We know that a great resource page full of accurate and helpful cheat sheets can save busy diabetes specialists time and energy.

That’s why we have put together our entire list of cheat sheets so you can access them with ease.

These sheets and cards include information to study for certification exams and to use in your clinical setting. Plus, we have included teaching sheets for people with diabetes.

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Our Summer 2020 Boot Camp begins September 16th!

In each webinar, either Coach Beverly, Dr. Isaacs, or Ms. Armstrong, highlight the critical content of each topic area, so you can focus your study time most efficiently. They also launch multiple poll questions to help participants focus on key concepts and assess their knowledge while learning the best test-taking strategies. 

2020 Boot Camp Live Stream Webinar Schedule with Coach Beverly

All courses air at 11:30 a.m. (PST)

1. Diabetes – Not Just Hyperglycemia | Sept 16
2. ADA Standards of Care | Sept 23
3. Insulin Therapy – From Basal/Bolus to Pattern Management | Sept 30
4. Insulin Intensive – Monitoring, Sick Days, Lower Extremities | Oct 7
5. Meds for Type 2 | Oct 14
6. Exercise and Preventing Microvascular Complications | Oct 21
7. Coping & Behavior Change | Oct 28
8. “The Big Finish” Test Taking Boot Camp | Nov 4

Can’t make it live?
No worries! All video presentations and podcasts will be available now on-demand.

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Accreditation: Diabetes Education Services is an approved provider by the California Board of Registered Nursing, Provider 12640, and Commission on Dietetic Registration (CDR), Provider DI002. Since these programs are approved by the CDR it satisfies the CE requirements for the CDCES regardless of your profession.*  

The use of DES products does not guarantee the successful passage of the CDCES exam. CBDCE does not endorse any preparatory or review materials for the CDCES exam, except for those published by CBDCE.

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For people with type 1 diabetes, access to Continuous Glucose Monitoring (CGM) technology, is considered a standard of care by most experts.

There is plenty of research that demonstrates CGM use is associated with not only improved A1c but significantly decreases time in hypoglycemic range and ketoacidosis rates.

Researchers wondered if this translates into cost savings?

YES.
According to a study presented at the Heart in Diabetes virtual meeting.

After three years of follow-up, the savings were substantial.

• Multiple daily injection plus CGM users saved between $5,777 and $8,549.
• CGM users with continuous subcutaneous insulin infusion saved between $2,732 and $4,753 per person, compared with non-CGM users.

“In this study, we showed that it didn’t make any difference how you deliver insulin,” Grunberger said. “This difference is in how you monitor glucose.”

George Grunberger, MD, FACP, MACE, Chairman Grunberger Diabetes Institute and more

Glucose Crises are Expensive

According to Grunberger, the cost of diabetes ketoacidosis (DKA) in the U.S. is over 5 billion dollars a year.

Having a CGM reduces DKA rates, hospitalization, and leads to cost savings.

A study in the United Kingdom showed that for 900 people using the Freestyle Libre (Abbott), DKA episodes were reduced by 80% within six months of using this device.

A study in Belgium followed 1,913 people with type 1 diabetes using the Freestyle Libre CGM.

Not only did they see a dramatic reduction in hospitalizations from DKA and hypoglycemia, but the researchers also observed a fifty percent drop in work absenteeism.

The data shows CGM’s are associated with cost savings due to less diabetes emergencies and decreased work absenteeism.

Full Story: Healio (free registration)/Endocrine Today (8/31) 

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Accreditation: Diabetes Education Services is an approved provider by the California Board of Registered Nursing, Provider 12640, and Commission on Dietetic Registration (CDR), Provider DI002. Since these programs are approved by the CDR it satisfies the CE requirements for the CDCES regardless of your profession.*  

The use of DES products does not guarantee the successful passage of the CDCES exam. CBDCE does not endorse any preparatory or review materials for the CDCES exam, except for those published by CBDCE.

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In March of this year, the Centers for Medicare and Medicaid Services (CMS) approved a $35 dollar monthly cap for Medicare Part D enrollees starting in 2021.

