1. Canadian Diabetes Association Clinical Practice Guidelines Monitoring for Glycemic Control Chapter 9 Lori Berard, Ian Blumer, Robyn Houlden, David Miller, Vincent Woo

2. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Key Messages 1.Glycated hemoglobin (A1C)  measure every 3 months (6 months if stable at target) 2.Self monitoring Blood Glucose (SMBG) is an aid to assess interventions and hypoglycemia 3.Individualize the frequency of SMBG 4.SMBG and continuous glucose monitoring (CGM) needs to be linked with structured educational program to facilitate behaviour change 2013

3. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Glycated Hemoglobin: A1C Reliable measure of mean plasma glucose over 3-4 months Valuable indicator of treatment effectiveness Measure every 3 months when glycemic targets are not being met or treatments adjusted Measure every 6 months if stable at glycemic targets

4. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recognize pitfalls of A1C: Conditions that can Affect Value Factors affecting A1C Increased A1CDecreased A1CVariable Change in A1C ErythropoiesisB12/Fe deficiency Decreased erythropoiesis Use of EPO, Fe, or B12 Reticulocytosis Chronic liver Dx Altered hemoglobin Fetal hemoglobin Hemoglobinopathies Methemoglobin Altered glycationChronic renal failure ↓↓erythrocyte pH ASA, vitamin C/E Hemoglobinopathies ↑ erythrocyte pH Erythrocyte destruction SplenectomyHemoglobinopathies Chronic renal failure Splenomegaly Rheumatoid arthritis HAART meds, Ribavirin Dapsone AssaysHyperbilirubinemia Carbamylated Hb ETOH Chronic opiates Hypertriglyceridemia

5. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association A1C Reporting: NGSP vs. IFCC Units Canada continues to report A1C in NGSP units of % Some countries report A1C in IFCC SI units (mmol/mol) instead of the NGSP units The equation below can be used to convert A1C from NGSP (%) to IFCC (mmol/mol) IFCC (mmol/mol) = 10.93(NGSP%) – 23.50 NGSP (%)IFCC (mmol/mol) 4.020 5.031 6.042 6.548 7.053 8.064 9.075 10.086 11.097 12.0108 NGSP = National Glycohemoglobin Standardization Program; IFCC = International Federation of Clinical Chemistry and Laboratory Medicine

6. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association SMBG is a tool, not an intervention Teach patients to “MONITOR WITH MEANING”

7. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Monitoring with Meaning … SMBG accompanied by structured educational program to facilitate behaviour change results in improved outcomes Teach patients 1. How and when to perform SMBG 2. How to record the results 3. Meaning of various BG levels 4. How behaviour and actions affect SMBG results 1.Parkin CG et al. J Diabetes Sci Technol. 2009;3:500-508. 2.Polonsky WH, et al. Diabetes Care. 2011;34:262-267.

8. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Individualize Frequency of SMBG CDA SMBG tool - provides guidance on appropriate situations for SMBG utilization http://guidelines.diabetes.ca 2013

9. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association

10. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Regular SMBG is required:

11. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Increased frequency of SMBG may be required: Daily SMBG is not usually required if:

12. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association

13. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association

14. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 1 1.For most individuals with diabetes, A1C should be measured every 3 months to ensure that glycemic goals are being met or maintained. Testing at least every 6 months should be performed in adults during periods of treatment and lifestyle stability when glycemic targets have been consistently achieved [Grade D, Consensus].

15. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 2 2.For individuals using insulin more than once a day, SMBG should be used as an essential part of diabetes self-management [Grade A, Level 1, for type 1 diabetes; Grade C, Level 3 for type 2 diabetes] and should be undertaken at least 3 times per day [Grade C, Level 3] and include both pre- and postprandial measurements [Grade C, Level 3]. In those with type 2 diabetes on once-daily insulin in addition to oral antihyperglycemic agents, testing at least once a day at variable times is recommended [Grade D, Consensus].

16. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association When glycemic control is not being achieved, SMBG should include both pre-and postprandial measurements to modify lifestyle and medications [Grade A, Level 1]. If achieving glycemic targets or receiving medications not associated with hypoglycemia, infrequent SMBG is appropriate [Grade D, Consensus]. Recommendation 3 3.For individuals with type 2 diabetes not receiving insulin therapy, SMBG recommendations should be individualized depending on type of antihyperglycemic agents, level of glycemic control, and risk of hypoglycemia. [Grade D, Consensus]. 2013

17. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 4 4.In many situations, for all individuals with diabetes, more frequent testing should be undertaken to provide information needed to make behavioural or treatment adjustments required to achieve desired glycemic targets and avoid risk of hypoglycemia [Grade D, Consensus].

18. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 5 5.In people with type 1 diabetes with inadequate glycemic control despite an optimal treatment regimen, real-time continuous glucose monitoring may be used to improve glycemic control [Grade B, Level 2] and reduce hypoglycemia [Grade B, Level 2]. 2013

19. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 6 6. In order to ensure accuracy of BG meter readings, meter results should be compared with laboratory measurement of simultaneous venous FPG at least annually, and when indicators of glycemic control do not match meter readings [Grade D, Consensus].

20. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 7 7.Individuals with type 1 diabetes should be instructed to perform ketone testing during periods of acute illness accompanied by elevated BG, when preprandial BG levels remain >14.0 mmol/L or in the presence of symptoms of DKA [Grade D, Consensus]. Blood ketone testing methods may be preferred over urine ketone testing, as they have been associated with earlier detection of ketosis and response to treatment [Grade B, Level 2].

21. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association CDA Clinical Practice Guidelines http://guidelines.diabetes.cahttp://guidelines.diabetes.ca – for professionals 1-800-BANTING (226-8464) http://diabetes.ca http://diabetes.ca – for patients