Monitoring Glycemic control : Guidelines 2016
Glycemic Targets can be monitored and controlled through two primary techniques:Self-monitoring of blood glucose (SMBG) and A1C. Continuous glucose monitoring(CGM) or interstitial glucose is supposedly a useful subordinate test to SMBG in selective patients. Patients under clinical trials are subjected to SMBG as multi factorial intervention to demonstrate the benefit of intensive glycemic control on diabetes complications. Therefore, SMBG is considered a necessary component of effective therapy. It is a method whereby patients can assess their own response to therapy and know whether they have been able to meet their glycemic targets. InCorporating SMBG results in management of the disease can be a useful instrument in preventing hypoglysemia, adjusting medications(particularly prandial insulin doses)& guidance for medical nutritional therapy.
A1C on the other hand reflects average glycemic readings over several months and therefore, is a strong indicator of diabetic complications.Therefore A1C testing should be incorporated routinely in patients with diabetes at the time of initial assessment and part of continuing care. A1c 3 monthly reading determine whether patients’ glycemic targets have been reached and maintained. The frequency of A1C testing should depend on the clinical situation, the treatment regimen, and the clinician’s judgment.
Given below are major recommendations suggested by American Diabetes Association in the standards of Diabetes Care 2016, for the two monitoring and controlling techniques SMBG and A1C.
Recommendations: (SMBG)
- When prescribed as part of a broader educational context, self-monitoring of blood glucose (SMBG) results may help to guide treatment decisions and/or self-management for patients using less frequent insulin injections or non-insulin therapies.
- When prescribing SMBG, ensure that patients receive ongoing instruction and regular evaluation of SMBG technique, SMBG results, and their ability to use SMBG data to adjust therapy.
- Most patients on intensive insulin regimens (multiple-dose insulin or insulin pump therapy) should consider SMBG prior to meals and snacks,occasionally post prandially, at bedtime, prior to exercise, when they suspect low blood glucose, after treating low blood glucose until they are normoglycemic, and prior to critical tasks such as driving.
- When used properly, continuous glucose monitoring (CGM) in conjunction with intensive insulin regimens is a useful tool to lower A1C in selected adults (aged 25 years) with type 1 diabetes.
- Although the evidence for A1C lowering is less strong in children, teens, and younger adults, CGM may be helpful in these groups. Success correlates with adherence to ongoing use of the device.
- CGM may be a supplemental tool to SMBG in those with hypoglycemia unawareness and/or frequent hypoglycemic episodes.
- Given variable adherence to CGM, assess individual readiness for continuing CGM use prior to prescribing.
- When prescribing CGM, robust diabetes education, training, and support are required for optimal CGM implementation and ongoing use.
- People who have been successfully using CGM should have continued access after they turn 65 years of age.
A1C TESTING
Recommendations
- Perform the A1C test at least two times a year inpatients who are meeting treatment goals (and who have stable glycemic control).
- Perform the A1C test quarterly in patients whose therapy has changed or who are not meeting glycemic goals.
- Point-of-care testing for A1C provides the opportunity for more timely treatment changes.
A1C GOALS
- A reasonable A1C goal for many non pregnant adults is 7% (53mmol/mol).
- Providers might reasonably suggest more stringent A1C goals (such as,6.5% [48 mmol/mol]) for selected individual patients if this can be achieved without significant hypoglycemia or other adverse effects of treatment. Appropriate patients might include those with short duration of diabetes, type 2 diabetes treated with lifestyle or metformin only, long life expectancy, or no significant cardiovascular disease.
- Less stringent A1C goals (such as 8% [64 mmol/mol]) may be appropriate for patients with a history of severe hypoglycemia,limited life expectancy, advanced micro vascular or macro vascular complications, extensive co morbid conditions, or long-standing diabetes in whom the general goal is difficult to attain despite diabetes self-management education, appropriate glucose monitoring, and effective doses of multiple glucose-lowering agents including insulin.
HYPOGLYCEMIA
Recommendations
- Individuals at risk for hypoglycemia should be asked about symptomatic and asymptomatic hypo glycemia at each encounter.
- Glucose (15–20 g) is the preferred treatment for the conscious individual with hypoglycemia, although any form of carbohydrate that contains glucose may be used. Fifteen minutes after treatment, if SMBG shows continued hypoglycemia, the treatment should be repeated. Once SMBG returns to normal, the individual should consume a meal or snack to prevent recurrence of hypoglycemia.
- Glucagon should be prescribed for all individuals at increased risk of severe hypoglycemia, defined as hypoglycemia requiring assistance, and caregivers, school personnel, or family members of these individuals should be instructed in its administration. Glucagon administration is not limited to health care professionals.
- Hypoglycemia unawareness or one or more episodes of severe hypoglycemia should trigger re-evaluation of the treatment regimen.
- Insulin-treated patients with hypoglycemia unawareness or an episode of severe hypoglycemia should be advised to raise their glycemic targets to strictly avoid further hypoglycemia for at least several weeks in order to partially reverse hypoglycemia unawareness and reduce risk of future episodes.
- Ongoing assessment of cognitive function is suggested with in-creased vigilance for hypoglycemia by the clinician, patient, and caregivers if low cognition or declining cognition is found.
For further details look up chapter 5 on page 539 on the following link:http://care.diabetesjournals.org/site/misc/2016-Standards-of-Care.pdf
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