars for the chronic control of heart failure with reduced ejection fraction.18000:27:40.100 --> 00:27:51.410Dr Gary Deed: So the standards of therapy have moved on, and now include what was traditionally a diabetes medication, but is now also considered a heart failure medication.18100:27:51.470 --> 00:27:57.510Dr Gary Deed: and also considered chronic kidney disease medication which the Sglt. To inhibit. A class.18200:27:58.390 --> 00:28:09.079Dr Gary Deed: If you're congested, you'd start with the ace inhibitor and an Sgl. T. 2 inhibitor or an arnie ace inhibitor combination, and an Sgl. T to inhibitor.18300:28:09.400 --> 00:28:14.529Dr Gary Deed: Then, considerating something to expire on a lactone.18400:28:14.840 --> 00:28:21.119Dr Gary Deed: Then you might add a beta blocker. Once the fluid overload is managed nuptitrate doses.18500:28:21.320 --> 00:28:22.719Dr Gary Deed: But if your patients18600:28:22.880 --> 00:28:24.580Dr Gary Deed: not congested.18700:28:24.670 --> 00:28:28.130Dr Gary Deed: you may start with the arnie ace inhibitor and a beta blocker.18800:28:28.290 --> 00:28:31.160Dr Gary Deed: but then you would add18900:28:31.210 --> 00:28:32.840Dr Gary Deed: the mineral log19000:28:34.830 --> 00:28:42.379Dr Gary Deed: the spir on a lactone class, and an S. L. T. 2 inhibitor, so you can notice the 4 of them are used. So don't forget19100:28:42.740 --> 00:28:49.589Dr Gary Deed: people. Diabetes, of course, get heartfare as well. I just wanted to mention about these non-glycemic extra benefits.19200:28:52.800 --> 00:28:58.959Dr Gary Deed: and I notice some in the chat function. You're getting the links to those and clears, being very active in putting those through.19300:28:59.560 --> 00:29:02.359Dr Gary Deed: so have a look in the chat function and download those links.19400:29:02.930 --> 00:29:04.429Dr Gary Deed: Let's do a case study.19500:29:04.700 --> 00:29:22.500Dr Gary Deed: I think it's important that we put it into clinical practice. Angela looks very similar to patient mind 62 year old. although that's not a real image. teacher wants a nozambic script repeat. So she came in, said, Where's my olympic well sad type, 2 diabetes. For 11 years19600:29:22.510 --> 00:29:29.150Dr Gary Deed: I had past gestational diabetes. You know that it's a great linkage to developing diabetes never smoked.19700:29:29.370 --> 00:29:36.319Dr Gary Deed: She, of course, unfortunately, has the multi morbidity of hyper epidemi hypertension that clusters with diabetes.19800:29:36.470 --> 00:29:41.309Dr Gary Deed: But at this present time has no established cardiovascular disease. That you're aware of19900:29:41.740 --> 00:29:53.889Dr Gary Deed: hemoglobin a one, C has risen. because of intermittent use with and supply of of the G Lp: one receptorganis from 7 point, one to 7.8% in the old units20000:29:54.470 --> 00:30:04.020Dr Gary Deed: the current therapy is met, forming at maximum dose of 2 grams, a Sulfon area, glycoside at 60 milligrams once a day20100:30:04.090 --> 00:30:09.549Dr Gary Deed: the Assembly, as I mentioned, and also blood pressure, medication and step and use20200:30:09.580 --> 00:30:16.189Dr Gary Deed: I pressure a piece of target. But she's obese, nothing to be found on cardiac and respiratory examination.20300:30:16.510 --> 00:30:18.649Dr Gary Deed: Passing glucose is elevated.20400:30:18.880 --> 00:30:24.889Dr Gary Deed: Total cholesterol. An Ldl target is probably not a target. So you worry about adherence.20500:30:24.960 --> 00:30:38.899Dr Gary Deed: for this lady or you need dose adjustment on that. a reservoir statin because their Ldl targets probably could be below 2 for this lady. If you develop cardiovascular disease, we want to go certainly below 1.8 or even lower20600:30:39.370 --> 00:30:41.420Dr Gary Deed: triglycerides are slightly elevated.20700:30:42.560 --> 00:30:53.339Dr Gary Deed: She has some some protein area, and C. K. Dis, so C. K. D. 3 B. Egfr is slightly lowered as well.20800:30:53.760 --> 00:31:06.189Dr Gary Deed: So you know what i'm going to ask you. Here is you know. What are the questions you do for a patient like that. See, she's on semoglutite. She can't now get it. Her glucose is not a target.20900:31:06.460 --> 00:31:08.249Dr Gary Deed: Cholesterol is not a target.21000:31:08.610 --> 00:31:13.110Dr Gary Deed: How do we maximize benefits and minimize risk21100:31:13.340 --> 00:31:23.670Dr Gary Deed: noting that, you know. At 62 she probably has elevated cardiovascular risks, despite having no existent disease. So she's got multiple cardiovascular risk factors.21200:31:24.300 --> 00:31:33.350Dr Gary Deed: all right. So when you go back to those choices, remember that multiple cardiovascular risk factors, there's very clear diagram of choices. And21300:31:33.570 --> 00:31:51.550Dr Gary Deed: so we'll come back to that in a moment about you know. What would you do for this woman So you have to think what a Angela's personal concerns, you know. Does she understand a diabetes Does she have a concern about died Is it weight that her really big concern is about And that's why she was on the glp. One receptor, agnist.21400:31:52.240 --> 00:31:55.369Dr Gary Deed: Are there any risks of just doing nothing21500:31:55.860 --> 00:32:11.309Dr Gary Deed: Well, I was thinking medicine inertia is a problem. But but maybe doing nothing is maybe not the best option for this one. Certainly about lifestyle, cause you like to. You always go back to that. Make sure she understands adherence and persistence with medication.21600:32:12.080 --> 00:32:19.330Dr Gary Deed: It would a really good time to have a look at her for any existent or or continuing complications that may have arisen.21700:32:20.470 --> 00:32:32.059Dr Gary Deed: Get our eyes checked, you know. Consider looking at the feet again, don't forget about those things. Assessing renal function is not just during Egf, as I mentioned in there. There's also album anduri which we checked.21800:32:32.310 --> 