Self Monitored Blood Glucose (SMBG)

Glucose monitoring engages the patient as an active member in their diabetes management and allows for informed decision making.

Self monitored blood glucose is a component of effective DM care. Patients use SMBG levels to obtain useful information about the status of their diabetes and insight into the effects of diet and activity on their diabetes control. Results of SMBG can be useful in preventing hypoglycemia and help with adjustments of medications, nutrition, and physical activity. Even a minimum number of glucose tests each day can yield useful information.

There is no one single glucose monitoring pattern which is useful for patients with diabetes over the course of their disease. A prescription for SMBG should take into account the complexity of the DM treatment regimen and the patient’s risk of hypoglycemia. Recommend glucose monitoring to obtain the most useful information.

Efficient glucose monitoring allows for a patient centered context to adjust treatment. Does the patient have stable versus unstable glucose control? Is the patient having hypoglycemic episodes? Does the patient require a titration of medications? Are you trying to evaluate the effects of food or a change in nutrition, activity or the effect of illness? For each scenario glucose monitoring will be performed at different times to allow the appropriate question to be answered. Patients should be introduced to several formats of glucose monitoring, and how to utilize the information to enhance DM self management.

For patient safety, glucose testing supplies and hypoglycemia treatment should be available at all times. Glucose levels should be checked more frequently during an illness or if symptoms of hypoglycemia ensue.

Ensure that patients receive initial instructions and routine follow-up evaluation of SMBG technique. Many patients like the option of “no coding” test strips and the use of offsite testing on the palm, forearm, thighs and calf. These sites tend to have less discomfort. Glucose monitors should be checked for accuracy periodically and replaced every three years.

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Patterns of Glucose Monitoring

Patients use different SMBG strategies based on context. Examples of context include: • if a person has stable glucose levels • if a person has unstable glucose levels • if a person is having hypoglycemia / safety issues • for the effects of food and activity (concepts taught in Diabetes Self Management Education, DSME) • for changes in nutrition, activity or sick days

1. Stable glucose levels a. Check BG pre-breakfast and pre-dinner on even days and pre-lunch and pre-bedtime on odd days. The patient checks their glucose level twice a day but the alternating fashion gives the patient and provider a glimpse of the glucose levels throughout the day and to look for patterns.

Before After Before After Before After Bedtime Breakfast Breakfast Lunch Lunch Dinner Dinner Monday X X Tuesday X X Wednesday X X Thursday X X

a. Less frequent SMBG can be used in patients on oral hypoglycemic agents (OHA) or for whom more frequent SMBG is cost prohibitive. Check the glucose pre-breakfast one day and pre-dinner the following day. Or less if necessary but still keeping up this basic pattern.

b. For a broader picture of BG control, the patient should check and record their glucose pre-meals and bedtime for three days prior to the visit.

2. Hypoglycemia a. To avoid hypoglycemia patients should check their glucose if they have: i. symptoms of hypoglycemia, ii. plans on increasing their activity iii. a change in nutrition, or iv. will be driving and have not eaten in the past three hours.

3. Nutrition and Sick days are a common cause of both hyperglycemia and hypoglycemia. Patients should check their glucose level if they feel ill. Glucose monitoring should be done every 2-4 hours or if symptoms of hypoglycemia ensue.

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4. Unstable BG and Medication Adjustment. Patients should check their glucose based on the expected effect of an oral hypoglycemic agent or insulin. For instance, if a patient is started on mealtime insulin, to assess the affect of the pre-meal insulin on the BG, the patient should focus monitoring of glucose levels either pre- or post lunch, dinner and HS. Post meal SMBG should be done 2 hours after the meal. Or, to adjust a bedtime basal insulin dose the patient will need to check the fasting blood glucose regularly while recording the HS glucose level three times per week.

a. Staggered Glucose Levels enable the patient to look at both fasting and a pre and post meal glucose each day.

Before After Before After Before After Bedtime Breakfast Breakfast Lunch Lunch Dinner Dinner Monday X X X Tuesday X X X Wednesday X X X Thursday X X X Friday X X X Saturday X X X Sunday X X X

5. Food and activity – Each patient should periodically examine the effects of their meal choices on glucose control. This powerful approach is a major focus of DSME. Patients are encouraged to record and review their food choices to determine the effects of food on their pre- and post meal glucose levels. This can be done similarly for pre, immediately and one hour after physical activity.

a. In DSME, if the patient is on oral medication, the patient will have been instructed to record the fasting, two hour after meals and bedtime for three days. SMBG record should be brought to each health care visit. Ideally this is coupled with the patient’s observations concerning how food choices and activity affect glucose. Pt should not snack between a meal and a two hour after meal BG check. If the patient is on insulin, the patient will have been instructed to record pre and post meals for three days.

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Before After Before After Before After Bedtime Breakfast Breakfast Lunch Lunch Dinner Dinner Breakfast Breakfast Lunch Dinner Monday X X X X X Tuesday X X X X X Wednesday X X X X X

b. If the patient is on insulin, the patient will have been instructed to record pre and post meals for three days.

Before After Before After Before After Bedtime Breakfast Breakfast Lunch Lunch Dinner Dinner Breakfast Breakfast Lunch Dinner Monday X X X X X X X Tuesday X X X X X X X Wednesday X X X X X X X

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2009 Comparison of Frequently Used Glucometers

* Most features and least expensive glucose test strips (November 2009)

Glucometer Alternate Sample Results Strips w/ cost Range Coding Comparison Table Sites Size(uL) (sec)

Freestyle Freedom 50 for $28 Yes 0.3 20-500 None 5 Lite 100 for $58 (all)

50 for $35 Yes FreeStyle Lite 0.3 20-500 None 5 100 for $68 (all) * 50 for $20 Yes 0.5 20-600 None 6 WaveSense Presto 100 for $41 (forearm, palm) 50 for$29 Yes Contour 0.6 10-600 None 5 100 for $57 (forearm, palm) Yes One Touch Ultra Mini 50 for $47 1 20-600 Yes 5 (forearm, palm) 50 for $40 Yes Accu-Check Avia 0.6 10-600 Yes 5 100 for $77 (all) 50 for $25 Yes Reli-On Micro 0.3 20-600 None 7 (palm)

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