Lecture 2: Glucose Monitoring: Prevention & Care

A group of metabolic diseases characterized by hyperglycemia occurring from poor insulin production and/or activity due to resistance

diabetes

What is the AACE (American Association of Clinical Endocrinology) Diagnostic criteria for diabetes in terms of

• Fasting Plasma Glucose

• A1C

• Random Blood Glucose

• 2 hour 75 gram oral glucose tolerance test (OGTT)

• FPG = 126 +

• A1c = 6.5 +

• random = 200+

• OGTT = 200+

What is the AACE Diagnostic criteria for prediabetes in terms of

Impaired Fasting Glucose (IFG) - inadequate basal insulin secretion + beta cell dysfunction + resistance

A1C (tests average sugar for 2-3 months)

2 hour 75 gram oral glucose tolerance test (OGTT) - more prevelant (insulin resistance in muscle)

Fasting = 100-125

A1c = 5.7-6.4%

Random glucose = 140-199

What is the difference between the American Diabetes Association (ADA) vs the American Association of Clinical Endocrinologists (AACE)?

AACE guidelines are more strict

which guidelines are being described?

• “standards of care in diabetes” published ANNUALLY in diabetes care

• guidelines REVISED to clarify recommendations or reflect NEW evidence

• used commonly by PRIMARY care providers

American Diabetes Association (ADA)

which guidelines are being described?

• Medical guidelines for Clinical Practice” published in endocrine practice

• Medication therapy instructions are MORE DETAILED AND STRICT

• Preferred by endocrinologists

American Association of Clinical Endocrinologists (AACE)

What are some social determinants of for diabetes?

1. Race and ethnicity (American Indian most common)

2. Education

3. Family outcome

4. Metropolitan residence

___% of the population has diabetes

it is the ____th highest cause of death

____ diagnosed while ___ million undiagnosed

12% of the population

7th

29.1 diagnosed 11 not diagnosed

What are the risk factors of developing type 1 diabetes?

1. autoimune

2. genetic

3. environment

4. race (white)

What are the NONmodifiable risk factors of developing type 2 diabetes?

Age 35+

Race (minorities)

Family

gestational diabetes

PCOS

What are the MODIFIABLE risk factors of developing type 2 diabetes?

1. Overweight/ Obese = BMI of 25+

2. Hypertension (130/80 +)

3. Dyslipidemia (HDL <40 and triglycerides 150+)

4. Smoking

5. Metabolic Dysfunction Associated Static Liver Disease (MASLD)

6. Lack of Physical Activity

7. Prediabetes

Is the following describing type 1 or type 2 diabetes?

• Immune - mediated

• Autoimmune destruction of insulin secreting pancreatic islet cells

• leads to absolute insulin deficiency

type 1

Is the following describing type 1 or type 2 diabetes?

• functioning beta cells thereby ability to produce insulin

• muscles and peripheral tissues are resistant to insulin effects

type 2

How many risk factors does Bertram have for diabetes? What are they?

5

1. high blood pressure (130/80 + and on lisinopril)

2. A1C (6.5+)

3. obesity - BMI (25+)

4. age (35+)

5. smoking

What are secondary complications of diabetes?

1. heart disease (heart)

2. neuropathy (nerves)

3. retinopathy/cataract/glaucoma (eyes)

4. stroke (heart)

5. chronic kidney disease (kidney)

6. cancer

7. liver disease

8. infections

9. cognitive functional disability

Name some preventative measures of diabetes?

1. glucose monitoring (check A1c 3-6 months)

2. blood pressure (check at every clinic visit)

3. cholesterol & triglycerides (prevent CV disease)

4. kidney (albumin to creatinine ratio & eGFR ANUALLY)

5. Skin Care (moisturize skin AND treat cuts)

6. Dental Care (visit dentist 2x a year, brush 2x and floss 1x daily)

7. Eye Care (eye exam every 1-2 years)

8. Bone Mineral Density (risk for fractures increase)

9. Foot Exams (ankle-brachial index, visual inspections)

Self Monitoring of Blood Glucose is helpful for patients receiving glucose lowering therapies like insulin

What is the purpose of SMBG?

