Monitoring Glycemic Control

Canadian Diabetes Association Clinical Practice Guidelines Expert Committee

Lori D. Berard RN, CDE Ian Blumer MD, FRCPC Robyn Houlden MD, FRCPC David Miller MD, FRCPC Vincent Woo MD, FRCPC

  • Key Messages
  • Recommendations
  • Figures
  • Full Text
  • References

Key Messages

  • Glycated hemoglobin (A1C) is a valuable indicator of treatment effectiveness and should be measured every 3 months when glycemic targets are not being met and when diabetes therapy is being adjusted.
  • Awareness of both measures of glycemia, self-monitoring of blood glucose (SMBG) results and A1C, provide the best information to assess glycemic control.
  • SMBG should not be viewed as an intervention but rather as an aid to assess interventions and hypoglycemia.
  • Timing and frequency of SMBG should be determined individually based on the type of diabetes, the treatment prescribed, the need for information about blood glucose (BG) levels and the individual's capacity to use the information from testing to modify behaviours or adjust medications.
  • SMBG and continuous glucose monitoring (CGM) should be linked with a structured educational and therapeutic program designed to facilitate behaviour change for improving BG levels.

Glycated Hemoglobin Testing

Glycated hemoglobin (A1C) is a reliable estimate of mean plasma glucose (PG) levels over the previous 3 to 4 months for most individuals (1). The mean level of blood glucose (BG) in the 30 days immediately preceding the blood sampling (days 0 to 30) contributes 50% of the result and the prior 90 to 120 days contributes 10% (2,3). In uncommon circumstances, where the rate of red blood cell turnover is significantly shortened or extended, or the structure of hemoglobin is altered, A1C may not accurately reflect glycemic status ( Table 1 ).

A1C is the preferred standard for assessing glycated hemoglobin, and laboratories are encouraged to use assay methods for this test that are standardized to the Diabetes Control and Complications Trial (DCCT) reference (4–6). A1C is a valuable indicator of treatment effectiveness and should be measured every 3 months when glycemic targets are not being met and when diabetes therapy is being adjusted. Testing at 6-month intervals may be considered in situations where glycemic targets are consistently achieved (4). A1C is now also being used for diagnosis of diabetes (see Screening for Type 1 and Type 2 Diabetes chapter, p. S12).

In Canada, the A1C continues to be reported using the National Glycohemoglobin Standardization Program (NGSP) units (%). In 2007, a consensus statement from the American Diabetes Association, European Association for the Study of Diabetes and the International Diabetes Federation called for A1C reporting worldwide to change to dual reporting of A1C with the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) SI units (mmol/mol) and derived NGSP units (%) with the hope of fully converting to exclusive reporting in SI units (7). However, this has not been adopted worldwide, with both Canada and the United States still using the NGSP units (%) (8). Although there are some advantages to reporting in SI units, the most notable disadvantage is the massive education effort that would be required to ensure recognition and adoption of the new units. At this time, Canada is not performing dual reporting. Therefore, throughout this document, the A1C will still be written in NGSP units (%). For those who wish to convert NGSP units to SI units, the following equation can be used: IFCC = 10.93(NGSP) – 23.50 (9) (see Appendix 11 for conversion of A1C from NGSP units to IFCC SI units).

Self-Monitoring of Blood Glucose

Self-monitoring of blood glucose (SMBG) can serve as a useful adjunct to other measures of glycemia, including A1C. Most people with diabetes will benefit from SMBG for a variety of individual reasons (10,11). SMBG is the only way to confirm, and appropriately treat, hypoglycemia. It can provide feedback on the results of lifestyle and pharmacological treatments, and increase patient empowerment and adherence to treatment. It can provide information to both the patient and healthcare professionals to facilitate longer-term treatment modifications and titrations as well as shorter-term treatment decisions, such as insulin dosing for people with type 1 or type 2 diabetes. In situations where A1C does not accurately reflect glycemia ( Table 1 ), SMBG is essential (12).

SMBG is most effective when combined with an educational program that incorporates behavioural changes (lifestyle modification and/or oral hypoglycemic agents) in response to BG values (13–17). As part of this education, patients should receive instruction on (1) how and when to perform SMBG, (2) how to record the results in an organized fashion, (3) the meaning of various BG levels, and (4) how behaviour and actions affect SMBG results.

