Blood glucose monitoring - Pharmaceutical Society of Australia

Blood glucose monitoring - Pharmaceutical Society of Australia
John Facts
Bell says
Behind the Fact Card
Blood glucose monitoring Pharmacist CPD Module number 227
Blood glucose monitoring
By Carolyn Allen
Blood glucose monitoring guides the
management of diabetes mellitus.
Diabetes management aims to keep
blood glucose at a concentration
that minimises the acute symptoms
and long term complications
of diabetes. Blood glucose can
be monitored by measuring
glycosylated haemoglobin or
blood glucose concentrations. All
people with type 1 diabetes and
many people with type 2 diabetes
measure their own blood glucose
using a personal blood glucose
meter. This self-monitoring of blood
glucose can only improve a person’s
blood glucose levels if the person
can measure their blood glucose
accurately, and interpret and act on
the results. Pharmacists can provide
advice on suitable equipment and
correct techniques for measuring
blood glucose. They can also assist
with interpretation of results.
Learning objectives
After reading this article, pharmacists
should be able to:
• Discuss the benefits of blood
glucose management in
diabetes mellitus
• Explain the aim and use of
glycosylated haemoglobin
monitoring
• Explain the aims and uses
of self monitoring of blood
glucose (SMBG)
• Recommend suitable SMBG
equipment for a person
with diabetes.
Competencies (2010) addressed:
1.3.2, 6.1.1, 6.1.2, 6.1.3, 6.2.3, 6.3.1,
6.3.2, 6.3.3, 7.1.4, 7.2.3
6
This education module is independently researched and compiled by PSA-commissioned authors and peer reviewed.
Blood glucose monitoring guides the management of diabetes mellitus.
Diabetes mellitus
Diabetes mellitus is a chronic condition
caused by insufficient insulin secretion
and/or decreased sensitivity (resistance)
of body tissues to insulin. Insulin is a
hormone secreted by the beta cells of
the islets of Langerhans in the pancreas
in response to an increase in the glucose
concentration in the blood. Insulin
promotes the uptake, use and storage
of glucose by body tissues, especially
muscles, adipose tissue and the liver. It
also promotes protein and fat synthesis
and storage. Diabetes mellitus results
in high blood glucose concentrations
(hyperglycaemia) and impaired
carbohydrate, protein and fat metabolism,
which cause the acute symptoms and long
term complications of diabetes. There are
three main types of diabetes mellitus
known as type 1 diabetes, type 2 diabetes
and gestational diabetes.1,2
Type 1 diabetes
Type 1 diabetes is caused mainly by
immune-mediated destruction of the
beta cells of the islets of Langerhans
in the pancreas. It generally develops
inPHARMation June 2012 I © Pharmaceutical Society of Australia Ltd.
during childhood or adolescence, but
can also develop in adults. People with
type 1 diabetes require lifelong treatment
with insulin.2,3
If a person with type 1 diabetes does
not receive sufficient insulin, they can
develop diabetic ketoacidosis (DKA).3
DKA is a life-threatening condition which
develops when the body does not have
enough insulin to meet its basic metabolic
requirements. The lack of insulin leads to
the use of fatty acids instead of glucose as
an energy source. The metabolism of fatty
acids by the liver produces ketones (organic
acids) which can accumulate in the blood
and cause metabolic acidosis.1,4 See Practice
Point 3.
Type 2 diabetes
The overall defect in type 2 diabetes can
range from a predominant peripheral insulin
resistance (relative insulin deficiency) to a
predominant defect of insulin secretion,
with or without insulin resistance. Insulin
therapy may be required if blood glucose
levels cannot be adequately managed
with lifestyle management and other
medications. Type 2 diabetes is not usually
Blood glucose monitoring Pharmacist CPD Module number 227
associated with ketoacidosis.3 About 90% of
people with diabetes have type 2 diabetes.2
Gestational diabetes
Gestational diabetes is defined as glucose
intolerance which is first detected during
pregnancy. It occurs in approximately
5–10% of pregnancies. About 50% of
women with gestational diabetes can
manage their blood glucose levels with diet
and exercise. Gestational diabetes is usually
treated with insulin if it cannot be managed
by diet and exercise alone. Metformin
is occasionally used, but the safety of
metformin during pregnancy has not been
fully established.3
Long term complications
Over time, diabetes can cause
microvascular and macrovascular
complications that are associated with
significant morbidity and mortality.
