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Blood glucose self-monitoring in management of diabetes
mellitus
Author
David K McCulloch, MD
Section Editor
David M Nathan, MD
Deputy Editor
Jean E Mulder, MD
Last literature review version 19.1: January 2011 | This topic last updated:
February 9, 2011
INTRODUCTION — All patients with diabetes mellitus who use insulin and some patients
who take other glucose lowering medications that can cause hypoglycemia should measure
their blood glucose concentrations to help maintain good glucose control. The effectiveness
of self-monitoring in patients with type 2 diabetes who do not use hypoglycemic agents is
less certain.
Self-monitoring of blood glucose (SMBG) usually requires intermittent capillary blood
sampling and the use of a glucose meter, with different frequencies of testing indicated for
type 1 and type 2 diabetes. Devices to sample the glucose continuously from subcutaneous
fluid are now available, with ongoing development in progress.
In addition to self-monitoring of blood glucose, periodic measurement of glycosylated
hemoglobin (A1C) permits estimation of chronic glycemic control. Several practical points
about blood glucose monitoring will be reviewed here, including the accuracy of glucose
meters and glucose sticks, the accuracy of the operator, and how to use the glucose
information that is obtained. The use of A1C measurements to estimate mean blood glucose
is reviewed elsewhere. (See "Estimation of blood glucose control in diabetes mellitus".)
INDICATIONS
Type 1 diabetes — Results of the Diabetes Control and Complications Trial (DCCT) [1] and
a follow-up study to that trial [2] demonstrate that intensive insulin therapy is appropriate
for most patients with type 1 diabetes, to decrease the risk of both micro- and
macrovascular disease. (See "Insulin therapy in adults with type 1 diabetes mellitus".)
SMBG is an important component of a regimen for intensive insulin therapy. Self-monitoring
allows adjustments of insulin and diet content to be made based on immediate feedback of
glucose results, and allows timely intervention for low glucose readings to avert serious
hypoglycemic events. Self-monitoring of blood glucose is also important for patients with
type 1 diabetes who are not managed with intensive insulin, although they may require
somewhat less frequent testing.
The American Diabetes Association (ADA) recommends that patients with type 1 diabetes
monitor blood glucose at least three times daily [3,4]. For most patients with type 1
diabetes, testing blood sugar levels before and at intervals after meals; before, during, and
after exercise; and occasionally during the night will provide useful information for
adjusting insulin and carbohydrate intake.
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Type 2 diabetes — The fasting blood glucose concentration is often used to monitor
control in type 2 diabetes since it correlates well with A1C values [5,6]. Fasting blood
glucose concentrations are fairly stable in patients with type 2 diabetes, but can vary by
about 15 percent from day to day, and therefore changes in therapy should be based on an
average over several days [7]. Some have argued that nonfasting blood glucose
measurements are a better marker of glycemic control than fasting values [6].
The effectiveness of SMBG in terms of improving glycemic control in patients with type 2
diabetes is less clear than for type 1 diabetes. Multiple observational studies have evaluated
SMBG in type 2 diabetes, with some showing benefit [8,9] and others not [10-13]. Metaanalyses of randomized trials report conflicting results, with one reporting no benefit
[14] and two subsequent analyses, limited to trials evaluating SMBG in non-insulin users,
reporting a modest decrease in A1C in the SMBG group compared with control (pooled
mean difference -0.24 percent) [15,16]. In one of the larger trials included in the metaanalysis, 610 patients with type 2 diabetes who were treated with oral agents were
randomly assigned to SMBG or non-SMBG groups [17]. After 27 weeks, A1C decreased in
both groups. However, there was a significantly greater reduction in A1C in the SMBG group
(between group difference 0.25 percent). In contrast, other randomized trials have not
shown a significant reduction in A1C with self monitoring of glucose versus no monitoring
[18,19], and in one study of newly diagnosed patients, SMBG was associated with higher
scores on a depression scale [19].
Studies of SMBG have multiple potential biases. Patients who comply with self-monitoring
may have better lifestyle compliance as well, or may have worse glucose control and
therefore are more motivated. Patients who are less motivated may not be willing to
participate in randomized studies, so even randomized trials may represent only a selected
patient population [20].
Monitoring blood glucose is a tool, not a therapeutic intervention. It provides important
information with which motivated patients can modify their behavior and improve their A1C
values safely. However, SMBG is expensive. In an economic analysis of self-monitoring of
blood glucose (SMBG) using data from a UK trial [18], SMBG with or without training in
patient-initiated management of SMBG feedback, was unlikely to be cost-effective [21].
