Round Table. Resources to support insulin-treated patients

Transcription

1 HighLights Round Table. Resources to support insulin-treated patients Conducted by: Giovanni Sartore Department of Medical and Surgical Sciences, University of Padua, Padua, Italy With the participation: Sara Da Costa, Nurse Consultant, Diabetes Visiting Fellow, University of Brighton, Western Sussex Hospitals NHS Foundation Trust, England Anna Ercoli, Consultant and Trainer in Psychology-based Human Resource Development, Udine, Italy Giorgio Grassi, Division of Endocrinology and Metabolism, Department of Internal Medicine, San Giovanni Battista University Hospital, Turin, Italy Christina Kanaka-, Associate Professor of Pediatric Endocrinology-Juvenile Diabetes, First Department of Pediatrics, University of Athens Medical School, Greece Alberto Maran, Department of Medicine, Metabolic Medicine, University of Padua, Italy Christina Schmid, Institute for Diabetes-Technology Forschungs- & Entwicklungsgesellschaft mbh at University of Ulm, Germany Mirko Serra, Staff member of Diabetando.net, Bologna, Italy

2 Social media, apps and networking: evolution, pros and cons, psychological aspects, experiences, proposals It can be very important for diabetic patients and Health Care Providers to have a positive attitude towards technology and social networks. The patient s approach may be openminded and willing ( I perceive technologies as promoting cognitive evolution of the human mind and skills ), or closed and resistant ( I ll learn about later ), or neutral ( I make the effort only in certain circumstances ). The best approach is to turn these technical instruments into opportunities to promote cognitive, emotional or physical well-being. Technology is interconnected with science and culture and supports the person, especially in the medical field, generating a psychological and social change. Diabetology, in particular, may benefit from novel information technologies by obtaining and maintaining a good glycaemic control, experimenting alternative routes of insulin administration, allowing exchange of information among patients and with healthcare professionals via internet and mobile phones, providing systems for monitoring blood glucose and possible complications or conditions associated with diabetes during the patients follow-up (Figure 1). Social media, social networks in particular, are also based on new information technologies. These instruments are able to connect people by rapid and disseminated interaction with a few key elements (text, music, videos, icons). However, one must be aware that the interface of these contacts is a machine (a computer) and not a real person. Social media are, therefore, mainly based on a dialogue with oneself and the empathy with the social interlocutor is only a virtual one. Indeed, patients often Figure 1. Different technologies supporting diabetes patients. establish a contact on social

3 media, but are then strongly motivated to extend the dialogue in person. In this respect, the networking tools can be very effective in helping patients to emerge from their isolation. Moreover, these communication tools may work by supporting a patient s self-confidence, especially when dealing with all the technical activities required by their status of being a person with diabetes (auto-efficacy). Thus, technology and social networks are at the service of the person and the community, provided they are used in an effective, responsible and informed way. Social networks may also help the physician, who can answer patients better in writing than by talking. In this case the information can be more precise, because it is separated from emotional aspects; nevertheless, a face-to-face consultation is always necessary to motivate a patient. The social media and forums for diabetes patients may help de-motivated, frustrated patients to exchange views with other patients with similar experiences, drawing a kind of psychological support from them. However, if the patient is seeking therapeutic advice, contact with a diabetologist is essential and the forums should be used to be connected with specialists only. In conclusion, the wide choice of methods of communication allow people to use the method best suited to them (person-to-person contacts or social networking). From the point of view of healthcare professionals, since not all patients can be reached through a single method of communication, the availability of a variety of options, including social media and networking, expands the possibility of talking with patients.