00:32:42.670Dr Gary Deed: If you've got Alpine and area, it's important to repeat the test, because sometimes they are variable just to make sure it's a persistent album in your renal impairment.21900:32:42.920 --> 00:32:45.969Dr Gary Deed: and also checking your far as well.22000:32:46.350 --> 00:32:51.869Dr Gary Deed: So if you had one abnormal album, and you may want to repeat that within a space of about 3 months22100:32:52.110 --> 00:32:54.220Dr Gary Deed: this was repeated. Host was abnormal.22200:32:54.500 --> 00:32:56.030Dr Gary Deed: so she's already got22300:32:56.660 --> 00:32:58.340Dr Gary Deed: chronic kidney disease.22400:32:58.500 --> 00:33:01.759Dr Gary Deed: She's already got multiple cardiovascular risk factors.22500:33:02.060 --> 00:33:08.319Dr Gary Deed: We already know that chronic kidney disease increases cardiovascular disease and the risks.22600:33:08.530 --> 00:33:09.430Dr Gary Deed: So22700:33:09.620 --> 00:33:22.420Dr Gary Deed: her diabetes is important and the glucose is important because of the glycemic effects on retinopathy, for instance, peripheral neuropathy amongst other things. But what about a cardiovascular risk and a renal risk22800:33:22.900 --> 00:33:32.599Dr Gary Deed: So what sort of key questions. Are you going to ask yourself when you're going to say this is the alternative pathway we're going to choose.22900:33:33.310 --> 00:33:41.410Dr Gary Deed: I do want to mention that Don't forget about sick day management guidelines which are in our handbook. When you're choosing any therapy.23000:33:41.420 --> 00:33:57.979Dr Gary Deed: it's not just giving the script to the patient is forward thinking about what if the patient gets to diarrhoea or vomiting patients travelling overseas Sick day, mentoring guidelines are in the front page of the introduction on the website to the type 2 diabetes guidelines for the23100:33:58.270 --> 00:34:07.960Dr Gary Deed: If we're going to do S. G. L. T. 2 inhibits, we'll come back to that in a moment about per-operative guidelines. But we're going to go to the Q. And a. We want to see what people would choose23200:34:13.580 --> 00:34:15.309Dr Gary Deed: going to move on.23300:34:15.429 --> 00:34:18.260Dr Gary Deed: So those are all therapies.23400:34:18.870 --> 00:34:22.180Dr Gary Deed: Good choices available for patients23500:34:22.500 --> 00:34:27.719Dr Gary Deed: fix Those combinations are available to help reduce pill burden and improve adherence.23600:34:28.120 --> 00:34:31.850Dr Gary Deed: I'm thinking about maximizing dose of oral therapies.23700:34:31.949 --> 00:34:38.390Dr Gary Deed: combining with lifestyle and and dietary change, may actually improve a patient quite well.23800:34:38.620 --> 00:34:57.530Dr Gary Deed: But, as I said that G. L. P. One recept Agnes Weekly dosages were quite potent in hemoglobin, a one, c. Lowering so removal of those doses. We do have some patients where the Glycemic management becomes dysregulated. And and this is why I want to talk about the need for insulin in some patients.23900:34:58.840 --> 00:35:03.409Dr Gary Deed: Remember that our fasting, glucose, and post pride of glucose do contribute to24000:35:03.830 --> 00:35:05.510Dr Gary Deed: hemoglobin a one, c.24100:35:05.800 --> 00:35:25.549Dr Gary Deed: We know that the fasting, glucose component is very important. with elevated glucose hemoglobin a one c's and as we get lower hemoglobin, a one, c. Still above target. The post-prandal glucose is is also contributing so it's a combination of both depending on the hemoglobin a one, c.24200:35:29.680 --> 00:35:46.660Dr Gary Deed: So if you're going to make a decision about the G. O. P. One or se darkness, some of you may think the insulin is a considered choice because triple oral therapy. There people aren't at goal, and there's no way that person stays a goal. I mean the a. One, C might rise to 8 point, 5 to 9%,24300:35:46.670 --> 00:35:56.740Dr Gary Deed: despite oral choices, to be unusual. But it is possible, so you should consider that insulin is possible to be commenced, and it is able to be done in general practice.24400:35:57.490 --> 00:36:08.699Dr Gary Deed: Remember that when you choose the insulin, it should be added to the oral therapies, where tolerated, especially when there are above hemoglobin a one, C targets. Anyway, you do it's not to replace all oral therapies. Initially.24500:36:09.340 --> 00:36:21.890Dr Gary Deed: We're going to start a dose. We're going to talk about starting either a basal insulin or probably a co-formulated insulin in a moment, the normal studying days for both would be about 10 units per day.24600:36:22.710 --> 00:36:29.729Dr Gary Deed: especially if they're symptomatic. But if they're highly centered, it can go to 10 to 15 or higher, maybe even 20 units, if they're highly symptomatic.24700:36:30.810 --> 00:36:41.129Dr Gary Deed: But remember the most effective dice for their glucose mans is never usually this dose, and they need to be tightrated and you need to teach them about self-guard glucose, monitoring24800:36:41.430 --> 00:36:43.899Dr Gary Deed: to know learn how to adjust the dose.24900:36:45.370 --> 00:36:53.140Dr Gary Deed: I wanted to bring you up to date this is from the very recently released, a European25000:36:53.210 --> 00:37:01.739Dr Gary Deed: association with the study of diabetes and the American Diabetes Association consensus statement on the management of diabetes. But the place of insulin.25100:37:03.670 --> 00:37:04.600Dr Gary Deed: So25200:37:04.720 --> 00:37:12.009Dr Gary Deed: they, of course, said, oh, if a glp, one receptor Agnes, is available, consider that as a first injectable.25300:37:12.050 --> 00:37:20.139Dr Gary Deed: however, because they're not available, consider adding insulin. When the a onec targets are not being met with, say triple oral therapy.25400:37:21.350 --> 00:37:23.379Dr Gary Deed: But remember,25500:37:23.450 --> 00:37:27.419Dr Gary Deed: that insulin is used. If the severe