Metabolic & Endocrine Disease Summit (MEDS) Newsletter
Amy Butts PA-C, BC-ADM
By: Ellen D. Mandel DMH, MS, PA-C, RDN
Aesop’s Fable: How Smart Insulin Pen Technology Wins the Race
MEDS welcomes Amy Butts PA, a talented and experienced clinician to its faculty ranks. Amy has been an Endocrine PA for more than two decades and her passion for this clinical area precedes her PA education. Amy credits her strong family history of both types 1 and 2 diabetes mellitus combined with a PA rotation scheduling glitch as the reason for her out-of-the-gate PA job. As she explains, her cardiovascular rotation was canceled leaving her with an open rotation slot. Being resourceful, she contacted the Endocrinologist with whom she had a previous rotation and secured more time with him. Lucky for Amy and MEDS, she did such a great job; she was offered the position upon graduation. She has a roster of over 4,000 patients now. Life is like that!
In addition to her employment, Amy applies her passion to improving diabetes patient care nationally with her American Diabetes Association (ADA) membership on their Primary Care Advisory Group and by serving on the Editorial Board for Clinical Diabetes. Additionally, she is Education Committee Chair of the American Society of Endocrine PAs (ASEPA). As with many MEDS faculty members, where does she find the time?
A love of technology drove her decision to become an insulin pump trainer early on. She describes how she loves “pushing buttons and playing around” with devices. This logically led to pioneering usage of smart insulin pen technology in her practice. Amy will be discussing how to incorporate this technology as it becomes increasingly prevalent due to more companies securing FDA approval and as its use expands to children.
Amy thinks there are many challenges with insulin delivery for people with diabetes (PWD) - missed doses, forgetting devices, and skipping meals. She notes that missing just two-mealtime injections/week can elevate A1c by 0.3% - 0.4%. Further, bringing continuous glucose monitoring (CGM) into patient care and integrating it to smart insulin pen technology provides a vehicle for patients to understand how their behaviors impact their own glucose control.
Amy will be presenting with two other lecturers on the topic of “Diabetes Technology” for the July MEDS. She will weave her philosophy of how patient empowerment builds essential trust and directly supports diabetes technology inclusion in her clinical practice. With the application of CGM and smart insulin pen technology, an improved time in range (TIR) is attainable. Amy notes, “We as a medical community have been taught and engaged with A1c, it is our ‘go to’ in evaluating patient control. However, CGM has opened our eyes to how using only the A1c has limited our knowledge.” Amy contends that the A1c alone is not really the best approach. TIR, glycemic variability, and eliminating extreme excursions are also major players. MEDS attendees will learn how to incorporate this technology into their practice.
During Amy’s career, she has been exposed to implicit clinician bias; it’s not always the patient’s fault when goals are not attained. For example, clinicians bear some responsibility when considering recent data from the “T1D Exchange” clinic registry, which demonstrates that only a minority of adults and youth with T1DM meet ADA goals for HbA1c. Further, although CGM use has substantially increased in recent years, racial disparities remain in both technology use and glycemic control.
Amy will explain how to combat numeracy challenges, the ability to understand and work with numbers, and how smart insulin pen technology helps. She consistently sees how it can be successfully used in carbohydrate counting leading to a better quality of life as well as improved TIR for her patients.
Amy’s philosophy will resonate with MEDS attendees. She stresses a patient centric model of care, with individualization, collaboration, and mutual goal setting. Aesop’s Fable of the Tortoise and the Hare exemplifies her strong belief in positive thinking and patient empowerment. Minimizing negativity reduces patient discouragement and deflation. Amy says, “Focus on what works and remember that slow and steady wins the race.” She wants her patients to enjoy their office visits and look forward to seeing her; showing up is a key to care. MEDS attendees will want to see Amy’s presentation too!
Devices & Technology: “What is a smart insulin pen?”
https://www.diabetes.org/healthy-living/devices-technology/smart-insulin-pen Accessed 20210614.
