Top10 Techniques for Attaining Glucose Goals

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Top-10 Techniques for Attaining Glucose Goals

• Gary Scheiner MS, CDE
• Owner/Director
• Integrated Diabetes Services
• Wynnewood, PA
• www.integrateddiabetes.com
• Gary_at_integrateddiabetes.com
• 877-735-3648

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Agree on the goals.
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Agree on the goals.

• Acceptable target ranges
• Pre-meals (70-160? 80-180? 80-200?)
• 1-Hr Postprandial (lt180? 200? 240?)
• of BGs in-range
• Improve upon recent past (gt50? 70?)

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Agree on the goals.

• Acceptable Hypoglycemia
• Define Hypo (lt80? 70? 60?)
• Per Week (lt5? 3? 2?)
• Allowable severe lows (usually 0)
• HbA1c Target
• Short term Improve upon recent past
• Long term Ultimate goal

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Individualize the plan of care.
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Individualize the plan of care.

• No 2 kids are the same.
• No 2 caregivers are the same.
• Patients are your clients.
• Adapt to their needs! (not vice versa)

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Individualize the plan of care.

• Nature of services provided
• Teaching style
• Rate of progression
• Overall goals

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Dont Pigeon-Hole.
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Dont Pigeon-Hole

• Not everyone fits the usual formulas.
• Programs should be tailored to the clients
  needs, interests and abilities.
• Offer a menu of options with pros cons of
  each
• Conventional Therapy
• MDI
• CSII

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Stay Cutting Edge.
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Stay Cutting-Edge.

• Medical Treatments
• Insulin cocktails
• Diluting insulin
• Oral agents
• Incretins

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Stay Cutting-Edge.

• Learn utilize the latest devices
• Continuous Glucose Monitors
• Downloading/Analysis Software
• Pumps, Pens
• Injection Ports
• New Meters
• Online resources

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Stay Cutting-Edge.

• Think Outside the Box!
• Be willing to try new things.
• Diabetes management, by its very nature, is TRIAL
  AND ERROR.

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Empower Thy Patients.
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Empower Thy Patients.

• Show how to self-evaluate critically.
• Explain the process for making sound
  self-adjustments.
• Detail when to contact the HCP.

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Empower Thy Patient.

• Teach your patients well.
• Use tools fully properly.
• Expert carb counters.
• Ready for sick days.
• Manage lows properly.
• Troubleshoot effectively.

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Respect the Basals.
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Start with the basals.

• Basal insulin is the foundation of the
  management program.
• Make sure the basal insulin is right before
  attempting to fine-tune boluses.
• Conduct fasting tests to verify
• pumpers around-the-clock
• injectors overnight

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Start with the basals.
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Start with the basals.

• Basal Testing Conditions
• No food raising BG
• Last meal ? 4 hours prior
• Last meal fairly low in fat
• No calories during the test (d/c if lt70)
• No bolus insulin lowering BG
• Last bolus ? 4 hours prior
• No boluses during the test (d/c if gt250)
• No temp rates, suspension or disconnection

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Start with the basals.

• Basal Testing Conditions
• No unusual stress, illness or hormonal changes
• Usual daily activities (no heavy exercise during
  test)
• Check BG every 1-2 hours (every 2-3 hours OK
  overnight)

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Start with the basals.
Sample Basal Testing Schedule
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Start with the basals.

• Grounds for adjustment
• Consistent rise or fall through the test phase
• Change of more than 30 mg/dl through the test
  phase
• If irregular pattern, repeat test
• Make changes 1 hr prior (pump) 10 of basal dose
  (injections)

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Plan for Communication.
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Plan for communication.

• Who?
• Parent?
• Child?
• Shared?
• Who receives/replies at your end?

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Plan for communication.

• What?
• Blood Sugars Only?
• Pre, or Pre Post?
• Carbs, Insulin, Activity?
• Programmable meter/pump?
• WRITTEN LOGSHEETS RULE!

• www.integrateddiabetes.com..

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Plan for communication.
Blood glucose values by themselves tell us when
something is wrong, but they dont tell us why.

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Plan for communication.

• When?
• Daily?
• Weekly?
• Monthly?
• For special circumstances?
• Prior to appointments?

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Plan for communication.

• How?
• Phone
• Fax
• E-Mail
• Website (Carelink, etc.)
• Transmission of pump/meter data

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Think Activity.
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Think Activity

• Encourage it.
• Support it.
• Think about it whenever dosing.

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Think Activity

• Sometimes insulin works like a unit, sometimes it
  dont.
• Insulin is only as effective as the body is at
  using it.

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Think Activity

• Use Activity Multipliers when determining
  boluses

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- 25
- 50
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Think Activity

• Encourage daily activity, year-round

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Monitor Adjust Often.
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Monitor Adjust Often

• Pediatric Type-1 SMBG
• Fasting
• Pre-meals, snacks, bedtime
• 1-hr post-meals (rotating)
• Prior to sports/exercise
• Hourly during prolonged sports/exercise
• Every 2-3 hours during illness
• 3 a.m. (at least once weekly)

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Monitor Adjust Often

• Collect the data
• Weekly (patients/families)
• Monthly/Quarterly (HCP)
• Analyze the data by time of day
• gt 30 high?
• gt 10 low?
• Find the Culprit

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Monitor Adjust Often

• The Usual Suspects
• The Insulin Program
• Basal Insulin
• IC Ratio
• Correction Factor
• Exercise Variation
• Lifestyle Issues
• Hormone Changes
• Sabotage

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Instill the Right Attitude.
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Instill the Right Attitude
First Impressions Count Be Aggressive From the
Get-Go.

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Instill the Right Attitude
Let Kids Be Kids

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Instill the Right Attitude
But Know When to Say When.
Structure Works. Certain Things Must Get Done.

• Blood Glucose Monitoring
• Insulin Administration
• Hypo Prevention/Management
• Timely Professional Care

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Think Like A Pancreas!