Diabetes Mellitus Glucose Management

Aka: Diabetes Mellitus Glucose Management, Blood Glucose Monitoring Goals, Blood Glucose Monitoring Schedule, Blood Glucose Monitoring, Blood Sugar Monitoring

1. History: Diabetes Mellitus Pharmacology
   1. 1922: Crude Insulin Extracts by Banting and Best
   2. 1940: NPH Insulin developed
   3. 1950: Sulfonylureas developed
   4. 1960: Biguanides off market
   5. 1970: Second Generation Sulfonylureas
2. Protocol: Blood Glucose Monitoring Goals
   1. Target Blood Glucose (>50% of readings in range)
      1. Children under age 6
         1. Before meals: 100-180 mg/dl
         2. Bedtime and overnight: 110-200 mg/dl
      2. Children age 6 to 12
         1. Before meals: 90-180 mg/dl
         2. Bedtime and overnight: 100-180 mg/dl
      3. Children age 13 to 19
         1. Before meals: 90-130 mg/dl
         2. Bedtime and overnight: 90-150 mg/dl
      4. Adult
         1. Fasting (before breakfast): <105 mg/dl
         2. Before Meals: 70-120 mg/dl
         3. Two hour post-prandial <160 mg/dl
         4. Before bedtime: 100-160 mg/dl
      5. Adjust target to Blood Glucose 100-160 mg/dl before meals IF
         1. Recurrent Hypoglycemia
         2. Decreased Life expectancy
            1. Frail elderly
            2. Cognitive disorder
         3. Serious comorbid medical condition
            1. Coronary Artery Disease
            2. Cerebrovascular Accident
            3. End Stage Renal Disease
            4. Hypoglycemia unaware
   2. Target Hemoglobin A1C (check 3-4 times per year)
      1. Under age 6 years: 7.5 to 8.5%
      2. Age 6 to 12: <8.0%
      3. Age 13-19: <7.5%
      4. Age 20 and older: <7.0%
   3. Additional Monitoring
      1. Urine Ketone Indication (Type I Diabetes Mellitus)
         1. Blood Glucose exceeds 240 for 2 values
         2. Concurrent illness or infection
3. Protocol: Scheduled Blood Glucose Monitoring
   1. Individualized and negotiated
   2. Minimum monitoring routine
      1. Type I Diabetes Mellitus: At least three times daily
      2. Type II Diabetes Mellitus: At least once daily
      3. Karter (2001) Am J Med 111:1-9
   3. Ideal monitoring routine
      1. Before meals (qAC)
      2. After meals (2 hours post-prandial)
      3. Bedtime (qHS)
   4. Monitoring in Special Circumstances
      1. Blood Sugar at 3 am
         1. Obtain prior to adjusting overnight Insulin
         2. Obtain if morning Hyperglycemia
            1. Hyperglycemia (Dawn Phenomena)
            2. Nocturnal Hypoglycemia (Somogyi Phenomena)
      2. Exercise in Diabetes Mellitus
         1. Check Glucose before and after Exercise
   5. Consider 2 hour post-prandial Glucose (PPG) weekly
      1. PPG is earliest detectable glycemic abnormality
      2. PPG correlates best with Hemoglobin A1C
      3. PPG correlates with vascular complications
4. Protocol: Blood Glucose data utilization
   1. Imperative to review Blood Sugar logs frequently
   2. Certain monitors can download stored values to PC
      1. Calculates Glucose ranges, median, and means
      2. Plots Glucose trends overall and by time of day
      3. Shows pie chart of high, low, and ideal Glucose
   3. Correlate Blood Sugar readings with Hemoglobin A1C
   4. Review Blood Sugar trends between clinic visits
   5. If Hemoglobin A1C does not correlate with Glucose
      1. Check meter accuracy
      2. Assess patient finger stick Blood Sugar skills
      3. Monitor Blood Glucose more frequently
      4. Refer for diabetes education
   6. Adjust Management if
      1. Hypoglycemic Episodes (treat these first)
      2. Blood Glucose or Hemoglobin A1C target goals per age not met
      3. Example of adult indications for adjusted medications
         1. Fasting or pre-meal Serum Glucose exceeds 140 (>50% of readings)
         2. Bedtime Glucose exceeds 160 (>50% of readings)
         3. Hemoglobin A1C exceeds 7.0%
5. Efficacy: Intensive Glucose lowering effects (on average goal of Hgb A1c <7.0%)
   1. DCCT results
      1. Retinopathy reduced by 63%
      2. Neuropathy reduced by 60%
      3. Nephropathy reduced by 54%
      4. Complication-free living increased by >15 years
      5. Life expectancy extended by >5 years
      6. (1993) N Engl J Med 329:977-86
      7. (1996) JAMA 276:1409-15
   2. Combined study results
      1. Microvascular Disease
         1. Improved outcomes in UGDP, UKPDS, DCCT/EDIC, ADVANCE
         2. No difference for outicomes n ACCORD and VADT
      2. Macrovascular Disease
         1. Improved outcomes in UKPDS, DCCT/EDIC
         2. No difference for outcomes in UGDP, ADVANCE, ACCORD and VADT
      3. Overall Mortality
         1. No difference in mortality UGDP, UKPDS, DCCT/EDIC, ADVANCE, VADT
         2. Increased mortality with ACCORD
   3. Summary
      1. Only one study showed increased mortality with intensive Glucose control (ACCORD)
      2. All other studies showed improved outcomes or no difference
   4. Studies
      1. ACCORD
         1. (2008) N Engl J Med 358: 2545-59
      2. ADVANCE
         1. (2008) N Engl J Med 358: 2560-72
      3. DCCT/EDIC
         1. (2005) N Engl J Med 353: 2643-53
      4. UKPDS
         1. (1998) Lancet 352: 837-53
   5. References
      1. Kendall (2008) Park Nicollet Primary Care Update Lecture, St Louis Park, MN