Recommendations for SMBG

A Diabetes Update
What’s new since the 2008 clinical
practice guidelines

Objectives
To gain knowledge related to:
‣ History of diabetes
‣ Current diabetes statistics
‣ Current diabetes practice
‣ New models in organization of diabetes
care
‣ Implications for future diabetes care and
management

History
‣ 1552 BCE- Egyptian physician makes the first known
mention of diabetes as passing of too much urine
‣ 1776- First diagnostic tests for diabetes- evaporating 2
quarts of urine leaving saccharine compounds and
tasting urine for sweetness
‣ 1920, Oct.-Banting first conceives of insulin
‣ 1921, Summer-Banting and Best discover insulin
‣ 1922, Jan.-1 st patient treated with insulin
‣ 1950’s-first oral medications for Type 2
‣ 1966- first pancreas transplant
‣ 1971- first portable blood glucose monitor
‣ 1999- first islet cell transplant

Incidence and Prevalence
KB IH BC
Prevalence 6.1% 6.6% 6.9-7.4%
Incidence 4,482 43,536 202,442- 338,000
Sources: Primary Health Care registry (DAD); Discharge Abstract Database (DAD), Medical Services Plan (MSP),
2008/09.
http://www.diabetes.ca/documents/get-involved/CDA_BC_Cost_Model_Report_Backgrounder_FINAL.pdf
http://www40.statcan.ca/l01/cst01/health54a-eng.htm

Type 1 Diabetes
‣ Absolute insulin
deficiency
‣ Rapid onset
‣ Always fatal prior to
1922
‣ 10% of all diabetes

Type 2 Diabetes
‣ Predominantly insulin
resistance with
relative insulin
deficiency
‣ Slow onset and
decline
‣ 90% of all diabetes

Gestational Diabetes
‣ glucose intolerance
with onset or first
recognition during
pregnancy
‣ Usually a transitory
state
‣ Approx. 50- 60 % go
on to Type 2 diabetes
later in life

Diagnosis Type 1 or 2
Fasting PG >7.0 mmol/L
or
casual PG >11.1 mmol/L + symptoms
polyuria, polydipsia and unexplained weight loss
or
2hPG in a 75-g OGTT
11.1 mmol/L
or
Hemoglobin A1C > 6.5%

A1C: evolved recommendation
‣ A1C >6.5% has been added as a
diagnostic criterion for Type II DM
• confirmatory test still required
• A1C

Diagnosis Gestational
IADPSG diagnostic criteria for gestational
diabetes mellitus (75-g OGTT)
Fasting plasma glucose 5.1
1 hr plasma glucose 10.0
2 hr plasma glucose 8.5
One abnormal value constitutes GDM.
http://www.perinatalservicesbc.ca/sites/bcrcp/files/Guidelines/Obstetrics/Updated_guideline10b.pdf

GDM -evolved recommendation.
‣ Not without controversy
‣ Consensus guideline
‣ HAPO study-23,316 participants
‣ Strong associations of increased birth
weight and increased cord blood c-peptide
below previous diagnostic levels for GDM

Blood Glucose Targets
for Management

Targets Type 1 and Type 2-
Adult
A1C (%) ≤ 7.0
FPG or pre-prandial PG (mmol/L) 4.0-7.0
(5.0–8.0 if angina )
2-hr postprandial PG (mmol/L) 7.0-10.0
(5.0–8.0 if A1C targets not being met)
Canadian Diabetes Association 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes
in Canada

Target Implications
‣ Was a trend to tighter targets HbA1c< 6.5% (IDF and
ACE)
‣ ACCORD Trial- intensive and routine managed groups
‣ Halted early- increased mortality in intensive group
http://www.accordtrial.org/public/index.cfm?CFID=55793&CFTOKEN=e8ea93ef16f5646d-560D983A-AF4E-7E83-27265E2B83ED8592

Targets Type 1 and Type 2
Pregnant and Gestational
‣ Fasting/preprandial PG: 3.8 to 5.2 mmol/L
‣ • 1h postprandial PG: 5.5 to 7.7 mmol/L
‣ • 2h postprandial PG l: 5.0 to 6.6 mmol/L
Canadian Diabetes Association 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in
Canada

Other follow-up Laboratory Tests
‣ A1C q3 months
‣ Lab/glucose meter comparison at least annually
‣ Annual random urine for ACR
‣ Annual serum creatinine (every 6mos for people
with nephropathy)
‣ Type 1 should test for ketones with elevated BG
during acute illness (>14.0mmol/L pre-prandial) or
having symptoms of DKA

