Frequent Blood Glucose Monitoring Research Articles

A Multicomponent Motivational Intervention to Improve Adherence Among Adolescents With Poorly Controlled Type 1 Diabetes: A Pilot Study

To adapt and pilot test a multicomponent motivational intervention that includes family-based contingency management (CM) for adolescents with poorly controlled type 1 diabetes. A total of 17 adolescents, age 12-17 years (M = 14.8, SD = 1.5), with type 1 diabetes (duration M = 6.2 years, SD = 4.5) and mean HbA1c of 11.6% (SD = 2.5%) were enrolled. Adolescents and their parents received 14 weeks of motivational interviewing, clinic-based CM, and parent-directed CM that targeted increased blood glucose monitoring (BGM). Adolescents significantly increased their BGM (p < .001) and showed significantly improved HbA1c levels (glycemic control) from pre-to posttreatment (p < .0001). The magnitude of improvements in the frequency of BGM and glycemic control in adolescents with type 1 diabetes is encouraging and will be tested in a randomized controlled trial.

Type 1 Diabetes Mellitus

1. Justin M. Gregory, MD* 2. Daniel J. Moore, MD, PhD† 3. Jill H. Simmons, MD‡ 1. *Pediatric Endocrinology Clinical Fellow, Ian Burr Division of Pediatric Endocrinology and Diabetes, Vanderbilt University School of Medicine, Nashville, TN. 2. †Assistant Professor of Pediatrics, Assistant Professor of Pathology, Microbiology, and Immunology, Ian Burr Division of Pediatric Endocrinology and Diabetes, Vanderbilt University School of Medicine, Nashville, TN. 3. ‡Assistant Professor of Pediatrics, Ian Burr Division of Pediatric Endocrinology and Diabetes, Vanderbilt University School of Medicine, Nashville, TN. * ADA: : American Diabetes Association DKA: : diabetic ketoacidosis HbA1c: : glycosylated hemoglobin I:C ratio: : insulin-to-carbohydrate ratio IV: : intravenous TDD: : total daily dose T1DM: : type 1 diabetes mellitus T2DM: : type 2 diabetes mellitus 1. All children with type 1 diabetes mellitus (T1DM) should have their blood sugar managed with basal-bolus insulin treatment by either multiple daily injections or an insulin pump. 2. All children with T1DM should have access to a pediatric endocrinologist with a diabetes management team with resources to support patients and families. 3. All children with T1DM should be monitored for symptoms and/or screened for commonly associated conditions such as thyroid and celiac disease. After completing this article, readers should be able to: 1. Recognize the presenting signs and symptoms of type 1 diabetes mellitus (T1DM). 2. Know the key principles of effective diabetes self-management and the diabetes care team’s role in facilitating effective self-management. 3. Know the acute and chronic complications of (T1DM). 4. Identify how different categories of insulin analogues are used in daily insulin regimens. True, it is a fight, but there is pleasure in the struggle. Victory comes to the courageous; and without courage and common sense, success awaits no one. I look upon the diabetic as charioteer and his chariot as drawn by three steeds named Diet, Insulin, and Exercise. It takes skill to drive one horse, intelligence to manage a team of two, but a man must be a very good teamster who can get all three to pull together.EP Joslin, 1933 Type 1 diabetes mellitus (T1DM) is a disorder of glucose homeostasis characterized by autoimmune destruction of the insulin-producing pancreatic β-cell that progressively leads to insulin deficiency and resultant hyperglycemia. If left untreated, insulin deficiency leads to progressive metabolic derangement, with worsening hyperglycemia, ketoacidosis, starvation, and death. In …

Type 1 Diabetes Mellitus

Type 1 Diabetes Mellitus

Cognitive–behavioral therapy for adolescents with Type 1 diabetes and subclinical depressive symptoms

