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Blood Glucose Monitoring: a Practical Guide for Use in the Office and Clinic Setting

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Blood Glucose Monitoring: a Practical Guide for Use in the Office and Clinic Setting In Brief Interpretation of self-monitoring of blood glucose (SMBG) results is not routinely practiced in the office and clinic setting. However, such interpreta- tion in the presence of patients may facilitate improved patient-provider discussion, clinical decisions, and ability to manage glycemic patterns. This review outlines key steps in a systematic review of SMBG data, including 1) identifying the degree of blood glucose control using mean and standard deviation or variance, 2) identifying patient safety concerns with regard to hypoglycemia, and 3) understanding the factors influencing blood glucose control by noting trends and patterns. Case studies are provided to illustrate the process for using and interpreting electronic SMBG downloads. Blood Glucose Monitoring: A Practical Guide for Use in the Office and Clinic Setting In 1978, the introduction of home In an uncontrolled study conducted blood glucose meters for self-moni- at two community pharmacies in Vir- Peggy Soule Odegard, PharmD, toring of blood glucose (SMBG) pro- ginia, blood glucose values decreased vided a new window through which significantly at 12 months compared BCPS, CDE, and Jennifer Rose people with diabetes could observe to baseline (P < 0.05), while medica- Beach, PharmD, CDE and respond to the daily influences tion adherence was maintained at on blood glucose affecting their dia- 90% for those receiving pharmacist betes.1,2 This new vantage point on review and consultation about their blood glucose also provided health SMBG results.5 care providers with a novel and effec- Some third-party insurers offer free tive way to provide counseling, target blood glucose meters through their therapy, and empower people with drug benefit. However, personalized diabetes to have more control over training and instruction of patients or management of their diabetes. Since regular monitoring of results does not that time, the technology of blood appear to be linked to these programs. glucose monitoring has developed Instead, clients are referred to the meter significantly to facilitate convenience use instructions available through the of meter use and interpretation of blood glucose meter manufacturer’s results.3 Specific developments that websites.6,7 The consensus statement have driven the market include developed by people with diabetes at substantial reduction in meter size, the seventh annual “Taking Control speed of testing (5 seconds is com- of Your Diabetes” conference indicates mon now), automated controls and that patients desire to have increased strip coding, minimal need for blood participation in decisions and under- (as low as 0.3 µl), enhanced memory, standing of test results. Systematic and the ability to download results. review and discussion with patients Table 1 displays the key features of about SMBG results makes this desire several popular meters. a possibility.8 Although technology has ad- Whether in a clinic, office, or vanced to facilitate increased use of pharmacy setting, key challenges home blood glucose meters, published to systematic and ongoing SMBG reports describing systematic review consultation and review include poor and interpretation of this information provider familiarity with meters by health care providers are limited. because of a lack of training and A major diabetes trial conducted in workload limitations precluding community pharmacies that involved more extensive consultation with free distribution of blood glucose patients. These limitations in the monitors, education on use, and translation of meter technology into ongoing monitoring and consultation daily practice may negatively affect with pharmacists on results, demon- initial meter education and follow-up strated improved diabetes control.4 monitoring of results. In a clinic or 100 Diabetes Spectrum Volume 21, Number 2, 2008 Table 1. Selected Downloadable Blood Glucose Meters and Their Features 10 Update to Practice / Diabetes Technology Research From Name Coding Blood Testing Time Test Range Hematocrit Test Memory Special Volume (µl) (seconds) (mg/dl) Limits Features and (%) Notes Accu-Chek No coding 1.5 5 10–600 25–65 300 glucose Strips are Compact required readings with housed inside Plus* time and meter. Do date; 7-, 14-, not use if on and 30-day peritoneal averages dialysis. Accu-Chek Snap-in code 4 26 10–600 20–65 480 glucose Strips are Advantage* key readings with curved for time and ease of use. date; 7-, 14-, and 30-day averages Accu-Chek Snap-in code 0.6 5 10–600 Not reported 500 glucose Up to four Aviva* key in package readings with alarms can insert time and be set in the date; 7-, 14-, meter. Do and 30-day not use if on averages peritoneal dialysis. Ascencia Automatic 0.6 