Analyzing Glucose Data

Transcription

1 Analyzing Glucose Data Objectives Identify when insulin needs to be adjusted Identify pattern of high and low BGs Provide sources of information on how to adjust insulin Titrate insulin doses based on BGs records

2 Using Pattern Control with Insulin Start insulin Select insulin(s) Calculate insulin units/kg/day Initiate insulin and keep food, glucose, and insulin records Titrate If most glucose values >200 mg/dl increase total dose When most glucose values < 200 mg/dl use pattern control Assess Assess adherence, ease of use, numeracy, carb counting skills, background and mealtime insulin ratio Pattern Control Recognize glucose patterns Analyze cause of out of target readings Examples? Take steps to bring glucose into target Two types of glucose patterns: Out of target at about the same time of day for 2 3 days Trending up or down throughout the day or overnight

3 Set Glucose Targets Type 1 or Type 2 IDC Targets IDC Modified Targets A1C < 7% <8% Fasting and Premeal mg/dl mg/dl 2 hr. Postmeal < 180 mg/dl < 200 mg/dl Goal is to achieve > 50% BGs in target May consider modified targets. Decreased life expectancy Frail elderly History of severe hypoglycemia Severe cardiovascular disease Examples include: Cognitive disorders Psychosocial barriers ESRD IDC Clinical Consensus Statement 2013 Next Step to Achieving Effective Insulin Dose Table 2 If fasting glucose: Change dose that affects glucose by: < 70 mg/dl Decrease 1 3* units or 10% mg/dl No change mg/dl Increase 1 3 units > 200 mg/dl Increase 3 5 units or 10% * Use 1 unit when dose is < 10 units Guide to Starting and Adjusting Insulin for Type 2 Diabetes, 2015

4 Titrating Premixed with Rapid Acting Insulin Metformin/Sensitizers BG Testing: Fasting and pre dinner every day minimum ) Consider before midday meal and bedtime occasionally Titrating Premixed Insulin If more than half BG 200, but not in target, Use titration table (table 2) Out of Target BG Fasting Pre evening Meal Adjusted dose Pre evening Meal Prebreakfast Guide to Starting and Adjusting Insulin for Type 2 Diabetes, 2015, IDC

5 Premixed Insulin Titration Breakfast Lunch Evening Meal HS Pre Med Post Pre Med Post Pre Med Post Med/BG Mon u u Tue u u Wed 94 33u u Premeal target mg/ dl Causes of High Premeal Glucose Levels Extra carb intake Less activity More than hours between doses (premixed) Too little insulin

6 Titrating Background and Mealtime Insulin Metformin / Sensitizers BG Testing: Fasting Before all meals 1 2 hrs after at least one meal Titrating Background and Mealtime Insulin If more than half fasting BG < 200 mg/dl: Use titration table (table 2 on adjustment guide) BG Out of Target Dose to Adjust Fasting Background dose Before Midday/Evening Meal Previous meal dose Pre to postmeal rise >50 mg/dl Increase that meal s dose 1 3 units or 10% Pre to postmeal drop Decrease that meal s dose 1 3 units or 10% Guide to Starting and Adjusting Insulin for Type 2 Diabetes, 2015, IDC

7 Background/Mealtime: Which Glucose are Out of Target? Breakfast Lunch Evening Meal HS Pre- Med Post Pre Med Post Pre Med Post Med/BG Mon RA RA RA LA Tue RA RA RA LA Wed RA RA RA LA Started 0.2 units/kg x 80 kg (176#) = 16 units LA 0.2 units/kg x 80 kg (176#) = 16 units RA divided between 3 meals Titrating Background and Mealtime Insulin If more than half fasting BG < 200 mg/dl: Use titration table (table 2 on adjustment guide) BG Out of Target Dose to Adjust Fasting Background dose Before Midday/Evening Meal Previous meal dose Pre to postmeal rise >50 mg/dl Increase that meal s dose 1 3 units or 10% Pre to postmeal drop Decrease that meal s dose 1 3 units or 10% Guide to Starting and Adjusting Insulin for Type 2 Diabetes, 2015, IDC

8 Applying Glucose Targets Day Breakfast Lunch Dinner Bedtime Pre Med Post Pre Med Post Pre Med Post Pre Med Mon 110 RA RA RA 166 LA RA= Rapid Acting LA= Long Acting Applying Glucose Targets Day Breakfast Lunch Dinner Bedtime Pre Med Post Pre Med Post Pre Med Post BG Med Mon 178 RA RA RA LA RA= Rapid Acting LA= Long Acting