Frequency of SMBG

The recommended frequency of SMBG must be individualized to each person's unique circumstances. Factors influencing this recommendation will include type of diabetes, type of therapy, adequacy of glycemic control, literacy and numeracy skills, propensity to hypoglycemia, awareness of hypoglycemia, occupational requirements and acute illness.

Type 1 and type 2 treated with insulin
For people with type 1 diabetes, SMBG is an essential daily activity. In a large cohort study, performance of ≥3 self-tests per day was associated with a statistically and clinically significant 1.0% absolute reduction in A1C (7). The evidence is less certain in people with type 2 diabetes treated with insulin, although the above principles likely apply (7). In a large, nonrandomized study of individuals with stable type 2 diabetes using insulin, testing at least 3 times a day was associated with improved glycemic control (18).

More frequent testing, including preprandial and 2-hour postprandial PG (18,19) and occasional nocturnal BG measurements, is often required to provide the information needed to reduce hypoglycemia risk, including unrecognized nocturnal hypoglycemia (20–24).

Type 2 diabetes not treated with insulin
For people with type 2 diabetes treated with lifestyle management, with or without oral antihyperglycemic agents, the effectiveness of SMBG in terms of improving glycemic control, as well as the optimal frequency, is less clear (10,11,25–34). However, a series of recent meta-analyses, all using different methodologies and inclusion criteria, have generally shown a small benefit to reducing A1C in those individuals performing SMBG compared to those who did not (35–41). The magnitude of the benefit was small, with (absolute) A1C reductions in these meta-analyses ranging from 0.2% to 0.5%. These analyses demonstrated greater A1C reductions in those performing SMBG when the baseline A1C was >8% (17,35,38,42). SMBG has been demonstrated to be most effective in persons with type 2 diabetes within the first 6 months after diagnosis (43). Also of significance, there is no evidence that SMBG affects patient satisfaction, general well-being or general health-related quality of life (43).

It is important to recognize that most trials in non-insulin-treated patients with type 2 diabetes are of limited value as baseline A1C levels were typically <8.0%, and these trials did not include a component of educational and therapeutic intervention in response to BG values. Several recent, well-designed randomized controlled trials that have included this component have demonstrated reductions in A1C (17,44,45). In the STeP trial, 483 poorly controlled subjects, not on insulin (mean A1C >8.9%), were randomized to either an active control group with enhanced usual care or a structured testing group with enhanced usual care and at least quarterly use of structured SMBG (17). At 1 year, there was a significantly greater reduction in mean A1C in the structured testing group compared with the active control group (-0.3%, p=0.04). Significantly, more structured testing group subjects received a treatment change recommendation compared with active control group subjects. In the ROSES (Role of Self-Monitoring of Blood Glucose and Intensive Education in Patients with Type 2 Diabetes Not Receiving Insulin) trial, subjects were randomly allocated to either a self-monitoring-based disease management strategy with education on how to modify lifestyle according to SMBG readings or to usual care (44). Results of SMBG were discussed during monthly telephone contact. After 6 months, significantly greater reductions in mean A1C (-0.5%, p=0.04) and body weight (-4.0 kg, p=0.02) were observed in the SMBG group compared with the usual care group. In the St. Carlos trial, newly diagnosed patients with type 2 diabetes were randomized to either an SMBG-based intervention or an A1C-based intervention (45). In the SMBG intervention group, SMBG results were used as both an educational tool to adhere to lifestyle changes as well as a therapeutic tool for adjustment of pharmacologic therapy. Treatment decisions for the A1C cohort were based strictly on A1C test results. After 1 year of follow-up, the median A1C level and body mass index (BMI) were significantly reduced in patients in the SMBG intervention group (from 6.6% to 6.1%, p<0.05; and from 29.6 to 27.9 kg/m2, p<0.01). In the A1C group, there was no change in median A1C or BMI.

