Self-monitoring of blood glucose in diabetic patients: from the least common denominator to the greatest common multiple

The Effect of Blood Glucose Self-Monitoring Among Inmates With Diabetes

The increasing prevalence and risk of complications from diabetes necessitate patient participation and attentiveness to select appropriate foods, perform regular physical activity, and be active in diabetes management and self-maintenance. Diabetes is often largely asymptomatic; consequently, early diagnosis and treatment are necessary. Inmates are a unique population challenged by the increased prevalence of chronic conditions including diabetes. Diabetes standards for inmates contain diagnostic and treatment management guidelines that incorporate personal glucose monitoring for insulin users. In December 2009, the Federal Bureau of Prisons initiated a program to distribute glucose meters to insulin-dependent inmates to facilitate self-monitoring blood glucose. The purpose of this study was to evaluate the effect of these glucose meters on hemoglobin A1c levels.

Practical approaches for self-monitoring of blood glucose: an Asia-Pacific perspective

Comprehensive glycemic control is necessary to improve outcomes and avoid complications in individuals with diabetes. Self-monitoring of blood glucose (SMBG) is a key enabler of glycemic assessment, providing real-time information that complements HbA1c monitoring and supports treatment optimization. However, SMBG is under-utilized by patients and physicians within the Asia-Pacific region, because of barriers such as the cost of monitoring supplies, lack of diabetes self-management skills, or concerns about the reliability of blood glucose readings. Practice recommendations in international and regional guidelines vary widely, and may not be detailed or specific enough to guide SMBG use effectively. This contributes to uncertainty among patients and physicians about how best to utilize this tool: when and how often to test, and what action(s) to take in response to high or low readings. In developing a practical SMBG regimen, the first step is to determine the recommended SMBG frequency and intensity needed to support the chosen treatment regimen. If there are practical obstacles to monitoring, such as affordability or access, physicians should identify the most important aspects of glycemic control to target for individual patients, and modify monitoring patterns accordingly. This consensus paper proposes a selection of structured, flexible SMBG patterns that can be tailored to the clinical, educational, behavioral, and financial requirements of individuals with diabetes.

Increased glycemic variability and decrease of the postprandial glucose contribution to HbA1c in obese subjects across the glycemic continuum from normal glycemia to first time diagnosed diabetes

OBJECTIVE

The contribution of postprandial glycemia (PPG) to hyperglycemia has been shown to decrease as HbA1c increased in type 2 diabetic patients. This study aimed at examining, in a series of overweight/obese patients without known glycemic disorder, the contribution of PPG to a "relative" hyperglycemia (glucose values≥5.5 mmol/L) and the presence of glycemic variability according to HbA1c levels.

METHODS

Seventy overweight/obese inpatients (body mass index 35.2±6.8 kg/m2) without known glycemic disorder were included. Participants were classified according to an oral glucose tolerance test (according to the American Diabetes Association criteria) as patients with normoglycemia (n=33), with intermediate hyperglycemia (n=24) or diabetes (n=13). They were separated into HbA1c quartiles (Q1 to Q4). A 24 hour continuous glucose monitoring was used under a 1800 kcal diet and minimal physical activity. We assessed PPG contribution (3 hour period after each meal) to the "relative" 24 hour hyperglycemia (glucose values ≥5.5 mmol/L); the remaining time was considered as the fasting/post-absorptive period.

RESULTS

HbA1c range was from 5.1% to 7.4% (32 to 57 mmol/mmol). From the lowest to the highest HbA1c quartile, the area under the curve (AUC) for the "relative" hyperglycemia presented a 17-fold increase for the fasting/post-absorptive (p<0.001) period and a 7-fold increase postprandially (p<0.001). The percent of PPG contribution to the "relative" hyperglycemia was calculated with the following formula [100×(postprandial 3 hour AUC-3 h AUC for a constant 5.5 mmol/L glycemia)/(total 24 h AUC-24 h AUC for constant 5. 5 mmol/L glycemia)] and decreased from Q1 to Q4 of HbA1c (81.2%, 66%, 65.8%, 57%; p<0.001). Increasing HbA1c quartiles were associated with higher daily mean blood glucose level (p<0.001) and higher levels of daily glucose variability indices, including mean amplitude of glycemic excursions (p<0.01).