Prevent and identify HYPOglycemic episodes and guide INSULIN DOSING

true/false: patients NOT reliant on insulin may benefit more with regular follow up with a clinician to track management and blood sugar control

true

Who benefits from Self Monitoring of Blood Glucose?

1. insulin therapy

2. pregnancy

3. frequently sub- or supra therapeutic

4. recent sickness or surgery

When should you self test your glucose levels?

1. pre- and post- prandial (before and after eating)

2. before and after exercising for critical tasks (make sure you don’t go hypoglycemic)

3. before bed (to see if you should eat something before)

4. after treating HYPOglycemia (make sure you are back on track)

Are the following statements true or false?

• pain is dependent on the meter

• smaller blood sample = less pain

• SMBG is painful no matter what

• one is able to feel when their blood glucose is high

false W

How accurate do monitors have to be to be approved by the FDA?

>75 mg/dl = 95% of readings have to be ± 20% actual value (ex. 180 could come up as 144-216)

<75 mg/dL (risk for hypoglycemia) = 95% of readings must be ± 15% (tighter bc/ hypoglycemia risk)

(ex. 70 could come up as 59-81)

What are control solutions and how do you use them?

liquid containing a KNOWN specific amount of sugar (glucose) to test if your blood glucose meter and test strips are working properly

Use control when:

• get unusual results / results don’t match how you feel

• strips haven’t been stored properly

• when you buy a new monitor or test strips to see if its working correctly

when should you discard control solutions?

after 9- days

know your model when you reorder

Who should AVOID alternate site testing (should continue sides of fingertips)?

1. acutely ill

2. acutely hyPOglycemic

3. FREQUENTLY hyPOglycemic

4. 2 hours AFTER a meal, insulin dose, or exercise

because blood flow to the fingertips is the fastest— if you are hypoglycemic you would want to know FAST

where should you avoid pricking for test?

moles

veins

bones

tendons

Fingerstick Technique:

1. wash hands and ______ fingers turning hand _____ to increase blood flow

2. dry hands completely

3. allow hand to dangle below ____ level

4. where should the injection site be?

5. prick site firmly with _______, keeping hand below ____ level

6. gently _____ fingers near the puncture site to encourage a large drop of blood (DO NOT MILK THE FINGER AND DO IT TOO HARD)

1. massage, downward

3. hip

4. between center and side of finger (preferably middle or ring finger)

5. lancet, heart

6. squeeze

what are some factors for monitor selection?

monitor / display / blood sample size

alternate site testing

timing devices

collaboration

accuracy / temp sensitivity

ease of use

memory/ data management

what are some scenarios that would lead to false lows on glucose monitors?

• test strip not fully inserted into meter

• not enough blood on strip

• squeezing fingertip too hard because blood is not flowing

what are some scenarios that would lead to false highs on glucose monitors?

patient sample site Is contaminated with sugar

what scenarios can lead to the monitor reading to high or low?

test strips/control solutions stored at temperature extremes

sites other than fingertips

test strip/control solution cracked

steps of making most of your meter

1. wash hands

2. test..then test again

3. take care of strips

4. use control solution

Reflects average blood glucose levels over 3 months tested at least quarterly or twice a year

(long term average blood glucose)

A1c

immediate blood sugar snapshot tested multiple times a day (few times weekly)

self monitoring blood glucose

A1c Tests:

When would it wise for people to check their A1c quarterly (every 3 months)?

• newly diagnosed

• recent change to therapy (see how you are reacting to it)

• poorly controlled or unstable

A1c Tests:

When is it okay for people to get tested every 6 months instead of quarterly (every 3 months)?

people who have stable glycemic control

point of care testing of A1c

how can you test for A1c?

• doctors office/ lab

• at home (point of care testing)

What are treatment goals according to ADA?

A1c

Preprandial

2-hr post prandial

Blood pressure

Lipids

A1c = <7% (<6.5 if low risk of hypoglycemia or <8 f limited life expectancy)

Preprandial = 80-130mg/dl

2 hour post prandial = <180 mg/dL

BP = <130/80

lipids: tx and statin dose based on risk status

What are treatment goals according to AACE?

