Drs. Bhoyrul, Dodson and Einhorn address questions from the audience.
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as questions come up here in the panel, I have a question for both of you. Just sort of in terms of you both mentioned kind of devices for monitoring wireless devices, that kind of thing and just want to get your sense. I'm kind of where that's headed uh in terms of you know uh continuous glucose monitoring um for both pre gastric bypass, post gastric bypass and then just in the management of diabetes generally I would like to see continuous glucose monitoring and non diabetic patients. I think that's going to give us a tremendous insight into the dietary habits both before and after surgery. But I'll say it again. I know I would agree, you know, data helps drive actions and especially in motivated people certainly with pre diabetes and diabetes, uh putting on a continuous glucose monitor and just seeing the output is often all the therapy a person needs and they're fine for you know, the next year or or to um what we don't have yet is a 24 73 65 monitoring. We don't have, you know like the uh the uh implantable devices that you have in cardiology for measuring heart rhythms. Um But but we will, one of my startups is a local company that is working on an implantable uh continuous glucose media that will last a couple of years after implantation. And with that kind of an output, you know, we might be able to get some way to you know, going to edit out the noise. A lot of noise as you know as in electrophysiology, a lot of noise. A lot of noise in uh the glucose world as well. But as C G. M becomes really cheap and easy to use as it is now um it will become smaller and more acceptable to more patients. It will simply be the standard of care as you heard from a couple of us. You know a one c was very useful in its day. Um Time time to move on without data. We cannot can't afford now, especially with telemedicine and Covid we found out that it's so nice being able to speak to patients over over zoom. But without the right data you can make decisions and and that's where these devices and getting patients to step on. Body composition analyzes at home is going to make a huge difference for us because we we found, you ask a patient how much do you weigh today and one day they won't tell you the truth. And secondly it doesn't even help us knowing what they want because it doesn't tell us anything about their body fat in their metabolic rates. Yeah you can if you're doing a member of people had to be admitted to the hospital to work up arrhythmias, you know, you know, I worked on behalf of Bernie Lounge, so we did that a lot. Um and that used to be also true in the world of glucose. And again, as as we can do more, it's transformative in terms of, you know, drug development um and management and remote monitoring. So, you know, we've been jealous of you cardiologist for a while so slowly catching up. Yeah, it's both of you mentioned, you know, we've had the benefit of having remote monitoring and as I mentioned earlier today, the specific device, an implantable human dynamic monitor has been incredibly useful, particularly over the course of this last year. And that's something that changes the pressures go up before weight goes out before patients get symptomatic and so we can be proactive as opposed to reactive and I think that's really the key across the board. And I think it would be interesting to see a study with watching, knowing how much of an interplay there is with glucose control and and wait and heart failure. It would be interesting to see a patient or a study in patients with human dynamic monitor and continuous glucose monitoring to see how improvements in their glucose control affects their human dynamic pressures and they're feeling pressure. Would be interesting to see, right and just imagine in most diabetes management you got every three months at most, not every we every three months you connect with the patient and get a couple of numbers the A one C and maybe a couple of pre and post meal numbers. Um so it took maybe a year or two to get under control. Now that same year or two becomes weeks at least. It should be weeks or a month or two because you can see the effects right away. So it's, it's transformational. One of the questions that came up from the attendees is the following. For Dr Einhorn as a primary care provider. I find it extremely challenging to get a continuous glucose monitor for my type two diabetes, mostly Medicare patients. So I'm stuck using the A one C. Fasting blood glucose for regular management. Any tips on getting these for patients since it is far superior. Yes. So you should be thinking of the monitor as a intermittent device rather than a truly continuous device. So intermittent would mean for two weeks at a time. And uh, the the the device itself is 30 bucks, 30 to 40 bucks For the two weeks. And uh, the uh you do need to get a $68 handheld device at first activate. So there's but other than that it's $30 to get two weeks of monitoring. $30 spent once, twice three times a year is