The evidence is less clear about how often, once recommended, SMBG should be performed by persons with type 2 diabetes not treated with insulin. Separate from one's ability to use SMBG in order to lower A1C, SMBG should be considered for the prevention, recognition and treatment of hypoglycemia in persons whose regimens include an insulin secretagogue due to the higher risk of hypoglycemia with this class of agents (46). On the other hand, for patients with type 2 diabetes who are managed with lifestyle, with or without oral antihyperglycemic agents associated with low risk of hypoglycemia, and who are meeting glycemic targets, very infrequent checking may be needed.

The Canadian Diabetes Association has published the “Self-Monitoring of Blood Glucose (SMBG) Recommendation Tool for Healthcare Providers,” which defines basic SMBG requirements to provide guidance to healthcare professionals regarding appropriate utilization of SMBG ( Appendix 4 ) (available at: ( .../SMBG_HCP_Tool_9.pdf ).

Verification of accuracy of SMBG performance and results

Variability can exist between BG results obtained using SMBG devices and laboratory testing of PG. At BG levels >4.2 mmol/L, a difference of <20% between SMBG and simultaneous venous FPG is considered acceptable (47). In order to ensure accuracy of SMBG, results should be compared with a laboratory measurement of FPG at least annually or when indicators of glycemic control (A1C) do not match SMBG readings. Periodic re-education on correct SMBG technique may improve the accuracy of SMBG results (48,49). In rare situations, therapeutic interventions may interfere with the accuracy of some SMBG devices. For example, icodextrin-containing peritoneal dialysis solutions may cause falsely high readings in meters utilizing glucose dehydrogenase. Care should be taken to select an appropriate meter in such situations.

Alternate site testing

Meters are available that allow SMBG using blood samples from sites other than the fingertip (forearm, palm of the hand, thigh). Accuracy of results over a wide range of BG levels and during periods of rapid change in BG levels is variable across sites. During periods of rapid change in BG levels (e.g. after meals, after exercise and during hypoglycemia), fingertip testing has been shown to more accurately reflect glycemic status than forearm or thigh testing (50,51). In comparison, blood samples taken from the palm near the base of the thumb (the thenar area) demonstrate a closer correlation to fingertip samples at all times of day and during periods of rapid change in BG levels (52,53).

Table 1
Factors that can affect A1C (74)
A1C, glycated hemoglobin.
Factor Increased A1C Decreased A1C Variable Change in A1C
Erythropoiesis Iron deficiency
B12 deficiency
Decreased erythropoiesis
Use of erythropoietin, iron or B12
Reticulocytosis
Chronic liver disease
 
Altered hemoglobin     Fetal hemoglobin
Hemoglobinopathies
Methemoglobin
Genetic determinants
Altered glycation Alcoholism
Chronic renal failure
Decreased erythrocyte pH
Ingestion of aspirin, vitamin C or vitamin E
Hemoglobinopathies
Increased erythrocyte pH
 
       
Erythrocyte destruction Increased erythrocyte lifespan:
Splenectomy
Decreased erythrocyte lifespan:
Chronic renal failure
Hemoglobinopathies
Splenomegaly
Rheumatoid arthritis
Antiretrovirals
Ribavirin
Dapsone
 
       
Assays Hyperbilirubinemia
Carbamylated hemoglobin
Alcoholism
Large doses of aspirin
Chronic opiate use
Hypertriglyceridemia Hemoglobinopathies

Ketone Testing

Ketone testing is recommended for all individuals with type 1 diabetes during periods of acute illness accompanied by elevated BG, when preprandial BG levels remain elevated (>14.0 mmol/L), or when symptoms of diabetic ketoacidosis (DKA), such as nausea, vomiting or abdominal pain, are present (4). If all of these conditions are present in type 2 diabetes, ketone testing should be considered, as DKA also can occur in these individuals.

During DKA, the equilibrium that is usually present between ketone bodies shifts toward formation of beta-hydroxybutyric acid (beta-OHB). As a result, testing methods that measure blood beta-OHB levels may provide more clinically useful information than those that measure urine acetoacetate or acetone levels. Assays that measure acetoacetate through urine testing may not identify the onset and resolution of ketosis as quickly as those that quantify beta-OHB levels in blood, since acetoacetate or acetone can increase as beta-OHB decreases with effective treatment (47). Meters that quantify beta-OHB from capillary sampling may be preferred for self-monitoring of ketones, as they have been associated with earlier detection of ketosis and may provide information required to prevent progression to DKA (54–56). This may be especially useful for individuals with type 1 diabetes using continuous subcutaneous insulin infusion, as interruption of insulin delivery can result in rapid onset of DKA (54).

