GLUCOSE MONITORING SAVVY

by Paula Ackerman, MS, RD, CDE

9/10

Weve Come A Long Way

Ames Reflectance Meter (1969)

Currently Bayer Company

Required 50 microliters of blood

Current meters use 0.5 or less

Monitoring Of Blood Glucose Why?

Monitoring Of Blood Glucose Why?

Cornerstone of Diabetes Management

Helps manage intercurrent illness. Allows for Pattern Management. Evaluates pre-meal and post-meal BG patterns. Coordinates amount and timing of food, activity and meds to reach target BGs. Identifies safe levels to operate equipment. (e.g. driving)
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Assists in achieving and maintaining glycemic goals. Provide immediate blood glucose results to detect, avoid and/or correct: Hyperglycemia. Hypoglycemia Hypoglycemia unawareness.
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In 2006, what percentage of adults with diabetes checked their blood glucose at least once a day?
A.

Monitoring Of Blood Glucose How?

A1C testing at least twice a year

Lab Single

40% (rate for 1997) B. 63% C. 74% D. 86% (those treated with insulin)
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testing use, disposable home testing device

A1C Now

Self-Monitoring of Blood Glucose

Home

use
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A1C vs eAG

A1C (%) 6 6.5 7 7.5 8 8.5 9 9.5 10

eAG (mg/dl) 126 140 154 169 183 197 212 226 240

A1C Now+ (Bayer Diabetes Care)

Single use, disposable device
Home

A1c
3

month weighted average Listed as a percentage Correlates to a BG number

or providers office

eAG (Estimated Average Glucose) Linear relationship between A1c and average BG level allowing A1C to be reported in familiar units 28.7 X A1C 46.7

http://professional.diabetes.org/GlucoseCalculator.aspx
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99% lab accuracy Results in 5 minutes 5 uL blood sample (finger, heel, ear) National Glycohemoglobin Standardization program certified Reimbursable www.a1cnow.com

GlycoMark Blood Test (GlycoMark Inc)

BG Meters

GlycoMark: FDA approved non-fasting blood test for 1,5-anhydroglucitol (1,5-AG)

reflects

Sensor Meters
Measures

postprandial BG (> 180 mg/dl) over 1-2 wks Post meal hyperglycemia linked to CVD, retinopathy, other complications A1C misses up to 40% of those with near normal levels who are elevated post meal

electronic charge resulting from reaction of strip enzyme and glucose in the drop of blood. meters are plasma calibrated

Newer

Normal serum 1,5-AG in adults and children:

10-30ug/ml

Readings are 12% higher than whole blood calibrated meters (older ones)
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Target Blood Glucose Ranges

ADA1
Pre meal Peak post meal 2 hours post meal A1C
1. 2.

Target Blood Glucose Ranges

A1C 7.0% 8.0% 49% 45% 18% 33% 14% 41% 8.5% 42% 12% 46%

AACE2
< 110 mg/dl Within target range < 140 mg/dl Below target range Above target range

70 130 mg/dl < 180 mg/dl

< 7%

< 6.5%
Brewer KW et al. Diabetes Care. 1998.
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American Diabetes Association (2010) Clinical Practice Recommendations American Association of Clinical Endocrinologists (2002)

Assessment of Client

Selecting An Appropriate Meter

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Psychosocial concerns

Readiness to learn Fears Reminder of diagnosis Empowerment

Immediate results

Reduction of anxiety

Hypoglycemia unawareness
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Assessment of Client
Identify
Pain

Assessment of Client

Barriers

Cognitive and fine motor abilities.

Attention

perception with finger poke. Elevated or fluctuating readings. Cost: insurance coverage Inconvenience, esp away from home. Dislike of record keeping.

span

Chronic and acute illness

Memory Manual

impairment

dexterity

Tremors Age

Work on a realistic plan with client.

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Assessment of Client

Assessment of Client

Older Adults
Less

Children
Small

Functional visual ability may require:

Tactile Strips

strip handling Small blood sample Larger display screen Memory

blood sample Comfortable lancet Quick results Memory

markings on strips.

that are not damaged by touching. meters. of placement of blood on strip.

