New AACE Statement Urges 'Meaningful Monitoring' of Glucose

Miriam E Tucker

February 18, 2016

A new consensus statement provides guidance on self-monitoring of blood glucose for patients with diabetes.

The statement, developed by a panel cochaired by Timothy S Bailey, MD, director of the AMCR Institute, Escondido, California, and AACE president George Grunberger, MD, chair of the Grunberger Diabetes Institute, Bloomfield Hills, Michigan, was published online February 10 in Endocrine Practice. As it notes, it reflects "the official position of the American Association of Clinical Endocrinologists and American College of Endocrinology."

A main theme of the statement is "meaningful monitoring," the idea that monitoring should be used in a way that informs management decisions. "Glucose monitoring by itself makes no sense. It has to be done in the context of therapy, [with] specific goals. Monitoring for monitoring's sake will never accomplish anything," Dr Grunberger told Medscape Medical News in an interview.

The document also outlines the history of blood glucose monitoring and covers current recommendations for use of conventional meters and strips, as well as continuous glucose monitoring (CGM). It also provides detailed guidance on assessment of meter accuracy and interpretation of glucose data.

More Than "Monitoring for Monitoring's Sake"

The following recommendations are made for outpatient self-monitoring frequency and use of CGM in different patient groups:

  • Adults with type 1 diabetes: At least twice per day, up to six to 10 times per day, including before meals, occasionally postprandial, before exercise or driving, and at bedtime. Continuous glucose monitoring is recommended, particularly for those with history of severe hypoglycemia or hypoglycemic unawareness

  • Children with type 1 diabetes: At least four times per day, including before eating and at bedtime. Testing 1 to 2 hours after eating, overnight, and before/after exercise may be helpful. Recommendation for CGM is the same as in adults.

  • Type 2 diabetes patients using insulin, sulfonylureas, or glinides: Structured blood glucose monitoring is recommended, depending on how the medications are used. Those on intensive insulin should monitor fasting, premeal, bedtime, and periodically in the middle of the night, while those on less intensive regimens can monitor less often. Data on CGM in these patients are limited.

  • Type 2 patients at low risk for hypoglycemia: Daily blood glucose monitoring is not recommended, although initial measurements taken at meals and bedtime may help patients understand how food and exercise affect their blood glucose levels. There is no CGM recommendation.

  • Gestational diabetes: For those not treated with insulin, fasting and 1-hour postprandial tests are recommended. Those treated with insulin should measure fasting, preprandial, and 1-hour postprandial. Data on CGM benefits in women with preexisting diabetes are unclear, but it may be helpful for those using insulin.

In general, Dr Grunberger said, both finger-stick monitoring and CGM can be helpful in determining where the patient may be having problems — overnight, after meals, or after eating certain foods, for example. That information, he said, can be used to titrate treatment. After that, the results can be used to dictate the need for further monitoring. For patients at low risk for hypoglycemia who don't adjust medication doses based on the readings, it may mean monitoring only rarely or not at all.

Overall, he said, it's important that monitoring "involves the patient in understanding why they're doing it and what to do with the results."

Meter Accuracy an Issue

The document also provides detailed information about glucose-meter accuracy and interpretation of patient glucose data. Explanations are given for concepts such as bias, precision, arithmetic deviation, and "mean absolute relative difference" (MARD), which has often been reported in studies of both meter and CGM accuracy in comparison with reference measures.

There is also an explanation of standards from the International Organization for Standardization (ISO) used by the Food and Drug Administration to approve glucose meters used in the United States. This topic became controversial in 2013, when the US Centers for Medicare & Medicaid Services initiated its competitive bidding process for blood glucose meters and test strips for Medicare beneficiaries, aiming to cut costs by steering seniors to lower-priced products.

This provoked strong opposition by some in the diabetes community and by manufacturers of brand-name meters, which sponsored studies showing significantly lower accuracy in the generic meters. Although all meters and strips sold in the United States must meet FDA standards for accuracy at the time of approval, data for some of the brands suggest that they haven't maintained adequate performance over time. In response, the AACE was among several organizations that have called for more rigorous postmarket surveillance of glucose testing products

Dr Grunberger has received speaker honoraria and research support for his role as investigator from AstraZeneca, Eli Lilly, Merck, Novo Nordisk, and Sanofi and speaker honoraria from Boehringer Ingelheim, GlaxoSmithKline, and Janssen Pharmaceuticals. Dr Bailey has received speaker/consultant honoraria and research support from Novo Nordisk; consultant honoraria and research support from Bayer, Medtronic, and Sanofi;  and research support from Abbott Laboratories, ACON Laboratories, Alere, Animas, Cebix, Bristol-Myers Squibb, Dexcom, Eli Lilly, GlaxoSmithKline, Halozyme, Insulet, LifeScan, MannKind, Merck, Orexigen Therapeutics, and Tandem Diabetes Care. Disclosures for the coauthors are listed in the article.

Endocr Pract . Published online February 10, 2016. Article

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