RELEVANCE AND EFFECTIVE USE OF SELF- MONITORING OF BLOOD GLUCOSE · 2019-03-20 · RELEVANCE AND EFFECTIVE USE OF SELF-MONITORING OF BLOOD GLUCOSE Lori Berard, RN, CDE Winnipeg Regional

RELEVANCE AND EFFECTIVE USE OF SELF-

MONITORING OF BLOOD GLUCOSE

Lori Berard, RN, CDE

Winnipeg Regional Health Authority, Health Science Centre

Winnipeg Diabetes Research Group Winnipeg, MB

PRESENTATION OUTLINE

• Objectives

• Monitoring Glycemic Control

• CDA Recommendations for SMBG

• Provincial Reimbursement

• Patient Case Scenarios

• Summary

• Discuss the benefits and value of SMBG

• Understand the 2013 Canadian Diabetes

Association SMBG recommendations for

people with diabetes, and implement them

into daily practice

• Recognize challenges in SMBG and help people

discover ways to facilitate positive outcomes

OBJECTIVES After attending this session, delegates will be able to:

Polling Question

The most effective way to determine overall glucose

control is:

a) A1c

b) Self-monitoring of blood glucose levels

c) Use of a machines “average”

d) All of the above

MONITORING

GLYCEMIC CONTROL

MEASURING BLOOD GLUCOSE LEVELS

• Glycated hemoglobin (A1C) is a reliable estimate of mean

plasma glucose (PG) levels over the previous 3 to 4 months

for most individuals

• The fasting plasma glucose (FPG) test is performed after a person

has fasted for at least 8 hours

• A postprandial plasma glucose (PPG) test measures blood glucose

levels following a meal

– Should be done 2 hours from the start of the meal

• SMBG identifies glycemic excursions to allow for day to day

adjustments of activity, diet and medication

CDA Clinical Practice Guidelines. Can J Diabetes 2013;37(Suppl 1):S1-S212;

Parkin CG, Davidson JA. J Diabetes Sci Technol. 2009;3(3):500-508.

SET TARGETS FIRST: CURRENT

RECOMMENDATIONS

For whom A1C (%) FPG (mmol/L) PPG (mmol/L)

Most adults with

Type 1 or Type 2

diabetes

≤ 7.0

4.0 – 7.0

5.0 – 10.0

5.0 – 8.0 if unable to

achieve A1C target

Pregnant women

Individualized

< 5.3 1 hour < 7.8

2 hours < 6.7

Children < 6 years < 8.0 6.0 – 10.0 —

Children 6 – 12 years ≤ 7.5 4.0 – 10.0 —

Children 13 – 18 years ≤ 7.0 4.0 – 7.0 5.0 – 10.0

Frail elderly ≤ 8.5 5.0 – 12.0 —

CDA Clinical Practice Guidelines. Can J Diabetes 2013;37(Suppl 1):S1-S212.

A1C VARIABILITY

A1C may be within the target range, but this can be achieved with

consistent blood glucose or day-to-day highs and lows



BENEFITS OF SMBG

SMBG can

• determine preprandial and postprandial hyperglycemia

• confirm hypoglycemia, allowing for appropriate treatment

• detect glycemic excursions, providing immediate feedback to

patients about the effect of food choices, activity, and medication

on glycemic control

Awareness of SMBG and A1C provide the

best information to assess glycemic control



SMBG CAN HELP IDENTIFY AND TREAT

HYPO- AND HYPERGLYCEMIA

Hypoglycemia

• Shaky, light-headed, nauseated

• Hungry

• Sweaty

• Heart rate is faster

• Weak

• A numbness or tingling in

tongue or lips

• Nervous, irritable, anxious

• Headachy

• Drowsy

• Confused, unable to concentrate

• Lose consciousness

Hyperglycemia

• Thirsty

• Urinate more often than usual,

especially during the night

• Tired, loss of energy

• Blurred vision

• Weight loss

• Pallor

CDA Publications: Lows and highs: blood glucose levels; Signs & Symptoms;

Diabetes in the Workplace: A Guide for Employers & Employees.

