Download Glucose Meters and Pattern Management

Monitoring and Management
Jennifer Danielson, PharmD, MBA, CDE
Clinical Assistant Professor
University of Washington School of Pharmacy
Learning Objectives
1.
2.
3.
4.
5.
6.
Identify patients who would benefit from self-monitoring of
blood glucose (SMBG).
Recommend how often patients should SMBG.
Interpret readings from SMBG.
Apply results of SMBG to recommending appropriate drug
therapy (e.g. pattern management).
Relate results from glucose meters to HbA1c results.
Discuss use of continuous glucose monitoring (CGM) and
interpret CGM trend results.
Treatment Guidelines
Healthy eating
Being active
Monitoring
Taking medication
Problem solving
Healthy coping
Reducing risks
Glycemic Goals
10.0
ADA A1c Goal < 7%
•Pre-prandial 80-130 mg/dL
•Post-prandial (PPG) < 180mg/dL
9.0
8.0
7.0
6.0
AACE A1c Goal < 6.5%
•Fasting plasma (FPG) < 110 mg/dL
•PPG < 140 mg/dL
Inpatient setting:
Acute care 140-180mg/dL
Upper range of normal
Critical care 110-140mg/dL
A1c 5.0
ADA. Diabetes Care 2013: 36 (supp 1): S1-S10.
AACE. Endocr Pract 2011; 17(supp 2): 1-53.
ADA Standards for SMBG
• SMBG for patients on multiple insulin injections or
pumps
–
–
–
–
–
–
Prior to meals/snacks
Occasionally post-prandial
Bedtime
Prior to exercise
Hypoglycemia
Prior to critical tasks (such as driving)
• SMBG is a useful guide for less frequent insulin
injections and non-insulin therapies
• When prescribing SMBG, ensure patients receive
ongoing instruction & evaluation, plus follow-up to
adjust therapy
ADA. Diabetes Care 2013: 36 (supp 1): S1-S10.
ADA Standards for SMBG
• CGM is a useful tool to lower A1c in
adults ≥25yo on multiple injections per
day or using a pump (Type 1)
• CGM may be useful for people younger
than 25yo
• CGM is a supplemental tool for patients
with hypoglycemia unawareness or
frequent hypoglycemia
ADA. Diabetes Care 2013: 36 (supp 1): S1-S10.
AACE
Standards
for
SMBG
In general, SMBG recommended for all patients with diabetes.
Patients using insulin:
Patients not using insulin:
•
•
•
≥2 times per day qnd before injections
More often, if not at A1c goal or
hypoglycemia
Recommended but the frequency of
testing should be individualized
CGM is a good for obtaining better A1c control and for patients with hypoglycemia
AACE. Endocr Pract 2011; 17(supp 2).
Randomized Trials in Type 2 Patients Not Using Insulin
Study
Design
Fontbonne et al.
19961
Randomized
Allen et al. 19902
Randomized
(n)
Duration
Results
68 = SMBG
72 = urine
68 = control
6 months
•50% compliance w/twice
QOD
•A1c reduction 0.5% 0.1% (not significant)
27 = SMBG
27 = urine
6 months
•87% compliance w/before
meals QOD
•A1c reduction 2% both
groups (not significant)
•25% compliance w/six
Muchmore et al.
Randomized 12 = SMBG*
40 weeks
times daily
3
1994
= control
Farmer A, Wade A, Goyder E, 11
et al.
Impact of self monitoring of blood glucose
•A1c reduction 1.5% &
in the management of patients*more
with intensive
non-insulin treated diabetes:0.8%
open
group
(notparallel
significant)
nutrition counseling
randomised trial. BMJ.2007; 335:132.
N=453, 3etyears,
mean
A1c 7.5%,
reduction60.17%
•100% compliance w/6
Schwedes
al.
Randomized
113A1c
= SMBG*
months(not significant)
20024
times per day
•A1c reduction 1% & 0.5%
(not significant)
110 = control
*more intensive
nutrition counseling
Guerci et al.
20035
Randomized
Davidson et al.
20056
Randomized
345 = SMBG
344 = control
6 months*
43 = SMBG
45 = control
6 months
(but >40% drop
out in both
groups)
(both received
diet
counseling/mgmt)
•Compliance unclear w/6
times per week
•A1c reduction 0.9% &
0.5% (significant)
•45% compliance w/before
and after meals 6 days/wk
•A1c reduction 0.8% &
0.6% (not significant)
Non-Randomized Trials in Type 2 DM
Using Insulin
Not Using Insulin
• Non-randomized trials
• At least 8 trials,
consistently showing
– Over dozen studies, most
relationship between
showing no relationship between
SMBG and A1c reduction
monitoring and A1c reduction
but not all randomized,
Fullerton
B, flaws
et al. 2SMBG in patients
Type
diabetes
who arehave
– with
Those
that2 show
difference
many with
with uneven treatment or
using
Cochrane Review: flaws
Jan 2012.
