Kirchheim- Verlag. 11 years, type 1 diabetes since 5 years old

Transcription

1 C A S E S T U DY / I n T E r D I S z i p l i n ä r e F a l l D I S k U S S I o n A Consensus of Clinical Cases on Self-Monitoring of Blood Glucose A European Perspective O. Schnell, Munich, Germany; H. Alawi, Saarlouis, Germany; T. Battelino, Ljubljana, Slowenia; A. Ceriello, Coventry, United Kingdom; P. Diem, Berne, Switzerland; A. Felton, London, United Kingdom; W. Grzeszczak, Zabrze, Poland; K. Harno, Helsinki, Finland; M. Hummel, Munich, Germany; P. Kempler, Budapest, Hungary; I. Satman, Istanbul, Turkey; Recently, advanced international guidelines and recommendations on selfmonitoring of blood glucose (SMBG) have been published. They support the structured implementation of the SMBG in diabetes. Individualized strategies are required to apply optimized and efficacious treatment approaches. The Consensus of European experts focuses on 9 clinical cases, which address aspects of the daily clinical practice: 1. Paediatric patient with type Paediatric patient with type 1 diabetes C A S E 1 Aims: The case focuses on an adolescent with type 1 diabetes with insulin pump therapy. Diabetes was diagnosed at the age of 5 years. Visit 1 1 diabetes, 2. Patient with gestational diabetes, 3. Type 2 diabetic patient with elevated postprandial blood glucose levels, 4. Type 2 diabetic Patient with lack of motivation and adherence, 5. Type 2 diabetic patient at risk of hypoglycaemia or with hypoglycaemia unawareness, 6. Obese type 2 diabetes patient with oral glucose lowering agents with initiation of insulin therapy, 7. Type 2 diabetic patient with coronary artery disease, 8. Type 2 diabetic patient with nephropathy, 9. Elderly Type 2 diabetic patient ( 80 years of age). The 9 clinical cases aimed at presenting typical clinical settings, in which SMBG could be useful and recommended. The clinical cases focus on intermittent or continuous SMBG and cannot present the entire background and medical history of the patients. The cases are considered to be role models for clinical situations, which can be frequently detected. and glycaemic levels of the patient Clinical characteristic Age Gender Diabetes duration 16 years female BMI 23 kg/m 2 Patient s history Presence of diabetic complications 11 years, type 1 diabetes since 5 years old 115/62 mmhg happy adolescent none one mild Glycaemic status prior to treatment initiation/modification: 7.9 % Glucose lowering agents erratic adolescent lifestyle high, but varying, may forget a bolus occasionally high, knows it all mean 178 mg/dl (9.9 mmol/l) mean dinner 144 mg/dl (8 mmol/l) to 270 mg/dl (15 mmol/l) 6 hours PP continuous insulin infusion (CSII), fast-acting insulin analogue Tab. 1: and glycaemic levels of the paediatric patient with type 1 diabetes at visit 1. Diabetes, Stoffwechsel und Herz, Band 19, 4/

2 I n T E r D I S z i p l i n ä r e F a l l D I S k U S S I o n / C A S E S T U DY Schnell et al.: Clinical cases of SMBG Dinner Day Daily Totals Average (6): 212 mg/dl Friday Carbs: 83 g 1,00 2,60 3,70 2,10 Insulin: 34,2 IU Bolus: 28 % Average (8): 155 mg/dl Saturday Carbs: 187 g 1,70 6,90 2,50 0,30 1,60 5,00 Insulin: 30,5 IU Bolus: 59 % Average (12): 191 mg/dl Sunday Carbs: 243 g 1,70 3,00 1,40 6,70 1,60 5,20 1,00 0,90 Insulin: 34,8 IU Bolus: 62 % Average (10): 167 mg/dl Monday Carbs: 271 g 1,70 8,50 2,20 2,10 3,30 4,70 1,40 Insulin: 37,9 IU Bolus: 63 % Average (9): 170 mg/dl Tuesday Carbs: 238 g 1,50 6,20 1,50 4,40 2,00 4,40 1,00 Insulin: 34,8 IU Bolus: 60 % Average (11): 186 mg/dl Wednesday Carbs: 209 g 1,50 8,40 2,20 2,20 1,20 4,20 0,70 3,30 Insulin: 37,4 IU Bolus: 63 % Average (11): 173 mg/dl Thursday Carbs: 282 g 1,40 9,60 2,50 3,20 2,70 2,70 4,30 Insulin: 38,4 IU Bolus: 69 % Average (12): 148 mg/dl Friday Carbs: 274 g 1,00 4,80 8,10 1,20 0,90 3,00 0,70 1,50 4,40 Insulin: 36,9 IU Bolus: 69 % Average (13): 170 mg/dl Saturday Carbs: 247 g 1,30 1,50 1,90 10,0 3,70 2,00 1,50 1,50 1,30 0,90 4,70 Insulin: 42,9 IU Bolus: 71 % Average (14): 158 mg/dl Sunday Carbs: 302 g 0,90 1,10 3,70 9,30 3,70 0,40 1,40 1,10 4,10 4,10 0,50 Insulin: 44,5 IU Bolus: 68 % Tab. 2: Blood glucose diary of the paediatric patient with type 1 diabetes (mg/dl (mmol/l)). Continuous glucose monitoring Fig. 1: Continuous glucose monitoring result of the paediatric patient with type 1 diabetes at visit 1. fast-acting insulin with continuous insulin infusion food intake: calories per day glycaemic targets: : < 7 % preprandial glucose: mg/dl (4 8 mmol/l) postprandial glucose: < 180 mg/dl (< 10 mmol/l) educational activities: review of downloads, carbohydrate counting, more exercise Visit 2 (3 months later) and glycaemic levels of the patient Clinical characteristic Hypoglycaemic episodes per month (mild and severe) Glycaemic status in response to treatment initiation/modification: 117/67 mmhg one mild 7.2 % 124 mg/dl (6.9 mmol/l) 153 mg/dl (8.5 mmol/l) average dose adjustment as discussed with the download adaptation of basal insulin profile continue 6 SMBG daily and CGM when feasible next visit 3 months later Tab. 3: and glycaemic levels of the paediatric patient with type 1 diabetes at visit Diabetes, Stoffwechsel und Herz, Band 19, 4/2010