hyperglycemia.25600:37:27.530 --> 00:37:35.380Dr Gary Deed: acute glycemic dysregulation, such as weight loss and severe fatigue. All of those factors Polyure, Polydipsia.25700:37:36.110 --> 00:37:43.029Dr Gary Deed: they recommend starting with the basal insulin added to the oral therapies. As I said, 10 units25800:37:43.220 --> 00:37:49.610Dr Gary Deed: or alternative 0 point 1 to point 2 milligrams so units per kilogram per day.25900:37:49.990 --> 00:37:51.570Dr Gary Deed: usually at bedtime.26000:37:51.690 --> 00:37:55.650Dr Gary Deed: bit more flexibility doesn't have to be given with the meal.26100:37:56.050 --> 00:37:59.549Dr Gary Deed: You titrate to the fasting. Blood, glucose target.26200:38:00.290 --> 00:38:07.089Dr Gary Deed: and those targets are embedded in our guidelines and try to look for26300:38:07.790 --> 00:38:12.950Dr Gary Deed: glycaemia. Certainly under 7 are at breakfast time or pre-prandly at breakfast.26400:38:14.240 --> 00:38:26.449Dr Gary Deed: when it's a target. You might then think about what other therapies you might be, add, and if they're not a target, you might think about other therapies called basal plus, or a co-formulated insulin.26500:38:26.610 --> 00:38:29.079Dr Gary Deed: Let's go to those those other choices26600:38:29.690 --> 00:38:35.100Dr Gary Deed: when you're making it switch. These are the characteristics of weekly Gop. One reception, Agnes and Insulin.26700:38:35.260 --> 00:38:38.939Dr Gary Deed: Both are very moderate to high glucose, lowering.26800:38:39.300 --> 00:38:51.430Dr Gary Deed: though the hypoglycemic risk for G. L. P one or Sepiagnos often are added to oral therapies other than sulfon areas as low as insulin is moderate to high. So you have to think about that. That's why people need glucose monitoring26900:38:51.730 --> 00:38:58.659Dr Gary Deed: G Lp. One recept agents who had moderate weight loss wears insulin doesn't necessarily promote weight loss, but there may be some gain.27000:39:00.250 --> 00:39:13.250Dr Gary Deed: G. L. P. One. A sectarians were tight-tradable with semoglutite, but not with dualoglotide but insulin is always titratable. It is the most titratable therapy for glucose lowering that's available27100:39:14.270 --> 00:39:18.790Dr Gary Deed: you do routinely require structured glucose, monitoring with insulin. So it requires.27200:39:18.890 --> 00:39:28.370Dr Gary Deed: if you're going to step up to that, a patient that requires education and provision of those resources you see supported by a credential diabetes educator, and your practice nurses where appropriate27300:39:28.600 --> 00:39:34.650Dr Gary Deed: glp one orcepti Agnes, we do not necessarily routinely recommend glucose monitoring27400:39:35.630 --> 00:39:45.730Dr Gary Deed: Remember the G. L. P. One receptor is couldn't contrindicated, and not on the Pbs. With Dpp. 4, and certainly not on the pbs with the nest lt 2 inhibitor, but could be used with met Foreman27500:39:46.730 --> 00:40:05.130Dr Gary Deed: engine can be used across the range with any of those therapies as well, but very importantly. Why, the G. L. P. One receptor agents might have been used not only for glycemia and weight management, but also for the major adverse cardiac events. Benefit that has been shown in clinical trials. That's what May stands for27600:40:05.390 --> 00:40:13.770Dr Gary Deed: where the insulin doesn't have any clear mace benefits currently, certainly not harmful, but no mace benefits.27700:40:14.170 --> 00:40:23.209Dr Gary Deed: So in choosing. It's not necessarily ideal, and it's not exactly the same, of course. And so you have to consider those alternative issues.27800:40:23.530 --> 00:40:24.459Dr Gary Deed: Now27900:40:25.010 --> 00:40:32.500Dr Gary Deed: you started Basil Insulin, but remember the potency of the Gop. One of Sept. Agnes Weekly once might have been that they both addressed28000:40:32.510 --> 00:40:53.190Dr Gary Deed: both the fasting and and the post meal glucose. So some people actually need to go to a either a basal plus or a premixed or a co-formulated instant when you step up, so that option is available to you. So you don't have to just start with basal, although many people consider that an easy choice. But it may not easy, may not necessarily be the best for the patient28100:40:54.200 --> 00:41:09.730Dr Gary Deed: when you step up, and because the G. L. P. One or recept axis, we're not only helping Basin, but also post meal glucose. You might have to then think Well, I need both the base legend and a bolus or meal-time insulin combined, which is called basal. Plus. That's 2 injections a day.28200:41:10.050 --> 00:41:14.680Dr Gary Deed: So this bit more complex and require multiple adjustments of each dose28300:41:15.940 --> 00:41:34.580Dr Gary Deed: pre-mixed insulin, are very are some of the longer on the market, and they actually cloudy instance that need to be reconstituted prior to injection that got variability of their glycemic management, and they don't have full basal insulin effect over 24 h.28400:41:35.830 --> 00:41:43.560Dr Gary Deed: So there are more modern instances. So the baseline, and, as you see in the second part of this graph is a slow 24 h Engineers28500:41:44.020 --> 00:41:47.670Dr Gary Deed: try to keep the glucose on dimension, and then you have these peaks that happen28600:41:47.710 --> 00:41:51.060Dr Gary Deed: meal time, and either you can do fasting.28700:41:51.090 --> 00:41:52.889Dr Gary Deed: I add a fasting28800:41:52.960 --> 00:42:20.029Dr Gary Deed: fast acting insulin to the basal to get some control, or you may consider a co formulated insulin which has the basal engine added, but a pandal component given at the largest meal of the day. The wonderful nature of the new co formulations is that that dose can be adjusted. If the person has one day a large breakfast, and you can choose to change it to breakfast the next day, or if it's the dinner, you can change it around so it's not fixed.28900:42:22.730 --> 00:42:33.600Dr Gary Deed: So the old premix is required. Suspension. It's in the blue box here, and a variable glycemic control incomplete coverage where some new co-formulations29000:42:33.610 --> 00:42:47.410Dr Gary Deed: that are available have a long acting. declar deck insulin but also a short acting meal Time or bolus insulin mixed together. Don't have to mix them, so to speak. They're they're suspended.29100:42:47.420 --> 00:42:55.080Dr Gary Deed: They don't have this variability that occurs with the premix very simple formula. So it's something to think about.29200:42:56.610 --> 00:43:03.660Dr Gary Deed: So I want to just say so. Say, if you've started a patient, You've added the baseline on to the oral therapy, says the baseline down there.29300:43:03.710 --> 00:43:15.430Dr Gary Deed: but the people aren't a target. Well, then, you might have to. If you're using a single basal luncheon, you might then have to add another injectable as Bart, which is a meal time insulin to that. So 2 pins.29400:43:15.750 --> 00:43:35.510Dr Gary Deed: whereas if you're going to go down the co-formulated route, you'd you'd start with the baseline and the orals, but then you just switch to a single combined injection. which is the co-formulated if you' to escalate to twice a day. You can see that the number of injections per day on the right-hand column are less29500:43:36.030 --> 00:43:38.989Dr Gary Deed: just something to think about when you're making a choice for the patients.29600:43:40.810 --> 00:43:47.030Dr Gary Deed: But remember, many people may respond to Bayes Lynchland on top of oral29700:43:47.090 --> 00:43:51.120Dr Gary Deed: therapies, as the choice that may work for them.29800:43:51.500 --> 00:43:57.209Dr Gary Deed: You don't have to get a more complex therapies. If you do, this column here might be less complex.29900:43:59.920 --> 00:44:14.200Dr Gary Deed: So the basal I so the code formulations that are available. there's a daggled deck, and as part combination it's trade name is rising in 70. 30 can be given once a day or twice a day.30000:44:14.370 --> 00:44:20.079Dr Gary Deed: whereas the the equivalent. If you're going to use largeen u 100 or glaji.30100:44:20.160 --> 00:44:31.239Dr Gary Deed: you 300 flooding you 100 is there There are several products on the market. There's one product. We glad you knew 300, which is a trade name to jail.30200:44:31.340 --> 00:44:38.150Dr Gary Deed: and if I have to add, and so, as you have to consider 2 injections per day. I think that was obvious in the previous slide.30300:44:38.820 --> 00:44:40.810Dr Gary Deed: All right.30400:44:41.270 --> 00:44:47.119Dr Gary Deed: We're getting near the end here, which is probably a good thing. I'm going to talk about how to make those choices.30500:44:47.990 --> 00:44:55.589Dr Gary Deed: Let's summarize a little bit. Going back to that woman. How would you make that choices But not all. Your patients are exactly the same as my teacher before. But30600:44:55.670 --> 00:45:00.079Dr Gary Deed: are the patients phenotypically at high cardiovascular risk30700:45:00.640 --> 00:45:08.350Dr Gary Deed: Remember our patient. She had chronic kidney disease. She had hypertension, hyperlipidemia, she's in that category.30800:45:09.210 --> 00:45:15.740Dr Gary Deed: or do they have existing cardiovascular disease already, and or existing kidney disease or the30900:45:16.080 --> 00:45:20.070Dr Gary Deed: guidelines suggest the Htt: 2 inhibitors are the obvious choice.31000:45:20.170 --> 00:45:23.049Dr Gary Deed: Add it to metformin, if appropriate.31100:45:23.880 --> 00:45:32.339Dr Gary Deed: Remember weight focus. We talk about G. L. P. One receptors, Agnes and weight was an issue, and maybe that's the issue with our teacher that we talked about before.31200:45:32.350 --> 00:45:49.149Dr Gary Deed: If that's an issue, the Sgt: 2 inhibitors do help assist weight management, and they're not not indicated for weight management as a sole weight loss drug, but they will promote weight, loss, inappropriate patients, and I think it's something to think about. It's really sensible choice.31300:45:50.360 --> 00:45:51.550Dr Gary Deed: in my opinion.31400:45:51.810 --> 00:46:00.450Dr Gary Deed: Lower hyperglycemic risks. Well, the S. L. T. 2 inhibitors again added to met formula or a D. P. 4 inhibitor. In that instance.31500:46:03.340 --> 00:46:09.239Dr Gary Deed: any time you add any of those oral agents to a sulfon area. The hypoglycemia risk increases31600:46:10.220 --> 00:46:16.130Dr Gary Deed: high glycemic efficiency. If they're really the glucose. is31700:46:16.400 --> 00:46:20.869Dr Gary Deed: decompensated by the removal of the Gop. One or subjectness internally is available.31800:46:21.250 --> 00:46:33.989Dr Gary Deed: But you need educational support. Glucose monitoring through some means education on hyperglycemia, and the risk with driving, Remember, over 5 to drive is well known.31900:46:34.000 --> 00:46:44.410Dr Gary Deed: and also the weight, gain risk which might have undone some of the work you've done with the glp. One recept, Agnes, but some patients do require it because it can be quite a dangerous decomposition.32000:46:45.620 --> 00:47:02.480Dr Gary Deed: If you want to consider. I'm. Continuing a form of a geop G. L. P. One receptor, Agnes loraglatide, which is a victims for our type. 2 diabetes patient's trade name has had proven cardiovascular benefit by the way. But there are considerable costs in that approach32100:47:03.040 --> 00:47:04.710Dr Gary Deed: non-pbs. Funded.32200:47:07.310 --> 00:47:23.790Dr Gary Deed: I don't want to give lip service to obesity. But there are now tga approved and and and available options. Remember. sem glue tide as way. Jovi is not available currently.32300:47:23.800 --> 00:47:28.339Dr Gary Deed: so you've got fentamine, which might be appropriate for some patients as oral therapy.32400:47:29.030 --> 00:47:34.280Dr Gary Deed: Wallie Step, which is the intestinal