According to an ADA Survey, more than 1/3 of Medicare enrollees self-reported that cost limits their ability to purchase insulin.

In an attempt to make insulin more affordable for those enrolled in Medicare part D, CMS has agreed to limit the amount paid for monthly to no more than $35 per month. Insulins covered by participating plans will not be subject to the deductible or donut hole phases of Part D coverage.

Under this new option, Medicare enrollees with diabetes will pay $35 per each 30-day supply of a covered insulin prescription until they reach the catastrophic coverage phase, during which they will pay 5% co-insurance.

As beneficiaries have more consistent, predictable access to the prescription drugs they need, the model projects that health will improve and the total cost of care will decline for our nation’s senior population.

Medicare D Enrollment Cost

In exchange for these additional benefits, enhanced plans have slightly higher premiums, which are paid for by beneficiaries or through other means, such as a Medicare Advantage plan.

In 2020, average monthly premiums in Part D are $32.09 for a basic plan and $49.32 for an enhanced plan.

Affordability continues to be a barrier for people living with diabetes’ access to insulin. We hope that these changes are a step in the right direction for making insulin affordable for all.

Click ADA Website here to read more.

See CMS.gov Newsroom announcement here.

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We want to hear from you!

As changes like this happen, we find that feedback from our community helps us better understand how these changes apply to real-life situations. We want to know, how have these CMS changes impacted the people you work with? Fill out our quick survey to let us know!

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Insulin Cost Savings |
Resources for Diabetes Specialists

“The cost of insulin is a real problem. It can lead to insulin rationing and at its worst, people have died due to a lack of insulin,” explains Diana Isaacs, PharmD, BCPS, BC-ADM, BCACP, CDCES & ADCES 2020 Diabetes Educator of the year.

Read our article Insulin Cost Savings | Resources for Diabetes Specialists for insulin cost-saving resources.

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Some brands of long acting Metformin are being recalled since they contain higher than acceptable levels of NDMA (see list below).

The U.S. Food and Drug Administration has recommended recalls of certain metformin products that may contain the impurity N-nitrosodimethylamine (NDMA) above the acceptable intake limit.

Patients taking recalled metformin should continue taking it until a doctor or pharmacist gives them a replacement or a different treatment option. It could be dangerous for patients with type 2 diabetes to stop taking their metformin without first talking to their health care professional.

Remind patients not to stop medication until they check with their provider.

Find more info on the FDA Website here

Recalled Products

• The agency is also asking all manufacturers of extended release versions of metformin to evaluate their risk of excessive NDMA and to test at-risk product before each batch is released onto the U.S. market. If testing shows NDMA above the acceptable intake limit, the manufacturer must inform the agency and should not release the batch to the U.S. market.
• FDA’s testing has shown elevated levels of NDMA in some extended release (ER) metformin formulation but not in the immediate release (IR) formulation or in the active pharmaceutical ingredient.

For a complete listing of diabetes medications and insulin, download our DiabetesEd Medication PocketCards

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Join Meds Management for Type 2 Webinar with Coach Beverly

Purchase 1.5 CE | $29.00 or No CEs | Free

Written by Diana Isaacs, PharmD, BCPS, BC-ADM, BCACP, CDCES & ADCES 2020 Diabetes Educator of the year

The cost of insulin is a real problem. It can lead to insulin rationing and at its worst, people have died due to a lack of insulin.

A recent survey reported that 26% of respondents living in the US rationed insulin at last once in the last year.

The retail price for a box of insulin pens is about $500. Many people need more than one box of pens per month. Even with health insurance, people struggle to afford this. I remember one of my patients telling me she was only taking half of her prescribed dose of insulin glargine because her daughter was taking the same insulin and they both needed it. This just broke my heart!

Fortunately, the Food and Drug Administration (FDA), as well as drug companies, have heard the outcries from people who require insulin to live. In response, there are some helpful new programs that make insulin more affordable. However, it can be difficult to navigate all of the new information. To help make navigation easier, we have created an ADCES Access & Affordability page with Insulin Cost-Savings Resource Guide.

