Blood glucose self-monitoring in management of adults with diabetes mellitus
- David K McCulloch, MD
David K McCulloch, MD
- Washington Permanente Medical Group
All patients with diabetes mellitus who use insulin and some patients who take other glucose-lowering medications that can cause hypoglycemia should measure their blood glucose concentrations to help maintain safe, target-driven glucose control. The effectiveness of self-monitoring in patients with type 2 diabetes who do not use hypoglycemic agents is less certain.
Self-monitoring of blood glucose (SMBG) usually requires intermittent capillary blood sampling and the use of a glucose meter, with different frequencies of testing indicated for type 1 and type 2 diabetes. Devices to sample the glucose continuously from subcutaneous fluid are also available, with ongoing development in progress.
In addition to SMBG, periodic measurement of glycated hemoglobin (A1C) estimates chronic glycemic control. Several practical points about blood glucose monitoring will be reviewed here, including the accuracy of glucose meters and glucose test strips, the accuracy of the operator, and how to use the glucose information that is obtained. The use of A1C measurements to estimate mean blood glucose is reviewed elsewhere. (See "Estimation of blood glucose control in diabetes mellitus".)
Based upon the results of randomized trials (described below), we suggest SMBG in patients who take medications that can cause hypoglycemia and that need to be adjusted based on ambient glucose levels. For example, in order to avoid hypoglycemia and achieve target glucose levels, patients with type 1 diabetes who take mealtime 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.
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.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Diabetes Control and Complications Trial Research Group, Nathan DM, Genuth S, et al. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993; 329:977.
- Nathan DM, Cleary PA, Backlund JY, et al. Intensive diabetes treatment and cardiovascular disease in patients with type 1 diabetes. N Engl J Med 2005; 353:2643.
- American Diabetes Association. Standards of medical care in diabetes--2013. Diabetes Care 2013; 36 Suppl 1:S11.
- Karter AJ, Ackerson LM, Darbinian JA, et al. Self-monitoring of blood glucose levels and glycemic control: the Northern California Kaiser Permanente Diabetes registry. Am J Med 2001; 111:1.
- Karter AJ, Parker MM, Moffet HH, et al. Longitudinal study of new and prevalent use of self-monitoring of blood glucose. Diabetes Care 2006; 29:1757.
- Faas A, Schellevis FG, Van Eijk JT. The efficacy of self-monitoring of blood glucose in NIDDM subjects. A criteria-based literature review. Diabetes Care 1997; 20:1482.
- Harris MI, National Health and Nutrition Examination Survey (NHANES III). Frequency of blood glucose monitoring in relation to glycemic control in patients with type 2 diabetes. Diabetes Care 2001; 24:979.
- Davis WA, Bruce DG, Davis TM. Is self-monitoring of blood glucose appropriate for all type 2 diabetic patients? The Fremantle Diabetes Study. Diabetes Care 2006; 29:1764.
- Franciosi M, Pellegrini F, De Berardis G, et al. Self-monitoring of blood glucose in non-insulin-treated diabetic patients: a longitudinal evaluation of its impact on metabolic control. Diabet Med 2005; 22:900.
- Coster S, Gulliford MC, Seed PT, et al. Self-monitoring in Type 2 diabetes mellitus: a meta-analysis. Diabet Med 2000; 17:755.
- Welschen LM, Bloemendal E, Nijpels G, et al. Self-monitoring of blood glucose in patients with type 2 diabetes who are not using insulin: a systematic review. Diabetes Care 2005; 28:1510.
- Poolsup N, Suksomboon N, Rattanasookchit S. Meta-analysis of the benefits of self-monitoring of blood glucose on glycemic control in type 2 diabetes patients: an update. Diabetes Technol Ther 2009; 11:775.
- Malanda UL, Welschen LM, Riphagen II, et al. Self-monitoring of blood glucose in patients with type 2 diabetes mellitus who are not using insulin. Cochrane Database Syst Rev 2012; 1:CD005060.
- Farmer AJ, Perera R, Ward A, et al. Meta-analysis of individual patient data in randomised trials of self monitoring of blood glucose in people with non-insulin treated type 2 diabetes. BMJ 2012; 344:e486.
- Clar C, Barnard K, Cummins E, et al. Self-monitoring of blood glucose in type 2 diabetes: systematic review. Health Technol Assess 2010; 14:1.
- Barnett AH, Krentz AJ, Strojek K, et al. The efficacy of self-monitoring of blood glucose in the management of patients with type 2 diabetes treated with a gliclazide modified release-based regimen. A multicentre, randomized, parallel-group, 6-month evaluation (DINAMIC 1 study). Diabetes Obes Metab 2008; 10:1239.
- Farmer A, Wade A, Goyder E, et al. Impact of self monitoring of blood glucose in the management of patients with non-insulin treated diabetes: open parallel group randomised trial. BMJ 2007; 335:132.