Thus, self-monitoring of glucose may not be necessary at all, or only in unusual
circumstances, for patients with type 2 diabetes who are diet-treated or who are treated
with oral agents not associated with hypoglycemia. SMBG may be helpful in patients who
take medications that can cause hypoglycemia. SMBG may also be useful for some type 2
diabetic patients who would take action to modify eating patterns or exercise, as well as be
willing to intensify pharmacotherapy, based on SMBG results. The ADA recommends that
patients with type 2 diabetes who are treated with insulin or oral hypoglycemic drugs
monitor blood glucose daily [3,4].
URINE TESTING — Although measuring urine glucose is less painful and may arguably be
easier than measuring blood glucose, it has significant errors that limit its accuracy as a
reflection of glycemic control and is not recommended [22].
Testing for ketonuria — Measurement of urinary ketones is less subject to error because
any positive value suggests the presence of ketonemia. The urine should be tested for
ketones if the blood glucose concentration is above 240 mg/dL (13.3 mmol/L), during
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periods of illness or stress, or if there are symptoms compatible with ketoacidosis such as
nausea, vomiting, and abdominal pain [22].
The present of ketones in the urine does not always mean that the person has impending
ketoacidosis. Ketonuria indicates that the person is in a catabolic state and is breaking
down fat, and can occur in anyone who has a negative caloric balance while dieting.
However, in the absence of a person purposely trying to restrict calories, the presence of
urine ketones along with hyperglycemia is more serious than hyperglycemia alone. Under
these circumstances, the person should be advised to retest every two to three hours, take
measures to keep well-hydrated, and take extra insulin if indicated. Treatment of diabetic
ketoacidosis is discussed separately. (See "Treatment of diabetic ketoacidosis and
hyperosmolar hyperglycemic state in adults".)
SOURCES OF ERROR
Operator — Errors in SMBG are most frequently attributed to operator-error [23].
Problems arise from failure to calibrate the meter correctly, dirty meters, inadequate hand
washing, or improper storage of the test strips.
We recommend use of one of the newer glucose meters in which the patient adds a drop of
blood to a strip already inserted into the meter. Patients who are motivated and test often
usually get much more reliable results than those who are less interested or who test less
often (such as non-expert clinicians) [24,25].
We also recommend the following steps to increase the accuracy of glucose monitoring:
z
z
The glucose meter and strips should be brought in for clinic visits. The patient's
method of testing should be observed periodically and any technical mistakes
corrected. Patients should be queried regarding storage of strips.
The glucose meter should be calibrated with a control solution (provided with the
glucose meter) every few boxes of strips. If this is out of range, or if SMBG results do
not seem consistent with expectations, we recommend that the patient bring the
glucose meter in to be checked against meters of known accuracy or with a
simultaneous lab value.
Blood glucose meters — Most glucose meters are reasonably accurate, and require only a
small drop of blood. Even with newer meters, however, accuracy during episodes of
hypoglycemia and in patients with poor peripheral tissue perfusion may be less than
optimal [26-28].
In the past, glucose meters reported whole blood glucose values, which made it difficult to
compare finger stick results with results from a laboratory, which are always plasma.
However, the majority of available glucose meters now provide plasma or conversion to
plasma readings rather than whole blood glucose values (by providing direct plasma
readings or by multiplying the capillary whole blood value by 1.12). Thus, results from most
available glucose meters and commercial laboratories should now be comparable.
Glucose strips — Some glucose strips have considerable batch to batch variation, and
require recalibration to a meter every time a new batch is used. Many strips are packaged
in groups (10, 25, 50, or 100) inside a can containing a desiccant to control humidity.
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Common errors include leaving the lid off for periods of time, with exposure to heat,
moisture, and humidity, and mixing lots of strips into one can for convenience. Patients
often forget to match the code on the strip bottle to the meter code, with uncompensated
batch variation causing erroneous glucose value readings.
Site of testing — Several blood glucose meters are now available that use sites other than
the finger to obtain blood samples in an effort to reduce the discomfort involved with
fingersticks. A study of one device that can be used to obtain samples from the arm found
that it provided accurate results and was less painful than fingerstick testing [29].
Monitoring from alternate sites, such as the skin of the forearm, may give slightly lower
results than those taken at the fingertips, since they may sample venous blood rather than
capillary blood. While this should not be a problem if the patient uses one or the other site
exclusively, the between-test variability will increase if multiple sites are used. In addition,
during times when the blood glucose concentration is either rising rapidly (such as
immediately after food ingestion) or falling rapidly (in response to rapidly acting insulin or
exercise), blood glucose results from alternate sites may give significantly delayed results
compared with fingerstick readings (figure 1) [30,31].
Other sugars — The FDA issued a safety alert in February 2006 that some glucose
monitors (those using the enzyme glucose dehydrogenase pyrroloquinoline quinone or GDHPQQ) will give falsely elevated readings in patients who have received treatments
containing other sugars, including xylose as part of a d-xylose absorption test, maltose or
galactose in IV solutions (IV immune globulin is formulated with maltose), or icodextrin in
peritoneal dialysis fluids [32]. Not all glucose meters use this enzyme, and the test method
used is identified in the package insert for the glucose strips. Several patient deaths were
attributed to inappropriate insulin treatment for falsely elevated glucose strip readings.
CONTINUOUS GLUCOSE MONITORING — Real-time continuous glucose monitoring
systems (CGMS) have the potential to improve glycemic control while decreasing the
incidence of hypoglycemia [33,34]. However, the efficacy compared with SMBG is not
certain, CGMS is expensive, and because of reliability issues CGMS does not eliminate the
need for fingersticks. CGMS has the greatest potential value in patients with hypoglycemic
unawareness who are at risk for or have severe hypoglycemia; unfortunately, currently
available meters are most inaccurate in the low range of glucose.
CGMS may also be valuable in controlling daily fluctuations in blood glucose. Fluctuations in
blood glucose, identified by continuous glucose monitoring, correlate more strongly than
A1C levels with urinary markers indicative of activation of oxidative stress and free radical
formation [35]. This has theoretical clinical implications, as free radicals have been
implicated in endothelial damage and the formation of atherosclerotic plaques. One may
therefore hypothesize that control of daily blood glucose fluctuations, in addition to
management of chronic hyperglycemia in diabetic patients, could be important in protection
against micro- and macrovascular disease [36]. However, in the DCCT, the degree of withinday and between-day variability in SMBG excursions had no influence on the development
or progression of either retinopathy or nephropathy [37].
Most of the continuous blood glucose monitoring systems that are available, or in
development, measure the glucose content of interstitial fluid using an electrochemical
enzymatic sensor. Interstitial fluid is accessed by a needle sensor inserted subcutaneously
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[38,39] or by implanting the whole device subcutaneously [40]. Some devices extract
interstitial fluid across the skin using an applied electrical potential (iontophoresis). An older
version of such a device gave unreliable readings [41,42], but there have been subsequent
technological improvements.
With some devices, the patient receives no information while wearing the device. Results
can be determined in a clinician's office and graphed, providing useful information about the
extent of within-day and between-day variations in blood glucose and the frequency of
unrecognized hypoglycemia (figure 2) [39]. Newer devices provide the patient with real
time results of glucose values on a continuous basis.
Efficacy — The effectiveness of continuous glucose monitoring (CGM) on glycemic control
has not yet been established [20]. Studies to date have demonstrated variable outcomes
with regard to improving glycemic control and hypoglycemia [38,43-46]:
z
z
z
In one randomized trial of insulin-requiring diabetic patients (type 1 n = 75; type 2 n
= 16), the group that had access to a continuous display had less time with
hypoglycemia and hyperglycemia, more time at target glucose range, and less
nocturnal hypoglycemia, although there was no difference in A1C levels [38].
Another randomized trial compared SMBG (four or more times daily) and CGMS in
poorly controlled insulin-treated patients (n = 128) [43]. Improvement in A1C was
the same in both groups after 12 weeks, but those who used CGMS had less
hypoglycemia measured in week 12.
In a 26-week multicenter trial comparing CGM with SMBG in 322 motivated adults
and children with type 1 diabetes, already receiving intensive insulin therapy (insulin
pump or multiple daily injections) and performing self blood glucose monitoring on
average six to seven times daily, there was a small but significant between group
difference in A1C levels (-0.5 percent) favoring CGM in patients who were ≥25 years
of age [44]. In contrast, there was no between group difference in A1C levels in those
15 to 24 or 8 to 14 years of age.
The rate of severe hypoglycemia was low and did not differ between the two study
groups. However, one patient (≥25 years of age) randomly assigned to CGM had six
episodes of severe hypoglycemia.
z
In another trial, 156 children and adults with poorly-controlled type 1 diabetes were
randomly assigned to CGMS continuously, CGMS intermittently, or SMBG (five times
daily) for three months [45]. There was a significant 1 percent reduction in A1C in the
continuous CGMS group compared with intermittent CGMS or SMBG. There was not a
significant A1C reduction in the intermittent CGMS group.
Continuous glucose monitoring devices have also been used in conjunction with insulin
pump therapy, an approach known as sensor-augmented insulin pump therapy.
(See "Insulin therapy in adults with type 1 diabetes mellitus", section on 'Continuous
subcutaneous insulin infusion (insulin pump)'.) Studies are currently evaluating the efficacy
of a fully automated closed loop system of insulin delivery based upon continuous glucose
sensing. One small short-term study reported near normal glucose levels with the use of
such a system and no hypoglycemic events [47].
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Reliability — The interstitial fluid glucose sensor yields lower glucose values, compared
with venous plasma glucose, when blood glucose concentrations are rapidly rising (figure 2)
[39]. The reproducibility of results has also been called into question. When 11 adults (six
type 1 diabetic patients, three type 2 diabetic patients, and two normal subjects) wore two
interstitial fluid glucose sensors simultaneously, over 70 percent of the measurements
differed by 10 percent or more, and 7 percent of the readings differed by over 50 percent
[48].
The CGMS tend to be less accurate in the lower glucose range (<70 mg/dL or 3.9 mmol/L)
and may be inadequate for reliably detecting hypoglycemia. In one study, 91 children and
adolescents wore one or two CGMS; the absolute median difference between over 400
paired hypoglycemic blood glucose values was 19 mg/dL (1.0 mmol/L), with 42 percent of
values falling within 15 mg/dL (0.9 mmol/L) of the reference glucose [42].
These studies emphasize that continuous glucose sensing devices should not be relied upon
exclusively to give patients information about their blood glucose concentrations. Patients
must continue to do several fingersticks daily to calibrate the currently available devices
and to verify that the sensor readings are accurate.
Preliminary data from studies of implantable CGMS in adults with type 1 diabetes showed
that 96 to 98 percent of the sensor glucose results fell within an acceptable margin of error
after 5 to 90 days of continuous use [40,49,50]. When subjects were allowed to see and
use these data to guide therapeutic decisions, they were able to maintain significantly fewer
episodes of hypo- and hyperglycemia [40].
In two studies comparing four continuous glucose monitors, the clinical accuracy was
similar among the four during euglycemia (96 to 99 percent), but was higher for two of the
monitors (Navigator and Glucoday) during hypoglycemia (96 to 97 versus 84 percent) [51].
Cost — Currently available CGMS instruments are relatively expensive. Initial costs are
approximately one to two thousand dollars for devices that directly sample subcutaneous
fluid, with additional costs for supplies ranging between two and four hundred dollars per
month. Costs are lower for the iontophoretic device.
USING THE INFORMATION — For most patients with type 1 diabetes, testing blood sugar
levels before and at intervals after meals; before, during, and after exercise; and
occasionally during the night will provide useful information for adjusting insulin and
carbohydrate intake. At a minimum, monitoring should be used to avoid and/or help treat
potentially dangerous hypoglycemia. (See "Cases illustrating problems with intensive insulin
therapy for diabetes mellitus", section on 'Morning hyperglycemia'.)
However, this regimen will be effective only if the patient is able to use the information to
make appropriate dietary or therapeutic adjustments. As an example, patterns of glycemic
control can be most easily identified if the blood glucose values are entered in columns,
corresponding to times of the day, and the relation to both food intake and exercise noted
Many glucose meters provide data management features which can be downloaded onto a
computer, allowing graphic representation of glycemic variation by time of day, or over a
period of weeks, allowing calculation of means, and visualization of trends and variances.
Unless results are reviewed on a frequent basis to detect and address blood glucose
patterns, self-monitoring will not fulfill its purpose. Relying on the automatic data storage of
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the meters, without regularly reviewing the results, may detract from the clinical utility of
monitoring.
Optimal use of the data obtained is best done in two stages:
z
z
Pattern identification — Patterns, as opposed to intermittent problems, are best
identified if there are a relatively large number of measurements. Thus, blood glucose
values should be recorded four to seven times daily for several days and evaluated for
patterns of variation which allow adjustment of doses or types of insulin at different
times of the day.
Insulin algorithms — Once a basic regimen of eating, exercise, and insulin dosing has
been established, there will still be a day-to-day variability in blood glucose values
due, among other factors, to the vagaries of insulin and food absorption. (See "Insulin
therapy in adults with type 1 diabetes mellitus".) This can be effectively treated by an
insulin algorithm in which the before-meal dose of short-acting insulin is adjusted
according to the blood glucose value and, for patients who use carbohydrate counting,
anticipated carbohydrate content of the meal. The adjustments should be small in
patients who are very sensitive to insulin or who are taking low doses of insulin (as
with a continuous insulin pump). (See "Cases illustrating problems with intensive
insulin therapy for diabetes mellitus", section on 'Insulin algorithm' and "Cases
illustrating problems with intensive insulin therapy for diabetes mellitus", section
on 'Late afternoon hypoglycemia' and "Cases illustrating problems with intensive
insulin therapy for diabetes mellitus", section on 'Late morning hyperglycemia'.)
The frequency of SMBG in patients with type 2 diabetes, while most often less than for
patients with type 1 diabetes, is dependent on the glycemic targets set, and the treatments
used. (See "Case illustrating blood glucose monitoring in type 2 diabetes".) If SMBG is
initiated to improve glycemic control, patient education strategies are necessary to ensure
successful management of SMBG feedback. In one small longitudinal study of patient views
on SMBG, the frequency of testing decreased over time, often because patients did not
know how to respond to high readings, and patients perceived that providers were more
interested in A1C values than glucose logs [52].
With a well-educated and motivated patient, therapeutic advice can often be given over the
telephone or even via fax or e-mail. It is important not to recommend many changes at the
same time. Having made a change, it is usually best to wait several days until the effect of
that change can be assessed from further blood glucose measurements.
Patients with special needs — Visually impaired patients may have difficulty using
glucose meters; with help, this problem can be overcome with "talking meters" or largescreen meters. Patients or providers may contact:
American Association of Diabetes Educators (AADE)
444 N. Michigan Ave., Suite 1240
Chicago, IL 60611-3901
Tel: 1-800-338-3633
INFORMATION FOR PATIENTS — Educational materials on this topic are available for
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patients. (See "Patient information: Diabetes mellitus type 1: Overview" and "Patient
information: Diabetes mellitus type 2: Overview" and "Patient information: Self-blood
glucose monitoring in diabetes mellitus".) We encourage you to print or e-mail these topic
reviews, or to refer patients to our public web site, www.uptodate.com/patients, which
includes these and other topics.
SUMMARY AND RECOMMENDATIONS
z
z
z
z
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Self-monitoring of blood glucose (SMBG) is an important component of the intensive
insulin regimen recommended for most patients with type 1 diabetes. Patients with
type 1 diabetes will usually require testing before and at intervals after meals; before,
during, and after exercise; and occasionally during the night, to adjust insulin doses
for meals and avoid hypoglycemic events. (See 'Type 1 diabetes' above.)
The benefit of SMBG for patients with type 2 diabetes is less clear. SMBG may not be
necessary for patients who are not taking medications associated with hypoglycemia.
(See 'Type 2 diabetes' above.)
Errors in SMBG may result from poor technique (improper calibration, dirty hands or
machine), lower test sensitivity in measuring low blood glucose levels, improper
storage of test strips, or interfering substances. (See 'Sources of error' above.)
Blood is usually sampled from the fingertips. Alternative sites may be less painful, but
can give less reliable results when there are rapid fluctuations in blood sugar.
(See 'Site of testing' above.)
Continuous glucose monitoring systems (CGMS) report blood glucose levels to the
patient in real time. Some studies have shown fewer periods of hypoglycemia with
CGMS, but there are concerns with reproducibility of glucose results, particularly in
the lower glucose range, with currently available CGMS. Studies are currently
evaluating the efficacy of a fully automated closed loop system of insulin delivery
based upon continuous glucose sensing. (See 'Continuous glucose monitoring' above.)
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GRAPHICS
Change in blood glucose using forearm and fingerstick
testing after a 75g oral glucose load at time 0 and
intravenous insulin at time 115 minutes
Data from Jungheim, K, Koschinsky, T. Diabetes Care 2002; 25:956.
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Accuracy of CGMS: Correlation of CGMS and simultaneous
hemocue
Results of continuous glucose monitoring compared with intermittent values
checked with a laboratory-quality assay. Courtesy of Dr. David Nathan.
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Blood glucose self-monitoring in management of diabetes mellitus
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