3 C A S E S T U DY / I n T E r D I S z i p l i n ä r e F a l l D I S k U S S I o n Continuous glucose monitoring, continuous insulin infusion, carbohydrate intake Basal rate and continuous glucose monitoring Statistics Average BG (mg/dl) ± 55 BG Readings ,1/day Readings above target 7 64 % % Readings below target -- 0 % -- 0 % Sensor average (mg/dl) 177 ± ± 44 Average AUC > 140 mg/dl 42,7 1 d 0 h 29,1 9 d 18 h Average AUC < 70 mg/dl 0,0 1 d 0 h 0,0 9 d 18 h Daily carbs (g) ± 36 Carbs/bolus insulin (g/u) 8,8 10,0 Total daily insulin (U) 37,4 37,5 ± 4,2 Daily basal (U) 13,7 37 % 13,0 35 % Daily bolus (U) 23,7 63 % 24,5 65 % Primes 1 0,5 U 28 30,3 U ,2 2, Tab. 4: Statistics of continuous glucose monitoring, continuous insulin infusion and carbohydrate intake of the paediatric patient with type 1 diabetes. Patient with gestational diabetes C A S E 2 Aims: The case demonstrates SMBG and insulin therapy in gestational diabetes. Fig. 2: Results of basal rate and continuous glucose monitoring. Visit 1 (29 th week of gestation) Clinical Characteristics and glycaemic levels of the patient Age Gender Diabetes duration BMI Patient s history Presence of diabetic complications Hypoglycaemic episodes per month 33 years female 4 weeks 27.5 kg/m 2 (before gestation) 120/75 mmhg no previous DM, especially no GDM in the previous pregnancy none (fetal ultrasound: fetal development normal; especially abdominal circumference of the fetus within normal range, normal abdominal circumference/head circumference ratio) none primary school teacher (work between 8:00 and 13:00) house work in the afternoon walking 30 min/day after dinner quit smoking with pregnancy (prev 5 6 cigarettes per day for 7 years) alcohol occasionally Tab. 5: Clinical Characteristics and glycaemic levels of the patient with gestational diabetes at visit 1. Diabetes, Stoffwechsel und Herz, Band 19, 4/ Continuation see next page 5

4 I n T E r D I S z i p l i n ä r e F a l l D I S k U S S I o n / C A S E S T U DY Schnell et al.: Clinical cases of SMBG Level of diabetes-related adherence/motivation Level of diabetes-related knowledge/education Glycaemic status prior to treatment initiation/modification: Treatment and recommendations anxiety at diagnosis of GDM (danger for the offspring?) now very high motivation for optimal diabetes treatment (wants to do the best for the baby) received education sessions from nurse educator and dietitian SMBG: every morning and 1 h after breakfast, dinner, and lunch previously no diabetes (family history: mother suffers on type 2 diabetes) 2 nd pregnancy (1 st pregnancy: no GDM, child 5 years of age, birth wt 3.3 kg) at 24 th week of gestation 1 hr BG 155 mg/dl (8.6 mmol/l) at 25 th week of gestation: OGTT 100 g glucose: 89 mg/dl (4.9 mmol/l) 1 hr 201 mg/dl (11.1 mmol/l) 2 hr 176 mg/dl (9.7 mmol/l) 3 hr 160 mg/dl (8.9 mmol/l) initial (25 th week): diet & physical activity; checks fasting BG in the morning and 1 hr after breakfast, after dinner, and after lunch daily reviewed every 2 weeks by a diabetologist continues on obstetric care at 29 th week: 108 mg/dl (6.0 mmol/l), and 1 hr (breakfast) 135 mg/dl (7.5 mmol/l) initially resistant to start insulin, however start with one injection per day: NPH insulin 6 U day at 10 pm Continuation Tab. 5: Clinical Characteristics and glycaemic levels of the patient with gestational diabetes at visit 1. (week 29) Ratinonale: Reduce in the morning (basal insulin at night). Monday 104 (5.8) 156 (8.7) 112 (6.2) 143 (7.9) Tuesday 113 (6.3) 145 (8.0) 109 (6.0) 138 (7.7) Wednesday 118 (6.5) 138 (7.7) 109 (6.0) Thursday 108 (6.0) 121 (6.7) 98 (5.4) Friday 91 (5.1) 137 (7.6) 112 (6.2) Saturday 97 (5.4) 129 (7.2) 121 (6.7) Sunday 103 (5.7) 112 (6.2) 138 (7.7) 129 (7.2) Tab. 6: in week 29 of the patient with gestational diabetes (mg/dl (mmol/l)). glucose lowering agents: basal insulin (6 IU NPH insulin at bedtime, 10 pm) food intake (kcal/day): glycaemic targets: : 6.0 % (IDF recommendation) preprandial glucose: < 100 mg/dl (5.6 mmol/l) (IDF recommendation) postprandial glucose 1 hr: < 140 mg/dl (< 7.8 mmol/l) intensify SMBG: pre- and postprandial Visit 2 (2 weeks later, 31 th week of gestation) Monday 103 (5.7) 144 (8.0) 97 (5.4) 140 (7.8) 95 (5.3) 145 (8.0) 88 (4.9) Tuesday 102 (5.7) 140 (7.8) 103 (5.7) 143 (7.9) 91 (5.1) 137 (7.6) 88 (4.9) Wednesday 101 (5.6) 137 (7.6) 95 (5.3) 153 (8.5) 91 (5.1) 160 (8.9) - Thursday 108 (6.0) 166 (9.2) 97 (5.4) 137 (7.6) 95 (5.3) 152 (8.4) 83 (4.6) Friday 101 (5.6) 154 (8,5) 103 (5.7) 142 (7.9) 93 (5.2) 149 (8.3) - Saturday 95 (5.3) 154 (8.5) 110 (6.1) 161 (8.9) 91 (5.1) 143 (7.9) 90 (5.0) Sunday 101 (5.6) 166 (9.2) 97 (5.4) 154 (8.5) 93 (5.2) 144 (8.0) - Tab. 7: in week 31 of the patient with gestational diabetes (mg/dl (mmol/l)). 6 Diabetes, Stoffwechsel und Herz, Band 19, 4/2010

