clinical case studies (smbg) - diabetes technology society · 2016-04-29 · clinical case studies...
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Clinical Case Studies (SMBG)
Jane Seley, DNP, MPH, MSN, BC-ADM, CDE, CDTC, CEDT
New York Presbyterian/ Weill Cornell Medical CenterNew York, New York
Blood Glucose MonitoringClinical Case Studies
Jane Jeffrie SeleyDNPMPHGNPBC-ADMCDECDTCEDTCFAAN
DiabetesNursePractitionerNewYork-PresbyterianHospital
WeillCornellMedicineNewYork,NY
Topics• DiagnosingDiabetes• Frequency&timingofbloodglucose(BG)
monitoringinrelationtodiabetesmeds• Structured testing& patternanalysis• Usingsoftwaretoidentifypatterns• MotivatingpatientstomonitorBG• WhattodowhenA1c&BGdoesn’tmatch
AmericanDiabetesAssociationCriteriafortheDiagnosisofDiabetes
A1C≥6.5%.ThetestshouldbeperformedinalaboratoryusingamethodthatisNGSPcertifiedandstandardizedtotheDCCTassay.*ORFPG≥126mg/dL (7.0mmol/L).Fastingisdefinedasnocaloricintakeforatleast8h.*OR2-hPG≥200mg/dL (11.1mmol/L)duringanOGTT.ThetestshouldbeperformedasdescribedbytheWHO,usingaglucoseloadcontainingtheequivalentof75ganhydrousglucosedissolvedinwater.*ORInapatientwithclassicsymptomsofhyperglycemiaorhyperglycemiccrisis,arandomplasmaglucose≥200mg/dL (11.1mmol/L).
↵*Intheabsenceofunequivocalhyperglycemia, resultsshouldbeconfirmedbyrepeattesting.
AmericanDiabetesAssociation.(2016).2.ClassificationandDiagnosisofDiabetes.DiabetesCare,39(Supplement1),S13-S22.
DiagnosingDiabetesSUMMARY
Fastingplasmaglucose(FPG)≥126mg/dL (7.0mmol/L)*
OR2-hplasmaglucose ≥200mg/dL(11.1mmol/L)during anOGTT*
ORA1C≥6.5%*
ORRandomplasmaglucose
≥200mg/dL(11.1mmol/L)
AmericanDiabetesAssociationStandardsofMedicalCareinDiabetes.Classificationanddiagnosisofdiabetes.DiabetesCare2016;39(Suppl.1):S13-S22
*Intheabsenceofunequivocalhyperglycemia, resultsshouldbeconfirmedbyrepeattesting.
KeyTimesToCheckBloodGlucose• BeforeMeals
• AfterMeals(1-2hours)
• BeforeBed
• Wheneverhypoglycemiaorhyperglycemiaissuspected
• StartwithaskingpatienthowmanytimesadaytheyarewillingtocheckBG
-Hirsch, etal.(2008).Self-monitoring ofbloodglucose(SMBG)ininsulin- andnon-insulin-using adultswithdiabetes:Consensusrecommendations forimprovingSMBGaccuracy,utilization, andresearch.Diab Tech&Ther, Vol 10,pp.419-439.-AmericanDiabetesAssociation(2015).StandardsofMedicalCareInDiabetes- 2015.DiabetesCare: 38(1),S1-94
AmericanDiabetesAssociation(ADA)&EuropeanAssociationfortheStudyofDiabetes(EASD)
AdultBloodGlucose(BG)TargetRecommendations• Pre-mealBG target:80-130mg/dl(4.4-7.2mmol)
• Post-mealBGtarget:Lessthan180mg/dl(9.9mmol/l)at1-2hours
• A1c:lessthan7%formostpatients
• Consider:age,lifeexpectancy,yearsofdiabetes,complications,co-morbidities,hypoglycemiarisk
• Hypoglycemia:BGbelow70mg/dl(3.9mmol)• Hyperglycemia:BGabove180mg/dl(9.9mmol/l)
1)-AmericanDiabetesAssociation (2015).StandardsofMedicalCareInDiabetes- 2015.DiabetesCare: 38(1),S1-942) Inzucchi SE et al. Management of Hyperglycemia in Type 2 Diabetes, 2015: A Patient Centered Approach: Update to a Position Statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2015;38:140–149.