SUMMARY Aims: The purpose of this study was to adapt and pilot an evidence-based individual cognitive–behavioral therapy (CBT) intervention to reduce depressive symptoms in adolescents with Type 1 diabetes and subclinical depressive symptoms, a group at increased risk of poor self-management and glycemic control. Materials & methods: Nine adolescents (aged 13–18 years) participated in a 12-session individual CBT intervention. Participants and their caregivers completed measures of depressive symptoms and diabetes management pre- and post-intervention. Blood glucose monitoring frequency and HbA1c were obtained via chart review. Results: Paired-samples t-tests indicated improvements in depressive symptoms, measured by adolescent (t[8] = 5.38; p = 0.0004; Cohen’s d = 1.59) and caregiver report (t[8] = 2.50; p = 0.04; Cohen’s d = 0.66) and diabetes self-management, measured by adolescent report (t[8] = -3.24; p = 0.01; Cohen’s d = -0.98) following intervention completion. Conclusion: CBT is a promising interv...

PM.76 A Question of Probity: Phantom Blood Glucose Value Recording in a Self-Monitoring Pregnant Diabetic Woman

IntroductionA successful doctor-patient relationship is based on perceived mutual trust. The importance of this is underscored in pregnant diabetic women where self monitoring of blood glucose (SMBG) levels by patients’...

Practical Approach to Management of Inpatient Hyperglycemia in Select Patient Populations

Hospitalized patients frequently transition between various levels of care and changing clinical situations. Optimal management of hospitalized patients with hyperglycemia includes awareness of situations that may significantly affect glucose and/or insulin metabolism. A review of published clinical trials reveals practical approaches to the management of hyperglycemia in select patient populations that may prove useful for the hospital clinician. We outline approaches to the management of hyperglycemia in hospitalized patients receiving glucocorticoids, patients with severe or end-stage renal disease undergoing hemo- or peritoneal dialysis, and patients receiving total parenteral or enteral feeding, in addition to patients transitioning from intravenous insulin infusion to subcutaneously administered insulin. Key considerations underlying these management methods include a proactive approach, frequent blood glucose monitoring, daily review of blood glucose patterns, and daily reassessment of the insulin regimen and associated orders.

In-hospital Management of Diabetes

In-hospital Management of Diabetes

Comparing daily versus less frequent blood glucose monitoring in patients with mild gestational diabetes

Objective: The prevalence of gestational diabetes mellitus (GDM) is increasing. This study was designed to determine if different frequencies in blood glucose (BG) monitoring, without regard to other variables, would allow timely detection of hyperglycemia requiring pharmacologic treatment in mild GDMs.Methods: Retrospective chart review, limited to self-glucose monitoring values, of 120 mild GDM patients who required pharmacologic therapy. Three data sets were constructed from each patient’s BG log: (1) all available BG; (2) every other day’s BG blocked; (3) only every third day’s BG available for review. The blocked BG datasets were compared with daily values.Results: 95% and 97% of subjects were started on pharmacologic therapy before or within 7 d of the reference date using every other day and every third day BG logs, respectively.Conclusions: Based exclusively on BG values, without regard to other clinical information, every other day or every third day BG monitoring in mild GDM does not delay the initiation of pharmacologic therapy.

OHP-030 Efficacy of Health Literacy in the Self-Education of Diabetic Patients

BackgroundThe increased prevalence of chronic diseases, including diabetes, requires a critical review of models of care and the introduction of new strategies of intervention. Health Literacy (HL) is a tool...

Safe and Effective Use of a Glycemic Control Protocol for Neonates in a Cardiac ICU*