light paste inhibitor, which has some side effects32500:47:35.140 --> 00:47:38.810Dr Gary Deed: remember the combination of Buproprian and Naltrexane32600:47:39.690 --> 00:47:57.129Dr Gary Deed: is also appropriate. in some patients requires titrated dose. can be well tolerated in some patients and contraindications of course and do so. Sorry country indications. You need careful dose adjustment of concomitant32700:47:57.140 --> 00:47:59.890Dr Gary Deed: Ssris, although that it's not32800:48:00.010 --> 00:48:05.760Dr Gary Deed: absolute contradication, might have to reduce the dose and reduce the dose in renal impairment.32900:48:07.310 --> 00:48:17.070Dr Gary Deed: Loraglatide, which is injectable. G. L. P. One recept, Agnes comes as saxender, and that's an option as well Again, not all of these are non-pbs subsidized.33000:48:18.780 --> 00:48:32.739Dr Gary Deed: Remember the diabetes sorry strain diabetes, society and Australian obesity societies have combined and worked on Australian ABC management algorithm which is available through that download site.33100:48:33.470 --> 00:48:34.390Dr Gary Deed: Well.33200:48:35.060 --> 00:48:42.230Dr Gary Deed: I think we've covered a lot of ground today. I've done a lot of talking, and I notice there's some many33300:48:44.180 --> 00:48:51.009Dr Gary Deed: questions there, and I I noticed that Roy thank you. My spelling for why Jovi was as wrong as where Jovi33400:48:51.050 --> 00:48:57.529Dr Gary Deed: we go. V. Why not available yet, but just watch out for that. It may be released next year.33500:48:58.830 --> 00:49:10.200Dr Gary Deed: What is the reason Behind the withdrawal of Xenotide by Emma. Thank you for attending Emma. I think it's because they're not widely. I mean I can't talk for the country company.33600:49:10.220 --> 00:49:22.370Dr Gary Deed: but it's a company decision behind that. I don't think there's any. There's certainly not an issue with safety or any other issues around that exenerate. I can't come into that33700:49:22.650 --> 00:49:26.649Dr Gary Deed: without I think you need to ask the company that makes it33800:49:27.890 --> 00:49:42.449Dr Gary Deed: so. Catherine asks this mark variance between the guidelines and the pbs allowed, prescribing absolutely, and that occurs not just in diabetes across many, many. Chronic disease areas! How do we best negotiate this Well.33900:49:42.460 --> 00:49:53.950Dr Gary Deed: I can only recommend that you adhere to the Pbs guidelines, or if you're going to prescribe Outside the Pbs guidelines, it means it so. Patients may have to pay for one of those drugs privately.34000:49:56.240 --> 00:50:02.810Dr Gary Deed: Catherine says it seems that the su if sulfon er is a really effectively obsolete.34100:50:03.190 --> 00:50:15.600Dr Gary Deed: Not necessarily. They're quite potent glucose lowering. But remember, now, diabetes isn't just about glucose lowering. It's about understanding the phenotype of the patients. So34200:50:15.680 --> 00:50:20.449Dr Gary Deed: you know, patients have hidden or existent cardiovascular34300:50:20.760 --> 00:50:21.830Dr Gary Deed: disease.34400:50:22.270 --> 00:50:33.939Dr Gary Deed: cardiovascular risk factors, or chronic kidney disease, risk factors, etc. And when you're effectively managing patients, you should be making a choice that covers all of those in the most efficient fashion.34500:50:33.960 --> 00:50:35.529Dr Gary Deed: So safari is34600:50:35.750 --> 00:50:45.879Dr Gary Deed: great glucose, lowering, quite efficacious, and when in used in combination or alone. But they may not have those additional non-glycemic benefits34700:50:45.920 --> 00:50:49.730Dr Gary Deed: across heartfare chronic kidney disease, cardiovascular risk factors, etc.34800:50:52.280 --> 00:50:58.300Dr Gary Deed: and yes, the Pbs. Does insist that we use them after metform, and unfortunately, in many of the pathways.34900:50:58.680 --> 00:51:09.539Dr Gary Deed: and remember the pbs is driven, not necessarily by all of the evidence, but is driven by cost factors as well, and sophia is a very cost-effective for the government.35000:51:10.930 --> 00:51:16.529Dr Gary Deed: if we need to move to an Sialt to inhibit a Catherine, and they may well cost the patient35100:51:16.680 --> 00:51:24.859Dr Gary Deed: Not necessarily for removing the G. L. P. One receptor, Agnes. Just go back and look at the combinations available. S Lt. 2 S. Can be combined with metform35200:51:24.870 --> 00:51:42.550Dr Gary Deed: can be combined with softener. If that's your choice can be combined with Mac Forman and a. Dpp. 4 together. They can be combined with the Dp. Before as well. I mean it's multiple combination can be combined with insulin. So they're pretty freely available in Pbs combinations35300:51:43.050 --> 00:51:44.509Dr Gary Deed: Jennifer asked.35400:51:45.160 --> 00:51:49.559Dr Gary Deed: Can we comment on the Pbs criteria for those combinations, please35500:51:49.630 --> 00:51:57.290Dr Gary Deed: the combinations really apply to the medications.35600:51:57.970 --> 00:52:04.110Dr Gary Deed: So if the S. Lt. Two's are available on the Pbs. In combination with met format.35700:52:04.140 --> 00:52:09.680Dr Gary Deed: this Lt. Two's are above all, in the Pbs incubation with35800:52:10.100 --> 00:52:11.969Dr Gary Deed: Dpp. 4 inhibitors.35900:52:12.960 --> 00:52:21.249Dr Gary Deed: It's not a triple combination drug. Unfortunately, Sl: T. 2 inhibits are allowed with insulin. So I hope that makes answers your question, Jennifer.36000:52:22.760 --> 00:52:25.170Dr Gary Deed: If a patient36100:52:26.010 --> 00:52:34.590Dr Gary Deed: it's already on triple theory, this is roars on and agencies over 7. Are we better adding an su or going on to insulin36200:52:34.840 --> 00:52:45.100Dr Gary Deed: good question. So triple therapy that's probably messed met form and cell phone you re sorry mid-form, and Dpp for an S. G. L. T 2 inhibitor, and you think of it adding an issue.36300:52:45.470 --> 00:53:00.769Dr