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Blood Glucose Monitoring: A Practical Guide for Use in the Office and Clinic Setting. Diabetes Spectrum. 21(2):100-111. Spring 2008.
This article describes a method for evaluating and interpreting self-monitoring of blood glucose (SMBG) results in the office and clinic setting. The authors contend that such interpretation in the presence of patients may facilitate improved patient-provider discussion, clinical decisions, and the ability to manage glycemic patterns. They outline key steps that should be included in a systematic review of SMBG data: identifying the degree of blood glucose control using mean and standard deviation or variance, identifying patient safety concerns with regard to hypoglycemia, understanding the factors influencing blood glucose control by noting trends and patterns, suggesting strategies for achieving improved blood glucose control, and providing reinforcement to patients with diabetes that this information is valuable and useful in their care. Specific topics include patient records and logbook reviews, meter memories and computation, meter downloads and analysis, problems with basal glucose control, problems with prandial glucose control, frequency of testing, and continuous glucose monitoring (CGM). The article includes case studies that illustrate the process for using and interpreting electronic SMBG downloads. One chart summarizes selected diabetes management software programs. 5 figures. 4 tables. 17 references.
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Continuous Glucose Monitoring: The Future of Diabetes Management. Diabetes Spectrum. 21(2):112-119. Spring 2008.
This article brings readers up to date on continuous glucose monitoring (CGM), technology used to provide real-time information about interstitial fluid glucose levels as part of a diabetes management plan. CGM provides short-term feedback about the effectiveness of diabetes interventions such as insulin administration, and it provides warnings when glucose concentrations become dangerously high or low. The authors stress that CGM has made the attainment of near-normal blood glucose concentrations an achievable goal for most patients with diabetes. However, they note that several challenges remain to be addressed, including the high cost of the devices, limitations in approved clinical uses, and insurance coverage for the technology. The article reviews the strengths and weaknesses of current CGM technology and provides information about how these devices can best be used in clinical practice for the care of people with diabetes. The authors conclude that CGM can offer diabetes patients a major advance in improving glycosylated hemoglobin (A1C) values and reducing the occurrence of disruptive hypoglycemia. 3 figures. 2 tables. 20 references.
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Diabetes Technology During the Past 30 Years: A Lot of Changes and Mostly for the Better. Diabetes Spectrum. 21(2): 78-83. Spring 2008.
This article offers a critical review of the changes in technology in the field of diabetes care and management, including those in glucose measurement, insulin administration, and types of insulin. The author describes the technology and equipment but focuses more on issues of patient compliance and quality of life. The author stresses that diabetes is still all-encompassing, needing attention multiple times a day, whether it’s checking blood glucose levels, calculating each meal and snack, or remaining vigilant to symptoms of hypoglycemia. Technological advances have not eased this burden of managing diabetes. Other topics addressed include parent-child relations, the members of the patient care team, attempts to match insulin dosage to food intake, the need for mathematical skills on the part of patients or parents, self-monitoring of blood glucose (SMBG), point-of-care glycosylated hemoglobin (A1C) tests, analog insulins, insulin pumps, patient selection for new technologies, and the use of continuous glucose monitoring (CGM). 5 figures. 35 references.
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Continuous Glucose Monitoring: Is It the Right Fit? Today’s Dietitian. 9(11): 32-36. November 2007.
This article informs dietitians about continuous glucose monitoring (CGM), a way to track real-time glucose readings. CGM systems consist of three parts: a sensor, transmitter, and receiver. After a disposable sensor is placed just beneath the skin in the abdomen, a plastic catheter is inserted to measure interstitial fluid (ISF) glucose levels. Patients can replace the sensor themselves as necessary. The transmitter, placed on top of the sensor, converts the ISF signal to a glucose value and transmits it to the receiver. The wireless receiver displays glucose values every 1 to 5 minutes. The system can be programmed to alert patients to pre-established high or low blood glucose levels. The author discusses the use of blood glucose levels versus ISF levels, the importance of calibration of the equipment, the U.S. Food and Drug Administration’s (FDA) approval of CGM devices as an adjunct only, patient selection for CGM, and real-life, practical concerns when using the CGM. The author reports that real-time CGM system monitoring enables responsive corrections to unpredictably high and low blood glucose levels and learning through immediate feedback about which foods and physical activities adversely impact blood glucose levels. One sidebar shares the story of a certified diabetes educator who uses the CGM to help manage her own diabetes.
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Moderators, Monitoring And Management of Hypoglycaemia. IN: Frier, B. and Fisher, M., eds. Hypoglycaemia in Clinical Diabetes. 2nd ed. Somerset, NJ: John Wiley & Sons. 2007. pp 100-120.
