Transcript Type 2 diabetes mellitus treated with

Blood glucose self-monitoring
in type 2 diabetes mellitus
Emma Harris
Medicines Management Pharmacist
West Suffolk Clinical Commissioning Group
Educational Event 28th January 2014
West Suffolk Hospital Education Centre
WSCCG Prescribing Data
•
Total spend on all BGTS by 10%
• No.4 on the WSCCG Rx Recommendation
Top 10 savings areas (excluding PIP metrics)
• Potential 12-month saving of £92,442
T2DM not treated with insulin
NICE CG87: The management of type 2 diabetes
Self-monitoring of plasma glucose should be
available to:
• those on oral glucose-lowering medications to
provide information on hypoglycaemia
• assess changes in glucose control resulting
from medications and lifestyle changes
• monitor changes during intercurrent illness
• ensure safety during activities, including
driving
NICE CG87
Assess at least annually & in a structured way:
• self-monitoring skills
• the quality and appropriate frequency of
testing
• the use made of the results obtained
• the impact on quality of life
• the continued benefit
• the equipment used
Medical Standards of Fitness to Drive
Drivers Medical Group, DVLA, Swansea (2013)
(2012)
“Drivers with a Group 1 licence on insulin
have been advised to test their blood glucose
before driving.
If this practice were to be encouraged in
people on sulphonylureas, it would
increase enormously the cost of blood
glucose monitoring.”
• Greatest risk of hypoglycaemia in first 3
months of sulphonylurea treatment
• Maintain current practice
• Extra testing only in those people who are
 starting treatment
 experiencing hypoglycaemia or
reduced awareness
•
For Group 1 drivers (car/motorcycle) the
frequency of blood glucose monitoring should
depend on the clinical context
•
A Group 2 driver (bus/lorry) on a sulphonylurea
or glinide is required by law to monitor blood
glucose at least twice daily and at times
relevant to driving
Position Statement on Self monitoring of blood glucose (SMBG)
for adults with Type 2 diabetes (April 2013)
• Exact role of SMBG in Type 2 diabetics not on insulin
less clear and widely debated
• Volume & cost of Rx for monitoring rising
• SMBG should be available to people receiving
sulphonylurea and prandial glucose regulators
• Access to SMBG based on individual assessment
• Arbitrary withdrawal of SMBG in those who clearly
benefit should not occur
• Reflect on practice
• Responsibility to use resources wisely
• Education, appropriate and timely reviews,
responding to results
• Support those who find SMBG useful
• Identify those who gain no benefit
• SMBG performed indefinitely?
• Testing for a defined period may be appropriate
Type 2 diabetes mellitus treated with:
Drug class
Meglitinides
Examples
Nateglinide, Repaglinide
(Prandial glucose
regulators/Glinides)
Sulfonylureas
Glibenclamide, Gliclazide,
Glimepiride, Glipizide, Tolbutamide
THESE MEDICINES CAN CAUSE HYPOGLYCAEMIA
Blood glucose monitoring may therefore be required in patients:
• who are not stabilised on treatment
• who are drivers
• in other certain circumstances
Type 2 diabetes mellitus treated with:
Diet and exercise alone
Drug Class
Alpha glucosidase inhibitors
Examples
Acarbose
Biguanides
DPP-4 Inhibitors (Gliptins)
Metformin
Linagliptin, Sitagliptin, Saxagliptin,
Vildagliptin
Exenatide, Liraglutide, Lixisenatide
Pioglitazone
Dapagliflozin
GLP-1 Analogues (Incretin mimetics)
Thiazolidinediones (Glitazones)
SGLT2 Inhibitors
REGULAR BLOOD GLUCOSE MONITORING NOT NECESSARY
A supply of blood glucose test strips may be required
(as an acute prescription) in certain circumstances
Blood glucose monitoring may be required in patients:
 with acute illness
 up to 7 days post-surgery
 co-prescribed steroids
 undergoing significant changes in pharmacotherapy or fasting
 at increased risk of hypoglycaemia/hypo unawareness
 with unstable or poor glycaemic control (HbA1c >8.0%)
 with postprandial hyperglycaemia
 who are pregnant or planning pregnancy
DVLA guidance
for diabetic patients managed by sulphonylurea or glinide tablets
Driver Group
DVLA Advice
Group 1
It may be appropriate to monitor blood
(cars, motorcycles) glucose regularly and at times relevant to
driving
Group 2
(buses, lorries)
There is a requirement that the patient
regularly monitors blood glucose at least
twice daily and at times relevant to driving





How frequently
Clinical judgement
should my
patient test their
Choice of treatment
blood glucose?
How many
DVLA
test strips
should I
Seek advice
prescribe?
Repeat vs. acute prescription
 Regular review
 Suitable quantities to meet patient
needs, prevent stockpiling and waste
 Patient education
Questions