Gary Deed: I probably wouldn't although that's this is my opinion. When you get to quadruple therapy. The efficacy of the additional oral agents is is reduced. It's like a losing battle is that36400:53:00.780 --> 00:53:12.820Dr Gary Deed: each time, you know, maybe the first combination you get a 1%, a one, c. Lowering, and the next one, you add is another point, 5.7. But by the time you get to quadruple. You may only be getting a point 2 to36500:53:13.030 --> 00:53:18.450Dr Gary Deed: to 5% reduction. So maybe you have to think about it stepping up to insulin.36600:53:19.520 --> 00:53:36.919Dr Gary Deed: But i'm not saying that it's not impossible it Remember the pill burden that can occur with that combination, and maybe a fixed dose combination may assist you, but be wary when you're adding as use or insulin. Both of those step ups require patient, glucose, monitoring adherence to driving36700:53:36.930 --> 00:53:44.610Dr Gary Deed: testing before driving over 5 to drive and education on hyperglycemic risks.36800:53:47.840 --> 00:54:02.070Dr Gary Deed: cho asks, what is the compliance with the diabetic diet Well, cho really actually yeah, we don't use the word diabetic diet anymore. I think. we go back to healthy eating. That's appropriate for that patient.36900:54:02.080 --> 00:54:21.579Dr Gary Deed: there, certainly Some guidelines to help you depends on the the phenotype of the patient in front of you. So if this high cardiovascular risk and diabetes you might consider if it's culturally appropriate, and a Mediterranean base died looking at incorporating. You know more say.37000:54:21.590 --> 00:54:26.069Dr Gary Deed: fish and plant-based proteins in the diet, as well37100:54:26.130 --> 00:54:30.280Dr Gary Deed: more nuts and seeds and more fiber.37200:54:30.350 --> 00:54:42.650Dr Gary Deed: If there are high glycemic variabilities, or a high glycemic load. and and when you're monitoring the patient, you might consider reducing the glycemic index of food choices37300:54:42.900 --> 00:54:55.010Dr Gary Deed: some patients may step up to higher protein, lower carbohydrate choices. I would suggest that you do that with the guidance of a credential to sorry your credential.37400:54:55.580 --> 00:55:00.450Dr Gary Deed: sorry, accredited, practicing dietician.37500:55:00.750 --> 00:55:14.009Dr Gary Deed: Just a little. Take a message when we're going to higher protein, or even the Ketogenic dyes. it may increase the risk with an S. G. L. T. 2 inhibitors. So you only go to those much more involved37600:55:14.020 --> 00:55:24.550Dr Gary Deed: dietary choices with a higher protein. Ketogenic diet. Seek their advice of a practicing accredited Dietitian, especially if they are on Sdt. To inhibitor.37700:55:26.180 --> 00:55:41.430Dr Gary Deed: Ross asks, Can you confirm that you can't prescribe G. L. P. One receptor and a. D. P. 4 in S. L. T, 2. Is that because it's dangerous, or just because the Pbs Doesn't. Allow Pbs. Doesn't. Allow the Sgl. T. 2, and the G. O. P. One37800:55:41.440 --> 00:55:46.459Dr Gary Deed: as a subsidized prescribing. It is certainly not dangerous accommodation. But37900:55:46.490 --> 00:56:04.310Dr Gary Deed: remember, i'm not going to have the gop. One receptors vowel for a while. So this is a theoretical thing in the interim. but the combination, in fact, has been utilized in some clinical trials, and also utilizing clinical practice, and from a common sense perspective it and they actually seem to be synergistic.38000:56:04.320 --> 00:56:06.870Dr Gary Deed: But Pbs does not lay out the combination.38100:56:07.190 --> 00:56:26.489Dr Gary Deed: D PP. 4 inhibitors, and G. Lp. One of subtractions are partly contrindication, not as as a dangerous thing, but because the Dp. Before inhibitor naturally degrades some some G Lp one receptor, Agnes, you may be altering the pharmaco dynamics of a G. L. P. One receptor, Agnes, so that's not considered to be useful.38200:56:27.370 --> 00:56:41.510Dr Gary Deed: You may pay and Rod says, Can you patient pay on a private script if it's a Pbs issue Certainly. So you can pay for whatever you like, if you so the patient so understands the cost, and also understands the benefit, and you are happy to prescribe them.38300:56:42.050 --> 00:56:53.509Dr Gary Deed: So. G. L. P. One receptacles can only be used with net form and plus or minus insulin. Currently the Pbs have yeah restrictions, and maybe it's a good time to go back and look at those38400:56:53.520 --> 00:57:09.569Dr Gary Deed: pbs restrictions before you re-prescribe them. I really think you need to do that, and it's, interesting, because there's a lot of confusion about what's allowed, and what in combination. And obviously there's been prescribing outside of Pbs guidelines, not saying you're doing, Ros. I'm just saying maybe people have been38500:57:09.880 --> 00:57:10.470Yes.38600:57:10.780 --> 00:57:12.189Now38700:57:12.460 --> 00:57:31.189Dr Gary Deed: West Fee says, to check for micro album in your is better to check first morning. You don't have to do first morning checks for a urine acr. It can now be done without doing first morning checks. But you should repeat it if there's an abnormal result, because sometimes there are variances that occur due to multiple environmental factors.38800:57:31.200 --> 00:57:36.279Dr Gary Deed: including overt physical activity that can create a false positive.38900:57:38.430 --> 00:57:48.050Dr Gary Deed: Would you use ever use, Michelle asks. Would I ever use optician over to jail, I certainly may. I have some patients who are39000:57:48.060 --> 00:58:05.700Dr Gary Deed: kept on. That's glad you knew 100 for those on the audience versus glad you knew 300. Whoever. Why would you do that When there's some evidence of additional benefits in lower rates of nocturnal hypoglycemia by using you glaging you 300, which is to so39100:58:05.710 --> 00:58:16.989Dr Gary Deed: it's much of a much as as long as the patient's some monitoring. Well, maybe