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Consensus

Blood self- in type 1 and type 2 : reaching a multidisciplinary consensus

ARTICLE POINTS David Owens, Anthony H Barnett, John Pickup, David Kerr, Phyllis The provision of Bushby, Debbie Hicks, Roger Gadsby and Brian Frier 1home blood glucose monitoring materials is Introduction key to empowerment and In the light of evidence that emerged from the UKPDS (1998) and the delivery of good the DCCT (1993), individual patients must be made aware of the glycaemic control safely. importance of blood glucose monitoring. A multidisciplinary group of healthcare professionals met to discuss blood glucose self-monitoring The NSF for 2Diabetes outlined in type 1 and . This article outlines the consensus that the importance of they reached and provides a general basis upon which individual regular monitoring patient care plans may be formulated. Advice is given on home blood of HbA1c levels. glucose monitoring systems for people with different regimens for type 1 and type 2 diabetes. General 3recommendations and specific n the UK in 2001, approximately £90 with suitable training (National Diabetes considerations million was spent on blood glucose Support Team, 2003). are given for blood Itesting strips for people with The recently published NSF for glucose monitoring in diabetes (National Prescribing Centre, Diabetes (England and Wales) and 2002). This amount is estimated to be recommends that diabetes services type 2 diabetes. 40% more than the amount spent on oral should be: agents to lower blood glucose levels The article concludes (Tiley, 2002). Therefore the cost of ‘...person-centred, developed in partnership, with advice on home 4 home blood glucose monitoring is of equitable, integrated and outcome- blood glucose monitoring orientated.’ for different diabetes legitimate concern to healthcare providers (Burrill, 2002). regimens, and these are Important elements of the document outlined in a table. Several primary care trusts (PCTs) in include Standard 3, which specifies that: England have recently instructed general practitioners (GPs) to reduce the ‘...all children, young people and adults provision of blood glucose monitoring with diabetes will receive a service that David Owens, CBE, MD, FRCP, strips, in some cases suggesting no more CBiol, FIBiol, Professor and encourages partnership in decision- Consultant Diabetologist, than one test per day for all people with making, supports them in managing their Llandough Hospital, Penarth; diabetes irrespective of the type of Anthony H Barnett, BSc, MD, FRCP, diabetes and helps them adopt and Professor of Medicine, University diabetes or clinical need. The National maintain a healthy lifestyle.’ of Birmingham, and Consultant Diabetes Support Team (NDST) has Physician, Birmingham Heartlands and Solihull NHS Trust; John Pickup responded by making reference to the This recommendation relates to both DPhil, FRCPath, Professor of National Institute for Clinical Excellence outpatient and inpatient care. Standards 4 Diabetes and Metabolism, Guy’s and 5 clearly state that all people with Hospital London; David Kerr, MD, (NICE) guidelines published in September FRCP, Consultant Physician, 2002, reaffirming that self-monitoring diabetes will receive support to optimise Bournemouth Diabetes and should be used as part of integrated self- their blood glucose control (DoH, 2001). Endocrine Centre; Phyllis Bushby, Diabetes Specialist Nurse, care (NDST, 2003). It is well accepted that in people with Sherwood Forest Hospitals NHS However, the NICE guidance makes no type 1 or type 2 diabetes good glycaemic Trust; Debbie Hicks, Senior Diabetes Specialist Nurse, Hull and recommendations for frequency of testing control is essential to minimise the risk East Yorkshire Hospital NHS Trust; according to treatment regimen (NICE, of long-term vascular complications Roger Gadsby, GP, Nuneaton, Senior Lecturer in Primary Care, 2002). In addition, the NDST statement (DCCT Group, 1993; UKPDS, 1998). University of Warwick. Brian Frier also highlighted the benefits that self- Management of diabetes according to the MD FRCP, Professor and standards established by the NSF for Consultant Diabetologist, Lothian monitoring of blood glucose offers people University Hospitals NHS Trust. with diabetes when used appropriately Diabetes is dependent upon the control

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Table 1: Recommendations regarding blood glucose monitoring in type 1 diabetes PAGE POINTS

