1. Monitoring and Management
Jennifer Danielson, PharmD, MBA, CDE
Clinical Assistant Professor
University of Washington School of Pharmacy

2. Learning Objectives
Identify patients who would benefit from self-monitoring of blood glucose (SMBG).
Recommend how often patients should SMBG.
Interpret readings from SMBG.
Apply results of SMBG to recommending appropriate drug therapy (e.g. pattern management).
Relate results from glucose meters to HbA1c results.
Discuss use of continuous glucose monitoring (CGM) and interpret CGM trend results.

3. Treatment Guidelines
Healthy eating Being active Monitoring Taking medication Problem solving Healthy coping Reducing risks

4. Glycemic Goals ADA A1c Goal < 7% Pre-prandial 80-130 mg/dL
Post-prandial (PPG) < 180mg/dL
10.0
9.0
8.0
7.0
6.0
A1c 5.0
AACE A1c Goal < 6.5%
Fasting plasma (FPG) < 110 mg/dL
PPG < 140 mg/dL
Inpatient setting:
Acute care mg/dL
Critical care mg/dL
Upper range of normal
ADA. Diabetes Care 2013: 36 (supp 1): S1-S10.
AACE. Endocr Pract 2011; 17(supp 2): 1-53.

5. ADA Standards for SMBG
SMBG for patients on multiple insulin injections or pumps
Prior to meals/snacks
Bedtime
Prior to exercise
Hypoglycemia
Prior to critical tasks (such as driving)
SMBG is a useful guide for less frequent insulin injections and non-insulin therapies
When prescribing SMBG, ensure patients receive ongoing instruction & evaluation, plus follow-up to adjust therapy
ADA. Diabetes Care 2016: 39 (supp 1): S1-S112.

6. ADA Standards for SMBG
CGM is a useful tool to lower A1c in adults ≥25yo on multiple injections per day or using a pump (Type 1)
CGM may be useful for people younger than 25yo
CGM is a supplemental tool for patients with hypoglycemia unawareness or frequent hypoglycemia
ADA. Diabetes Care 2013: 36 (supp 1): S1-S10.

7. ADA Standards for SMBG
CGM is a useful tool to lower A1c in adults ≥25yo on multiple injections per day or using a pump (Type 1)
CGM may be useful for people younger than 25yo
CGM is a supplemental tool for patients with hypoglycemia unawareness or frequent hypoglycemia
ADA. Diabetes Care 2016: 39 (supp 1): S1-S112.

8. Randomized Trials in Type 2 Patients Not Using Insulin Study Design
Duration
Results
Fontbonne et al
Randomized
68 = SMBG
72 = urine
68 = control
6 months
50% compliance w/twice QOD
A1c reduction 0.5% - 0.1% (not significant)
Allen et al
27 = SMBG
27 = urine
87% compliance w/before meals QOD
A1c reduction 2% both groups (not significant)
Muchmore et al
12 = SMBG*
11 = control
*more intensive nutrition counseling
40 weeks
25% compliance w/six times daily
A1c reduction 1.5% & 0.8% (not significant)
Schwedes et al
113 = SMBG*
110 = control
100% compliance w/6 times per day
A1c reduction 1% & 0.5% (not significant)
Guerci et al
345 = SMBG
344 = control
6 months*
(but >40% drop out in both groups)
Compliance unclear w/6 times per week
A1c reduction 0.9% & 0.5% (significant)
Davidson et al
43 = SMBG
45 = control
(both received diet counseling/mgmt)
45% compliance w/before and after meals 6 days/wk
A1c reduction 0.8% & 0.6% (not significant)
Farmer A, Wade A, Goyder E, et al. Impact of self monitoring of blood glucose
in the management of patients with non-insulin treated diabetes: open parallel group
randomised trial. BMJ.2007; 335:132.
N=453, 3 years, mean A1c 7.5%, A1c reduction 0.17% (not significant)
This is Type 2 diabetes patients NOT on insulin, randomized trials.

9. Non-Randomized Trials in Type 2 DM
Using Insulin
Not Using Insulin
At least 8 trials, consistently showing relationship between SMBG and A1c reduction but not all randomized, many with flaws2
Still, A1c reduction range: 0.16% to 0.88% (significant in all cases)
Non-randomized trials
Over dozen studies, most showing no relationship between monitoring and A1c reduction
Those that show difference have flaws with uneven treatment or self-selection1
Meta-analyses & Reviews
Conflicting results but suggest that SMBG may be helpful in gaining better glycemic control
Significant reduction in A1c of 0.39% to 0.42% (depending on statistical model used)2
1McAndrew, et al. Does patient blood glucose monitoring Improve diabetes control? Systematic Review.
Diabetes Educator : 991.
2Welschen, Bloemendal, Nijpels, et al. SMBG in patients with Type 2 diabetes not using insulin: a systematic review.
Diabetes Care 28: , 2005.
2Ramachandra, Ellis. SMBG in insulin-requiring type 2 diabetes. Diabetes Tech and Thera 2008;10:S1.