To investigate the safety and efficacy of a hyperglycemia protocol in neonates with critical cardiac illness. Neonates are often regarded as high risk for hypoglycemia while receiving continuous insulin infusions and thus have been excluded from some clinical trials. A retrospective review. A pediatric cardiac ICU in a tertiary academic center. Neonates with critical cardiac illness who developed hyperglycemia were placed on an insulin-hyperglycemia protocol at the attending physician's discretion. Insulin infusions were titrated based on frequent blood glucose monitoring. Critical illness hyperglycemia was defined as a blood glucose less than 140 mg/dL. Hypoglycemia was defined as moderate (≤ 60 mg/dL) or severe (≤ 40 mg/dL). Initiating blood glucose, lowest blood glucose during insulin infusion, doses of insulin, duration of insulin, and time to blood glucose greater than 140 mg/dL were evaluated. A total of 44 patients were placed on the protocol between January 2009 and October 2011. The majority of insulin infusions were initiated in the early postoperative period (33 of 44, 75%). Moderate hypoglycemia occurred in two patients (4.5%), with blood glucose levels of 49 and 53 mg/dL. No episodes of severe hypoglycemia occurred. A total of 345 discrete blood glucose levels were analyzed; two of these being greater than 60 mg/dL (0.58%). Mean blood glucose prior to starting insulin was 252 ± 45 mg/dL and time until euglycemia was 6.1 ± 3.9 hours. The mean duration of insulin infusion was 24.6 ± 38.7 hours, mean peak dose was 0.10 ± 0.05 units/kg/hour, and mean insulin dose was 0.06 ± 0.02 units/kg/hour. For postoperative patients, mean time after bypass until onset of hyperglycemia was 2.2 ± 2.6 hours. A glycemic control protocol can safely and effectively be applied to neonates with critical cardiac disease. Neonates with critical cardiac illness should be included in clinical trials evaluating the benefits of glycemic control.

Frequency of Mealtime Insulin Bolus as a Proxy Measure of Adherence for Children and Youths with Type 1 Diabetes Mellitus

Electronic measures of adherence can be superior to patient report. In type 1 diabetes, frequency of blood glucose monitoring (BGM), as measured by patients' home blood glucose meters, has already been identified as a valid proxy of adherence. We present methodology to calculate adherence using insulin pump records and evaluate the reliability and validity of this methodology. Blood glucose meter data, insulin pump records, and corresponding hemoglobin A1c (HbA1c) levels were randomly gathered from clinical and research databases for 100 children and youths (referred to hereafter as youths) with type 1 diabetes (mean±SD age, 12.7±4.6 years). Youths' mean frequency of daily BGM was calculated. Additionally, we calculated a mean mealtime insulin bolus score (BOLUS): youths received 1 point each for a bolus between 0600 and 1000 h, 1100 and 1500 h, and 1600 and 2200 h (maximum of 1 point/meal or 3 points/day). Simple correlations between youths' HbA1c level, age, frequency of BGM, and insulin BOLUS scores were all significant. Partial correlations and multiple regression analyses revealed that insulin BOLUS scores better explain variations in HbA1c levels than the electronically recorded frequency of daily blood glucose measures. Our procedures for calculating insulin BOLUS scores using insulin pump records demonstrate better concurrent validity with youths' HbA1c levels than that of the frequency of BGM with youths' HbA1c levels. Our analyses have shown that insulin bolus scoring was superior to the frequency of BGM in predicting youths' HbA1c levels.

Self monitoring of blood glucose level among diabetic patients in Muscat, Oman: A pilot study

Introduction: Monitoring of blood glucose (BG) is an important aspect of the diagnosis and management of diabetes. Self monitoring of blood glucose (SMBG) of patients at home can provide patients and physicians with valuable information in the management of diabetes mellitus. Objective: The aim of this pilot study was to assess the awareness, attitude and practice of SMBG among primary care diabetic patients in Muscat region. Materials and Methods: The study was conducted in two phases. In the first phase 140 patients attending diabetes clinics at various health centers in Muscat region were interviewed to identify patients who practice SMBG. In the second phase a closed ended questionnaire containing 10 questions related to demographic characteristics and attitude was self administered to 50 patients recruited from the first phase to generate the data. Results: It was found that only one third of the patients use glucometer to monitor their BG at home. However, majority of the patients were aware of the significance and importance of glucose home monitoring and thus recommended the practice of SMBG to other diabetic patients. Participants acknowledged the role of pharmacist in educating and training the patient about the proper use of glucometers. Patients were convinced with the device performance and pricking finger was not a deterrent, but at the same time the frequency of BG monitoring was poor among the participants. Conclusion: Overall the participants had a positive attitude towards SMBG but there is a room for the improvement among the participants who showed poor frequency of BG monitoring. There is a need to aware and educate the Omani diabetic patients about the importance of SMBG to achieve the desired therapeutic goals.

