Improved Metabolic Control in Diabetic Patients using the CGMS Park Jeong Eun Cheil General Hospital & Women s Health care Center
내용 1. 정의와사용이유 2. 종류와특징 3. 사용방법과주의사항 4. 관련연구 5. 핵심메시지
CGMS
환자의질문은계속된다 인슐린은늘렸는데왜혈당은떨어지지않을까요? 환자의불안과잘못된선택에명확한증거를제시하고싶다 보통은저혈당이일어나서잠에서깨었는데오늘은아무느낌이없 었어요저혈당을못느껴잠에서못깨어나면어쩌죠? CGM 선택 환자에대한정보증가 적극적관리 혈당향상 Improved knowledge and improved glucose control 운동을 1 시간 30 분했는데혈당이더올라갔어요. 왜그렇죠? 식혜를하루한번먹어도식후 2시간혈당이정상이예요. 자주먹어도되겠어요
Continuous Glucose Monitoring System 10 sec. 5 min. 288/day 3~6 days
RESEARCH PATIENT For Safety in Life - 야간저혈당 - 저혈당무감지증 - 식후심한고혈당 - 혈당의변화가심할때 - 임신부 - 제 1 형당뇨병소아 SMBG CGMS
CGMS RECOMMENDATIONS ADA 2013 Continuous glucose monitoring (CGM) in conjunction with intensive insulin regimens can be a useful tool to lower A1c in selected adults (aged 25 years) with type 1 diabetes. ( A ). AACE Although 2010 the evidence for A1c lowering is less strong in children, teens, and Personal younger devices adults, can CGM be used may for be glucose helpful in control these and groups. prevention Success of correlates hypoglycemia with in adherence patients with to ongoing type 1 diabetes use of the and device.(c) pregnancy with diabetes. CGM may be a supplemental tool to SMBG in those with hypoglycemia unawareness and/or frequent hypoglycemic episodes(e ) KDA 2013 혈당의변동폭이크거나저혈당이빈번한경우에혈당조절을감시하는방법으로지속적혈당측정기기를사용할수도있다. [E]
CGMS is Accurate? Accuracy and lag time errors due to interstitial fluid delays Timing of calibration 안정된혈당시기의값 ( 식전, 자기전 ) No multiple meters 한가지종류의혈당기사용 Human error 혈당측정후 5분이내입력 Meter accuracy (expired strips, compromised strips, etc.) 혈당기점검 Storage of sensor 10~15% 오차범위센서삽입부위 Physiologic lag : 5 to 10 minutes, Especially undergoing rapid change Calibration of sensor (SMBG and enter glycemic values into the CGMS monitor ) is essential when blood glucose levels are stable. Continuous Glucose Monitoring, Endocr Pract. 2010;16(No. 5)
Professional CGM Gold = Retrospective CGM 병원소유 Masking 된 CGM 데이터가다운로드될때까지 의료진도환자도모른다 Bias 없이환자상태평가 No alerts 교육시간이짧고환자도배우기쉬움 과정처방- 동의 ( 가격등 )-미리목욕- 자가혈당측정과입력방법-CAL Error시혈당측정 식사, 운동, 인슐린주사시간기록 Cable 주의, 최소한의핸들링 ( 자가조작금지 ) (hyperglycemia or hypoglycemia) 단종, 차후 Medtronic ipro 1999 FDA, USA -> 2002, 국내승인
Personal CGM Guardian Real Time 환자나병원소유 계속적으로혈당치가보여짐으로써즉각적인치료적조정이실시간으로가능 혈당조절에대한열의저혈당없이혈당을철저하게잘조절하려는환자 HbA1c가 7% 이내의동기부여가매우잘되는제1형당뇨병을가진초등학생이나청소년영문으로나타나는여러가지표시들을해독하고적절한대처를할수있고 Alarm이울리는것도바로알아차려야하기때문에시각, 청각에장애가없는환자 Continuous Glucose Monitoring, Endocr Pract. 2010;16(No. 5) 731
인슐린펌프 + CGM MiniMed Paradigm Real-Time MiniLink transmitter and sensor Insulin Pump + Guardian Real Time
Abbott Freestyle Navigator 종류 Personal CGM DexCome Seven Plus ensor and transmitter, Medtronic Guardian REAL-Time i52 k transmitter and MiniMed MiniMed Paradigm REAL-Time Revel System S dii6 Continuous Glucose Monitoring, Endocr Pract. 2010;16(No. 5)
Personal CGM Medtronic Guardian Real-Time MiniMed Paradigm Real-Time Freestyle Navigator Dexcom Seven STS 혈당측정범위 (mg/dl) 40-400 40-400 20-500 40-400 혈당이보여지는간격 ( 분 ) 5분단위 5분단위 1분단위 5분단위 센서수명 3(6) 일 3(6) 일 5일 7일 초기보정소요시간 2시간 2시간 10시간 2시간 보정횟수 Calibration 혈당추세화살표 Arrows SMBG 고혈당 / 저혈당알람 Alarm, Alert SMBG 예상고혈당 / 저혈당알람 Predictive SMBG 하루 2회 하루 2회 5일에 4회 하루 2회 있음 있음 있음 없음 있음 있음 있음 있음 있음 없음 있음 없음 인슐린펌프와의연동없음있음없음없음 Advanced Module, 지속혈당감시, 당뇨병학회
실제사용방법
실제사용방법
사용시주의점 Not Water Proof X-rays, MRIs and CT scans If you are going to have an X-ray, CT scan, MRI or other type of exposure to radiation, take off your insulin pump, BG meter, MiniLink transmitter and glucose sensor and remove them from the area. keeping the cell phone at least 12 inches (31 cm) away from the receiving device, transmitter Air Travel The Federal Aviation Administration (FAA) requires that devices with radio frequency capabilities should not be used on an aircraft.
