Measuring blood glucose levels with point-of-care testing (POCT) A1C and blood glucose levels are usually calculated in a labora- tory using venous blood. Results are generally standardized to NGSP methodology and are reliable estimates of glycemic mea- sures, referred to as central laboratory testing (CLT). Because it may take 24 hours or longer to obtain the results, neither the patient nor the health care provider has access to current glyce- mic measures during a patient’s appointment. For this reason, it is becoming increasingly common in outpatient settings to use point-of-care testing (POCT), which analyzes a capillary sample in
a desktop analyzer. The standard of care is teaching anyone doing POCT the importance of quality control with procedure. POCT of blood glucose levels is widely used in hospitals and pri- mary care settings to provide rapid results and facilitate the timely treatment of hypoglycemia and hyperglycemia as well as in-office decision making related to medications and glycemic manage- ment. POCT should not be used for diagnosing diabetes 14 . 2. Joan would likely benefit from BGM along with attending diabetes education classes. Performing BGM provides data that illustrate how food, physical activity, and medication use affects blood glucose levels. Blood glucose meters have evolved over the 10 years since Joan was diagnosed and selecting a new one that will meet her individual needs is important. To choose the best blood glucose meter for her, consideration should be given to Joan’s preferences; insurance coverage; and individual needs such as display size, auditory function, and meter size. 3. Joan would likely benefit from diabetes self-management education and support (DSMES). This need should be assessed and provided annually as appropriate. Joan’s health care provider may suggest a change in her medications and encourage BGM until glycemic goals are achieved. It is important to tell Joan that if she is on Medicare, they will only pay for enough strips for one day of checking. Other insurance companies may vary unless the person with diabetes is on insulin three times/daily. Joan must bring her meter or logbook to every visit with her health care provider so they can go over the results and assist with clinical decision making.
Case study 2 Joan is a 57-year-old Hispanic female with a history of type 2 dia- betes for 10 years. Her BMI is 29.0, and she has stage 1 hyper - tension. Her medication regimen includes glipizide 20 mg daily; metformin 1,000 mg twice daily; and chlorthalidone 25 mg daily. Joan’s A1Cs have been 8.4% and 9.2% in the past year. Joan states that she feels tired but otherwise is well. After Joan was di- agnosed with type 2 diabetes, she learned how to test her blood glucose but has not done so in the last couple of years. Joan ac- knowledges that she has not felt confident performing blood glu - cose monitoring (BGM). She states her healthcare provider never asks her about testing her blood glucose or seeing her logbook. Questions 1. How would you interpret the A1C results? 2. Would you recommend BGM for Joan? 3. What additional support would be appropriate for Joan? Discussion 1. Joan’s A1C results indicate her glycemic goals are not in the range recommended by the American Diabetes Association (ADA). During the last year, two A1C levels were done. Because neither of Joan’s A1C values were in the target range of less than 7.0%, her A1C levels should be assessed quarterly.
ADDITIONAL MONITORING
The goals for the treatment of diabetes are purposeful to prevent or delay potential complications, which optimize the patient’s quality of life. With that goal in mind, it is vital to understand that blood glucose levels only tell part of the story. Because diabe- tes is a leading risk factor for cardiovascular disease, stroke, and renal failure, it is essential to monitor and control the factors as- sociated with these vascular complications. Blood pressure, lipid Hypertension Hypertension is defined as a blood pressure (BP) sustained at or above 140/90 mmHg and is commonly associated with type 1 and type 2 diabetes 24 . Treatment recommendations for patients with diabetes and hypertension should be individualized with acknowl- edgment of patient preferences, cardiovascular risk assessment, potential adverse effects, significant drug-drug, drug-disease, or drug-food interactions, and accessibility of antihypertensive med- ications. Recommendations for individuals with diabetes and high Dyslipidemi Because dyslipidemia is common in patients with diabetes, lipid levels should be screened 24 . A lipid panel includes the total cho- lesterol, low- density lipoprotein (LDL), high-density lipoprotein (HDL), and triglyceride levels. Hypertriglyceridemia, high LDL cholesterol (especially the small, dense LDL particles), and low levels of HDL cholesterol commonly coexist with diabetes. For patients under the age of 40, it is recommended to obtain a lipid End-stage renal failure End-stage renal failure is a common microvascular complication of diabetes. In fact, diabetic nephropathy is known as the leading cause of end- stage renal disease in the United States 24 . Screening for kidney disease involves urine testing for albumin levels. Albu-
profile, and urine albumin levels should be measured at every routine clinical visit to alert the clinician to potential complications related to diabetes. For more information on the monitoring and treatment of the following conditions, please review the American Diabetes Associations Standards of Medical Care in Diabetes, re- leased in January of 2022. cardiovascular risk should have a BP target of <130/80 mmHg if this BP can be safely attained; an individual with diabetes and a lower cardiovascular risk would benefit from a BP <140/90 mmHg. The patient’s blood pressure should be measured at every outpa- tient visit and treated aggressively to achieve and maintain tar- get pressure levels. All hypertensive patients would benefit from home blood pressure monitoring. profile at the time of diagnosis, at the initial medical evaluation, and then every 5 years thereafter, unless there is a need for more frequent monitoring. If the patient is on medication for dyslipid- emia, the recommendation is to obtain a lipid profile at the initia - tion of the medication, 4 to 12 weeks after initiation or a change in dose, and then annually monitor the response to therapy.
min is a plasma protein particle that is typically too large to be eliminated by healthy kidneys. In diabetic nephropathy, renal tu- bules are damaged, and albumin begins to escape into the urine. The earliest sign of nephropathy is the appearance of persistent
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