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Introduction To Glucose Monitoring In Diabetes Seyed Adel Jahed, M.D., Endocrinologist

Introduction To Glucose Monitoring In Diabetes Seyed Adel Jahed, M.D., Endocrinologist Gabric Diabetes Education Association. 7 th Aug 2019 RIES Tehran, Iran. Agenda. HbA 1c SMBG CGMS. Disclosures. I have taken part in scientific congresses with sponsorship by:

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Introduction To Glucose Monitoring In Diabetes Seyed Adel Jahed, M.D., Endocrinologist

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  1. Introduction To Glucose Monitoring In Diabetes Seyed Adel Jahed, M.D., Endocrinologist Gabric Diabetes Education Association 7th Aug 2019 RIESTehran, Iran

  2. Agenda HbA1c SMBG CGMS

  3. Disclosures I have taken part in scientific congresses with sponsorship by: • Medtronic (Iran-Behdasht) • Roche I am a regular user of Flash-Libre Freestyle

  4. Traditional means of control

  5. Rahbar S. An abnormal hemoglobin in red cells of diabetics.ClinChimActa. 1968; 22:296-8. Gebel E. Diabetes Care. 2012; 35:2429-31. Azizi MH, et al. Arch Iran Med. 2013; 16:743 – 45.

  6. A quarter century ago:the DCCT is establishing the importance of HbA1c The Diabetes Control and Complications Trial Research Group. N Engl J Med 1993; 329:977-86.

  7. The DCCT: Hypoglycemia alarms The Diabetes Control and Complications Trial Research Group. N Engl J Med 1993; 329:977-86.

  8. The wrong conclusion taken from DCCT do we really need to compromise between control and hypoglycemia? Dahl-Jørgensen. Diabetologia. 1994;37(12):1172-7.

  9. Lack of association between HbA1c levels and hypoglycemia risk Munshi MN, et al. J Diabetes Complications. 2017;31:1197-9.

  10. HbA1c can be lowered without increased risk of hypoglycemia • Relative risk for severe hypoglycemia and hypoglycemic coma by HbA1c category for each treatment year • A trend analysis in a cohort of 37,539 patients • It covers an estimated proportion of 80% of all pediatric diabetes patients in Germany and Austria. 1995 2012 1995 2012 Karges B, et al. PLOS Medicine 2014;11(10): e1001742. https://doi.org/10.1371/journal.pmed.1001742

  11. The limitation of HbA1c officially stated in “the Standards of Care 2018” • HbA1C does not provide a measure of glycemic variability or hypoglycemia. For patients prone to glycemic variability, especially patients with T1DM T2DM with severe insulin deficiency, glycemic control is best evaluated by the combination of results from HbA1C and SMBG or CGM. Diabetes Care 2018;41(Suppl. 1):S55–S64 | https://doi.org/10.2337/dc18-S006

  12. Self-Monitoring of Blood Glucose • (SMBG)

  13. SMBG is an outcome measurement component of “monitoring,” which is included in the AADE7 (American Association of Diabetes Educators) Self-Care Behavior among the other six diabetes self-care behaviors: • being active • following a healthy eating plan • taking medications properly • practicing healthy coping strategies • reducing risks • problem solving • SMBG allows patients to evaluate their individual response to therapy and assess whether glycemic targets are being achieved. SMBG is an integral component of effective therapy. Diabetes Care 2016 Jan; 39(Supplement 1): S1-S2.

  14. T1DM: correlation between greater SMBG frequency and lower HbA1C 11.0 10.5 10.0 9.5 9.0 Mean A1C • 13-26 years 8.5 • 1-13 years 8.0 7.5 • 26-50 years • > 50 years 7.0 6.5 0-2 3-4 5-6 7-8 9-10 11-12 ≥13 SMBG per day Miller KM, et al. Diabetes Care. 2013;36:2009-14.

  15. Major clinical trials of insulin-treated patients have included SMBG as part of the multifactorial interventions to demonstrate the benefit of intensive glycemic control on diabetes complications.