Future Perspectives in Glucose Monitoring Sensors

The prevalence of diabetes is increasing. Improved glucose control is fundamental to reduce both long-term micro- and macrovascular complications and short-term complications, such as diabetic ketoacidosis and severe hypoglycemia. Frequent blood glucose monitoring is an essential part of diabetes management. However, almost all available blood glucose monitoring devices are invasive. This determines a reduced patient compliance, which in turn reflects negatively on glucose control. Therefore, there is a need to develop noninvasive glucose monitoring devices that will reduce the need of invasive procedures, thus increasing patient compliance and consequently improving quality of life and health of patients with diabetes.

945

Introduction: Usual treatment of hypoglycemia with dextrose 50% contributes to excessive glycemic variability, a phenomenon which has been previously associated with mortality in critically ill patients. Hypothesis: Implementation of a blood glucose specific hypoglycemia treatment protocol will provide resolution of hypoglycemic episodes with reduced glucose variability. Methods: This quasi-experimental retrospective analysis was conducted at a 772-bed community teaching hospital in Detroit, Michigan. Data regarding hypoglycemia management was collected prior to protocol implementation in February 2011. In addition to specific dextrose 50% recommendations, the hypoglycemia protocol specified frequency of blood glucose monitoring following treatment and recommendations to prevent future episodes of hypoglycemia. Glucose variability, amount of dextrose administered, subsequent glucose monitoring, hypoglycemia recurrence, and mortality were compared between pre- and post-protocol groups. Results: The blood glucose coefficient of variability in the post-protocol group (n = 53) was significantly decreased compared with the pre-protocol group (n = 52), 40.9% vs. 49.3%, respectively (p = 0.048). Amount of dextrose 50% administered was significantly reduced between groups (21.2 grams pre-protocol vs. 11.5 grams post-protocol; p < 0.001). The time to first blood glucose check was 36 minutes after protocol implementation compared to 61 minutes before the protocol (p = 0.003). The incidence of recurrent hypoglycemia following dextrose administration and ICU mortality were similar between groups. Conclusions: Implementation of the described hypoglycemia protocol provided safe and effective management of hypoglycemia with reduced glycemic variability.

Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients

To evaluate the literature and identify important aspects of insulin therapy that facilitate safe and effective infusion therapy for a defined glycemic end point. Where available, the literature was evaluated using Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) methodology to assess the impact of insulin infusions on outcome for general intensive care unit patients and those in specific subsets of neurologic injury, traumatic injury, and cardiovascular surgery. Elements that contribute to safe and effective insulin infusion therapy were determined through literature review and expert opinion. The majority of the literature supporting the use of insulin infusion therapy for critically ill patients lacks adequate strength to support more than weak recommendations, termed suggestions, such that the difference between desirable and undesirable effect of a given intervention is not always clear. The article is focused on a suggested glycemic control end point such that a blood glucose ≥ 150 mg/dL triggers interventions to maintain blood glucose below that level and absolutely <180 mg/dL. There is a slight reduction in mortality with this treatment end point for general intensive care unit patients and reductions in morbidity for perioperative patients, postoperative cardiac surgery patients, post-traumatic injury patients, and neurologic injury patients. We suggest that the insulin regimen and monitoring system be designed to avoid and detect hypoglycemia (blood glucose ≤ 70 mg/dL) and to minimize glycemic variability.Important processes of care for insulin therapy include use of a reliable insulin infusion protocol, frequent blood glucose monitoring, and avoidance of finger-stick glucose testing through the use of arterial or venous glucose samples. The essential components of an insulin infusion system include use of a validated insulin titration program, availability of appropriate staffing resources, accurate monitoring technology, and standardized approaches to infusion preparation, provision of consistent carbohydrate calories and nutritional support, and dextrose replacement for hypoglycemia prevention and treatment. Quality improvement of glycemic management programs should include analysis of hypoglycemia rates, run charts of glucose values <150 and 180 mg/dL. The literature is inadequate to support recommendations regarding glycemic control in pediatric patients. While the benefits of tight glycemic control have not been definitive, there are patients who will receive insulin infusion therapy, and the suggestions in this article provide the structure for safe and effective use of this therapy.