5 10–600 0–70 in 480 glucose Optional Contour (new new meters, readings with meal mark- 2007 ver- 20–60 in old time and ers with sion)† meter version date; 14-day postmeal average reminder alarms Ascencia Automatic 1 5 20–600 20–55 420 glucose Strips housed Breeze2† readingswith in meter. May time and be better for date; 1-, 7-, arthritis suf- and 30-day ferers. averages OneTouch Manual 1 5 20–600 30–55 150 glucose Ultra‡ readings with time and — date; 14- and 30-day aver- ages OneTouch Manual 1 5 20–600 30–55 500 glucose Meal markers Ultra2‡ readings with and other time and comments date; 7-, 14-, available. and 30-day averages OneTouch Manual 1 5 20–600 30–55 500 glucose UltraMini readings with — (new version)‡ time and date OneTouch Manual 1 5 20–600 30–55 More than Electronic UltraSmart‡ 3,000 records logbook op- with 7-, 14-, tions includ- 30-, 60-, and ing insulin, 90-day aver- exercise, ages health data, medication, and food continued on p. 102 Diabetes Spectrum Volume 21, Number 2, 2008 101 Table 1. Selected Downloadable Blood Glucose Meters and Their Features ,10 continued Name Coding Blood Testing Time Test Range Hematocrit Test Memory Special Volume (µl) (seconds) (mg/dl) Limits Features and (%) Notes Precision Xtra Calibrator in 0.6 5 20–500 30–60 450 glucose Tests blood (new version)§ each test strip readings with ketones box time and (strips use 1.5 date; 7-, 14-, µl; 10-second and 30-day results) averages Therasense Manual 0.3 7–15 20–500 0–60 250 glucose Freestyle§ readings with time and — date; 14-day average Therasense Manual 0.3 7 20–500 0–60 250 glucose Up to four Freestyle readings with daily alarms Flash§ time and can be set date; 14-day in meter. Do average not use if on peritoneal dialysis. Therasense Manual 0.3 5 20–500 0–60 250 glucose Up to four Freestyle Free- readings with daily alarms dom§ time and can be set date; 14-day in meter. Do average not use if on peritoneal dialysis. Therasense Automatic 0.3 5 20–500 15–65 400 glucose Up to four Freestyle Lite§ readings with daily alarms time and can be set date; 7-, 14-, in meter. Do and 30-day not use if on averages peritoneal dialysis. Truetrack|| Code chip 1 10 20–600 30–55 365 glucose Value meter readings with option 14- and 30- day averages Prodigy Automatic 0.6 6 20–600 20–60 450 glucose Talking Autocode¶ readings with meter; value time and meter option date; 7-, 14-, 21-, 28-, 60-, and 90-day averages *Roche (1-800-858-8072, www.accu-chek.com) †Bayer (1-800-248-8100, www.BayerDiabetes.com) ‡Lifescan (1-800-227-8862, www.lifescan.com) §Therasense (1-888-522-5226, www.AbbottDiabetesCare.com) ||Home Diagnostics (1-800-803-6025, www.homediagnostics.com) ¶Diagnostic Devices, Inc. (1-800-243-2636, www.prodigymeter.com) provider office setting, interpreta- function or downloading results to providers in rapid interpretation of tion of meter data is often limited evaluate the mean blood glucose and SMBG information in the clinic and to either reviewing patient logbooks standard deviation (SD). office setting. In this review, we will or records with infrequent use of the Software technology that is read- discuss, through the presentation of 7- or 14-day blood glucose averaging ily available and easy to use can assist two case studies, these technologies 102 Diabetes Spectrum Volume 21, Number 2, 2008 method of record keeping in diabetes. Update to Practice / Diabetes Technology Research From , continued However, interpretation of SMBG based on handwritten logbook records is dependent on patients’ record-keep- ing intensity and organization, and these records can vary dramatically in terms of helpfulness in making management decisions. Some patients who bring in a handwritten logbook are very careful to note the time of day, how much insulin or medication was given, what was eaten, and the corre- sponding blood glucose result. Other patients provide a collection of results, in random order, without indicating the date, time, or reason for taking the blood glucose measurement. When relying on handwritten SMBG results, it is essential that results are organized, timed, and provide a sense of the influence of Figure 1. Sample SMBG logbook. medications and lifestyle on blood glucose to allow for meaningful and suggest a step-by-step method for use of meter memory histories and diabetes care decision making. If log- same-visit interpretation of SMBG computation, and electronic meter books are lacking sufficient informa- results in the clinic or office setting. downloads with external software tion to provide feedback on diabetes analysis. Regardless of method, there self-management, patients should Case Study 1 are five standard goals for a system- be specifically instructed to increase B.T. is an 80-year-old woman with atic review: SMBG, including the time of day to type 2 diabetes, who has come to the 1. Estimate the degree of blood test and timing with regard to meals clinic for a checkup of her diabetes.
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