- O'Kane MJ, Bunting B, Copeland M, et al. Efficacy of self monitoring of blood glucose in patients with newly diagnosed type 2 diabetes (ESMON study): randomised controlled trial. BMJ 2008; 336:1174.
- Saudek CD, Derr RL, Kalyani RR. Assessing glycemia in diabetes using self-monitoring blood glucose and hemoglobin A1c. JAMA 2006; 295:1688.
- Goldstein DE, Little RR, Lorenz RA, et al. Tests of glycemia in diabetes. Diabetes Care 2004; 27:1761.
- Simon J, Gray A, Clarke P, et al. Cost effectiveness of self monitoring of blood glucose in patients with non-insulin treated type 2 diabetes: economic evaluation of data from the DiGEM trial. BMJ 2008; 336:1177.
- Lewandrowski K, Cheek R, Nathan DM, et al. Implementation of capillary blood glucose monitoring in a teaching hospital and determination of program requirements to maintain quality testing. Am J Med 1992; 93:419.
- Sacks DB, Bruns DE, Goldstein DE, et al. Guidelines and recommendations for laboratory analysis in the diagnosis and management of diabetes mellitus. Clin Chem 2002; 48:436.
- Freckmann G, Baumstark A, Jendrike N, et al. System accuracy evaluation of 27 blood glucose monitoring systems according to DIN EN ISO 15197. Diabetes Technol Ther 2010; 12:221.
- Trajanoski Z, Brunner GA, Gfrerer RJ, et al. Accuracy of home blood glucose meters during hypoglycemia. Diabetes Care 1996; 19:1412.
- Brunner GA, Ellmerer M, Sendlhofer G, et al. Validation of home blood glucose meters with respect to clinical and analytical approaches. Diabetes Care 1998; 21:585.
- Desachy A, Vuagnat AC, Ghazali AD, et al. Accuracy of bedside glucometry in critically ill patients: influence of clinical characteristics and perfusion index. Mayo Clin Proc 2008; 83:400.
- Kuo CY, Hsu CT, Ho CS, et al. Accuracy and precision evaluation of seven self-monitoring blood glucose systems. Diabetes Technol Ther 2011; 13:596.
- Fineberg SE, Bergenstal RM, Bernstein RM, et al. Use of an automated device for alternative site blood glucose monitoring. Diabetes Care 2001; 24:1217.
- Ellison JM, Stegmann JM, Colner SL, et al. Rapid changes in postprandial blood glucose produce concentration differences at finger, forearm, and thigh sampling sites. Diabetes Care 2002; 25:961.
- Jungheim K, Koschinsky T. Glucose monitoring at the arm: risky delays of hypoglycemia and hyperglycemia detection. Diabetes Care 2002; 25:956.
- Peel E, Douglas M, Lawton J. Self monitoring of blood glucose in type 2 diabetes: longitudinal qualitative study of patients' perspectives. BMJ 2007; 335:493.
- Polonsky WH, Fisher L, Schikman CH, et al. Structured self-monitoring of blood glucose significantly reduces A1C levels in poorly controlled, noninsulin-treated type 2 diabetes: results from the Structured Testing Program study. Diabetes Care 2011; 34:262.
- Klonoff DC. Continuous glucose monitoring: roadmap for 21st century diabetes therapy. Diabetes Care 2005; 28:1231.
- Hirsch IB. Clinical review: Realistic expectations and practical use of continuous glucose monitoring for the endocrinologist. J Clin Endocrinol Metab 2009; 94:2232.
- Garg S, Zisser H, Schwartz S, et al. Improvement in glycemic excursions with a transcutaneous, real-time continuous glucose sensor: a randomized controlled trial. Diabetes Care 2006; 29:44.
- Monsod TP, Flanagan DE, Rife F, et al. Do sensor glucose levels accurately predict plasma glucose concentrations during hypoglycemia and hyperinsulinemia? Diabetes Care 2002; 25:889.
- Nielsen JK, Djurhuus CB, Gravholt CH, et al. Continuous glucose monitoring in interstitial subcutaneous adipose tissue and skeletal muscle reflects excursions in cerebral cortex. Diabetes 2005; 54:1635.
- http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm431385.htm (Accessed on January 29, 2015).
- Juvenile Diabetes Research Foundation Continuous Glucose Monitoring Study Group, Tamborlane WV, Beck RW, et al. Continuous glucose monitoring and intensive treatment of type 1 diabetes. N Engl J Med 2008; 359:1464.
- Deiss D, Bolinder J, Riveline JP, et al. Improved glycemic control in poorly controlled patients with type 1 diabetes using real-time continuous glucose monitoring. Diabetes Care 2006; 29:2730.
