clinical case studies (smbg) - diabetes technology society · 2016-04-29 · clinical case studies...

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

[email protected]

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.


• A28yearoldelementaryschoolteacherwithType1DMfor12yearsandanA1cof7.6%takingglargine oncedailyandlispropre-mealsbasedoncurrentBGandgramsofcarbseaten.

• Otheroptions?


• A52y.o.restaurantmanagerwithType2DMtakingmetformin,glipizide,sitagliptinandU300glargine withanA1cof10.4%


• A20yearoldcollegestudentwithType1DMfor5years:A1c8.3%,hast:slim G4insulinpumpwithDexcom sensor


• 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?

34

clinical case studies (smbg) - diabetes technology society · 2016-04-29 · clinical case studies...

Documents