self glucose monitoring in type 1 and type 2 diabetes professor of internal medicine, sétif...

Self Glucose Monitoring in type 1 and type 2 Diabetes

Self Glucose Monitoring in type 1 and type 2 Diabetes

Professor of internal medicine, Sétif department hospital

rmalekdz@gmail.com

11th Meeting of the Mediterranean Group for the Study of Diabetes

Malta, April 25, 2009

R MALEKAlgeria

Plan Introduction and history of self monitoring blood glucose (SMBG)

Impact of SMBG in patients with Type 1 and Type 2 diabetes

Others tools

Recommendations

Plan Introduction and history of self monitoring blood glucose (SMBG)

Impact of SMBG in patients with Type 1 and Type 2 diabetes

Others tools

Recommendations

4

Introduction

Exercise

LegalRights

Glucagon Administrati

on

Health&

Learning

Nutrition

InsulinAdministratio

n

Monitoring

Blood Glucose

Ketones

Hypoglycemia &

Hyperglycemia

History 1

1956Priscilla white,

Do you think that patients must learn how how to make their own rate of glycemias?Suggestion considered as ridiculous

Diabetes

1962Keen and Knignt

First sample of blood glucose (blot method)

Lancet

1964Rennie et al

Fast Test by enzymatic methodDextrostix

Lancet

History 2

1970Mezzafer

ri et al

Dextrostix with glucometer Lancet

1971Alexander Marble

“Good knowledge of the past glycemia, essential for the diagnosis and the treatment and a stable base.In the same way, the recognition it is required to select in each situation, the best moment of obtaining the sample of blood… like a guide of the therapy The sample of blood is function of the type of desired information…”

1975Clara lowy

SMBG during pregnancy Regarded as irresponsible

1978 Glucometers Dextrostix Ames, Reflotest Mannheim)

History 3

1981 strips with visual readingbandelettes à lecture visuelle Chemistrip BG ou BM test clycaemic 20-800

1985 10New meters

1990’s miniaturized meter.Reduction of the reaction time and reduced samples of blood

25053

Reduction of risk, evidence base medicine

Study DCCT (1)

UKPDS (2)

Kumatomo (3)

Steno 2 (4)

HbA1c ↓ 2 % ↓0,9% ↓2 % ↓0,5 %Retinopathy ↓ 63 ↓ 17-21

%↓ 69 % ↓ 58 %

Nephropathy

↓ 54 %

↓ 24-33%

↓ 70 % ↓ 61 %

Neuropathy autonome

↓ 60 %

- - ↓ 6%

Macrovascular disease

↓ 41 %

↓ 16 % - ↓ 53 %1. DCCT Research Group. N. Engl J Med 1993.; 329 977-9862. UKPDS 35. BMJ 2000;321:405–13. Ohkulo y et al. Diabetes Res Clin Pract 1995; 28:103-117.4. .N; Engl.J.Med. 348 (5):383-393, 2003.

8

Plan Introduction and history of self monitoring blood glucose (SMBG)

Impact of SMBG in patients with Type 1 and Type 2 diabetes

Others tools

Recommendations

COCHRANE collaboration: meta-analyze of 5 ERCstudies comparing diabetics with and without SMBG

TYPE 1 diabetes: relation between the HBA1C

and the frequency of the SMG

Davidson PC, and Al Abstracts from the 64th Scientific Sessions off the ADA; June 4-8, 2004; Orlando, Florida. Abstract 430-P

8

7

6

5

9

8.5

7.5

6.5

5.5

9.5

MANY TESTS PER DAY

Hb

A1c

2 4 6 8 10 12

378 DT1 under pump

Relation between the number of glycemiasand HbA1C in type 1 diabetes

SMBG is associated with a better glycemic control in type 2 diabetes

SMBG is associated with a better glycemic control in type 2 diabetes nontraited by

insulin

Each addition of a test/day, drops by HbA1c of 0,3%

When adherence is total HbA1C = 1.0% in T1 DM 0.6% in T2 DM p < .0001

24,312 Kaiser Northern Californian adults (95% DT2/5%DT1

No test < 1 test/day 1 test/day at least 3 test/day

The access to strips improves SMBG and metabolic control

Free strips (n=32) Paying strips (n=31)

Guerci B. Metab Diabetes. 2003; 29:587 - 594

InclusionFine study

Hb

A1c

(%)

ASIA STUDYASIA: Self-monitoring Active Intervention

689 old not selected T2D from 40 to 75 years,

6 months follow-up.