General recommendations Specific considerations Diabetes UK have 1re-emphasised in a Blood glucose monitoring should be regarded Factors which indicate a need position statement that as an integral part of treating all people with for more frequent testing: people with diabetes type 1 diabetes. Hypoglycaemia unawareness should have access to People with type 1 diabetes should be educated Frequent hypoglycaemia home blood glucose to monitor blood glucose and adjust treatment Exercise monitoring which is appropriately. Certain employments based on individual As the majority of people with type 1 diabetes Intercurrent illness clinical need and not on are liable to instability of glycaemic control, Driving an ability to pay. during such times or periods of instability, Children monitoring should ideally take place 4 or more Pregnancy There is a lack of times per day to prevent hypoglycaemia Breastfeeding 2randomised controlled and control hyperglycaemia. Outpatient procedures clinical trials in support of Drug/alcohol abuse the role of blood glucose Change of regimen monitoring in the treatment of type 1 and Advanced complications type 2 diabetes, and results (autonomic neuropathy, from meta-analyses are nephropathy). inconclusive.

of blood glucose. The utilisation of home multidisciplinary group that home blood Home blood glucose monitoring has an blood glucose monitoring, in addition to glucose monitoring has an important and 3 important and essential regular HbA measurement, is not essential role to play in ensuring the 1c role to play in ensuring however, clearly defined. safety and efficacy of glucose lowering the safety and efficacy Similarly, Diabetes UK have therapies in order to prevent the onset of glucose lowering re-emphasised in a position statement and limit the progression of therapies in order to that people with diabetes should have complications related to hyperglycaemia. prevent the onset and access to home blood glucose In the quest for normoglycaemia, the limit the progression of monitoring which is based on individual evidence suggests an increasing risk of complications related to clinical need and not on an ability to pay hypoglycaemia. From the patients’ hyperglycaemia. (Diabetes UK, Accessed March, 2004). perspective, this most feared However, no detailed recommendations complication of diabetes is a major Home blood glucose on monitoring have been produced. limiting factor in the achievement of 4monitoring empowers people with diabetes to Therefore, guidance is needed. good glycaemic control, especially for understand and thereby There is a lack of randomised people on insulin therapy. better manage their own controlled clinical trials in support of the The measurement of HbA1c has an glycaemic control. role of blood glucose monitoring in the integral part to play in the management treatment of type 1 and type 2 diabetes, of diabetes, providing an overall and results from meta-analyses are indication of ambient blood glucose levels inconclusive (Coster et al, 2000). This over time, whereas home blood glucose deficiency is an important contributor to monitoring provides people with diabetes the variation in practice both in primary the opportunity to manage their and secondary care. Some clinical studies requirements on a day-to-day basis. have suggested that home blood glucose monitoring in type 2 diabetes confers no The need for home blood significant benefit in improving glycaemic glucose monitoring control (Patrick et al, 1994; Gallichan, Home blood glucose monitoring 1997). However, there is an increasing empowers people with diabetes to body of evidence indicating the benefits of understand and thereby better manage home blood glucose monitoring their own glycaemic control. It also (Nyomba et al, 2003; Muhrata et al, 2003). forms the basis upon which the clinician It is the collective view of this can interpret the individual patient’s