Beyond the Recommendations:
Common Practice
‣ electrolytes, BUN, Cr q 6 months with A1C
‣ ACR
‣ AST, ALT for people being treated with metformin or a
statin
‣ FBG yearly
‣ TSH (thyroid disease & diabetes tend to co-occur)
‣ Blood lipids @ diagnosis then q1-3 years as clinically
indicated
‣ Evolving use of hs-CRP to evaluate cardiovascular risk
‣ Apo-B to monitor hyperlipidemia

Tools

Medication

Insulin
Insulin categories referred to now as
bolus, basal and premixed
Inhaled insulin was not released
BC- Insulin pumps covered for
pediatric Type 1

Other New Medications
‣ Victoza- GLP1 receptor agonist
‣ Byetta- incretin mimetic
Use early to preserve insulin function
‣ Otelixizumab- investigational
immunotherapeutic
http://clinicaltrials.gov/ct2/show/NCT01123083?term=defend-2&rank=1
.

Tools SBGM

Canadian Optimal Medication Prescribing and Utilization
Service (COMPUS)
takes the position that:
Routine self-monitoring of blood
glucose by most adults with type 2
diabetes using oral anti-diabetes
drugs is
not recommended.
COMPUS Volume 3, Issue 6 July 2009
http://www.bcguidelines.ca/guideline_diabetes.html#controversies_in_care_smbg
http://www.cadth.ca/index.php/en/compus/blood-glucose
http://www.cadth.ca/index.php/en/compus/blood-glucose/reports

The CDA maintains…
‣ “[the COMPUS study] significantly undervalues
safety and clinical considerations including
hypoglycemia and diabetes complications”
‣ The frequency of self-monitoring of blood glucose
should be individualized depending on glycemic
control and type of therapy and should include both
pre- and postprandial measurements of blood
glucose levels.
‣ There is clear evidence for reduced episodes of
hypoglycemia in patients with type 2 diabetes who
practice frequent self-monitoring of blood glucose
http://www.diabetes.ca/for-professionals/css-news-entry/position-statement-and-paper/

The Canadian Journal of Diabetes:
‣ “SMBG… …valuable for both patients and healthcare
professionals”
‣ SMBG recommended, though:
• no consensus within & between professional groups
• highly individual
Celeste Latter BSc MHI, Pam McLean-Veysey BSc(Pharm), Peggy Dunbar MED PDt, Dawn
Frail BSc(Pharm) MSc, Ingrid Sketris PharmD MPA(HSA), Wayne Putnam MD FCFP
CANADIAN JOURNAL OF DIABETES. 2011;35(1):31-38.
‣ The new version of the clinical practice guidelines will be
available in 2013. The evidence is mounting quickly that
health professionals working with people with type 2
diabetes who do not require insulin must use SMBG in
more selective and limited circumstances (7).
http://www.diabetes.ca/documents/for-professionals/CJD--March_2011--H.Dean_.pdf

BC MoH
‣ Recently CADTH (Canadian Agency for Drugs
and Technologies in Health) investigated the
evidence relating to SMBG. Their findings
identified that evidence supporting routine
SMBG for individuals not on insulin therapy is
poor and associated costs are escalating. As
such the Ministry of Health is requesting Health
Authorities review their practice and policy
relating to … SMBG practice.

Organization of Care

Organization of Care
‣ Self Management- Goal setting and action
planning
‣ Attachment to practice, Primary Care
Home
‣ Integrated Health Networks, Family Health
Care teams

Attachment to Practice Evaluation
• Clear inverse relationship between the level of
attachment to a primary care practice, and costs, for
higher care needs patients
• Most of the differential in costs is in hospital costs
• Therefore, activities which foster greater attachment of
patients to a particular primary care practice have the
potential to reduce health care costs
Hollander, M.J., Kaldec, H., Hamdi, R., & Tessaro, T. (2009)
Increasing value for money in the Canadian healthcare system:
New findings on the contribution of primary care.
Healthcare Quarterly, 12(4), 30-42.
Adapted from BCMA

Implications
‣ Need for improved self management options
‣ Need for more primary care providers
‣ Health professionals will need training in self
management support
‣ Better electronic communication tools
‣ Patient registries
‣ Reminders
‣ Access- expanded hours and locations, Dr.’s offices,
education (in person and on line), labs, pharmacies,
point of care tools and supplies
‣ Improved prevention efforts
‣ Consider costs to the patient
http://www.diabetes.ca/documents/for-professionals/CJD--June_2008--Cameron,_D.pdf

KB IHN outcomes
‣decrease in ER visits 22-63%
‣decrease in acute admissions 25-
88%
‣decrease in hospital LOS 23-85%

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