Chapter 8: Glycemic control targets and glucose monitoring
Moderator(s): Forum Admin, David Maahs
Page 1 of 1
Thread Actions

4/3/2018 at 8:24:00 AM GMT
Posts: 39
Chapter 8: Glycemic control targets and glucose monitoring

Dear ISPAD member/friend,

Thank you for your continued interest in the 2018 ISPAD Clinical Practice Consensus Guidelines and in the previous drafts chapters we shared with you.

We are happy to announce that chapter 8 on Glycemic control targets and glucose monitoring for children and adolescents with type 1 diabetes is now ready for you to read and comment on. We are looking forward to hearing your thoughts and input on this chapter.

Kind regards,

David Maahs

ISPAD Secretary-General



Last edited Wednesday, May 30, 2018
4/16/2018 at 10:31:29 PM GMT
Posts: 9

The authors have thoroughly revised and updated this chapter taking into account the impact of diabetes technology on current management and safely attainable glycemic control. While acknowledging the NICE guidelines and proposed Swedish guidelines, they have chosen <7% to be the new ISPAD HbA1c target.

Both in the summary and at the conclusion of the chapter, they have stated that targets should be individually determined with the goal of achieving a value as close to normal as possible while avoiding severe hypoglycemia as well as frequent mild and moderate hypoglycemia and optimizing quality of life. I personally endorse this recommendation. HbA1c is a "barometer" of psychosocial functioning, and for many children and adolescents, the crucially important family support and socioeconomic resources necessary to ensure good outcomes are not available. For such patients, every encounter in the Diabetes Clinic can feel like a failure because the HbA1c is ALWAYS above the specified target value. We must never forget that we are taking care of children with an incurable disease and, despite its great importance in long-term health outcomes, we must continue take care of the "whole child".

I have several additional minor comments that warrant attention.

  P.2 In the Executive Summary and Recommendations: the precise meaning is unclear of the statement:  “These assessments also enable evaluating: 

·     Each individual’s glycemic determinants

·     Health care center care

·     Compliance with stated standards …”

The authors should be more explicit.

 

Page 3 articulate symptoms of hypoglycemia or hyperglycemia 

 

Reference #30 specifically refers to higher A1c in African Americans. Add references to show variation in HbA1c values despite similar BG values in other populations?

 

Page 6 operating hazardous machinery

 

P. 8 “… although some CGM values must still be confirmed by fingerstick glucose measurement (57). Explain when this is necessary.

 

P.10 It is my understanding that the flash CGM device is placed on the back of the upper arm (not forearm)?

 

P.11 references 82,83 are out of place

 

P.13 #94 is not the correct citation for this statement; ditto #96

 

P. 14 insulin delivery devices (not decides)



4/25/2018 at 2:09:52 PM GMT
Posts: 5
I thank all authors for another very well reviewed chapter.
I appreciate an individual HbA1c goal. Hba1C of below 7% will be reached in even less percentage of our actually treated Patient cohort even in well organised and well equipped countries.
We should keep in mind that a reduction of the HbA1c Goal will not per se reduce the HbA1c in each Patient. On the other Hand such a Guideline Change could get us forced by insurance companies to be more strict to assure this goal. This could be either beneficial or could have the adverse effect that patients could be swamped. This aspects should be mentioned in the discussion in my view

BW Thomas Kapellen


4/26/2018 at 8:19:37 AM GMT
Posts: 5
This is a very thoughtful chapter by the ISPAD Guidelines Editors and others.

My concern is that it is perhaps too thoughtful and descriptive. Its aim is to safeguard individuals who cannot accept or access the latest in diabetes technology.

The Chapter would be enhanced by a Table of Glycaemic Targets to achieve a target HbA1c of 7%. The targets are presented in descriptive manner in sections for ADA Guidelines and for NICE Guidelines. We need ISPAD Guidelines.

Metrics for glycaemic variability as a target when using CGM should be more clearly explained i.e. SD and CV, especially as coefficient of variation is a Recommendation of the International Consensus on Use of CGM with the concepts stable and unstable which could be included in the Table.


4/29/2018 at 5:59:07 PM GMT
Posts: 7

Thank you for this new and thoroughly revised document, which reads very well.

