Marta AlvesMarta Alves, Celestino Neves, Ana Varela, Cristina Arteiro, Luís Miguel Pereira, Davide Carvalho, , Celestino Neves, Ana Varela, Cristina Arteiro, Luís Miguel Pereira, Davide Carvalho, José Luís Medina.José Luís Medina.

Endocrinology Service, S. João Hospital, Faculty of Medicine, University of Porto, Endocrinology Service, S. João Hospital, Faculty of Medicine, University of Porto,

PortugalPortugal

2008

TRANSIENT INTERSTITIAL GLUCOSE MONITORING IMPROVES

GLYCAEMIC CONTROL11th Meeting of the Mediterranean Group for the Study

of DiabetesMalta, April 23–26, 2009

BackgroundBackground

Self-monitoring with a blood glucose meter is useful but limited:Self-monitoring with a blood glucose meter is useful but limited: Patient adherence/nocturnal glycaemia/post-prandial periodPatient adherence/nocturnal glycaemia/post-prandial period Isolated glycaemic valuesIsolated glycaemic values Does not access asymptomatic hypoglycaemiasDoes not access asymptomatic hypoglycaemias

HbA1c interpretation:HbA1c interpretation: Limited in some situations (ex: anaemia, haemolysis, haemoglobin variants, Limited in some situations (ex: anaemia, haemolysis, haemoglobin variants,

liver disease)liver disease) Reflexes the mean blood glucose levelsReflexes the mean blood glucose levels

Do not able us to correctly interpret the real metabolic controlDo not able us to correctly interpret the real metabolic control

We need a method that enables us to read the “whole story”We need a method that enables us to read the “whole story”

BackgroundBackground

The continuous glucose monitoring system The continuous glucose monitoring system (CGMS), detects fluctuations of glucose levels, (CGMS), detects fluctuations of glucose levels, informing about informing about direction, magnitude, duration, direction, magnitude, duration, frequency and its causes,frequency and its causes, allowing a more allowing a more realistic perception of glycaemic control.realistic perception of glycaemic control.

Continuous intersticial glucose Continuous intersticial glucose monitoringmonitoring

Glucoday® (A. Menarini Diagnostics) is na Glucoday® (A. Menarini Diagnostics) is na intersticial glucose monitoring device which intersticial glucose monitoring device which allows the knowledgment of continuous allows the knowledgment of continuous intersticial glucose concentrations in the intersticial glucose concentrations in the subcutaneous tissue.subcutaneous tissue.

It uses microdyalisis technique to access It uses microdyalisis technique to access intersticial glucose concentration.intersticial glucose concentration.

Reading of results:Reading of results: each second each second (record (record of the mean value each 3 minutes)of the mean value each 3 minutes)

Reading limits: 10-600 mg/dLReading limits: 10-600 mg/dL

Para PC

Microfibra

Pele

Sistema GlucoDay

Tubos de Nylon

RS-232 Porta IVPorta Serie

Desperdicio SoluçãoTampão

CPU

Microdiálise

Ecran

Bomba

Biosensor

GlucoDay

Continuous intersticial glucose Continuous intersticial glucose monitorizationmonitorization

This system was This system was validated in several validated in several studies. It was studies. It was shown a good shown a good correlation between correlation between intersticial and blood intersticial and blood glucose levelsglucose levels..

Boland EA, et al. Boland EA, et al. Diabetes CareDiabetes Care 24:1858–1862, 24:1858–1862, 2001.2001.

5 - Gross TM, et al. 5 - Gross TM, et al. Diabetes Technol TherDiabetes Technol Ther 2:49 2:49 – 56, 2000.– 56, 2000.

Chee W, et al. Chee W, et al. Endocrinol Metab Clin N Am Endocrinol Metab Clin N Am 33:175-195, 2004. 33:175-195, 2004.

Jeha GS, et al. Jeha GS, et al. Diabetes CareDiabetes Care 27:2881-2886, 27:2881-2886, 2004.2004.

ObjectivesObjectives

To evaluate To evaluate GlucoDayGlucoDay potentialities in clinical potentialities in clinical practice.practice.

To access monitoring parameters of glycaemic To access monitoring parameters of glycaemic control.control.

To compare A1c values before and after To compare A1c values before and after knowledgement of the results and consequent knowledgement of the results and consequent institution of adjusted therapeutical measures. institution of adjusted therapeutical measures.