4 Helping young and adult diabetics to choose the right glucometer Healthcare professionals agree on the efficacy and importance of glucometers in clinical practice, while from the diabetic patients perspective a glucometer is a device that allows them to lead a normal life, of a quality similar to that of the unaffected population. People affected by diabetes rely on measured values of blood glucose to control and adjust their therapy, thus inaccurate self-monitoring blood glucose (SMBG) systems can lead to the risk of false treatment decisions. Many SMBG systems are currently on the market and it can be difficult to choose the right system (Figure 2). Some key features should be fulfilled by all SMBG system. A good, valid system should be safe and reliable, have a good analytical performance (measurement precision and system accuracy), and should also be user-friendly. The ease of use of the system, in terms of handling, display readability and clear instructions for use, is important. Moreover, SMBG systems are used in different settings (at home, at school, during sports, on holiday, etc.) and by individuals with very different characteristics (with regards to age, vision, dexterity, education, etc.). Consequently, SMBG systems must meet different requirements. For example, in the case of elderly patients the system should be easy to handle, must have a wide display, large buttons and loud signal tones. For the test strip size, an intuitive guidance menu and an instruction booklet in large font are also important. On the other hand, in the case of young patients, the requirements can be completely different. It may be more important to have a compact and lightweight system, with efficient connectivity to smartphone applications and a robustness enabling the device to be carried during sport activities, even in harsh conditions and at high altitudes. Figure 2. The large variety of SMBG systems currently on the market.

5 Integrative functions, such as the bolus calculator, are also often preferred. A design allowing young patients to measure blood glucose without attracting too much attention may also be desirable. When patients are questioned about the main requirement for a glucometer, in most cases the answer is analytical performance, especially when a microinfusion system is used and the insulin dose for administration during boluses is selected on the basis of a measured level of glycaemia. Another issue is how painful the finger pricking can be, especially when several glucose measurements are needed per day, for example in the case of practising sport, because numerous pricks can be particularly annoying. Moreover, a painful finger pricking may discourage paediatric diabetics or newly diagnosed patients. Usually, the choice of the right glucometer for a specific patient is made by the diabetologist or by the nurse, who needs to take in account the single patient s abilities and conditions. A system facilitating correct handling of the strip can be useful for elderly patients, for whom simple instruments are more suitable. In contrast, young, newly diagnosed patients need to be educated by physicians to measure glycaemia and to manage correctly the mass of information generated by an instrument with high connectivity. The vast amount of data collected by the more sophisticated glucometers can be useful to recap blood glucose variability on a daily period, nocturnal episodes hypoglycaemia or hyperglycaemic episodes after physical activity, thus allowing the quick identification of problems that could be otherwise neglected. For example, data memory is a very useful function for the physicians, who can examine the complete glycaemic profile at the time of every consultation. However the patients are still encouraged to keep a personal diary, which has an educational purpose, in particular for young patients undergoing insulin therapy, who may learn to personalise the insulin plan based on the comparison of data recorded on different days. Moreover, joint examination of the diary by the patient and nurse together may help to foster the patient s confidence on blood testing and to teach him or her to maximise the benefit of blood glucose measurements for therapy. Besides the numbers, required by the diabetologist to examine trends and profiles, the diary should also contain various information about the patient s habits (type of meal, activities, and other aspects). This allows the physician to have a more complete picture of the patient s status and conditions and to generate the most personalised therapy possible. In conclusion, the teamwork of physicians and nurses underlies the best choice of instrument for a specific patient. Besides considering the technology of the instrument, it is of paramount importance to evaluate the patient as a person, with his or her characteristics, abilities and life conditions.

6 Blood glucose monitoring systems for self-testing: the importance of meeting performance requirements to ensure good therapeutic decisions All SMBG devices will need to comply with the new ISO performance requirements within the next three years, which will guarantee that increasingly accurate instruments will be available in the future. At present, more than half of the currently available instruments already meet the requirements of the ISO standard of accuracy. In terms of clinical safety, the main criterion for minimum system accuracy is correct measurements of 95% of the results in a specific risk area, i.e. below 100 mg/dl (Figure 3) - near hypoglycaemia - because the results in this area have clinical consequences of whether or not to administer a specific therapy, with possible significant medical risks, if based on wrong glycaemic measurements. Regular and standardised evaluations of SMBG meters and test strips are necessary to ensure adherence to quality and accuracy standards. A typical source of error is incorrect storage of the vials containing the test strips. For example, improper closure of the vials, leading to excessive exposure of the strips to humidity, can have a dramatic impacts on the strips stability and the measurement performance (Figure 4). Unfortunately patients do not always manage strips correctly. Vials should be opened for the limited time required to remove a strip and then closed immediately. Figure 3. A comparison of how different SMBG systems meet the ISO Moreover, the strips should standard for minimum system accuracy. not be stored in high