AmericanAssociationofClinicalEndocrinologists:AACEADULTBloodGlucose(BG)Targets
• Pre-MealBG:Lessthan110mg/dl(6.1mmol/l)• Post-MealBG:Lessthan140mg/dl(7.7mmol/l)
at2hours• CheckingBGbefore&after samemeal:qhelpsclinicianevaluatemeals&medsqhelpspatient learnhowfoodchoices,insulindosesand
physicalactivityaffectsBGandifadjustmentsareneeded
Handelsman,etal.(2011).AmericanAssociationofClinicalEndocrinologistsMedicalGuidelinesforClinicalPracticeforDevelopingaDiabetesMellitusComprehensiveCarePlan.EndocrinePractice,17(Suppl 2).
PediatricA1CandBGTargetsADA(2015)* ISPAD(2014)*BloodGlucoseGoals
Fasting/BeforeMeals90–130mg/dL(5-7.2mmol/L)
70–145mg/dL(4–8mmol/L)
Post-Prandial NoRecommendation90–180mg/dL(5-10mmol/L)
Bedtime90–150mg/dL(5-8.3mmol/L)
120-180mg/dL(6.7-10mmol/L)
Overnight90–150mg/dL(5-8.3mmol/L)
80–162mg/dL(4.5–9mmol/L)
A1C7.5% 7.5%
*BGgoalsshouldbeindividualizedtoasnearnormalaspossiblewhileavoidingsevere/excessivehypoglycemia
AmericanDiabetesAssociation.Children andadolescents.Sec.11.InStandardsofMedicalCareinDiabetes2015.DiabetesCare2015;38(Suppl.1):S70–S76
Rewers MJ,Pillay K,deBeaufort C,CraigME,HanasR,AceriniCL,MaahsDM.Assessmentandmonitoring ofglycemiccontrol inchildrenandadolescentswith diabetes(chapteroftheISPADClinical PracticeConsensusGuidelines2014Compendium).PediatricDiabetes2014:15(Suppl.20):102–114.
BGMonitoringBasedonInsulinRegimen
• BasalInsulinOnly:FastingBGatleast3x/week• BolusInsulinOnly:BGpre/postsamemeal,minimumonepairperweekforeachmeal
• Basal/BolusInsulin:Combinationoffasting(atleast3x/week)andpre/postmealpairs(minimumonepairperweekforeachmeal)
• Pre-MixInsulin:Combinationoffasting(atleast3x/week)andpre/postmealpairs(minimumonepairperweekforeachmeal)andafewbedtimessinceeachdosehasdualpeak
-AACEDiabetesCarePlanGuidelines (2011).Endocrine Practice:17(Suppl 2).Availableat:https://www.aace.com/files/dm-guidelines-ccp.pdf-Polonsky WH, Fisher L, Schikman CH, Hinnen DA, Parkin CG, Jelsovsky Z, Peersen B, Schweitzer, M, Wagner RS.Structured self-monitoring of blood glucose significantly reduces A1c levels in poorly controlled, noninsulin-treated type 2 diabetes.Diabetes Care, 34:262-267, 2011.
WhatToDoWithTheData
“Checkinginpairs”& short-termexperiments helppatients&cliniciansproblemsolvetoadjustandbalancemeals,medications&physicalactivity
Parkin C,DavidsonJA.Valueofself-monitoringbloodglucosepatternanalysisinimprovingdiabetesoutcomes.JDiabetesSci Technol,3(3);500-508,2009
BGM:WhatWouldYouRecommend?
• Anewlydiagnosed37yearoldsocialworkerwithType2DMandanA1cof8.2%onlifestylemodifications,takingmetformin850mgwithbreakfastanddinner.