CONCLUSIONS

In overweight/obese patients, HbA1c was associated with lower PPG contribution to "relative" hyperglycemia and greater glycemic variability. The present findings support the importance of postprandial period in glycemic exposure even before the appearance of diabetes.

Medical resource use, disturbance of daily life and burden of hypoglycemia in insulin-treated patients with diabetes: results from a European online survey

Hypoglycemia is common in patients with diabetes, and any severe hypoglycemic event can increase the fear of future hypoglycemic events. To try to reduce hypoglycemic events, many patients with diabetes maintain their blood glucose levels with a 'safety margin' (i.e., at higher than recommended values) and maintain hyperglycemia. Following this strategy leads to raised glycated hemoglobin levels, which are, consequently, linked to an increased risk of diabetic complications and increased healthcare costs. In the present survey (n = 1848), conducted in Germany, France and the UK, approximately a third of the patients were very worried about hypoglycemia, and a similar proportion reported maintaining hyperglycemia. Overall, the mean number of emergency room visits and hospitalizations (excluding emergency room visits) per patient per 12 months was 0.65 and 0.47, respectively. In addition, 10% of the patients reported that they had taken days off work because of hypoglycemia during the previous 12 months. Furthermore, 80% of diabetics in the three countries said they would value a meter that tells them when their blood glucose level is getting high/low at a particular time of the day. Thus, the survey outlines the potential scale, in a real-world setting, of 'hidden' costs associated with hypoglycemia and fear of hypoglycemia; such costs are likely to have a major detrimental impact on the overall emotional and economic burden of diabetes, which may be reduced through broader use of blood-glucose monitors for self-monitoring of blood glucose.

Personalizing treatment in type 2 diabetes: a self-monitoring of blood glucose inclusive innovative approach

A strong correlation exists between improved blood glucose control, obtained from the earliest stages of diabetes, and the prevention of complications. However, tight glycometabolic control does not always translate into an advantage for every patient. Because the characteristics of individual patients play an important role in diabetes care, there is a need to develop personalized action plans. This article suggests tailored therapeutic algorithms for some of the commonest type 2 diabetes phenotypes, taking into consideration age, body mass index, presence of micro- and macrovascular complications, hypoglycemia risk, and the co-existence of chronic renal failure. Particular emphasis is placed on exploiting information supplied through the rational use of self-monitoring of blood glucose as a tool for optimizing diabetes management, according to the prevalence of fasting/preprandial or postprandial hyperglycemia.

Effects of a structured self-monitoring of blood glucose method on patient self-management behavior and metabolic outcomes in type 2 diabetes mellitus

BACKGROUND

The purpose of this study was to evaluate the effect of structured self-monitoring of blood glucose (SMBG) on patient self-management behavior and metabolic outcomes in patients with type 2 diabetes mellitus (T2DM).

METHODS

From January to June 2009, 30 patients with basic diabetes education were followed for a period of 90 days. To provide assessment of glycemic control and frequency of dysglycemia, patients, underwent 3 consecutive days of seven-point SMBG during each month for 3 consecutive months, using the ACCU-CHEK 360° View tool. Glucose profiles of the first and third month were used for comparison.

RESULTS

Hemoglobin A1c (HbA1c) improved significantly during the 90-day period in all patients [confidence interval (CI) 95%, 0.32-1.64%, p < .05] and those with poor metabolic control (group B; CI 95%, 0.86-2.64%, p < .05). Mean blood glucose (MBG) values decreased significantly in group B (CI 95%, 0.56-24.78 mg/dl, p < .05) and all cases (CI 95%, 1.61-19.73 mg/dl, p < .05). Meanwhile, there was an average decrease of 15.7 mg/dl in fasting blood sugar (FBS) levels in the whole subjects. Mean postprandial blood glucose levels (MPP) decreased by 19.3 and 11.3 mg/dl in group B and in all cases, respectively. However, there were no significant changes in HbA1c, MBG, FBS, and MPP in people with good metabolic control.

CONCLUSION

A structured SMBG program improves HbA1c, FBS, MPP, and MBG in people with poorly controlled diabetes. This improvement shows the importance of patient self-management behavior on metabolic outcomes in T2DM.

