Glucose Monitoring

Diabetes is one of the most commonly diagnosed chronic health conditions in

the adult population in the United States

and is one of the 5 most costly chronic conditions, accounting for more than $51 billion in annual health care spending.

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It affects more than 29 million Americans,

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and an additional 89 million are prediabetic.

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If those with prediabetes do not make lifestyle changes, including increasing their physical activity and weight loss, 15% to 30% will have diabetes within 5 years.

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Uncontrolled diabetes can lead to serious health consequences and is the leading cause of blindness, kidney failure, and nontraumatic lower-extremity amputation among people 20 to 74 years.

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Proper and timely pharmacologic and nonpharmacologic management of this condition are necessary to prevent the progression of the disease and avoidable health consequences.

About 90% to 95% of patients with diabetes have type 2 diabetes (T2D), in which the pancreas can still produce insulin. The remaining 5% to 10% have type 1 diabetes (T1D), where there is minimal production to absolute insulin insufficiency.

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One of the key differences in managing T1D and T2D is the necessity of insulin therapy. Because of a lack of insulin production, everyone with T1D needs to take insulin. Those with T2D typically start with oral medications and may progress to insulin therapy.

Insulin therapy can be daunting for both the patient and provider, which can lead to a delay in insulin initiation. For example, patients may have a needle phobia or view needing insulin as a failure in their disease management,

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and providers may postpone treatment because of a belief that insulin

should be delayed until necessary or they lack confidence in insulin’s clinical efficacy.

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Insulin also requires more time to manage and has risks, such as hypoglycemia. To prevent serious hypoglycemia or hyperglycemic episodes, patients should regularly monitor their blood sugar.

All patients with diabetes also should have their blood sugar level monitored by a health care professional. The spacing between visits depends on the level of control, but some patients need to check their sugar throughout the day as well.

There is no exact global consensus on when to initiate insulin therapy. The therapy is very individualized, so patient characteristics, such as the ability to comply with therapy, chronic hyperinsulinemia, end-organ damage, general health status, personal preference, or the risk for hypoglycemia must be considered.

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That being said, according to the American College of Endocrinology and the American Association of Clinical Endocrinologists’ 2018 Consensus Statement, patients who have a glycated hemoglobin (A1C) level above 8% who are already taking 2 oral antihyperglycemics, and have longstanding T2D, are less likely to achieve their A1C

goal with a third oral antihyperglycemic.

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This A1C goal must also be individualized, as stringent goals of less than 6.5% may not be appropriate for many patients and may even worsen outcomes.

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If patients present initially with an A1C level above 9% and they are symptomatic, consider starting insulin or dual therapy, or if the A1C goal has not been met within 3 months of triplet therapy, proceed to insulin.

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If patients are self-testing their glucose, they should check their blood sugar level after treating a hypoglycemia episode or meals; anytime hypoglycemia is suspected; before eating, exercise, or performing potentially hazardous activities, such as driving; and at bedtime.

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CONTINUOUS GLUCOSE MONITORING

Some patients may need to check their blood sugar level very frequently. These individuals benefit from continuous glucose monitoring (CGM). CGM requires a device that has a sensor that is inserted under the skin to check interstitial glucose, not blood glucose, every few minutes.

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The transmitter sends the results to the receiver, which may or may not be a part of an insulin pump.

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There are 4 CGM devices available, one of which can be used without an insulin pump and sends data directly to an Apple device (Dexcom’s G5 Mobile device).

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Patients with T1D, who are prone to hypoglycemia, but who are unware when hypoglycemia episodes occur, are candidates for this.

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They see an improvement with glucose management, have fewer hypoglycemia episodes, and need fewer finger sticks.

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Other benefits of CGM is the device’s ability to alarm the patient of dangerous values and even offer treatment decisions based on the results.

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The American Diabetes Association generally recommends that blood sugar levels be between 80 and 130 mg/dL before meals and below 180 mg/dL 2 hours after meals.

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Sara Hunt, MSN, RN, PHN, FNP-C

, is a licensed and board-certified family nurse practitioner, a public health nurse, an adjunct assistant professor of health policy, and a doctor of nursing practice student at the University of California, San Francisco. She was the spring 2015 health policy fellow at the American Association of Nurse Practitioners’ Government Affairs Office in Washington, DC.

REFERENCES

1. American Public Health Association. Public health and chronic disease cost savings and return on investment. APHA website. apha.org/~/media/files/pdf/factsheets/chronicdiseasefact_final.ashx. Accessed August 14, 2018.
2. CDC. More than 29 million Americans have diabetes; 1 in 4 doesn’t know [press release]. Atlanta, GA: CDC; June 14, 2014. cdc.gov/media/releases/2014/p0610-diabetes-report.html. Accessed August 14, 2018.
3. American Diabetes Association. Diagnosis and classification of diabetes mellitus.Diabetes Care. 2009;32(suppl 1):S62-S67. doi: 10.2337/dc09-S062.
4. Peyrot M, Rubin RR, Lauritzen T, et al; International DAWN Advisory Board. Resistance to insulin therapy among patients and providers: results of the cross-national Diabetes Attitudes, Wishes, and Needs (DAWN) study.Diabetes Care. 2005;28(11):2673-2679.
5. Home P, Riddle M, Cefalu WT, et al. Insulin therapy in people with type 2 diabetes: opportunities and challenges?Diabetes Care. 2014;37(6):1499-1508. doi: 10.2337/ dc13-2743.
6. Garber AJ, Abrahamson MJ, Barzilay JI, et al. Consensus statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the Comprehensive Type 2 Diabetes Management Algorithm — 2018 executive summary.Endocr Pract. 2018;24(1):91-120. doi: 10.4158/CS-2017-0153.
7. Petznick A. Insulin management of type 2 diabetes mellitus.Am Fam Physician. 2015;84(2):183-190.
8. American Diabetes Association. Diabetes management guidelines. National Diabetes Education Initiative website. www.ndei.org/ADA-diabetes-management- guidelines-self-monitoring-blood-glucose-SMBG-insulin.aspx.html. Published 2016. Accessed August 30, 2018.
9. Garber AJ, Abrahamson MJ, Barzilay JI, et al. AACE/ACE comprehensive diabetes algorithm 2015.Endocr Pract. 2015;21(4):438-447. doi: 10.4158/ep15693.cs.
10. National Institute of Diabetes and Digestive and Kidney Diseases. Continuous glucose monitoring. NIDDKD website. niddk.nih.gov/health-information/diabetes/over- view/managing-diabetes/continuous-glucose-monitoring. Published 2017. Accessed August 30, 2018.
11. McElwee-Malloy M. The right CGM for you.Diabetes Forecast.2016. main.dia- betes.org/dforg/pdfs/2016/2016-cg-cgm-decision-tree.pdf. Accessed August 30, 2018. 12. Mayo Clinic. Blood sugar testing: why, when and how. Mayo Clinic website. mayoclinic.org/diseases-conditions/diabetes/in-depth/blood-sugar/art-20046628. Published May 4, 2018. Accessed August 30, 2018.
12. Mayo Clinic. Blood sugar testing: why, when and how. Mayo Clinic website. mayoclinic.org/diseases-conditions/diabetes/in-depth/blood-sugar/art-20046628. Published May 4, 2018. Accessed August 30, 2018.