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glycaemic profile, including both either state. Reliance on subjective PAGE POINTS preprandial and postprandial blood signs/symptoms (without testing) has glucose levels reflecting lifestyle and been shown on occasions to be Individual patients 1should be made aware different treatment modalities (Blonde et disturbingly unreliable (Pramming et al, of the importance of al, 2002). 1990). blood glucose monitoring It is known that people with poor Alterations in treatment. Any change in in recognition of the glycaemic control are more likely to blood glucose lowering therapies evidence emanating from suffer from the long-term vascular requires detailed monitoring of blood the DCCT and UKPDS. complications of diabetes and have an glucose to improve safety whilst increased risk of death from a diabetes- optimising effectiveness. HbA1c represents a related cause (DCCT Group, 1993; 2historical integrated UKPDS, 1998). This group believe that (2) Circumstances that require measure of blood glucose the individual patient should be made additional blood glucose information: and does not reflect the aware of the importance of blood glucose Patients with impaired awareness of variability in blood monitoring in recognition of the evidence hypoglycaemia. Home blood glucose glucose concentrations. emanating from the DCCT and UKPDS. monitoring is mandatory in people who Depending on the This article is intended to provide a are suspected or confirmed to have 3treatment regimen, general basis upon which individual patient unawareness of hypoglycaemia. knowledge of actual care plans may be formulated. Key factors Meeting targets. The national targets preprandial and/or supporting the need for home blood defined by NICE, the General Medical postprandial blood glucose monitoring in people with type Services contract (GMS2) and the NSF glucose levels is needed 1 diabetes or with type 2 diabetes can be for Diabetes require regular HbA1c to avoid hyperglycaemia divided into those that are: monitoring. In order to achieve these and hypoglycaemia. (1) Absolute requirements for blood targets, appropriate blood glucose glucose monitoring. measurements are necessary (NICE, Any change in blood (2) Situations that demand additional 2002; DoH, 2001; BMA, 2003). glucose lowering 4 information than can be derived from Everyday circumstances. The following therapies requires detailed monitoring of HbA1c measurement alone. circumstances normally require frequent blood glucose to improve monitoring of blood glucose in order to safety whilst optimising (1) Absolute requirements for avoid hypoglycaemia: effectiveness. home blood glucose monitoring: Exercise There is more to diabetes control than Certain employment (such as shift People who adopt by HbA1c alone. The gold standard is work) 5intensive insulin represented by 3–6 months regular Intercurrent illness therapies such as multiple HbA1c testing (DoH, 2001). This Driving of vehicles (drivers must be daily injections or insulin standard may be only be possible for able to evidence test data) pumps require regular those people attending a review at Children feedback regarding blood 6-monthly intervals. As HbA reflects Pregnancy glucose levels. 1c glucose exposure over the lifespan of red Breastfeeding blood cells (120 days) it is a weighted Outpatient procedures measure of average blood glucose Drug/alcohol abuse (monitoring is control, with 50% of the final value desirable although it is realised that reflecting the final 30 days (Pickup, 2003). adherence may be variable and As such, it represents a historical unreliable). integrated measure of blood glucose and Intensive treatment programmes. does not reflect the variability in blood People with diabetes who adopt glucose concentrations. Therefore, its intensive insulin therapies such as interpretation requires additional multiple daily injections or insulin information derived from blood glucose pumps require regular feedback profiles. regarding blood glucose levels. This is Hypoglycaemia/hyperglycaemia. Depending particularly relevant for self-adjustment on the treatment regimen, knowledge of of insulin dose according to actual preprandial and/or postprandial circumstances (content of foods, blood glucose levels is needed to avoid exercise, etc).

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Patient empowerment. Blood glucose both the patient and clinician with PAGE POINTS monitoring is an objective basis for detailed data from which to better assess people with diabetes to self-regulate current glycaemic control and form the The most important their diabetes both safely and basis for improving and/or adjusting the 1principles for regular effectively. Patient empowerment is a treatment (such as insulin dosage). For blood glucose prerequisite for effective diabetes care those patients who are less able to monitoring in patients (DoH, 2001; Diabetes UK website, interpret their own blood glucose data, with type 1 or type 2 accessed 2004). this approach may be particularly diabetes must be quality Pre-pregnancy counselling. Monitoring of useful. and stability of control blood glucose is desirable to achieve It is well accepted that patients with and avoidance of appropriate glycaemic control prior to type 1 diabetes should monitor their hypoglycaemia. conception. blood glucose levels as part of their self- Glycaemic control is Special clinical situations: management programmes. The European generally less stable Dialysis Diabetes Policy Group states that all 2 in people with type 1 Acute coronary syndromes patients with type 1 diabetes should test diabetes than those with Terminal care their blood glucose on a regular basis type 2 diabetes and those Perioperative management and appropriate training and frequent with type 2 diabetes are at The most important principles for review of technique should be greater risk of regular blood glucose monitoring in undertaken (European Diabetes Policy hypoglycaemia and patients with type 1 or type 2 diabetes Group 1998, 1999). hyperglycaemia. must be quality and stability of control and avoidance of hypoglycaemia (DCCT, IDF desktop guide Appropriate training 1993). recommendations 3and education is Recommendations from the International required so that people with diabetes can safely Monitoring in type 1 diabetes Diabetes Federation desktop guide adjust their insulin doses In general, glycaemic control is less regarding frequency of home blood according to their blood stable in people with type 1 diabetes glucose monitoring for patients with type glucose results. than in those with type 2 diabetes and 1 diabetes are as follows (European people with type 1 diabetes are at Diabetes Policy Group 1998, 1999): Frequent testing greater risk of hypoglycaemia and Results are recorded (with date and time, 4during the 2 weeks hyperglycaemia. More frequent blood insulin dose, hypoglycaemia) to provide a preceding a clinic visit glucose testing may therefore be needed. cumulative record as a basis for day-to- will provide both the For most people with type 1 diabetes day changes in therapy. patient and the clinician this may require an average of 4 tests per Different patterns of testing according to with detailed data from day to include preprandial and bedtime need: which to better assess current glycaemic values, on initiation of insulin. More Four or more times a day during control. frequent testing is indicated in certain illness, lifestyle changes, pre- circumstances as can be seen in Table 1. conception, in pregnancy and Patient empowerment is an important impaired awareness of hypoglycaemia. element in defining the necessary At night (0200–0400 h) if unrecognised frequency of blood glucose testing night-time hypoglycaemia is suspected. (DoH, 2001). Appropriate training and One or two multipoint profiles a week education is therefore required so that (on different types of day). people with diabetes can safely adjust their Once daily testing is the minimum insulin doses according to their blood acceptable frequency (at different times glucose results. This approach results in a of day). more flexible lifestyle for the patient. Daytime tests preprandially and 1–2 h For people who have highly variable after meals. blood glucose control, more frequent tests Regular bedtime tests in people prone per day may be required for a period of to nocturnal hypoglycaemia. time, according to need. There could also be benefits from more Monitoring in frequent testing during the 2 weeks preceding a clinic visit. This will provide Because of the risks posed to the foetus