Continuous Glucose Monitoring Systems

Continuous glucose monitoring systems (CGMSs) measure glucose concentrations in the interstitial fluid. Two types of devices are available. The “real time” (also called “personal”) CGMS provides information directly to the user by displaying moment-to-moment absolute glucose levels and trending artrs, and by providing alarm notifications in the event that the glucose level is above or below a preset limit. A “blinded” (sometimes referred to as “professional”) CGMS captures, but does not display, the glucose readings, which are then downloaded onto a computer for viewing and retrospective analysis by the healthcare provider (typically in conjunction with the user).

Continuous glucose monitoring (CGM) technology incorporates a subcutaneously inserted sensor, an attached transmitter and, in the case of real-time CGM, a display unit (which may be a standalone unit or be integrated into an insulin pump). In professional CGM, the “transmitter” captures and retains the data. In Canada, one real-time CGMS and two professional CGMSs are available. Real-time CGM has been consistently shown to reduce A1C in both adults (57–66) and children (58,60,62,63,65–67) with type 1 diabetes, and to reduce A1C in adults with type 2 diabetes (68). Real-time CGM also has been shown to reduce the time spent in hypoglycemia (65,69). Professional CGM has been shown to reduce A1C in adults with type 2 diabetes (70) and in pregnant women with type 1 or type 2 diabetes (71).

Successful use of CGM is, unsurprisingly, dependent on adherence with using the CGMS; the greater the time wearing the device, typically the better the A1C (59,60,63,64,67,72). Like SMBG, CGM provides the best outcomes if it is associated with structured educational and therapeutic programs. CGM is not a replacement for SMBG because SMBG is still required for calibration of the CGM device and, for real-time CGM, to confirm interstitial measurements prior to making therapeutic changes or treating suspected hypoglycemia.

Recommendations

  • For most individuals with diabetes, A1C should be measured every 3 months to ensure that glycemic goals are being met or maintained. Testing at least every 6 months should be performed in adults during periods of treatment and lifestyle stability when glycemic targets have been consistently achieved [Grade D, Consensus].
  • For individuals using insulin more than once a day, SMBG should be used as an essential part of diabetes self-management [Grade A, Level 1 (21), for type 1 diabetes; Grade C, Level 3 (10), for type 2 diabetes] and should be undertaken at least 3 times per day [Grade C, Level 3 (10,18)] and include both pre- and postprandial measurements [Grade C, Level 3 (18,19,73)]. In those with type 2 diabetes on once-daily insulin in addition to oral antihyperglycemic agents, testing at least once a day at variable times is recommended [Grade D, Consensus].
  • For individuals with type 2 diabetes not receiving insulin therapy, SMBG recommendations should be individualized depending on type of antihyperglycemic agents, level of glycemic control and risk of hypoglycemia [Grade D, Consensus].
    • When glycemic control is not being achieved, SMBG should be instituted [Grade B, Level 2 (33,38) ] and should include periodic pre- and postprandial measurements and training of healthcare providers and patients on methods to modify lifestyle and medications in response to SMBG values [Grade B, Level 2 (17)].
    • If achieving glycemic targets or receiving medications not associated with hypoglycemia, infrequent SMBG is appropriate [Grade D, Consensus].
  • In many situations, for all individuals with diabetes, more frequent testing should be undertaken to provide information needed to make behavioural or treatment adjustments required to achieve desired glycemic targets and avoid risk of hypoglycemia [Grade D, Consensus].
  • In people with type 1 diabetes, real-time continuous glucose monitoring may be used to improve glycemic control [Grade B, Level 2 (58) ] and reduce hypoglycemia [Grade B, Level 2 (65,69) ].
  • In order to ensure accuracy of BG meter readings, meter results should be compared with laboratory measurement of simultaneous venous FPG at least annually and when indicators of glycemic control do not match meter readings [Grade D, Consensus].
  • Individuals with type 1 diabetes should be instructed to perform ketone testing during periods of acute illness accompanied by elevated BG, when preprandial BG levels remain >14.0 mmol/L or in the presence of symptoms of DKA [Grade D, Consensus]. Blood ketone testing methods may be preferred over urine ketone testing, as they have been associated with earlier detection of ketosis and response to treatment [Grade B, Level 2 (55) ].