Microvascular complications result from
damage to small blood vessels and nerves
and include nephropathy, retinopathy,
neuropathy and impaired wound healing.2
Macrovascular complications result from
damage to major blood vessels and include
coronary heart disease, cerebrovascular
disease (e.g. stroke) and peripheral vascular
disease.2 Cardiovascular disease is the major
cause of death in people with diabetes,
accounting for approximately 50% of
all fatalities.5
Blood glucose management
Long term management of blood glucose
levels can minimise the complications
of diabetes, particularly microvascular
complications. The 1993 Diabetes Control
and Complications Trial (DCCT) and 1998
United Kingdom Prospective Diabetes
Study (UKPDS) were landmark studies that
demonstrated that intensive blood glucose
management substantially reduced the
onset and delayed the progression of
microvascular disease in type 1 and type 2
diabetes respectively.6 In these studies
intensive blood glucose management
meant keeping blood glucose levels as
close as possible to the normal range.7
There is also evidence that tight long term
blood glucose management reduces the
risk of cardiovascular disease in both type 1
and type 2 diabetes.8
Consequently, management of blood
glucose levels is vital to the care of people
with diabetes. Blood glucose management
aims to:9
• Relieve the symptoms of hyperglycaemia
(e.g. excessive thirst, polyuria, blurred
vision, recurrent infection)
• Avoid acute complications of
hyperglycaemia (e.g. diabetic
ketoacidosis, hyperosmolar
non‑ketotic coma)
• Avoid hypoglycaemia
• Reduce long term microvascular and
macrovascular complications of diabetes.
Assessment of blood
glucose management
In Australia, blood glucose is usually
monitored by measuring blood levels
of glycosylated haemoglobin (HbA1C)
and glucose.
Glycosylated haemoglobin
testing
Glucose in the bloodstream passes into
red blood cells and binds irreversibly
to haemoglobin to form a subtype
of haemoglobin called glycosylated
haemoglobin (HbA1C). This process occurs
continuously over the 120-day life span
of each red blood cell. The proportion of
haemoglobin in the glycosylated form gives
an indication of the average blood glucose
concentration over the preceding two
to three months, and correlates with the
development of diabetes complications.5,10
HbA1C measurements are used by health
professionals to assess long term blood
glucose management. Measurements can
be performed by laboratory test or by a
point‑of-care testing device. See Practice
Point 1.
Facts Behind the Fact Card
Practice point 1
Point-of-care testing for
glycosylated haemoglobin
(HbA1C)29,30
Point-of-care (POC) testing means
pathology testing that is performed
on-site by a health professional
during a patient consultation. Some
general practice and rural and remote
medical services are using desktop
point‑of‑care devices for HbA1C and
other pathology tests. Trials have
shown good correlation between
test results from POC devices and
laboratories for HbA1C measurements,
however a 2011 systematic review
concluded that more research is
needed to investigate the role of HbA1C
POC testing in improving diabetes
management.
The national Quality Assurance for
Aboriginal and Torres Strait Islander
Medical Services (QAAMS) Program
currently provides point-of-care HbA1C
testing for diabetes management in
over 100 indigenous medical services
across Australia.
The HbA1C of an adult without diabetes is
about 3%–6.5% of the total haemoglobin.10
Current guidelines for both type 1 and
type 2 diabetes recommend that diabetes
management should generally aim to keep
HbA1C at ≤7% of the total haemoglobin.
The landmark diabetes studies have found
that an HbA1C of 7% or less correlates with
a low absolute risk of developing long
term microvascular complications. If HbA1C
is above 7%, guidelines recommend
changes in therapy to improve blood
glucose levels. However, the HbA1C target
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7
John Facts
Bell says
Behind the Fact Card
Practice point 2
Continuous glucose
monitoring (CGM)
Intermittent blood glucose
measurements may miss some high
and low blood glucose levels and can
lead to wrong decisions about insulin
dosing and carbohydrate intake.
Continuous information about glucose
levels can be provided by CGM
systems that measure glucose in the
interstitial fluid. A CGM device contains
a disposable sensor that is inserted
into subcutaneous tissue (e.g. in
the abdomen) and records glucose
concentrations every few minutes for
24 hours a day. Some CGM products
can also communicate with an insulin
pump (e.g. by wireless transmitter).
These CGM systems can improve
glycaemic control, but their routine
use is limited by cost.
Other monitoring systems are being
investigated, for example non-invasive
devices that can determine blood
glucose concentration by shining
infrared light onto the skin and
analysing the reflected light.7,9,13,26
Blood glucose monitoring Pharmacist CPD Module number 227
level needs to be individualised and may
need to be higher (or lower) than 7% for
some patients. The HbA1C target level is
influenced by a number of factors such as
age, co-morbidities, pregnancy and the risk
of hypoglycaemia.5,6,7
Australian diabetes management
guidelines recommend HbA1C be checked
at least every six months (every three to
four months if treatment targets are not
being met).9 A blood sample for HbA1C
measurement can be taken at any time
of day.
