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Table of Contents
EDITORIAL
Year : 2015  |  Volume : 19  |  Issue : 2  |  Page : 193-195

Glycemic monitoring with once-weekly Glucagon-like peptide 1 receptor agonist (GLP1RA) use


1 Department of Endocrinology, Bharti Hospital and BRIDE, Karnal, India
2 Department of Endocrinology, St. John's Medical College, Bengaluru, Karnataka, India
3 Division of Endocrinology and Diabetes, Medanta The Medicity, Gurgaon, Haryana, India

Date of Web Publication14-Jan-2015

Correspondence Address:
Sanjay Kalra
Department of Endocrinology, Bharti Hospital and BRIDE, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2230-8210.149313

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How to cite this article:
Kalra S, Ganapathi M, Mithal A. Glycemic monitoring with once-weekly Glucagon-like peptide 1 receptor agonist (GLP1RA) use. Indian J Endocr Metab 2015;19:193-5

How to cite this URL:
Kalra S, Ganapathi M, Mithal A. Glycemic monitoring with once-weekly Glucagon-like peptide 1 receptor agonist (GLP1RA) use. Indian J Endocr Metab [serial online] 2015 [cited 2019 Oct 21];19:193-5. Available from: http://www.ijem.in/text.asp?2015/19/2/193/149313

Various recommendations are available on the self-monitoring of blood glucose (SMBG) in persons with diabetes. [1],[2],[3],[4] It is understood that individuals have different requirements for SMBG, based upon the nature of their therapy, the risk of hypoglycemia, the level of knowledge and skills to practice self-dose adjustment, and their willingness to monitor themselves. [1]

Self-monitoring of blood glucose allows persons to assess their glycemic status, adjust therapy on their own, and detect hypoglycemia in a timely manner. SMBG promotes better understanding of the condition and helps in modifying dietary and physical activity patterns, apart from informing changes in drug dosages. [2]

Self-monitoring of blood glucose is strongly recommended in persons on insulin therapy, irrespective of whether they have type 1 or type 2 diabetes. Such unequivocal suggestions do not exist for noninsulin treated type 2 diabetes, however. This is due to inconsistent results reported from randomized controlled trials and observational studies, the data of which have been reviewed exhaustively in earlier publications. [5] The International Diabetes Federation Working group have made a few "tentative conclusions," based on this analysis. The authors proposed that SMBG had the potential to improve glycemic control in noninsulin-treated type 2 diabetes, only if combined with self-adjustment on diet and lifestyle, based on the results. SMBG is not found to be a useful adjunct in stable patients or in persons undergoing rapid intensification of therapy. Other reviewers conclude that in noninsulin treated persons with a duration of diabetes >1 year, the effect of SMBG on glycemic control is of a limited magnitude and duration. [6]

Diabetes UK recommends SMBG for persons on sulfonylurea and prandial glucose regulators. The need for SMBG, its frequency, and the action to be taken must be clarified by shared decision-making involving both patient and health care provider. [2] Yet others (National Health Service Diabetes Working Group) feel that SMBG can motivate diabetes self-management, and reduce glycated hemoglobin (HbA1c) levels. [2] The American Diabetes Association cites low-level evidence to support the helpful nature of SMBG in guiding treatment decisions and/or patient self-management for persons on noninsulin therapies. [4]

Other accepted means of glycemic monitoring include laboratory based glucose monitoring (LBGM) and HbA1c. [4] HbA1c is recommended every 3 months in persons with uncontrolled type 2 diabetes, and in those who have recently changed therapy. The frequency may be reduced in persons enjoying adequate, stable, and control. LBGM is a frequently used method of assessment in many countries. The frequency of LBGM depends upon various factors including expected change in glucose values, risk of hypoglycemia and patients' convenience.


   Long-Acting Glucagon Like Peptide-1 Receptor Agonists Top


Long-acting glucagon-like peptide-1 receptor agonists (GLP1RA) such as exenatide once weekly (QW), dulaglutide, and albiglutide, have recently been approved for use in diabetes. These drugs are used in a QW dose, with virtually no requirement for dose titration. [7]

The development and use of these molecules poses various questions related to the necessity of SMBG in persons on these drugs. No recommendation or consensus has been published so far on this aspect of diabetes care. An analysis of the pharmacokinetic and pharmacodynamic properties of the long-acting GLP1RA helps in approaching this clinical challenge.

