Canadian Diabetes Association Clinical Practice Guidelines Monitoring for Glycemic Control Chapter 9...

Canadian Diabetes Association Clinical Practice Guidelines

Monitoring for Glycemic Control

Chapter 9

Lori Berard, Ian Blumer, Robyn Houlden, David Miller, Vincent Woo

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association

Key Messages

1. Glycated hemoglobin (A1C) measure every 3

months (6 months if stable at target)

2. Self monitoring Blood Glucose (SMBG) is an aid to

assess interventions and hypoglycemia

3. Individualize the frequency of SMBG

4. SMBG and continuous glucose monitoring (CGM)

needs to be linked with structured educational

program to facilitate behaviour change

2013


Glycated Hemoglobin: A1C

• Reliable measure of mean plasma glucose over 3-4 months

• Valuable indicator of treatment effectiveness

• Measure every 3 months when glycemic targets are not being met or treatments adjusted

• Measure every 6 months if stable at glycemic targets


Recognize pitfalls of A1C: Conditions that can Affect Value

Factors affecting A1C

Increased A1C Decreased A1C Variable Change in A1C

Erythropoiesis B12/Fe deficiency Decreased erythropoiesis

Use of EPO, Fe, or B12Reticulocytosis Chronic liver Dx

Altered hemoglobin

Fetal hemoglobin Hemoglobinopathies Methemoglobin

Altered glycation Chronic renal failure ↓↓erythrocyte pH

ASA, vitamin C/E Hemoglobinopathies ↑ erythrocyte pH

Erythrocyte destruction

Splenectomy HemoglobinopathiesChronic renal failureSplenomegalyRheumatoid arthritisHAART meds, RibavirinDapsone

Assays HyperbilirubinemiaCarbamylated HbETOHChronic opiates

Hypertriglyceridemia


A1C Reporting: NGSP vs. IFCC Units

• Canada continues to report A1C in NGSP units of %

• Some countries report A1C in IFCC SI units (mmol/mol) instead of the NGSP units

• The equation below can be used to convert A1C from NGSP (%) to IFCC (mmol/mol)

IFCC (mmol/mol) = 10.93(NGSP%) – 23.50

NGSP (%) IFCC (mmol/mol)

4.0 20

5.0 31

6.0 42

6.5 48

7.0 53

8.0 64

9.0 75

10.0 86

11.0 97

12.0 108

NGSP = National Glycohemoglobin Standardization Program; IFCC = International Federation of Clinical Chemistry and Laboratory Medicine


SMBG is a tool, not an intervention

Teach patients to

“MONITOR WITH MEANING”


Monitoring with Meaning …

• SMBG accompanied by structured educational

program to facilitate behaviour change results in

improved outcomes

• Teach patients

1. How and when to perform SMBG

2. How to record the results

3. Meaning of various BG levels

4. How behaviour and actions affect SMBG results

1. Parkin CG et al. J Diabetes Sci Technol. 2009;3:500-508. 2. Polonsky WH, et al. Diabetes Care. 2011;34:262-267.


Individualize Frequency of SMBG

• CDA SMBG tool - provides guidance on appropriate

situations for SMBG utilization

http://guidelines.diabetes.ca

2013

http://www.guidelines.diabetes.ca/


Regular SMBG is required:


Increased frequency of SMBG may be required:

Daily SMBG is not usually required if:


Recommendation 1

1. For most individuals with diabetes, A1C should be

measured every 3 months to ensure that glycemic

goals are being met or maintained.

Testing at least every 6 months should be

performed in adults during periods of treatment

and lifestyle stability when glycemic targets

have been consistently achieved [Grade D,

Consensus].


Recommendation 2

2. For individuals using insulin more than once a day,

SMBG should be used as an essential part of

diabetes self-management [Grade A, Level 1, for type 1 diabetes;

Grade C, Level 3 for type 2 diabetes] and should be undertaken

at least 3 times per day [Grade C, Level 3] and include

both pre- and postprandial measurements [Grade C,

Level 3].

In those with type 2 diabetes on once-daily

insulin in addition to oral antihyperglycemic

agents, testing at least once a day at variable

times is recommended [Grade D, Consensus].


When glycemic control is not being achieved, SMBG should include both pre-and postprandial measurements to modify lifestyle and medications [Grade A, Level 1].

If achieving glycemic targets or receiving medications not associated with hypoglycemia, infrequent SMBG is appropriate [Grade D, Consensus].

Recommendation 3

3. For individuals with type 2 diabetes not receiving insulin therapy, SMBG recommendations should be individualized depending on type of antihyperglycemic agents, level of glycemic control, and risk of hypoglycemia. [Grade D, Consensus].

2013


Recommendation 4

4. In many situations, for all individuals with diabetes,

more frequent testing should be undertaken to

provide information needed to make behavioural or

treatment adjustments required to achieve desired

glycemic targets and avoid risk of hypoglycemia [Grade D, Consensus].


Recommendation 5

5. In people with type 1 diabetes with inadequate

glycemic control despite an optimal treatment

regimen, real-time continuous glucose

monitoring may be used to improve glycemic

control [Grade B, Level 2] and reduce hypoglycemia [Grade B,

Level 2].

2013


Recommendation 6

6. In order to ensure accuracy of BG meter readings,

meter results should be compared with laboratory

measurement of simultaneous venous FPG at

least annually, and when indicators of glycemic

control do not match meter readings [Grade D, Consensus].


Recommendation 7

7. Individuals with type 1 diabetes should be

instructed to perform ketone testing during periods

of acute illness accompanied by elevated BG,

when preprandial BG levels remain >14.0 mmol/L or

in the presence of symptoms of DKA [Grade D, Consensus].

Blood ketone testing methods may be preferred

over urine ketone testing, as they have been

associated with earlier detection of ketosis and

response to treatment [Grade B, Level 2].


CDA Clinical Practice Guidelines

http://guidelines.diabetes.ca – for professionals

1-800-BANTING (226-8464)

http://diabetes.ca – for patients

http://guidelines.diabetes.ca/

http://diabetes.ca/

Canadian Diabetes Association Clinical Practice Guidelines Monitoring for Glycemic Control Chapter 9...

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