Foster NC, Beck RW, Miller KM et al. State of Type 1 Diabetes Management and Outcomes from the T1D Exchange in 2016–2018 Diabetes Technology & Therapeutics, 2019;21(2):66-72. doi: 10.1089/dia.2018.0384
https://investor.lilly.com/news-releases/news-release-details/lilly-collaborates-internationally-leading-diabetes-technology. Accessed 20210614.
https://www.medtronicdiabetes.com/products/inpen-smart-insulin-pen-system. Accessed 20210607.
https://www.novonordisk.com/our-products/smart-pens/novopen-6.html. Accessed 20210607.
Randlov I, and Poulsen JU. How Much Do Forgotten Insulin Injections Matter to Hemoglobin A1c in People with Diabetes? A Simulation Study. J Diabetes Sci Technology. 2008;Mar; 2(2): 229–235. doi: 10.1177/193229680800200209.
Warshaw H, Isaacs D, and MacLeod J. The Reference Guide to Integrate Smart Insulin Pens into Data-Driven Diabetes Care and Education Services. The Diabetes Educator. 2020; Vol. 46, Supplement 4: 3S – 20S. doi.org/10.1177/0145721720930183
The Endocrine World of AI
Interview With: Ashlyn Smith PA-C
By: Ellen D. Mandel DMH, MS, PA-C, RDN
In the world of endocrine disorders, AI has nothing in common with artificial intelligence and Ashlyn Smith can tell us why. As a PA working for nearly ten years in Endocrinology, she has seen many cases of adrenal insufficiency, the real AI of endocrine disorders. Ashlyn explains that her love of Endocrinology grew from an initial undergraduate knowledge deficit, which she strove to correct through intentional PA school rotations and intensive study. She now works full time in an adult Endocrine practice in Arizona, where she balances her leadership role as president of the American Society of Endocrine PAs, along with teaching for Midwestern University. Fortunately for us, MEDS attendees will gain important knowledge about AI during the July virtual sessions.
Ashlyn is one of the newer members of the MEDS faculty, joining during the pandemic, and she quickly came to recognize the quality and passion of her faculty peers. She describes her realization that there were essentially no other symposia that specifically catered to the NP/PA audience, and how MEDS filled an essential patient care niche across the country.
When it comes to AI and the Primary Care clinician, Ashlyn has a few pointers. First, AI does not always present in a textbook manner. While classic primary AI presentation includes hypotension, hyponatremia, hyperkalemia, abdominal pain and hyperpigmentation, not all cases fit this pattern. AI may present due to secondary causes such as prolonged use of steroids used to treat many common medical disorders including autoimmune diseases, rheumatologic conditions, COPD and even severe migraines. As with many endocrine disorders, the patient’s past medical history—often a complex puzzle—may seem like, yet not result in, an AI diagnosis.
A key point, which Ashlyn will describe in greater detail during MEDS, is the importance of the appropriate selection and timing of laboratory testing. She provides examples of clinicians using random testing of adrenal and pituitary hormones resulting in either misdiagnosis or missed diagnoses of AI and other endocrine disorders. Ashlyn will also describe how she finesses her approach to patients who have self-diagnosed AI or been led to erroneously believe they have AI through internet searches or care given by non-allopathically medically trained providers. With so much misinformation, Ashlyn’s endocrine acumen comes into play as she stays abreast of research on this topic and applies cutting edge decision-making and treatment options for her patients.
Many MEDS attendees hail from Primary Care practices, and may be challenged in making an AI diagnosis. Ashlyn will detail the how and when of testing and proper referrals. She will explain how common co-morbidities such as depression, anxiety, obesity, trauma and medication classes may mimic AI and interfere with diagnostic testing, leading the clinician down an unnecessary and costly diagnostic trail. AI is not a clear-cut diagnosis, but Ashlyn reassures Primary Care clinicians that they can correctly begin the diagnostic process by following the simple rules she will describe at MEDS.
Ashlyn has worked throughout the COVID pandemic, dealing with self-referred patients with legitimate complaints of fatigue, insomnia, weight gain and lethargy. Ashlyn explains that empathy is essential and must be combined with appropriate testing and diagnosis. As patients return to their pre-COVID lives, they may notice weight gain and increased fatigue with activities of daily living. Some will seek out an endocrine causality. Those who experienced a COVID infection may develop as-yet-unknown effects of the virus and its treatment on their adrenals and other endocrine organs. Ashlyn plans to cover a significant amount of vital information to correctly diagnose and treat AI, demonstrating that there is nothing artificial to her endocrine intelligence.