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by both hyperglycaemia and its potential at least once per day during basal insulin PAGE POINTS teratogenic effects and hypoglycaemia, dose titration. It is recommended that regular monitoring of blood glucose is testing be conducted at different times Pregnant women who 1can achieve glycaemic important in gestational diabetes of the day to avoid hypoglycaemia. control through diet alone especially when using insulin (Homko et People who are maintained on once should monitor their blood al, 1998). Women with gestational daily basal insulin, who have stable glucose at least once every diabetes who are on insulin should glycaemic control and do not experience 2 days including fasting monitor their blood glucose at least hypoglycaemia should test their blood and 1 h postprandial. four times per day, ensuring that they glucose twice or three times a week. include both fasting blood glucose and However, people with type 2 diabetes People with type 2 1 h postprandial blood glucose who require twice-daily should 2diabetes who use measurements. monitor twice a day at various times insulin or oral Pregnant women who can achieve to include preprandial, postprandial hypoglycaemic agents glycaemic control through diet alone and pre-bedtime blood glucose should monitor their should monitor their blood glucose at measurements. blood glucose at least once daily, varying the least once every 2 days including fasting Combined insulin and oral time of testing between and 1 h postprandial. According to clinical fasting, preprandial and practice, a full profile may be necessary antidiabetic therapy postprandial glucose on alternate days. People with diabetes who use insulin and levels during the day. an oral antidiabetic agent should monitor Monitoring in type 2 diabetes their blood glucose at least once per day. People with People with type 2 diabetes are more During insulin dose titration, fasting 3type 2 diabetes who stable and do not require monitoring as blood glucose should be measured once use a multiple daily frequently as those with type 1 diabetes. per day. Once the insulin dose is insulin regimen should People with type 2 diabetes who use established it is recommended that monitor their blood insulin or oral hypoglycaemic agents testing be conducted at different times glucose in the same should monitor their blood glucose at of the day to identify hypoglycaemia way as those with type 1 diabetes. least once daily, varying the time of as required, especially nocturnal testing between fasting, preprandial and hypoglycaemia. A minority of people Fasting blood postprandial glucose levels during the day. with less stable glycaemic control may 4 glucose should be At treatment initiation, the frequency of require more frequent testing. The risk tested at least once per monitoring may need to be increased. The of hypoglycaemia is relatively low in day during basal insulin European Diabetes Policy Group states these people compared with those with dose titration. that all people should have access to type 1 diabetes (Allen et al, in press). effective self-monitoring of blood glucose Glycaemic control (European Diabetes Policy Group, 1999, Diet and exercise 5managed by diet and 1999). In practice, the level of monitoring Glycaemic control managed by diet and exercise in people with will vary according to the treatment exercise in people with type 2 diabetes is type 2 diabetes is regimen in use and the target level of generally best monitored through HbA generally best monitored 1c through HbA testing. glycaemic control set for the patient. A testing (Franciosi et al, 2001). Blood 1c minority of people with unstable glucose monitoring should not be glycaemic control may require more required routinely when control is frequent testing during such periods. stable, however, certain circumstances will require more frequent testing. Multiple daily insulin injection Therefore, education should be provided regimens regarding blood glucose monitoring People with type 2 diabetes who use a technique, interpretation of the results, multiple daily insulin regimen should etc (European Diabetes Policy Group monitor their blood glucose in the same 1999, 1999). way as those with type 1 diabetes as can People who self-monitor will be aware be seen in Table 1. of the effect that eating and exercise have on their blood glucose levels. This Conventional insulin therapy information can help to motivate people Fasting blood glucose should be tested to alter their diet and increase physical