All long-acting GLP1RA have a half-life of 4-5 days, are prescribed QW, and can be injected up to 4 days after a missed dose. They provide significant glucose lowering throughout the day and can reduce both fasting and postprandial glycemic levels. They are associated with a very low risk of hypoglycemia and a good tolerability profile. [7]


   Suggestions for Glycemic Monitoring with Once-weekly Glucagon Like Peptide-1 Receptor Agonists Top


With this in mind, we suggest the following:

Approach to self-monitoring of blood glucose

  • As in all persons with diabetes, discussion related to the need for, frequency of, and implications of, SMBG should be made in a person-centered manner, with individualized decisions based upon the biopsychosocial model
  • Recommendations related to SMBG in persons on QW GLP1RA should consider biomedical factors such as
    • Glucagon like peptide-1 receptor agonist naivety or otherwise
    • Expected changes in glycemia
    • Expected variability of glycemic control
    • Concomitant therapy.
      • Sulfonylurea
      • Insulin.
  • Recommendations related to SMBG in persons on QW GLP1RA should consider psychosocial factors such as Willingness and ability to self-adjust dietary intake Willingness and ability to self-adjust physical activity patterns Patient's perception of benefits of SMBG.


Frequency of self-monitoring of blood glucose

  • Glucagon like peptide-1 receptor agonist naοve persons may benefit from frequent SMBG for the first 2-4 weeks of therapy, to assess level and consistency of glycemic control
  • Persons with relatively high glycemic levels, and/or in whom sudden correction of hyperglycemia is expected, and/or in whom a high degree of glycemic variability is expected, may benefit from regular SMBG
  • Persons with relatively lower, stable levels of glycemia may not require regular SMBG. Laboratory testing at regular intervals may suffice [8]
  • Persons on QW GLP1RA and concomitant sulfonylurea/insulin therapy should perform intermittent SMBG, to assess glucose control throughout the day, and detect asymptomatic episodes of hypoglycemia
  • The frequency of SMBG that is suggested for patients on multiple dose insulin or insulin pump therapy is not necessary for those on QW GLP1RA (SMBG prior to meals and snacks, occasionally postprandial, at bedtime, prior to exercise, on suspicion of low blood glucose, after treatment of low blood glucose until normoglycemia is achieved, and prior to critical tasks such as driving)
  • Persons on QW GLP1RA, without ulfonylurea/insulin
  • therapy, may not necessarily require SMBG. Intermittent laboratory testing of glucose values may suffice.


Other means of glycemic monitoring

  • LBGM may suffice for the vast majority of persons on GLP1RA, provided they are not on concomitant insulin therapy
  • Continuous glucose monitoring is not required with QW GLP1RA therapy, except as a research tool
  • Glycated hemoglobin should be performed every 3 months in patients who have recently begun GLP1RA or who are not at target
  • Glycated hemoglobin estimation frequency may be reduced to 2-3 times/year in persons in good control.



   Conclusion Top


These recommendations, though empirical or experience-based, provide a framework upon which to practice rational diabetes care using QW GLP1RA. They reinforce the potential to use these drugs in clinical settings where access to regular SMBG or HbA1c testing in limited. These recommendations should help create a holistic perspective of the cost-benefit ratio, which requires relatively less resources and manpower, both for administration and for followup.

 
   References Top

1.
Self-monitoring of Blood Glucose in Non-insulin Treated Type 2 Diabetes. Available from: http://www.idf.org/webdata/docs/SMBG_EN2.pdf. [Last accessed on 2014 Nov 16].  Back to cited text no. 1
    
2.
Position Statement- Diabetes UK. Available from: http://www.diabetes.org.uk/Documents/Position%20statements/Diabetes-UK-position-statement-SMBG-Type 2-0413.pdf. [Last accessed on 2014 Nov 16].  Back to cited text no. 2
    
3.
Klonoff DC, Blonde L, Cembrowski G, Chacra AR, Charpentier G, Colagiuri S, et al. Consensus report: The current role of self-monitoring of blood glucose in non-insulin-treated type 2 diabetes. J Diabetes Sci Technol 2011;5:1529-48.  Back to cited text no. 3
    
4.
American Diabetes Association. Standards of medical care in diabetes-2014. Diabetes Care 2014;37 Suppl 1:S14-80.  Back to cited text no. 4
    
5.
Self-monitoring of blood glucose in type 2 diabetes: Systematic review. Available from: http://www.journalslibrary.nihr.ac.uk/__data/assets/pdf_file/0017/65303/FullReport-hta14120.pdf. [Last accessed on 2014 Nov 16].  Back to cited text no. 5
    
6.
Malanda UL, Welschen LM, Riphagen II, Dekker JM, Nijpels G, Bot SD. Self-monitoring of blood glucose in patients with type 2 diabetes mellitus who are not using insulin. Cochrane Database Syst Rev 2012;1:CD005060.  Back to cited text no. 6
    
7.
Kalra S. Choosing appropriate glucagon-like peptide 1 receptor agonists: A patient-centered approach. Diabetes Ther 2014;5:333-40.  Back to cited text no. 7
    
8.
Sacks DB, Arnold M, Bakris GL, Bruns DE, Horvath AR, Kirkman MS, et al. Executive summary: Guidelines and recommendations for laboratory analysis in the diagnosis and management of diabetes mellitus. Clin Chem 2011;57:793-8.  Back to cited text no. 8
    




 

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