Self Monitoring (home blood glucose testing) in Diabetes

Standards for self-monitoring by people with diabetes, especially those with Type 2 diabetes, not using insulin has been an area of debate for some time. As a consequence, recommendations for patients vary considerably not only across Trafford but throughout the UK.

Both the UKPDS (1998) and the DCCT (1993) studies highlighted the relationship between the increased incidence of microvascular complications and poor glycaemic control. In the light of this evidence it is essential that people with diabetes are made aware of the importance of appropriate monitoring.

Following the DiGEM study (2007) Trafford’s guideline has been updated to ensure quality and efficiency of self-monitoring for people with diabetes. This guideline has been developed jointly by the diabetes team at Trafford Trust and the PCTs Medicines Management Team.

This guideline is not intended to deny people with diabetes access to self-monitoring BUT to ensure that people monitor appropriately and that advice given is consistent.

Patient Choice and Education

Informed patient choice and education for self-monitoring is hugely important. As professionals it is easy to give advice and recommendations but we need to remember patients’ are individuals.

If the decision is made to go ahead with self monitoring it is extremely important that the patient is fully informed to achieve the greatest benefit from self-monitoring but perhaps most importantly, know what the results mean for them individually.

Education of patients who undertake self-monitoring of their diabetes is essential and should be part of a good quality education programme with accompanying support and information.

This must include:

  1. How to self-monitor
  2. When to test
  3. What targets are being aimed for
  4. What to do with the results
  5. When and where to seek advice

The results must be reviewed regularly with the patient.

Diabetes Type & Treatment / Monitoring Regimen
All people with Type 1 diabetes and people with Type 2 diabetes using insulin /
  • Blood glucose monitoring should be seen as an integral part of diabetes management in those patients using insulin. Patients should be advised to regularly monitor their blood glucose and to alter treatment appropriately (see table1)
  • Patients using insulin are liable to instability of glycaemic control and should therefore monitor regularly according to individual patient requirements
  • For example; in a patient using twice daily insulin, it would be recommended that blood glucose be tested twice daily. One test would be a fasting glucose & the second test at a different time each day (see table1)
  • A change in the frequency of testing is required:
During a period of illness
Deterioration in glycaemic control
Dialysis
Pre-conception
Pregnancy
Gestational diabetes
Change of insulin regimen
Terminal care
Impaired awareness of hypoglycaemia
Pre surgery, treatment with steroids
Significant changes in lifestyle – diet/exercise/weight loss
Insulin pumps; basal bolus regime
Diabetes Type & Treatment / Monitoring Regimen
People with Type 2 diabetes on oral therapy (this includes newly diagnosed non-symptomatic patients who you are trialling lifestyle changes pre treatment) /
  • HbA1cis the real outcome in these people. Blood glucose monitoring should not be required routinely. Remember 3 monthly HbA1c checks may be appropriate for certainindividuals (see table 1)
  • Blood glucose may require monitoring in “special” circumstances:
During a period of illness
Deterioration in glycaemic control
When therapy is changed
Co-prescription of steroids
Significant changes in lifestyle; diet/exercise/weight loss
Patients with postprandial hyperglycaemia (potential link with macrovascular disease)
  • In a newly diagnosed patient with an HbA1c > 7.0%, self monitoring may help the patient in making any lifestyle adjustments. The need to continue monitoring should however be reviewed regularly as the patient responds to lifestyle changes or treatment (see table 1)
  • For patients monitoring in “special” circumstances, it should be explained that blood glucose monitoring might be a short-term measure. This should be discussed with the health care professional

