Diabetes: Section 6 and 7. Glycemic Targets and Blood Glucose Devices

January 14, 2020 0 By Jose Scott


We are going to talk about Glycemic targets so this is section six of your slides All right. So a1 C testing, how do we determine what their target? Number should be so we want to perform the a1c test at least twice a year Who are are doing fine who are meeting their goals and have stable blood Sugar’s these are the people that need to be bringing in or everybody should be bringing in their blood sugar monitor at every single visit and Either you can upload them to the computer or look so their meter, or they should have it written down I always like people writing it down because number Number one it puts it in the cognitive side of their brain. So they’re more accountable to what they’re seeing and number two It’s easier to see a graph although there’s a lot of phone apps now that are able to Show a graph or like a bunch of readings at one time so you can take a look at that I do love the new apps that are out now Otherwise you want to do it quarterly if they’re not meeting their goal All right, so these are mean glucose levels for specific a1c levels, so if you see for example if they have between a 7.5 and some point 9 will come down here and The mean fasting glucose is around 167 in other countries, they use millimoles but in the United States we use milligrams per deciliter We do things different, you know in the United States with numbers. Everyone else is on the metric system except for us, right? Alright, and then this is a pre-meal glucose Post-meal and these are averages if somebody comes back and has an a1c Around seven point five to seven point nine nine so you can help show the patient, you know Your a1c is this well, that tells me your blood Sugar’s up in the 170s most of the time So a reasonable A1c goal for many non pregnant adults is less than seven. That’s an a recommendation So remember reasonable? So that is what I’m going to show you How are we going to choose what they’re a 1 Siegel’s is we might we might want to have them be lesson 6.5. It just depends and I’m going to show you the graph that will help you determine What your patients a 1c goal is going to be? I think it’s nice that we do have more leeway to determine Ourselves what the a1c goal should be I think it’s really good for accountable care and quality of care So these are a summary so the pre prandial glucose is Recommended 80 to 130 in an a1c of less than seven and the peak Postprandial less than 180. But again, this is what a reasonable is, but it might not necessarily be what you want for your patient because someone who is at an a1c of 6.9 remember still has diabetes and so if they’re younger and don’t have any other major comorbidities that would interfere with bringing their a1c down then you should have their target be lower because With higher blood sugar means you’re doing damage to your body. So it means complications and less stringent a1c goals such as less than 8 may be more appropriate also, so if you have an elderly person that They’re more at risk for hyper Hypoglycemia, maybe you want them on the higher side? So this is an important Graph or a table? I should say or whatever picture And I have this in the article that I’m going to post to you And this is how you determine help determine where this a1c should be. So if you see a 1c 7.7 7.0 Less stringent more stringent. So you go down the line. So what are the risks associated with hypoglycemia? All right. Let’s say we have Mary who is age 85. Okay, so she’s 85 years old and She’s kind of frail She’s had diabetes for thirty years she has end-stage COPD and high blood pressure and that goes with it high cholesterol that stuff so she’s not on a statin because they took her off it cuz she’s 85 and we need Cholesterol for our brain so we took we took her off that she’s on an ACE inhibitor She’s on a beta blocker Because you’ll find most elderly are on beta blockers because when I did nursing home rounds I still was like candy, basically uh that people were on and So her life expectancy having COPD is probably not Too long. So when we say ten years that is what we kind of use as a guide. They have a ten year life expectancy All right, and we talked about her comorbidities She has some more severe comorbidities shorter life expectancy. She’s had long-standing diabetes and She’s elderly so I’m thinking age and vascular complications. Not really sure patient preference I’d say at her condition if she has cognitive impairment then it would probably be more here But if someone that she’s like that’s it. I want to make change. He’s really You know cognitively with it then you know that might be a little different but you got all these other ones going against you and then what are her support system and Resources I will say in the nursing home. They don’t give them diabetic diets I have not been to one nursing home at least around where I live in Kenosha That have diabetic diets for the patients they’re always chasing blood Sugar’s so yes, they have dietitians there and resources but it’s not To me in my opinion We have an understanding problem and a funding problem and so I don’t blame it on the nurses I don’t blame it on that it’s a