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Canadian Diabetes Association Clinical Practice Guidelines Monitoring for Glycemic Control

Canadian Diabetes Association Clinical Practice Guidelines Monitoring for Glycemic Control. Chapter 9 Lori Berard, Ian Blumer, Robyn Houlden, David Miller, Vincent Woo. Key Messages. 2013. Glycated hemoglobin ( A1C )  measure every 3 months (6 months if stable at target)

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Canadian Diabetes Association Clinical Practice Guidelines Monitoring for Glycemic Control

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  1. Canadian Diabetes Association Clinical Practice GuidelinesMonitoring for Glycemic Control Chapter 9 Lori Berard, Ian Blumer, Robyn Houlden, David Miller, Vincent Woo

  2. Key Messages 2013 • Glycated hemoglobin (A1C)  measure every 3 months (6 months if stable at target) • Self monitoring Blood Glucose (SMBG) is an aid to assess interventions and hypoglycemia • Individualize the frequency of SMBG • SMBG and continuous glucose monitoring (CGM) needs to be linked with structured educational program to facilitate behaviour change

  3. 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

  4. Recognize pitfalls of A1C: Conditions that can Affect Value

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

  6. SMBG is a tool, not an interventionTeach patients to“MONITOR WITH MEANING”

  7. Monitoring with Meaning … • SMBG accompanied by structured educational program to facilitate behaviour change results in improved outcomes • Teach patients • How and when to perform SMBG • How to record the results • Meaning of various BG levels • How behaviour and actions affect SMBG results Parkin CG et al. J Diabetes Sci Technol. 2009;3:500-508. Polonsky WH, et al. Diabetes Care. 2011;34:262-267.

  8. Individualize Frequency of SMBG 2013 • CDA SMBG tool - provides guidance on appropriate situations for SMBG utilization http://guidelines.diabetes.ca

  9. Regular SMBG is required:

  10. Increased frequency of SMBG may be required: Daily SMBG is not usually required if:

  11. Recommendation 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].

  12. Recommendation 2 • For individualsusing insulin more than once a day, SMBG shouldbe 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].

  13. Recommendation 3 • For individuals with type 2 diabetes not receiving insulin therapy, SMBG recommendations shouldbe individualized depending on type of antihyperglycemic agents, level of glycemic control, and risk of hypoglycemia. [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]. 2013

  14. Recommendation 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].

  15. Recommendation 5 2013 • 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].

  16. Recommendation 6 • In order to ensure accuracy of BG meter readings, meterresults 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].

  17. Recommendation 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].

  18. CDA Clinical Practice Guidelines http://guidelines.diabetes.ca – for professionals 1-800-BANTING (226-8464) http://diabetes.ca – for patients

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