Wavesense technology glucometer Linus for routine self-monitoring and clinical practice

Conventional glucometer systems for plasma/blood glucose monitoring are based on colorimetry or static electrochemistry using a fixed input signal. The recent glucometer Linus, Wellion, Agamatrix, USA, based on wavesense dynamic electrochemistry, uses a time-varying input signal to give a more accurate glucose reading. The purpose of this study was to compare the plasma glucose (PG) readings obtained by nursing staff from glucometer Linus and PG values estimated on an approved analyzer Daytona™, Randox, Global Medical Instrumentation, Inc., MN, USA. In the course of 5 weeks, 221 fingerprick capillary blood samples were taken from persons with diabetes at different times and investigated using glucometer Linus. Within two following minutes, blood from the same fingerprick was also collected in a tube and centrifuged; the plasma was analyzed on the Daytona™ analyzer. Statistical analysis was performed using the software SPSS v. 15.0, SPSS Inc., Chicago, IL, USA. A total of 221 paired PG values were plotted on the error grid diagram indicating that 218 values (98.6%) of the glucose readings (Linus vs. Daytona) were within the clinically accurate zone A (maximum difference ±20%) and 3 values (1.4%) within the acceptable zone B. Daytona showed 4 PG values <4.2 mmol/l (75 mg/dl) and their difference of respective Linus readings was always <0.83 mmol/l (15 mg/dl). Correlation of results was strong (r = 0.992). Glucometer Linus readings correspond to the ISO and FDA standards. So, Linus appears to be an accurate device for PG-self-monitoring and clinical practice.

Meta-analysis of the benefits of self-monitoring of blood glucose on glycemic control in type 2 diabetes patients: an update

BACKGROUND

Our systematic review and meta-analysis of the benefit of self-monitoring of blood glucose (SMBG) in improving glycemic control in type 2 diabetes was published in 2008. With the few studies that have emerged afterward, we undertook subsequent meta-analysis of the available evidence to update the results.

METHODS

Clinical trials of SMBG were identified through electronic searches (MEDLINE, EMBASE, and The Cochrane Library) up to and including June 2009. Studies were included if they met the following inclusion criteria: (1) randomized controlled trial comparing SMBG versus non-SMBG in type 2 diabetes patients not using insulin and (2) hemoglobin A1c (HbA(1c)) reported as an outcome measure. The efficacy was estimated with the mean difference in the changes of HbA(1c) from baseline to final assessment between the SMBG and the non-SMBG groups.

RESULTS

SMBG was effective in reducing HbA(1c) in non-insulin-treated type 2 diabetes (pooled mean difference, -0.24%; 95% confidence interval, -0.34% to -0.14%; P < 0.00001). Glycemic control significantly improved among the subgroup of patients whose baseline HbA(1c) was >or=8%. In contrast, no significant effect of SMBG was detected in patients who had HbA(1c) <8%.

CONCLUSIONS

The available evidence suggests the usefulness of SMBG in improving glycemic control in non-insulin-treated type 2 diabetes as demonstrated by the reduction of HbA(1c) levels. In particular, SMBG proved to be useful in the subgroup of patients whose baseline HbA(1c) was >or=8%.

Self-Monitoring of Blood Glucose (SMBG) in insulin- and non-insulin-using adults with diabetes: consensus recommendations for improving SMBG accuracy, utilization, and research

Current clinical guidelines for diabetes care encourage self-monitoring of blood glucose (SMBG) to improve glycemic control. Specific protocols remain variable, however, particularly among non-insulin-using patients. This is due in part to efficacy studies that neglect to consider (1) the performance of monitoring equipment under real-world conditions, (2) whether or how patients have been taught to take action on test results, and (3) the physiological, behavioral, and social circumstances in which SMBG is carried out. As such, a multidisciplinary group of specialists, including several endocrinologists, a health psychologist, a diabetes nurse practitioner, and a patient advocate (the Panel), discuss within this review article how the potential of SMBG might be fully realized in today's healthcare environment. The resulting recommendations cover technological, clinical, behavioral, and research considerations with the aim of achieving short- and long-term benefits, ranging from fewer hypoglycemic episodes to lower complication-related costs. The panel also made suggestions for designing future studies that increase the ability to discern optimal models of SMBG utilization for individuals with diabetes who may, or may not, use insulin.