In 2011, Australian laboratories introduced
a change to their reference system
for reporting HbA1C. The ‘%’ unit for
HbA1C is being replaced by the Systeme
International (SI) unit which is ‘mmol/
mol’. This means the HbA1C level of 7%
will become 53 mmol/mol. The mmol/
mol reference unit represents millimoles
of HbA1C per mole of haemoglobin. The
Australian Pharmaceutical Formulary and
Handbook 22nd edition (APF22) contains
a table of equivalent HbA1C values under
the old and new reporting systems.
Pathology laboratories will report HbA1C
measurements in both ‘mmol/mol’ and ‘%’
for an interim period before the ‘%’ units are
phased out.11,12
Blood glucose testing
People with diabetes generally monitor
their own blood glucose levels, using
a personal blood glucose meter. This is
called Self Monitoring of Blood Glucose
(SMBG). Until the advent of blood glucose
meters, direct measurement of blood
glucose needed a laboratory test and selfmonitoring involved using urine dipsticks
to measure glucose concentrations in urine.
The concentration of glucose in urine was
used as an indicator of the blood glucose
concentration. SMBG complements HbA1C
data by providing immediate feedback
about blood glucose levels and blood
glucose patterns which can be used for
day-to-day management of diabetes.5
SMBG is useful for: 9
• self-adjusting diet, exercise and
insulin doses
• motivating patients to be involved in
self-management of their diabetes
• identifying hyperglycaemia and
hypoglycaemia
• assisting diabetes healthcare providers to
modify treatment.
8
inPHARMation June 2012 I © Pharmaceutical Society of Australia Ltd.
SMBG can help people with diabetes to
understand how diet, physical activity,
medications, stress and illness affect their
blood glucose levels. However, SMBG can
only improve blood glucose levels if people
modify their behaviour and medications
in response to their SMBG results. People
need to know why and how to perform
accurate blood glucose measurements,
and how to interpret and act on the results.
Diabetes educators play a vital role in
teaching people about diabetes selfmanagement, including how to perform
SMBG and make decisions based on blood
glucose levels. Pharmacists can help their
customers by collaborating with their local
diabetes educators and clinics.13,14,15
Frequency of SMBG
Current Australian treatment guidelines
recommend that the frequency and timing
of SMBG should be individualised according
to a number of factors including the type
of diabetes a person has, how stable their
blood glucose levels are, the treatment they
are using, their risk of hypoglycaemia, their
general health, their ability and willingness
to measure their blood glucose levels,
the impact of SMBG on their quality of life
and financial costs.7,9,16
People using insulin
Routine SMBG is essential for people
who are using insulin. People with type
1 diabetes on intensive insulin regimens
for tight blood glucose management
are usually advised to check their blood
glucose levels at least four times a day.
People using an insulin pump (continuous
subcutaneous insulin infusion) may need
to check more often. Blood glucose levels
are used to modify insulin doses and
food intake, and to assist in planning for
exercise. Young children often need to have
their blood glucose levels checked more
frequently , because they usually cannot
identify symptoms of hypoglycaemia and
signs may not be apparent to their parents
or carers. During illness, people with type
1 diabetes need to measure their blood
glucose more frequently, and also need
to monitor ketone levels.7,9,16 See Practice
Point 3.
Most people with type 2 diabetes who are
using insulin do not need to check their
blood glucose as frequently as people
with type 1 diabetes. Some literature has
Blood glucose monitoring Pharmacist CPD Module number 227
suggested that most people using basal
insulin and oral hypoglycaemic drugs do
not need to check their blood glucose any
more than 14 times per week.17
Practice point 3
Diabetic ketoacidosis (DKA)4,7
People with type 2 diabetes not
using insulin
There is conflicting evidence and debate
about the benefits of SMBG for people
with type 2 diabetes who are not using
insulin.9,17 The optimum frequency and
timing of measurements, whether SMBG
is associated with improved diabetes
outcomes, and which people with
type 2 diabetes should perform SMBG
remain uncertain.5
Current Australian guidelines recommend
that SMBG should be considered for all
people with type 2 diabetes. The guidelines
particularly recommend SMBG for all
people who are on treatment that can
cause hypoglycaemia (e.g. sulphonylureas
and insulin). However, the guidelines advise
that the decision to perform SMBG, and the
frequency and timing of measurements
should be individualised and based on
collaborative decisions between the person
with diabetes and their diabetes health care
team. Factors that influence the decisions
include whether the person is willing and
able to both perform SMBG and make
behavioural changes to improve their blood
glucose levels, and the diabetes care team
support that is available.5,13,17
Australian general practice guidelines for the
management of type 2 diabetes suggest that
initially blood glucose should be checked
three or four times daily. Once blood glucose
is stable, routine checks may be performed
at different times of the day on two or three
days per week, or less frequently for elderly
people. More frequent checks are required in
certain circumstances (See section on ‘Times
to test’).13
The International Diabetes Federation (IDF)
guidelines suggest that it may be valuable
to periodically perform intensive or ‘focused’
SMBG over short periods of time to identify
daily blood glucose patterns. For example,
a structured SMBG regimen which checks
blood glucose before and after each meal
and at bedtime over the course of one to
three days.15
The Structured Testing Program (STeP) study
published in 2011 assessed the effectiveness
of a structured SMBG regimen in patients
with poorly controlled, non‑insulin-treated
type 2 diabetes. Patients in the control group
Facts Behind the Fact Card
checked their blood glucose according
to their doctors’ usual recommendations.
