Advanced Technologies And Treatments For Diabetes (ATTD)

pattern management

This leads us to talking about pattern management – basically, this means reviewing several days of blood glucose records and working with your healthcare team to make adjustments in diabetes therapy based on these trends. Ms Meyer explained that in her experience, patients can be tempted to react to every high blood glucose reading with a completely new insulin regimen, explaining that this was “usually” unnecessary. She gave the example of a male patient who suddenly began measuring blood glucose readings around 350 mg/dl before bedtime a few nights in a row. Instead of reacting immediately and thinking this was a new pattern. Ms. Meyer wanted to identify the source of the high numbers. She asked him,

“Did you eat anything unusual?’

He replied, “No.”

And then she asked, “Were where you by any chance fighting with your wife?”

She got silence and a blank stare, followed by, “How did you know?”

lessons learned from continuous glucose monitoring
Dr. Satish Garg, MD (Denver, Colorado)

Dr. Garg, highly regarded diabetes technology expert at the Barbara Davis Center for Childhood Diabetes at the University of Colorado School of Medicine briefly presented the findings of a study on extended use of the sensor for the DexCom SEVEN continuous glucose monitor. Full results will be revealed at the annual American Diabetes

Association (ADA) meeting in June. Dr. Garg indicated that this study would demonstrate that 10-day use of the DexCom SEVEN is safe and viable option - we’ve heard considerable anecdotal evidence suggesting that sensor use can be extended from FDA-approved seven-day use, but this is the first study we’ve come across that actually confirms this.

Dr. Garg said that many of his patients had told him that they achieve better control when they take rapid-acting analogs “a long while” before eating a meal, rather than after eating a meal. Many of his patients find that it’s best to double the interval before meals recommended by the drug manufacturer; we would recommend consulting your healthcare provider if you are thinking about making any changes to your insulin dosing regimen. He added that there is a huge need for more rapid-acting insulins that can be taken after a meal. See this issue's Learning Curve to learn more about rapid acting insulin.

use of new technologies for monitoring and treating diabetes in pregnancy
Dr. Yariv Yogev, MD (Israel)

Dr. Yogev lamented the dramatic increase in the prevalence of diabetes in pregnancy (gestational diabetes) over the last two decades. He attributed this to advanced maternal age, obesity, and better screening for diabetes in pregnancy. Maternal diabetes increases risk of birth complications and newborn death.

Gestational diabetes; a word from the American Diabetes Association
“A fasting plasma glucose level greater than 126 mg/dl (7.0 mmol/l) or a casual plasma glucose over 200 mg/dl (11.1 mmol/l) meets the threshold for the diagnosis of diabetes, if confirmed on a subsequent day, and precludes the need for any glucose challenge (additional test to confirm diagnosis).”

He stated that current blood glucose guidelines for pregnancy were too lenient. In a recent study, of 57 non-diabetic women in the second half of pregnancy, researchers found that the mean blood glucose was 83 mg/dl, fasting glucose was 75 mg/dl, and pre-prandial (before meals) was 78 mg/dl. The mean post-prandial (after meals) peak value was 110 mg/dl. He explained that this “gap” between the actual value of 83 mg/dl and the ADA’s value of 126 mg/dl suggests that we are failing to diagnose many women with gestational diabetes (or at least abnormal blood glucose). Dr. Yogev believes that the current ADA gestational diabetes guidelines for acceptable glucose values should be lowered and brought closer to values seen in pregnant women who do not have gestational diabetes. He recommended the use of continuous glucose monitoring and insulin pumping to achieve better glycemic control during pregnancy. He conceded, however, that there have not been many conclusive studies examining insulin pump use in pregnancy, and a recent meta-analysis – a study analyzing data from a collection of other studies - found no difference in blood glucose control between daily injections and insulin pumping. He discredited the study, arguing that a meta-analysis is, “like a sausage. Only the butcher and the statistician knows what was put in…” More studies are needed to settle the issue of whether insulin pumping offers improved control during pregnancy and we look forward to them optimistically.