Abbreviations:
BG, blood glucose; DKA, diabetic ketoacidosis; FPG, fasting plasma glucose; SMBG, self-monitoring of blood glucose.

References

  1. 1 R.J. McCarter J.M. Hempe S.A. Chalew Mean blood glucose and biological variation have greater influence on HbA1c levels than glucose instability: an analysis of data from the Diabetes Control and Complications Trial Diabetes Care 29 2006 352 355
  2. 2 D. Goldstein R. Little R. Lorenz Tests of Glycemia in Diabetes Diabetes Care 27 2004 1761 1773
  3. 3 L. Calisti S. Tognetti Measure of glycosylated hemoglobin Acta Biomed 76 suppl 3 2005 59 62
  4. 4 American Diabetes Association Standards of medical care in diabetes–2007 Diabetes Care 30 suppl 1 2007 S4 S41
  5. 5 D.B. Sacks D.E. Bruns D.E. Goldstein Guidelines and recommendations for laboratory analysis in the diagnosis and management of diabetes mellitus Clin Chem 48 2002 436 472
  6. 6 American Diabetes Association European Association for the Study of Diabetes International Federation of Clinical Chemistry and Laboratory Medicine, and the International Diabetes Federation Consensus statement on the worldwide standardization of the HbA1c measurement Diabetologia 50 2007 2042 2043
  7. 7 Consensus Committee Consensus statement on the worldwide standardization of the hemoglobin A1C measurement: the American Diabetes Association, European Association for the Study of Diabetes, International Federation of Clinical Chemistry and Laboratory Medicine, and the International Diabetes Federation Diabetes Care 30 2007 2399 2400
  8. 8 D. Sacks Measurement of hemoglobin A1c: a new twist on the path to harmony Diabetes Care 35 2012 2674 2680
  9. 9 C. Weykamp W.G. John A. Mosca The IFCC reference measurement system for HbA1c: a 6-year progress report Clin Chem 54 2008 240 248
  10. 10 A.J. Karter L.M. Ackerson J.A. Darbinian Self-monitoring of blood glucose levels and glycemic control: the Northern California Kaiser Permanente Diabetes Registry Am J Med 111 2001 1 9
  11. 11 A.J. Karter M.M. Parker H.H. Moffet Longitudinal study of new and prevalent use of self-monitoring of blood glucose Diabetes Care 29 2006 1757 1763
  12. 12 C.L. Malekiani A. Ganesan C.F. Decker Effect of hemoglobinopathies on hemoglobin A1c measurements Am J Med 121 2008 e6
  13. 13 C.G. Parkin J.A. Davidson Value of self-monitoring blood glucose pattern analysis in improving diabetes outcomes J Diabetes Sci Technol 3 2009 500 508
  14. 14 M. Franciosi F. Pellegrini G. De Berardis QuED Study Group The impact of blood glucose self-monitoring on metabolic control and quality of life in type 2 diabetic patients: an urgent need for better educational strategies Diabetes Care 24 2001 1870 1877
  15. 15 S.L. Norris J. Lau S.J. Smith Self-management education for adults with type 2 diabetes: a meta-analysis of the effect on glycemic control Diabetes Care 25 2002 1159 1171
  16. 16 W.H. Polonsky J. Earles S. Smith Integrating medical management with diabetes self-management training: a randomized control trial of the Diabetes Outpatient Intensive Treatment program Diabetes Care 26 2003 3048 3053
  17. 17 W.H. Polonsky L. Fisher C.H. Schikman Structured self-monitoring of blood glucose significantly reduces A1C levels in poorly controlled, noninsulin-treated type 2 diabetes: results from the Structured Testing Program study Diabetes Care 34 2011 262 267
  18. 18 P. Sheppard J.J. Bending J.W. Huber Pre- and post-prandial capillary glucose self-monitoring achieves better glycaemic control than pre-prandial only monitoring. A study in insulin treated diabetic patients Practical Diabetes Int 22 2005 15 22