Glycemic variability: the third component of the dysglycemia in diabetes. Is it important? How to measure it?

THE dysglycemia of diabetes includes two components: (1) sustained chronic hyperglycemia that exerts its effects through both excessive protein glycation and activation of oxidative stress and (2) acute glucose fluctuations. Glycemic variability seems to have more deleterious effects than sustained hyperglycemia in the development of diabetic complications as both upward (postprandial glucose increments) and downward (interprandial glucose decrements) changes activate the oxidative stress. For instance, the urinary excretion rate of 8-iso-PGF2alpha, a reliable marker of oxidative stress, was found to be strongly, positively correlated (r = 0.86, p < .001) with glycemic variability assessed from the mean amplitude of glycemic excursions (MAGE) as estimated by continuous glucose monitoring systems (CGMS). These observations therefore raise the question of whether we have the appropriate tools for assessing glycemic variability in clinical practice. From a statistical point of view, the standard deviation (SD) around the mean glucose value appears as the "gold standard." By contrast, the MAGE index is probably more appropriate for selecting the major glucose swings that are calculated as the arithmetic mean of differences between consecutive peaks and nadirs, provided that the differences be greater than the SD around the mean values. Furthermore, calculating the MAGE index requires continuous glucose monitoring, which has the advantage to detect all isolated upward and downward acute glucose fluctuations. In conclusion, the increasing use of CGMSs will certainly promote better assessment and management of glycemic variability.

Targeting prandial hyperglycemia: how important is it and how best to do this?

The contribution of postprandial glucose (PPG) excursions to the overall hyperglycemia of patients with type 2 diabetes depends on the degree of diabetic control. PPG is a major contributor in patients with hemoglobin A(1c) (HbA(1c)) levels below 7.3%, whereas the contribution of fasting plasma glucose (FPG) is preponderant in poorly controlled patients. In addition, the loss of postprandial glycemic control precedes stepwise degradation of fasting with worsening diabetes. As a consequence, monitoring after meals is particularly important in patients with HbA(1c) levels ranging from 6.5% to 8%. In such patients, targeting PPG below 140 mg/dL should be one of the main objectives to achieve HbA(1c) less than 6.5%. The new hypoglycemic agents, such as the glucagon-like peptide-1 analogues and the dipeptidyl peptidase-4 inhibitors which have a gluco-dependent insulinotropic effect, should normally reinforce our therapeutic armamentarium for achieving the glycemic targets that should include the three components of the glucose triad: HbA(1c), FPG, and PPG.

Overnight CSII as supplement to oral antidiabetic drugs in type 2 diabetes

AIM

To evaluate the potential advantages of a constant overnight subcutaneous delivery of insulin in type 2 diabetic patients who fail to achieve glycaemic control on oral antidiabetics.

METHODS

Ten type 2 diabetic patients treated with oral antidiabetic drugs without gaining sufficient glycaemic control were included in this three-period study. All patients received continuous subcutaneous insulin infusion (CSII) with a short-acting insulin analogue, 2 IU/h, for 8 h during three consecutive nights (period A). Based upon the results from period A, two additional dose regimens of three nights (period B and C) were studied in random order. Serum insulin aspart, human insulin and plasma glucose (PG) profiles were recorded.

RESULTS

In period A, fasting plasma glucose (FPG) was reduced from a mean +/- s.d. (mmol/l) value of 11.6 +/- 2.9 to 5.5 +/- 1.6 (p < 0.0001) during the first night. No additional lowering of FPG was seen the two succeeding nights. FPG narrowed as the range before the infusion was 7.3-15.2 mmol/l compared with 3.6-6.1 mmol/l on the last morning after infusion. The variability in PG profile during the first and the last night of CSII was small and not significantly different. The rising insulin aspart was mirrored by a decrease in human insulin. In period B and C, similar tendencies as for period A were seen. In period A, two patients each experienced one mild hypoglycaemic episode.

CONCLUSIONS

CSII with an insulin analogue overnight effectively reduced FPG without occurrence of major hypoglycaemia in type 2 diabetic patients who fail to achieve glycaemic control on oral antidiabetic treatment.