5 C A S E S T U DY / I n T E r D I S z i p l i n ä r e F a l l D I S k U S S I o n Therapy adjustment recommendations dose adjustment of previous medication: elevate NPH Insulin from 6 IU to 7 IU addition of new medication and switch to basal-bolus insulin therapy: aspart insulin premeals 3 times daily ( IU) food intake: reduce breakfast carbohydrate intake, and increase carbohydrate intake in pre-breakfast snack recommendations for SMBG protocol: seven per day (three preprandial and three 1 hr postprandial BG plus bedtime) scheduling of next visit: 2 weeks later Visit 3 (4 weeks later, 35 th week of gestation) and glycaemic levels of the patient 120/75 mmhg 1 mild hypo within last 2 weeks, no severe hypoglycaemia Glycaemic status in response to treatment initiation/ modification: 6.3 % 102 mg/dl (5.7 mmol/l) 1 hr 142 mg/dl (7.9 mmol/l) no change OK review dietary habits Tab. 8: of the patient with gestational diabetes at visit 3. Monday 100 (5.5) 108 (6.0) 97 (5.4) 140 (7.8) 91 (5.1) 137 (7.6) 86 (4.7) Tuesday 98 (5.4) 140 (7.8) 103 (5.7) 143 (7.9) 94 (5.2) 130 (7.2) 88 (4.9) Wednesday 109 (6.0) 137 (7.6) 96 (5.3) 126 (7.0) 90 (4.9) 137 (7.6) 91 (5.0) Thursday 108 (5.9) 137 (7.6) 103 (5.7) 137 (7.6) 95 (5.3) 140 (7.8) 80 (4.4) Friday 96 (5.3) 135 (7.5) 101 (5.6) 142 (7.9) 92 (5.1) 133 (7.4) 78 (4.3) Saturday 104 (5.7) 131 (7.3) 105 (5.8) 137 (7.6) 94 (5.2) 131 (7.3) 92 (5.1) Sunday 103 (5.7) 130 (7.2) 93 (5.4) 134 (7.4) 88 (4.8) 130 (7.2) 84 (4.2) Tab. 9: in week 35 of the patient with gestational diabetes (mg/dl (mmol/l)). glucose lowering agents: no change, dosage: increase bedtime NPH by 1 IU from 7 to 8 IU food intake (kcal/day): sufficient glycaemic targets: : 6.0 % preprandial glucose: < 100 mg/dl (< 5.6 mmol/l) postprandial glucose: < 140 mg/dl (< 7.8 mmol/l) educational activities: routine dietitian visits, continue on routine obstetric care visits, continue SMBG schedule next visit: 2 weeks later recommendation for post gestational procedure: within the first 5 days after delivery daily SMBG to verify that patient now shows BG measurements within the norm/to exclude persistent diabetes at 3 and 12 months after delivery: repeat OGTT with 75 g glucose Diabetes, Stoffwechsel und Herz, Band 19, 4/

6 C A S E S T U DY / I n T E r D I S z i p l i n ä r e F a l l D I S k U S S I o n C A S E 3 Type 2 diabetic patient with elevated postprandial blood glucose levels Aims: The case focuses on postprandial blood glucose levels and aims at illustrating potentials of SMBG in a patient with type 2 diabetes, who is treated with oral glucose lowering agents. Visit 1 and glycaemic levels of the patient Age Gender Diabetes duration 61 years male 5 years BMI 28 kg/m 2 Patient s history Presence of diabetic complications Glycaemic status: 140/85 mmhg healthy until 5 years ago, when diabetes was diagnosed during a periodic check none not reported sedentary activity; manager low medium 7.8 % 109 mg/dl (6.1 mmol/l) 183 mg/dl (10.2 mmol/l) Glucose lowering agents metformin 850 mg Tab. 10: of the type 2 diabetic patient with elevated postprandial blood glucose levels at visit 1. Glucose lowering agents: continue metformin 850 mg Food intake (kcal/day): : 6.5 % Preprandial glucose: 108 mg/dl (6.0 mmol/l) Postprandial glucose: 133 mg/dl (7.4 mmol/l) Educational activities: basic information Recommendations for SMBG protocol: staggered, once every three months Schedul ing of next visit: 3 months later Visit 2 (3 months later) and glycaemic levels of the patient Hypoglycaemic episodes per month (mild and severe) Glycaemic status 135/75 mmhg not reported 7.9 % 106 mg/dl (5.9 mmol/l) 189 mg/dl (10.5 mmol/l) Tab. 11: of the type 2 diabetic patient with elevated postprandial blood glucose levels at visit 2. Glucose lowering agents: metformin 850 mg Addition of new medication: sitagliptin 100 mg Food intake (kcal/day): : 6.5 % Preprandial glucose: 108 mg/dl (6.0 mmol/l) Postprandial glucose: 133 mg/dl (7.4 mmol/l) Educational activities: basic information Recommendations for SMBG protocol: as previously performed; helpful to recognize where was the problem Scheduling of next visit: e. g. 3 months later Diabetes, Stoffwechsel und Herz, Band 19, 4/

7 I n T E r D I S z i p l i n ä r e F a l l D I S k U S S I o n / C A S E S T U DY Schnell et al.: Clinical cases of SMBG Staggered Monday 99 (5.5) 167 (9.2) Tuesday 108 (6.0) 193 (10.7) Wednesday 102 (5.7) 151 (8.4) Thursday 90 (5.0) 171 (9.4) Friday 108 (6.0) 177 (9.8) Saturday 99 (5.5) 185 (10.2) Sunday 88 (4.9) 159 (8.8) Tab. 12: of the type 2 diabetic patient with elevated postprandial blood glucose levels at visit 2 (mg/dl (mmol/l)). Visit 3 (3 months later) and glycaemic levels of the patient Hypoglycaemic episodes per month (mild and severe) Glycaemic status 130/80 mmhg not reported 7.0 % 106 mg/dl (5.9 mmol/l) 140 mg/dl (7.8 mmol/l) Tab. 13: of the type 2 diabetic patient with elevated postprandial blood glucose levels at visit 3. Glucose lowering agents: metformin 850 mg 1 0 1, sitagliptin 100 mg Food intake (kcal/day): : 6.5 % Preprandial glucose: 108 mg/dl (6.0 mmol/l) Postprandial glucose: 133 mg/dl (7.4 mmol/l) Educational activities: basic information Recommendations for SMBG protocol: staggered SMBG regimen, once every three months Scheduling of next visit: 3 months later Staggered Monday 99 (5.5) 135 (7.5) Tuesday 102 (5.7) 140 (7.8) Wednesday 106 (5.9) 136 (7.5) Thursday 97 (5.4) 135 (7.5) Friday 99 (5.5) 131 (7.3) Saturday 108 (6.0) 136 (7.5) Sunday 97 (5.4) 140 (7.8) Tab. 14: of the type 2 diabetic patient with elevated postprandial blood glucose levels at visit 3 (mg/dl (mmol/l)). 4 Diabetes, Stoffwechsel und Herz, Band 19, 4/2010