  19. 19 G.H. Murata J.H. Shah R.M. Hoffman Diabetes Outcomes in Veterans Study (DOVES) Intensified blood glucose monitoring improves glycemic control in stable, insulin-treated veterans with type 2 diabetes: the Diabetes Outcomes in Veterans Study (DOVES) Diabetes Care 26 2003 1759 1763
  20. 20 The Diabetes Control and Complications Trial Research Group The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus N Engl J Med 329 1993 977 986
  21. 21 Epidemiology of severe hypoglycemia in the Diabetes Control and Complications Trial. The DCCT Research Group Am J Med 90 1991 450 459
  22. 22 E.A.M. Gale R.B. Tattersall Unrecognised nocturnal hypoglycaemia in insulin-treated diabetics Lancet 1 1979 1049 1052
  23. 23 G. Vervoort H.M. Goldschmidt L.G. van Doorn Nocturnal blood glucose profiles in patients with type 1 diabetes mellitus on multiple (> or =4) daily insulin injection regimens Diabet Med 13 1996 794 799
  24. 24 T.W. Jones P. Porter R.S. Sherwin Decreased epinephrine responses to hypoglycemia during sleep N Engl J Med 338 1998 1657 1662
  25. 25 E.I. Boutati S.A. Raptis Self-Monitoring of blood glucose as part of the integral care of type 2 diabetes Diabetes Care 32 suppl 2 2009 S205 S210
  26. 26 A. Faas F.G. Schellevis J.T. van Eijk The efficacy of self-monitoring of blood glucose in NIDDM subjects. A criteria-based literature review Diabetes Care 20 1997 1482 1486
  27. 27 M.I. Harris National Health and Nutrition Examination Survey (NHANES III) Frequency of blood glucose monitoring in relation to glycemic control in patients with type 2 diabetes Diabetes Care 24 2001 979 982
  28. 28 S. Coster M.C. Gulliford P.T. Seed Self-monitoring in type 2 diabetes mellitus: a meta-analysis Diabet Med 17 2000 755 761
  29. 29 L.M. Welschen E. Bloemendal G. Nijpels Self-monitoring of blood glucose in patients with type 2 diabetes who are not using insulin: a systematic review Diabetes Care 28 2005 1510 1517
  30. 30 L.M. Welschen E. Bloemendal G. Nijpels Self-monitoring of blood glucose in patients with type 2 diabetes who are not using insulin Cochrane Database Syst Rev 2 2005 CD005060
  31. 31 M.B. Davidson M. Castellanos D. Kain The effect of self monitoring of blood glucose concentrations on glycated hemoglobin levels in diabetic patients not taking insulin: a blinded, randomized trial Am J Med 118 2005 422 425
  32. 32 W.A. Davis D.G. Bruce T.M. Davis Is self-monitoring of blood glucose appropriate for all type 2 diabetic patients? The Fremantle Diabetes Study Diabetes Care 29 2006 1764 1770
  33. 33 W.A. Davis D.G. Bruce T.M. Davis Does self-monitoring of blood glucose improve outcome in type 2 diabetes? The Fremantle Diabetes Study Diabetologia 50 2007 510 515
  34. 34 A. Farmer A. Wade E. Goyder Impact of self monitoring of blood glucose in the management of patients with non-insulin treated diabetes: open parallel group randomised trial BMJ 335 2007 132
  35. 35 S. Allemann C. Houriet P. Diem C. Stettler Self-monitoring of blood glucose in non-insulin treated patients with type 2 diabetes: a systematic review and meta-analysis Curr Med Res Opin 25 2009 2903 2914
  36. 36 J.P. Jansen Self-monitoring of glucose in type 2 diabetes mellitus: a Bayesian meta-analysis of direct and indirect comparisons Curr Med Res Opin 22 2006 671 681
  37. 37 G. McGeoch S. Derry R.A. Moore Self-monitoring of blood glucose in type-2 diabetes: what is the evidence? Diabetes Metab Res Rev 23 2007 423 440
  38. 38 N. Poolsup N. Suksomboon S. Rattanasookchit Meta-analysis of the benefits of self-monitoring of blood glucose on glycemic control in type 2 diabetes patients: an update Diab Technol Ther 11 2009 775 784
  39. 39 A. St John W.A. Davis C.P. Price T.M.E. Davis The value of self-monitoring of blood glucose: a review of recent evidence J Diabetes Complications 24 2010 129 141
