Studies have clearly demonstrated the benefits of tight glycemic control in preventing macrovascular (MI, stroke, peripheral vascular disease) and microvascular (neuropathy, nephropathy, and retinopathy) complications. The studies that have shown this benefit with the use of insulin have relied heavily on patients monitoring their blood glucose at home (self-monitoring of blood glucose or SMBG).
Your patients with diabetes at the GOODLIFE/SHARING clinics will likely have been counseled about how often to check their sugars and will have been told to write these down in a log book, which they are to bring to every clinic visit.
As of September, 2010, patients are being given glucometers that keep an internal record of glucose readings, and patients are instructed to bring their glucometers with them at each visit. Their glucose readings can be downloaded into a software program for review and analysis.
You will want to ascertain the following information from the patient:
- How often s/he performs SMBG and what time of day, especially in relation to meals. This should be categorized by time of day (e.g., preprandial, 1-2 hours postprandial, bedtime, etc.).
- What the blood glucose levels have been running. If the patient has brought in a completed log or glucometer that stores readings, your job is made easier. The goals are 90-130 preprandial (before meals), <180 1-2 hours after meals, and 110-150 at bedtime (plasma blood glucose levels).
- If the patient has periods of hypoglycemia or hyperglycemia.
Hypoglycemia (glucose 70 or less) can be fatal, so it is important to determine the usual timing of these episodes, the frequency, and possible precipitating factors, such as a change in medication or addition of new medications, or weight, a change in exercise or meal frequency or timing, symptoms of diseases that could contribute to new hypoglycemia (e.g., hypothyroidism, gastroparesis or malabsorption, or renal failure). It is also important that the patient understands how to appropriately treat hypoglycemia when it occurs. If their blood sugars are increasing or are high (above 130 mg/dl fasting or above 180mg/dl after meals), you should ask if they have changed their diet, frequency of exercise, or had interval weight gain, started new medications, are not taking the ones currently prescribed, or had recent symptoms of depression or illness which can increase blood sugar readings (as discussed below). Illness stresses the body, leading to increased cortisol release and more difficulty managing blood glucose. Click here for link on hypoglycemia.
- If the patient has adequate supplies to continue SMBG. Often, patients will need refills of test strips or lancets. Note this information and be sure the patient gets what s/he needs before leaving the clinic.
- The date and level of the patient's last Hemoglobin A1c. This is important to determine that the patient's self-monitoring accords with the A1c level. As discussed in the A1c section, glycosylated hemoglobin (as indicated by the A1c) gives a fairly reliable measure of the patient's average blood glucose over the preceding 90 days. If there is a discrepancy between the patient's A1c and reported SMBG, you should be suspicious of either meter error for the patient's home device or misreporting by the patient.