This chapter on moderators, monitoring, and management of hypoglycemia is from a textbook that provides in-depth information for the understanding and management of hypoglycemia in clinical diabetes care. The authors note that despite advances in insulin pharmacology and delivery and in patient education, the lifetime frequency of symptomatic hypoglycemia remains substantial, with the average patient likely to experience thousands of episodes over the course of his or her life with insulin-treated diabetes. They review risk factors for the development of hypoglycemia and address lifestyle moderators, including alcohol and hypoglycemia, and caffeine. The authors also address monitoring, including self-awareness self-monitoring of blood glucose (SMBG), and continuous glucose monitoring systems (CGMS). Treatment of hypoglycemia can be thought of as a spectrum of increasing therapeutic complexity, depending on the severity of the hypoglycemia and the clinical status of the patient. 11 figures. 3 tables. 65 references.
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Early Patient and Clinician Experiences with Continuous Glucose Monitoring. Diabetes Spectrum. 21(2):128-133. Spring 2008.
This article reports on a study that evaluated data from a 12-week study of patients using the FreeStyle Navigator continuous glucose monitoring (CGM) system. The authors note that CGM can assist in overcoming some of the limitations of self-monitoring of blood glucose (SMBG) by providing the ability to track glucose levels 24 hours a day, observe glucose trends and patterns, and receive alarms or alerts for actual and impending hypoglycemia and hyperglycemia. In the study, the authors evaluated responses to questionnaires from both clinicians and patients. Topics include initial impression and ease of use, important features and benefits, data management software, patient compliance, overall experience, future purchase and usage of CGM devices, training materials and content, and individual versus group training. Clinicians noted the ability to train easily on the CGM system, and both patients and clinicians felt they were able to make more informed decisions on therapy adjustments based on information from the receiver and the data management reports. Patients liked the ability to make day-to-day decisions based on the 1-minute glucose readings, threshold and projected glucose alarms, and the glucose trend arrows that allowed them to observe the rate and direction of glucose change. The authors conclude that CGM can be a valuable adjunct to diabetes care but improvement in control depends on the willingness and ability of patients to use CGM information to modify their diabetes management. 3 figures. 1 table. 6 references.
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Nuts And Bolts of Achieving End Points with Real-Time Continuous Glucose Monitoring. Diabetes Care. 31(Suppl 2): S146-S149. February 2008.
This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, reviews the basics of using real-time continuous glucose monitoring (RT-CGM) as a component of comprehensive diabetes management. The author cautions that RT-CGM is most appropriate in patients who are skilled in diabetes self-management. Training issues include the implications of the physiologic lag between interstitial and capillary blood glucose levels, as well as the increased risk among RT-CGM users for hypoglycemia related to blind postprandial bolusing. Patients must understand the importance of calibrating their equipment during steady-state conditions to improve sensor accuracy. In addition, they need to use fingerstick measurements for treatment decision making when the glucose level is changed rapidly. The author notes that consideration of “insulin on board” and the impact of the glycemic index of different foodstuffs on postprandial glucose patterns can help minimize the risk for hypoglycemia from supplemental boluses taken to correct postprandial hyperglycemia. The article includes colorful figures that help readers learn to translate the data received from RT-CGM. 4 figures. 9 references.
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Use of Continuous Glucose Monitoring to Evaluate the Glycemic Response to Food. Diabetes Spectrum. 21(2): 134-137. Spring 2008.
This article considers the use of continuoug glucose monitoring (CGM) to evaluate the glycemic response to food in patients with diabetes. CGM can be used to track glucose levels 24 hours a day, observe glucose trends and patterns, and send alarms or alerts for actual and impending hypoglycemia and hyperglycemia. Glucose values, trend arrows, line graphs, and alarms viewed on the device screen provide real-time perspective. The authors discuss factors affecting postprandial glycemia (PPG), how to evaluate personal glycemic responses to food, PPG response to mixed meals, prandial insulin dosing, timing of the meal bolus, different types of boluses, and insulin sensitivity determined with CGM. The authors conclude by supporting the use of CGM for clinicians and patients to more effectively and easily evaluate the patient’s glycemic response to various types of foods and meals. This information gives patients the ability to more effectively adjust prandial insulin and lifestyle therapy based on their food choices. However, clinicians must take the responsibility for training patients in how to interpret the data and make appropriate decisions. 3 figures. 11 references.
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Use of Real-Time Continuous Glucose Monitoring Technology in Children and Adolescents. Diabetes Spectrum. 21(2): 84-90. Spring 2008.