Bornstein SR, Allolio B, Arlt W et al. Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2016;101(2):364-389.
Fleseriu M, Hashim IA, Karavitaki N et al. Hormonal Replacement in Hypopituitarism in Adults: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2016;101(11):3888-3921.
PCOS: A Common Female Endocrinopathy
Interview With: Mimi Secor, DNP, FNP-BC
By: Ellen D. Mandel, DMH, MS, PA-C, RDN
Stein and Leventhal initially described what is now called Polycystic Ovarian Syndrome (PCOS) in 1935, and likely would not have predicted how much remains unknown of a condition with an estimated prevalence of 5-15%, which supports the difficulty of its diagnosis. PCOS, now considered one of the most common endocrinopathies affecting women is near and dear to Mimi Secor’s heart. Mimi has had an interesting career, beginning as an ER nurse, moving along into GYN practices, and starting her own business, while fitting in 10 years as an NP in Alaska. And keep in mind—Mimi was not around in 1935.
When asked how she gravitated to this specialty area, she replied that in the course of her workday, she saw so many women in distress with PCOS-like symptoms, and felt that she could be helpful. Challenged with this opportunity, she dug into learning as much as possible, noting that “We often don’t like what we don’t have adequate knowledge and experience in.” This mantra is why MEDS is so fortunate to have Mimi as faculty from its inception and how attendees rave about her lectures. Conversely, Mimi is also fueled by the sophistication of questions from the PA/NP attendees.
As common as PCOS is, its diagnosis is not always so straightforward, and there is more than one set of guidelines in the literature. Mimi will explain, a PCOS diagnosis is primarily clinical, not laboratory based and has core findings of hyperandrogenism, insulin resistance, and chronic anovulation.
However, the plot thickens as one considers how anovulation manifests with such menstrual questions as frequency, missed or skipped, and duration of each bleed along with the possibility of pregnancy. Also, when should the clock start ticking relative to an expected normalcy of menstrual cycles?
A clinical diagnosis is often challenging, as clinicians might prefer a firm set of laboratory tests to establish the diagnosis. NPs and PAs may recall the commonly published ovary ultrasound textbook image of the “string of pearls.” Mimi will explain how this textbook image may contribute to, but not make the actual diagnosis.
Mimi’s many years working with women with PCOS has heightened her skill set in broaching the topic of family planning. Clinicians know that abnormal menses bodes poorly for conception success. Similar to many endocrine disorders, PCOS seems to run in families. Therefore, women may come to a Primary Care office for a PCOS work-up already stressed about their chances of current or future childbearing. They may know of aunts, siblings or grandmothers with worst-case stories about failed conception outcomes. Through case studies, Mimi will expound on broaching the conception topic, which is pertinent to women even with no immediate interest in conception.
An interesting idea is the possibility that PCOS is another variant of diabetes. Years ago, clinicians concerned themselves with juvenile and maturity onset diabetes only, until laboratory and genetic testing revealed the diagnostic in-between. Another point that Mimi will discuss is the role of a new laboratory marker, sex hormone-binding globulin (SHBG) as a diagnostic tool. SHBG is a glycoprotein, which regulates the bioavailability of sex steroid hormones (think testosterone) and has an inverse association with PCOS, obesity, insulin resistance, metabolic syndrome, and type 2 diabetes mellitus. At times, Primary Care clinicians note the availability of a new lab test and feel compelled to order it. Mimi will explain why this approach may not be in the best interest of the patient while it drives up healthcare costs.
Stein and Leventhal bear the eponymous precursor to PCOS and there is much to learn. Are there any cardiometabolic risks associated with PCOS? How can we best minimize future morbidity and mortality through early identification and treatment? What lab tests might you consider as you work through PCOS lookalikes? Does the microbiome hold any answers to PCOS? Mimi will teach us that PCOS is not a just a string of pearls, but a potentially life altering condition which Primary Care attendees may translate into real world diagnosis and management.
Bednarska S and Siejka A. The Pathogenesis and Treatment of Polycystic Ovary Syndrome: What’s New?” Adv Clin Exp Med. 2017;26(2):359-367.