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activity in order to improve their derivatives and may be misinterpreted as glycaemic status where necessary. an expression of concomitant disease PAGE POINTS Situations that may require blood such as macrovascular disease. Hypoglycaemia is glucose monitoring, include the Special circumstances 1more common than following: assumed in people with Periods of illness. Special circumstances comprise acute type 2 diabetes on Change in therapy. coronary syndromes, dialysis, pregnancy, sulphonylureas, and less Prescribing of steroids. People with terminal care, driving and metabolic common on meglitinide type 2 diabetes who take concomitant emergencies. derivatives. steroids should monitor at least once per day, to include midday, before the Acute coronary syndromes People with diabetes evening meal and 2 hours after the People with diabetes who are in coronary 2who are in coronary evening meal. care units should be monitored using care units should be Patients with postprandial hospital laboratory facilities. The patient’s monitored using hospital laboratory facilities. hyperglycaemia (due to the potential link coronary care team will determine the with macrovascular disease). frequency of blood glucose monitoring. Pregnant women with Where regular HbA1c testing is not People who are newly diagnosed with 3type 1 diabetes available. hypoglycaemia need to be educated about should monitor their blood glucose monitoring as it relates to blood glucose at least Metformin monotherapy (or in their treatment (Malmberg et al, 1996). four times per day to combination with glitazones) include both fasting and As for diet and exercise. These people Dialysis 1h postprandial blood are seldom prone to hypoglycaemic Patients undergoing dialysis will be under glucose measurements. episodes. the care of their renal unit. The patient’s renal team will therefore determine the Pregnant women who Glitazone monotherapy (or in blood glucose monitoring frequency 4can achieve optimal glycaemic control through combination with metformin) according to the dialysis programme and diet alone should monitor As for diet and exercise. These people dialysis perfusate (peritoneal dialysis). their blood glucose once are not prone to hypoglycaemic every 2 days and fasting Pregnancy episodes. and 1h postprandial blood Women with type 1 diabetes should glucose on alternate days. Sulphonylurea or non-sulphonylurea monitor their blood glucose at least four insulin secretagogues times per day to include both fasting and Patients receiving Hypoglycaemia is a common occurrence 1h postprandial blood glucose 5terminal care will in people treated with sulphonylureas measurements. On occasions a full day require monitoring to and less so in those treated with the profile may be required comprising of ensure that they avoid insulin secretagogues. If severe, 6 or more blood glucose measurements. hypoglycaemia and hypoglycaemia may be associated with Women with type 2 diabetes should be periods of excessive hyperglycaemia. significant morbidity and mortality treated as above if they are on insulin (Asplund et al, 1983; Holstein and treatment. Egberts, 2003; Jennings et al, 1989; Shorr Women who can achieve optimal et al, 1997; Miller et al, 2001). Blood glycaemic control through diet alone glucose should therefore be tested to should monitor their blood glucose once ensure that asymptomatic hypoglycaemia every 2 days and fasting and 1 h is identified. postprandial blood glucose on alternate Testing of blood glucose is days. recommended at least 3 times per week. Testing should be undertaken at Terminal care different times of the day to ensure Patients receiving terminal care will that hypoglycaemia is identified. require monitoring to ensure that they Hypoglycaemia is more common than avoid hypoglycaemia and periods of assumed in people with type 2 diabetes excessive hyperglycaemia. Monitoring on sulphonylureas (Jennings et al, 1989) more than once per day may be and less common on meglitinide necessary in people whose diabetes is