BGM:WhatWouldYouRecommend?
• A28yearoldelementaryschoolteacherwithType1DMfor12yearsandanA1cof7.6%takingglargine oncedailyandlispropre-mealsbasedoncurrentBGandgramsofcarbseaten.
• Otheroptions?
BGM:WhatWouldYouRecommend?
• A52y.o.restaurantmanagerwithType2DMtakingmetformin,glipizide,sitagliptinandU300glargine withanA1cof10.4%
BGM:WhatWouldYouRecommend?
• A20yearoldcollegestudentwithType1DMfor5years:A1c8.3%,hast:slim G4insulinpumpwithDexcom sensor
BGM:WhatWouldYouRecommend?
• An82y.o.Chinesemalewithtype2diabetesfor11yearsonpre-mixanaloginsulinbeforebreakfastanddinnerwithmultipleco-morbiditiesandanA1cof7.8%
BGM:WhatWouldYouRecommend?Consider:• A1c&BGResults&Goals• Currentdiabetesmedicationregimen
andhowyou&thepatientwillusetheinformation
• Lifestyle/Schedule• HypoglycemiaRisk• Reimbursement
Inzucchi SE et al. Management of Hyperglycemia in Type 2 Diabetes, 2015: A Patient Centered Approach: Update to a Position Statement of the American Diabetes Association and the European Association forthe Study of Diabetes. Diabetes Care 2015;38:140–149.
InterpretingBloodGlucoseData
ThePerilsofReviewingBGDataDirectlyonMeter
PatternAnyone?
BloodGlucose(BG)RecordKeeping
LogBook• Helpsreviewresultsquickly
bytimeofdayandmeal• Assistswithrealtimebasic
patternidentification• Commentscanbeeasily
addedwhenBGishigher orlowerthanexpectedtodiscusswithclinicianatalatertime
MeterMemory• Eliminatesdataentryerrors
e.g.wrongday,time(ifclockissetright),wrongresultorillegiblehandwriting
• CanbetransferredtoPCorotherdevicetoanalyze
• Providescharts,graphsanddatastatisticstofacilitateadvancedpatternmanagement
Roche360°View:HandwrittenStructuredTesting3Day/7pointprofile
Availableat:www.accu-chekconnect.com
IdentifyingPatternsbyReviewingDataTypesofReports:• Electronic LogBook• PieChart:Shows%oflows,highs&inrange• ModalorStandard Day:Plotsalltheresultsfor
atimeperiodsuperimposedonone24hr chart• TwoWeekSummaryReport:Plotsresultsday
byday• Histogram:FrequencyDistributionbyBGRange• Statistics:highest&lowestBGs,means,
standarddeviationsforpre& postprandialBGsbytimeofday,frequenciesofresults
MeterDownloads:ElectronicLogBook
MeterDownloads:ModalDayPlotsBGsbyTimeofDayon24hrGraph
MeterDownloads:PieCharts
MeterDownloads:StandardWeekPlotsBGbyDayofWeek
MeterDownloads:GlucoseTrendsDaybyDay
MeterDownloads:HistogramsFrequencybyBGRanges
AdjustingMeals,PhysicalActivity&DiabetesMedicationsBasedonBG
Consider:• Arepreandpostprandialglucosetargetsmet?
IsA1catgoal?DoesA1cmatchBGs?• Carbohydrateintake(amount,type,timing)• Diabetesmedication(amount,type,timing)• Activitylevel/exercise(frequency,type,timing)• Factorsthatcouldinfluencehighorlowglucose
levels:Physicalstressorillness(e.g.menses,flu),Emotionalstress(shorttermorongoing?)
MotivatingPatientsToMonitorBGEducation&Practice
FocusOn…Why?
Why?-WhatBGnumbersmeanatdifferent
timesofday–Setindividualtargets&
changeovertime..
When?FrequencyofBGM?Best
timestocheck?
