At our support group sessions we've talked about home blood glucose
testing. I encouraged almost all of my patients to do it, even those
with minimal problems. For the most part blood glucose cannot be
perceived and testing is necessary to know your levels and get
important feedback as to the influence of various factors. A1c is
useful as a guide to blood glucose control over the long term but does
not give information about daily fluctuations.
The timing of testing is important. Blood glucose fluctuates
throughout the day depending on food intake, activity level,
medication effects, and many other factors such as psychological
stress and the many hormones that the body manufactures and emits
intermittently. Key times to test are before and after meals. Diabetic
patients with type 1 and those with type 2 on complicated insulin
regimens should test several times daily.
The majority of type 2 patients taking less complicated treatment, and
particularly those with consistent meal and activity schedules, tend
to have a stable blood glucose pattern, rising and falling in a
similar manner on a daily basis. For such patients I recommended a
less intense amount of testing, still testing at key times mentioned
above but limiting the number of days of testing to between 1 and 3
days weekly. The point with this approach is less to adjust things on
a daily basis and more to try to pick out a pattern, particularly of
high or low times during the day, which might be used for longer term
treatment changes. Doing this is much more useful than the common
practice of testing daily before breakfast which measures glucose at
one point in the day but misses all the rest of the fluctuation.
A more recent approach to blood glucose testing is with CGM
(continuous glucose monitoring), using a tiny glucose sensor which is
inserted under the skin and which measures and transmits blood glucose
information every few minutes to a remote monitoring device, such as
an insulin pump screen, a cell phone or even a wrist watch device.
Tremendous strides have been made in the development of these devices
in recent years, especially in accuracy and duration. In fact the most
recently available sensors work out of the box without calibration and
can be used as a substitute for finger sticks and give accurate
results for up to 7 days.
Continuous glucose monitoring is fast becoming the standard of care
for treatment of type 1 diabetes, primarily because one receives not
just a real time blood glucose reading, but more importantly because
trends are identified. It is more important when using insulin to
understand in which direction the blood glucose is heading and how
fast. Also because of this ability to show trends, CGM devices can
give out alarms that warn when the blood glucose is heading too low or
too high.
CGM devices hold great promise in the quest for automating insulin
treatment since their data can be linked wirelessly to insulin pumps,
thus advancing toward the promise of an "artificial pancreas". Many
innovators are working diligently toward this goal. However, as CGM
devices have become easier and simpler to use it seems to me that they
should be useful for monitoring of blood glucose in type 2 patients as
well, not constantly, but periodically, as a better way to do the
intermittant analysis which I mentioned above. For this purpose a less
expensive easier to use device with less high tech features would be
most desirable.
Today's newsletter was actually prompted by my happening upon news
about the soon to be marketed FreeStyle Libre. This is a somewhat
lower tech and lower cost CGM device that looks to me like it would be
good for most type 2 patients and would even make sense for those type
1 patients who wish to continue with insulin shots rather than a pump
and could reasonably take the place of most of their fingerstick
testing. The sensors are unobtrusive, about the size of 2 stacked
quarters and look like a cinch to apply. They can be kept on in the
shower and even be used under water for a short time. Instead of a
continuous display on a monitor as with most sensor systems,
information is transmitted to a small, low cost monitor when it is
passed over the sensor, like items at a checkout counter. Whenever
this is done, on the monitor screen appears your present glucose
reading, a graph depicting what's been happening over the last 8 hours
and an arrow indicating which direction and how rapidly your glucose
is changing. In addition various graphs useful to analyze the last 90
day's data can be called up on the screen or downloaded to a computer.
The rechargable monitor device is supposed to sell for $60 and the
sensors which last 10 days I'm told will sell for $40, far lower than
the other available CGM systems. These prices might be particularly
appealing for Medicare type 2 diabetic patients for whom CGM is not
covered and who might use the devices only periodically to analyze
their blood glucose responses. If I were still in practice I would
certainly be interested in using this system to analyze my patients.