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stable, and adjusted as the need arises. monitoring four or more times per day PAGE POINTS as required during insulin initiation and Driving The emergence of adjustment in dosage and/or insulin 1metabolic Hypoglycaemia is a very important and regimen. emergencies such as potentially dangerous problem for People with type 2 diabetes who use drivers especially in people who are multiple daily insulin injections should require frequent blood treated with insulin. Blood glucose have access to home blood glucose glucose monitoring. testing is therefore recommended before monitoring in the same way as people any journey, and should be repeated at with type 1 diabetes. For people with All people with type 1 regular intervals on long journeys (every type 2 diabetes who are using a 2diabetes should have 2 h). However, it is reported that few conventional insulin regimen and who access to home blood drivers heed this advice (Graveling et al, have stable control, blood glucose glucose monitoring four in press). Legal precedent in a recent monitoring two or three times a week or more times per day as fatal accident case has indicated that it is should be adequate. required. the responsibility of the driver to ensure Due to the risk of hypoglycaemia People with type personal safety to drive by testing blood associated with sulphonylureas, based on 32 diabetes who use glucose. Blood glucose monitoring at least three tests per week, blood multiple daily insulin equipment should be carried in the glucose should be tested at different injections should have vehicle. It is recommended that testing is times of the day to ensure that access to home blood especially important in people who have asymptomatic biochemical hypoglycaemia glucose monitoring in impaired awareness of hypoglycaemia. It is identified. the same way as people is also recommended that a prophylactic Well-controlled people with type 2 with type 1 diabetes. snack should be taken if the blood diabetes on diet and exercise, with or glucose is less than 5.0 mmol/l (Cox et al, without metformin or thiozolidinedione People with 2002). Blood glucose monitoring is a (glitazone) treatment do not need daily type 2 diabetes who 4 prerequisite for vocational licences (C1) home blood glucose monitoring, unless are using a conventional insulin regimen and who in insulin-treated drivers (Frier, 1999). they are de-stabilised by other factors have stable control such as intercurrent illness, etc. should monitor their Metabolic emergencies Frequency of testing should be adjusted blood glucose two or The emergence of metabolic where control is regarded as unstable due three times a week. emergencies such as diabetic to certain circumstances, in an attempt to ketoacidosis (DKA) and hyperosmolar improve control whilst at the same time People with type 2 non ketotic hyperglycaemia/coma avoiding hypoglycaemia. Recommendations 5diabetes who have (HONK) and hypoglycaemia requires regarding blood glucose monitoring are good control on diet and more frequent blood glucose monitoring outlined in Table 2. exercise, metformin or to assist in the assessment of these life glitazone treatment do threatening situations, to determine ‘If you cannot measure it, you cannot not need daily home blood response, or lack of, to treatment and improve it’. Lord Kelvin 1824-1907 glucose monitoring, unless the need for hospital admissions. Home they are destabilised by blood glucose testing equipment is not other factors. Supported by an unrestricted designed for use in hospital during the educational grant from acute stabilisation/treatment period of Roche Diagnostics Ltd, Lewes, UK such metabolic emergencies.

Conclusions Regular monitoring of HbA is 1c Allen K V, McAulay V, Sommerfield A J, important for all people with diabetes as Frier BM Hypoglycaemia is uncommon described in the NSF for Diabetes (DoH, with combination therapy of oral antidiabetic drugs and bedtime isophane (NPH) insulin 2001). Provision of appropriate home for type 2 diabetes. Practical Diabetes blood glucose monitoring materials is International in press key to successful patient empowerment Asplund K, Wilholm BE, Lithner F (1983) to deliver good glycaemic control safely. Glibenclamide-associated hypoglycaemia: a All people with type 1 diabetes should report on 57 cases. Diabetologia 24: 412–17 have access to home blood glucose Blonde L, Ginsberg BH, Horn S (2002) Frequency