The patients using the structured testing
program measured their blood glucose
before and after each meal and at bedtime
(seven times a day) for three consecutive
days prior to each of five clinic visits during
the 12 month study period. They also plotted
the results on a paper graph (the ACCUCHEK 360° View 3 day profiling tool available
from Roche Diagnostics). These patients
were taught how to identify blood glucose
patterns (using the graph), and change their
diet and physical activity in response to
these patterns. Their doctors were provided
with treatment strategies to use in response
to the patterns. At each clinic visit the
patient and doctor used the blood glucose
patterns to guide treatment decisions.
The study researchers concluded that the
structured SMBG program contributed to
significant HbA1C reductions, and improved
self‑monitoring efficiency by focusing on
blood glucose monitoring quality (blood
glucose measurements that contribute
to positive action) rather than quantity
(frequency of measurements).18,19
Blood glucose level targets
The normal blood glucose concentration
range is 4.0–6.0 mmol/L in the fasting state
and 4.0–7.7 mmol/L two hours after a meal.
In principle, diabetes management aims to
keep blood glucose levels as close to normal
(non-diabetes) levels as possible. In practice,
blood glucose level targets depend on
the individual, the type of diabetes and
the treatment regimen. Over‑zealous
management can result in severe
hypoglycaemia and needs to be avoided.13,16
DKA is an acute, life‐threatening
metabolic disturbance that occurs
mostly in type 1 diabetes. It is caused
by insulin deficiency, and consequent
increases in counter‑regulatory
hormones (e.g. glucagon,
hydrocortisone, catecholamines).
DKA is characterised by uncontrolled
hyperglycaemia, high blood ketone
levels and metabolic acidosis.
Symptoms include rapid breathing,
fruity-acetone smelling breath,
nausea, vomiting, abdominal pain
and dehydration.
DKA can be triggered by physiological
stresses that increase insulin
requirements (e.g. infection, acute
myocardial infarction, trauma).
Management of type 1 diabetes
on ‘sick days’ involves measuring
blood glucose more frequently and
monitoring ketone levels, to detect
signs of DKA and guide insulin dosing.
Ketone testing should always be
performed if the blood glucose level is
above 15 mmol/L.
Most people monitor ketones by
measuring ketone levels in urine,
using a urine dipstick (e.g. KetoDiastix).
The urine ketone level is an indication
of the blood ketone level. Blood
ketone levels can also be measured
directly using a blood glucose meter
that can measure both glucose
and ketones.
Urine testing is currently more
practical than blood testing. Urine
ketone dipsticks have a longer
shelf‑life than blood ketone test strips
so have a greater chance of being
‘in‑date’ when needed. In addition,
urine tests are not dependent on a
specific type of meter to provide a
reading (not all blood glucose meters
can measure ketones).
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9
John Facts
Bell says
Behind the Fact Card
Blood glucose monitoring Pharmacist CPD Module number 227
Targets for type 1 diabetes
Practice point 4
Alternate Site Testing (AST)14
Many blood glucose meters can test
blood samples taken from sites other
than the fingertips. This is called
alternate site testing. People who find
finger pricking painful may prefer to
use other less sensitive sites. Common
alternate testing sites include the
forearm, upper arm, thigh and base of
the thumb. AST can encourage some
people (especially children) to test
more often, which may facilitate better
blood glucose management.
Most alternate sites have a lower
concentration of blood vessels than
the fingertips, which means AST is
slower to register rapid changes in
blood glucose. Alternative sites should
not be used when blood glucose levels
are likely to be fluctuating (e.g. less
than two hours after meals and
physical activity), during illness or to
confirm hypoglycaemia.
For correct AST, the product
information for the meter and lancing
device need to be followed.
The ‘National Evidence Based Clinical
Care Guidelines for Type 1 Diabetes in
Children, Adolescents and Adults’ published
by the National Health and Medical
Research Council (NHMRC) provides
guidance on blood glucose level targets
for management of type 1 diabetes.7
See Table 1.