How poorer quality of life in adolescence predicts subsequent type 1 diabetes management and control

ObjectiveDetriments in quality of life (QOL) may contribute to the common, costly decline in adolescents’ type 1 diabetes management and control, yet we know little about how this might happen. MethodsParticipants were 150 adolescents (age 13–18) with type 1 diabetes and their parents. We constructed a latent QOL variable from a multi-informant, multi-domain assessment when participants entered the study. The QOL variable was examined in relation to prospective assessments of diabetes management (blood glucose monitoring frequency; BGM) and control (hemoglobin A1c). We used an indirect path model to test the links among these variables, using bias-corrected bootstrapping. ResultsPoorer QOL at baseline was indirectly linked with higher A1c at 12 months via less frequent BGM obtained at 6 months (b=−0.01, 95% CI=−0.025, −0.004, p<0.05). Older age (b=−0.32), longer diabetes duration (b=−0.07), and insulin delivery via injections versus the insulin pump (b=0.67) were covariates of less frequent BGM, and unmarried caregiver status was associated with higher A1c (b=−0.76), all ps<0.05. ConclusionsIn this study, poorer QOL acted as a barrier to effective diabetes management, subsequently altering diabetes control. Practice implicationsEfforts to monitor and enhance QOL may hold promise for improving adolescents’ diabetes outcomes in the future.

Clinical islet xenotransplantation: how close are we?

Type 1 diabetes (T1D) is a major health problem throughout the world. In the U.S., it is estimated that about 1.5 million people suffer from T1D. Even when well controlled—by frequent monitoring of blood glucose and administration of insulin, the long-term complications of the disease are significant and include cardiovascular disease, nephropathy, retinopathy, and neuropathy (1). Here we review recent progress in preclinical models of pig islet xenotransplantation and discuss the remaining challenges that need to be addressed before the application of this form of therapy can be established in patients with T1D. During the past decade, islet allotransplantation alone (without previous kidney transplantation) using deceased human donor pancreata has been indicated mainly in patients who have had T1D for >5 years with life-threatening hypoglycemic episodes and wide fluctuations in blood glucose levels. Although the initial long-term results were rather disappointing (2), the results of islet allotransplantation have improved significantly in recent years, with 5-year insulin-independent normoglycemia achieved in >50% of patients at experienced centers (3). There is increasing evidence that successful islet allotransplantation greatly reduces the incidence of hypoglycemic episodes (2) and reduces or slows the incidence of late complications of T1D (4). This may extend the indications for islet transplantation to patients with progressive complications. For example, islet transplantation in a patient with preterminal renal failure may prevent disease progression, possibly avoiding the need for hemodialysis and kidney transplantation, provided that nonnephrotoxic immunosuppressive drug therapy is administered. Currently, in the U.S., the median waiting time for a kidney allograft from a deceased human donor is >4 years (5). However, islets from two deceased human donor pancreata are frequently required to achieve normoglycemia in a diabetic patient. Because of the limited number of suitable deceased donor pancreata, the overall number of …

Adherence patterns in patients with type 2 diabetes on basal insulin analogues: missed, mistimed and reduced doses

