Glucose Monitoring Self Blood Glucose Monitoring

In order to obtain blood glucose control and to maintain this on a daily basis, it is essential for patients with diabetes to do SBGM. The DCCT and other studies clearly demonstrated the importance of this approach and it is now considered as one of the cornerstones of therapy. However one of the findings of the DCCT was that with intensive therapy the number of severe hypoglycemic episodes increase. The data obtained from monitoring are used to assess the efficacy of the treatment program and the frequency of hypoglycemia, to make adjustments to the program that will involve medication change as well as reviewing medical nutrition therapy and the effects of exercise. A great deal of progress has been made in the accuracy and ease of use of the glucose monitoring equipment. Monitors are now available that need very small amounts of blood and can record and store many blood glucose results with date, time of test and even provide 14-day averages of selected tests. Some of the monitors can be downloaded into personal computers and can provide a number of presentations of the data, including pie charts, line diagrams, and bar graphs. It is not clear if presenting data in this way is superior to patient records done manually. For the visually impaired, specific monitors are also available so that almost every patient or care giver has access to this type of information to aid in obtaining the best control possible safely. In its position statement the ADA made a number of recommendations (36). It states that most patients with type 1 diabetes can only obtain blood glucose close to normal with SBGM because of the increased risk of hypoglycemia with intensive therapies. Therefore not only should all insulin treated patients monitor but patients on sulfonylureas also need monitoring to avoid asymptomatic hypoglycemia. The optimal frequency for testing is actually dictated by the needs and goals of the individual patient (Table 4). For type 1 patients tests should be done

TABLE 4 Recommended Targets for Blood Glucose

Goal

Preprandial capillary plasma glucose (mg/dL) Peak postprandial capillary plasma glucose (mg/dL) HbAic (%)

Source: From Refs. 50 and 51.

four times daily, a fasting test and then before each meal and bedtime. Some patients on more intensive treatment programs may need to do block tests one day a week consisting of the above frequency with additional testing after meals and possibly at 3 a.m. to check for nocturnal hypoglycemia. The exact frequency of testing in type 2 patients on oral medication is not known but testing must be individualized to meet the needs of the patient and the goals set for the degree of control. The role of SBGM in stable diet controlled type 2 patients is unknown at present. A recent report by Harris using data from the NHANES 111 noted that the frequency of SBGM was more common as the HbAic increased (37). The report also noted that most patients treated with oral medications or diet rarely monitored their blood glucose. The data obtained from 1480 subjects found that 29% patients treated with insulin, 65% treated with oral agents and 80% of those treated with diet alone had never monitored their blood glucose or did it less than once a month. It was also noted that 39% of insulin treated and 5% to 6% of oral agent or diet controlled patients monitored at least once daily. Part of this low-monitoring rate may be a reflection of the policy of Medicare reimbursing monitoring strips and monitors only in insulin treated patients during the years 1988 to 1994. However, data obtained in 1998, after Medicare started to reimburse the costs of monitoring regardless of insulin treatment, a survey from 1997 to 1999, showed that the number of patients monitoring at least once daily increased by 44% over the earlier period. It is obvious that the costs of monitoring plays an important role in the level of patient acceptance and utilization. Not only are these cost issues pertinent but also the health care beliefs of the patients and providers in using this approach. In addition the issues of pain, discomfort, and inconvenience of testing all need to be addressed and will determine the degree of success. The role of government and third party payers in improving this situation is readily apparent given the enormous burden of diabetes in all countries.

In order to use SBGM properly, each patient should be taught by a diabetes nurse educator, who can evaluate the correct testing technique and use of the monitor selected. Most of the new blood glucose monitors are calibrated to reflect plasma glucose levels that have become the standard measurement in most laboratories. Since the plasma glucose is 10% to 15% higher than whole blood, patients need to know what they are measuring in the event their meter still reads whole blood. To use SBGM optimally requires proper interpretation of the data and this has to be taught to the patient. They need to use the data to assess the effects of nutrition, exercise, and their pharmacological therapy. The use of newer oral drugs, rapid acting insulin analogues, and basal insulin also make it important to test more often. These treatments have specific actions and effects on blood glucose. Rapid acting insulin is used to control postmeal glucose levels and basal insulin to provide up to 24 h coverage. Therefore to obtain the best control it is necessary for the patient to test at specific times to maximize the benefits of the treatment and to avoid hypoglycemia. As noted above a major concern with the use of more intensive therapy is the risk for severe hypoglycemia and its consequences. A report by Cox in 1994 determined whether severe hypoglycemia could be predicted by the results of SBGM, blood glucose variability and the HbA1c (38). They found that patients who recorded variable and frequent low blood glucose readings during routine SBGM were at higher risk for subsequent severe hypoglycemia.

The ADA also has recommendations for glucose testing by health-care providers for routine outpatient management of diabetes. It states that laboratory glucose testing should be available for use as needed as in diet controlled or certain patients taking oral medication. Management of the patient is done with the SBGM data in conjunction with the HbA1c results. The laboratory glucose can also be useful if it is done simultaneously with the patients monitor test to check the accuracy of the patient results. If this is done using portable capillary testing devices rather than the laboratory, then rigorous quality control measures must be used to ensure the validity of the results.

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