  40. 40 A. Towfigh M. Romanova J.E. Weinreb Self-monitoring of blood glucose levels in patients with type 2 diabetes mellitus not taking insulin: a meta-analysis Am J Manag Care 14 2008 468 475
  41. 41 Canadian Optimal Medication Prescribing and Utilization Service. Systematic review of use of blood glucose test strips for the management of diabetes mellitus. 2009. Available at ...Report_of_Clinical_Outcomes.pdf. Accessed April 25, 2012.
  42. 42 S. Skeie G.B.B. Kristensen S. Carlsen S. Sandberg Self-monitoring of blood glucose in type 1 diabetes patients with insufficient metabolic control: focused self-monitoring of blood glucose intervention can lower glycated hemoglobin A1C J Diabetes Sci Technol 3 2009 83 88
  43. 43 U.L. Malanda L.M.C. Welschen I.I. Riphagen Self-monitoring of blood glucose in patients with type 2 diabetes mellitus who are not using insulin Cochrane Database Syst Rev 1 2012 CD005060
  44. 44 M. Franciosi G. Lucisano F. Pellegrini ROSES: role of self-monitoring of blood glucose and Intensive education in patients with type 2 diabetes not receiving insulin. A pilot randomized clinical trial Diabet Med 28 2011 789 796
  45. 45 A. Duran P. Martin I. Runkle Benefits of self-monitoring blood glucose in the management of new-onset Type 2 diabetes mellitus: the St Carlos Study, a prospective randomized clinic-based interventional study with parallel groups J Diabetes 2 2010 203 211
  46. 46 UK Prospective Diabetes Study (UKPDS) Group Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33) Lancet 352 1998 837 853
  47. 47 D.B. Sacks D.E. Bruns D.E. Goldstein Guidelines and recommendations for laboratory analysis in the diagnosis and management of diabetes mellitus Clin Chem 48 2002 436 472
  48. 48 S.L. Norris M.M. Engelgau K.M. Narayan Effectiveness of self-management training in type 2 diabetes: a systematic review of randomized controlled trials Diabetes Care 24 2001 561 587
  49. 49 R. Bergenstal J. Pearson G.S. Cembtrski Identifying variables associated with inaccurate self-monitoring of blood glucose: proposed guidelines to improve accuracy Diabetes Educ 26 2000 981 989
  50. 50 K. Jungheim T. Koschinsky Glucose monitoring at the arm: risky delays of hypoglycemia and hyperglycemia detection Diabetes Care 25 2002 956 960
  51. 51 J.M. Ellison J.M. Stegmann S.L. Colner Rapid changes in postprandial blood glucose produce concentration differences at finger, forearm, and thigh sampling sites Diabetes Care 25 2002 961 964
  52. 52 D.M. Bina R.L. Anderson M.L. Johnson Clinical impact of prandial state, exercise, and site preparation on the equivalence of alternative-site blood glucose testing Diabetes Care 26 2003 981 985
  53. 53 K. Jungheim T. Koschinsky Glucose monitoring at the thenar: evaluation of upper dermal blood glucose kinetics during rapid systemic blood glucose changes Horm Metab Res 34 2002 325 329
  54. 54 B. Guerci M. Benichou M. Floriot Accuracy of an electrochemical sensor for measuring capillary blood ketones by finger stick samples during metabolic deterioration after continuous subcutaneous insulin infusion interruption in type 1 diabetic patients Diabetes Care 26 2003 1137 1141
  55. 55 F. Bektas O. Eray R. Sari Point of care blood ketone testing of diabetic patients in the emergency department Endocr Res 30 2004 395 402
  56. 56 A.S. Khan J.A. Talbot K.L. Tieszen Evaluation of a bedside blood ketone sensor: the effects of acidosis, hyperglycaemia and acetoacetate on sensor performance Diabet Med 21 2004 782 785