Talking

Provide written and picture reinforcement. Remember: both hyperglycemia and hypoglycemia impair learning and retention.
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Method

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Assessment of Client

Assessment of Client

Select an appropriate lancet device.

Minimal

Demonstrate proper testing procedure. Have them return demonstrate BG test.

Observe Assist

pain but adequate sample size. Lancet disposal

Selection of appropriate meter.

Meter Size

technique for proper procedure. if necessary.

size of display screen Memory Cleaning functions and maintenance.

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If client cannot correctly demonstrate:

Re-demo. Select

a more appropriate meter based on cognitive and physical abilities.

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Assessment of Client
Troubleshooting
Ensure

Factors That Affect Accuracy

Meter Limitations User Error Alternate Site Testing Test Strips

Meter Problems

they are using the meter correctly

Frequent demonstrations required to ensure proper use of meter ! ! !

Review

Calibration/Coding
Maintenance Other
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factors affecting accuracy service number

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Customer

BG Test Strips in the News

Meter Limitations

Aug 09: FDA reported potential for falsely BG with use of glucose dehydrogenase pyrroloquinoline quinone (GDH-PQQ) test strips

All meters have limitations & interfering substances

Bayer Contour Precision Xtra No No No No No No No Accu-Chek FreeSytle Lite No No No No No Yes Yes Yes One Touch Yes Yes Yes Yes Yes No No No

Strips cant distinguish between glucose and other nonglucose sugars found in peritoneal diaylsis solution (Extraneal), certain immunoglobulins, abatacept (Orencia); tositumomab (Bexxar) or products containing maltose, galactose or xylose. Concern: potential for overtreatment with insulin and masking hypoglycemia Strips affected: Accu-Chek, FreeStyle, TRUEtest, . Cozmonitor, OmniPod

Oxygen Uric Acid Acetaminophen Ascorbic Acid Salicylates Maltose* Galactose* Xylose*

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No No No No No No No

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Yes Yes * HCP initiated

Meter Limitations
AccuChek Aviva Accu-Chek Compact Plus One Touch Ultra 2 Bayer Contour FreeStyle Lite/ Freedom Precision Xtra

Hematocrit Levels

BG Range Hematocrit Humidity

Strip expiration

10-600 20-70% 10-90%

Until exp date

10-600 25-65% 20-85%

Until exp date

20-600 30-55% 10-90%

3 mo after open

10-600 0-70% 10-90%

6 mo after open or exp

20-500 15-65% 5-90%

Until exp date

20-500 30-60% 10-90%

Until exp date

hematocrit (from anemia, some cancers, CKD/dialysis) can give false high reading. hematocrit (from dehydration) will give false low reading. Each meter lists a range of hematocrits for which it is accurate.
Important

Double dose Altitude Meter cost 50 strips

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Yes < 10,150 $17.94 $25-37

Yes < 10,150 $25.48 $26-39

No < 10,000 $29.95 $27-47

No ?? $9.25 $23-39

Yes < 10,000 $29.50 $27-36

Yes < 7,200 $24.28 $27-48

when monitoring pregnant women.

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User Error

User Error

Obtaining an adequate blood sample.

Wash

Contaminated Sample
Wash

hands in warm water. Hang hand at side and gently shake. Use appropriate lancet to yield adequate sample. Milk finger gently from base to tip. Best bleeders are thumb and ring finger

hands thoroughly, rinse well and dry completely. Alcohol use is not necessary

If used, ask: Is finger dry before testing?

Testing Site
Finger

Inadequate sample
Application

of sample to strip.