Polling Question

The most effective utilization of SMBG values really is:

a) Self-management decisions by the person with diabetes

b) Just a number to be written down for future discussion

c) A clinical diagnostic to help guide the health care

provided in making treatment choices

d) Only relevant if there is lots of numbers

SMBG + SELF-MANAGEMENT EDUCATION

Self-management education involves active patient participation

in self-monitoring and decision making

Self-management that incorporates SMBG may allow the person

with diabetes to make informed choices on a day to day basis

with respect to:

• Diet

• Exercise

• Medication(s)

Leading to better disease control

CDA Clinical Practice Guidelines. Can J Diabetes 2013;37(Suppl 1):S1-S212

STeP STUDY

Structured Testing Program (STeP) Study

• 12-month, prospective, cluster-randomized, multicenter study of 483

poorly controlled (A1C ≥7.5%), insulin-naïve type 2 diabetes patients

• Patients were randomized to:

– Active control group (ACG) with enhanced usual care

– Structured testing group (STG) with enhanced usual care and at least

quarterly use of SMBG

– Adherent STG (STG/a) patients used SMBG throughout the 12-month

trial. Nonadherent STG (STG/na) patients discontinued use of SMBG

during the trial

Polonsky WH, Fisher L, Schikman CH, et al. Diabetes Care. 2011;34(2):262-267

STeP STUDY

Polonsky WH, Fisher L, Schikman CH, et al. Diabetes Care. 2011;34(2):262-267

CDA RECOMMENDATIONS

FOR SMBG

Polling Question

In people with type 2 diabetes not requiring insulin, the best

evidence that SMBG makes a difference is:

a) Preventing hypoglycemia

b) Adjusting oral medications

c) Making food and activity changes when medications

cannot be adjusted

d) In newly diagnosed people with type 2 diabetes

2013 CDA GUIDELINES FOR SMBG

Recommendations for SMBG frequency can be found in the “SMBG

Recommendation Tool for Healthcare Providers” and the interactive

online “Self-SMBG Frequency & Pattern Tool”

http://guidelines.diabetes.ca/bloodglucoselowering/smbgtool











REGULAR SMBG FREQUENCY

Situation SMBG Recommendation

Using multiple daily injections of insulin

(≥ 4 times per day)

Using an insulin pump

SMBG ≥ 4 times per day

(Suggested SMBG Pattern)

Using insulin < 4 times per day

SMBG at least as often as insulin is being given

(Suggested SMBG Pattern)

Pregnant (or planning a pregnancy),

whether using insulin or not

Hospitalized or acutely ill

SMBG individualized and may involve


Starting a new medication known to cause

hyperglycemia (eg, steroids)

Experiencing an illness known to cause

hyperglycemia (eg, infection)

SMBG individualized and may involve


CDA Clinical Practice Guidelines Expert Committee. Appendix 4. Can J Diabetes 2013;37(Suppl 1):S197-S212.

http://guidelines.diabetes.ca/BloodGlucoseLowering/SMBGRecommendationSheet


INCREASED SMBG FREQUENCY

Situation SMBG Recommendation

Using drugs known to cause hypoglycemia

(eg, sulfonylureas, meglitinides)

SMBG at times when symptoms of hypoglycemia

occur or at times when hypoglycemia has previously

occurred

Has an occupation that requires strict

avoidance of hypoglycemia

SMBG as often as is required by employer

Not meeting glycemic targets

SMBG ≥ 2 times per day, to assist in lifestyle and/or

medication changes until such time as glycemic

targets are met

Newly diagnosed with diabetes

(< 6 months)

SMBG ≥ 1 time per day (at different times of day) to

learn the effects of various meals, exercise and/or

medications on blood glucose

Treated with lifestyle and oral agents and is

meeting glycemic targets

Some people with diabetes might benefit from very

infrequent checking (SMBG once or twice per week)

to ensure that glycemic targets are being met

between A1C tests




SMBG FREQUENCY

Daily SMBG is not USUALLY required if the person with

diabetes is treated only with lifestyle and is meeting

glycemic targets or has pre-diabetes

However, SMBG can be used as a teaching tool in newly

diagnosed patients who are not on medication to learn the

effects of various meals, exercise and/or medications on

blood glucose


PROVINCIAL

REIMBURSEMENT

PROVINCIAL REIMBURSEMENT

• Reimbursement for blood glucose test strips for people with diabetes

varies from province to province and for different groups such as

seniors, low income individuals and those on social assistance.

• Some provinces, like Ontario and British Columbia, have instituted

coverage limitations for certain patient profiles, based on an

individual’s current diabetes therapy. Other provinces are expected

to follow.

• Additional test strips may be reimbursed for people who have been

directed by a healthcare professional for clinical reasons, to monitor

blood glucose levels more closely

ONTARIO AND BRITISH COLUMBIA



Treatment Category Annual Quantity Limit

Managing diabetes with insulin

3,000 test strips

Managing diabetes with anti-diabetes

medications with a high risk of causing

hypoglycemia (low blood sugar)

400 test strips

Managing diabetes with anti-diabetes

medications with a low risk of causing

hypoglycemia (low blood sugar)

200 test strips

Managing diabetes through diet/lifestyle therapy

only (no insulin or anti-diabetes medications)

200 test strips


Take a few moments to discuss your personal

experiences with reimbursement structures in

your area.