7 humidity environments (such as a bathroom or laundry room). It is also very important to follow the instructions for use very carefully, where all limitations of use (interferences, ambient conditions, etc.) should be clearly reported. Many handling errors could be avoided by carefully reading the instructions for use, provided by the manufacturers of SMBG systems. In conclusion, patients must be instructed Figure 4. Effects of incorrect storage of strips on the stability of the on how to use their systems strips, expressed in days for each vial. properly, as even the best possible SMBG will not work if not managed correctly by the patient. An additional source of possible mistakes in the correct evaluation of blood glucose levels is to compare the results obtained with different kinds of devices, such as a continuous glucose monitor (CGM) sensor and a glucometer. The differences observed may be very confusing and disorienting for the patient. Continuous monitoring can be very popular among patients because of the increased confidence about hypoglycaemic risks, for example during sporting activities or journeys abroad.

8 DKA management: from prevention to treatment The main goal of health care professionals is to recognize the early signs of diabetes (polyuria, polydypsia, weight loss) and all possible efforts are made to raise awareness among the public, teachers and parents about these early signs. The scope is the earliest possible diagnosis of type 1 diabetes, before the development of diabetic ketoacidosis (DKA), which is a serious condition that may lead to diabetic coma or even death. The prevention of DKA requires teamwork and can involve a variety of actions, such as forming networks between primary care settings and specialised centres, providing round-the-clock telephone helpline coverage seven days a week, and producing educational TV advertising on the early recognition of signs and symptoms of diabetes. DKA can be assessed by measuring ketones in both the urine and blood. Ketone testing in the urine measures acetoacetate and acetone, it is a semi-quantitative method, is subject to measurement errors, is hampered by having to wait for urine to be voided (which can be after hours in the typically dehydrated patient) and gives a relatively late indication of ketosis. Blood ketone testing measures beta-hydroxybutyric acid and gives immediate, reliable and quantitative results. The method of choice for ketone self-testing is now point-of-care measurement of ketones in capillary blood using a ketone meter. There are several benefits of blood ketone testing. Patients can check progress and prompt early contact with health care professionals thus enabling quick decisions by clinicians (advice, assessment, admission). Moreover, ketone testing can reduce costs, by preventing admissions to hospitals and facilitating discharge from Accident and Emergency departments. It is, therefore, essential that all type 1 patients can undergo ketone testing and have DKA advice. All cases of recurrent DKA could be prevented if all patients and healthcare professionals treating patients with diabetes were provided with sufficient, continuous ongoing education on a regular basis. It is of paramount importance to recognize DKA quickly in pregnant women, because this condition can be very dangerous for the mother and, above all, for the foetus. When the mother has DKA or even only hyperketonaemia, the ketone body (beta-hydroxybutyric acid) can accumulate in the foetus brain (Figure 5), where it can cause haemodynamic abnormalities, leading to ischaemia with the possible impairment of some neuronal systems in the neonate and consequent neuropsychological handicaps. Every effort should be made to avoid the onset of DKA in the mother, because the foetus is completely dependent on the mother for its glucose supply. The positive part is that pregnant women with diabetes are generally very motivated to use an insulin pump to avoid any

9 complications to the foetus. Not only should women with diabetes be educated during pregnancy, but one step earlier - they must also be prepared for conception, encouraging optimisation of the controls. It is important that the obstetric team is competent and experienced in spotting early warning signs of DKA. Figure 5. Ischaemic infarctions in the brain of a neonate whose mother had DKA.