False elevations in blood glucose readings with use of icodextrin (extraneal) peritoneal dialysis solution.
Mr. BP is a 67-year-old male who started peritoneal dialysis (PD) three weeks ago and is coming into the PD clinic to see the multi-disciplinary team.
His past medical history includes: Type 2 diabetes mellitus for the past eight years, a myocardial infarction three years ago and benign prostatic hypertrophy.
His current insulin regimen is:
* Insulin glargine (Lantus) 20 units at bedtime
* Insulin lispro (Humalog) 6 units with meals
His CCPD prescription is:
* Total volume: 11,000 mL * Total time: 9 hrs
* Fill volume: 1,900 mL
* Last fill: 1000 mL icodextrin
Mr. BP presents at the clinic complaining that his blood sugar levels have been higher than normal since he started peritoneal dialysis. His current A1C is 6.8%. His blood glucose meter readings have been between 10 mmol/L and 15 mmol/L and he has been increasing his dose of fast-acting insulin to accommodate for this, which has resulted in one or two hypoglycemic episodes. He is wondering if he should increase his long-acting insulin instead and questions if the dialysis sugar solutions are the cause of his poor diabetes control.
Icodextrin is a starch-derived polymer indicated for a single daily peritoneal dialysis exchange. It is typically used in the long (8to 16-hour) dwell during continuous ambulatory peritoneal dialysis (CAPD) or automated peritoneal dialysis (APD) (Baxter, n.d.). Since this solution is commonly used, nephrology health care practitioners and patients must be aware of its potential drug-lab interaction with blood glucose meters. Icodextrin PD solutions can falsely elevate blood glucose levels and lead to erroneous administration of insulin, which may result in hypoglycaemia complications (Health Canada, 2008). As a result, warnings have been issued by Health Canada and the manufacturer of blood glucose meters and icodextrin PD solutions.
The drug-lab interaction with blood glucose meters occurs as a result of the absorption and subsequent metabolism of icodextrin. Approximately 40% of icodextrin is absorbed during a 12-hour dwell via the lymphatic system and then moves into the blood stream (Baxter, n.d.). Within the blood circulation, amylases break down the icodextrin into oligosaccharides including maltose (Riley, Chess, Donovan, & Williams, 2003). The maltose by-product can contribute to the blood glucose measurements of non-glucose-specific blood glucose meters resulting in falsely elevated blood glucose measurements (Schleis, 2007). Glucose meters that use strips containing glucose dehydrogenase pyrroloquinolinequinone (GDH-PQQ) or glucose dye oxidoreductase as the enzymatic assay are susceptible to this interaction (Health Canada, 2008). On average, the use of icodextrin can increase blood glucose readings by approximately 3.6 [+ or -] 1.4 mmol/L in these blood glucose meters, but the reading may be higher (Schleis, 2007). However, no conversion factor can be used because the over-estimation varies widely.
Blood glucose meters
The safest way for patients using icodextrin dialysis solution to monitor their blood glucose is with a blood glucose meter that uses a glucose-specific assay. The following assays are glucose specific (Health Canada, 2008).
* Dehydrogenase-nicotinamide adenine dinucleotide
* Glucose dehydrogenase flavin adenine dinucleotide
* Glucose oxidase
* Glucose hexokinase
To assist renal nurses with blood glucose meter selection for patients who use icodextrin PD solution, Table One provides details on some of the currently available blood glucose meters that should not be used. Table Two provides details on some of the currently available blood glucose meters that can be used. Information was obtained via verbal correspondence with each respective company on October 8, 2009.
Mr. BP observed that his blood glucose levels had increased after starting dialysis. It is important for the health care team to assess his current blood glucose meter before responding to his blood glucose levels. Raising his insulin doses due to falsely elevated blood glucose levels places him at increased risk of hypoglycaemic reactions including hypoglycaemic coma.
Table One. Blood glucose meters that may falsely elevate blood glucose readings and therefore should NOT be used in patients receiving icodextrin (Extraneal) peritoneal PD solution Company Blood glucose meter Abbott All FreeStyle: FreeStyle[R] FreeStyle Freedom[R] FreeStyle Flash[R] FreeStyle Lite[R] FreeStyle Freedom Lite[R] Roche ACCU-CHEK Compact Plus ACCU-CHEK Aviva ACCU-CHEK Aviva Nano Table Two. Blood glucose meters that will not falsely elevate blood glucose readings and therefore CAN be used in patients receiving icodextrin (Extraneal) peritoneal PD solution Company Blood glucose meter Abbott Precision Xtra[R] Bayer Contour[R] Breeze II[R] LifeScan All LifeScan Meters: OneTouch[R] Select[TM] OneTouch[R] Ultra[R] InDuo[R] System OneTouch[R] Basic [R] OneTouch[R] SureStep[R] OneTouch[R] Fast Take[R] OneTouch[R] Profile[R] OneTouch[R] UltraMini OneTouch[R] Ultra 2 OneTouch[R] UltraSmart OneTouch[R] UltraLink Roche ACCU-trend GC Tremblay Harrison Oracle[R]
When initiating icodextrin solution for diabetic PD patients, it is imperative for nephrology health care practitioners to review the type of blood glucose meter the patient is using at home and to ensure that it is compatible with icodextrin PD solutions. This will assist in decreasing the erroneous administration of insulin and potentially dangerous hypoglycaemic events.
Baxter. (n.d.). Baxter PD--The Role of EXTRANEAL (icodextrin) Peritoneal Dialysis Solution in Fluid Management. Retrieved March 26, 2009, from http://www.renalsource.com/extraneal/fluid.html
Health Canada. (2008). Health Canada Issued Important Safety Information on Possible interference of icodextrin, intravenous immunoglobulins, galactose and d-xylose with certain blood glucose monitors. Retrieved October 9, 2009, from http://www.hc-sc.gc.ca/dhp-mps/medeff/advisories-avis/prof/_2008/gluc_met_nth-aah-eng.php
Riley, S.G., Chess, J., Donovan, K.L., & Williams, J.D. (2003). Spurious hyperglycaemia and icodextrin in peritoneal dialysis fluid. British Medical Journal, 372(7415), 608-609.
Schleis, T.G. (2007). Interference of Maltose, Icodextrin, Galactose, or Xylose with some blood glucose monitoring systems. Pharmacotherapy, 27(9), 1313-1321.
By Jenny Ng, BScPhm,ACPR, RPh, and Marion Elligsen, BScPhm, RPh
Jenny Ng BSc.Phm, ACPR, RPh is Renal Pharmacist, Sunnybrook Health Sciences Centre, Toronto, ON
Marion Elligsen, BSc.Phm, RPh is Pharmacy Fellow, Sunnybrook Health Sciences Centre, Toronto, ON
Correspondence to: Jenny Ng, BScPhm, ACPR, RPh, Renal Pharmacist, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Toronto, ON M4N 3M5 E-mail: Jenny.Ng@Sunnybrook.ca
Department editor: Eleanor Ravenscroft, RN, PhD, CNeph(C)
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|Title Annotation:||Practice corner|
|Author:||Ng, Jenny; Elligsen, Marion|
|Date:||Oct 1, 2009|
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