Top-10 Techniques for Attaining Glucose Goals Gary Scheiner MS, CDE Owner/Director Integrated Diabetes Services Wynnewood, PA

10 Agree on the goals.

Acceptable target ranges Pre-meals (70-160? ? ?) 1-Hr Postprandial (<180? 200? 240?) % of BGs in-range Improve upon recent past (>50%? 70%?)

Agree on the goals. “Acceptable” Hypoglycemia Define Hypo (<80? 70? 60?) # Per Week (<5? 3? 2?) Allowable severe lows (usually 0) HbA1c Target Short term: Improve upon recent past Long term: Ultimate goal

9 Individualize the plan of care.

No 2 kids are the same. No 2 caregivers are the same. Patients are your clients. Adapt to their needs! (not vice versa)

Individualize the plan of care. Nature of services provided Teaching style Rate of progression Overall goals

8 Don’t Pigeon-Hole.

Don’t Pigeon-Hole Not everyone fits the usual formulas. Programs should be tailored to the client’s needs, interests and abilities. Offer a “menu” of options with pros & cons of each  Conventional Therapy  MDI  CSII

7 Stay Cutting Edge.

Stay Cutting-Edge. Medical Treatments  Insulin “cocktails”  Diluting insulin  Oral agents  Incretins

Stay Cutting-Edge. Learn & utilize the latest devices Continuous Glucose Monitors Downloading/Analysis Software Pumps, Pens Injection Ports New Meters Online resources

Stay Cutting-Edge. Think Outside the Box!  Be willing to try new things.  Diabetes management, by its very nature, is TRIAL AND ERROR.

6 Empower Thy Patients.

Show how to self-evaluate critically. Explain the process for making sound self-adjustments. Detail when to contact the HCP.

Empower Thy Patient. Teach your patients well.  Use tools fully & properly.  Expert carb counters.  Ready for sick days.  Manage lows properly.  Troubleshoot effectively.

5 Respect the Basals.

Start with the basals. Basal insulin is the foundation of the management program. Make sure the basal insulin is right before attempting to fine-tune boluses. Conduct fasting tests to verify  pumpers: around-the-clock  injectors: overnight

Start with the basals.

Basal Testing Conditions: No food raising BG  Last meal  4 hours prior  Last meal fairly low in fat  No calories during the test (d/c if <70) No bolus insulin lowering BG  Last bolus  4 hours prior  No boluses during the test (d/c if >250)  No temp rates, suspension or disconnection

Start with the basals. Basal Testing Conditions: No unusual stress, illness or hormonal changes Usual daily activities (no heavy exercise during test) Check BG every 1-2 hours (every 2-3 hours OK overnight)

TestLast Meal / Bolus By Check BG atMay Eat / Bolus Again at Overnight 6pm (skip night snack) 10pm, 1am, 4am, 7am7am Morning 3am (skip bkfst) 7am, 9am, 11am, 12noon 12 noon Afternoon 8am (skip lunch) 12 noon, 2pm, 4pm, 5pm 5pm Evening 1pm (skip dinner) 5pm, 7pm, 9pm, 10pm10pm Sample Basal Testing Schedule Start with the basals.

Grounds for adjustment Consistent rise or fall through the test phase Change of more than 30 mg/dl through the test phase If irregular pattern, repeat test Make changes 1 hr prior (pump); 10% of basal dose (injections) Start with the basals. 

4 Plan for Communication.

Plan for communication. Who? Parent? Child? Shared? Who receives/replies at your end?

What? Blood Sugars Only? Pre, or Pre & Post? Carbs, Insulin, Activity? Programmable meter/pump? WRITTEN LOGSHEETS RULE! Plan for communication.

Blood glucose values by themselves tell us when something is wrong, but they don’t tell us why. Plan for communication.

When? Daily? Weekly? Monthly? For special circumstances? Prior to appointments?

Plan for communication. How? Phone Fax Website (Carelink, etc.) Transmission of pump/meter data

3 Think Activity.

Think Activity Encourage it. Support it. Think about it whenever dosing.

Think Activity Sometimes insulin works like a unit, sometimes it don’t. Insulin is only as effective as the body is at using it.

Think Activity Use Activity “Multipliers” when determining boluses: - 25% - 50% + 20%

Think Activity Encourage daily activity, year-round

2 Monitor & Adjust Often.

Monitor & Adjust Often Pediatric Type-1 SMBG Fasting Pre-meals, snacks, bedtime 1-hr post-meals (rotating) Prior to sports/exercise Hourly during prolonged sports/exercise Every 2-3 hours during illness 3 a.m. (at least once weekly)

1. Collect the data Weekly (patients/families) Monthly/Quarterly (HCP) 2. Analyze the data by time of day > 30% high? > 10% low? 3. Find the Culprit Monitor & Adjust Often

The “Usual Suspects” The Insulin Program Basal Insulin I:C Ratio Correction Factor Exercise Variation Lifestyle Issues Hormone Changes “Sabotage” Monitor & Adjust Often

1 Instill the Right Attitude.

Instill the Right Attitude First Impressions Count: Be Aggressive From the Get-Go.

Instill the Right Attitude Let Kids Be Kids

Instill the Right Attitude But… Know When to Say When. Structure Works. Certain Things Must Get Done. Blood Glucose Monitoring Insulin Administration Hypo Prevention/Management Timely Professional Care

Think Like A Pancreas!