10. SMBG in Type 2 Diabetes Pre-requisites Consequences Diagnosis
Knowledge
Skills
Awareness
Understanding
in Cultural Context
Interpretation
Response
Achieve glycemic control
Reduce complications
Less symptom distress
Improved quality of life
Improved patient attitudes
MK Song, TH Lipman. Concept analysis: Self-monitoring in type 2 diabetes mellitus. Intnl Jour Nurs Stud. 45 (2008)

11. ADA Standards for A1c Testing
Patient at goal: A1c at ≥2 times/yr Patient not at goal: A1c quarterly Use point of care technology to provide opportunity for timely changes

12. Cases 1 and 2

13. Pattern Management
Applying results of home blood glucose monitoring to drug therapy management.
Recognizing highs/lows that occur in patterns.
Adjusting drug therapy to address the patterns of highs and lows seen.
Follow-up on results for changes made.

14. Glucose Triad Postprandial blood glucose Fasting blood glucose A1c
Lower
Higher

15. Effect on Blood Glucose
Basal drugs  Fasting
Metformin
TZDs
Sulfonylureas
Intermediate and long-acting insulin
Lantus®
Levemir®
NPH
Bolus drugs  Postprandial
Short and rapid acting insulin
Regular
Humalog®
Novolog®
Apidra®
Sulfonylureas
Meglitinides
Acarbose
DPP-4 inhibitors
GLP-1 analogues

16. Effect on Blood Glucose
Basal drugs  Fasting
Metformin
TZDs
Sulfonylureas
Intermediate and long-acting insulin
Lantus®
Levemir®
NPH
Bolus drugs  Postprandial
Short and rapid acting insulin
Regular
Humalog®
Novolog®
Apidra®
Sulfonylureas
Meglitinides
Acarbose
DPP-4 inhibitors
GLP-1 analogues

17. Slide adapted from Zane Brown, MD Professor UW Medicine

18. Case Example B L D HS
104
146
110
176
106
136
164
118
132
126
120
222
148
134
122
138
116
212
Now, what do they think?
Show the averages for the columns.

19. Case Example B L D HS
104
146
110
176
106
136
164
118
132
126
120
222
148
134
122
138
116
212
Now, what’s the problem?
Highest at bed time, but fastings more controlled.
What to do:
Go to 2g/day metformin probably. Always, education about eating and exercise. Seems he eats large supper and eats very light lunch. Could go for a walk after dinner.

20. Case Example B L D HS
110
126
118
196 98 72 56
202
188
112
120
164 96 64
100
212
102
194
Seems his highs are still bedtime. Fasting is good.
What to do: add secretagogue at supper maybe, more education about carbs etc. for supper meal.
Would you have him check in middle of night?
Perhaps to be sure dose at supper is OK, and not rebounding by morning. 20

21. Estimated Average Glucose (eAG)
Formula: 28.7 x A1C – 46.7 = eAG
eAG (CI 95%)
A1c
97 (76-120) 5%
126 ( ) 6%
154 ( ) 7%
183 ( ) 8%
212 ( ) 9%
249 ( )
10%
269 ( )
11%
298 ( )
12%
wide CIs
weighted most to last 30 days
Diabetes Care :

22. What if you saw it like this?SD

23. Actual Download Print-Out
Print out image from: CliniPro by Numedics

24. Cases 3 through 5 24

25. Continuous Glucose Monitoring
Alternative site testing
Measures subcutaneous fluid not blood
~10 minute delay in results
Must know the caveats with hypoglycemia
Continuous Glucose Monitoring Systems
Medtronic Guardian REALtime CGMS
Dexcom SEVEN
Minimed Paradigm
Abbott FreeStyle Navigator
With CGMS the caveats are:
Now you have 2 SQ pokers in you, but hopefully only one device to read
Results lag 15 minutes behind real current numbers so must take into account
Cost is around $1,000 initially, then must still purchase transmitters as you replace those every few days
Still use finger testing some as back up or to verify

26. Daily Use Glucose change is gradual. Glucose is increasing moderately.
Glucose is increasing rapidly.
Glucose is decreasing moderately.
Glucose is decreasing rapidly.

27. 72 mg/dL CGM Interpretation What should the patient do to respond?
11:10 am

28. 72 mg/dL CGM Interpretation What should the patient do to respond?
11:25 am

29. 118 mg/dL CGM Interpretation What should the patient do to respond?
12:20 pm

30. 196 mg/dL CGM Interpretation What should the patient do to respond?
2:02 pm