Here is a list of different strategies to access affordable insulin.

Why is insulin so expensive?

Insulin is considered a Biologic Drug, which makes it more expensive to produce.

Insulin is made from recombinant DNA technology, making it a biologic drug. Biologic drugs depend on unique manufacturing conditions that are proprietary and difficult to exactly replicate. Therefore, when the drug brand name patent expires, other companies can’t make true generics.

Until recently, the pathway for approval was called a follow-on biologic. This is how Basaglar (insulin glargine) and Admelog (insulin lispro) are classified. In March 2020, the FDA announced that regulatory requirements would change allowing for biosimilar products. This may ultimately increase market competitiveness in hopes to further reduce insulin prices. Basaglar and Admelog offer about a 15-20% discount from their reference products of Lantus and Humalog, respectively. Many argue these cost savings is just not enough.

Generic Insulins

Because insulin is a biologic drug, a true generic must come from the same manufacturer. Recently Lilly and Novo Nordisk have created generic insulins.

Lilly offers generics of insulin lispro, insulin lispro mix 75/25, and insulin lispro junior kwik pen.

Novo Nordisk offers generics of their insulin, which they are calling a “follow on Brand” and includes insulin apart and insulin aspart mix 70/30.

Both Lilly and Novo offer approximately a 50% cost savings from the original insulin product and the pharmacist can make an automatic substitution if you ask.

Walmart and some other pharmacies also offer ReliOn insulins. These include Novolin R, Novolin N, and Novolin 70/30. These are slower acting insulins that may predispose people to more hypoglycemia, but they are only $25/vial or $44/5 pack of pens and do not require a prescription in most states. Access to these insulins can be truly life-saving in some circumstances. Every person with diabetes needs to be aware that they can purchase these insulins without a prescription if they are ever out of insulin.

New Programs that Cap Insulin Pricing

Lilly announced a program capping insulin co-pays at $35/month for those paying with cash or commercial insurance. This will dramatically lower monthly costs for many people with diabetes.

Sanofi has a Valyou program that allows up to 10 vials or 10 boxes of insulin pens for a maximum of $99/month. Of note, Sanofi’s program will only work for those without insurance.

Novo Nordisk recently started the My $99 insulin program. What’s unique about this program is that it will work for those with commercial insurance or government plans like Medicare. Most other programs exclude people with Medicare. This program covers up to 3 vials or 2 packs of pens.

Co-Pay Cards

Most insulins offer a co-pay card which can bring down the price of insulin most commonly to $0 to $25/month depending on the manufacturer and type of insulin. For any person with a commercial insurance plan, it’s good to check if a co-pay card is available for the insulin before picking it up from the pharmacy.

The things to be aware of about these cards are that they have maximum savings and sometimes that is much less than the total cost of the insulin. Also, they only work for people with commercial insurance meaning they won’t for people without health insurance or that have a government insurance plan like Medicare. They also do not always work if the drug is not covered on the insurance plan. In that case, it would be preferable to switch to an insurance-covered on the insurance plan.

Patient Assistance Plans

These are programs offered through pharmaceutical companies for people without health insurance or that have Medicare but still struggle to pay for medications. There are various income requirements to be eligible, but depending on the program it can be 250-400% above the Federal poverty line. Many people are surprised to find that they are eligible, so this is a good option to look into which can make the insulin completely free. There is typically a packet of information that needs to be completed and then if eligible, the insulin is shipped to the prescriber’s office for the patient to pick up.

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In summary, It can be challenging to keep all of this information straight. This is why I worked with a team of amazing diabetes care and education specialists at ADCES to create the ADCES Access & Affordability page with Insulin Cost-Savings Resource Guide. We update this resource frequently and it includes links to patient assistance programs, co-pay cards, and other cost savings programs. We hope you find it useful and that your patients with diabetes will benefit.

Special thanks to our guest contributor for this article: Diana Isaacs, PharmD, BCPS, BC-ADM, BCACP, CDCES & ADCES 2020 Diabetes Educator of the year

References:

Conner F, Pfiester E, Elliott J, Slama-Chaudhry A. Unaffordable insulin: patients pay the price. The Lancet Diabetes & Endocrinology 7 (10), 748,2019.