SMBG: 344 (2 tests/j 3 fois/s - without ASG: 345p=0.009

8,1

8,4

9,08,9

Karter J Diabetes Care 29:1757 - 1763, 2006

N=5441 NR = 3147 NR = 720

HbA1c = - 0,35

HbA1c = - 0,42

HbA1c = - 0,23

p = 0.0001

New users of the SMBG , 3 years follow-upARISON BEFORE ASG AND AFTER ASG

132

STUDY DIGEM: RESULT of HBA1C in T2DNon insulinotraited after 12 months of follow-up

N=152

N=150

N=151

7,49%

7,53%

7,41%

453 DT2 not insulinotraities moy. HbA1c= 7,5%

24.312 DIABETICS- T1D: 1159 (34% at least 3 tests/day)

- T2D insulinotherapy : 552 at least 1 test day)

- DT2 : OAD: 12786 (at least 1 test/day)

- DT2 :lifestyle: 4815 (41% a periodic test)

Plan Introduction and history of self monitoring blood glucose (SMBG)

Impact of SMBG in patients with Type 1 and Type 2 diabetes

Others tools

Recommendations

- The pain: the ends of fingers are rich in nervous terminations (sensitivity +++)- Certain professions or certain leisures require a frequent use of the fingers: musicians (guitarists, pianists…), health workforces, plumbers, users of computer, hairdressers…

Obstacles with the self-monitoring at the end

of the fingers

Valeurs cibles

0

3

6

8

11

14

17

GLY

CEM

IA m

mol/

l

8:30 12:00 16:00 22:30

Continuous measurementCapillary glycemias

Limits of SMBG( glucose excursions)

Glycemic excursions in type 2 diabetes

Nadir-2h of the morning

Each individual passes more than 60% of his day in PPG

Importance des périodes post-prandiales par rapport aux autres périodes (2)

1) Patsch JR et coll. Inverse relationship between blood levels of high density lipoprotein subfraction 2 and magnitude of post prandial lipemia. Proc Natl Acad Sci USA 1983; 80 : 1449-1453(2) Monnier L et coll. Intérêt de la détermination de la glycémie post-prandiale dans le diabète de type 2. Diabétologie et facteurs de risques 1999; 5-42 : 265-269

Glycaemic Indices : Present and Futur

Plan Introduction and history of self

monitoring blood glucose (SMBG)

Impact of SMBG in patients with Type 1 and Type 2 diabetes

Others tools

Recommendations

Gluco Watch ®

Holter glycémique en temps réel : de la théorie à la pratique

Wolpert HA . Diabetes Care 2008 ; 31 (S2) : S146-149.

he monitoring of the glycemia rests on the measurement of the rate of HbA1c and the self-monitoring by capillary glycemia.

A third way currently experiences a strong development: the holter glycemic.

System C-GMS is a tool for functional explorations intended for the doctors who allows to record uninterrupted the glycemias during 72h with restitution of the results computerized at the end of the exploration.

Guardian RTÒ makes it possible to read the glycemia in real-time: it is intended to the patients.

The CGMS (glucose sensor)

Plan Introduction and history of self monitoring blood glucose (SMBG)

Impact of SMBG in patients with Type 1 and Type 2 diabetes

Others tools

Recommendations

Indications of SMBGINDISCUTABLE INDICATIONS:

- to prevent hypoglycemias

- diabetes with insulin: DT1, DT2, diabetes gestationnel

- DT 2 with risk of hypoglycémia (SU) (safety indication )

POSSIBLE INDICATIONS: to improve control glycemic

- patient insufficiently balanced with HbA1c > 7,5%

- well educated patient able to adapt its treatments

TEMPORARY INDICATIONS:

- intercurrent pathology

- surgical act

- catch of hyperglysemic drugs

(SMBG) American Diabetes Association Recommendations

Type 1 diabetes; SMBG 3 or more times per day

glycemias capillaires/j (pre and post prandiales and before laying down it)

Type 2 diabetes: No specific frequency is recommended

Several insulin injections: ≥ 3 times per day

Patients who receive injections less frequent or treated by oral hypoglycémiants: the ideal frequency was not established, but must be sufficient to facilitate the attack of the objectives glycemic.

Pre-conceptual pregnancy & GDM 4-6 times daily

Standards of medical care in diabetes. Diabetes Care 2008

Type 1 diabetes: guidelines for SMBG in children.

International society for pediatric and adolescent diabetes (IPSAD)

SMBG at least3-4 times a day recommended, plus periodic testing of postprandial and nocturnal BG, before and after exercise.

Essential during acute illness.

utilize to achieve self-management: insulin type dose and dose

adjustment modification of life-style Adapting with new situations

Self-monitoring : which conditions?

• Clear objectives according to each patient

• Self-monitoring becomes obsolete if:

• No adjustment therapeutic• No changes in the dietary habits• No other impact on the patient and his

balance glycemic

American Diabetes Association. Diabetes Care S4-S41.

Advantages of self monitoring . ADA• Helps the patients and their close relations with better

ncluding/understanding the diabetes

• Allows the patients to take part in the evaluation of the answer to the treatment and attack of their objectives

• Useful results for: To prevent hypoglycemia To adjust the posology of the treatments To adapt the food and the degree of physical

exercise

• Grandes ERC* indicates that the autotitration of insulin according to the SMBG: can improve

Control of HbA1C1,2 Reductions of the GAJ1,2 Do not exacerbate the risk of hypoglycémie1-3

American Diabetes Association. Diabetes Care 95-9.

American Diabetes Association. Diabetes Care S4-S41.

Merci pour votre attention