In silico simulation of long-term type 1 diabetes glycemic control treatment outcomes

OBJECTIVES

The goals of this study were to develop (1) a safe and effective protocol for the clinical control of type 1 diabetes using conventional self-monitoring blood glucose (SMBG) measurements and multiple daily injections with insulin analogues, and (2) an in silico simulation tool of type 1 diabetes to predict long-term glycemic control outcomes of clinical interventions.

METHODS

The virtual patient method was used to develop a simulation tool for type 1 diabetes using data from a type 1 diabetes patient cohort (n = 40). The tool was used to test the adaptive protocol (AC) and a conventional intensive insulin therapy (CC) against results from a representative control cohort. Optimal and suboptimal basal insulin replacements were evaluated as a function of SMBG frequency in conjunction with the (AC and CC) prandial control protocols.

RESULTS

In long-term glycemic control, the AC protocol significantly decreased hemoglobin A1c in conditions of suboptimal basal insulin replacement for SMBG frequencies > or = 6/day, and reduced the occurrence of mild and severe hypoglycemia by 86-100% over controls, over all SMBG frequencies in conditions of optimal basal insulin.

CONCLUSIONS

A simulation tool to predict long-term glycemic control outcomes from clinical interventions has been developed to test a novel, adaptive control protocol for type 1 diabetes. The protocol is effective and safe compared to conventional intensive insulin therapy and controls. As fear of hypoglycemia is a large psychological barrier to glycemic control, the AC protocol may represent the next evolution of intensive insulin therapy to deliver increased glycemic control with increased safety. Further clinical or experimental validation is needed to fully prove the concept.

Chronobiology in the endocrine system

Biological signaling occurs in a complex web with participation and interaction of the central nervous system, the autonomous nervous system, the endocrine glands, peripheral endocrine tissues including the intestinal tract and adipose tissue, and the immune system. All of these show an intricate time structure with rhythms and pulsatile variations in multiple frequencies. Circadian (about 24-hour) and circannual (about 1-year) rhythms are kept in step with the cyclic environmental surrounding by the timing and length of the daily light span. Rhythmicity of many endocrine variables is essential for their efficacy and, even in some instances, for the qualitative nature of their effects. Indeed, the continuous administration of certain hormones and their synthetic analogues may show substantially different effects than expected. In the design of drug-delivery systems and treatment schedules involving directly or indirectly the endocrine system, consideration of the human time organization is essential. A large amount of information on the endocrine time structure has accumulated, some of which is discussed in this review.

Continuous glucose monitoring in patients with type 2 diabetes: Why? When? Whom?

The overall assessment of glycaemic control in patients with type 2 diabetes should normally include the monitoring of three parameters that are usually depicted as the 'glucose triad': HbA(1c), fasting plasma glucose (FPG) and postprandial glucose (PPG) excursions. However one additional marker, the so-called 'glucose variability' might be as important as the three others since it has been demonstrated that both upward and downward glucose fluctuations are potent activators of oxidative stress. Even though many methods have been proposed for assessing glucose fluctuations, the 'mean amplitude glucose excursions' (MAGE) index remains the 'gold standard'. However MAGE estimation requires the use of continuous glucose sensors. Despite the debate on the reliability and cost of the devices that permit glucose monitoring, we suggest that interventional trials designed to evaluate the effects of glucose fluctuations on diabetic complications should benefit from the use of continuous glucose monitoring systems (CGMSs). More prosaically, the use of these technologies could be extended to current clinical care of type 2 diabetic patients especially for motivating them to accept earlier insulin treatments in case of 'oral antidiabetic drug secondary failure', and further for choosing the most appropriate insulin regimen.

[Drug treatment in type 2 diabetes (part 2)]

Insulin secretagogues and insulin sensitizers can be combined with one another as well as with other treatments (described below). Alpha-glucosidase inhibitors delay intestinal absorption of carbohydrates and reduce postprandial glycemia. Orlistat and sibutramine improve insulin sensitivity by helping patients lose weight. Orlistat inhibits hydrolysis of dietary triglycerides. Sibutramine, a noradrenaline and serotonin reuptake inhibitor, reinforces feelings of satiety and increases energy expenditure. After approximately 10 years, insulin therapy is usually required together with oral antidiabetic agents (except glitazones) or alone if HbA(1c) (glycosylated hemoglobin) is>6.5%. New guidelines for management of type 2 diabetes were published in 2006.