This article considers the use of real-time continuous glucose monitoring (CGM) in children and adolescents as part of a comprehensive program of diabetes care. The authors combine research findings and clinical experience to describe the importance of realistic expectations of CGM, wearability considerations, and the potential benefits of glucose alarm features for pediatric patients. CGM systems measure glucose in the interstitial fluid, rather than blood glucose, providing interstitial glucose readings every 1 to 5 minutes. CGM systems are approved for adjunctive use and should be used in addition to blood glucose testing. The authors stress that real-time CGM alarms for actual or projected high glucose can help alert children and adolescents to missed meal boluses and facilitate correction actions earlier than conventional blood glucose testing alone. This is one of the benefits cited as a reason for interest in CGM in this population. In addition, retrospective glucose trends can be used to make medication or lifestyle modifications. 2 figures. 2 tables. 15 references.
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Assessing Glycemic Control Using Home Blood Glucose Monitoring, Continuous Glucose Sensing, and Glycated Hemoglobin (A1C) Testing. IN: Unger, J. Diabetes Management in Primary Care. Philadelphia, PA: Lippincott Williams and Wilkins. 2007. p. 321-362.
Self blood glucose monitoring (SMBG) allows patients to take charge of their own diabetes management. This chapter about SMBG, continuous glucose sensing, and glycated hemoglobin (A1C) testing is from a textbook that offers primary care physicians evidence-based guidelines for evaluating and treating all patients with diabetes. In this chapter, the author discusses blood glucose meters and computer-based data management systems, the link between glycemic variability and long-term diabetes-related complications, glycated hemoglobin testing, improving the utility of SMBG, and the role of continuous glucose monitoring. The author emphasizes that both the chronic and sustained levels of hyperglycemia, as well as the acute daily fluctuations of glucose levels, are important factors in managing diabetes. The degree of chronic hyperglycemia is determined by A1C testing. The chapter includes a list of “take-home points” that summarize the concepts discussed, as well as case reports that illustrate the topics covered. 17 figures. 4 tables. 38 references.
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New Products. Diabetes Forecast. 60(1 Suppl RG): RG2-RG5. January 2007.
This article, from the annual resource guide that is published as a supplement to Diabetes Forecast, outlines many of the new products that use technology to help people with diabetes manage their disease. Three new continuous glucose monitoring systems can keep track of blood glucose around the clock, and five new blood glucose monitors incorporate features such as data upload capability, 300-test memory, and enhanced programmability. Two new pumps and two new infusion sets promise to make wearing a pump easier and more comfortable, and new lancets and lancing devices aim to make checking blood glucose levels less painful. New syringes, medical identification watches, and a unisex messenger bag are also included. For each new product, the article offers a brief description, and the name, telephone number, and website of the manufacturer or distributor. The author notes that drug treatment has evolved as well, and new options include two type 2 combination pills, two insulins, an insulin pen, two treatments for low blood glucose, and a drug specifically designed to ease the pain of diabetes-related nerve damage. Some of the products are illustrated with a small, full-color photograph. 9 figures.
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Patients Take Charge: A Report from the ADA’s Annual Scientific Sessions. Diabetes Forecast. 60(10): 35-39. September 2007.
This patient education article, from a magazine for people with diabetes, presents a report from the American Diabetes Association’s 67th Scientific Sessions, which took place in Chicago in June 2007. Every year, this conference is held to report on recent research and discuss the latest innovations in diabetes care. At this year’s conference, patient-centered care was the topic on everyone’s agenda. The author notes that some of this change in focus to patient-centered care is a result of new thinking in diabetes education; some is driven by changes in technology. The author reports on some of the specific topics covered at the conference, including continuous glucose monitoring (CGM), getting health insurance covered for CGM, Conversation Maps as a diabetes education tool, and the benefits of these new tools. A sidebar reports on statistics that demonstrate how Americans with type 1 or type 2 diabetes have improved their blood glucose levels over the past 5 years. These statistics showed an interesting seasonal fluctuation in average glycosylated hemoglobin levels (A1C). 6 figures.
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Trailblazers. Diabetes Forecast. 60(3): 32-34. Spring 2007.
Recent years have seen the development of several classes of drugs that may be of use for people with diabetes. This article reviews each of them, providing information from health care professionals who have experience prescribing these medications. The drugs discussed include Exubera (inhalable insulin), DPP-4 inhibitors (including sitagliptin), Byetta (exenatide), and Symlin (pramlintide acetate). For each, the author considers short-term and long-term effects, costs, any monitoring tests that need to be performed, and patients for whom the drug might be appropriate. One sidebar brings readers up-to-date on continuous glucose monitoring systems.
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Monumental Research: Part 2. Diabetes Forecast. 59(11): 46-50. November 2006.
This article is the second in a series of two articles that describe the activities and research presented at the American Diabetes Association’s 66th Scientific Sessions (June 2006, Washington, D.C.). The authors summarize recent research on exenatide in patients with islet cell transplants, the ongoing need to have physicians and health care providers focus on intensified treatment in order to achieve the best results, the impact of birth control pills on kidney disease in people with diabetes, how losing weight can reduce health care costs, a new insulin pump (Omni-Pod) without tubing, continuous glucose monitoring, and recent advances in inhaled insulin. 1 figure.
