ΕΠΑΡΚΕΙΑ ΤΡΟΠΩΝ ΕΚΤΙΜΗΣΗΣ ΓΛΥΚΑΙΜΙΚΟΥ ΕΛΕΓΧΟΥ 1 Δ. Κιόρτσης Ενδοκρινολόγος Καθηγητής Ιατρικής Σχολής Παν/μίου Ιωαννίνων
Percentage with Diabetes Number with Diabetes (Millions) Number and Percentage of U.S. Population with Diagnosed Diabetes, 1958-2013 8 25 7 6 Percentage with Diabetes Number with Diabetes 20 5 4 3 15 10 2 1 5 0 1958 61 64 67 70 73 76 79 82 85 88 91 94 97 00 03 06 09 11 Year 0 CDC s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics
Age-adjusted Prevalence of Obesity and Diagnosed Diabetes Among US Adults Obesity (BMI 30 kg/m 2 ) 1994 2000 2013 No Data <14.0% 14.0% 17.9% 18.0% 21.9% 22.0% 25.9% > 26.0% Diabetes 1994 2000 2013 No Data <4.5% 4.5% 5.9% 6.0% 7.4% 7.5% 8.9% >9.0% CDC s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics
Σακχαρώδης Διαβήτης Καλό γλυκαιμικό έλεγχο Αποφυγή υπογλυκαιμιών
5 ΕΚΤΙΜΗΣΗ ΓΛΥΚΑΙΜΙΚΟΥ ΕΛΕΓΧΟΥ Μέτρηση HbA1C Αυτοέλεγχο (SMBG)
Mean Glucose Levels for Specified A1C Levels Mean Plasma Glucose* Mean Fasting Glucose Mean Premeal Glucose Mean Postmeal Glucose Mean Bedtime Glucose A1C% mg/dl mmol/l mg/dl mg/dl mg/dl mg/dl 6 126 7.0 <6.5 122 118 144 136 6.5-6.99 142 139 164 153 7 154 8.6 7.0-7.49 152 152 176 177 7.5-7.99 167 155 189 175 8 183 10.2 8-8.5 178 179 206 222 9 212 11.8 10 240 13.4 11 269 14.9 12 298 16.5 These estimates are based on ADAG data of ~2,700 glucose measurements over 3 months per A1C measurement in 507 adults with type 1, type 2, and no diabetes. The correlation between A1C and average glucose was 0.92. A calculator for converting A1C results into estimated average glucose (eag), in either mg/dl or mmol/l, is available at http://professional.diabetes.org/eag. ADA. 6. Glycemic Targets. Diabetes Care. 2015;38(suppl 1):S35; Table 6.1
Recommendations: A1C Perform the A1C test at least two times a year in patients meeting treatment goals (and have stable glycemic control) E Perform the A1C test quarterly in patients whose therapy has changed or who are not meeting glycemic goals E Use of point-of-care (POC) testing for A1C provides the opportunity for more timely treatment changes E ADA. 6. Glycemic Targets. Diabetes Care 2015;38(suppl 1):S34
Depicted are patient and disease factors used to determine optimal A1C targets. American Diabetes Association Dia Care 2015;38:S33-S40 2015 by American Diabetes Association
9 ΜΕΙΩΣΗ HbA1C Βελτίωση μικροαγγειοπάθειας Βελτίωση μακροαγγειοπάθειας
10 ΒΑΘΜΟΣ ΔΙΑΚΥΜΑΝΣΗΣ ΣΑΚΧΑΡΟΥ Συσχέτιση με σοβαρές υπογλυκαιμίες Συσχέτιση με μίκρο-μάκροαγγειοπάθεια
11 Αυτοέλεγχος γλυκόζης (SMBG) Απλός, δεν απαιτεί βοήθεια Γρήγορος Αρκετά αξιόπιστος Ανίχνευση υπερ-υπογλυκαιμίας Εκπαίδευση Οργάνωση δύσκολων έργων (οδήγηση, χειρισμός μηχανημάτων κλπ)
12 Αυτοέλεγχος γλυκόζης (SMBG) Πόνος Οικονομικά ζητήματα Άγχος Τα μειονεκτήματα εξαρτώνται κυρίως από τον ασθενή
A: Association between frequency of SMBG per day and HbA1c. Kellee M. Miller et al. Dia Care 2013;36:2009-2014 2013 by American Diabetes Association
Recommendations: Glucose Monitoring (1) Patients on multiple-dose insulin (MDI) or insulin pump therapy should do SMBG B Prior to meals and snacks Occasionally postprandially At bedtime Prior to exercise When they suspect low blood glucose After treating low blood glucose until they are normoglycemic Prior to critical tasks such as driving ADA. 6. Glycemic Targets. Diabetes Care 2015;38(suppl 1):S33
Fig 2 Change in HbA1c levels over 12 months' follow-up of patients with non-insulin treated type 2 diabetes according to randomisation group. Andrew Farmer et al. BMJ 2007;335:132 2007 by British Medical Journal Publishing Group
16 Αυτοέλεγχος γλυκόζης (SMBG) Ινσουλινοθεραπευόμενος ΣΔ ξεκάθαρα βελτίωση γλυκαιμικού ελέγχου Μη ινσουλινοθεραπευόμενος ΣΔ αντικρουόμενα στοιχεία στον γλυκαιμικό έλεγχο
17 Αυτοέλεγχος γλυκόζης (SMBG) 4-5 φορές πιο πιθανόν υποστροφή ΣΔ Καλύτερη εφαρμογή διαιτητικών οδηγιών Μεγαλύτερη μείωση βάρους Διακοπή SMBG οδηγεί σε αύξηση HbA1C
Recommendations: Glucose Monitoring (2) When prescribed as part of a broader educational context, SMBG results may be helpful to guide treatment decisions and/or patient self-management for patients using less frequent insulin injections B or noninsulin therapies E When prescribing SMBG, ensure that patients receive ongoing instruction and regular evaluation of SMBG technique and SMBG results, as well as their ability to use SMBG data to adjust therapy E ADA. 6. Glycemic Targets. Diabetes Care 2015;38(suppl 1):S33
19 Αυτοέλεγχος γλυκόζης (SMBG) Δεν είναι θεραπεία αλλά εργαλείο
ΌΧΙ ΑΠΟΛΥΤΑ ΕΠΩΦΕΛΗΣ Η ΧΡΗΣΗ HbA1C, SMBG 20 Όχι κατάλληλη χρήση Μέτρια εκπαίδευση του ασθενή Μικρό ποσοστό ασθενών με σοβαρή ινσουλινοπενία
Recommendations: Glucose Monitoring (3) When used properly, CGM in conjunction with intensive insulin regimens is a useful tool to lower A1C in selected adults (aged 25 years) with type 1 diabetes. A Although the evidence for A1C lowering is less strong in children, teens, and younger adults, CGM may be helpful in these groups. Success correlates with adherence to ongoing use of the device. B CGM may be a supplemental tool to SMBG in those with hypoglycemia unawareness and/or frequent hypoglycemic episodes. C Given variable adherence to CGM, assess individual readiness for continuing use of CGM prior to prescribing. E When prescribing CGM, robust diabetes education, training, and support are required for optimal CGM implementation and ongoing use. E ADA. 6. Glycemic Targets. Diabetes Care 2015;38(suppl 1):S33
22 ΣΥΜΠΕΡΑΣΜΑΤΑ Μέτρηση HbA1C και SGBM πολύ χρήσιμες Κατάλληλη χρήση Καλή και συνεχιζόμενη εκπαίδευση Μικρή μειοψηφία με ΣΔ τύπου 2 άλλες μεθόδους