8 C A S E S T U DY / I n T E r D I S z i p l i n ä r e F a l l D I S k U S S I o n C A S E 4 Patient with lack of motivation and adherence Aims: The case focuses on type 2 diabetes and adherence. Diabetes was diagnosed 1.5 years ago. Visit 1 Clinical Characteristics and glycaemic levels of the patient Age Gender Diabetes duration 42 years male 1.5 years BMI 37.6 kg/m 2 Patient s history Presence of diabetic complications 135/80 mmhg no no none high food intake, few physical activity; workman in a factory, voluntary fireman 7 on a scale ranging from 0 to 10 Glycaemic status prior to treatment initiation/modification: Mean 6.2 % Glucose lowering agents 5 on a scale ranging from 0 to 10 metformin 500 mg Tab. 15: of the patient with lack of motivation and adherence at visit 1. Glucose lowering agents: metformin 500 mg Food intake (kcal/day): < 6.5 % Monday 112 (6.2) Tuesday Wednesday Thursday Friday 114 (6.3) Saturday Sunday 121 (6.7) Tab. 16: of the patient with lack of motivation and adherence at visit 1. Note: Very few SMBG (only fasting BG values). In this patient SMBG had been recommended for educational purposes. Therapy adjustment recommendations Dose adjustment of previous medication: no Addition of new medication: no Switch to new medication: no Recommendations for SMBG protocol: no specific recommendations (according to the figure in the new IDF Guidelines, page 29 32) Scheduled visit 2: 9 months later The patient does not come back: The patient was unhappy with his diabetologist? Low level of compliance? Or both? Diabetes, Stoffwechsel und Herz, Band 19, 4/

9 I n T E r D I S z i p l i n ä r e F a l l D I S k U S S I o n / C A S E S T U DY Schnell et al.: Clinical cases of SMBG Visit 2 (3 years later) and glycaemic levels of the patient Hypoglycemic episodes per month (mild and severe) Level of diabetes-related adherence/ motivation Level of diabetes-related knowledge/ education 130/80 mmhg none idem much lower than previously 4 on a scale ranging from 0 to 10 Patient somewhat disappointed by his results I cannot control my diabetes anymore idem 5 on a scale ranging from 0 to 10 Tab. 17: of the patient with lack of motivation and adherence at visit 2 3 years later. Glucose lowering agents: metformin 850 mg 1 0 1, gliclazide 30 LR 4/day Food intake (kcal/day): % reduction for the short term, < 7 % for the mid-term Educational activities: diet ++ and consequences of the diet on blood glucose The patient is referred for poor glycaemic control: mean : 8.8 % current antidiabetic treatment: metformin 850 mg gliclazide 30 LR 3/day body weight: 121 kg Monday Note: Very few SMBG Tuesday 256 (14.2) Wednesday Thursday Friday Saturday Sunday Tab. 18: of the patient with lack of motivation and adherence at visit 2 3 years later (mg/dl (mmol/l)). Therapy adjustment recommendations Dose adjustment: same treatment, but gliclazide 30 LR has been uptitrated to 4/day Addition of new drug: no Switch to new drug: no Recommendations for SMBG protocol: 2 fasting BG/day (morning, evening), 1 /day in the evening during the weekdays, 2 to 3 / day during the weekend Schedule next visit: 5 months later Visit 3 (6 months later) The patient seems happy again: I know what kind of food increases my blood sugar This information enables and motivates me to modify the way I eat and to reduce hyperglycaemic food This may be the reason why I lost weight and improved my 6 Diabetes, Stoffwechsel und Herz, Band 19, 4/2010

10 C A S E S T U DY / I n T E r D I S z i p l i n ä r e F a l l D I S k U S S I o n (the weeks following the previous visit) Monday 210 (11.7) 186 (10.3) 268 (14.9) Tuesday 232 (12.9) 175 (9.7) 278 (15.4) Wednesday 201 (11.2) 169 (9.4) 249 (13.8) Thursday 208 (11.6) 185 (10.3) 275 (15.3) Friday 216 (12.0) 195 (10.8) 266 (14.8) Saturday 224 (12.4) 295 (16.4) 188 (10.4) 289 (16.1) 195 (10.8) 258 (14.3) Sunday 234 (13.0) 282 (15.7) 198 (11.0) 287 (15.9) 201 (11.2) 275 (15.3) Tab. 19: of the patient with lack of motivation and adherence at visit 3 (the weeks following the previous visit) (mg/dl (mmol/l)). Note: 1. This information encourages the patient to reduce his food intake with less hyperglycaemic food part 1: SMBG gives the patient information (the weeks before the actual visit) Note: 1. Significant improvement of both post prandial and fasting BG values part 2: patient s changes according to the information obtained from SMBG Body weight: 114 kg (vs. 121 kg) : 7 % (vs. 8.8 %) Monday 145 (8.1) 128 (7.1) 178 (9.9) Tuesday 138 (7.7) 125 (6.9) 185 (10.3) Wednesday 139 (7.7) 115 (6.4) 156 (8.7) Thursday 142 (7.9) 137 (7.6) 165 (9.2) Friday 144 (8.0) 138 (7.7) 162 (9.0) Saturday 156 (8.7) 186 (10.3) 112 (6.2) 189 (10.5) 128 (7.1) 198 (11.0) Sunday 148 (8.2) 189 (10.5) 125 (6.9) 182 (10.1) 115 (6.4) 169 (9.4) Tab. 20: of the patient with lack of motivation and adherence at visit 3 (the weeks before the actual visit) (mg/dl (mmol/l)). Patient with a high level due to a motivation or adherence issue who previously had good glycaemic control. In this patient previously easily well controlled, diabetes was forgotten in his mind. He was very disappointed when he discovered that his was high. The patient seemed overwhelmed by his diabetes. SMBG helped him to see and understand the reasons of his hyperglycaemic excursions. The information obtained from SMBG enables and encourages the patient to reduce his food intake with less hyperglycaemic food. This leads to significant reduction of both weight and. Diabetes, Stoffwechsel und Herz, Band 19, 4/