Targets for type 2 diabetes
The ‘National Evidence Based Guideline for
Blood Glucose Control in Type 2 Diabetes’
published by the NHMRC recommends
blood glucose level targets that are
associated with an HbA1C ≤ 7%. The targets
recommended by the NHMRC are:5,13
• 6.1–8.0 mmol/L in the fasting state
(before meals)
• 6.0–10.0 mmol/L two hours after meals.
Times to check blood
glucose
The best times to check blood glucose
are those that provide the most valuable
information about blood glucose patterns
over the day. Commonly used times are
fasting (before breakfast), immediately
before lunch, immediately before dinner,
two hours after a meal and at bedtime.
Values before meals give information about
baseline blood glucose levels which are
affected by general factors such as weight,
diet, activity and long- acting medications.
Values at two hours after meals give
information about peak blood glucose levels
which are affected by the baseline blood
glucose level, the food eaten and shortacting medications.13
Related Fact Cards
Blood Glucose Monitoring
Diabetes Type 1
Diabetes Type 2
Alcohol
Exercise and the Heart
Fat and Cholesterol
High Blood Pressure
Extra monitoring is recommended in certain
circumstances including:16,20
• During times of more or less physical
activity (e.g. rigorous exercise)
• During sickness or stress
• When changing routine or eating habits
(e.g. travelling )
SMBG procedures and
equipment
Procedures
To perform a blood glucose measurement,
the person must first wash and dry
their hands. Then they pierce their skin
(preferably the side of a fingertip) with
a lancet to obtain a small drop of blood.
The blood is then applied to the test strip
or test cassette in a blood glucose meter.
The meter displays the results digitally
within a few seconds. Diabetes guidelines
currently recommend that people then
record the results, along with details about
their diet and daily activities, in a log book
or diary which can easily be reviewed at
diabetes clinic visits.16,22
Most blood glucose meters on the market
have functions for storing and arranging
blood glucose data, and downloading it
onto a computer. Some meters currently
available overseas can download data to
smart phones and other electronic devices.
Computer software available from blood
glucose meter companies can analyse the
downloaded data and display it in various
forms (e.g. graphs, charts, deviations from
pre-set goals) to show blood glucose
Table 1. NHMRC guide to blood glucose level targets for type 1 diabetes7
Oral health
Infants and young
children
Young people
Adults (based on targets
used in the DCCT trial)
Smoking
Before meals
5–10 mmol/L
4–7 mmol/L
3.9–6.7 mmol/L
Vision Impairment
Two hours after meals
6–10 mmol/L
5–10 mmol/L
5–10 mmol/L
Weight and Health
Bedtime
6–10 mmol/L
6–10 mmol/L
At 3am
10
• When changing or adjusting medication
• When experiencing symptoms of
hypoglycaemia or hyperglycaemia
• When experiencing night sweats or
morning headaches
• For women who are pregnant or
planning pregnancy
• Pre/post minor surgical day procedures
• Post dental procedures.
The National Diabetes Society advises
people who are at risk of hypoglycaemia
(mainly those on insulin or sulphonylureas)
to check their blood glucose level before
they drive and every two hours during
driving. The National Diabetes Society
recommends a blood glucose level of above
5 mmol/L while driving.21
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5–8 mmol/L
Above 3.6 mmol/L
Blood glucose monitoring Pharmacist CPD Module number 227
patterns and trends. Pharmacists could use
this software to download a customer’s
SMBG data to a pharmacy computer or
other electronic device, in order to provide
an interpretive service.23,24
Blood glucose meters
A blood glucose meter is a small,
electronic device that measures the
glucose concentration of a blood sample
placed on a test strip. Meters measure
the glucose concentration whole blood
from a capillary, but most meters are
programmed to report the result as the
equivalent plasma glucose concentration.
Blood glucose concentrations in plasma
are about 10–15% higher than in whole
blood, so it is important to know which
level a meter reports. Results from a
meter that reports plasma levels can be
more easily compared with results from
laboratory tests (which report plasma blood
glucose levels).25
There are a number of blood glucose
meters on the market in Australia. Most
of these are available from state and
territory diabetes organisations (Diabetes
Australia), pharmacies and some diabetes
centres. The most suitable meter for an
individual will depend on a number of
factors including their manual dexterity,
visual acuity and cognitive abilities, and the
features of the meter. Doctors and diabetes
educators often help people to choose
an appropriate blood glucose meter.
