AACE Issues Guidance for Glucose Monitoring in Diabetes

The new statement provides guidance for clinicians managing patients with diabetes.
The new statement provides guidance for clinicians managing patients with diabetes.

Glycemic control is a critical aspect of diabetes care, with glucose monitoring playing a significant role in successful management of the disease. Recognizing the importance of glycemic measurement in diabetes management, the American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE) have published a consensus statement on outpatient glucose monitoring.

The statement, according to an AACE press release, incorporates new information that reflects evolving technology and provides clinicians with “detailed analyses to support precise recommendations for the type of system and frequency of use for either self-monitoring of blood glucose (SMBG) or continuous glucose monitoring (CGM) to reduce short- and long-term complications of diabetes.”

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There are many challenges for patients with current glucose monitoring modalities, noted the authors of the consensus statement. Some include the considerable variation in accuracy and precision between different manufacturers' products, while others involve cost and access issues. Despite these problems, the consensus statement encourages “meaningful monitoring”—individualized clinical management that is customized to each patient's preference and lifestyle. This is meant to empower patients to manage glucose levels to reduce complications, particularly hypoglycemia.

“Meaningful monitoring is meant to distinguish the effective application of glucose monitoring that we are advocating from the ad hoc prescription of glucose testing supplies to patients without clear guidance on how and when to test and what technology to use,” said Timothy Bailey, MD, FACE, FACP, co-chair of the 2016 consensus statement writing committee.

Although glucose monitoring alone is not adequate to promote optimal diabetes management, it plays a necessary and crucial role in preventing or delaying the complications of diabetes, he explained. In order to optimize the clinical management of diabetes, it is imperative that patients and health care professionals collaborate closely when adapting new monitoring technology.

“In the past, glucose monitoring, which we now refer to as GM, was synonymous with fingerstick capillary glucose testing (SMBG), which we now call BGM. More recently CGM has become more available. In the pipeline are devices, such as the Abbott Libre device, which blur the distinction between BGM and CGM and will make the prescription of testing supplies more nuanced,” Dr Bailey, of the Advanced Metabolic Care and Research Institute in Escondido, California, told Endocrinology Advisor

“With this statement, AACE seeks to clearly articulate how the changing landscape of glucose monitoring impacts the way endocrinologists and other diabetes-focused clinicians should recommend how and when people with diabetes might best monitor glucose levels.”

This consensus statement is the second to be published on GM. Victor Lawrence Roberts, MD, MBA, professor of internal medicine at the University of Central Florida College of Medicine in Orlando, who chaired the committee that worked on the first statement, said this new document reflects the advances in technology and provides better definitions for clinicians and their patients.

“This paper is written by endocrinologists for endocrinologists, but we wanted to appeal to a wider audience,” Dr Roberts said in an interview. “We provide the tools and they have to do the managing. The practice of it and the utilization are doable.”

While the document does not delve into the complexities of insulin adjustments based on the GM data obtained, one of the aims of the 2016 consensus statement is to provide a primer on GM accuracy and to describe various ways to characterize accuracy, such as mean absolute relative difference (MARD). Over the years, the value of BGM in type 2 diabetes has been controversial. However, studies have shown a benefit for patients with type 2 diabetes who are receiving insulin therapy, especially involving multiple daily injections (MDI), “basal-bolus” therapy, or continuous subcutaneous insulin infusion, according to the consensus statement.

Furthermore, BGM meters and CGM sensors in recent years have improved significantly in terms of accuracy and data usefulness. In addition, there have been significant advances with automated analyses and interpretation.

However, clinicians and patients still face significant challenges, with Dr Roberts citing a lack of reimbursement for providing comprehensive diabetes care as a major problem. The most expensive components of care include medicines, equipment, and laboratory tests, he said, and insurance companies need to realize that aggressive treatment of diabetes is essential to avoid complications.

“The truth is that I go through it every day in the office. Yes, it looks a bit intimidating, but because patients now demand better control and achieve better control, it is impossible to maintain an HbA1c below 7% without having CGM,” said Dr Roberts.

“A series of studies that looked at CGM showed that the more patients wear them, the more likely they are to stay in control. The CGM is a video of what is going on, but a blood draw is just a picture. The patient gets a visual of the situation instead of a snapshot. Patients take well to it. The majority of the patients are not well-controlled and this is a powerful tool to get there and stay there,” he added.

Nevertheless, CGM requires attention and detail, noted Dr Roberts. Major diabetes organizations currently recommend routine BGM for patients with type 2 diabetes, and many recommend CGM for patients with a history of severe hypoglycemia and for patients who are not achieving target HbA1c levels.

The consensus statement states that many pediatric patients with type 1 diabetes may be candidates for CGM, especially if they and their family caregivers have the appropriate training.1 Although no strong evidence indicates that using CGM will allow a patient to live longer, it is likely they will have better quality of life, Dr Roberts added.

“They feel better, they aren't victimized as much. They are in control and they are less likely to be depressed,” he said.

The document states that meaningful monitoring in patients with type 2 diabetes should be individualized based on the risk for hypoglycemia estimated based on prior history and the presence of hypoglycemia unawareness. Clinicians must also factor in whether a patient is on medications with relatively high hypoglycemia risk, such as insulin, sulfonylureas, or glinides. 

The authors note that more trials are warranted to help better identify the settings in which CGM can be most beneficial and cost-effective.

While technology has already had a significant effect on GM, more changes are coming down the pike. For instance, data sharing via the Internet, which has already been started by Nightscout, Dexcom Share, and Medtronic, will alter management, the authors note. The use of smart watches and new mobile phones may enable patients to monitor and adjust their lifestyle and therapy on a continuing real-time basis. Also, CGM devices are now available with a longer duration of use (2 weeks) and some devices are factory calibrated, eliminating additional calibrations by the end user.

Sources

  1. Bailey TS, Grunberger G, Bode BW, et al. American Association of Clinical Endocrinologists and American College of Endocrinology 2016 Outpatient Glucose Monitoring Consensus Statement. Endocr Pract. 2016;22(2):231-261. doi:10.4158/EP151124.CS.
  2. American Association of Clinical Endocrinologists' 2016 Outpatient Glucose Monitoring Consensus Statement Offers Guidelines for Physicians' Management of Diabetes Patient Care [news release]. Jacksonville, FL: AACE Public & Media Relations; February 10, 2016. http://media.aace.com/press-release/american-association-clinical-endocrinologists-2016-outpatient-glucose-monitoring-cons. Accessed February 19, 2016.
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