DM Full Guideline (2010) - VA/DoD Clinical Practice Guidelines Home

Version 4.0
MODULE G – GLYCEMIC CONTROL
ANNOTATIONS
VA/DoD Clinical Practice Guideline
for the Management of Diabetes Mellitus
A. Patient with Diabetes Mellitus (DM)
Every patient with DM, regardless of its duration, needs to negotiate an appropriate goal for glycemic control target
with his or her provider, and plan a treatment strategy to achieve this goal.
Glycemic control should be reevaluated at every regular interim visit or in the context of visits that relate to other
concurrent problems that could affect glycemic control.
B. Assess Glycemic Control
OBJECTIVE
Determine the patient’s level of glycemic control.
BACKGROUND
Glycosylated hemoglobin measured or reported as HbA 1 c, is the only laboratory test measure validated in
randomized controlled trials as a predictor of risk for microvascular complications. Hence, periodic measurement of
HbA 1 c is recommended to assess glycemic control over time.
Self-monitoring of blood glucose (SMBG) is the process by which patients use a home blood glucose monitor to
gain timely knowledge regarding their diabetes control. SMBG may enable patients to make self-care decisions as
directed by their provider. Monitoring devices vary in features, readability, portability, and cost. The choice of
meter is based on personal preference, cost, features, and ease of use, as well as by the core formulary in the
patient’s institution.
The test schedule is based on treatment and blood glucose goals. Readings outside the blood glucose goals and
illness are indications for more frequent testing. Scheduled (i.e. before breakfast, post prandial, bedtime) SMBG
may be beneficial if followed by feedback. This means that the healthcare team should obtain the results, provide
feedback to the patient, and document the interaction in the record. Documenting and discussing the readings results
with the patients will help patients maximize the use of their meters and foster optimal health status.
SMBG is indicated for persons on insulin. Although the evidence does not support the routine use of SMBG for
patients not on insulin, SMBG might be beneficial for individual patients meeting the above criteria.
The Working Group recommends a risk stratified approach to the use of SMBG to enable stable patients to
determine if they are hyperglycemic in the face of symptoms or intercurrent illness; evaluate symptoms of
hypoglycemia if on sulfonylurea therapy, and to manage active titration of medications.
RECOMMENDATIONS
1. HbA 1 c should be measured in patients with diabetes at least annually, and more frequently (up to 4 times
per year) if clinically indicated, to assess glycemic control over time.
2. Self Monitoring of Blood Glucose (SMBG) may be used to monitor glycemic control and adjust treatment
[B]
3. Patients, for whom SMBG is appropriate, should receive instruction on the proper procedure, the
importance of documenting results, and basic interpretation and application of results to maximize
glycemic control.
4. SMBG results should be discussed with the patient to promote understanding, adjust treatment regimens,
and facilitate treatment adherence. [B]
5. Remote electronic transmission of SMBG data should be considered as a tool to assess glycemic patterns.
[C]
6. The frequency of SMBG in patients using insulin should be individualized based on the frequency of
insulin injections, hypoglycemic reactions, level of glycemic control, and patient/provider use of the data to
adjust therapy. [C]
Module G: Glycemic Control Page 42