Pharmacists can also help, and pharmacy
staff who sell blood glucose meters need
to understand the differences between
the various meters and know how to use
them. Manufacturers can provide meter
demonstration kits.16,23,24
Features to consider when choosing a
blood glucose meter include:23,24
• Ease of use
• Size of meter
• Size, type and lighting of the
display screen
• Battery type and life
• Need for cleaning and other maintenance
• Effect of temperature on accuracy
• The type of testing strips
• Method of calibration (some
automatically calibrate to test strips)
• The size of blood sample required
(varies from 0.3–1.5mL)
• Time taken to deliver result
• The ability to test ketones (see Practice
Point 3)
• The ability to test blood from sites other
than fingertips (see Practice Point 4)
• Whether the meter reports results
as plasma or whole blood glucose
concentrations
• The ability to provide audible feedback
(e.g. for vision-impaired people)
• The size of the memory (for storage and
recall of data)
• Features for data management
(e.g. providing averages of several
readings)
• Features for downloading data to
a computer, smart phone or other
electronic device
• The ability to add alerts (e.g. alarm clock)
and record comments (e.g. pre- and post
meal markers)
• Features for communicating with an
insulin pump (e.g. wireless transmitter)
• The costs of the meter and associated
equipment
• The manufacturer’s support service.
The accuracy of blood glucose meters
should be checked periodically,
according to the manufacturer’s
instructions. Quality control checks can be
performed by:
• Checking blood glucose using the meter
at the same time as having blood drawn
for a laboratory test, and comparing
the results.
• Using meter-specific control
solutions that contain known glucose
concentrations. Control solutions are
expensive and have a short shelf-life
so may be impractical for consumers
to keep and use. Some diabetes clinics
and pharmacies keep control solutions
and offer a ‘meter check’ service.14,16
Some pharmacies offer meter ‘clean and
check’ days.
• Using inbuilt electronic controls to check
that the meter is working properly.
These do not test the accuracy of the
results.26
Facts Behind the Fact Card
Practice point 5
Screening for type 2
diabetes13,14,32,33
’Screening’ has been defined as the
process of identifying those who are
at sufficiently high risk of a disorder to
warrant further investigation or action.
Australian guidelines recommend
using the Australian Type 2 Diabetes
Risk Assessment Tool (AUSDRISK)
as the first step of screening for type
2 diabetes. AUSDRISK can identify
people who are at high risk of diabetes
and should have a screening blood
test. General practice guidelines
recommend that all adults over
40 years of age be screened with the
AUSDRISK tool every three years.
Pharmacists could use the AUSDRISK
tool to help identify customers at risk
of diabetes.
The recommended blood test for
screening and diagnosis of diabetes
is laboratory measurement of the
fasting glucose concentration in
venous blood. If capillary blood
testing with a blood glucose meter
is used for screening, the results
need to be confirmed by laboratory
measurement of venous blood glucose
concentrations.
The Use of Blood Glucose Meters
position statement issued by the
Australian Diabetes Educators
Association (ADEA) recommends
against capillary blood testing with
a blood glucose meter as a method
of screening for diabetes, except in
certain defined circumstances (e.g. in
remote indigenous communities).
Test strips
A test strip holds the blood in the meter.
Some meters need to have a test strip
inserted each time, while some meters
use a preloaded cassette of test tape.
The test strips used for a particular
blood glucose meter must be the type
specified in the product information.
Each container or batch of test strips has
a calibration code that must be entered
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John Facts
Bell says
Behind the Fact Card
Practice point 6
Resources and patient services
Diabetes Australia
A national federated body of state
and territory organisations supporting
people with diabetes, and professional
and research bodies concerned
with diabetes.
Website: www.diabetesaustralia.com.au
Australian Diabetes Educators
Association (ADEA)
An Australian organisation for health
care professionals providing diabetes
education and care.
Website: www.adea.com.au
Australian Diabetes Society
The peak medical and scientific
body in Australia for diabetes care
and outcomes.
Website: www.diabetessociety.com.au
The Australian Type 2 Diabetes Risk
Assessment Tool (AUSDRISK)
Website: www.ausdrisk.com.au
Diabetes Forecast Consumer
Guide Charts
Each chart has information about
products available to people
with diabetes
Website: http://forecast.diabetes.org/
consumerguide/charts
International Diabetes Federation (IDF)
An umbrella organisation of over 200
national diabetes associations in over
160 countries.
Website: www.idf.org
National Diabetes Services Scheme
(NDSS)
The Australian Government scheme for
subsidising the costs of diabetes-related
products. The NDSS is administered by
Diabetes Australia. Some pharmacies are
NDSS Access Points.
NDSS Info Line : 1300 136 588
Website: www.ndss.com.au
12
Blood glucose monitoring Pharmacist CPD Module number 227
into the meter before those test strips can
be used. The calibration may be automatic
(the meter reads a code on the strip) or
may need to be done manually (e.g. by
inserting a microchip or entering a code).
Test strips are sensitive to light, moisture
and extremes of temperature. They must be
stored in their original container, handled
with care and discarded after their expiry
date. The test strips used to measure blood
glucose are different to the test strips used
to measure blood ketones.27,28
Lancets and lancet devices
A lancet is a small needle used to puncture
the skin in order to obtain a blood sample.