9 Background & Mealtime Titration Breakfast Lunch Evening Meal HS Pre Med Post Pre Med Post Pre Med Post Med/BG Mon RA RA RA LA Tue RA RA RA LA Wed RA RA RA LA What is your assessment? Hypoglycemia Address lows (two at same time of day) Reduce insulin Non insulin reasons for lows: Carb counting errors Delayed or missed meals Increased activity Hypoglycemia treatment for BG < 70 mg/dl 15 grams carb Retest in 15 minutes, repeat carb if needed

10 Insulin to Carb Ratio (ICR) Amount of insulin needed to cover a specific amount of carbohydrate in the diet Mealtime dose determined for each meal/snack based on how much carbohydrate will be consumed. Starting an Insulin to Carb Ratio (ICR) Breakfast Lunch Evening Meal HS Pre Med Post Pre Med Post Pre Med Post Med/BG Mon RA RA RA LA Tue RA RA RA LA Wed RA RA RA LA Patient tells you she eats 4 carb choices (60g) at every meal

11 Two Ways to Write insulin to Carb Ratios 1 unit insulin: grams? carb Example: Take 1 unit insulin per 10 grams carb Eat 60 grams of carb, take units 6 units? insulin : 1 carb choice Example: Take 1.5 units per carb choice Eat 4 carb choices, take units 6 Insulin Basics, 3 nd Ed Good Candidates for Insulin to Carb Ratio Lifestyle Considerations Desires mealtime flexibility Varies amount of carb at meals and snacks Dines out frequently Skips or delays meals Works rotating shifts Travels frequently/ changes time zones Varies exercise time/intensity Diabetes Considerations Able to count carbs Able to solve problems using glucose records Monitors glucose frequently Able and willing to adjust insulin Desires tighter control IDC Clinical Consensus Statement, Mealtime Insulin, 2010

12 If Background/Mealtime insulin are Split 50/50, then if Background Insulin Rapid Acting Insulin per Carb Choice 15 units 1 unit units 1.5 units 30 units 2 units 45 units 3 units 60 units 4 units Amount of background insulin divided by 15 Fish et al. Insulin April, 2008 Insulin to Carb Ratio vs Fixed meal dose DAFNE Trial (type 1 DM) Structured education program A1C improved by 1% and quality of life improved using ICR Severe hypoglycemia, weight, and lipids remained unchanged Adjust to Target Trial (type 2 DM) Weekly adjustments Both lowered A1C, less insulin needed for carb counting (1.7 vs. 1.9 u/kg) No difference in severe hypoglycemia DAFNE Study Group, BMJ, 2002 Bergenstal, Johnson, Powers et al. Diabetes Care 2008

13 Assessing the ICR Pre meal BG 90 Med RA 6 units Lunch: 1 pork chop 1 med baked potato (2 choices) ½ cup broccoli 1 cup skim milk (1 choice) ½ cup lite ice cream (1 choice) 1 2 hr post BG Ratio: 1.5 units per carb choice Timing of Rapid Acting Insulin Matters at start of meal 30 min before 15 min before N= 10 T1DM using insulin aspart* CGM, 3 visits Usual ICR, identical meals for the individual, Diab Care 33: , 2010

14 Correction Factor for Insulin Adjustment (sliding scale, sensitivity factor) What is a Correction Factor? States how much 1 unit of insulin lowers glucose level Based on insulin sensitivity When to use: Premeal (not postmeal) Bedtime: Can be used cautiously if fasting BG not in target Correction scale typically started at higher glucose level. control/rules control/correction factor I

15 Correction Factor Pre meal BG 246 Med RA 6 + Sandwich ( 2 choices) Apple (1 choice) Diet soda 1 2 hr post BG 3 Ratio: 2 units per carb choice Post meal target: < 180 mg/dl Give correction factor premeal only Calculating the Correction Factor: The 1800 Rule 1800 Total Daily Insulin = mg/dl drop in BG from 1 unit mealtime insulin Example: Calculate total daily insulin dose 50 units: 25 units background + 25 mealtime 1800 total daily insulin = 36 mg/dl 1 unit of mealtime insulin will decrease the BG by 36 mg/dl (round to 35 or 40 to make calculations for patient easier) Blood Glucose Pattern Control, IDC, 2008

16 Correction Scale Example: 1 unit drops BG 35 mg/dl Glucose (mg/dl) Insulin units Premeal BG 246 Med 2 hr post BG RA Sandwich ( 2 choices) Apple (1 choice) Diet soda Continuous Glucose Monitor (CGM)

17 CGM Transmitter and Sensor

18 The%20Management%20of%20Type%201%20Diabetes%20 Resources How to contact a diabetes educator: American Association of Diabetes Educators (AADE) National Diabetes Education Program American Diabetes Association American Dietetic Association Guide to Eating Right When You Have Diabetes, by Maggie Powers