I agree with differentiated targets for HbA1c, but would suggest the following, referring to the World Bank as we do in other situations, for example membership fees:

≤ 6.5% (48 mmol/mol): All high-income countries with access to pumps and sensors

≤ 7.0% (52 mmol/mol): Middle-high income countries where MDI with analogs is available

≤ 7.5% (58 mmol/mol): Low or middle-low countries with access only to limited BG monitoring and human insulin

Patients with hypoglycemia unawareness need higher glucose levels just for a short time (14 days) to restore a higher awareness threshold level, not higher HbA1c targets (Fanelli CG, Diabetes 1993;42:1683-89.).

We must respect that all children have the right to the same effectiveness of treatment to ensure lowest possible risk of both long-term complications and early cognitive development. The barrier in treatment and target setting should be the economy in the place where the child lives, not the performance and willingness of caregivers in optimizing the therapy below a certain HbA1c threshold, provided this can be done without an increase in moderate or severe hypoglycemia. Many studies have shown that this is possible. The huge difference in mean HbA1c over all age groups in 8 high-income countries [varying between 7.6% (59 mmol/mol) in Sweden and 8.8% (72 mmol/mol) in Wales in 2013 (Charalampopoulos D. Diabetes Care 2018;online)] shows clearly that well funded health care systems can perform and provide quite differently. The percentage below the current ISPAD target 7.5% was 49% in Sweden and 17% in Wales. This is concerning, but the study should also be viewed from the optimistic side, ie showing what is achievable. Important processes for improvement in pediatric diabetes care are ongoing in many countries, and where not, health politics unfortunately has not steered this way.

I am missing a recommendation to keep track of mean glucose levels over 7, 14 and 30 days as this will give the family a good picture of the level of glycemic control at home, and prompt for adjustments when increasing levels are found. Although there is a wide variation in the individual relationship between glucose levels and HbA1c, the individual family can easily keep track of changes. Downloading data from meters and CGM devices should be recommended at home and office visits. Mean glucose level and SD over 14 days should be recorded at visits as well as % below 4.0 mmol/l (70 mg/dl) and time in target. Defining the target for families is important. Many studies use 3.9-10 mmol/l (70-200 mg/dl), while we in Sweden use 4-8 mmol/l (70-145 mg/dl). The discussion on low and high glycators is interesting, but only mentioned in the recommendations. I am missing the scientific background. So far there seems not to be sufficient evidence to conclude that high glycators can be given higher HbA1c targets.

You refer only to a very brief summary of the 2015 NICE guidelines where a target HbA1c of 48 mmol/l (6.5%) is recommended. The most important sentence in the NICE 2015 guidelines is in my opinion (page 20):

“Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that an HbA1c target level of 48 mmol/mol (6.5%) or lower is ideal to minimize the risk of long-term complications.”

This is a fact, not a target. After changing the target from 7.0% to 6.5% in Sweden, I have communicated this to every family in my practice. Not one family has objected; on the contrary they have appreciated an honest and straight forward message. From there on we have discussed individual targets and personal limitations.

If you add risk of chronic complications to the emerging evidence of the detrimental effect of chronic hyperglycemia on the developing brain (Mauras N. Diabetes 2015;64:1770-9.), there can be no question on the crucial effect of the level of metabolic control in young children. Chronic hyperglycemia and glucose fluctuations during the years of brain development have been shown to affect growth of hippocampus negatively, questioning the current practice of tolerating some hyperglycemia to minimize the risk of hypoglycemia in young children with T1D (Foland-Ross LC. Pediatr Diabetes 2018;online). Chronic hyperglycemia early in life will affect the brain’s structure and development negatively (white matter dysfunction due to demyelination). (Aye T, Diabetes Care 2012;35:2167-73). This can result in the brain being more vulnerable to any subsequent insult (hypoglycaemia, head injury, alcoholism, other central nervous system conditions) that occurs later in the child’s life (Ryan, C. Pediatr Diabetes 2006;7:289-97).

We had a well-attended pro- and con discussion at the ISPAD meeting in Innsbruck, and arguments for a lower HbA1c target than the current 7.5% are now included in the chapter. The lower targets of 6.5% in UK and Sweden are mentioned. However, I am surprised at finding the sentence “these guidelines admit that there is “no evidence” for this decrease”. The mentioned reference is to NICE, but just a mini-summary where evidence levels are not within the scope of the contents. The full NICE 2015 Guidelines provide both interesting reading and reference to evidence:

Page 173 in the pediatric guidelines (Children full-guideline-435396349.pdf):

“An HbA1c threshold of 6.5% (DCCT units) was developed jointly with the developers of the guidance for type 1 diabetes in adults because although older studies indicated an association between lower HbA1c values and an increased risk of severe hypoglycaemia, this relationship is less clear with modern management strategies.”