11 C A S E S T U DY / I n T E r D I S z i p l i n ä r e F a l l D I S k U S S I o n C A S E 5 Type 2 patient at risk of hypoglycaemia or with hypoglycaemia unawareness Aims: The case focuses on type 2 diabetes and the risk of hypoglycaemia. Diabetes was diagnosed 12 years ago. The patient presents with frequent hypoglycaemic episodes. Visit 1 and glycaemic levels of the patient Age Gender Diabetes duration 66 years male 12 years BMI 28 kg/m 2 Patient s history Presence of diabetic complications Glycaemic status prior to treatment initiation/modification: Current diabetes medication 145/80 mmhg long duration of diabetes; insulin use for over 5 years; reduced β-cell reserves, i. e. low C-peptide levels mild nephropathy with microalbuminuria; polyneuropathy with loss of sensation in feet mild: 6 events/month severe: 0.08 events/month retired; occasional moderately strenuous exercise, i. e. walking, garden work; dietary habits and CHO intake somewhat irregular not well motivated for self-care, but injects insulin s. c. and does occasional SMBG testing preprandially in the morning only basic knowledge, but unawareness of protective physiological responses at lower blood glucose levels 7.5 % 151 mg/dl (8.4 mmol/l) 198 mg/dl (11.0 mmol/l) basal insulin (insulin glargine) 40 IU in the evening, Metformin 500 mg t. i. d. Tab. 21: of the type 2 patient at risk of hypoglycaemia or with hypoglycaemia unawareness at visit 1. Monday Tuesday 140 (7.8) Wednesday Thursday Friday Saturday 151 (8.4) Sunday 1. Provider is not showing much interest in SMBG results. 2. Targets for SMBG have not been set. 3. Questions the value of SMBG. Diabetes, Stoffwechsel und Herz, Band 19,?/ Tab. 22: of the type 2 patient at risk of hypoglycaemia or with hypoglycaemia unawareness at visit 1 (mg/dl (mmol/l)). Glucose lowering agents: metformin, insulin glargine :750 mg t. i. d., 40 IU s. c. in the morning Food intake (kcal/day): : 7 %, Preprandial glucose: mg/dl ( mmol/l) Postprandial glucose: < 162 mg/dl (9.0 mmol/l) Educational activities: SMBG education revisited 13

12 I n T E r D I S z i p l i n ä r e F a l l D I S k U S S I o n / C A S E S T U DY Schnell et al.: Clinical cases of SMBG 1. Increase awareness of blood glucose. 2. Enable insulin dose adjustment. 3. Avert hypoglycaemic events and improve safety. Therapy adjustment recommendations Dose adjustment of previous medication: done Addition of new medication: ramipril 2.5 mg o. d., ASA 100 mg o. d. Switch to new medication: not needed Food intake: nutrition and CHO intake evaluation Recommendations for SMBG protocol: detection of asymptomatic hypoglycaemia; pre-lunch and pre-supper SMBG Educational activities: prevention of hypoglycaemia Scheduling of next visit: e. g. 3 months later 1. Integrity of counter-regulatory response testing. 2. Early detection of hypoglycaemia. 3. Association of diet or exercise to possible hypoglycaemic events. Visit 2 (3 months later) Clinical Characteristics and glycaemic levels of the patient Glycaemic status in response to treatment initiation/ modification: 135/73 mmhg mild: 3 events no severe 6.53 % 118 mg/dl (6.6 mmol/l) 179 mg/dl (9.9 mmol/l) no change improved motivation, knowledge, skills, and willingness to incorporate planned SMBG monitoring of preprandial blood glucose requirements to identify and manage hypoglycaemia Tab. 23: of the type 2 patient at risk of hypoglycaemia or with hypoglycaemia unawareness at visit Monitoring asymptomatic hypoglycaemia. 2. SMBG resulting in therapy adjustments. 3. Presence of protective physiological responses. Monday 122 (6.8) 104 (5.8) 118 (6.6) Tuesday Wednesday Thursday 129 (7.2) 68 (3.8) 124 (6.9) Friday Saturday 158 (8.8) Sunday Tab. 24: of the type 2 patient at risk of hypoglycaemia or with hypoglycaemia unawareness at visit 2 (mg/dl (mmol/l)). Drug: insulin glargine Dosage: reduced to 38 IU in the morning Food intake (kcal/day): 1 800, but redistribution of CHO, pre- and postprandial glucose: unchanged Educational activities: Self-care education continued 14 Diabetes, Stoffwechsel und Herz, Band 19,?/2010

13 C A S E S T U DY / I n T E r D I S z i p l i n ä r e F a l l D I S k U S S I o n 1. Assist the patient to better understand diabetes. 2. Empower patient to take more responsibility of controlling the disease. 3. Address specific requirements for hypoglycaemia and awareness. Therapy adjustment recommendations Dose adjustment: ramipril, 5 mg o. d. Addition of new drug: not deemed necessary Switch to new drug: not necessary Recommendations for SMBG protocol: continue monitoring as planned; performance and accuracy testing of glucose meter Schedule next visit: e. g. 4 6 months later, but online reporting of SMBG 1. Enable timely adjustment of care. 2. Transformation to online reporting for improved preventative decision making. 3. Ability to optimize treatment as diabetes progresses. C A S E 6 Obese type 2 diabetes patient with oral glucose lowering agents and initiation of insulin therapy Aims: The case focuses on type 2 diabetes and the initiation of insulin therapy. In the patient, diabetes was diagnosed 12 years ago. Visit 1 and glycaemic levels of the patient Age Gender Diabetes duration BMI Patient s history Presence of diabetic complications Glycaemic status prior to treatment initiation/modification: 58 years male 12 years 32 kg/m 2 (unchanged in the previous year) 120/75 mmhg no hypertension; no heart disease, no myocardial infarction; no cerebral vascular event symptoms of peripheral neuropathy; erectile dysfunction absence of hypoglycaemic episodes plays golf occasionally, 30 min walking once a week; profession: manager in a company; smoking: 30 cigarettes/day: alcohol consumption: 250 ml red wine daily BG monitoring: 3 per week in the morning, sometimes before dinner and lunch; GP visits: 1 2 per year; specialist visits: none; no specific food intake educational programmes in the past: none 10.3 % 232 mg/dl (12.9 mmol/l) 285 mg/dl (15.8 mmol/l) Glucose lowering agents glimepirid 3 mg acarbose 50 mg metformin 850 mg exenatide 10 µg (for six months) Tab. 25: of the obese type 2 diabetes patient with oral glucose lowering agents and initiation of insulin therapy at visit 1. Diabetes, Stoffwechsel und Herz, Band 19,?/

14 I n T E r D I S z i p l i n ä r e F a l l D I S k U S S I o n / C A S E S T U DY Schnell et al.: Clinical cases of SMBG (the weeks following the previous visit) Monday 234 (13.0) 256 (14.2) Tuesday 346 (19.2) Wednesday 198 (11.0) 282 (15.7) Thursday Friday 186 (10.3) 261 (14.5) Saturday 206 (11.4) Sunday 228 (12.7) Tab. 26: (the weeks following the previous visit) of the obese type 2 diabetes patient with oral glucose lowering agents and initiation of insulin therapy at visit 1 (mg/dl (mmol/l)). Therapy recommendations Drug modification: glimepirid 3 mg 1 0 0, metformin mg 1 0 1, addition of new medication: insulin glargine 16 IU (10:00 pm), stop acarbose and exenatide Food intake (kcal/day): : < 7 % Preprandial glucose: mg/dl ( mmol/l) Postprandial glucose: < 140 mg/dl (7.8 mmol/l) no hypoglycaemic episodes Visit 2 (6 weeks later) and glycaemic levels of the patient Educational activities: diabetes education programme for initiation of insulin therapy (5 times per week 4 hours every day (group session) Recommendations for SMBG protocol: daily fasting BG, 7 spot glucose profile once per week Scheduling of next visit: weekly consultations on the phone, visit in the clinical practice 6 weeks later Glycaemic status in response to treatment initiation/modification: Glucose lowering agents 130/80 mmhg no 8.7 % 194 mg/dl (10.8 mmol/l) 235 mg/dl (13.1 mmol/l) three times per week: 30 min walking, two times per week: fitness club; smoking: 20 cigarettes/day, alcohol consumption: ¼ l red wine 1 2 per week motivated; aims at increasing physical activity good insulin glargine 32 IU (10 p.m.) glimepirid 3 mg 1 1 metformin mg 2 1 Tab. 27: of the obese type 2 diabetes patient with oral glucose lowering agents and initiation of insulin therapy at visit Diabetes, Stoffwechsel und Herz, Band 19,?/2010