  57. 57 B. Guerci M. Floriot P. Böhme Clinical performance of CGMS in type 1 diabetic patients treated by continuous subcutaneous insulin infusion using insulin analogs Diabetes Care 26 2003 582 589
  58. 58 D. Deiss J. Bolinder J.P. Riveline Improved glycemic values control in poorly controlled patients with type 1 diabetes using real-time continuous glucose monitoring Diabetes Care 29 2006 2730 2732
  59. 59 Juvenile Diabetes Research Foundation Continuous Glucose Monitoring Study Group Continuous glucose monitoring and intensive treatment of type 1 diabetes N Engl J Med 359 2008 1464 1476
  60. 60 Juvenile Diabetes Research Foundation. Continuous Glucose Monitoring Study Group The effect of continuous glucose monitoring in well-controlled type 1 diabetes Diabetes Care 32 2009 1378 1383
  61. 61 Juvenile Diabetes Research Foundation. Continuous Glucose Monitoring Study Group Sustained benefit of continuous glucose monitoring on A1C, glucose profiles, and hypoglycemia in adults with type 1 diabetes Diabetes Care 32 2009 2047 2049
  62. 62 M.A. O'Connell S. Donath D.N. O'Neal Glycaemic impact of patient-led use of sensor-guided pump therapy in type 1 diabetes: a randomised controlled trial Diabetologia 52 2009 1250 1257
  63. 63 D. Raccah V. Sulmont Y. Reznik Incremental value of continuous glucose monitoring when starting pump therapy in patients with poorly controlled type 1 diabetes Diabetes Care 32 2009 2245 2250
  64. 64 Juvenile Diabetes Research Foundation Continuous Glucose Monitoring Study Group Effectiveness of continuous glucose monitoring in a clinical care environment Diabetes Care 33 2010 17 22
  65. 65 T. Battelino M. Phillip N. Bratina Effect of continuous glucose monitoring on hypoglycemia in type 1 diabetes Diabetes Care 34 2011 795 800
  66. 66 R.M. Bergenstal W.V. Tamborlane A. Ahmann Effectiveness of sensor-augmented insulin-pump therapy in type 1 diabetes N Engl J Med 363 2010 311 320
  67. 67 H.P. Chase R.W. Beck D. Xing Continuous glucose monitoring in youth with type 1 diabetes: 12-month follow-up of the Juvenile Diabetes Research Foundation continuous glucose monitoring randomized trial Diabetes Technol Ther 12 2010 507 515
  68. 68 H.J. Yoo H.G. An S.Y. Park Use of a real-time continuous glucose monitoring system as a motivational device for poorly controlled type 2 diabetes Diabetes Res Clin Pract 82 2008 73 79
  69. 69 S. Garg M. Voelmle C. Beatson Use of continuous glucose monitoring in subjects with type 1 diabetes on multiple daily injections versus continuous subcutaneous insulin infusion therapy Diabetes Care 34 2011 574 579
  70. 70 E. Cosson E. Hamo-Tchatchouang L. Dufaitre-Patouraux Multicentre, randomised, controlled study of the impact of continuous subcutaneous glucose monitoring (GlucoDay) on glycaemic control in type 1 and type 2 diabetes patients Diabetes Metab 35 2009 312 318
  71. 71 H.R. Murphy G. Rayman K. Lewis Effectiveness of continuous glucose monitoring in pregnant women with diabetes: randomised clinical trial BMJ 337 2008 a1680
  72. 72 I.B. Hirsch J. Abelseth B.W. Bode Sensor-augmented insulin pump therapy: results of the first randomized treat-to-target study Diabetes Technol Ther 10 2008 377 383
  73. 73 C.L. Rohlfing H.M. Wiedmeyer R.R. Little Defining the relationship between plasma glucose and HbA(1c): analysis of glucose profiles and HbA(1c) in the Diabetes Control and Complications Trial Diabetes Care 25 2002 275 278
  74. 74 R.M. Goldenberg A.Y.Y. Cheng Z. Punthakee M. Clement Use of glycated hemoglobin (A1C) in the diagnosis of type 2 diabetes mellitus in adults Can J Diab 35 2011 247 249
 
Reproduced with permission from Canadian Journal of Diabetes © 2013 Canadian Diabetes Association. To cite this article, please refer to For citation.