Davida Kruger, a certified nurse practitioner in diabetes, works in the Henry Ford Health System in Detroit. She spoke to us recently about the imperative of education, about patients enthusiastic response to new drugs, and about the challenge of adherence.
diaTribe: Let's start off with something basic! What do you recommend for type 1 and type 2 patients to achieve their blood glucose goals?
Kruger: It is very individualized, but we do say to the patients, "Look. We know if your fasting blood sugar is over 126 on a regular basis, you're setting yourself up for retinopathy and other complications." But if we can safely keep their blood glucose levels between 80 and 120, wed love to do that.
diaTribe: Actually it seems like you emphasize the cause and effect more than other people. You make it very tangible to patients. Is that deliberate?
Kruger: Absolutely. Because the thing is, I don't go home with them at night. What I can do is offer them information, but ultimately the patient is her own expert on her own diabetes. So I may say to you, "I really think you need to get your fasting blood sugars under 100." But I put it in terms of best practices, because this is what we know. I try to take the research and put it into layman's terms. Its not that I want you to be on a statin just because I said you should be on a statin, but let me tell you why I think you should be on a statin even if your LDL is good. Here's how it will affect whats happening in your heart. If there's a blockage, I'm not going to know about it until you have chest pain. If I give you a statin, I might prevent that blockage from happening in the first place. Your greatest risk with diabetes is heart disease. How am I going to protect you from that greatest risk? What can you do with nutrition? What can you do with physical activity? Instead of saying, "You will do it because I tell you to do it," you get them to buy into it. It has to be their decision if they want to do it.
diaTribe: But why are some patients reluctant?
Kruger: The workload from diabetes is phenomenal. If patients can't do it for a month at a time, you can't beat them up over it or make them scared -- or say, Oh, my God, you're going to die. It's just, "Let's get you back on the bandwagon. What happened so we can learn from the last month?" I'm on the road right now, and I know I've gained weight not because of what I'm eating, but because I can't exercise. There's no time in my day. I'd be exercising right now if I weren't talking to you. Seriously. I was on a four and a half hour flight yesterday. I'm going to be on a four and a half hour flight tomorrow. I've got meetings today and phone calls tonight. Where do I put exercise in my schedule? And I know that at 52 years old, if I don't exercise, I get fat. The reality is some months I'm going to be fatter than other months.
diaTribe: Education is important for every disease, but what makes diabetes different?
Kruger: The reality is that educated patients have better outcomes, but it's more than just A1c's. It's how do they control their life with diabetes. Education allows you to make better decisions. When you look at nutrition and think about how patients eat fast food all the time, they have no clue what they're putting in their body. They may know its not great for them, but do they know how many calories are in a Big Mac? They might know if someone educated them. We're all over these parents for obese kids, but has anybody ever said to them, "Do you know what you're feeding your kids? Do you know what's in it? How many parents read the labels?" If you had those kinds of classes for people on a regular basis and access to this kind of information, would people make better decisions? I think they would.
diaTribe: Where do most patients learn about diabetes?
Kruger: Ninety-nine percent of the information patients get is from each other. They're out there blogging every day. Thats where they're getting most of their information. They're also very savvy about good Web sites, and I send them to good ones all the time.
diaTribe: Let's talk about new products starting with technology. Are a lot of people coming in and asking about continuous monitoring?
Kruger: When is it ready? When is it ready?
diaTribe: We're disappointed that our insurance doesn't pay for it yet.
Kruger: Oh, you're not alone. A lot of patients could afford the meter but not the durables. That's what were running into. They'll put out for the meter, but if they don't have insurance, they can't afford the durables on a regular basis.
diaTribe: What else are you hearing from patients who are using some of these new drugs and devices?
Kruger: On Symlin, it's the first time in their life they've ever been able to follow a meal plan because theyre not hungry. (Editors note: Test Drive in diaTribe #2 will focus on Symlin.) So now we have to go back and provide an opportunity for patients to really learn the nutrition plan; whether it be Weight Watchers or ADA approved, whatever. It's the first time that they've had control of their food intake, so let's go back and provide the support and education in medical nutrition. Patients are thrilled with how flat their blood glucoses are after meals as well.
diaTribe: Weve heard that the outcomes in the field are actually better than they were in the clinical trials.
Kruger: Yes, I would say that too. The outcome in the field is a hundred percent better.
diaTribe: Wow - why do you think that is?
Kruger: I'm constantly saying that we finally have a chance to take these drugs out for a real test drive, because when you have to hold to the letter of a protocol in a clinical trial, you can't be your own clinician. You can be a safety guru to make sure that the patient is safe, and you can also make sure the protocol is followed to the letter, but you can't individualize treatment. Now I get to sit in front of the individual patient and see how Symlin or Byetta best fits into their life. And I'll tell you, the A1c lowering and the weight loss with both of these drugs are so much more dramatic than we ever saw in the clinical trials.
diaTribe: So what are you seeing? Are you actually seeing A1c drops of more than a point or so, from a lowish baseline?
Kruger: Yes. Yes. Yes. In fact, what I'm seeing is so dramatic, and I know I'm not the only one, that I keep trying to send these case studies to Amylin saying these are better than what you're using for your training. And they keep saying, "We can't use them because we have to stay within the guidelines." So, yes, I am seeing dramatic weight loss, and I am seeing dramatic lowering of A1c's way beyond what the FDA approval was based on.
diaTribe: Can you talk about how patients feel about the drugs now that they've been out for a year?
Kruger: Oh yes. You know, there are always naysayers in the world, but I'll tell you that my patients do not turn away from three extra injections a day if they get the benefit of Symlin. And people with type 2 diabetes who are not on injections do not mind taking the two injections if they get to use Byetta. It's a different thought process with Symlin. I am not minimizing the fact that theres a whole psychology to taking injections. But we can lay out benefits to a patient - their A1c will be lower, their blood glucoses will be better, and they probably will lose weight and feel better. I do not hang my hat on the weight loss part because some patients aren't going to lose weight, and I don't want them to get discouraged from the improvement of the A1c because for them that's still a major benefit, and that's not a reason not to use a drug. But I'll tell you, I don't have patients that turn away from using Symlin or Byetta because those drugs are injectables. I just don't.
diaTribe: Why do you think adherence is such a problem?
Kruger: Well, I think what you have to remember is that life is really ... busy. I think if you look at any of us - I have hypertension, I have elevated lipids, and I have all of these other issues that I am personally dealing with. I understand what the ramifications are if I don't take care of them. Do I always eat well? And when I'm on the road, how do I compensate for all of that and how do I manage to get all of that done and still live my life? Then you think about people who have all those diseases I just mentioned, and they have diabetes on top 0f that. That's typical. And I'm saying to them, I want you to exercise. I want you to follow a diet. I want you to take six blood glucoses a day. I want you to wear an insulin pump. I want you to take Symlin and I want you to call me every three days. So, tell me, would you have time to have a life? So is the issue adherence, or is it life?