I wouldn't change, but if I certainly may initiate on Gladi and U 300 over the U 100, which is opticular.39200:58:19.110 --> 00:58:24.399Dr Gary Deed: Ros says, is there any role at all for the issue should we be deprescribing in patients that are on it39300:58:24.410 --> 00:58:43.509Dr Gary Deed: i'm not suggesting deep prescribing just for what we've talked about tonight There is a role but you know there are risk patients, phenotyp patient, an elderly patient, a patient with chronic kidney disease. Maybe there may be a elevated risk of hypoglycemia, continuing the issue, especially at a higher dose.39400:58:43.520 --> 00:59:02.569Dr Gary Deed: so maybe those patients over 65. a patient is a bit psychopathic, and it's got that type of elderly onset of type, 2 diabetes. Just be wary of those patients. hyperglycemia risk. if they're i'm in a job where hyperglycem is an issue truck drivers manual workers heavy equipment.39500:59:02.600 --> 00:59:08.269Dr Gary Deed: Consider those as being probably those where you need to reduce or reconsider39600:59:09.310 --> 00:59:28.109Dr Gary Deed: anonymous. diagnosis of diabetes, please asymptomatic patient results, show fasting glucose slightly high at 5.7. It's only slightly high, certainly not in the diabetes range. By the way, we asked them to do a glucose tolerance test is this, then, shows a glucose.39700:59:28.200 --> 00:59:47.329Dr Gary Deed: If this, then, shows a glucose in the diabetes range. Does that confirm diabetes mellitus Well, the fasting hopefully won't be elevated on the glucose tolerance test. It would be unusual with that initial 5 point, 7. However, they could have a post-prandial glucose. Rise39800:59:47.340 --> 01:00:01.539Dr Gary Deed: but that would then make them into what we call the pre-diabetes range. not necessarily diabetes and so that's called a, you know, impaired glucose tolerance.39901:00:02.000 --> 01:00:16.349Dr Gary Deed: So this is a difficult question. Do you do a glucose tolerance test with that person who's getting fast in glucose That's how I know what I would do is, repeat the fasting glucose, and see what it is. Repeat the same test40001:00:16.860 --> 01:00:19.370Dr Gary Deed: on a different day. Make sure they're fasting.40101:00:19.450 --> 01:00:22.259Dr Gary Deed: or do a hemoglobin, a one, c.40201:00:22.300 --> 01:00:24.180Dr Gary Deed: Or a combination of those40301:00:24.530 --> 01:00:44.299Dr Gary Deed: by the days we'll probably confirm they don't have diabetes. But if you want to go to the oral glucose tolerance test. You know that there are variabilities in patients. Tolerance vomiting can occur as many reasons or or glucose tolerance Tests have got intrinsic problems with sensitivity and specificity. So i'd probably do repeat the fasting and and or a hem glad may one see40401:00:45.300 --> 01:00:56.250Dr Gary Deed: Michelle. so I hope I can get through all these in time. I'm just checking. I'm got about a minute left. But anyway, is it worth having a patient test fasting and posted glucose levels before initiating it.40501:00:56.260 --> 01:01:13.350Dr Gary Deed: Determine if a basal insulin or a co formulation would be best. I think that's a great thing, and I think you should be teaching them to do the testing. Certainly before you start the insulin, so they know exactly how to test it. I think that's good. If there's past pandal or fasting elevator would consider a co formulation.40601:01:13.720 --> 01:01:15.759Dr Gary Deed: Okay.40701:01:15.780 --> 01:01:25.539Dr Gary Deed: you could all but you could quite rightly to start the basel and consider the co-formulation, especially if the hemoglobin, a one, c. Does not achieve target or the post-pranial still remains high.40801:01:26.010 --> 01:01:45.540Dr Gary Deed: what about the side effects of S. G Lt. 2 inhibitors Yes, there's you only symptoms and some, but mostly around the mycotic thrush. and they can be managed quite well with often over the counter or prescribed medications. They're well known as a role effect. can be a problem more so in females and uncircumcised males.40901:01:45.600 --> 01:02:01.199Dr Gary Deed: I mentioned before. Also that there's a very rare risk that if patient are going for operations. So 3 days before a major operation where this fasting you should consider withdrawing the Slt two's before those operations, or even a colonoscopy with as fasting.41001:02:01.320 --> 01:02:13.150Dr Gary Deed: If there is a simple procedure like a day procedure such as gastroscopy, you should stop the S. L. T. 2 s for the day before. only 24 h before 3 days from the major surgery41101:02:13.620 --> 01:02:18.249Dr Gary Deed: recommence, when our food intake is commenced again.41201:02:19.670 --> 01:02:34.249Dr Gary Deed: If someone's on insulin and and a G Lp. One and unable to get it well, you may have to step up to co-formulation. If the gl person was on a insulin and gop one or step dragon. That that's a no brainer. Go into a co-formulation and monitor the glucose.41301:02:34.690 --> 01:02:41.169Dr Gary Deed: They've asked how many patients are choosing sex sender, which is some lyrical type to insulin41401:02:41.180 --> 01:02:55.399Dr Gary Deed: and also Don't forget about our kabase and those patients. Akabase is that oral agent that is associated with some patients having gastron. Tesl upset, but it very much addresses past pand or glucose rises. I think that's an option. I think we should think about41501:02:56.440 --> 01:03:05.009Dr Gary Deed: Almost there can each one begin with other injectable, hyperglycemic agents, or the only other injectable is the glp one or a sep directness And Yes, it can.41601:03:05.820 --> 01:03:20.630Dr Gary Deed: When they're available. Would I be be a reason for you not to prescribe an issue Would you even say a contradication I believe that is a clinical contradication. and because it may contribute to that, and the risk of hyperglycemia is also a clinical contradication.41701:03:21.820 --> 01:03:29.190Dr Gary Deed: If a patient can't tolerate med format at all. Are they allowed to have an S. Lt. To G Lp: one combination of Dpp. 441801:03:29.200 --> 01:03:42.289Dr Gary Deed: on a pbs. No under the Pbs. They should be on an issue, and a Sglt, 2 inhibitor or and or a Dpb. 4 inhibitor, or they can take one, met form in a week.41901:03:42.390 --> 01:03:51.479Dr Gary Deed: If they can take that one a week that's still in combination, you might be able to get away with one tablet per week. I'm not trying to play games, but I think that's possible. Otherwise you need the issue.42001:03:55.770 --> 01:04:14.939Dr Gary Deed: If I don't reach all your questions we can get back to you within the timeframe, because I know we're really running out of time. I'm 2 min over, and this a hell of a lot of questions. Excuse the language to go, so I might have to ask clear whether we can answer some of these questions. Offline42101:04:16.930 --> 01:04:20.289Dr Gary Deed: as well, because I know people. We've probably gone over time.42201:04:20.300 --> 01:04:39.330Specific Interest Zoom Chair : So over to you clear. Yeah, sure, Gary. Possible to go for another minute if you want to. Yeah, if you're happy, no worries and of course we'll get back to anyone we don't get to, and there will be a recording of this available which will be sending out to you after this Webinar in the next couple of days.42301:04:39.340 --> 01:04:54.670Dr Gary Deed: anya! And Anya, I said. Once we get the gop one with sept Diagonus back. Should we withdraw, insulin and reinstate the Gop. One Accept to Agnes. I really think that is an option again, because there are other non glycemic benefits from the gop one receptor, so I would think42401:04:54.680 --> 01:05:22.049Dr Gary Deed: that would be useful. but but remember, when you restart the gop, one recept Agnes the glycemic ffc efficacy does not occur immediately. So you don't just stop the insulin, but you may have to reduce the dose by 20, or even 50% at that time for the first week or so, but get them to self monitor or get the credential diabetes educated to help you know how to recommence the gop one receptiveness, or people, or an inchland.42501:05:22.900 --> 01:05:36.950Dr Gary Deed: If someone's on insulin are they supposed to test their blood glucose level before they drive each time Yes, they are. there is a guidelines, and should be over 5 to drive, and certainly be testing every 2 h if they're driving, so I do recommend it42601:05:37.020 --> 01:05:49.250Dr Gary Deed: Low carbohydrate diet certainly an option in many patients. if they can do that if it's culturally appropriate if they're monitoring their glucose. if they're on ancient. Be careful, Localized carbohydrates42701:05:49.260 --> 01:06:09.609Dr Gary Deed: can exacerbate the risk of a hypoglycemic event, and also with cell phone. Your is so. It ain't as easy as just saying, Use a low carbohydrate diet for all patients. Understand the phenotype Are they monitoring their glucose Are they on a insulin or sulfon area, or another agent Of course, is hypoglycemia, because it may exacerbate that42801:06:09.720 --> 01:06:13.250German version of Assembly is available and42901:06:13.500 --> 01:06:32.219Dr Gary Deed: and Tgi approved. If you go to the tga website and search for semi glue tide and some updates. There is a telephone number or a website. You can contact Trouble. Is it cost 384 a $7 per script, I as an alternative to self import semi-glotide as a Zp.43001:06:33.190 --> 01:06:51.570Dr Gary Deed: Can you switch from one G L. P. One receptor another easily. Yes, you can. except the weekly ones. the semi-glotide has multiple doses so the equivalent dose of the current. dualoglutide or Trilicity is equivalent to the point. 5 milligrams43101:06:51.580 --> 01:07:04.050Dr Gary Deed: of the the semi-glutoid so semi-glotide has a high dose range. So if you're on the one milligram of semi-glotide. It's not quite equivalent to the43201:07:04.060 --> 01:07:16.739Dr Gary Deed: gil a blue tide dose in some clinical trials it may be though I mean it did some adherence and work on diet. It's such a thing you could switch, but that's currently43301:07:17.180 --> 01:07:19.240Dr Gary Deed: out there in the published literature.43401:07:19.460 --> 01:07:26.890Dr Gary Deed: and lastly, how do you interpret fructose of mine result levels. Why don't you utilize some routinely43501:07:27.240 --> 01:07:48.769Dr Gary Deed: I think that. there are variabilities and sensitivity and specificity. I might use those in a patient who's got deny and deficiency severe anemia, chronic kidney disease, and each laboratory has their own reference. as well. But remember that doesn't interpret over the length of the time of 3 months that a hemoglobin, a one, C would do.43601:07:48.970 --> 01:08:05.109Dr Gary Deed: I think we've covered it all, Claire. I think hopefully, that's been a useful talk for everyone tonight, and I really really enjoyed talking to everyone, and I really wish everyone would have. a really healthy Christmas or holiday season.43701:08:05.140 --> 01:08:11.359Dr Gary Deed: and let's be happy and choppy for the New Year, and thank you so much for attending tonight.43801:08:11.460 --> 01:08:36.169Specific Interest Zoom Chair : Thank you, Gary, and thank you. Everyone for attending on behalf of the Rcgp. And thank you. Dr. Gary D for your expertise tonight. I'm sure everyone's got a lot out of it. And, as I said before, we'll be sending you an email with all the links that Gary mentioned tonight, and also recording in the next couple of days. So if you think you missed anything don't worry you'll get a copy of all this, so thanks very much. Everybody, and have a great Christmas and New Year, and of course join our diabetes sig for more updates in 2,023.43901:08:36.220 --> 01:08:38.749Specific Interest Zoom Chair : Thanks very much, everyone. Good night. 153554b96e
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