Objective:To describe basal insulin analogue dosing irregularities, the effect of these events on patient functioning, well-being and diabetes management, and the identification of patients most at risk.Research design and methods:The GAPP2 (Global Attitude of Patients and Physicians 2) study was an online multinational cross-sectional study of patients with type 2 diabetes currently treated with basal insulin, and healthcare professionals (HCPs) involved in the care of such patients. Basal insulin adherence patterns were evaluated with respect to three types of dosing irregularity: missed, mistimed [±2 hours from prescribed time], and reduced dose over the last 30 days.Results:A total of 3042 patients treated with basal insulin analogues and 1222 prescribers completed the full survey; 38% of patients reported any type of basal insulin dosing irregularity in the last 30 days. Patients reported missing (22% on 3 ± 0.16 occasions), mistiming (24% on 4.2 ± 0.21 occasions) or reducing (14% on 4.2 ± 0.24 occasions) basal insulin doses, with 15% of patients reporting multiple types of dosing irregularities. For most patients, missed (83%) and mistimed doses (82%) were unintentional, whereas the majority (87%) of patients reducing doses did so intentionally. Patients who intentionally missed or reduced a dose of basal insulin were significantly more likely to have performed this dosing irregularity on multiple occasions. Fifty-three percent of patients increased the frequency of blood glucose monitoring, and 17% of patients extended the duration of more frequent blood glucose monitoring by one or more days as a result of unintentional missed doses. Reduced dosing was highest in a subset of patients reporting self-treated hypoglycaemia.Conclusions:Basal insulin dosing irregularities including missed, mistimed and reduced doses are common. A significant proportion of patients also report undertaking these irregular dosing behaviours at a frequency that would be considered by prescribers to negatively impact diabetes management. This is despite the potential under-reporting due to recall or social bias that may be a limitation of a self-reported survey around these behaviours.

Triplet Pregnancy in a Diabetic Mother with Kidney Transplantation, Case Report and Review of Literature

Background: Triplet pregnancy carries an increased risk of both maternal and fetal complications. Reported cases of triplet pregnancy with kidney transplantation are few. Despite showing fare outcomes, they were associated with perinatal complications. Presence of diabetes in such cases worsens both fetal and maternal outcomes. Case summary: We report here a case of 31-years female patient with kidney transplantation who had her first pregnancy 5 years post transplant. Pregnancy was complicated by gestational diabetes, miscarriage and post-partum impaired glucose tolerance. She developed frank diabetes mellitus during her second pregnancy one year later and it was ended in a premature live singleton birth. Two years later, she had a triplet pregnancy after ovulation induction with clomiphene. Glycemic control was maintained using intensive insulin therapy guided by frequent home blood glucose monitoring (HbA1c was 5.8% at 22 weeks). Both gynecological and nephrological care was carried out through close outpatient follow up. Pregnancy was complicated by hypertension and mild renal dysfunction without proteinuria and ended in elective premature abdominal delivery at 32 weeks gestation. She had 3 male babies with very low birth weight (1300, 1200 and 950 g), the largest one developed sepsis and required ICU then incubator for 50 days. The other two required incubator only for 35 days. Their weights after 11 months were 10, 11 and 8 kg respectively. The mother is now normotensive with normal renal function and impaired glucose tolerance. Conclusion: Care of diabetic kidney recipients with triplet pregnancy constitutes a special challenge requiring multispecialty skilled team to insure best outcome.

Protocolo de actuación en la diabetes gestacional

Gestational diabetes (GD) is defined as intolerance to carbohydrates beginning during gestation. Identification and treatment of women with GD can reduce maternal and fetal morbidity. Treatment is based on diet, exercise and frequent blood glucose monitoring for a HbA1c < 6.5% and adequate weight gain. Assessment of fetal growth, amniotic fluid and cardiotocographic records must be started early. Insulin is indicated when these objectives are not achieved. The key objective during labor is to prevent maternal hyperglycemia, fetal acidosis and neonatal hypoglycemia. Patients treated with diet or low doses of insulin do not require intravenous insulin infusion during labor and delivery antepartum as with patients with high doses of insulin. After birth, as a rule, will retire insulin to all patients with GD and re-evaluate all of them in the postpartum.