generally an investment that most people can afford. Now. If you're if you have diabetes or take a diabetes drug, you should be able to get a type of monitor that's called the pro, as opposed to the so the pro is when the patient doesn't see the results in real time, they get recorded for two weeks. Then the patient comes and visits you and you download the results and you look at them together. That will almost always be covered at least once or twice a year. The general rule is as often as someone merits an A one C. By the guidelines, you can get two weeks of continuous glucose monitoring. So I think it's the minority of people with diabetes who need or want to wear a device 24/7. If you have type one diabetes, you're on an insulin pump. You take insulin throughout the day. Well you know you need data all the time. Um but for most of our patients to get stabilized on oral agents and maybe one injection of insulin a day and they still need to continuous monitoring at least once or twice to know what's going on. Because until you've done that you actually just don't know what's going on. It's like instead of a cardio graham you listen to the heart. Well I mean you know you know a lot from that but the cardia graham tells you a lot more. So so the A. One C. Told us a lot but the C. G. M. Tells us that much more and it's quick uh and it ultimately saves money because the patient gets under control much faster, knows are under control. So it's more adherent and they don't need to see you as much unless you want them to and they may want to because it's actually a weird word, but it's actually fun to be doping out glucose patterns. It's why people who don't have diabetes at all where these continuous monitors because they learned a lot just in, you know, their regular lives. So once you know what you're looking at, it just gives you so much information so you can get them um but not for continuous use uh and even Medicaid will pay for them and certainly for that. But I said the pro model where they wear it and then come back and see you to discuss the results. Another question uh in the from the attendees, how do you or how should we decide between SGL T two inhibitors and GLP one? So if their patient has any election, the heart failure or chronic kidney disease, the specific studies on the S. G. L. T. Two's clearly show them to be superior and and you will get weight loss with them also. Um For the patients who need more glycemic control and weight loss, the GLP ones are simply more effective at that, especially the same magnetite as Epic and Red Bell says. And and more to come by the way, the the GLP ones as dr barrel, those are being not studied at higher and higher doses and people are willing to tolerate some of the Gi side effects that build up slowly because the weight loss can be so significant. So in general and in the heart failure conference, SGL T two S. S. C. L. T two's in Arenal Conference. SGL T two, S. S. C. L. T two's in diabetes weight management, separate GLP Once fact of the matter is you often need both. Um because the the SDLP two s are oral, they've tended to be an easier first step. And so after Metformin, the STL T two is the usual, but I told you coming up is an oral GLP one and and more to come and so to some extent, fielder's choice. But certainly for CHf, although DR Borough pointed out that there really should be a very clear effect of GLP one on the heart. The heart failure outcomes have not been as clear for GLP one as they have been for SGL T two. You mentioned in your review of the trials, looking at SGL T2 inhibitors in heart failure or just generally that the vast majority of patients were already on that foreman, was that true or what what was the percentage of that in the heart failure trial, since there wasn't really a diabetic population per se? Yeah. So I won't it depends on the trial, but there's no question that the S. G. L. D. Two's work independent of metformin. So it's it's only not. The point of the slide was to say Metformin does not detract from what we know about the SGL T two's, but since you don't have to have diabetes, you don't need to have met foreman to benefit from the STL T. Two. God. Um and you know, just to point uh Sunil that you made in reviewing those cases that we've collaborated on, just that, you know, we think about heart failure and obesity is a sort of, you know, uh the interplay between them. And what happens often is that these patients with advanced heart failure, they can't you know, it's sort of an a vicious cycle, I guess, and their obesity gets worse as their heart failure gets worse and it kind of continues to spiral out of control. We can intervene and do things like an l bad or something like that on select patients, but then sometimes they get stuck in that in that um treatment option without the ability to go to a heart transplant, which is ultimately the goal in the right patient for the younger patient. Um And with your treatment, you know, I just want to touch on the fact that obesity or at least a B. M. I. As it's defined above 35 is considered a contra indication of