  16. Appropriate frequency and timing of SMBG • No universally accepted standards for frequency and timing • Many factors should be considered: • Type of diabetes • Willingness to perform SMBG • Level of diabetes control • Medication regimen • Lifestyle and daily schedule with regard to activity, food, and work • Physical ability to check blood glucose • Ability to problem-solve and take action • Financial limitations • Comorbid conditions

  17. SMBG for people with T1DM or T2DM on MDI regimen • Before meals and snacks • Post-prandials(occasionally) • At bedtime • Before exercise • When hypoglycemia is suspected • After hypoglycemia treatment (until normoglycemia is attained) • Before crucial tasks such as driving

  18. Patterns in doing SMBG

  19. Structured testing • For people with non-insulin treated T2DM the 2009 IDF SMBG guidelines suggest: “Focused” SMBG regimens based on the specific glucose data required (i.e., fasting vs. postprandial)

  20. Possible testing regimens • meal-based testing schemes: • The 3-point regimen • The 5-point regimen • The 7-point regimen • The staggered-frequency regimen • Goal: • the effect of food consumed on the rise in blood glucose after specific mealtimes Austin, M. M. Diabetes Spectrum, 2013;26(2), 83-90.

  21. Three-point SMBG profileto check FPG and the effect of the largest meal

  22. Five-point SMBG profileto check FPG and the effect of the two large meals

  23. Seven-point SMBG profileto check FPG and the effect of all meals

  24. Paired meal-based SMBG profile(less intensive)

  25. Paired testing • Paired testing, before and 1–2 hours after a meal, has gained attention in recent years. • Research by Monnieret al. concluded that, as HbA1C approaches a target of 7%, postprandial blood glucose contributes more to the HbA1C result than does FPG. • In such situations, diabetes educators should encourage individuals to focus their efforts on reaching their postprandial blood glucose targets.

  26. Difficulty in coping? • Patients who resist performing SMBG 7-times/day for several days could instead Perform fewer tests over several days at a specific mealtime and then rotate testing every several days until all mealtimes can be assessed.

  27. Paired meal-specific SMBG profile- 1st week

  28. Paired meal-specific SMBG profile- 2nd week

  29. Paired meal-specific SMBG profile- 3rd week

  30. Paired meal-specific SMBG profileAll 3 weeks

  31. SMBG profile to assess fasting hyperglycemia

  32. Targeted SMBG profile (one test per day) weeks 1-2

  33. Targeted SMBG profile (one test per day)weeks 3-4

  34. Targeted SMBG profile (one test per day)weeks 5-6

  35. Targeted SMBG profile (one test per day)All weeks 1-6

  36. Staggered SMBG profileIn following controlled busy cases

  37. How to choose a Glucometer?

  38. SMBG Education Checklist • Operational Skills: Using the Meter • Selecting a meter • Ensuring meter accuracy • Documenting SMBG data • Addressing individual needs • Interpretation Skills: Using SMBG Data • Knowing blood glucose targets • Knowing the appropriate frequency and timing of glucose tests • Using pattern management in decision-making

  39. ISO 15197:2013 Standard require tighter BGMS accuracy

  40. Parkes consensus error grid for patients with diabetes The version for type 1 diabetes is used for regulatory purposes Parkes JL, et al. Diabetes Care. 2000; 23(8):1143-8.

  41. Parkes consensus error grid Parkes JL, et al. Diabetes Care. 2000; 23(8):1143-8.

  42. Factors that can affect glucose meter results • Tonyushkina K, Nichols JH. Journal of diabetes science and technology, 2009;3:971-80.

  43. Alternate site testing (AST) KarstenJungheim et al. Diabetes Care 2001;24(7)

  44. Alternate Site Testing (AST) • Meters are available that allow SMBG using blood samples from sites other than the fingertip (forearm, palm of the hand, thigh). • Accuracyof results over a wide range of BG levels and during periods of rapid change in BG levels is variable across sites. • During periods of rapid change in BG levels (e.g. after meals, after exercise and during hypoglycemia), fingertip testing has been shown to more accurately reflect glycemic status than forearm or thigh testing. • In comparison, blood samples taken from the palm near the base of the thumb (the thenar area)demonstrate a closer correlation to fingertip samples at all times of day and during periods of rapid change in BG levels. Berard, L. D. (2013). Can. J. Diabetes, (37).

  45. Interpreting SMBG

  46. Interpreting SMBG • If patients’ healthcare team does not use the SMBG data in clinical decision-making, then SMBG is of no value and a waste of resources! • Interpreting SMBG: problem-solving self-care behavior • Teaching patients problem-solving skills to act on SMBG results is crucial to improve outcomes.

  47. Problem-solving skills: The way to behavior change • Diabetes educators: key role in teaching problem-solving skills • Encouragingindividuals to write their blood glucose values • Logbook: linear and vertical manner to review results

  48. Pattern management in SMBG interpretation

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