Building Competency in Diabetes Education THE ESSENTIALS

BASAL-BOLUS INSULIN THERAPY | 12-6

GOALS AND DESIRED OUTCOMES OF INTENSIVE INSULIN THERAPY

For non-pregnant adult patients with type 1 or type 2 diabetes, “optimal glycemic control” has four indicators or goals:

1. BG levels approaching normal as safely possible. • Usually 4 to 7 mmol/L preprandially without severe fluctuations during the day. o It is generally accepted now that glucose variability(GV) should augment glycated hemoglobin (A1C) as a measure of glycemic control (3). However, it remains unknown and controversial if large fluctuations in glucose, from high to low, contribute directly to chronic complications. Clinically, we can see how severe fluctuations can negatively impact a person’s quality of life and present as a risk factor for hypoglycemia(4). o Monnier and Collette describe the possible link between hyperglycemia and oxidative stress and complications. They used continuous glucose monitoring systems (rtCGM) to determine the mean amplitude of glycemic excursions (MAGE) and suggested a value of 2.2 mmol/L (40 mg/dL) as the target variability level (5). Clinically, a deviation of 3 mmol/L is considered acceptable. o One study found time-dependent variation of FBG a strong predictor of all-cause and cardiovascular (CV) mortality in people with type 2 diabetes (6). o On the other hand, an analysis of Diabetes Control and Complications Trial (DCCT) data concluded that this was not supported, that pre-and post BG were equally predictive of microvascular complications (7). • Aim for an A1C of <7% for most people with type 1 or type 2 diabetes to reduce the risk of microvascular complications and, if achieved early in the course of the disease, CV complications. o Aim for FBG or preprandial BG: 4.0-7.0 mmol/L, and o 2-hour post prandial BG: 5.0-10.0 mmol/L • IF A1C of <7% is not achieved with the above targets and the risk of hypoglycemia is considered, lower the targets: o FBG 4.0-5.5 mmol/L, and

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