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poke vs. alternate site testing. best for suspected hypoglycemia or rapid changes in BG, post meal or within 1 hour of rapid acting insulin Alternate sites (palm, forearm, thigh, upper arm) are affected by food, activity, stress, illness, meds
Finger:

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Alternate Site Testing

Test Strips

When to use:

Fasting or 2+ hours since last meal/snack 2+ hours since last insulin dose 2+ hours since any activity

DO NOT use beyond expiration date

Check One

expiration date on each new vial of strips strips: 6 mo after opening

Touch strips: 3 mo after opening

When NOT to use:

If

Bayer

has hypoglycemia unawareness

Storage
Avoid

If suspect a low reading Within 2 hours of eating After exercise During illness Before driving
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exposure to heat, cold, humidity exposure to air

Consider temperature during shipping

Minimize Keep Altitude

in original container; recap immediately.

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Coding/Calibration
Failure to calibrate meter Encourage client to get in habit of calibrating
meter with each new box/bottle of strips.

Improper Coding
An improperly coded meter can provide a BG reading that is off by up to 30% If meter correctly coded
Probability Probability

Code chip Check strip Enter code on box of strips into meter

of 2 unit insulin dosing error: 7.1% of 3 unit insulin dosing error: 0.49%

If meter is miscoded:
probably probably

Many newer meters automatically calibrate.

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of a 2 unit insulin dosing error: up to 50% of a 3 unit insulin dosing error: up to 22.3%
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Calibration

Maintenance

Failure to comply with QA protocols

Use

Low Battery. Damage (scratches) to optic window of meter. Dirty meter

Clean

control solution with each new bottle of strips, if meter was dropped or whenever meter accuracy is questioned. strip viability, technique accuracy and correct functioning of meter.

Verifies

with water dampened Q-tip/cloth only. outer surface with gentle disinfectant. Dont use alcohol, cleaners with ammonia, glass cleaners or abrasive cleaners.
Clean
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Other

Frequency of SMBG

Factors Raising BG
Dehydration Hypoxia Anemia High

Factors Lowering BG
Hypotension Trauma/shock High High Low

Determined by how the data will be used monitoring during insulin adjust. Postprandial monitoring for glycemic effects of food portion Dependent on:
Medications Type

(low Hct)

oxygen tension hematocrit pH

pH

Mannitol Maltose

used
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of diabetes

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Frequency of SMBG: Type 1

Frequency of SMBG: Type 2

At target BG: at least 3 times daily Not at target: pre/post meal + occasional 2-3 am Additional times
always

At target BG (on insulin): at least 3 times daily At target BG (no insulin): at least once daily Not at target: pre/post meal + occasional 2-3 am Additional times
Anytime Before

check BG before administering insulin or changing insulin rates by pump suspected hypoglycemia
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suspected hypoglycemia

Anytime Before

driving
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driving

Does Timing Matter?

High in the Morning Why?

When BG levels are poorly controlled (A1C ~10%)

Fasting Post

Insulin Resistance
Liver

produces glucose overnight if cells are starved

BG contribute 70%

meal levels contribute 30%

Somogyi Effect Rebound Hyperglycemia

Hypoglycemia Body

in middle of night

releases hormones to counteract

When BG levels are well controlled (A1C ~7%)

Fasting Post

Dawn Phenomenon
Early

BG contribute 30%
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morning BG rise without hypoglycemia in night

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meal levels contribute 70%

Between

3-8 am, body releases counterregulatory hormones that make insulin less effective

Readings Elevated All Day??

Normal Preprandial/ Elevated Postprandial?

Normal pancreas secretes insulin in 2 phases:

Type 2: Cause: cells resistant to insulin, liver producing too much sugar and/or pancreas not making enough insulin What Helps? Exercise, wt loss, meds

1st Phase: within 10 minutes after glucose reaches bloodstream 2nd Phase: sustained release (~30 minutes post meal); lasts several hours Type 2s often lose 1st phase insulin release early in the disease

Type 1: Cause: not enough basal insulin What Helps? May need to increase dose
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Monitoring Tips

Other Tips for Success

Verify monitoring results in memory with log book entries.

Correlate

average BG level (in meter memory) with current A1C.

Use words like blood sugar checks, readings or measurements test has pass-fail interpretation Refer to results as: in target range or out of target range avoid good or bad Never use results to judge but to change treatment plan. Always praise for doing SMBG.
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Problem solve with client any questionable data. Verify technique. How neat and tidy is the book? Is more than 1 type of ink used?