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Next Generation: Continuous Glucose Monitors. Diabetes Forecast. 59(8): 52-55. August 2006.
This article brings readers up-to-date on changes in continuous blood glucose monitors. Rather than providing a one-time picture of the blood glucose levels at a single point in time, as current meters do, continuous monitors deliver readings every few minutes around the clock, providing a more comprehensive overview of the blood glucose changes over the course of a 24-hour period. Continuous glucose monitoring (CGM) measures blood glucose levels in the interstitial fluid (the fluid surrounding body cells) every 5 minutes and stores the readings; the technology is still invasive, using a tiny flexible probe inserted under the skin. The author notes that there are many benefits to using continuous blood glucose monitoring, but that the equipment is still far away from being available and accurate enough for everyday use. The author discusses cost issues, products that are being evaluated by the U.S. Food and Drug Administration (FDA), the problem of lack of ways to test these continuous monitors, accuracy issues, and patient perspectives on continuous monitors. To date, the FDA has approved two systems, which are being rolled out in certain parts of the country. Several other products are also under consideration for approval; one side bar reviews five of these products, listing the manufacturer’s website for each.
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Nutrition and Type-1 Diabetes Mellitus. IN: Brett, E.; Mechanick, J., eds. Nutritional Strategies for the Diabetic and Prediabetic Patient. Boca Raton, FL: CRC Press. 2006. pp. 105-116.
This chapter on nutrition and type 1 diabetes is from a book written to advance physicians’ knowledge in nutrition as it relates to diabetes and to help them provide evidence-based recommendations to their patients with diabetes. The author notes that even the most basic questions about diet and glucose management are subject to controversy. Patients must be taught to balance the glucose derived from foods they eat with the exogenous insulin they administer. The author uses the limited scientific data and clinical experience available to establish nutritional strategies for controlling glucose levels in patients with type 1 diabetes. Topics include insulin regimens, modern diabetes management, carbohydrate counting, the glycemic index, glycemic load, protein, fiber, sugar, dietary fats, getting started, the consequences of improved metabolic control, and the use of continuous glucose monitoring systems to evaluate dietary management. The author concludes that continuous glucose monitoring is the best way to understand the relationship between an individual’s diet, insulin, and exercise lifestyle. 2 tables. 50 references.
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Continuous Glucose Monitoring. Diabetes Self-Management. 22(1): 65-67. January-February 2005.
This article describes the technique of continuous glucose monitoring in which the CGMS System Gold device measures the glucose level of the interstitial fluid (the fluid between the cells of the body) just under the skin every 10 seconds, then averages the readings over five-minute intervals and stores those averages in memory. This results in 288 recorded glucose levels during the course of a 24-hour period. The system can be used for up to three days at a time. The author notes that the main advantage of a continuous glucose monitoring system is its ability to uncover patterns that are missed by conventional blood glucose monitoring. The author discusses the indications for continuous blood glucose monitoring, how it could be used to assist in making changes in insulin dosing or timing, the need for additional recordkeeping during the 3-day testing period to assist in analysis, the components of the equipment, calibrating the system for each individual user, and the details of using and returning the system. An additional section describes some of the other technological advances that are happening in the realm of continuous glucose monitoring. Readers are reviewed to the manufacturer's website for additional information (www.minimed.com). 1 figure.
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Current and Future Approaches to Monitoring Glycemia. Advanced Studies in Medicine. 5(10): S1117-S1128 p. December 2005.
The goal of blood glucose monitoring in diabetes is to obtain useful information about the patient’s overall glucose status in order to normalize glucose, prevent hypoglycemia, and minimize hyperglycemia through meaningful and timely interventions. This review article outlines current and future approaches to monitoring glycemia. The author stresses that self-monitoring of blood glucose (SMBG) is the foundation of diabetes care. Studies have shown a direct correlation between the use of SMBG and improved glycosylated hemoglobin (HbA1c) levels, a measure of blood glucose levels over time. Recommendations for patients with type 1 diabetes are to use SMBG at least 3 times daily; the optimal frequency for patients with type 2 diabetes is unknown, but the frequency should be sufficient to reach glucose goals. The accuracy of the results is instrument- and user-dependent, thus the clinician should evaluate each patient’s technique frequently, including use of alternate-site testing. The author considers several obstacles to optimal SMBG, including denial, ignored results, clinician passivity, pain, expense, and inconvenience, any of which can severely compromise a treatment plan. The article concludes with a section on the emerging technology of continuous glucose monitoring (CGM), including a review of the currently available CGM meters, in addition to those meters under development and review by the US Food and Drug Administration. The author focuses on the strengths and limitations of HbA1c measurement and the physiology behind its use as a diabetes marker. Four sidebars cover diabetic ketoacidosis; the electrochemistry of second-generation blood glucose meters; the role of the diabetes educator in implementing continuous glucose monitoring; and the history of the use of HbA1c in diabetes management. 7 figures. 4 tables. 25 references.