system issue why we don’t have Exceptional care in nursing homes, which is sad. So this patient I would probably have or I would have her goal be eight Somebody who’s kind of in the middle of these then say well, yeah we can do seven Because if they have advanced color complications But they’re newly diagnosed and they’re obese I’d say, you know what let’s get your blood sugar down We don’t want to further your complications if we have a younger person like say myself as I’m saying I’m younger But I am under fifty so I’m in that in that age range I am low on all of these so I need to be Below I need to be below the borderline diabetes range So in reality, yes, I don’t want my blood sugar even in the borderline so but in practice, let’s just set a goal of let’s say Less than six point five, that would be very reasonable and depending on your patient preference again I’m very highly motivated and to have I think good self-care capabilities I’m getting lower than that and I don’t have hypoglycemia Issues, but there are some people that do so those that do you have to figure out why are you having? Hypoglycemia, make sure that they have something on them that they can have if they have low blood sugar symptoms Glucose is the preferred treatment for the conscious individual if it’s less than 70 there are stages or different types of levels level one two, and three so if it’s less than seventy or level one level two is less than fifty four and Level three is when you have an altered Mental Status and you need help So glucagon should be prescribed for all individuals at risk of level two hypoglycemia and Available as needed give it to their caregivers at school so type one diabetics particularly family members And I need to know how to administer to administer it so it’s not limited to just health care professionals The laypeople need to know how to use that too. And Hypoglycemia, unawareness or one or more episodes of level 3 hypoglycemia should trigger Re-evaluation of the treatment so why are they having these? Hypoglycemic reactions or not aware. Maybe they’re on a beta blocker and beta blockers mask a hypoglycemia, and insulin treated patients with Hypoglycemia, unawareness or an episode of level 2 should be advised to raise their tart at the glycemic targets so that goes back to that Picture that I showed you and I always have that With me. I have like a little book which has all my diabetic stuff in there. I like picture so I have the pictures in there and my tables Alright And I’m just gonna talk a little bit about a diabetic technology real quickly There’s because I know you guys know a lot about this there’s syringes and there’s pens depends what the insurance company covers there’s insulin pumps mostly for type 1 diabetics and It’s a great option for under 7 years of age just because they’re not able to really Understand and getting the shots. It’s just easier for them. There’s different types of blood glucose monitoring So there’s the intermittent where you just check when you’re poking and Those that are on insulin need to check it at least before every single meal fasting and before bed Before exercise after exercise those with type 2 and oral medication Should definitely be checking a fasting blood sugar But if I find somebody that is more willing and Self-care, then I have them test it quite often because they need to change their lifestyle and they need to eat to their meter They need to know what foods are bringing their blood sugar up. So they know to stay away from those So glucose meter accuracy There’s always going to be some variances. It’s about a 95 percent variance versus the a1c with glucose meters and So if you just get the appropriate devices that are out there by prescription and the ones that are from CVS Walgreens Walmart Those are pretty accurate – like I said, I have two meters. I have a really good one a rely on No, yeah the reliance a Walmart and then I have an accu-check and they both are basically the same there are some substances though that can interfere with it such as uric acid galactose ILO’s tylenol which acetaminophen l-dopa Which would be for patients with markinson’s and vitamin C ascorbic acid, so just to keep that in mind also Used in in peritoneal Dialysis, there can be an issue with that. So there’s also the continuous blood glucose monitors and those are attached to them continuously or there’s the real-time one now, which you Can have it be 24/7 monitoring your glucose and then there’s an intermittent Scan glucose monitor and as well as the IV pumps, which I talked about so I do want to show you really quick Some of the this is hot. This is the only way I can find it. There’s the freestyle Libre and this goes on them On their upper arm and it stays on them. I think for three days. I’m not positive. I could be wrong on that But anyways, all they have to do is they don’t have to pulp themselves anymore. They just scan this Close to their arm and it’ll read there. So let’s the intermittent blood glucose Dario is very similar That’s the Dario and Dexcom is the continuous blood glucose monitoring if there’s there might be other ones out there These are the ones that I am familiar with so just to let you know and that is it for this video