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History!
Crude self-blood glucose monitoring was initially developed in 1965. The first commercially available home blood glucose monitoring devices were sold in 1970, weighed over 3 lbs and cost over $350 per month to operate. In the US there are about 30 self-blood glucose meter manufacturers selling $2 billion worth of strips and meters annually.
However, these devices provide only a static reading of ones blood glucose levels rather than an indication of real time continuous trending.
Indications
SMBG in patients who take medications that can cause hypoglycemia and that need to be adjusted based on ambient glucose levels.
In order to avoid hypoglycemia achieve target glucose levels patients with type 1 diabetes who take pre-prandial rapidacting or very rapid-acting insulins should usually test
before meals to adjust doses, based on meal size and content, anticipated activity levels, and glucose levels.
Similar guidelines apply to insulin-treated type 2 diabetes, although their glucose levels are characteristically more stable and they may require less frequent monitoring.
Indications
Patients treated with sulfonylureas or meglitinides, which can also cause hypoglycemia, should be tested once to twice per day during titration of their doses, but after a stable dose and target glycemic targets are achieved, may only need to test several times per week, usually in the morning or before dinner. All insulin and sulfonylurea patients need to test more frequently before and during long car rides, during sick days, and when there are changes in diet and exercise patterns.
Indications
Self-monitoring of glucose may not be necessary at all, or only in unusual circumstances, for patients with type 2 diabetes who are diet-treated or who are treated with oral agents not associated with hypoglycemia.
Type 1
SMBG is an integral part of intensive therapy in type 1 diabetes, which is widely accepted as recommended therapy owing to its benefits.
Self-monitoring allows adjustments of doses and timing of insulin and of timing and content of meals and snacks based on immediate feedback of glucose results and allows timely intervention for low or decreasing glucose levels to avert serious hypoglycemic events.
Self-monitoring of blood glucose is also important for patients with type 1 diabetes who are not managed with intensive insulin, although they may require somewhat less frequent testing
Type 1
The American Diabetes Association (ADA) recommends that patients with type 1 diabetes monitor blood glucose at least three times daily For most patients with type 1 diabetes, testing blood glucose levels more frequently is necessary to safely achieve A1C targets without hypoglycemia. Testing blood glucose levels before and at intervals after meals; before, during, and after exercise; and occasionally during the night will provide useful information for adjusting insulin and carbohydrate intake
Patients with hypoglycemia unawareness may need to test more frequently, particularly prior to driving or operating any machinery, watching small children, and other activities where compromise of cognitive function may be dangerous.
Type 2
The effectiveness of SMBG in terms of improving glycemic control in patients with type 2 diabetes is less clear than for type 1 diabetes.
Multiple observational studies have evaluated SMBG in type 2 diabetes, with some showing benefits and others not There is no evidence that SMBG affects quality of life or long-term clinically important outcomes (eg, diabetes complications).
Type 2
Monitoring blood glucose is a tool, not a therapeutic intervention.
It provides important information with which motivated insulin-treated patients can modify their behavior and improve their A1C values safely. SMBG may also be useful for some type 2 diabetic patients who would take action to modify eating patterns or exercise, as well as be willing to intensify pharmacotherapy, based on SMBG results SMBG is expensive. -unlikely to be costeffective
Type 2
Self-monitoring of glucose may not be necessary at all, or only in unusual circumstances, for patients with type 2 diabetes who are diet-treated or who are treated with oral agents not associated with hypoglycemia.
It may be unnecessarily burdensome in frail elderly individuals with cognitive impairment or difficulty with fine motor skills from neurological or musculoskeletal conditions. In such patients, the target for glycated hemoglobin (A1C) should be somewhat higher (8 percent) than for younger and more fit elderly patients, and therefore, there is little role for regular self-monitoring of blood glucose, unless the patient is taking insulin.