Page 193 in the adult guidelines (Adults-full-guideline-435400241.pdf)

Overall, low quality evidence from 43 studies (mostly observational and mostly case-series but including 3 randomised controlled trials), showed that with lower HbA1c values the risk and incidence of clinical outcomes was significantly reduced. The main outcomes assessed by the evidence included mortality, CVD, CHD, stroke, retinopathy, low-level (micro) albuminuria, severe hypoglycaemia. Of these outcomes, all but hypoglycaemia rates were improved with lower HbA1c and/or intensive insulin therapy.

Page 199:

In selecting an HbA1c target for the management of individuals with type 1 diabetes, the GDG (Guideline Development Group) recognised that individuals should achieve a target that minimised the risk of developing complications from glycaemia. Retinopathy is often the first microvascular complication to develop from inadequate glycaemic control, and particular attention was paid to the risk of retinopathy at varying levels of glycaemia reported by the Diabetes Control and Complications Trial. The GDG selected an HbA1c target of 6.5 % on the grounds that a minimal risk of retinopathy was achieved at this level, with further improvements in HbA1c not achieving any further significant reduction in retinopathy risk.

…the (DCCT) target for the intensive therapy group was an HbA1c of 6.05%. This was achieved at least once during the study by 44% of participants using intensive therapy; but sustained there by only 5%. The mean HbA1c achieved over the trial by the intensive therapy group was just under 7%.

The GDG therefore selected a target HbA1c value that is lower than the achieved HbA1c of the DCCT, as the evidence supports as associated with meaningful reduction in risk of complications, recognising that achieving the value of 7%, as done in the DCCT, was more likely if the target was set lower than this.

Pediatric guidelines again:

page 174:

“The study demonstrated that those healthcare professionals who aim for tighter glycaemic control achieve tighter glycaemic control in the children and young people they care for “(Swift, P. Pediatr Diabetes 2010;11:271-8.) (also consistent with Hanberger L.Diabetes Res Clin Pract. 2012 Jun;96:331-8.).

Page 175

“Although the guideline development group agreed that the HbA1c target for children and young people with type 1 diabetes should be set at 48 mmol/mol (6.5%) they recognised that this might not be achieved in every case. In accordance with recommendations in the guideline on type 1 diabetes in adults, the group made an additional recommendation that diabetes services should document the proportion of children and young people with type 1 diabetes who achieve an HbA1c level of 53 mmol/mol (7%) or lower.”

“The recommended target HbA1c level of 48 mmol/mol (6.5%) represents a tightening of glycaemic control compared with the 2004 guideline (which recommended that children and young people with type 1 diabetes and their families should be informed that the target for long-term glycaemic control was an HbA1c level of less than 7.5% without frequent disabling hypoglycaemia and that their care package should be designed to attempt to achieve this). The guideline development group emphasised that the result of the change would be to reduce the risk of long-term complications of type 1 diabetes in a population that will have a long duration of diabetes because the condition starts before adulthood.”

I look forward to a continued discussion on this important topic, perhaps the most important message in the Guidelines, and would therefore ask that the time for comments is extended.



Contact Us

ISPAD Executive Office
c/o K.I.T. Group GmbH
Association & Conference Management
Kurfürstendamm 71
10709 Berlin, Germany










Join ISPAD

Click the link below to join the Society!


Join Today!










Phone: +49 (0)30 24603-210
Fax: +49 (0)30 24603-200
Email: secretariat@ispad.or
g










Privacy Policy
Terms of Service
Legal Notice    

Disclaimer



































 © 2019 International Society for Pediatric and Adolescent Diabetes (ISPAD)






Association Management Software Powered by YourMembership  ::  Legal
This website uses cookies to store information on your computer. Some of these cookies are used for visitor analysis, others are essential to making our site function properly and improve the user experience. By using this site, you consent to the placement of these cookies. Click Accept to consent and dismiss this message or Deny to leave this website. Read our Privacy Statement for more.