- Juvenile Diabetes Research Foundation Continuous Glucose Monitoring Study Group, Beck RW, Hirsch IB, et al. The effect of continuous glucose monitoring in well-controlled type 1 diabetes. Diabetes Care 2009; 32:1378.
- Battelino T, Phillip M, Bratina N, et al. Effect of continuous glucose monitoring on hypoglycemia in type 1 diabetes. Diabetes Care 2011; 34:795.
- Tanenberg R, Bode B, Lane W, et al. Use of the Continuous Glucose Monitoring System to guide therapy in patients with insulin-treated diabetes: a randomized controlled trial. Mayo Clin Proc 2004; 79:1521.
- Pickup JC, Freeman SC, Sutton AJ. Glycaemic control in type 1 diabetes during real time continuous glucose monitoring compared with self monitoring of blood glucose: meta-analysis of randomised controlled trials using individual patient data. BMJ 2011; 343:d3805.
- Gandhi GY, Kovalaske M, Kudva Y, et al. Efficacy of continuous glucose monitoring in improving glycemic control and reducing hypoglycemia: a systematic review and meta-analysis of randomized trials. J Diabetes Sci Technol 2011; 5:952.
- Langendam M, Luijf YM, Hooft L, et al. Continuous glucose monitoring systems for type 1 diabetes mellitus. Cochrane Database Syst Rev 2012; 1:CD008101.
- Szypowska A, Ramotowska A, Dzygalo K, Golicki D. Beneficial effect of real-time continuous glucose monitoring system on glycemic control in type 1 diabetic patients: systematic review and meta-analysis of randomized trials. Eur J Endocrinol 2012; 166:567.
- Yeh HC, Brown TT, Maruthur N, et al. Comparative effectiveness and safety of methods of insulin delivery and glucose monitoring for diabetes mellitus: a systematic review and meta-analysis. Ann Intern Med 2012; 157:336.
- Lind M, Polonsky W, Hirsch IB, et al. Continuous Glucose Monitoring vs Conventional Therapy for Glycemic Control in Adults With Type 1 Diabetes Treated With Multiple Daily Insulin Injections: The GOLD Randomized Clinical Trial. JAMA 2017; 317:379.
- Beck RW, Riddlesworth T, Ruedy K, et al. Effect of Continuous Glucose Monitoring on Glycemic Control in Adults With Type 1 Diabetes Using Insulin Injections: The DIAMOND Randomized Clinical Trial. JAMA 2017; 317:371.
- Mastrototaro J, Shin J, Marcus A, et al. The accuracy and efficacy of real-time continuous glucose monitoring sensor in patients with type 1 diabetes. Diabetes Technol Ther 2008; 10:385.
- Castle JR, Pitts A, Hanavan K, et al. The accuracy benefit of multiple amperometric glucose sensors in people with type 1 diabetes. Diabetes Care 2012; 35:706.
- Damiano ER, El-Khatib FH, Zheng H, et al. A comparative effectiveness analysis of three continuous glucose monitors. Diabetes Care 2013; 36:251.
- Damiano ER, McKeon K, El-Khatib FH, et al. A comparative effectiveness analysis of three continuous glucose monitors: the Navigator, G4 Platinum, and Enlite. J Diabetes Sci Technol 2014; 8:699.
- Matuleviciene V, Joseph JI, Andelin M, et al. A clinical trial of the accuracy and treatment experience of the Dexcom G4 sensor (Dexcom G4 system) and Enlite sensor (guardian REAL-time system) tested simultaneously in ambulatory patients with type 1 diabetes. Diabetes Technol Ther 2014; 16:759.
- Kovatchev B, Anderson S, Heinemann L, Clarke W. Comparison of the numerical and clinical accuracy of four continuous glucose monitors. Diabetes Care 2008; 31:1160.
- Ritholz MD, Atakov-Castillo A, Beste M, et al. Psychosocial factors associated with use of continuous glucose monitoring. Diabet Med 2010; 27:1060.
- Klonoff DC, Buckingham B, Christiansen JS, et al. Continuous glucose monitoring: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2011; 96:2968.
- American Diabetes Association. Urine glucose and ketone determinations. Diabetes Care 1995; 18 Suppl 1:20.
- Weber C, Kocher S, Neeser K, Joshi SR. Prevention of diabetic ketoacidosis and self-monitoring of ketone bodies: an overview. Curr Med Res Opin 2009; 25:1197.
- Bektas F, Eray O, Sari R, Akbas H. Point of care blood ketone testing of diabetic patients in the emergency department. Endocr Res 2004; 30:395.
- Type 1 diabetes
- Type 2 diabetes
- SOURCES OF ERROR IN SMBG
- Blood glucose meters
- Glucose strips
- Site of testing
- USING THE INFORMATION
- CONTINUOUS GLUCOSE MONITORING
- Patient selection
- PATIENTS WITH SPECIAL NEEDS
- URINE TESTING
- Testing for ketonuria
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS