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Blood glucose monitoring

Blood glucose monitoring is a way of testing the concentration of glucose in the blood (glycemia).

It is important in the care of diabetes mellitus. A blood glucose test is performed by piercing the skin (typically, on the finger tip) to draw blood, then placing the blood on a chemically active disposable strip which indicates the result either by changing colour, or changing an electrical characteristic, the latter being measured by an electronic meter.

Most people with Type 2 diabetes test at least once per day (usually before breakfast) to assess the effectiveness of their diet and exercise. Many people with Type 2 use an oral medication to combat their insulin resistance, and test their blood glucose before and after breakfast to assess the effectiveness of their dosage. Diabetics who use insulin (all Type 1 diabetes and many Type 2s) usually test their blood sugar more often (3 to 10 times per day), both to assess the effectiveness of their prior insulin dose and to help determine their next insulin dose.

Improved technology for measuring blood glucose is rapidly changing the standards of care for all diabetic people. There are several methods of blood glucose testing currently available.

Chemical Test Strips

Chemical test strips are a medium cost method for monitoring blood glucose. A fairly large drop of blood, usually taken from the fingertip, is placed on a chemically prepared strip, called a blood glucose testing strip. The chemicals in the strip react with the blood, changing color according the concentration of glucose, which can then be read by comparing the color with a chart on the side of the test strip container.

These are recommended only for people who are occasionally monitoring their blood glucose level (prediabetic or type 2) and are not using insulin. They are useful for people who can't afford to use an electronic meter, and for people who dislike electronic meters.

The Betachek Diabetes Test Strips

Pamphlet for Use of Chemical Test Strips

Blood Glucose Meters

A blood glucose meter is an electronic device for measuring the blood glucose level. A relatively small drop of blood is placed on a disposable test strip which interfaces with a digital meter. Within several seconds, the level of blood glucose will be shown on the digital display.

While more expensive, blood glucose meters seem a breakthrough in diabetes self care. As the drops of blood needed for the meter become smaller, the pain associated with testing is reduced and the compliance of diabetic people to their testing regimens is improved. Although the cost of using blood glucose meters seems high, it is believed to be a cost benefit relative to the avoided medical costs of the complications of diabetes.

A recent and welcome advance is the use of small blood drops for blood glucose testing from other places than the finger tips. This alternate site testing uses the same test strips and meter, is practically pain free, and gives the real estate on the finger tips a needed break if they become sore. The disadvantage of this technique is that there is usually less blood flow to alternate sites, which prevents the reading from being accurate when the blood sugar level is changing.

One company has developed automatic self-coding meters.

Continuous Blood Glucose Monitoring

A continuous blood glucose monitor (CGM) determines blood glucose levels on a continuous basis (every few minutes). A typical system consists of:

a disposable glucose sensor placed just under the skin, which is worn for a few days until replacement
a link from the sensor to a non-implanted transmitter which communicates to a radio receiver
an electronic receiver worn like a pager (or insulin pump) that displays blood glucose levels on a practically continuous manner, as well as monitors rising and falling trends in glycemic excursions

Continuous blood glucose monitors measure the glucose level of interstitial fluid. Shortcomings of CGM systems due to this fact are:

continuous systems must be calibrated with a traditional blood glucose measurement (using current technology) and therefore require both the CGM system and occasional "fingerstick"
glucose levels in interstitial fluid lag temporally behind blood glucose values

Patients therefore require traditional fingerstick measurements for calibration (typically twice per day) and are often advised to use fingerstick measurements to confirm hypo- or hyperglycemia before taking corrective action.

The lag time discussed above has been reported to be about 5 minutes. Anecdotally, some users of the various systems report lag times of up to 10-15 minutes. This lag time is insignificant when blood sugar levels are relatively consistent. However, blood sugar levels, when changing rapidly, may read in the normal range on a CGM system while in reality the patient is already experiencing symptoms of an out-of-range blood glucose value and may require treatment. Patients using CGM are therefore advised to consider both the absolute value of the blood glucose level given by the system as well as any trend in the blood glucose levels. For example, a patient using CGM with a blood glucose of 100 mg/dl on their CGM system might take no action if their blood glucose has been consistent for several readings, while a patient with the same blood glucose level but whose blood glucose has been dropping steeply in a short period of time might be advised to perform a fingerstick test to check for hypoglycemia.

Continuous monitoring allows examination of how the blood glucose level reacts to insulin, exercise, food, and other factors. The additional data can be useful for setting correct insulin dosing ratios for food intake and correction of hyperglycemia. Monitoring during periods when blood glucose levels are not typically checked (e.g. overnight) can help to identify problems in insulin dosing (such as basal levels for insulin pump users or long-acting insulin levels for patients taking injections). Monitors may also be equipped with alarms to alert patients of hyperglycemia or hypoglycemia so that a patient can take corrective action(s) (after fingerstick testing, if necessary) even in cases where they do not feel symptoms of either condition. While the technology has its limitations, studies have demonstrated that patients with continuous sensors experience less hyperglycemia and also reduce their glycosylated hemoglobin levels.

Currently, continuous blood glucose monitoring is not automatically covered by health insurance in the United States in the same way that most other diabetic supplies are covered (e.g. standard glucose testing supplies, insulin, and even insulin pumps). However, an increasing number of insurance companies do cover continuous glucose monitoring supplies (both the receiver and disposable sensors) on a case-by-case basis if the patient and doctor show a specific need. The lack of insurance coverage is exacerbated by the fact that disposable sensors must be frequently replaced (sensors by Dexcom and Minimed have been FDA approved for 7- and 3-day use, respectively, though some patients wear sensors for longer than the recommended period) and the receiving meters likewise have finite lifetimes (less than 2 years and as little as 6 months). This is one factor in the slow uptake in the use of sensors that have been marketed in the United States.

Some current and future continuous glucose monitoring products include:

FreeStyle Navigator (recently approved by the FDA)
Medtronic Minimed Paradigm Real Time Continuous Glucose Monitor
The Guardian by Medtronic Minimed
Dexcom STS
GlucoDay S
Senzime

See this summary by a diabetes support group for a review of CGM products, performance and features. Participate in discussions with other CGM users in another diabetes community.

This technology is an important component in the effort to develop a closed-loop system connecting real-time automatic control of an insulin pump based on immediate blood glucose data from the sensor. One important goal is to develop an algorithm for automatic control, by which the system would function as an artificial pancreas. However, this is a long-term goal at this point for companies that manufacture such systems, as such an algorithm would need to be very complex in order to accurately control blood sugar levels without any user input.

Glucose sensing bio-implants

Longer term solutions to continuous monitoring, not yet available but under development, use a long-lasting bio-implant. These systems promise to ease the burden of blood glucose monitoring for their users, but at the trade off of a minor surgical implantation of the sensor that lasts from one year to more than five years depending on the product selected.

Products under development include:

Non-Invasive Technologies

Some new technologies to monitor blood glucose levels will not require access to blood to read the glucose level. Non-invasive technologies include near IR detection, ultrasound and dielectric spectroscopy. These will free the person with diabetes from finger sticks to supply the drop of blood for blood glucose analysis.

Most of the non-invasive methods under development are continuous glucose monitoring methods and offer the advantage of providing additional information to the subject between the conventional finger stick, blood glucose measurements and over time periods where no finger stick measurements are available (i.e. while the subject is sleeping). Products under development include:

Effectiveness

For patients with diabetes mellitus type 2, the importance of monitoring and the optimal frequency of monitoring are not clear. One randomized controlled trial found that self-monitoring of blood glucose did not improve the Hba1c among "reasonably well controlled non-insulin treated patients with type 2 diabetes". Additionally, a recent study found that a treatment strategy of intensively lowering blood sugar levels (below 6%) in patients with additional cardiovascular disease risk factors poses more harm than benefit. For those who are not on insulin, exercise and diet are the best tools to aid those with type 2: BG monitoring is in that case simply a tool to evaluate the success of diet and exercise. But those with type 2 who use insulin need to monitor their blood sugar frequently just as those with type 1.

Blood glucose monitoring recommendations

The National Institute for Health and Clinical Excellence (NICE), UK released updated diabetes recommendations on the 30th May 2008, which recommend that self-monitoring of plasma glucose levels for people with newly diagnosed type 2 diabetes must be integrated into a structured self-management education process.

Side effects

Piercing the body, particularly on the finger tips, to draw blood can be painful.

There haven't been any studies investigating the long term damage caused by continual body piercing.