Operator
Glucose strips
Other sugars
Site of testing
Sources of error
Operator
Errors in SMBG are most frequently attributed to operator-error failure to use test strips appropriate to the meter calibrate the meter correctly
dirty meters
inadequate hand washing improper storage of the test strips.
The glucose meter and strips should be brought in for clinic visits. The patient's method of testing should be observed periodically and any technical mistakes corrected. Patients should be queried regarding storage of strips. If SMBG results do not seem consistent with expectations, we recommend that the patient bring the glucose meter in to be checked against meters of known accuracy or with a simultaneous lab value. Most meters can be downloaded so that the actual measurements (rather than reliance on patients self-report of frequency of testing and specific results) can be reviewed.
Patients who are motivated and test often usually get much more reliable results than those who are less interested or who test less often (such as non-expert clinicians) We also recommend the following steps to increase the accuracy of glucose monitoring:
Glucose Strips
Some glucose strips have considerable batch to batch variation and require recalibration to a meter every time a new batch is used. Many strips are packaged in groups (10, 25, 50, or 100) inside a can containing a desiccant to control humidity. Common errors include leaving the lid off for periods of time, with exposure to heat, moisture, and humidity, and mixing lots of strips into one can for convenience.
Patients may forget to match the code on the strip bottle to the meter code, with uncompensated batch variation causing erroneous glucose value readings.
Fortunately, most meters now have eliminated the need to code each bottle of strips. Many newer meters overcome this problem by automatically recognizing codes for strips
Site of testing
Several blood glucose meters are now available that use sites other than the finger to obtain blood samples in an effort to reduce the discomfort involved with fingersticks. A study of one device that can be used to obtain samples from the arm found that it provided accurate results and was less painful than fingerstick testing Monitoring from alternate sites, such as the skin of the forearm, may give slightly lower results than those taken at the fingertips, since they may sample venous blood rather than capillary blood.
In addition, during times when the blood glucose concentration is either rising rapidly (such as immediately after food ingestion) or falling rapidly (in response to rapidly acting insulin or exercise), blood glucose results from alternate sites may give significantly delayed results compared with fingerstick readings
Site of Testing
Other sugars
The FDA issued a safety alert in February 2006 that some glucose monitors (those using the enzyme glucose dehydrogenase pyrroloquinoline quinone or GDH-PQQ) will give falsely elevated readings in patients who have received treatments containing other sugars, including xylose as part of a d-xylose absorption test, maltose or galactose in IV solutions (IV immune globulin is formulated with maltose), or icodextrin in peritoneal dialysis fluid Most glucose meters do not use this enzyme and the test method used is identified in the package insert for the glucose strips. Several patient deaths were attributed to inappropriate insulin treatment for falsely elevated glucose strip readings New test strips have been designed to minimize interference with non-glucose sugars
Insulin algorithms
Once a basic regimen of eating, exercise, and insulin dosing has been established, there will still be a day-to-day variability in blood glucose values due, among other factors, to the vagaries of insulin and food absorption. This can be effectively treated by an insulin algorithm in which the beforemeal dose of short-acting insulin is adjusted according to the blood glucose value and, for patients who use carbohydrate counting, anticipated carbohydrate content of the meal. The adjustments should be small in patients who are very sensitive to insulin or who are taking low doses of insulin (as with a continuous insulin pump)
Patterns, as opposed to intermittent problems, are best identified if there are a relatively large number of measurements. Thus, blood glucose values should be recorded four to seven times daily for several days and evaluated for patterns of variation, which allow adjustment of doses or types of insulin at different times of the day.
With CGM, the same patient would see: average glucose 151 mg/dl readings within target 62% of the time several episodes of hypo and hyperglycemia
are not at their A1C target have recurrent hypoglycemia or hypo unawareness All pregnant women with type 1 diabetes.