How?Practicewith
returndemos,Reviewtechnique
overtime
Nattrass M.Instrumentsforself-monitoringofbloodglucose.ClinicalChemistry,48(7)979-980,2002.KrugerD.Psychologicalmotivationandpatienteducation:aroleforcontinuousglucosemonitoring.DiabTech&Ther,2(1)S-93-S-97,2000.
MotivatingPatientsToMonitorBG• Considerwaystoimprovecomfort e.g.site
selection&preparation,equipmentused• Optimizereimbursement,preferredbrands,
lowerout-of-pocketcosts• LookatwhenpatientskipsBGmonitoringand
discussbarriers• Offerextrametertoleaveatworkorschool• Discuss BGresultsateveryvisitandmake
recommendationsbasedondata-Kempf K,KruseJ,MartinS.ROSSO-in-praxi:aself-monitoring ofbloodglucosestructured 12-weeklifestyleintervention significantlyimprovesglucometabolic control ofpatients withtype2diabetesmellitus.Diab Tech&Ther 12(7)547-553, 2010.-Hirsch, etal(2012).UsingMultipleMeasuresofGlycemia toSupport IndividualizedDiabetesManagement:Recommendations forClinicians, Patients,andPayors.Diab Tech&Ther, 14(11),973-983.
MotivatingPatientsToMonitorBGRecommend:• Washhandswithwarmwater&soap:AvoidETOH,
lotions• Choosesidesoffingers& rotate sitestoimprove
comfort• Milk/massagesitepriortopuncturetoincrease
bloodflow• Experimentwith differentlancets,lancingdevices
anddepthsettingsonlancingdevices• Encouragepatientstochangelancetsdaily• Encourageuseoflancingdeviceeverytimeto
minimizetrauma.
-FDABlood GlucoseMonitoring availableathttp://www.fda.gov/medicaldevices/productsandmedicalprocedures/InVitroDiagnostics/GlucoseTestingDevices/default.htmHirsch, etal.(2008).Self-monitoring ofbloodglucose(SMBG)ininsulin- andnon-insulin-using adultswithdiabetes:Consensusrecommendations forimprovingSMBGaccuracy,utilization, andresearch.Diab Tech&Ther,Vol 10,pp.419-439.-Klonoff, D.C.(2011).Improvingthesafetyofbloodglucosemonitoring. JDiabetesSciTechnol; 5(6):1307-1311
MotivatingPatientstoMonitorBG:ConsiderAlternativeSiteTesting(AST)
• ASTcanhelppatientsgivetheirfingersarest
• Bewareofpossiblelagtimeof 5-20minutes• Rubsitebeforelancingtoincreasebloodflow,mayreduce
“lag”time
• Recommendusingfingerorpalm:-whenBGisrapidlyrisingorfalling
e.g.post mealsorpostexercise-beforedriving
-ifhypoglycemiaissuspectedhttp://www.fda.gov/medicaldevices/productsandmedicalprocedures/InVitroDiagnostics/GlucoseTestingDevices/default.htm
LastButNotLeast:WhattodowhenA1c&BG don’tmatch
• MeasurementErrors?Checkforpresenceofhemoglobinopathies,hemolyticanemia,post-bloodtransfusionornutritionaldeficiencies(e.g.iron,folate,B12)
• Glucosevariability?Average(mean)bloodglucosemaybeareflectionofextremesrangingfromlowtohigh
• TimingofBGs?AreBGsdoneattheright timesthroughoutthedayandnight?
• NumberofBGs?ArethereenoughBGreadingsateachtimeofdaytogiveafairrepresentationtoidentifypatterns?
-Cohen, R.M.&Lindsell,C.J.(2012).WhenthebloodglucoseandHbA1cdon’t match:Turninguncertainty into opportunity.DiabetesCare:35;pp.2421-2422,-Hirsch, etal(2012).UsingMultipleMeasuresofGlycemia toSupport IndividualizedDiabetesManagement:Recommendations forClinicians,Patients, andPayors.Diab Tech&Ther,14(11),973-983
Questions?
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