why self montering is so important in all cases of diabetes

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Issue 543

Why Self-Monitoring of Blood Sugars Is Critical in All Patients with

Diabetes

Vigilant monitoring of glycemic levels is the key to success for

comprehensive glycemic control in patients with Type 2 diabetes....

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Comprehensive glycemic control, as demonstrated by desirable glycated

hemoglobin A1c (HbA1c), postprandial glucose (PPG), and fasting plasma

glucose (FPG)

levels, is imperative for managing patients with Type 2 diabetes. It is

important to minimize fluctuations in blood glucose levels, as they are

thought

to contribute to both the microvascular and macrovascular complications.

The HbA1c measurement itself is not always indicative of the magnitude or

frequency of glucose fluctuations during the course of a day. Therefore,

treatment

should be aimed at reducing not only HbA1c, but also PPG and FPG in order to

achieve glycemic control. At the same time, patient safety should be a

priority.

Glycemic control also means minimizing hypoglycemic episodes, which elevate

the risk for additional complications. In addition to being

life-threatening,

hypoglycemia may cause hypoglycemia unawareness and compromised

counter-regulatory mechanisms. It may also lead to serious short- and

long-term effects,

including cognitive impairment and dementia. As most patients are unable to

maintain glycemic control on monotherapy, fortunately, effective combination

regimens are available with agents having complementary mechanisms that act

upon HbA1c, PPG, and FPG with minimal risk of hypoglycemia or weight gain.

Acute glucose fluctuations above a mean value (HbA1c 7%, which is an

estimated average glucose [eAG] of 154 mg/dL) may trigger oxidative stress,

which contributes

to macrovascular damage through oxidation of low-density lipoprotein,

exacerbation of endothelial dysfunction, and other proatherogenic mechanisms

leading

to the development and progression of vasculopathies; treating to limit this

glycemic variability may minimize diabetic complications. Decreasing the

frequency

and magnitude of glucose fluctuations may prevent not only acute, but also

long-term consequences associated with hyperglycemia. Recent studies suggest

that monitoring HbA1c levels alone might not be sufficient to address the

pathogenesis of adverse events -- rather, acute fluctuations in blood

glucose

may also be instrumental. Lowering both FPG (i.e., plasma glucose levels

following an 8- to 12-hour fast) and PPG (i.e., plasma glucose levels 60,

90,

or 120 minutes after beginning a meal) levels has been shown to reduce the

risk of complications.

Recent evidence has demonstrated that control of postprandial hyperglycemia

is necessary to achieve HbA1c targets. In one study, it was shown that when

HbA1c levels were 6.5%, PPG levels contributed to approximately 90% of this

value. Consequently, treating postprandial hyperglycemia in addition to FPG

in efforts to reach HbA1c goals should be part of the overall strategy for

the prevention and management of complications associated with T2DM. It

should

be noted that when HbA1c values were >9%, the proportion of PPG involvement

decreased to 40%, demonstrating the importance of treating FPG. The break

point

appears to be when HbA1c is <7.3%; at that point, treatment of PPG levels

becomes more important than treating FPG levels.

AACE and ACE recommend that, in order to reach target HbA1c levels,

measurement of both FPG and PPG levels are necessary. HbA1c measurement

alone does not

disclose the magnitude or frequency of fluctuations in blood glucose

throughout the day. Daily glycemic measures, FPG and PPG, give a series of

snapshots

that, when used in combination with HbA1c, is a more reliable indicator of

blood glucose control. HbA1c should be measured every 2 to 6 months,

depending

on the blood glucose level, how stable that level is, and whether any

changes are made in patient therapy.

The ADA recommends measuring HbA1c at least every 6 months in patients who

are both meeting their glycemic goals and have stable blood glucose control,

and 4 to 6 times per year in patients whose therapy has changed or who are

not meeting their glycemic goals. Optimal PPG, FPG, and HbA1c values are

<180

mg/dL (10.0 mmol/L), 70 to 130 mg/dL (3.9 to 7.2 mmol/L), and <7.0%,

respectively. The contribution of PPG is greatest in patients with moderate

hyperglycemia

(<7.3%). Based on the ADA and IDF recommendations, physicians should focus

on monitoring HbA1c and promoting patient self-monitoring of blood glucose

(SMBG)

in an effort to improve those values, reach the glycemic goal, and reduce

the proportion of patients with diabetes-associated complications. Because

it

provides real-time data, SMBG is the optimal method for monitoring PPG and

FPG; SMBG also allows for early intervention.

Early comprehensive glucose control is essential for maintaining health and

reducing long-term microvascular and macrovascular complications of patients

with T2DM. Vigilant monitoring of glycemic levels is the key to improving

glycemic control. Current guidelines recommend treatment aimed at

controlling

both FPG and PPG to maintain HbA1c near target goals; at the same time,

hypoglycemia and its associated complications should be avoided. Combination

regimens

with antidiabetic agents that provide complementary mechanisms of action

afford the physician drug treatment options that are safe, with minimal risk

of

hypoglycemia, and effective for the management of daily glycemic control.

South Med J. 2010;103(9):911-916

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