Low-income American Indians' perceptions of diabetes

OBJECTIVE

To determine inner city American Indians' perceptions of diabetes; find out how they manage their disease; and identify what health care improvements may be necessary for this population.

DESIGN

Eight focus group discussions conducted with diabetic inner city American Indian adults.

SETTING

Focus group discussions led by moderator using open-ended questions with prompts.

PARTICIPANTS

Eligibility criteria include age (> or = 18 years), a self-reported diagnosis of diabetes, and self-identification as inner city American Indian. Participants were screened by telephone to ensure all criteria were met. Forty inner city American Indian men and women participated in 8 focus groups.

PHENOMENON OF INTEREST

American Indians' perception of diabetes, its treatment, and how they manage the disease.

ANALYSIS

Focus group discussions were tape recorded and transcribed verbatim. Transcripts were analyzed by coding responses and identifying common themes according to content analysis procedures. Quantitative data from self-administered demographic forms were analyzed.

RESULTS

Participants could verbalize information regarding treatment and management of diabetes, but few could apply this information to their own lives. Some participants were homeless or without insurance, which makes successful disease management difficult. Perceptions of the health care system varied; a majority felt the system was meeting their needs, whereas others said it was not adequate.

IMPLICATIONS FOR RESEARCH AND PRACTICE

The study identified the need for health care workers to develop a better understanding of how this population lives; doing so could improve patient compliance to treatment. The results may provide direction for the development of culturally specific diabetes education appropriate for low-income patients focusing on the diabetic diet and exercise, and suggesting ways that the patient can move from knowing the information to implementing behavior change.

Self-monitoring of blood glucose and type 2 diabetes mellitus

Self-monitoring of blood glucose (SMBG) in management of type 2 diabetes mellitus continues to be debated. However, SMBG is recognized as being useful (professional agreement) in three situations: sensitizing the type 2 diabetic patient to the advantages of diet control and physical exercise, determining and adapting the dosage of oral antidiabetic medication at the beginning of treatment or during a dosage change, and monitoring plasma glucose during intercurrent disease or during a treatment that may lead to acute blood glucose imbalance. However, the frequency, the timing of blood glucose monitoring, and the target blood glucose values remain poorly defined. It is well known that the postprandial period covers approximately 50% of the day, and several recent studies have shown the respective role of fasting, pre- and postprandial glucose levels in overall diurnal hyperglycemia in the type 2 diabetic and their respective contribution to the mean HbA1c level depending on how well blood glucose levels are controlled. Based on these studies, it is now possible to propose a SMBG scheme, specific to a given patient and for a defined therapeutic objective, taking the three physiological periods into account: postprandial, postabsorptive, and fasting. However, the optimal use of SMBG requires patient education and training. Using a specific, adapted, and optimal SMBG is only advantageous if the results are usable, and used, by the patient and healthcare professionals to improve the quality of blood glucose control (as shown by the HbAlc level) and the safety of intensified oral antidiabetic treatments (minimal risk of hypoglycemia).

Targeting postprandial hyperglycemia

In healthy individuals, blood glucose levels in the fasting state are maintained by the continuous basal-level insulin secretion. After a meal, the rise in postprandial glucose (PPG) is controlled by the rapid pancreatic release of insulin, stimulated by both glucose and the intestinal production of the incretins glucose-dependent insulinotropic polypeptide and glucagon-like peptide 1. In diabetic individuals, postprandial insulin secretion is insufficient to suppress an excessive rise in PPG. There is increasing evidence that elevated PPG exerts a more deleterious effect on the vascular system than elevation of fasting plasma glucose. In particular, individuals with normal fasting plasma glucose but impaired glucose tolerance have significantly increased risk of cardiovascular events. With the recognition of the importance of PPG and the availability of new pharmacologic options, management of diabetes will shift to greater attention to PPG levels. The prototype for such an approach is in the treatment of gestational diabetes and diabetic pregnancies where PPG is the primary target of efforts at glycemic control. These efforts have been extremely successful in improving the outlook for diabetic pregnant women. There are many approaches to reduction of PPG; dietary management and promotion of exercise are very effective. Sulfonylureas, meglitinides, metformin, thiazolidinediones, and disaccharidase inhibitors all counteract PPG elevation. The development of glucagon-like peptide 1 agonists such as exendin and dipeptidyl peptidase IV inhibitors such as vildagliptin offers a new approach to suppression of PPG elevation. New semisynthetic insulin analogues permit a more aggressive response to postprandial glucose elevation, with lower risk of hypoglycemia, than with regular insulin. Inhaled insulin also has a rapid onset of action and offers benefits in PPG control. It is proposed that an aggressive treatment approach focusing on PPG, similar to the current standards for diabetic pregancies, be directed at individuals with diabetes and impaired glucose tolerance.