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LifeScan

One Touch Ultra 2

1

Blood Glucose Meters

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microliter blood sample in 5 seconds Can flag pre and post meal readings 500 test memory Can download to computer
Results

One Touch Ultra Mini

1 microliter sample, results in 5 seconds Easy to use, lightweight, portable 50 Now

reading memory has downloading capability and 500 test memory

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These meters must be coded

LifeScan

Abbott Diabetes Care

OneTouch UltraLink
Uses

FreeStyle Lite and Freedom Lite

same One Touch test strips Wirelessly transmits BG reading to MiniMed Paradigm Insulin Pump Similar meter features as One Touch Ultra 2

No coding meters Upgrade of Flash and Freedom meters 0.3 microliter sample; 5 second testing 400 test memory

One Touch UltraSmart

Meter and logbook 3000 test memory

Precision Xtra

in one

These meters must be coded

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No coding 0.6 microliter sample, 5 second test Can also test blood ketones (separate strip)
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Roche Diagnostics

Roche Diagnostics

Accu-Chek Compact Plus

Self

AccuCheck Advantage

contained strips: 17 strip drum Automatic strip handling and coding 1.5 microliter sample; 5 second test 300 test memory Computer download capability

Must use code chip 4.0 microliter sample; 26 second test 480 test memory Computer download capability

Cannot do alternate site testing

Accu-Chek Aviva

Large readout Must use code chip 0.6 microliter sample; 5 second test 500 test memory Computer download capability

Multiclix: New lancet device

Self-contained, 6 lancet drum Lest painful: 11 depth settings

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Bayer Diagnostics

Bayer Diagnostics

Ascencia Breeze 2
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Ascencia Contour
The

strip autodisc No coding Large display 420 test memory 1.0 microliter sample 5 second test Computer download capability

first system to automatically correct for common variables that affect accuracy
Automatic Hematocrit

underfill detection, temperature control range of 0-70

No

coding required microliter sample, 5 second test 480 test memory; computer download capability Flag pre and post meal readings 2 hour post meal test alarm
0.6
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Bayer Contour USB

WaveSense
(AgaMatrix)
KeyNote, Presto, Jazz
More

Stores 2000 readings Uses contour test strips Plugs directly into computer usb port

Flags pre/post meal Set up individual goals View personal trends Set up testing reminders/alarms
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Glucofacts Deluxe DM Mgt software

accurate readings: corrects for common errors (hematocrit, altitude, temp, user error) 0.5 microliter sample; ~ 4 second test Computer download capability FREE logbook application on Apple iPhone Keynote: requires coding; strips ($17.95 for 50) Presto: no coding; 300 test memory; 14, 30 and 90 day averages; Meter ($20-25); strips (~$25 for 50) Jazz: for data management; 1865 test memory www.wavesense.info/

Other Inexpensive Meters

`

Talking Monitors (for Visually Impaired)

ReliOn (Wal-Mart); www.relion.com ` Ultima: 0.6 ul sample, results in 5 sec; 450 test memory; meter ($9); strips ($9 for 20, $20 for 50, $39 for 100) ` Micro: No coding; 0.3 ul sample; 50 test memory; meter ($12); strips ($21.94 for 50) Prodigy Pocket (Diagnostic Devices, Inc) www.prodigymeter.com No coding; small sample; results in 7 sec; 120 test memory free computer download at their website Meter ($15-20); strips ($20-25 for 50)

Accu-Chek Voicemate (Roche)

Works with AccuChek Advantage meter (code chip) 15 sec test; 480 test memory; Insulin vial label id ~$470-480 www.accu-chek.com

Prodigy Voice (Diagnostic Devices Inc)

TRUE Track (Home Diagnostics) www.presitgesmartsystem.com No coding , 1.0 ul sample; 10 sec test Sold under Rite Aid, Walgreens 55 Meter + strips ($22.99 w/50 strips, $47.99 w/100 strips)