PatientsPatients andand methodsmethods

The continuous glucose The continuous glucose monitoring with the monitoring with the GlucoDay® system, of GlucoDay® system, of the A. Menarini the A. Menarini Diagnostics was Diagnostics was performed in 53 type 1 performed in 53 type 1 diabetic patients with:diabetic patients with:

Bad glucose controlBad glucose control Nocturnal/asymptomatic Nocturnal/asymptomatic

hypoglycaemiashypoglycaemias

Age (years) Age (years) (mean±SD)(mean±SD)

37,7±12,337,7±12,3

Men (n/%)Men (n/%) 19 (35,8)19 (35,8)

Women (n/%)Women (n/%) 34 (64,2)34 (64,2)

Diabetes duration Diabetes duration (years) (mean±SD)(years) (mean±SD)

15,5±9,515,5±9,5

HbA1c % (mean±SD)HbA1c % (mean±SD) 8,6±1,9 (5-8,6±1,9 (5-12,9)12,9)

Patients and methodsPatients and methods

We evaluated: We evaluated: the number of episodes of hypoglycaemia <60 the number of episodes of hypoglycaemia <60

mg/dl (3.3 mmol/L) mg/dl (3.3 mmol/L) The number of episodes of hyperglycaemia The number of episodes of hyperglycaemia

(values above 200 mg/dl (11.1mmol/L))(values above 200 mg/dl (11.1mmol/L)) the percentage of time in hypoglycaemia the percentage of time in hypoglycaemia the percentage of time in hyperglycaemia the percentage of time in hyperglycaemia

• during the period of monitorization (~ 48 hours)during the period of monitorization (~ 48 hours)

ResultsResults

0

2

4

6

8

10

12

14

16

Episódios dehipoglicemia

Episódios dehiperglicemia

Hypoglycaemic episodes: 8,5 9,5

Hyperglycaemic episodes: 14,6 10,3

0

5

10

15

20

25

30

35

% tempo emhipoglicemia

% tempo emhiperglicemia

% of time in hypoglycaemia: 11,3 15

% of time in hyperglycaemia: 35 23,1

n %

0

50

100

150

200

250

300

350

12

.56

14

.01

15

.06

16

.11

17

.15

18

.20

19

.25

20

.30

21

.34

22

.39

23

.44

0.4

9

1.5

4

2.5

8

4.0

3

5.0

8

6.1

3

7.1

7

8.2

2

9.2

7

10

.32

11

.36

12

.41

Tempo (h)

Glu

co

se

(m

g/d

l)

Regular 8U

Regular 6U

NPH 12U

Regular 8U

Nocturnal hypoglycaemiasNocturnal hypoglycaemiasL.M.C., 35 Anos, DM1HbA1c=7,4%, Duração 25 Anos

Nocturnal hyperglycaemiasNocturnal hyperglycaemias

Bad glycaemic controlBad glycaemic control

Persistent hyperglycaemiasPersistent hyperglycaemias

MONITORIZAÇÃO CONTÍNUA DA GLUCOSE48 HORAS

0

100

200

300

400

500

600

700

800

Horas

Valo

res d

e G

luco

se m

g/d

l

Glucose Amostra Capilar

R.C.P.T., 74 Anos, DM1, Duração 40 Anos, HbA1c 12,4%

AssymptomaticAssymptomatic hypoglycaemiashypoglycaemias

MONITORIZAÇÃO CONTÍNUA DA GLUCOSE48 HORAS

0

50

100

150

200

250

300

350

400

Horas

Val

ore

s d

e G

luco

se m

g/d

l

Glucose Amostra Capilar

P.M.P.L.M., 48 AnosDM1, Duração 20 AnosHbA1c 12,9%

Average A1c before and 4 to 10 Average A1c before and 4 to 10 months after monitorizationmonths after monitorization

Before: Before: A1c 8,6A1c 8,6±±1,9%1,9%

After:After: A1c 7,6A1c 7,6±±1,2%1,2%

7,2

7,4

7,6

7,8

8

8,2

8,4

HbA1c prévia HbA1c após monitorização

8,6%

7,6%

ConclusionsConclusions Glycaemic profile obtained with CGMS gives us much Glycaemic profile obtained with CGMS gives us much

more information than conventional methods of blood more information than conventional methods of blood glucose control assessment. glucose control assessment.

With continuous intersticial glucose monitoring we can With continuous intersticial glucose monitoring we can know the patient glycaemic profile which allows:know the patient glycaemic profile which allows: better therapeutical approachesbetter therapeutical approaches,,

• improvement of metabolic controlimprovement of metabolic control essential for reduction of acute and chronic complications of essential for reduction of acute and chronic complications of

diabetes.diabetes.

We believe that TRANSIENT INTERSTITIAL GLUCOSE MONITORING IMPROVES GLYCAEMIC CONTROL