• Do you or your patients face

any challenges?

• How do you counsel patients on

optimizing testing?

PROVINCIAL REIMBURSEMENT Group Discussion

PATIENT CASE SCENARIOS

SMBG FREQUENCY AND PATTERNS

As mentioned earlier, the Canadian Diabetes Association interactive

SMBG Frequency & Pattern Tool can be used to help individualize

monitoring for patients. The tool can be found at


SMBG frequency and patterns are recommended

by answering the following:

• What type of diabetes does your patient have?

• Is your patient's A1C to target (typically ≤7.0%)?

• What drug(s) does your patient take for their type 2 diabetes?

• How often does your patient use insulin?/What type of insulin?

• Is your patient sick or starting a steroid drug?

• Has your patient recently been diagnosed with diabetes

(<6 months)?


PATIENT SCENARIO: ANNE

Patient Information:

• 45-year-old white female, Type 2

• 5’5 and 190 lbs (BMI of 31.6)

Medication:

• No Medication

Medical Information:

• Diagnosed 3 months ago

• A1C of 7.5% (target 7.0%)


Frequency Recommendation:

• SMBG once or more per day at different times of day to learn

effects of meals, exercise, medication(s)

Pattern Recommendation:

• Diagnosis of type 2 diabetes in the past 6 months or

not meeting glycemic targets

Choose one of the recommended SMBG patterns

CDA Clinical Practice Guidelines Self-Monitoring Blood Glucose (SMBG) Frequency & Pattern Tool:




What if Anne was diagnosed 9 months ago?


• SMBG 1 or more times per day




• No change from previously recommended SMBG patterns





What if Anne was diagnosed 9 months ago

and is at target?


• Infrequent SMBG recommended; 1 or 2 times per week


• Type 2 diabetes treated with lifestyle and oral agents AND is meeting

glycemic targets; If on a secretagogue, check also when

hypoglycemia is suspected or has occurred

Recommended SMBG pattern




PATIENT SCENARIO: JOSEPH

Patient Information:

• 52-year-old white male, Type 2

• 5’11 and 215 lbs (BMI of 30)

Medication:

• Metformin 1 g, PO, BID

Medical Information:

• Diagnosed 14 months ago

• A1C of 7.9% (target 7.0%)



• SMBG once or more per day at different times of day to learn

effects of meals, exercise, medication(s)




Choose one of the recommended SMBG patterns





What if one year later, Joseph is taking insulin once

daily and has an A1C of 8.5?


• SMBG 2 or more times a day until targets are met


• Basal Insulin Only (Not To Target)






What if one year later, Joseph is taking insulin once

daily and has an A1C of 6.8?


• SMBG at least as often as insulin is given


• Basal Insulin Only (To Target)





DIAGNOSIS OF TYPE 2 DIABETES IN THE

PAST 6 MONTHS OR NOT MEETING

GLYCEMIC TARGETS

Return to Presentation


TYPE 2 DIABETES TREATED WITH

LIFESTYLE AND ORAL AGENTS AND

IS MEETING GLYCEMIC TARGETS



DIAGNOSIS OF TYPE 2 DIABETES IN THE

PAST 6 MONTHS OR NOT MEETING

GLYCEMIC TARGETS



BASAL INSULIN ONLY (NOT TO TARGET)



BASAL INSULIN ONLY (TO TARGET)



SUGGESTED SMBG PATTERNS

FOR PATIENTS USING INSULIN

Next Slide


SUGGESTED SMBG PATTERNS

FOR PATIENTS USING INSULIN



SUMMARY

• SMBG can provide immediate feedback to patients about the effect of

food choices, activity, and medication on glycemic control

• Its benefits are enhanced when used by patients and healthcare

providers to respond with adjustments to:

– Dietary choices

– Physical activity

– Medication(s)

• The pattern recommendations discussed should be used as

guidelines to individualize SMBG patterns and care

THANK YOU!

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RELEVANCE AND EFFECTIVE USE OF SELF- MONITORING OF BLOOD GLUCOSE · 2019-03-20 · RELEVANCE AND EFFECTIVE USE OF SELF-MONITORING OF BLOOD GLUCOSE Lori Berard, RN, CDE Winnipeg Regional