To guide clinicians, patients, and researchers with evidence-based recommendations in the management of diabetes, the American Diabetes Association (ADA) included a new section on diabetes technology in their 2019 Standards of Medical Care in Diabetes. A review published in the Annals of Internal Medicine outlines these technology guidelines, focusing on self-monitoring of blood glucose and the use of continuous glucose monitors and automated insulin delivery systems.
The term diabetes technology encompasses the devices, hardware, and software that are used to assist in the management of blood glucose levels. For the current recommendations, the ADA Professional Practice Committee searched MEDLINE through November 2018 and evaluated high-quality studies, as well as incorporated feedback from the larger clinical community.
Self-Monitoring of Blood Glucose
Self-monitoring of blood glucose (SMBG) is an integral part of therapy for patients who use insulin. Continuous glucose monitoring (CGM) is another method to get continuous glucose readings and can be used to inform patients of the effects of medications, meals, and exercise on blood glucose level.
The updated guidelines recommend that most patients using intensive insulin regimens (multiple daily injections or insulin pump therapy) should assess glucose levels using SMBG or CGM before meals and snacks, at bedtime, occasionally postprandially, before exercise, when low blood glucose is suspected, after treating hypoglycemia until achieving normoglycemia, and before critical tasks (eg, driving). As for patients using less frequent insulin injections, SMBG may help guide treatment decisions.
There are potential benefits of SMBG for patients with type 2 diabetes who are not treated with insulin, including assessment of hypoglycemia and discrepancies between measured hemoglobin A1c (HbA1c) and glucose levels. Glucose monitoring may also help these patients understand how diet, physical activity, and medication treatment affect glucose levels.
In trials for which structured SMBG data were used to adjust therapy for patients not using insulin, the HbA1c reduction was greater compared with in studies without such adjustment. It is important to note that SMBG itself does not lower blood glucose levels, but the integration of this information into the treatment plan was responsible for the beneficial effect.
The guidelines recommend evaluation of the monitoring technique initially and at regular intervals, and it is vital that both the patient and the provider review the glucose readings. According to the guidelines, patients should receive ongoing instruction and evaluation of technique, results, and their ability to use the data in adjusting therapy.
The United States Food and Drug Administration approved home use of glucose monitors that follow an accuracy standard of 95% of readings within 15% for all blood glucose results in the monitor’s readable range, and 99% of readings within 20% of this range. Clinicians should be aware of factors that may interfere with glucose meter accuracy and choose appropriate devices for patients on the basis of these factors.