[acb-diabetics] Diagnosis and Treatment of type 2 Diabetes Chpt. 4

Thu Jan 6 00:34:16 GMT 2011

Diagnosis and Management of Type 2 Diabetes, 10th Edition, Ch 13-Pt 4

Assessment of the Treatment Regimen, Part 4

Diagnosis_and_Management_of_Type_2_DiabetesSteve V. Edelman, MD

Robert R. Henry, MD 

Applying SMBG Results to Adjust Insulin Doses

Patients can be taught how to analyze and use SMBG data to effectively make
adjustments in their insulin doses so that they can maintain and improve
glycemic control....

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Insulin algorithms can be used with SMBG to make appropriate day-to-day
changes in insulin dosing and to guide long-term treatment. The insulin
algorithm shown in Figure 13.3 is used for patients receiving intensive
insulin therapy. Self-adjustment guidelines for patients on a split-mixed
regimen are shown in Table 13.4; insulin unit changes are provided by the
physician on an individualized basis.

DCMS14Edelman-Fig13-2a

DCMS14EdelmanFig13-2b

DCMS14EdelmanFig13-3a

DCMS14Edelman-Fig13-3b

DCMS14EdelmanTab13-4

Advances in Glucose Monitoring

Over the past several years, home glucose monitoring devices have become
smaller, faster, and easier to operate with data analysis capabilities.
Computer generated data analysis can assist the care giver and the patient
in many different areas, including data collection from blood glucose
meters, certain insulin pumps, and other new devices. Computer software
programs can also create charts and graphs that reveal trends and patterns
in blood glucose values for easier evaluation by the patient and the
caregiver. There are many software programs that are not only user-friendly
for the patient, but are easy to read and analyze by the caregiver. Several
programs can generate one-page summaries of a person's diabetes monitoring
data intended for optimal presentation of information. Information typically
provided includes the standard day plot, before and after meals, pie graphs,
the preceding 14 days in a combination graph format (where diet, exercise,
and medication are shown with blood glucose levels) and a glucose line plot.
The goal ranges and usual insulin doses are usually printed on the bottom of
the page if applicable for that patient.

Advances in Devices for Bloodletting 

The fingerstick devices used to get a drop of blood for testing from the
patient have improved with depth adjustable and sharp, thin lancets. There
are meters that have the capability of getting blood from areas other than
the fingertips, such as the forearm, for patient comfort and convenience.
Other companies have developed bloodletting devices that can be used on the
fingertips and other areas with special attachments to the finger sticker.
Laser technology has also been designed to facilitate the bloodletting for
these home devices.

Advances in Continuous Glucose Monitoring

SMBG is a fundamental part of diabetes management It is mandatory for tight
glucose control. Intermittent measurement of capillary blood glucose via
fingersticks has long been the method of choice for self-monitoring.
However, such measurements provide isolated glucose values which do not
reflect variations occurring throughout the day and night. In addition, this
approach is dependent on patient education, diligence, and consistency.
Hence systems monitoring blood glucose concentrations on a continuous basis
have been developed. These devices allow for frequent and automatic glucose
measurements, and thus can detect and track changes in glucose levels over
time. This has tremendous implications for achieving near normalization of
glucose control while avoiding the most serious complication of intensive
glucose management, hypoglycemia. Several such devices are currently
available. 

The DexCom Seven with Open Choice (DexCom), Guardian Real-Time (Medtronic
Diabetes), and the FreeStyle Navigator (Abbott Diabetes Care) are currently
available and are composed of three basic parts: a sensor, a transmitter,
and a receiver or monitor. The sensor, like a patch, is worn for up to 5
days and then replaced. It is placed just under the skin and is attached to
a plastic sensor mount with adhesive to adhere to the skin. The small,
unobtrusive transmitter snaps into the sensor mount and sends glucose
information wirelessly to the pager-sized receiver, which can be worn on the
belt or carried in a handbag. The sensor measures glucose every 1 to 5
minutes (frequency varies according to the device). The receiver displays
the readings over time and provides high and low glucose level alarms that
warn in advance when levels are trending toward hypoglycemic or
hyperglycemic levels as determined the physician. 

These systems also store up to 60 days of data, which can be analyzed by the
patient or physician. Also available is the MiniMed Paradigm Real-Time
System (Medtronic Diabetes), which is comprised of a sensor, transmitter,
and insulin pump. 

It is important to note that these systems measure interstitial glucose, a
distinct physiologic space when compared with blood glucose. However,
clinical trials with the various devices have shown there is an adequate
correlation between interstitial and capillary blood glucose measurements.
Nevertheless, the use of such systems adds information on PPG excursions,
nocturnal hypoglycemia or hyperglycemia not previously detected by
fingerstick monitoring, thereby facilitating the tailoring of treatment
regimens for the individual patient. In addition, these devices are capable
of communicating with implantable insulin pumps.  

Totally noninvasive continuous glucose monitoring systems that utilize
infrared technology are also under development. 

Next Week: Acute Complications

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SUGGESTED READING

American Diabetes Association. Standards of medical care in diabetes-2010.
Diabetes Care. 2010;33(suppl 1):S11-S61.

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