For a summary of all this information, see the ADCES Insulin Cost Savings Resources Page.

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Accreditation: Diabetes Education Services is an approved provider by the California Board of Registered Nursing, Provider 12640, and Commission on Dietetic Registration (CDR), Provider DI002. Since these programs are approved by the CDR it satisfies the CE requirements for the CDCES regardless of your profession.*  

The use of DES products does not guarantee the successful passage of the CDCES exam. CBDCE does not endorse any preparatory or review materials for the CDCES exam, except for those published by CBDCE.

As the director of the diabetes research unit at the University of Texas Health Science Center at San Antonio, Ralph A. DeFronzo, MD, said, “Type 2 diabetes is a complex disease that often requires the use of multiple antidiabetic medications to improve glycemic control. Having three different diabetes medications in a single tablet is an important advance in diabetes treatment.”

Known as Trijardy XR, this medication combines the SGLT2 inhibitor empagliflozin, the DPP-IV inhibitor linagliptin, and metformin extended-release. Both empagliflozin and linagliptin lower blood glucose and empagliflozin has the added benefit of reducing the risk of cardiovascular death and chronic heart failure for those living with cardiovascular disease or chronic heart failure.

Additionally, a trial that was presented at the American Diabetes Association (ADA) Scientific Sessions by Healio found that linagliptin will not increase the risk for a cardiovascular event, nor will it contribute to the progression of renal disease among people with type 2 diabetes. This trial, known as the CARMELINA trial, was conducted over six years, across a group of 6,000 people. The trial demonstrated that no “between-group differences for the incidence of nonfatal myocardial infarction, nonfatal stroke and CV death during a median of 6 years.”

• Trijardy XR will be available in four dosages:
• 5 mg empagliflozin/2.5 mg linagliptin/1,000 mg metformin ER
• 10 mg empagliflozin/5 mg linagliptin/1,000 mg metformin ER
• 12.5 mg empagliflozin/2.5 mg linagliptin/1,000 mg metformin ER
• 25 mg empagliflozin/5 mg linagliptin/1,000 mg metformin ER.

There is no information on pricing as of yet. Read more about Trijardy here.

Sign up for Diabetes Blog Bytes – we post one daily Blog Byte from Monday to Friday. And of course, Tuesday is our Question of the Week. It’s Informative and FREE!  Sign up below!

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Happy Friday! As I get older, font sizes seem to be getting smaller. Excited to see the updated Injectables Algorithm, I turned my ADA Book to Standard 9 and quickly realized that in order to read the print, I had to hold the page inches from my nose. And there was no way could I read the footnotes even using my iphone flashlight to illuminate the words.

Thank goodness I collaborate with wonderful staff who boast youthful eyes and 2020 vision.

Robert (our Assistant Director and my high school senior) set to work recreating a draft of the document on Word. Getting the arrows to line up and fitting all the content in little boxes, was challenging, but he persevered. Taryn added the footnotes and I completed the final editing and the creation of the PDF.

We created this readable version because the algorithm is an important document that can be used to promote a collaborative practice.

Coach Beverly

I consider the ADA Standards my clinical “playbook”. The medication algorithms are of particular importance because it provides us with the opportunity to engage in a collaborative practice with our referring providers. “These are the evidence based medication recommendations from the ADA. I use it as a guide to recommend medication additions or changes”.

Enjoy our font enhanced Figure 9.2: Intensifying to Injectable Therapy

Then we can start a conversation exploring if a collaborative practice and medication adjustments using the algorithm is comfortable for the provider and perhaps include into our practice guidelines.

Enjoy this helpful 2 page reference guide, on us!

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Want more Standards of Care updates?

The 2020 Standards of Care is ready for viewing. Coach Beverly highlighted changes from 2019-2020 and summarized important need-to-know content for CDCES’s!

Purchase our Level 1 Standards of Care, or buy the full Level 1 bundle to benefit from all the 2020 updates! Earn 9.0 CEs for $109

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