More information can be found at https://www.freestylelibre.us/
testing. I encouraged almost all of my patients to do it, even those
with minimal problems. For the most part blood glucose cannot be
perceived and testing is necessary to know your levels and get
important feedback as to the influence of various factors. A1c is
useful as a guide to blood glucose control over the long term but does
not give information about daily fluctuations.
The timing of testing is important. Blood glucose fluctuates
throughout the day depending on food intake, activity level,
medication effects, and many other factors such as psychological
stress and the many hormones that the body manufactures and emits
intermittently. Key times to test are before and after meals. Diabetic
patients with type 1 and those with type 2 on complicated insulin
regimens should test several times daily.
The majority of type 2 patients taking less complicated treatment, and
particularly those with consistent meal and activity schedules, tend
to have a stable blood glucose pattern, rising and falling in a
similar manner on a daily basis. For such patients I recommended a
less intense amount of testing, still testing at key times mentioned
above but limiting the number of days of testing to between 1 and 3
days weekly. The point with this approach is less to adjust things on
a daily basis and more to try to pick out a pattern, particularly of
high or low times during the day, which might be used for longer term
treatment changes. Doing this is much more useful than the common
practice of testing daily before breakfast which measures glucose at
one point in the day but misses all the rest of the fluctuation.
A more recent approach to blood glucose testing is with CGM
(continuous glucose monitoring), using a tiny glucose sensor which is
inserted under the skin and which measures and transmits blood glucose
information every few minutes to a remote monitoring device, such as
an insulin pump screen, a cell phone or even a wrist watch device.
Tremendous strides have been made in the development of these devices
in recent years, especially in accuracy and duration. In fact the most
recently available sensors work out of the box without calibration and
can be used as a substitute for finger sticks and give accurate
results for up to 7 days.
Continuous glucose monitoring is fast becoming the standard of care
for treatment of type 1 diabetes, primarily because one receives not
just a real time blood glucose reading, but more importantly because
trends are identified. It is more important when using insulin to
understand in which direction the blood glucose is heading and how
fast. Also because of this ability to show trends, CGM devices can
give out alarms that warn when the blood glucose is heading too low or
too high.
CGM devices hold great promise in the quest for automating insulin
treatment since their data can be linked wirelessly to insulin pumps,
thus advancing toward the promise of an "artificial pancreas". Many
innovators are working diligently toward this goal. However, as CGM
devices have become easier and simpler to use it seems to me that they
should be useful for monitoring of blood glucose in type 2 patients as
well, not constantly, but periodically, as a better way to do the
intermittant analysis which I mentioned above. For this purpose a less
expensive easier to use device with less high tech features would be
most desirable.
Today's newsletter was actually prompted by my happening upon news
about the soon to be marketed FreeStyle Libre. This is a somewhat
lower tech and lower cost CGM device that looks to me like it would be
good for most type 2 patients and would even make sense for those type
1 patients who wish to continue with insulin shots rather than a pump
and could reasonably take the place of most of their fingerstick
testing. The sensors are unobtrusive, about the size of 2 stacked
quarters and look like a cinch to apply. They can be kept on in the
shower and even be used under water for a short time. Instead of a
continuous display on a monitor as with most sensor systems,
information is transmitted to a small, low cost monitor when it is
passed over the sensor, like items at a checkout counter. Whenever
this is done, on the monitor screen appears your present glucose
reading, a graph depicting what's been happening over the last 8 hours
and an arrow indicating which direction and how rapidly your glucose
is changing. In addition various graphs useful to analyze the last 90
day's data can be called up on the screen or downloaded to a computer.
The rechargable monitor device is supposed to sell for $60 and the
sensors which last 10 days I'm told will sell for $40, far lower than
the other available CGM systems. These prices might be particularly
appealing for Medicare type 2 diabetic patients for whom CGM is not
covered and who might use the devices only periodically to analyze
their blood glucose responses. If I were still in practice I would
certainly be interested in using this system to analyze my patients.
More information can be found at https://www.freestylelibre.us/