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Hi-Tech Advancements in Diabetes Management. Nephrology News & Issues. 19(10): 24, 27. 2005.
This article reviews recent technological advancements in diabetes management. The first device discussed is a continuous glucose monitoring system (Medtronic, Inc., Guardian RT Continuous Glucose Monitoring System), which measures blood glucose fluctuations throughout the day and night for up to 3 days. This type of monitoring can alert patients with hyperglycemia (high blood glucose levels) of their blood levels and may lead to a reduced risk in developing diabetes-related complications, such as retinopathy, blindness, and foot amputations. Another device recently available is a wristwatch that measures glucose every 10 minutes up to 13 times a day (Animas Technologies, GlucoWatch G2 Biographer). The sensor on the back of the watch has two tiny collection disks. A low electric current pulls glucose through the skin and collects it in those discs, then the value is displayed on the wristwatch. An alarm sounds if the sugars reach harmful levels. Other technological advances include a product to replace traditional blood glucose monitors with a noninvasive method that uses infrared light to read a patient's blood glucose level, a glucose-sensing contact lens that changes color in response to glucose levels, and a smart tattoo that changes color in response to glucose fluctuations. These latter devices are all still in the development stages.
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How to Inspect When She's Expecting: Use of Continuous Glucose Monitoring in Diabetes During Pregnancy. Diabetes Technology & Therapeutics. 7(5): 707-709. October 2005.
This editorial comments on a research study published in the same journal that evaluated the accuracy of the Continuous Glucose Monitoring System (CGMS) in five pregnant women with type 1 diabetes. The researchers concluded that the CGMS is a useful tool in the management of type 1 diabetes in pregnant women. However, the CGMS should only be used as a supplementary method of daily glucose level measurement because a small degree of error, mainly in the hypoglycemic range, is present. The commentary article introduces the research study after briefly reviewing the importance of blood glucose monitoring, particularly in pregnancy. The author then focuses on some of the research methodology issues that have resulted in an inability to adequately assess the accuracy of continuous glucose monitors. The author concludes by considering the clinical implications of how to use the CGMS to guide therapy in pregnancy complicated by diabetes, stressing that clinicians need to develop safe and effective real-time diabetes treatment algorithms for this patient population. 17 references.
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Continuous Glucose Monitoring System During Pregnancy of Women with Type 1 Diabetes Mellitus: Accuracy Assessment. Diabetes Technology & Therapeutics. 6(5): 645-651. October 2004.
The Continuous Glucose Monitoring System (CGMS®, Medtronic MiniMed, Northridge, CA) allows close monitoring of glucose patterns and might be helpful in explaining the persistence of high complication rates in pregnancies of women with type 1 diabetes. This study was undertaken to determine whether the CGMS accurately reflects glucose levels in pregnant women with type 1 diabetes mellitus. The study included 15 pregnant women with type 1 diabetes who used the CGMS and who were asked to determine at least seven fingerstick blood glucose levels each day, of which four were used for calibration of the CGMS. The patients were asked to keep a diary of the non-calibration blood glucose values. A total of 239 non-calibration blood glucose values were analyzed. Results show that the CGMS is an accurate tool for additional glucose monitoring in pregnant women with type 1 diabetes mellitus. However, the authors caution that treatment decisions should not be based on CGMS measurements alone as this can lead to clinically unacceptable treatment errors (the CGMS occasionally misleads in the hypoglycemic range). 3 figures. 34 references.
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Validation of the Continuous Glucose Monitoring System (CGMS) by the Use of Two CGMS Simultaneously in Pregnant Women with Type 1 Diabetes Mellitus. Diabetes Technology & Therapeutics. 7(5): 699-706. October 2005.
Tight blood glucose control in pregnant women with type 1 diabetes can reduce perinatal complications in both the mothers and babies. One component of tight blood glucose control is intensive monitoring of blood glucose levels. This article reports on a study that evaluated the accuracy of the Continuous Glucose Monitoring System (CGMS, Minimed, Sylmar, California) in pregnant women with type 1 diabetes. In this study, five women were asked to use two CGMS devices simultaneously. The measured glucose levels were then analyzed. Almost 80 percent of the data pairs could be classified in the same glucose range. The authors conclude that the CGMS is a useful tool in the management of type 1 diabetes in pregnant women. However, the CGMS should only be used as a supplementary method of daily glucose level measurement because a small degree of error, mainly in the hypoglycemic range, is present. The CGMS measures glucose levels in the interstitial fluid; the device is not intended to be used to change insulin dosages based directly on the numbers generated. The CGMS identifies patterns of glucose fluctuations and this information can be useful for adjusting insulin administration patterns, changing the patient's diet, or improving the educational efforts. 3 figures. 3 tables. 17 references.