EVIDENCE SUPPORTING THE USE OF CGM
T1DM STAR-1 Study (Adolescent & Adult) The Sensor-Augmented Pump Therapy for HbA1c Reduction (STAR-1) study 인슐린펌프 + SMBG only vs. 인슐린펌프 + SMBG + personal CGM. Primary end point: HbA 1c change Evaluated hyperglycemia and/or hypoglycemia incidence 98 adults and 40 adolescents (12 to 72 years of age) 6-Month HbA1c ( baseline HbA1c 8.44%) CGM + SMBG-treated patients: 7.77% SMBG patients: 7.84% HbA1c levels were similarly reduced in both groups. CGM device the least often and had the highest HbA1c levels.
1-2. JDRF(Adolescent & Adult) The Juvenile Diabetes Research Foundation (JDRF) Sensor Study Primary end point: HbA 1c change from baseline Hypoglycemia incidence Evaluated patients 15 to 24 and 25 years of age (adult groups)
Age Effect 심각한저혈당 (-) 센서사용빈도와 A1c 반비례
대상 8~14 세 (YOUTH) 연장 성인보다센서의사용빈도는적지만자주센서를사용한군에서저혈당의증가없이혈당이향상되고 12 개월까지유지
대상임신부 (Pregnancy) 390 min/24 h 192 min/24 h
T2DM RT-CGM 그룹에서하루총칼로리섭취량, 체중감소양이유의하게감소되었다. RT-CGM 그룹에서일주일단위의운동시간이유의하게증가되었다. Yoo et al. Diabetes Research and Clinical Practice. 2008. 82: 73-79
환자의가디언사용후기 지속혈당측정기기 (CGM) 를처음사용하면서얻은지속적혈당정보에굉장히놀랐다. 예전엔불가능했던음식, 운동그리고잠자는등의행동이아침저녁으로내혈당수치에어떤영향을주는지바로알수있었기때문이다. 지속혈당측정기기는중요한혈당정보를나에게제공함으로써내가당뇨를제대로관리할수있도록해준다. 때때로내스스로감지하기어려운위험한최저혈당수치를피할수있도록경보음으로알려준다. 이기기를사용하면서나는편한마음으로저혈당의두려움없이자신감있게혈당을관리한다.
미래에는 미래형 ( 통합형 ) 인슐린펌프 + CGMS+ SMBG=? 인슐린펜 +CGMS=? 인공췌장기?
제언 정확도와생리적지연에대한기술향상 연구 - Hospital 내에서의 CGM 연구 - 가장 target 되는환자군선정연구 - Health Outcome에대한장기간 (3~5년) 연구 - 보험적용의강력한 Evidence가되는연구
핵심메시지 지속혈당감시기기는혈당의즉각적인수치보다수일간의혈당패턴을알려준다. 지속혈당감시는특히제 1형당뇨병환자에게저혈당의증가없이효과적으로 HbA1c를감소시킨다 지속혈당감시는당뇨병임신부와제2형당뇨병환자의혈당조절에효과적이다. 지속혈당감시와인슐린펜의통합된모델이나미래의인공췌장기에대한기초단계로활용될수있다.
광주, 우리밀빵 195