heart transplant. And so that's why we get as aggressive as we do. So maybe, you know, if you wanted to touch upon kind of our select few that we've been able to get to a heart transplant by reducing their B. M. I. No, absolutely. And I think we have four now who who had successful heart transplant um by reducing the B. M. I. And and again none of them were um none of them were candidates because of their being. My darling carl vet actually wrote a book on it so I can use her name about her journey from having an L. VAD to having a sleeve gastrectomy and then having had a successful heart transplant. And I think there's gonna be many, many more to come. What's more exciting to me, however, is intervening for patients who are not there yet. And I think early intervention to prevent them from getting to needing an L. VAD or needing heart transplantation I think is really even even more exciting. Although there's no doubt that operating on the elderly patients has demonstrated our ability to do safe surgery on the sickest cohort. We've actually got to focus on intervening much earlier and by the time patients have a H. A. Three and four heart failure, Um even way before Alvin's, we ought to be thinking of of metabolic surgery to get them to to lose weight and have these weight loss independent effects on the heart failure, which I think um as it was demonstrated in one of our patient profiles, you know, who had an ejection fraction 18 and impunity pump who was heading for Elvis and now no longer needs an L. VAD and certainly doesn't need a heart transplant. That's where we need to be. By the way, I can recall when diabetes itself was a contra indication our transplant. And I was among those who uh you know, argued and wrote several things pointing out that that was based on already outdated data about how diabetics can do if properly managed. And so that was that was an interesting fight. And there's still this archaic thinking of surgery being a failure of medical treatment. And and we've got to get over that. We've got to look at the hand in hand approach between, you know, all our surgical patients end up continuing to need medical treatment of some sort of the other. It's just, you know, it's not one or the other. We we've got to start and I love the idea of a cardio metabolic unit because we've got to start collaborating. I think we're going to do it so. Well, no, that's fantastic. Yeah, there's there's precedent for that in other um kind of in a in a multidisciplinary approach of course. You know, we've been working more and more with oncologists and developing a cardio oncology clinic, the overlap in the syndromes, the toxicities from some of the chemotherapeutic agents that are used. But this is right for for really helping out a lot of people, a lot of patients, I think, who could benefit from this sort of multi disciplinary approach. It's funny you mentioned that, you know, I I distinctly remember attending during my Internal Medicine Residents residency, saying that the job of the Internal medicine doctor was to keep the patient out of the hands of the surgery. Really, that's not the case. And, you know, our specialty in heart failure is unique in that we collaborate so much with surgeons. Cardiothoracic surgeons with yourself of course. And we, you know, what we do is so contingent upon the services that the surgeons provide too. So it's it's a totally different mindset for sure. Well, I think, you know, to go back to Dan Akroyd and Chevy Chase, I think that the surgical characters that they portray are actually quite embedded in the perception of surgeons in general. You know, with these sort of, you know, bumbling idiots that tend to hurt people sometimes. Um, and I think, I think certainly scripts, that's not the case. But we've, as surgeons, we have not helped ourselves. Right. Right. So, I'm glad that's evolving for sure. Another question that's popped up for Dr Einhorn can GLP one be used for obesity in a non diabetic person. Maybe question for both. That's a question from uh, you may want to take that first, but I'm involved in some of that work. We use GLP one all the time. GLP one Agnes all the time in patients who are gaining weight after bariatric surgery. So, um, so even before they become but certainly non diabetic patients who suffer from obesity. We've been using oral some glue tied now and now that it's been available. We've been using injectable olympics. The answer is yes. Absolutely. The problem is getting it covered the problems is extremely expensive. And insurance companies you know tend to fight hard on that. Yeah and there are some so first they'll be higher doses. Um And so the same molecule, same everything tolerance to G. I. Effects over time. And there is a there's a new kid on the block to Zepa tight which combines GLP one with a G. I. P. Hormone. That by itself we didn't have much interest in but you know we're seeing some weight loss now this is in diabetes. So I'll come back to non diabetes but in people who had it will come in as a diabetes drug. We're seeing weight loss of 25-30 lb. That's your bariatric