Wednesday, January 18, 2012

Hypoglycemic unawareness and continuous glucose monitoring

Doctors and people with diabetes are all aware of the amazing benefits of achieving an A1c hemoglobin levels of < 7 .  Something that we do not discuss as often is the risk associated with achieving that goal. 
 Recently the ACCORD  study , designed to demonstrate the benefits of near normal A1c's , was stopped early because of the increased mortality in the treatment group related to hypoglycemia.

Low blood glucose levels ( less than 70 mg/dl ) are usually associated with some early warning signals , such as a feeling of anxiety, sweating and shaking shaking. The duration of diabetes and the number of hypoglycemic events over time blunt a persons awareness of these early warning signals . The loss of the early warning signals result in a condition know as hypoglycemic unawareness. 


Hypoglycemic unawareness  means that a person first awareness of a low glucose is cognitive impairment. This may result in the loss of a persons ability to take corrective measure to treat the low glucose levels and  then progress to severe hypoglycemia.

Severe Hypoglycemia  is defined as" hypoglycemia requiring the assistance of another person"  "This is one good reason for not living alone and having a up to date Glucagon emergency kit."


The occurrence of hypoglycemia mild or severe is a reason to see your doctor to discuss treatment options.


Preparation for the visit


   # 1 Good home glucose records with before meal , bedtime and 3 am test are important. 
   # 2 food records for 2 to 3 days  paying close attention to consistency of carbohydrate intake
   # 3 exercise records with the time of day and duration
  ( hint - Diabetes Office Visit App keeps these tools and the ability to share your results always at your finger tips)


Things to discuss with your doctor


#1  Discuss your current diabetes management and ways to improve your skills especially with food and  insulin. Discuss the use of insulin /carbohydrate ratios , timing of your insulin doses and switching  to a  different basal  insulin such as Lantus .
            
#2 Discuss medications that have a lower risk of hypoglycemia such as glucophage (metformin ), exentide (byetta ), liraglutide (victors) , sitagliptin (januvia) , saxagliptin ( onglyza) and older drugs such as acarbose
        
 #3  Discuss the use of temporary or permanent continuous glucose monitoring .  I personally feel that continuous glucose monitoring may be one of the best tools available in our efforts to reduce the risk  associated with hypoglycemia.


 I have attached a copy of a Medscape article  discussing guidelines for  using continuous   glucose monitoring. 

                             Have fun , be smart and defeat diabetes        David Calder, MD


Guidelines Address Continuous Glucose Monitoring
Laurie Barclay, MD



October 12, 2011 — Continuous glucose monitoring (CGM) assists people with diabetes in maintaining target blood glucose levels, according to an Endocrine Society clinical practice guideline published in the October issue of the Journal of Clinical Endocrinology and Metabolism.
"There are some caveats to consider before accepting continuous monitoring of glucose as a routine measure to improve glycemic control in diabetes," guidelines task force chair David C. Klonoff, MD, from Mills-Peninsula Health Services in San Mateo, California, said in a news release. "There are still concerns about the high costs of CGM and the accuracy of the various systems available. However, the new [clinical practice guideline] shows that CGM can be a beneficial tool to help maintain target levels of glycemia and limit the risk of hypoglycemia."
CGM, using various devices, measures glucose in the interstitial fluid; the intended use is for patients with type 1 or type 2 diabetes to make decisions about food, medicines, and exercise. A task force of experts, a methodologist, and a medical writer set out to develop evidence-based practice guidelines for identifying clinical scenarios in which CGM would be most beneficial to patients with diabetes. The goals of CGM are to maintain target levels of glycemia and to limit the risk for hypoglycemia in 3 potential settings: real-time (RT) CGM in hospitalized adults, RT-CGM in children and adolescent outpatients, and RT-CGM in adult outpatients.
The strength of the recommendations and the quality of the evidence were described using the Grading of Recommendations, Assessment, Development, and Evaluation system. Consensus was established in a group meeting, conference calls, and emails. The Diabetes Technology Society and the European Society of Endocrinology also reviewed and commented on preliminary drafts of these guidelines.
Specific recommendations for CGM are as follows:
  • While awaiting further evidence, RT-CGM alone should not be used for glucose management of adults in the intensive care unit or operating room.
  • Children and adolescent outpatients with type 1 diabetes mellitus (T1DM) and glycosylated hemoglobin (HbA1c) levels less than 7.0% should use RT-CGM with currently approved devices.
  • Pediatric, adolescent, and adult outpatients with T1DM and HbA1c levels of 7.0% or more should use RT-CGM if they are able to use these devices on a nearly daily basis.
  • The guidelines do not recommend for or against the use of RT-CGM by children younger than 8 years with T1DM.
  • Patients should be given treatment guidelines so that they can safely and effectively use the information obtained from RT-CGM.
  • Intermittent use of CGM systems capable of short-term retrospective analysis is recommended in children and adults with diabetes and possible nocturnal hypoglycemia, dawn phenomenon, and postprandial hyperglycemia; in patients with hypoglycemic unawareness; and in patients undergoing significant changes to their diabetes regimen.
  • Adults with T1DM and HbA1c levels less than 7.0% should use RT-CGM devices if they can use them on a nearly daily basis.
"CGM can be beneficial in maintaining target levels of glycemia and limiting the risk of hypoglycemia," the guidelines authors write.
All Endocrine Society clinical practice guidelines are supported entirely by society funds. Some members report various financial relationships with Bayer, C8 MediSensors, Insuline, LifeScan, Medtronic Diabetes, Roche, Diabetes Technology Society, MedTronic MiniMed, LifeScan, NovoNordisk, JDRF, UnoMedical, European Society of Endocrinology. KER Unit (Mayo Clinic), Abbott Diabetes, Eli Lilly, Macrogenics, Dexcom, the Endocrine Society, and/or Insulet.
J Clin Endocrinol Metabol. 2011;96:2968-2979. Abstract




and don't forget to visit Laughing at LIfe by Mark to gain a little insight into the lows from a personal point of view...





                 
          

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Your comments and questions are appreciated. David Calder,MD