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Novel Approach to Mitigating the Physiological Lag Between Blood and Interstitial Fluid Glucose Measurements. Diabetes Technology & Therapeutics. 6(5): 635-644. October 2004.
The lag between blood glucose levels and interstitial fluid (ISF) glucose levels (as measured by newer continuous glucose monitoring systems) can contribute significantly to accuracy error. Mitigating this physiological lag can be an important and useful means for improving the accuracy, and hence the clinical utility, of continuous glucose monitors. This article reports on a study that included 22 participants with diabetes in which a glucose excursion was induced through oral ingestion of a glucose load, and glucose levels in finger blood and forearm dermal (skin) ISF were monitored over a 56-hour period. ISF was sampled from two types of sites: sites at which local blood perfusion was elevated through modulated pressure application (test ISF), and control sites at which no perfusion elevation technique was employed (control ISF). Average lag times between the two ISF samples and finger capillary blood glucose were determined to be 38.3 minutes plus or minus 11.5 minutes, and 2.5 minutes, plus or minus 6.6 min, respectively, for the control and test ISF samples. Thus the pressure application reduced the ISF physiological error by an average of 95 percent in this test. The authors conclude that the use of a pressure modulation technique to create an elevation in blood flow holds promise for significantly reducing one of the most important components of accuracy error for continuous monitoring systems. 6 figures. 3 tables. 19 references.
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Choosing a Blood Glucose Meter. Diabetes Self-Management. 20(4): 99-100, 102-106. July/August 2003.
With the development of blood glucose meters for home use, it has become possible for people with diabetes to measure their blood glucose level within a matter of minutes. This rapid feedback allows patients the opportunity to see how food, medicines, exercise, and illness, among other things, influence blood glucose level. This information can be used to make adjustments to the diabetes therapy. Despite the advantages of self monitoring of blood glucose (SMBG), some people with diabetes resist this approach. This article familiarizes readers with the types of meters available, to help them understand the various models and features that are available. The article first lists recommended questions to ask before buying a meter, then reviews recent improvements, meters for special needs (such as visual impairment), alternate-site testing, learning meter technique, scheduling SMBG, displaying and analyzing the results, costs, and the use of the continuous glucose monitoring system (CGMS, Medtronic). The article features a lengthy chart that summarizes the technical features of blood glucose meters (arranged by product name). 1 table.
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Impact of Pramlintide on Glucose Fluctuations and Postprandial Glucose, Glucagon, and Triglyceride Excursions Among Patients with Type 1 Diabetes Intensively Treated with Insulin Pumps. Diabetes Care. 26(1): 1-8. January 2003.
This article reports on a study undertaken to assess the effects of adjunctive treatment with pramlintide, an analog of the beta cell hormone amylin, on 24 hour glucose fluctuations and postprandial (after a meal) glucose, glucagon, and triglyceride excursions in patients with type 1 diabetes who are intensively treated with continuous subcutaneous insulin infusion (CSII). In the study, 18 patients (16 of whom could be evaluated) with type 1 diabetes (aged 44 years, plus or minus 11 years) were given mealtime injections of pramlintide three times a day for 4 weeks in addition to their preexisting CSII regimen (16 lispro, 2 regular insulin). At baseline, patients had excessive 24 hour glucose fluctuations, with 59 percent of the continuous glucose monitoring system (CGMS) measurements greater than 140 milligrams per deciliter, 13 percent less than 90 milligrams per deciliter, and only 28 percent in the euglycemic (good levels of blood glucose) range. After 4 weeks on pramlintide, measures in the hyperglycemic range declined to 48 percent and measurements within the euglycemic range increased to 37 percent. This shift from the hyperglycemic to the euglycemic range occurred with a concomitant 17 percent reduction in mealtime insulin dosages and without relevant increases in measurements below the euglycemic range (15 percent) or any severe hypoglycemic events. 3 figures. 1 table. 26 references.
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Do Sensor Glucose Levels Accurately Predict Plasma Glucose Concentrations During Hypoglycemia and Hyperinsulinemia?. Diabetes Care. 25(5): 889-893. May 2002.
The MiniMed Continuous Glucose Monitoring System (CGMS) measures subcutaneous interstitial glucose levels that are calibrated against three of more fingerstick glucose levels daily. This article reports on a study undertaken to examine whether the relationship between plasma and interstitial fluid glucose is altered by changes in plasma glucose and insulin levels and how such alterations might influence CGMS performance. To achieve this, the authors used microdialysis to provide a means to measure changes in interstitial glucose levels directly. Results showed that although hyperinsulinemia (high levels of insulin in the blood) may contribute to modest discrepancies between plasma and sensor glucose levels, the CGMS is able to accurately track acute changes in plasma glucose when calibrated across a range of plasma glucose and insulin levels. 1 figure. 1 table. 13 references.