surgery level weight loss, which we really had never seen before. Um, So that may really change the tide. I think the, the medical treatments in the obesity world are becoming very exciting. And frankly, they may take the place of a lot of the diabetes therapies we're using today if they're, you know, that effective. But there's hepatitis one that I think is going to be um released really within the year. Getting the insurance companies pay for these things is still our biggest challenge. Yes. Yes. I mean, they don't want to have anything for obesity per se. It's I think part of why in drug development often Type two is the uh, is the pathway. But obesity management is actually the goal. Some of the larger companies novo in particular, really wants to be an obesity company and it will be once obesity is appropriately recognized. But as you say, the metabolic disease that it is. Yeah, it's unfortunate. The insurance companies won't take that long view. Understanding that earlier intervention will save money down the line for hospitalizations, for heart failure, for adverse cardiac events for all of those things. Um Well, that's why baby so so valuable for for scripts to get a head start as we become really fully accountable for population health and then we'll be able to capture those benefits. It's it's complicated before we're all really at risk for the population. But once you have that mindset, it's it's so clear. I couldn't agree with you more. It's, you know, we we hold these truths to be self evident right? Absolutely. Okay. Another thing you mentioned doctor in her during your talk was just about the water diaries is that occurs with S. E. L. T. Two inhibitors. And that's something that we've noticed too is that often we have to we prep patients that we will very likely go down on their loop diuretics as we as we add. And sometimes if they're on low dose we actually just stop the loop diuretic altogether. Understanding that there is going to be some amount of diaries is that occurs once they start there? S guilty to an order. So we need christian Mendy And this uh discussion group here. But uh as as as christian has explained it to me um you know your your your net viruses is most in the first week or two and then you come into relative steady state. Yet the benefit from the S. G. L. T. Two continues um and maybe even improves over time. And so it may be that when we're doing more of a natural recess there are counter regulatory um neuro hormonal uh issues that may take away some of the benefit that a water diaries. This gives you. So again this is this a speculative. That's a very interesting idea. The other you know in that therapy in combination with secure patrol val certain also seems to have an increased amount of diaries. Is and so it's been kind of revolutionary. Where here in our clinic you sometimes here are saying two patients you know it's okay to be liberal with your fluid intake. It's okay to be a little bit more liberal now with your salt intake because we don't want to have hypertension. We want to be able to have these patients continue their there's a cuba travel starting and there s DLT to an editor. So it's sort of revolutionary all across the board. I think in terms of how we're approaching these patients it would probably be worth now maybe inserting a word of caution that maybe I really should have inserted more. You know we're used to it in endocrinology but the STL T. Two s because they're so effective they can be problematic if the person stops fluid intake or stops caloric intake and they have a long biological half life. Okay so their activity goes beyond their ability to be measured in serum. So now the rule of scripts is if you're having an elective procedure you'll you're gonna be N. P. O. You discontinue the SCL 2 to 3 days in advance. Not one day not two days but three days in some other centres. It's five days. And that's because when you stop your oral intake especially you stop carbs and fluid you're still losing glucose and fluid. And so it's easy to get into a catatonic state and to get dehydrated. So it's important to respect the drug. And so are you know, when we prescribe the drug, simple instruction, No food or fluid, no drug. Yeah, that's good. So if you get sick, g I owe you just stop the drug until you're eating again. Yeah. It's very important to know. Absolutely. Another question that came up productive borough. Is there an age too high for bariatric surgery? Certainly by the time you get to, you know, 75 and it becomes harder to justify the oldest patient that we've operated on is 82. And um I did so very, very reluctantly. Guy Curtis referred him and I really went in kicking and screaming and really thought it was a terrible idea to operate on him. He's now 86 and doing incredibly well, keeps coming to clinic with with a new girlfriend and boasting about how well he's doing. And certainly he's opened up my eyes to some of these arbitrary limits that we set. Um, I really have to be taken much more to the context of functional status rather than age. Yeah. You know, we don't have our jerry