Routine SMBG is recommended for specific patient groups living with diabetes, particularly those on insulin therapy or other medications (e.g., sulfonylureas, meglitinides) that place them at high risk of hypoglycaemia.
As you learned in the last module, the frequency of SMBG is individualised based on specific needs. Globally, guidelines and recommendations for SMBG can vary, so it is important to be aware of any regional or local protocols when advising patients.
SMBG involves patients regularly monitoring their blood glucose levels to build a comprehensive 24-hour profile, including at the following points in a day:
- Fasting - first thing in the morning before food or drink (except water) is consumed
- Pre-prandial - before meals
- Post-prandial - 1.5 to 2 hours after meals
- Before bed
In general, patients are advised to check their levels before meals (pre-prandial) and at bedtime.
Traditionally, SMBG is performed using finger prick tests, which is the most common method for people with diabetes to check their blood glucose levels. Many glucose monitoring devices are available on the market, and in some areas, testing strips are sold in pharmacies. Pharmacists are well-positioned to support patients by ensuring they have the correct test strips suitable for the device they are using. However, the use of CGM and flash glucose monitoring devices is increasingly popular (covered in more detail later in this section).
Patient groups that routine SMBG is recommended for
In general, SMBG is recommended for the following groups:
- People living with type 1 diabetes.
- People living with type 2 diabetes, if they are on glucose-lowering medications that cause hypoglycaemia (e.g., meglitinides, sulfonylureas) and/or insulin.
- Certain groups of people living with diabetes, before and after exercise (this is typically recommended in people living with type 1 diabetes):
- People with intercurrent illness to monitor hypoglycaemia or hyperglycaemia that may arise.
- Those with established diabetes or a history of gestational diabetes pre-pregnancy and during their pregnancy.
- Individuals living with conditions or taking medications (e.g., corticosteroids) that require data on glycaemic patterns that HbA1c testing cannot provide.
- People whose HbA1c estimates would be unreliable (e.g., people with haemoglobin disorders).
SMBG is most effective when both the patient and their healthcare providers have the appropriate knowledge and understanding to plan the next course of action according to their blood glucose levels. For example, establishing what to do if the levels are outside of the acceptable range.
Task
In module 1, you were asked to research the normal, prediabetes and diabetes reference ranges for several diagnostic tests, including HbA1c. Now, building on that knowledge, this task will focus on self-monitoring blood glucose targets for people living with diabetes.
To complete this task, you need to research your national or local recommendations for fasting (no food or drink except water), pre-prandial (before a meal), and post-prandial (after a meal) blood glucose targets for the following groups:
- People with type 1 diabetes
- People with type 2 diabetes
- Pregnant women with any form of diabetes
- People on insulin and/or sulfonylureas
While it is important to understand the need for personalised blood glucose targets based on each patient's circumstances, it is important to be aware of the general management guidelines in place, which define targets for patients who are more stringently managing their diabetes.
Continuous glucose monitoring (CGM) and flash monitoring
A CGM (e.g., Dexcom®) or flash monitor device (e.g., Freestyle Libre®) is used by some people living with diabetes to monitor their blood glucose levels in real-time or near real-time. These devices have a small sensor that is inserted into the skin and measures the glucose levels in the interstitial fluid. The sensor is connected to a transmitter that sends information to the receiver or smartphone. Certain models are able to communicate with an insulin pump or pre-filled pen/cartridge so that appropriate amounts of insulin are automatically delivered to the patient. This is called a closed-loop system and is commonly known as an ‘artificial pancreas’.
CGM and flash monitoring devices can reduce the need for frequent finger prick tests whilst offering more detailed insights into the pattern of blood glucose levels throughout the day. Depending on the type of device, patients may need to scan the sensor periodically (flash monitoring) or receive continuous data (CGM). If the device detects an actual or impending hypoglycaemic or hyperglycaemic episode, it will trigger alerts or alarms to make the user aware so they can take action as necessary.
In some countries, flash monitoring or CGM devices are offered to anyone with type 1 diabetes. Those with type 2 diabetes who are on more than one daily insulin injection may also be offered these devices to help with their management. If patients with type 1 diabetes use this form of monitoring, they will still need to take blood glucose measurements using afinger prick test in certain situations, for example, to verify the accuracy of their flash monitoring or CGM device when their blood glucose levels are changing quickly, if their device stops working, or to confirm a suspected hypoglycaemic episode.
For insight into how Freestyle Libre® can have a positive impact on the life of a person with diabetes, watch this video: Using a Freestyle Libre 2 | Matt's Experience | Diabetes UK - YouTube.
Role of pharmacists
Pharmacists can play important roles in supporting patients in performing SMBG to manage their diabetes when supplying glucose monitoring machines and test strips.
They can advise patients on when to escalate concerns to their diabetes care team, such as in the event of persistently abnormal blood glucose readings.
Additionally, pharmacists can provide people living with diabetes with resources, such as a reference to the following video, demonstrating the correct method of checking blood glucose levels: How To Test Your Blood Sugar Levels | 7 Simple Steps | Diabetes UK - YouTube.
In the next section, we will explore important SICK day rules for individuals with diabetes, focusing on how to manage blood sugar levels during intercurrent illness effectively.