A1c

Preprandial

2-hr post prandial

Blood pressure

Lipids

A1c= 6.5% or less

preprandial = <110

2 hour post prandial = <140

BP = <130/80

lipids = tx and statin dose based on risk status

What are the 4 stages of development of ketoacidosis?

1. insulin shortage —> impairs glucose uptake and utilization

2. hyperglycemia —> increase in glucose due to glycogenolysis + gluconeogeneiss (since cells aren’t getting any glucose they are making more glucose)

3. lipolysis —> body breaks down fat into ketones

4. ketogenesis + acidosis —> ketone accumulation causes metabolic acidosis + complications

What are the symptoms of ketoacidosis?

1. abdominal pain

2. vomiting

3. confusion / stupor

4. frequent urination / thirst

5. klussmaul breathing (get rid of CO2 which is also acidic)

6. flu-like symptoms

7. fruity breath

8. coma

The presence of ketones at ELEVATED blood glucose that happens when the body lacks enough insulin to process blood sugar for energy

diabetic ketoacidosis

what are key diagnostic lab values for diabetic ketoacidosis that you should keep an eye out for?

Blood Glucose > 240 mg/dL

Urine Ketones

Serum Ketones

ph < 7.3 (acidic)

when should you test for ketones and how often should you test?

test every 4-6 hours if…

• you see symptoms

• blood glucose >260mg/dl

• acute illness

Urine Ketone Testing vs Blood Ketone Testing:

1. which is more expensive?

2. which is more accurate?

3. which shows ketone in “real time”

4. What does a positive test in the blood ketone testing look like?

5. How does urine ketone testing work?

1. blood ketone testing more expensive

2. blood ketone testing more accurate

3. blood ketone testing = real time

4. positive test for blood ketone testing = 0.6 + mmol/L

5. urine ketone testing = change in test strip after dipping in urine or change in urine after using test tablet

Continuous Glucose Monitoring:

Continuous automated interstitial glucose levels every __ -- __ minutes

Are there interstitial lags in readings?

every 1-5 minutes

yes

What are the benefits of continuous glucose monitoring?

• reduce hypoglycemic events and lower a1c

• quick detection and alerts of hypo/hyper glycemic

• provide data to help tend glucose levels and habits

MARD

mean absolute relative difference = average amount a CGM sensor reading varies from the actual blood glucose = accuracy of CGM

Sensor Life

How long a sensor can be worn before you have to replace it (most are 15 days)

Warm up time

initial period after sensor insertion during which the device calibrates and stabilizes

sample frequency

how often the device measures glucose

TIR

Time in Range: the amount of time a person with diabetes spends in their target glucose range

AGP

Ambulatory Glucose Profile: Visual overview of a person's glucose levels over time

what devices are available for continuous glucose monitoring?

How long do they last and what are some features?

1. dexcom 7 = 10d = smartwatch compatible + broad pump integration

2. decom G7 (new) = 15d =longer wear

3. Free Style libre 3 plus = 15d = smallest sensor + phone only

4. Free Stlye libre 2 plus = 15d = lower cost + optional reader (can use w/o phone)

5. medtronic instinct = 15d = smallest iCGM (integrated)

6. Eversense 365 = 365 days = IMPLANT (adhesive changed daily + removable smart transmitter)

Can CGMs be found OTC?
Can only people with diabetes/ pre diabetes get CGMs?

YES but they are VERY expensive (stelo + libre rio + lingo)

YES people who are into fitness can also get CGMs

How can you decide which CGM to give to your patient?

• cost

• pump integration

• smartphone compatibility

• patient dexterity/vision/skin

• sensor size

• lifestyle/wear time

• drug/drug interactions

which of the following is true regarding CGMs?

a. CGMS eliminate the need for SBGM

b. CGMS measure A1c daily

c. CGMs have warm up time and lag time associated with them

d. CGMs are only for type 1 diabetes

c. CGMs have warm up time and lag time associated with them