• not
Still,
A1c insulin.
reduction
1
self-selection
12
trials 0.16%
included
meta analysis, N=3259, A1c reduction 0.3%
range:
to in0.88%
Meta-analyses & Reviews
(significantatin6mos
all cases)
(significant
but not at •12mos)
– Conflicting results but suggest
that SMBG may be helpful in
gaining better glycemic control
– Significant reduction in A1c of
(depending on time measured
and statistical model used)2,3
1McAndrew,
et al. Does patient blood glucose monitoring Improve diabetes control? Systematic Review.
Diabetes Educator 2007 33: 991.
2Welschen, Bloemendal, Nijpels, et al. SMBG in patients with Type 2 diabetes not using insulin: a systematic review.
Diabetes Care 28:1510-1517, 2005.
2Ramachandra, Ellis. SMBG in insulin-requiring type 2 diabetes. Diabetes Tech and Thera 2008;10:S1.
3Fullerton B, et al. SMBG in patients with Type 2 diabetes who are not using insulin. Cochrane Review: Jan 2012.
SMBG in Type 2 Diabetes
Pre-requisites
Consequences
Awareness
•Diagnosis
•Knowledge
•Skills
•Achieve glycemic control
Understanding
in Cultural Context
•Reduce complications
Interpretation
•Improved quality of life
•Less symptom distress
•Improved patient attitudes
Response
MK Song, TH Lipman. Concept analysis: Self-monitoring in type 2 diabetes mellitus. Intnl Jour Nurs Stud. 45 (2008) 1700-1710.
ADA Standards for A1c Testing
Patient at goal:
A1c at ≥2 times/yr
Patient not at goal:
A1c quarterly
Use point of care
technology to provide
opportunity for timely
changes
http://wilburnmedicalusa.com/-c-0/siemens-dca-vantage-analyzer-p-149274?clid=CJK59qb7k8MCFVSSfgodnnkASQ
Cases 1 and 2
Pattern Management
Applying results of home blood glucose
monitoring to drug therapy management.
•
•
•
Recognizing highs/lows that occur in
patterns.
Adjusting drug therapy to address the
patterns of highs and lows seen.
Follow-up on results for changes made.
Lower
Fasting blood glucose
Postprandial blood glucose
Glucose Triad
A1c
Higher
Effect on Blood Glucose
Basal drugs  Fasting
Bolus drugs  Postprandial
•
•
•
•
• Short and rapid acting
insulin
Metformin
TZDs
Sulfonylureas
Intermediate and longacting insulin
– Lantus®
– Levemir®
– NPH
–
–
–
–
•
•
•
•
•
Regular
Humalog®
Novolog®
Apidra®
Sulfonylureas
Meglitinides
Acarbose
DPP-4 inhibitors
GLP-1 analogues
Effect on Blood Glucose
Basal drugs  Fasting
Bolus drugs  Postprandial
•
•
•
•
• Short and rapid acting
insulin
Metformin
TZDs
Sulfonylureas
Intermediate and longacting insulin
– Lantus®
– Levemir®
– NPH
–
–
–
–
•
•
•
•
•
Regular
Humalog®
Novolog®
Apidra®
Sulfonylureas
Meglitinides
Acarbose
DPP-4 inhibitors
GLP-1 analogues
Slide adapted from Zane Brown, MD Professor UW Medicine
Case Example
B
104
106
118
120
126
122
L
146
136
132
D
110
HS
176
164
126
222
148
138
134
116
212
Case Example
B
104
106
118
120
126
122
L
146
136
132
D
110
HS
176
164
126
222
148
138
134
116
212
Case Example
B
110
98
118
112
96
102
L
126
72
110
120
64
102
D
118
56
126
100
HS
196
202
188
164
212
194
Estimated Average Glucose (eAG)
http://professional.diabetes.org/GlucoseCalculator.aspx
Formula: 28.7 x A1C – 46.7 = eAG
eAG (CI 95%)
97
126
154
183
212
249
269
298
(76-120)
(100-152)
(123-185)
(147-217)
(170-249)
(192-282)
(217-314)
(240-347)
A1c
•wide CIs
•weighted
most to last
30 days
5%
6%
7%
8%
9%
10%
11%
12%
Diabetes Care 2008. 31:1473-1478
What if you saw it like this?
250
200
150
100
50
0
SD
Actual Download Print-Out
Print out image from: CliniPro by Numedics
Cases 3 through 5
Continuous Glucose Monitoring
• Alternative site testing
– Measures subcutaneous fluid not blood
– ~10 minute delay in results
– Must know the caveats with hypoglycemia
• Continuous Glucose Monitoring Systems
–
–
–
–
Medtronic Guardian REALtime CGMS
Dexcom SEVEN
Minimed Paradigm
Abbott FreeStyle Navigator
Daily Use
• Glucose change is gradual.
• Glucose is increasing moderately.
• Glucose is increasing rapidly.
• Glucose is decreasing moderately.
• Glucose is decreasing rapidly.
CGM Interpretation
• What should the patient do to respond?
72 mg/dL
11:10 am
CGM Interpretation
• What should the patient do to respond?
72 mg/dL
11:25 am
CGM Interpretation
• What should the patient do to respond?
118 mg/dL
12:20 pm
CGM Interpretation
• What should the patient do to respond?
196 mg/dL
2:02 pm