Current evidence regarding the value of self-monitored blood glucose testing

Many people with diabetes are falling short of attaining or maintaining glycemic goals. Self-monitoring of blood glucose (SMBG) is among the many strategies proposed to address the problem. SMBG complements hemoglobin A1c (HbA1c) testing by providing specific information regarding the effects of diet, exercise, and medications on glycemia. Although the importance of self-monitoring is appreciated for insulin-using patients, evidence is still emerging in support of self-monitoring for patients with type 2 diabetes managed with oral agents or diet. Evaluating the available evidence requires a good understanding of the study design and methodology. Although several clinical trials involving SMBG have been insufficiently powered to detect clinically meaningful differences in HbA1c, recent meta-analyses have reproducibly supported the benefit of self-monitoring in non-insulin-treated patients. Although additional work is needed to establish optimal frequency and timing of SMBG, these studies can serve as a basis for conservative recommendations to guide patients and their healthcare providers.

Strategies for improving glycemic control: effective use of glucose monitoring

Despite the increasing prevalence of diabetes, improved understanding of the disease, and a variety of new medications, glycemic control does not appear to be improving. Self-monitoring of blood glucose (SMBG) is one strategy for improving glycemic control; however, patient adherence is suboptimal and proper education and follow-up are crucial. Patients need to understand why they are being asked to self-test, what their glycemic targets are, and what they should do based on the results of self-monitoring. Patients also must be taught proper technique and must be given specific recommendations regarding frequency and timing for self-monitoring. Situations in which SMBG is essential or should be more frequent include self-adjustment of insulin doses, changes in medications, lack of awareness of hypoglycemia, gestational diabetes, illness, or when hemoglobin A1c (HbA1c) values are above target. SMBG should include postprandial monitoring to identify glycemic excursions after meals, to indicate the need for lifestyle adjustments, and to provide patient feedback on dietary choices.

An overview of the rationale for pharmacological strategies in type 2 diabetes: from the evidence to new perspectives

Therapeutic strategies in type 2 diabetic patients should not only integrate both the targets and indications of the different therapies but should be also a compromise between the patient's and physician's goals and willingnesses. The rationale for therapeutic targets is based on recommendations that differ from one country to another. Even though HbA1c remains the "gold standard", monitoring of blood glucose at fasting and postprandial time-points is a complementary tool for estimating both the quality and safety of diabetic control. Despite the lack of available strong evidence-based data it seems that achieving glucose levels < 130 mg/dl at fasting and < 180 mg/dl or < 140 mg/dl over postbreakfast or postlunch periods, respectively, might be a reasonable goal in most countries. The choice of appropriate strategies for treating type 2 diabetic patients should ideally be based on pathophysiological considerations. However for practical reasons, decisions for initiating or completing antidiabetic treatments are usually made by using such simple parameters as HbA1c and plasma glucose levels. The bridge between pathophysiological and clinical rationales can be obtained from the analysis of the relative contributions of fasting and postprandial glucose to the overall hyperglycaemia. In patients with HbA1c < 7.3%, postprandial glucose makes the major contribution to the overall hyperglycaemia, whereas the contribution of fasting glucose becomes progressively predominant in patients with HbA1c > 7.3%. As a consequence of these observations, initiation of antidiabetic treatments or implementation of second-line therapies should be aimed at reducing either postprandial excursions or fasting hyperglycaemia according to whether HbA1c levels are found respectively below or above a cut-off value of 7.3%.