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Spurious Reporting of Nocturnal Hypoglycemia by CGMS in Patients With Tightly Controlled Type 1 Diabetes. Diabetes Care. 25(9): 1499-1503. September 2002.
The Medtronic MiniMed Continuous Glucose Monitoring System (CGMS) is designed to continuously monitor interstitial fluid glucose levels within a range of 40-400 milligrams per deciliter. It is considered an important tool for overnight glucose monitoring. This article reports on a study undertaken to determine the accuracy of this system in individuals with tightly controlled diabetes. The study included 7 adolescents and young adults. Simultaneous glucose measurements obtained by glucose analyzer, Accu-Check Advantage meter, and CGMS were compared. The CGMS results were lower than analyzer readings in 74 percent of simultaneous pairs of tests performed during the 24 hour period of the study. There was a trend for the poorest correlation to occur in patients with the narrowest range in daily glucose levels. When the lowest CGMS reading of the night was compared with the simultaneous analyzer reading, the CGMS level was lower in all cases by an average of 38 percent (plus or minus 15 percent). In six of seven patients, the discrepancy was believed to be clinically significant; in at least four patients, overnight glucose levels reported by CGMS were falsely low, in a range that might have resulted in inappropriate reduction of overnight insulin dose. The authors conclude that CGMS reports of asymptomatic nighttime hypoglycemia (low blood glucose) may be spurious and should be interpreted with caution in patients with tightly controlled diabetes. 2 figures. 2 tables. 12 references.
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Hypoglycemia: An Excuse for Poor Glycemic Control?. Clinical Diabetes. 19(4): 161-167. 2001.
Although long term maintenance of normoglycemia (normal levels of blood glucose, or sugar) can prevent the onset and delay the progression of the microvascular (small blood vessels) complications of diabetes, a large percentage of patients with diabetes continue to have poorly controlled glucose levels. The risk of hypoglycemia (low levels of blood glucose) is a real obstacle to achieving glucose targets in patients with type 1 diabetes. However, risk of severe hypoglycemia in type 2 diabetes is minimal and should not be used as an excuse for failing to achieve glycemic goals. This article reviews the incidence of severe hypoglycemia in the major diabetes trials, the results of attempts to optimize glycemia to date, and the ways to ameliorate severe hypoglycemia in the treatment of both type 1 and type 2 diabetes. Strategies recommended for type 1 diabetes include: monitor blood glucose levels frequently; use physiological models of insulin replacement (such as multiple daily insulin injections and the newer types of insulin); avoid between meal snacks; consider the potential role of continuous glucose monitoring; and educate oneself, particularly about hypoglycemia. Severe hypoglycemia is relatively rare in patients with type 2 diabetes, however risk factors may include: a history of severe hypoglycemia, negative C peptide levels, a low level of diabetes education, or hypoglycemia unawareness. The authors conclude that patient education, empowerment, self monitoring of blood glucose (SMBG), more flexible and physiological insulin replacement regimens, and professional support can all minimize the frequency of severe hypoglycemia. 2 figures. 39 references.
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Insulin Pump Therapy in Young Children with Diabetes. Diabetes Spectrum. 14(2): 84-89. May 1, 2001.
This article reports on the experience of personnel at Childrens Hospital Los Angeles with insulin pump use in young children. The article presents the medical, educational, and psychological criteria for patient selection for continuous subcutaneous insulin infusion (CSII). Successful use of CSII requires that patients or family members have the requisite skills and knowledge and the appropriate attitude to learn pump therapy. In addition to learning how to insert, disconnect, protect, and program the pump, patients or caregivers must understand and successfully use carbohydrate counting, correct blood glucose levels outside the target range, manage sick days, and know how to adjust for exercise and changes in activity patterns. The article identifies the advantages and disadvantages of CSII in young children. CSII is easier and more convenient for many young patients, and it is more adaptable to erratic eating patterns. The main disadvantage of pump therapy in young children is that neither the pump nor the child is autonomous. The article also describes a modified method for pump initiation in young children. Other topics include the longitudinal results of the CSII experience at Childrens Hospital Los Angeles, the use of the pump at night in young children, and insulin pump therapy coupled with a continuous glucose monitoring system. The article concludes that the hospital has had an extremely positive experience with insulin pump therapy in young children, suggesting that CSII can be used with success in young children. 2 figures. 4 tables. 18 references. (AA-M).
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Limitations of Conventional Methods of Self-Monitoring of Blood Glucose. Diabetes Care. 24(11): 1858-1862. November 2001.