Type 2 diabetes

Table 1

Treatment / Control / Recommended Monitoring
Diet/Exercise/Metformin/
Glitazones / HbA1c 6.5% - 7% / 3 - 6 monthly HbA1c checks
Diet/Exercise/Metformin/
Glitazones / HbA1c >7% / Consider whether some short term monitoring would identify issues outside of lifestyle issues – see special circumstances
Sulphonylureas/Post Prandial Regulators / HbA1c 6.5% - 7% / Blood glucose monitoring three times a week e.g. one FBG, one BGpre prandial, one BG 2 hours postprandial varying the time each day
Sulphonylureas/Post Prandial Regulators / HbA1c >7% / Blood glucose monitoring twice a day e.g. one FBG, one BG 2 hours post prandial varying the time each day
Conversion to insulin / HbA1c 7.5% - 8% / Blood glucose monitoring twice a day e.g. one FBG, one BG 2 hours post prandial varying the time each day
Established* on insulin / HbA1c 6.5% - 7.5% / Blood glucose monitoring three times a week e.g. one FBG, one BG pre prandial, one BG 2 hours post prandial varying the time each day
Established* on insulin / HbA1c >7.5% / Blood glucose monitoring twice a day e.g. one FBG, one BG 2 hours post prandial varying the time each day
Conversion to GLP1 agonists / HbA1c >7.5% / Blood glucose monitoring twice a day e.g. one FBG, one BG 2 hours post prandial varying the time each day
Established* on GLP1agonists / HbA1c 6.5-7.5% / If also taking a Sulphonylurea/Post prandial regulator then blood glucose monitoring three times a week e.g. one FBG, one BGpre prandial, one BG 2 hours post prandial varying the time each day. Otherwise 3 monthly HbA1c checks
Conversion to Gliptins / HbA1c >7.5% / Blood glucose monitoring twice a day e.g. one FBG, one BG 2 hours post prandial varying the time each day
Established* on Gliptins / HbA1c 6.5-7.5% / If also taking a Sulphonylurea/Post prandial regulator then blood glucose monitoring three times a week e.g. one FBG, one BG pre prandial, one BG 2 hours post prandial varying the time each day. Otherwise 3 monthly HbA1c checks

*Established in the context of this guideline refers to the achievement of an HbA1c target agreed between the patient and practitioner (usually within 3 months)

All newly diagnosed patients with Type 2 diabetes or those experiencing difficulty managing their diabetes should be referred to the XPERT patient education course (Fax: 0161 746 2241)

Education is the key to self monitoring – many patients test too often with little understanding of how to interpret their results. This is wasteful and costly.

Please refer to above guidelines for more detailed information.

Abbreviations;

FBG = Fasting Blood Glucose

BG =Blood Glucose

Pre prandial = before meals

Post prandial = after meals

Varying the time of day means that the patients should not test at the same time each day (unless FBG), allowing a “pattern” of results to be obtained throughout the day. This will ensure any changes to medication are targeted.

Type 1 Diabetes

Blood glucose monitoring can vary between 2-6 times daily depending on the insulin regime

Ketone urine testing should be advised during periods of illness

NICE Guidance

NICE guidelines on the management of blood glucose in Type 2 diabetes recommend:

  • Self-monitoring should not be considered as a stand alone intervention
  • Self-monitoring should be taught if the need/purpose is clear and agreed with the patient
  • Self-monitoring can be used in conjunction with appropriate therapy as part of integrated self-care
  • Self-monitoring can motivate patients to make the necessary lifestyle changes that may need to happen to improve glycaemic control

Secondary Care Information

  • If a patient is taught how to self monitor in secondary care, the DSN will provide them with a blood glucose meter which will include a sample pot of approximately ten blood glucose testing strips and approximately ten finger pricking lancets. A written request will be given to the patient to ask their GP for a repeat prescription of these items. Please note that these items are not prescribed by the hospital.

Repeat Prescribing Systems

  • Please ensure appropriate quantities of test strips are calculated and supplied for each patient e.g. patient testing once daily – 100 strips should be issued every 3 months
  • Issuing appropriate quantities should help reduce stock-piling and the use of “out of date” strips
  • Patients should be advised that there is no benefit from testing any more frequently than advised
  • Patients should not be using two different brands of blood glucose testing strips at any one time e.g. if a patient is using two meters, one at home and one at work, it should be the same brand of meter & strips
  • Patients may request testing strips after purchasing their own meters. Take this as an opportunity to discuss blood glucose monitoring to decide if this is the best monitoring option for the patient
  • Please remember to prescribe finger pricking lancets
  • If patient is newly diagnosed or is monitoring as a “special circumstance”, prescribe as an “acute/current” item to ensure patient comes in for review

Final Check for Health Care Professionals

Does the patient adjust their treatment or make use of their blood glucose readings?

Yes – Continue as per Table 1 with regular review

No – Review

Conclusion

Monitoring in patients with diabetes is only one part of the overall diabetes management plan. Other essential factors are:

  • Smoking cessation
  • Lifestyle and dietary management (BMI and waist circumference)
  • BP management (<130/80mmHg)
  • Cholesterol management (cholesterol should be lowered despite initial level)
  • Eye screening
  • Foot screening
  • Micro-albuminuria and serum creatinine testing

Further information and guidance in relation to various aspects of Diabetes care can be found at

Authors: Louise Hopewell (DSN), Leigh Lord (MM Pharmacist)Sept 2011.Review Sept 2013