15 C A S E S T U DY / I n T E r D I S z i p l i n ä r e F a l l D I S k U S S I o n Monday 134 (7.4) 234 (13.0) 106 (5.9) 275 (15.3) 178 (9.9) 297 (16.5) 164 (9.1) Tuesday 108 (6.0) 171 (9.5) 194 (10.8) Wednesday 181 (10.0) 184 (10.2) 280 (15.6) 167 (9.3) 158 (8.8) Thursday 187 (10.4) 211 (11.7) 183 (10.2) Friday 141 (7.8) 137 (7.6) 223 (12.4) 297 (16.5) 191 (10.6) Saturday 118 (6.6) 154 (8.6) 124 (6.9) 158 (8.8) 189 (10.5) Sunday 136 (7.6) 210 (11.7) Tab. 28: of the obese type 2 diabetes patient with oral glucose lowering agents and initiation of insulin therapy at visit 2 (mg/dl (mmol/l)). Therapy adjustment recommendations Previous treatment: metformin mg 2 1, glimepirid 3 mg 1 1 Dose adjustment: Insulin glargine was increased stepwise to 32 IU within the previous 6 weeks Food intake (kcal/day): Addition of a second (rapid) insulin: start of ICT with Insulin glulisine: breakfast 2 IU per carbohydrate unit (CU), lunch 1,5 IU per CU, dinner 2,5 IU per CU Stop taking glimepirid Visit 3 (2 months later) and glycaemic levels of the patien : < 7 % Preprandial glucose: mg/dl ( mmol/l) Postprandial glucose: < 140 mg/dl (7.8 mmol/l) Educational activities: (individual session nurse educator), focus basal-bolus insulin regime Recommendations for SMBG protocol: first week: preprandial and at bedtime, second week: additional 2 h postprandial, weekly phone call and titration of insulin dosage Schedule next visit: 2 months later Glycaemic status in response to treatment initiation/modification: 130/80 mmhg no 7.2 % 112 mg/dl (6.2 mmol/l) 163 mg/dl (9.1 mmol/l) Tab. 29: of the obese type 2 diabetes patient with oral glucose lowering agents with initiation of insulin therapy at visit 3. Monday 148 (8.2) 109 (6.1) 97 (5.4) 156 (8.7) Tuesday 113 (6.3) 168 (9.3) 93 (5.2) 156 (8.7) 84 (4.7) 112 (6.2) 132 (7.3) Wednesday 177 (9.8) 74 (4.1) 88 (4.9) 102 (5.7) Thursday 129 (7.2) 77 (4.3) 87 (4.8) 164 (9.1) Friday 192 (10.7) 213 (11.8) 82 (4.6) 113 (6.3) 119 (6.6) 172 (9.6) Saturday 106 (5.9) 93 (5.2) 117 (6.5) 87 (4.8) 123 (6.8) Sunday 96 (5.3) 101 (5.6) 137 (7.6) 148 (8.2) Tab. 30: of the obese type 2 diabetes patient with oral glucose lowering agents with initiation of insulin therapy at visit 3 (mg/ dl (mmol/l)). Diabetes, Stoffwechsel und Herz, Band 19,?/

16 I n T E r D I S z i p l i n ä r e F a l l D I S k U S S I o n / C A S E S T U DY Schnell et al.: Clinical cases of SMBG C A S E 7 Type 2 diabetic patient who presents with coronary artery disease Aims: The case focuses on type 2 diabetes and coronary artery disease. Diabetes was diagnosed three months ago after an acute myocardial infarction, when an oral glucose tolerance test was performed. Visit 1 and glycaemic levels of the patient Age Gender Diabetes duration 67 years male 3 months BMI 26,15 kg/m 2 154/74 mmhg Patient s history admitted to the hospital with an acute myocardial infarction 3 months ago, coronary angiography: stenosis of the LAD with subsequent revascularization, PTCA Presence of diabetic complications diabetic retinopathy I none smoker: 10 cigarettes/day for 3 decades, stopped smoking 3 years ago moderate good Glycaemic status: oral glucose tolerance test (3 months ago) Glucose 0 min 188 mg/dl (10.4 mmol/l) Glucose 120 min 278 mg/dl (15.4 mmol/l) 8.3 % Glucose lowering agents glibenclamid 3.5 mg metformin 850 mg three day course 2.5 months ago during rehabilitation after the acute myocardial infarction Tab. 31: of the type 2 diabetic patient who presents with coronary artery disease at visit 1. Monday 215 (11.9) 278 (15.4) Tuesday Wednesday 188 (10.4) 253 (14.0) Thursday Friday 176 (9.8) 244 (13.5) Saturday 235 (13.0) Sunday Tab. 32: of the type 2 diabetic patient who presents with coronary artery disease at visit 1 (mg/dl (mmol/l)) Diabetes, Stoffwechsel und Herz, Band 19,?/2010

17 C A S E S T U DY / I n T E r D I S z i p l i n ä r e F a l l D I S k U S S I o n Therapy recommendations Glucose lowering agents: Continue with metformin 1 0 1, discontinue glibenclamid, add basal insulin IU Food intake (kcal/day): : 6.5 % Preprandial glucose: mg/dl ( mmol/l) Postprandial glucose: < 180 mg/dl (< 10.0 mmol/l) Educational activities: initiation of insulin therapy, 3 day training course Recommendations for SMBG protocol: : 3 4 measurements per day (pre- and postprandially, bedtime) Scheduling of next visit: 2 months later 1. Reduction of hyperglycaemia 2. Prevention of hypoglycaemia 3. Prevention of progression of CAD Visit 2 (2 months later) and glycaemic levels of the patient Glycaemic status: 148/73 mmhg not reported 7.4 % 148 mg/dl (8.2 mmol/l) 192 mg/dl (10.7 mmol/l) Tab. 33: of the type 2 diabetic patient who presents with coronary artery disease at visit 2. Monday 148 (8.2) 192 (10.7) 188 (10.4) Tuesday 127 (7.0) 168 (9.3) 191 (10.6) Wednesday 141 (7.8) 183 (10.2) Thursday 138 (7.7) 145 (8.0) 167 (9.3) Friday 127 (7.0) 181 (10.0) 201 (11.2) Saturday 119 (6.6) 134 (7.4) 173 (9.6) Sunday 131 (7.3) 171 (9.5) 156 (8.7) Tab. 34: of the type 2 diabetic patient who presents with coronary artery disease at visit 2 (mg/dl (mmol/l)). Glucose lowering agents: metformin 850 mg 1 0 1, increase in basal insulin IU Food intake (kcal/day): : 6.5 % Preprandial glucose: mg/dl (4,4 6,1 mmol/l) Postprandial glucose: < 180 mg/dl (< 10.0 mmol/l) Recommendations for SMBG protocol: : 3 4 measurements per day (pre- and postprandial, bedtime) Scheduling of next visit: 2 months later Diabetes, Stoffwechsel und Herz, Band 19,?/ Reduction of hyperglycaemia 2. Prevention of hypoglycaemia 3. Prevention of progression of CAD 19

18 I n t e r d i s z i p l i n ä r e F a l l d i s k u s s i o n / C a s e s t u dy Schnell et al.: Clinical cases of SMBG Type 2 diabetic patient with nephropathy Aims: The case focuses on type 2 diabetes and nephropathy. C a s e 8 Visit 1 and glycaemic levels of the patient Age Gender Diabetes duration 68 years male 15 years BMI 34 kg/m 2 Patient s history Presence of diabetic complications Glycaemic status prior to treatment initiation/modification: Glucose lowering agents 150/90 mmhg accidental, random diagnosis Tab. 35: of the type 2 diabetic patient who presents with nephropathy at visit 1. diabetic nephropathy (macroalbuminuria, GFR < 60 ml/min), coronary heart disease non STEMI 6 months ago, PTCA and 2 stents, ischaemic stroke 2 years ago, diabetic retinopathy and neuropathy mild, occasionally minutes per week walking (3 4 times); retiree from ½ year bigger motivation (after PTCA and stents implantation), cancel smoking low, no time just to no; wants to learn to live with diabetes 8.3 % 150 mg/dl (8.3 mmol/l) 210 mg/dl (11.6 mmol/l) NPH insulin evening (26 IU), glimepirid 3 mg morning Monday 210 (11.7) Tuesday 151 (8.4) Wednesday 170 (9.4) 230 (12.8) 140 (7.8) 260 (14.4) Thursday 210 (11.7) 143 (7.9) Friday 186 (10.3) 141 (7.8) Saturday 120 (6.7) 210 (11.7) Sunday 230 (12.8) Tab. 36: of the type 2 diabetic patient who presents with nephropathy at visit 1 (mg/dl (mmol/l)). 1. The patient has not any or has small knowledge about SMBG 2. High prebreakfast glucose levels 3. No asymptomatic hypoglycaemia 20 Diabetes, Stoffwechsel und Herz, Band 19,?/2010

19 C a s e s t u dy / I n t e r d i s z i p l i n ä r e F a l l d i s k u s s i o n Therapy recommendations Glucose lowering agents: Higher NPH insulin dose (32 IU ), intensive insulin therapy (short acting insulin before each meal) Dosage: short acting insulin: 6 IU before breakfast/6 IU before lunch/6 IU before supper Food intake (kcal/day): 2 400, 0,8 g protein/kg (88 g) :< 7.0 % Preprandial glucose: < 110 mg/dl (6.1 mmol/l) Postprandial glucose: < 140 mg/dl (7.8 mmol/l) Prebreakfast: < 110 mg/dl (6.1 mmol/l) Educational activities: individual education and focus groups 1. Stop glimepiride therapy 2. High dose of NPH insulin 3. Intensive insulin therapy Therapy adjustment recommendations Dose adjustment of previous medication: NPH insulin to 32 IU Addition of new medication: short acting insulin (3 times daily) Switch to new medication: blood pressure and lipid medication Food intake: change, about 600 kcal, restriction protein 0,8 g/kg b.w./day Recommendations for SMBG protocol: (according to the figure in the new IDF Guidelines, page 29 32) Scheduling of next visit: e. g. 3 months later Visit 2 (x months later) and glycaemic levels of the patient 1. Changes in insulin therapy 2. Additional medication 3. Changes food intake Glycaemic status in response to treatment modification: Hypoglycaemic episodes per month (mild and severe) Level of diabetes-related adherence/ motivation Level of diabetes-related knowledge/ education 7.7 % 120 mg/dl (6.7 mmol/l) 160 mg/dl (8.9 mmol/l) 140/90 mmhg 3 5/month 1 severe minutes per week walking (4 5 times); retiree after last visit, and education from ½ years bigger motivation (after PTCA and stent implantation), cancel smoking better, he took part in an education programme Tab. 37: of the type 2 diabetic patient with nephropathy at visit 2. Diabetes, Stoffwechsel und Herz, Band 19,?/

20 I n t e r d i s z i p l i n ä r e F a l l d i s k u s s i o n / C a s e s t u dy Schnell et al.: Clinical cases of SMBG Monday 120 (6.7) Tuesday 130 (7.2) 170 (9.4) Wednesday 140 (7.8) Thursday 140 (7.8) 180 (10.0) Friday 135 (7.5) Saturday 145 (8.1) 180 (10.0) Sunday Tab. 38: of the type 2 diabetic patient with nephropathy at visit 2 (mg/dl (mmol/l)). 1. Required a higher dose of NPH insulin 2. Modification short acting insulin dose Therapy recommendations Glucose lowering agents: NPH insulin 34 IU, short acting insulin 8 IU, 8 IU, 7 IU Food intake (kcal/day): : < 7.0 % Preprandial glucose: < 110 mg/dl (6.1 mmol/l) Postprandial glucose: < 140 mg/dl (7.7 mmol/l) Prebreakfast: < 110 mg/dl (6.1 mmol/l) Educational activities: individual and group therapy Therapy adjustment recommendations Dose adjustment: NPH to 32 IU Addition of new drug: no Switch to new drug: no Recommendations for SMBG protocol: (according to the figure in the new IDF Guidelines, page 29 32) Schedule next visit: e. g. 2 4 months later 1. The aim is to further stabilize the improvement of metabolic control 22 Diabetes, Stoffwechsel und Herz, Band 19,?/2010

21 C a s e s t u dy / I n t e r d i s z i p l i n ä r e F a l l d i s k u s s i o n C a s e 9 Elderly patient ( 80 years of age) with type 2 diabetes Aims: The case focuses on an elderly patient with type 2 diabetes. Visit 1 and glycaemic levels of the patient Age Gender Diabetes duration 82 years male 8 years BMI 26 kg/m 2 Patient s history Presence of diabetic complications Glycaemic status prior to treatment initiation/modification: 145/70 mmhg hypertension for 15 years myocardial infarction 10 years ago non-proliferative retinopathy parasympathetic autonomic neuropathy early sensory hypaesthesia no hypoglycaemia reported during the past 6 months retired machinist; does some DIY (Do It Yourself) at home no real motivation up to now, however, it is mainly due to the insufficient level of previous education; probably, can be improved substantially quite low up to now, but it reflects mainly the low level of local diabetes health services; the patient is interested to learn more on diabetes and its complications 9.3 % 183 mg/dl (10.2 mmol/l) 281 mg/dl (15.6 mmol/l) Glucose lowering agents gliclazid 30 mg Tab. 39: Clinical characterisitcs of the elderly patient ( 80 years of age) with type 2 diabetes at visit 1. none Until now, the patient had no glucose monitoring device at home and did not perform SMBG. Therapy adjustment recommendations Addition of new medication: metformin mg, acarbose 50 mg 1 0 0, aspirin 100 mg Switch to new medication: no Food intake: 140 g CH, kcal/day Recommendations for SMBG protocol measure twice a week fasting and pp glucose (2 hours after a main meal) : 8.0 % Preprandial glucose: 144 mg/dl (8.0 mmol/l) Postprandial glucose: 216 mg/dl (12.0 mmol/l) (until the next visit in 3 months) Educational activities: booklets and tables are provided for the patient, a glucometer has been suggested and the patient is willing to buy it himself Scheduling of next visit: 3 months later Previous glycaemic control was far from optimal. Reliable targets were suggested until the next visit. The patient accepted the need for self control of blood glucose at home (intermittent pattern testing). Diabetes, Stoffwechsel und Herz, Band 19,?/

22 I n t e r d i s z i p l i n ä r e F a l l d i s k u s s i o n / C a s e s t u dy Schnell et al.: Clinical cases of SMBG Visit 2 (x months later) and glycaemic levels of the patient Glycaemic status in response to treatment initiation/ modification: 135/65 mmhg no hypoglycaemic episode has been reported 8.4 % 160 mg/dl (8.9 mmol/l) 219 mg/dl (12.2 mmol/l) even more active in DIY (Do It Yourself) due to somewhat better general health condition clearly improved; he has read a lot on diabetes and he attends regularly a diabetes-club clearly improved as well; he has learned the CH and calorie content of some important food and drinks; his wife helps a lot; CH and calorie intake is noted regularly Tab. 40: of the elderly patient ( 80 years of age) with type 2 diabetes at visit 2. Monday 146 (8.1) 196 (10.9) Tuesday Wednesday 140 (7.8) 199 (11.0) Thursday Friday 160 (8.9) 218 (12.1) Saturday Sunday Tab. 41: of the elderly patient ( 80 years of age) with type 2 diabetes at visit 2 (mg/dl (mmol/l)). Therapy adjustment recommendations Glucose lowering agents: metformin mg, acarbose 50 mg 1 1 1, gliclazid 30 mg Food intake (kcal/day): no change (140 g CH, kcal) : 7.0 % Preprandial glucose: 135 mg/dl (7,5 mmol/l) Postprandial glucose: 180 mg/dl (10.0 mmol/l) Recommendations for SMBG protocol: the same patterns as previously recommended Educational activities: The patient s key effort is to avoid insulin therapy and accepts very well to learn more on diabetes Schedule next visit: 3 months later 24 Diabetes, Stoffwechsel und Herz, Band 19,?/2010

23 C a s e s t u dy / I n t e r d i s z i p l i n ä r e F a l l d i s k u s s i o n Literature 1. Schnell O, Alawi A, Battelino T, Ceriello A, Diem P, Felton A, Grzeszczak W, Harno K, Kempler P, Satman I, Verges B: Consensus statement on self-monitoring of blood glucose in diabetes. Diabetes Stoffw Herz 2009; 18: Klonoff DC, Bergenstal R, Blonde L, Boren SA, Church TS, Gaffaney J, Jovanovic L, Kendall DM, Kollman C, Kovatchev BP, Leippert C, Owens DR, Polonsky WH, Reach G, Renard E, Riddell MC, Rubin RR, Schnell O, Siminiero LM, Vigersky RA, Wilson DM, Wollitzer AO: Consensus report of the coalition for clinical researchself-monitoring of blood glucose. J Diabetes Sci Technol 2008; 2: International Diabetes Federation: Guideline for management of post-meal glucose. IDF, Brussels, 4. International Diabetes Federation: IDF guideline on self-monitoring of blood glucose in noninsulin treated type 2 diabetes. org/idf-guideline-self-monitoring-blood-glucosenon-insulin-treated-type-2-diabetes 5. Ryden L, Standl E, Bartnik M, Van den Berghe G, Betteridge J, de Boer MJ, Cosentino F, Jonsson B, Laakso M, Malmberg K, Priori S, Ostergren J, Tuomilehto J, Thrainsdottir I, Vanhorebeek I, Stramba-Badiale M, Lindgren P, Qiao Q, Priori SG, Blanc JJ, Budaj A, Camm J, Dean V, Deckers J, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo J, Zamorano JL, Deckers JW, Bertrand M, Charbonnel B, Erdmann E, Ferrannini E, Flyvbjerg A, Gohlke H, Juanatey JR, Graham I, Monteiro PF, Parhofer K, Pyorala K, Raz I, Schernthaner G, Volpe M, Wood D: Guidelines on diabetes, pre-diabetes, and cardiovascular diseases: executive summary. The Task Force on Diabetes and Cardiovascular Diseases of the European Society of Cardiology (ESC) and of the European Association for the Study of Diabetes (EASD). Eur Heart J 2007; 28: Rewers M, Pihoker C, Donaghue K, Hanas R, Swift P, Klingensmith GJ: Assessment and monitoring of glycemic control. ISPAD Clinical Practice Consensus Guidelines Pediatr Diabetes 2009;10: Corresponding author Prof. Dr. Oliver Schnell Diabetes Research Institute of the Diabetes Research Group, Helmholtz Center, Munich Ingolstädter Landstrasse Munich-Neuherberg, Germany Diabetes, Stoffwechsel und Herz, Band 19,?/