Deswal R, Yadav A and Dang AS. Sex Hormone Binding Globulin – an Important Biomarker for Predicting PCOS Risk: A Systematic Review and Meta-Analysis. Biology in Reproductive Medicine. 2018;64(1):12-24.
Lagana AS, Vitale SG, Noventa M and Vitagliano A. Editorial: Current Management of Polycystic Ovary Syndrome: From Bench to Bedside. International Journal of Endocrinology. 2018; https://doi.org/10.1155/2018/7234543.
Rasquin Leon LI and Mayrin JV. Polycystic Ovarian Disease. https://www.ncbi.nlm.nih.gov/books/NBK459251/. Last Updated July 10, 2020. Accessed May 8, 2021.
Introducing MEDS for 2021: Essential Endocrinology Topics for Essential Clinicians
Diabetes, thyroid conditions, kidney disease, obesity and lipid disorders are all singular non-communicable epidemics and taken together are a global pandemic. In 2021, this is not news. However, more than a decade ago, a pioneering Physician Assistant (PA), Scott Urquhart had a vision; how can cost-effective and high-quality medical care for endocrine related conditions be delivered with a relative national shortage of Endocrinologists?
Working as an Endocrine PA in a busy practice in West Virginia, he knew first-hand the toll these common endocrine disorders were taking and wanted to make a real and bigger difference. He knew that advance practice providers, Nurse Practitioners and PAs teaming up with physicians held the answer to the ever-expanding patient care void. He had his endgame in sight but needed other players on board to bring it to fruition.
Fortunately, he discovered a willing and progressive partner and MEDS – Metabolic & Endocrine Disease Summit was born. This partnership was the beginning of a now ten-year success story of bringing practical endocrine management strategies to NPs and PAs working in primary care and other related specialty offices across the country. An aggressive presentation schedule was implemented with MEDS offered twice a year in family-friendly venues (what better way to bring together primary care clinicians). As pharmacotherapeutics and technology were taking off, clinicians needed to be ahead of the curve, and just as important, needed to build and assure their confidence in safely and efficiently applying these treatment game-changers. Scott was proven right, as a capacity crowd filled the room for the first ever MEDS in Orlando, Florida.
As the vision took shape, selecting the right faculty was imperative. Faculty needed advanced knowledge and experience, along with excellent translational skills. With a high bar, MEDS faculty focused on the mantra of translating the complex language of endocrine; the why, who, how, and when of endocrine disorders into practical, doable advice for dedicated clinicians to carry back to their offices.
Scott collaborated with Christine Kessler, an NP leader in the endocrine community to draw experts in diabetes, disorders of the thyroid, adrenal, bone, and pituitary as well as lipids, nutrition, PCOS, and testosterone. Both CME and non-CME learning were included to achieve affordable registration fees and bring the newest options to the Summit.
As MEDS enters its eleventh year, the physician-NP-PA team has markedly expanded as MEDS’ “graduates” spread out across the nation with the word of how great MEDS is and what it does for their patient care capabilities. Since its inception, MEDS has educated over 10,000 clinicians, offering an average of 22 affordable CME/CEUs per Symposium. MEDS anticipates 1000 registrants for its upcoming virtual meeting. Many registrants attend more than once for knowledge updates and refreshers, while friendships flourish with the mutual desire to provide excellent patient care.
MEDS has been nimble as it partnered with MedscapeLive! to continue its mission. For the present time, it has pivoted to a virtual platform, streamlined its offerings, and continues to engage excellent clinician educators. MEDS offers core endocrine educational offerings coupled with the new and exciting.
Take a sneak peek at the lecture and case-based learning topics of MEDS 2021 for July and October – you’ll see there is nothing static or boring about endocrinology! The Agenda may be found here.
— Ellen D. Mandel, DMH, MS, PA-C, RDN
Meet Rick Pope PA-C
Rick Pope, PA-C, a founding MEDS lecturer will join us again for our July 2021 virtual symposium. His topic: “Osteoporosis – Who We Screen, Who Needs Bone-Density? FRAX, and Current Recommendations for Therapy” is not just for “boneheads,” a term Rick uses with the utmost respect. Indeed, osteoporosis (OP), defined by a statistically significant loss of bone mineral density, leads to significant morbidity, mortality and is commonly seen in both Primary Care and Rheumatology/Endocrine practices.