attrition with us right now unless he's on the phone. But I think the ability to assess ourselves. Yeah. And um, you know, assess our patients for kind of, you know, where they are on that continuum, because, as you say, age is not the criterion anymore. But sometimes people cover up, you know, have a spouse that covers up and uh, you know, the degree of frailty etcetera. You know, maybe a caution in terms of what they're by the way in diabetes, there's a very strong uh moved to de intensify therapy. As people come to you. Let's say they're they're later 80s, you know, to try to avoid insulin, to try to avoid therapies with uh with any side effects to accept higher blood sugars. Certainly. Um And in other words to to see the risk benefit ratio changed by um you know, how many years are left and by comorbidities. Um And so it was so if I see an A one c of you know, 7.5 in an 80 year old on four drugs, I want them on three or two or maybe one drug with an A one C of eight. Right? Um Follow up question, what are the downsides long term of bariatric surgery? So the two most common types of surgery of the sleeve gastrectomy and the gastric bypass? The sleeve. Almost nothing. I mean, sadly you can actually the stomachs of muscle and you can pretty much grow your stomach back to normal size. Um We tell all our sleeve gastrectomy patients take some multivitamins because that's just that's just good medicine. Um But you know almost nothing but the sleeve gastrectomy and the gastric bypass. We're changing the absorption of iron, calcium B. 12 vitamin D. Um And so it's very very important to keep up with those vitamin replacements. Sounds like a simple thing but if you look at patients five or 10 years down from gastric bypass only the minority of them actually keeping up with the vitamin replacements. So we're getting patients had a patient recently admitted with critical vitamin A deficiency 10 years after gastric bypass presenting with night blindness. So that's very very important. The other problem with gastric bypass that we've seen is a cohort of patients with addiction transfer And so in patients who truly had a food addiction and you do gastric bypass, which is the minority of them by the way, but who truly did addiction to alcohol, sex and gambling is is well described. So again, highlighting the importance first structured long term lifelong follow up and the reason they come into clinic every month for the first year and then every three months and then every year thereafter for the rest of their lives is to identify to test and to prevent some of these complications. Because the vast majority of them are preventable. Yeah. And I've seen they come to me with an elevated P. Th that was measured for some reason and it's almost always as you know, of course, uh they need more vitamin D. And some things. They need extraordinary amounts of vitamin D. Uh one or two people, 50,000 units just about every day just to normalize D. And normalize the P. Th to avoid osteoporosis etcetera, remarkable. And for people who are drinking after gastric bypass vitamin D. Requirement also goes through the roof. Got it. Um See any other questions here in the in the chat. Any other closing comments from from either like I nor nor dr borrow? Well, I just like what you said that you know, we really have the cohort to get together when it's time to have that collaborative center and I think will be very proud that, you know, scripts can really assume leadership in this area. I mean we have the team and we have the bench strength and so it will probably uh you know, a year plus, maybe a year or two in the making. And I don't think it's gonna build yet another building on the campus, but I think it would be a way for us to work together. That will be very enjoyable. And I think some research we can do together will be extraordinary and and really leveraging technology and I think the it's a perfect group of people to to leverage wireless technology and to really take measuring the right parameters to the next level in order to be able to offer you know, groundbreaking treatments. Absolutely, yeah. That's very, very exciting. And look forward to that collaboration hopefully in the near future. Um All right, well thank you both and thank you john, also for your talk, I know he's busy rounding in new york right now, but thank you all for your wonderful presentations. Um you know, learn something every time. Um I hear from you both. Um it's a wonderful session this morning. Um and so that concludes our Saturday portion of our heart failure Arrhythmias Conference. There is a session at 12:30 with Dr Gibson uh Non CMI symposium hosted by Boston Scientific. That will be coming up in a couple of minutes so please feel free to continue your attendance over on. It will be switched over on to that to that session. Uh And then our regular session will then resume again tomorrow morning at 7 30. Where we'll focus more on the arrhythmia side of our talks. All right, well thanks everyone for your attendance. Thank you both for your talks and uh and we'll take it from there. Have a good day.