CGM may also facilitate treatment adherence for women with type2 diabetes or insulin-requiring gestational diabetes. Youth with type 1 diabetes who are changing their diabetes regimen or are experiencing: nocturnal hypoglycemia dawn phenomenon hyperglycemia Hypoglycemia unawareness post prandial
Hypoglycemia unawareness or frequent hypoglycemia above target or with excess glucose variability
A1C
Requires
Minimed
* to an attached recorder (Medtronic iPro), or * through an attached transmitter (DexCom SEVEN PLUS) that sends the signals wireless to a receiver which can be set so that the patient is blinded to the data during the collection period.
iPro
SEVEN PLUS
SEVEN PLUS
Guardian RT
Receiver Display
Arrows are displayed that let the patient know the trend of glucose levels, either in an upward or downward direction. This allows the patient to take corrective measures before an episode of hypo- or hyperglycemia occurs.
Alarms can be set to warn the patient when glucose levels reach a certain level.
When analyzing CGM reports: 1. Look at overnight period first. 2. Look at preprandial levels. 3. Look at postprandial levels.
Similar guidelines apply to insulin-treated type 2 diabetes, although their glucose levels are characteristically more stable and they may require less frequent monitoring.
CASE DISCUSSION
The following case illustrates the value of blood glucose monitoring in patients with type 2 diabetes, depending upon the time, treatment, and stage of the disease
Case
A 56-year-old woman who is a clothing sales assistant presents with thirst, fatigue, and a vaginal yeast infection.
HEIGHT: 5 4 and WEIGHT 265 lbs Random blood glucose value is 260 mg/dL A1C (HbA1c) value is 9.4 % She eats a diet high in fat and carbohydrates
Exercises little
She watches TV for several hours nearly every evening, during which time she often eats two or three sugarcovered donuts
Initial treatment
Appropriate initial management
arrange for education about diabetes, in the form of written material, videos, and follow-up in an education and support group with other obese patients with type 2 diabetes;
advise her to modify her eating habits (reducing caloric intake and eliminating refined carbohydrate)
encourage her to walk on a treadmill for at least 30 minutes at least five evenings a week at home. She should also be asked to measure fasting blood glucose every morning. Metformin 500mg BID started
BG monitoring
Her thirst, fatigue, and vaginal infection subside soon thereafter. During the next three weeks, her blood glucose values during a typical week are as follows:
Day Before breakfast Mon 265 treadmillTue treadmillWed donuts!Thur exerciseFri treadmillSat donuts!Sun 184 175 305 280 190 174 Comments Exercised on Exercised on No exercise, 2 No Exercised on 3-mile walk. No
Follow-up
Follow-up During the next month, her blood glucose values during a typical week are as follows: Day s Before Before breakfast lunch meal Before Before Comment evening bedtime Evening 184 Evening Ev Ate 172
Mon 156 167 exerciseTue 141 Wed 178 Thur 160 exerciseFri 157 ening exerciseSat 159 late, no exerciseSun 204
F/U monitoring
During the next few weeks her bedtime dose of insulin is increased as follows:
Week NPH 1 204 140 Mean fasting blood glucose 168 163 148 286 134 Bedtime dose of 122 154 245 133 165
327
32
During the following year her A1C value rises to 8.4 percent, despite fasting blood glucose concentrations <130 mg/dL She is asked to measure blood glucose more often before lunch and dinner and at bedtime.
BG Monitoring
During the next three months, her blood glucose concentrations during a typical week are:
Day Before breakfast 119 128 147 123 130 Before lunch 198 251 236 Before evening meal 235 Before bedtime
266 241
Summary
In this case (based on an actual clinical case) we are trying to show how testing blood glucose at different times of the day and in different situations can help in making treatment decisions. There are several aspects of this case that are currently managed somewhat differently than in the past. While everyone would advocate vigorous support of healthy lifestyle change for a woman like this, many clinicians would recommend adding drugs and/or insulin at an earlier stage in an effort to get her HbA1c well below 7.0 percent as quickly as possible. One of the most common reasons for patients having an HbA1c that is too high is "clinical inertia" where additional treatments in a stepped protocol are not added soon enough.