Rick should know, he spent the bulk of his 30-plus year clinical career as a Rheumatology PA, having been recruited away from Pediatrics by a Rheumatologist desiring a PA in his practice. Rick presently teaches rheumatology topics to all five Connecticut PA programs as well as DNP students at the University of California (Irvine). He notes that the American College of Rheumatology now endorses hiring NPs and PAs due to a long-standing, nationwide shortage of Rheumatologists. The rising numbers of OP cannot be ignored. The National Osteoporosis Foundation (NOF) reports that 10 million Americans have OP and another 44 million have low bone density, placing them at risk for future OP: it is estimated to be responsible for 3 million fractures costing greater than $25 billion by 2025. As OP numbers continue to rise, primary care clinicians can tackle its diagnosis and management; Rick aims to tell us how.
OP treatment options have continued to evolve, with real advancements in the past few years, moving beyond bisphosphonates, a decade’s old drug. Rick explains that proper diagnosis and treatment is like a bone matrix, a puzzle of sorts whereby patients’ age, gender, ethnicity, activity pattern, smoking history, calcium, and vitamin D intakes along with socio-economic status all come together to formulate risk and help direct treatment strategies. It is more than just adequate vitamin D and calcium intake. He specifically wants to dispel the myth that hip fracture, or any OP related fracture (i.e. Colles, vertebral) is simply bad luck. Social determinants of health, a long-ignored concept plays an impactful role in OP. Rick points out that lifelong habits, as well as medical IQ affect OP risk. How do people learn about OP prevention, find a clinician and learn the right questions to ask to secure their own best care? Medically trained people have a high medical IQ, not so of most people. This supports his desire to educate NPs and PAs with MEDS.
There are a number of key updates to OP pharmacotherapeutics, which will be detailed at the upcoming MEDS. Rick will describe the recent (November 2020) removal of the FDA’s Black Box warning on teriparatide (Bonsity, Forteo) for patients using this PTH analog. Although the two-year use maximum has been removed, just how long they can be used remains open. Think bone markers!
Another OP concern has been balancing the risk of fragility fracture with the risk of atypical femur fracture with long-term bisphosphonate therapy. A 2020 publication in the New England Journal of Medicine followed >197,000 women (Kaiser Permanente) over the age of 50 years for a ten-year period and provides answers to this key question with some unexpected results. Rick will detail a helpful response to your patients’ questions about long-term risks of bisphosphonate therapy and ethnicity’s role.
Another question often posed by patients with existing OP relates to the risk of high impact exercise. Will it promote fractures, worsen osteopenia, or provide benefit? A recently published Australian study in the Journal of Bone and Mineral Research, examines the impact of high-intensity resistance and impact training’s effect on bone mineral density, as well as physical function in postmenopausal women with both osteopenia and OP. Rick will explain how the results of this LIFTMOR study may impact exercise decisions.
If you think OP is a dull topic, there are new, literally hot-off-the-press screening guidelines issued by the United States Preventive Services Task Force (USPSTF) for vitamin D. Rick has a lot to say about these guidelines and plans to review their translation and application for the general population versus those with OP. For example, which form of vitamin D (D2 or D3) might be more beneficial? There is so much to learn about bone health and Rick plans to cover as much terrain as possible. His lecture style converts complicated concepts to advice you can take back to your office. Rick continues to crack the code of bone health, helping to ease patient conversation and provide the best treatment options.
1. Osteoporosis – Fast Facts.pdf
2. Highlights of Prescribing Information: Forteo. Forteo-pi.pdf Accessed 20210422.
3. Black DM, Geiger EJ, Eastell R, et al. Atypical Femur Fracture Risk versus Fragility Fracture Prevention with Bisphosphonates. New England Journal of Medicine. 2020:383(8);743-53.
4. Watson SL, Weeks BK, Weis LJ, et al. High-Intensity Resistance and Impact Training Improves Bone Mineral Density and Physical Function in Postmenopausal Women With Osteopenia and Osteoporosis: The LIFTMOR Randomized Controlled Trial. Journal of Bone and Mineral Research. 2018;33(2):211-220.
5. Screening for Vitamin D Deficiency in Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2021:325(14);1436-1442.
— Ellen D. Mandel, DMH, MS, PA-C, RDN