Outpatient blood glucose monitoring (BGM) needs to be meaningful, and the best way to achieve that is to individualize the process, so that changes in control, which may flag need for changes in hypoglycemia agents, may emerge, according to the American Association of Clinical Endocrinologists consensus statement, published in the February 2016 issue of Endocrine Practice.
“Meaningful monitoring” as discussed in the consensus statement comes down to an individualized approach to clinical management that is customized to patient preference and lifestyle.
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For adults with type 1 diabetes mellitus, the statement endorsed existing clinical practice guidelines that recommend blood glucose testing upon awakening, after each meal, at bedtime, and before driving, with a frequency ranging from at least 4-6 each day to 10 or more times per day.
Blood glucose monitoring is also essential for achieving optimal control in children and adolescents with type 1 diabetes, but this can be particularly challenging in pediatric patients, according to the consensus statement’s authors (Endocr Pract. 2016, Feb;22[2]:231-61).
“Food intake and activity are unpredictable in very young patients, complicating parents’ efforts to regulate glucose levels,” wrote Dr. Timothy S. Bailey from the University of California, San Diego, and his coauthors.
“In adolescents, the emotional fatigue of managing their diabetes often leads to a reduced frequency of BGM, missed insulin doses, and markedly elevated hemoglobin A1c levels.”
Physicians, parents, and patients need to be cognizant of trends in glycemic control that might suggest the patient has outgrown the insulin dose and should be taught to make longer-term regimen adjustments. “Such pattern recognition requires maintaining and periodically reviewing an electronic or written log of blood glucose levels,” according to the consensus statement.
BGM was deemed essential to all patients with type 2 diabetes mellitus, even those not receiving insulin treatment, because it provides immediate feedback on glycemic control that is not provided with HbA1c measurement.
“Two of the goals for any BGM strategy are to empower patients to play a more active role in their diabetes management and to maximize the efficacy and safety of glucose-lowering therapies, including lifestyle management,” the authors wrote.
In patients on intensive insulin therapy with prandial and basal insulin, the authors recommended blood glucose monitoring be conducted when fasting, premeal, at bedtime and occasionally in the middle of the night.
In patients on basal insulin only or in combination with other diabetes medications, blood glucose testing was recommended at least when fasting and at bedtime.
When it comes to patients on noninsulin therapies for type 2 diabetes, guidelines advise that blood glucose monitoring be used only when patients or their caregivers are equipped to incorporate it and the resulting therapeutic adjustments into the diabetes care plan.
The only exception to this was in patients receiving noninsulin agents linked with a higher risk of hypoglycemia, such as sulfonylureas and glinides, in which case, they should test their fasting blood glucose at least once a day and periodically at other times, the authors recommended.
In pregnant women with gestational diabetes, the consensus was to test fasting and 1 hour postprandial if patients were not receiving insulin, and to test fasting, preprandial, and 1 hour postprandial in those receiving insulin.
The authors also noted that there is some variation in accuracy among the blood glucose monitors approved by the Food and Drug Administration, but the degree of accuracy required is dependent on the patient.
“As the technology advances, there is a vital need to integrate the multiple data inputs from insulin pumps, glucose sensors, glucose meters, and carbohydrate intake in a comprehensive and standardized way so clinicians and patients can make sense of it all.”
The consensus statement was produced by the American Association of Clinical Endocrinologists. All but one author declared fees, honoraria, and research grants from the pharmaceutical industry.