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of blood glucose monitoring in relation to Jennings AM, Wilson RM, Ward JD (1989) glycaemic control in patients with type 2 Symptomatic hypoglycaemia in NIDDM patients diabetes. Diabetes Care 25(1): 245–46 treated with oral hypoglycaemic agents. Diabetes ‘Frequency of Care 12(3): 203–08 British Medical Association (2003) Investing in testing should be general practice; the new General Medical Services Malmberg K, Ryden L, Hamsten A et al contract. British Medical Association, London (1996) Effects of insulin treatment on cause- adjusted where specific one-year mortality and morbidity control is unstable Burrill P (2002) Is self-monitoring of glycaemic in diabetic patients with acute myocardial control of any value? Pharmaceutical Journal infarction. DIGAMI study group. Diabetes by exceptional 268(7202): 847–848 insulin-glucose in acute myocardial infarction. European Heart Journal 17(9): circumstances, to Coster S, Gulliford MC, Seed PT, Powrie JK, 1337–44 Swaminathan R (2000) Self-monitoring in type 2 ensure better diabetes mellitus: a meta-analysis. Diabetic Miller CD, Phillips LS, Ziemer DC et al (2001) Medicine 17: 755–61 Hypoglycaemia in patients with type 2 diabetes glycaemic control mellitus. Archives of Internal Medicine 161(13): and avoidance of Cox DJ, Gonder-Frederick LA, Kovatchev 1653–59 BP, Clarke WL (2002) The metabolic hypoglycaemia. demands of driving for drivers with type Muhrata GH, Shah JH, Hoffman RM et al (2003) ’ 1 diabetes mellitus. Diabetes/Metabolism Intensified blood glucose monitoring improves Research Reviews 18(5): 381–385 glycaemic control in stable, insulin-treated veterans with type 2 diabetes. Diabetes Care DoH (2001) National Service Framework for Diabetes: 26(6): 1759–63 Standards. Department of Health, London National Prescribing Centre (2002) When and how Diabetes Control and Compilations Trial Research should patients with diabetes mellitus test blood Group (1993) The effect of intensive treatment glucose? MeReC Bulletin 13(1): of diabetes on the development and progression of long-term complications in insulin-dependent National Diabetes Support Team (2003) Glucose diabetes mellitus. New England Journal of self-monitoring in diabetes: fact sheet No 1. NHS Medicine, 329: 977–86 Modernisation Agency Clinical Governance Support Team Diabetes UK (2004) Position statement: home monitoring of blood glucose levels. Diabetes UK, NICE (2002) Management of type 2 diabetes: London http://www.diabetes.org.uk/infocentre/ management of blood glucose – inherited clinical state/monitoring.htm. Accessed: 04/04/04 guideline. National Institute of Clinical Excellence, London European Diabetes Policy Group 1999 (1999) A desktop guide to type 2 diabetes mellitus. Nyomba BLG, Berard L, Murphy LJ (2003) European Diabetes Policy Group 1999 Diabetic Facilitating access to glucometer reagents Medicine 16(9): 716–30 increases blood glucose self-monitoring frequency and improves glycaemic control: a European Diabetes Policy Group 1998 (1999) A prospective study in insulin treated diabetic desktop guide to type 1 (insulin dependent) patients. Diabetic Medicine 21: 129–35 diabetes mellitus. European Diabetes Policy Group 1998. Diabetic Medicine 16(3): 253–66 Patrick AW, Gill GV, MacFarlane IA, Cullen A, Power E, Wallymahmed M (1994) Home glucose Franciosi M, Pellegrini F, De Berardis D et al monitoring in type 2 diabetes: is it a waste of (2001) The impact of blood glucose self- time? Diabetic Medicine 1994 1: 62–65 monitoring on metabolic control and quality of life in type 2 diabetic patients. Diabetes Care Pickup JC (2003) Diabetic control and its 24(11): 1870–77 measurement. In: Pickup JC and Williams G (Eds) Textbook of Diabetes 3rd Edition 34.1-34.17 Frier BM (1999) Living with hypoglycaemia In: Blackwell Publishing, Oxford Hypoglycaemia in Clinical Diabetes Eds: Frier BM, Fisher BM. John Wiley and Sons, Chichester Pramming S, Thorsteinsson B, Bendtson I, 261–90 Binder C (1990) The relationship between symptomatic and biochemical hypoglycaemia Provision of Gallichan M (1997) Self monitoring of glucose by in insulin-dependent diabetic patients. ‘ people with diabetes: evidence based practice. Journal of Internal Medicine 228(6): 641–46 appropriate home British Medical Journal 314: 964 Shorr RI, Ray WA, Daugherty JR, Griffin MR (1997) blood glucose Graveling A J, Warren R E, Frier B M (In Press) Incidence and risk factors for serious Hypoglycaemia and driving in people with hypoglycaemia in older persons using insulin or monitoring insulin – treated diabetes: adherence to sulfonylureas. Archives of Internal Medicine materials is key recommendations for avoidance. Diabetic 157(15): 1681–86 Medicine to successful Tiley S (2002) Home blood glucose monitoring - Holstein A, Egberts EH (2003) Risk of what cost? Practical Diabetes International 19(8): patient hypoglycaemia with oral antidiabetic agents in S1–S4 patients with type 2 diabetes. Experimental and empowerment to Clinical Endocrinology and Diabetes 111: 405–14 UK Prospective Diabetes Study (UKPDS) group (1998) Intensive blood glucose control deliver good Homko CJ, Sivan E, Reece EA (1998) Is self- with sulphonylureas or insulin compared glycaemic control monitoring of blood glucose necessary in the with conventional treatment and risk of management of gestational diabetes mellitus. complications in patients with type 2 diabetes safely. Diabetes Care 21 (Supp 2): B118–22 (UKPDS 33). Lancet 352: 837–53 ’