Children with type 1 diabetes are usually asked to perform self monitoring of blood glucose (SMBG) before meals and at bedtime, and it is assumed that if results are in target range, along with HbA1c (glycosylated hemoglobin, a measure of blood glucose over time) measurements, then overall glycemic (blood glucose) control is adequate. However, the brief glimpses in the 24 hour glucose profile provided by SMBG may miss marked glycemic excursions. This article describes the MiniMed Continuous Glucose Monitoring System (CGMS) which has provided a new method to obtain continuous glucose profiles and opportunities to examine limitations of conventional monitoring. The MiniMed CGMS uses a glucose oxidase-based sensor to measure extracellular fluid glucose in subcutaneous tissue, which is calibrated against corresponding blood glucose levels. A total of 56 children with type 1 diabetes (age 2 to 18 years) wore the CGMS for 3 days. Patients entered four fingerstick blood samples into the monitor for calibration and kept records of food intake, exercise, and hypoglycemic (low blood glucose levels) symptoms. Data were downloaded, and glycemic patterns were identified. Despite satisfactory HbA1c levels and premeal glucose levels near the target range, the CGMS revealed profound postprandial hyperglycemia (high levels of blood glucose). Almost 90 percent of the peak postprandial glucose levels after every meal were above target (more than 180 milligrams per deciliter), and nearly 50 percent were greater than 300 milligrams per deciliter. Additionally, the CGMS revealed frequent and prolonged asymptomatic hypoglycemia in almost 70 percent of the children (often nocturnal). Repeated use of the CGMS may provide a means to optimize basal and bolus insulin replacement in patients with type 1 diabetes. 3 figures. 1 table. 13 references.
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Pilot Study of the Continuous Glucose Monitoring System. Diabetes Care. 24(12): 2030-2034. December 2001.
This article reports on a study undertaken to determine whether the continuous glucose monitoring system (CGMS, MiniMed, Sylmar, California) could be used to make clinical decisions and whether it has an impact on glycemia in children with type 1 diabetes. Pediatric subjects were recruited if they had glycosylated hemoglobin (HbA1c, a measure of blood glucose levels over time) levels greater than 8 percent with management problems (n = 35) or episodes of severe or nocturnal hypoglycemia (low blood glucose) or hypoglycemia unawareness associated with HbA1c levels less than 8 percent (n = 12). A total of 47 patients with a mean HbA1c value of 8.6 percent (plus or minus 1.6 percent; mean age 11.8 years plus or minus 4.6 years; youngest 2.7 years; diabetes duration 5.5 years plus or minus 3.5 years) on three to four insulin injections per day (n = 24) or insulin pump therapy (n = 23) were followed with the CGMS for a mean of 69.5 hours (plus or minus 28 hours). The CGMS includes a glucose sensor, an electrode impregnated with glucose oxidase, that is subcutaneously placed via a flexible catheter that can be easily tolerated for 3 days; the sensor is connected by cable to a lightweight monitor worn on the patient's clothing. Comparisons were made between the number of high and low glucose patterns discerned with the sensor or the logbook, and HbA1c levels were evaluated. In patients on injection therapy, 30 high or low glucose patterns were discerned with the logbook records and 120 patterns with the CGMS. Specific alterations of the diabetes regimen were made. An overall significant change in HbA1c from 3 months before wearing the sensor to 6 months after was found in the subjects. The authors conclude that the CGMS can be used by pediatric patients to detect abnormal patterns of glycemia. The information that was obtained could be used to alter the diabetes regimen and have a positive impact on glycemic outcome. 1 figure. 2 tables. 17 references.
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What's Ahead in Glucose Monitoring?. Postgraduate Medicine. 109(4): 41-49. April 2001.
This review article, the second of four articles on diabetes, discusses the latest technological advances in glucose monitoring. Self monitoring of blood glucose (SMBG) allows people who have diabetes to measure their blood glucose levels at home, adjust treatment regimens as needed, and achieve near normal blood glucose levels. Data from the Diabetes Control and Complications Trial (DCCT) showed that improvements in glycemic control, through intensive insulin therapy and SMBG, significantly reduced the microvascular complications of diabetes. The frequency of SMBG depends on the current glycemic state of the patient. People who have type 1 diabetes should test four or more times daily, whereas for people who have type 2 diabetes, SMBG can less intensive if insulin is not part of the treatment regimen and if glycosylated hemoglobin values are less than 7 percent. Since the publication of the DCCT findings, glucose monitoring has become a big business. As a result, new technologies have evolved rapidly. The new meters for intermittent monitoring are smaller and less dependent on technical aptitude than older models. They require less blood, and many provide downloadable information for glucose analysis. Data systems used with new meters provide valuable information that can greatly improve glycemic control. Continuous glucose sensing is another major breakthrough in diabetes management. An artificial, mechanical islet cell may be the next advance in bringing diabetes under control. The article includes case reports that illustrate the possible value of a continuous glucose monitoring system. 2 tables. 16 references. (AA-M).
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