Lancets with different gauges and technical
designs are available. Higher gauge
(smaller width) lancets cause less pain,
but they may not produce a big enough
blood sample. Manufacturers recommend
that each lancet be used once only.
Lancets need to be disposed of in a tamperproof sharps container unless they are
concealed in a lancet drum. Lancet drums
are small containers of preloaded lancets
used by some lancet devices (e.g. Multiclix
and Fastclix). Lancet drums eliminate the
need to handle lancets and can be disposed
of in household waste.
Lancet devices insert the lancet into
the skin. Most are spring loaded and
when triggered, automatically insert
then retract the lancet. Most devices can
also be adjusted to different depths of
skin penetration. A lancet should pierce
the skin only to the depth necessary to
get an adequate amount of blood as
deeper penetration causes more pain.
The penetration depth may need to
be different for different testing sites.
See Practice Point 4. A lancet device should
be used with the type of lancets specified
in the product information. Lancet devices
should not be shared and need to be
cleaned regularly, because of the risk of
transmitting infection.23,24,26,29
4. Merck Manual of Diagnosis and Therapy. Diabetic
Ketoacidosis [online]. 2007. At: www.merckmanuals.com
5. Colagiuri S, Dickinson S, Girgis S, et al. National Evidence
Based Guideline for Blood Glucose Control in Type 2 diabetes.
Canberra: Diabetes Australia and the NHMRC; 2009.
6. Cheung N Wah, Conn J, d’Emden M, et al. Position statement
of the Australian Diabetes Society: individualisation of
glycated haemoglobin targets for adults with diabetes
mellitus. Med J Aust. 2009;191(6):339–44.
7. Craig ME, Twigg SM, Donaghue KC, et al. National evidence
based clinical care guidelines for type 1 diabetes in children,
adolescents and adults. Canberra: Australian Government
Department of Health and Ageing; 2011.
8. Diabetes therapy: treatment targets [revised Jun 2009]. In:
eTG complete [Internet]. Melbourne: Therapeutic Guidelines;
2012.
9. Management plan for people diagnosed with diabetes
[revised Jun 2009]. In: eTG complete [Internet]. Melbourne:
Therapeutic Guidelines; 2012.
10.Hughes J, Tenni P, Soulsby N. Case Studies in Clinical Practice.
Use of Laboratory Test Data: Process Guide and Reference for
Health Care Professionals 2nd ed. Pharmaceutical Society of
Australia, 2009.
11.Lab Tests Online Australasia. At: www.labtestsonline.org.au
12.Sansom LN, ed. Australian Pharmaceutical Formulary and
Handbook. 22nd edn. Canberra: Pharmaceutical Society of
Australia; 2012.
13.Harris P, Mann L, Phillips P, et al. Diabetes Management in
General Practice. Guidelines for Type 2 Diabetes. 17th edn.
Diabetes Australia. 2011/12
14.Australian Diabetes Educators Association. Position
Statement: Use of Blood Glucose Meters [online]. 2010. At:
www.adea.com.au
15.International Diabetes Federation. Guideline on SelfMonitoring of Blood Glucose in Non-Insulin Treated Type 2
Diabetes [online]. 2009. At: www.idf.org
16.Diabetes Australia. Blood Glucose Monitoring [online]. 2008.
At: www.diabetesaustralia.com.au
17.Lowe J. Self-monitoring of blood glucose in type 2 diabetes.
Aust Prescr. 2010;33:138–40.
18.Polonsky W, Fisher L, Schikman C, et al. Structured selfmonitoring of blood glucose significantly reduces A1C levels
in poorly controlled, noninsulin-treated type 2 diabetes.
Diabetes Care. 2011;34:262–7
19.LoNigro R, Sredzinski M. Implications of STeP for Improved
Diabetes Control: A Payer Perspective.
20.Alford J. Home blood glucose monitoring: A useful self
management tool. Diabetes Voice. 2004;49:15–6.
21.Australian Diabetes Society. Driving and Diabetes in Australia
Booklet [online]. 2011. At: www.diabetessociety.com.au
22.Diabetes State/Territory Organisations. Blood glucose
monitoring: Talking Diabetes No.04 [online]. 2010. At: www.
diabetes-act.com.au
23.Repchinsky C, ed. Patient Self-Care. 2nd edn. Ottawa:
Canadian Pharmacists Association; 2010.
24.Krinsky D, ed. Handbook of Nonprescription Drugs. 17th edn.
Washington: American Pharmacists Association; 2012.
25.The Royal College of Pathologists of Australasia. RCPA Manual
[online]. At: www.rcpamanual.edu.au
26.Gould L. Blood Glucose Monitoring. inPHARMation Jun 2008.
Pharmaceutical Society of Australia
27.The Diabetes Medication Assistance Service (DMAS) Trainer’s
Manual. Diabetes Pilot Program Training for Pharmacists.