Audible no-coding meter with tactile features on buttons and earphone jack for privacy Approved by the National Federation of the Blind and the American Foundation for the Blind 0.6 microliters; 7 second test; 450 test memory $75-85 (meter, 10 strips, 10 lancets) Prodigy AutoCode: talking meter (English/Spanish) www.prodigymeter.com

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Talking Monitors (for Visually Impaired)

Talking Monitors (for Visually Impaired)

Advocate meters (Diabetic Supply of Suncoast) Talking meters with large display screen 0.7 microliters, 7 second test, 450 test memory www.dsosi.com Advocate Redi-Code No coding Advocate Duo Also checks blood pressure
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ForaCare meters (Diabetic Supply of Suncoast)

Talking 0.7

meters with large display screen microliters, 7 second test, 450 test memory www.foracare.com/usa

Fora V10: talking meter For a V12: No coding For a V20 and V22 Advanced talking functions
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Meter/Strip Combos

DIDGET

True2Go (Home Diagnostics, CVS)

Disposable meter, 0.5 microliter sample, 4 second test 99 test memory; $10 for meter, $35 for 50 strips www.cvs.com

Bayer Diabetes Care

www.bayerdigit.com

BG meter attached to the Nintendo DS and DS Lite Positively reinforces consistent BG testing habits by awarding points that kids can use to unlock new game levels and customize their gaming experience. Currently available at stores or online at CVS Pharmacy and Walgreens

SideKick (Home Diagnostics)

Disposable meter with 50 strips; 1.0 microliter sample 10 second test; ~$30-35 www.presitgesmartsystem.com

All in One (Intuity Medical)

Investigational device combining test strips, lancets and lancing devices in a convenient cartridge system No handling/disposing of supplies www.intuitymedical.com
.

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BG Testing in the Future

BG Testing in the Future

Skin Patches
Univ of Calgary: size of a deck of cards with 4 microneedles; penetrate skin to draw blood but not deep enough to hit a nerve; BG data sent to a wireless remote Sandia National Labs:

M-Powered Car (Medtronic Diabetes)

Glucose Continuous

sensing car sound an alarm if BG starts to dip glucose monitor chip worn & wirelessly transmits readings to a microchip in dashboard

ElectroNeedles and Posts (micron sized electrodes or posts that painlessly measure proteins and macromolecules)

Breath Test (for DM screening)

Drink Breath

Nano Ink Tattoo (Draper Laboratories)

Changes

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color based on BG: purple (low), orange (good), yellow (high) www.draper.com
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solution with radioisotope (carbon 13) analyzer measures amount of exhaled carbon dioxide

GlucoPhone

Only FDA approved cell phone/BG meter

Transmit Send

& receive BG results in real time text alerts to any cell phone

LG5200 model System is $225.95

Compatible GlucoPack

with Verizon LG 5200 phone meter (results in < 10 seconds), 25 GlucoPack test strips, 25 lancets , 1 lancing device, 1 bottle control solution Test stips: $10 for 50

www.glucophone.com
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iPhone Applications

Manual input of BG data, carbs and insulin doses (creating an electronic logbook and reports) which can be shared with others
Diabetes

Log

developed by Chris Ross (type 1)

UTS

Diabetes (www.utracksys.com)

Color coded BG values in graphs

WaveSense

Diabetes Manager www.wavesense.info/iphone

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Diabetes iPhone Apps

Lifescan iPhone 3.0

Interface Track Has

Resource Charts on Blood Glucose Monitoring

Diabetes

meter with iphone via wireless Bluetooth or a cable (no manual input) BG data; send readings & message to others a meal builder, insulin scheduler, BG graphs

Health Website

http://www.diabeteshealth.com/charts/
BG Meters comparison Continuous Glucose Monitoring comparison

Estimate Not

how much insulin is needed with meals (based on food intake) available yet

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Final Thoughts

Personalize each SMBG plan. Always praise client for any readings. Never use results to pass judgement. Dont expect perfect control.
Work

towards improved control.

Provide or refer for diabetes selfmanagement education.

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