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Table 2. Recommendations regarding blood glucose monitoring

Diabetes type Treatment group Monitoring regimen

Type 1 All people with Blood glucose monitoring should be seen as an integral part of treating diabetes type 1 diabetes type 1 diabetes. People with type 1 diabetes should be trained to monitor blood glucose and alter treatment appropriately. The majority of people with type 1 diabetes are liable to instability of glycaemic control and should therefore monitor blood glucose 4 or more times per day to prevent hypoglycaemia and treat hyperglycaemia. The following situations indicate the need for even more frequent testing: myocardial infarction, dialysis, pregnancy, terminal care, impaired awareness of hypoglycaemia.

Gestational All people with For women treated with diet, testing once every 2 days is recommended, diabetes gestational diabetes including fasting and 1 h postprandial blood glucose. For women treated with insulin or other pharmacotherapy, it is recommended that blood glucose should be monitored at least four times per day, to include the fasting state and 1h postprandially.

Type 2 Intensive insulin As with type 1 diabetes, monitoring should generally take place according to diabetes therapy need to prevent hypoglycaemia or hyperglycaemia.

Type 2 Conventional Fasting glucose should be tested at least once per day during titration. It is diabetes insulin therapy recommended that testing be conducted at different times of the day to identify hypoglycaemia. People with type 2 diabetes maintained on daily insulin who are stable and not experiencing hypoglycaemia should test their blood glucose once per day. Those people with type 2 diabetes requiring twice-daily insulins should monitor twice a day at various times to include pre and postprandial and pre-bedtime blood glucose measurements.

Type 2 Combined insulin Fasting glucose should be tested at least once per day during titration. In diabetes and oral antidiabetic addition, it is recommended that testing be conducted at different times of the therapy day to identify hypoglycaemia. People with type 2 diabetes who are maintained on daily insulin plus oral antidiabetic therapy should test their blood glucose once per day. People with type 2 diabetes who have unstable glycaemic control may require more frequent testing.

Type 2 Diet and exercise HbA1c is the real outcome measure in these people. Blood glucose monitoring diabetes should not be required routinely. However, people should be trained in blood glucose monitoring, interpretation of the results and appropriate amendments to treatment, as monitoring is required in special circumstances. Blood glucose may require monitoring, for example, once per day at varying times in the following circumstances: During a period of illness. When therapy is changed. If steroids are co-prescribed (to cover midday, before evening meal and 2 h after evening meal). When regular HbA1c testing is not available. Patients with postprandial hyperglycaemia (due to the potential link with macrovascular disease).

Type 2 Metformin As for diet and exercise diabetes (+/- glitazone)

Type 2 Glitazone As for diet and exercise diabetes (+/- metformin)

Type 2 Sulphonylurea alone Hypoglycaemia is a common occurrence in these people. Blood glucose should diabetes (or in combination therefore be tested to ensure that, if present, hypoglycaemia is identified. with other oral Testing of blood glucose is recommended at least 3 times per week. antidiabetic agents) Testing should be undertaken at different times of the day to ensure that hypoglycaemia is identified.