Canberra: Pharmaceutical Society of Australia; 2008.
Pharmacists are encouraged to read the
Counter Connection article for more
information about SMBG procedures,
equipment and trouble shooting.
28.Koda-Kimble M, ed. Applied Therapeutics: The clinical use of
drugs. 9th edn. Philadelphia: Wolters Kluwer; 2008.
References
31.Al-Ansary L, Farmer A, Hirst J et al. Point-of-care testing for Hb
A1c in the management of diabetes: a systematic review and
metaanalysis. Clin Chem.2011;57(4):568–76
1. Guyton A, Hall J. Textbook of Medical Physiology 11th edn.
Philadelphia: Elsevier Saunders; 2006.
2. Merck Manual of Diagnosis and Therapy. Diabetes Mellitus
[online] 2010. At: www.merckmanuals.com
3. Classification of diabetes [revised June 2009]. In:
eTG complete [Internet]. Melbourne: Therapeutic
Guidelines; 2012.
inPHARMation June 2012 I © Pharmaceutical Society of Australia Ltd.
29.Diabetes UK. Finger-pricking devices and lancets [online]. At:
www.diabetes.org.uk
30. Shephard M. Point-of-care testing comes of age in Australia.
Aust Prescr 2010;33:6-9
32.Screening for and diagnosis of diabetes [revised June
2009]. In: eTG complete [Internet]. Melbourne: Therapeutic
Guidelines; 2012.
33.Colagiuri S, Davies D, Girgis S, Colagiuri R. National Evidence
Based Guideline for Case Detection and Diagnosis of Type 2
Diabetes. Diabetes Australia and the NHMRC, Canberra, 2009.
Blood glucose monitoring Pharmacist CPD Module number 227
Facts Behind the Fact Card
Assessment questions for the pharmacist
Before undertaking this assessment, you
need to have read the Facts Behind the
Fact Card article in inPHARMation, and the
associated Fact Cards.This activity has been
accredited by PSA as a Group 2 activity.
Two CPD credits (Group 2) will be awarded
to pharmacists with eight out of 10
1. What are the intended outcomes of
tight blood glucose management in
people with diabetes?
a. Decreased risk of DKA and
increased risk of retinopathy.
b. Increased risk of nephropathy and
decreased risk of stroke.
c. Decreased risk of nephropathy
and decreased risk of
cardiovascular disease.
d. Decreased risk of coronary
artery disease and increased risk
of neuropathy.
2. Choose the CORRECT answer
about HbA1C.
a. HbA1C indicates the average blood
glucose concentration over the
preceding 2–3 weeks.
b. Diabetes management generally
aims to keep HbA1C at ≤7%.
c. HbA1C of 7% or more correlates
with a low absolute risk
of developing long term
microvascular complications.
d. The ‘mmol/mol’ units for HbA1C
are being replaced by ‘%’ units.
2
questions correct. PSA is authorised by the
Australian Pharmacy Council to accredit
providers of CPD activities for pharmacists
that may be used as supporting evidence of
continuing competence.
Accreditation number: CS120005
Submit answers online
This activity has been accredited for Group 2 CPD
(or 2 CPD credits) suitable for inclusion in an individual
pharmacist’s CPD plan.
up to
Select one correct answer from each
of the following questions.
Answers due 31 July 2012.
CPD Credits
GROUP 2
To submit your response to these
questions online, go to the PSA website
www.psa.org.au/selfcare
5. Choose the CORRECT statement
about blood glucose meters.
3. Choose the CORRECT answer
about SMBG.
a. Routine SMBG is recommended
for all people with type 2
diabetes.
b. Most people with type 2 diabetes
need to test as frequently as
people with type 1 diabetes.
c. Young children often require less
frequent SMBG.
d. Australian guidelines recommend
SMBG for all people who are on
insulin or sulphonylureas.
a. All blood glucose meters can be
used to diagnose diabetes.
b. All blood glucose meters
automatically calibrate to the
test strips.
c. All blood glucose meters can also
test for ketones.
d. All blood glucose meters need
to be periodically checked
for accuracy.
4. Which of the following are two aims
of SMBG for people with type 2
diabetes?
a. To keep fasting blood glucose
concentrations in the range
6–10 mmol/L and to avoid
hypoglycaemia.
b. To keep blood glucose
concentrations in the range
6–10 mmol/L before meals
and to motivate the patient
to become more involved in
self management.
c. To keep blood glucose
concentrations in the range 6–10
mmol/L two hours after meals
and to avoid hypoglycaemia.
d. To keep blood glucose
concentrations in the range 6–10
mmol/L two hours after meals
and to test at least four times
a day.
inPHARMation June 2012 I © Pharmaceutical Society of Australia Ltd.
13
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