Approved for 0.

5 CE units
CCCEP file no. 1057-2016-1867-I-P
Rexall Diabetes Care
Expiry: October 1, 2017 Program
by Tom Smiley, BScPhm, PharmD, CTE

Reviewers: Michael Boivin, BScPhm, CDE, CTE;

Section 1 Carlene Oleksyn, BSc(Pharm), CDE, CTH

Diabetes: Understanding Disclosures: The author and program faculty have no conflicts
of interest to disclose.
and Assessing
Module 1.3: Characterizing Self-Monitoring of
Blood Glucose (SMBG)

Introduction
Self-management of diabetes is one of the most important concepts in diabetes education. Although
diabetes professionals can provide optimal education and therapies, ultimately it is up to the patients to
integrate these positive changes into their daily lifestyle. It is the patient’s choice whether or not to adhere
to the lifestyle and medication regimens.

Self-monitoring of blood glucose (SMBG) is a tool that can help patients with diabetes make better choices
to control their blood glucose levels. With proper utilization of this tool, patients can avoid extreme
variances in blood glucose levels and improve safety by helping to reduce hypoglycemic readings.

This module will introduce the key concepts of SMBG and Module 1.4 will explore issues and practical
application of SMBG.

DIABETES CARE PROGRAM STUDY TOPICS

Welcome to this Rexall Diabetes Care Program module entitled "Characterizing Self-Monitoring of Blood
Glucose (SMBG)." This lesson will provide you with important education that reviews the following
diabetes-related topics:

1. Characterizing Self-Monitoring of Blood Glucose (SMBG)

2. Purpose of SMBG

3. Potential benefits of SMBG

4. Appropriate scheduling of SMBG

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Self-Monitoring of Blood Glucose

WHAT IS SMBG?
Self-monitoring of blood glucose is a method whereby a patient can draw a sample of his or her own blood
to provide a real-time measure of the current blood glucose level.1,2 There are several steps involved in
obtaining a result from a blood glucose monitor:

 the use of a lancing device to prick the finger

 a test strip to which the patient applies the blood

 a blood glucose meter that processes the test

WHAT IS THE PURPOSE OF SMBG?

The real-time assessment of blood glucose provides feedback on the results of lifestyle and
pharmacological treatments, and increases patient empowerment and adherence to treatment. 3 It also
provides information to facilitate long-term treatment modifications and titrations as well as shorter-term
treatment decisions.3 Awareness of both SMBG results and A1C provides the best information to assess
glycemic control.3

SMBG improves patient safety by allowing for immediate confirmation of hypoglycemia or hyperglycemia
based on a patient’s current symptoms.2 This allows for immediate adaptation of behaviour to reduce the
severity of these blood glucose excursions.

IS SMBG RECOMMENDED FOR MOST PATIENTS WITH DIABETES?

The 2013 Canadian Diabetes Association (CDA) clinical practice guidelines recommend that most people
with diabetes can benefit from SMBG.3 The guidelines list the following as potential benefits:3

 improvement in A1C

 avoidance and identification of hypoglycemia

 long-term treatment modifications and titrations as well as shorter-term treatment decisions such as
insulin dosing

 increased lifestyle flexibility. When used appropriately, SMBG allows for maintenance of glycemic
control during adjustments of:

o dietary choices
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Module 1.3: Characterizing Self-Monitoring of
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o physical activity

o hypoglycemic medications

PRACTICE TIP
The 2013 CDA clinical practice guidelines recommend SMBG for most patients with diabetes.

Benefits of SMBG
WHAT ARE THE SELF-MANAGEMENT BENEFITS OF SMBG TESTING?
 SMBG empowers the patient by providing the ability to self-regulate the condition and treatment.2

 Self-monitoring is both an educational and motivational instrument for demonstrating the impact of
medication and lifestyle on reaching glycemic targets.2

 Potentially destabilizing food choices and physical activity can be identified, enabling the patient to
make appropriate changes.2

 Consistent use of SMBG provides instant feedback on the effects of diet, exercise, and medication
on blood glucose levels.2

 Monitoring identifies any progression or change in the condition that requires intervention by the
diabetes team.2

 SMBG improves safety by identifying hypoglycemic reactions so they can be effectively treated. 2

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Evidence to Support SMBG

WHAT IS THE EVIDENCE THAT SUPPORTS SMBG?
Patients Currently Using Insulin
There is significant data showing a positive role of SMBG in any person with diabetes who uses insulin. 4
Frequent SMBG testing (> 3 times/day) has been associated with improvement in A1C readings in this
patient population.4

 In people with type 1 diabetes, performing ≥ 3 self-tests per day is associated with a statistically and
clinically relevant 1.0% reduction in A1C.3

 In people with type 2 diabetes using insulin therapy, SMBG is associated with improvements in
glycemic control.3

Patients Currently Using Other Antihyperglycemics and/or Lifestyle Modifications

The evidence in patients taking other diabetes medications is not nearly as robust. Two meta-analyses
found that SMBG leads to significantly lower blood glucose levels, although this effect may be clinically
modest.5,6 A Cochrane Collaboration review of the studies concluded SMBG might be effective at
improving glycemic control in this population.7

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Indications for SMBG

ARE THERE ANY GROUPS IN WHICH SMBG IS MORE CRITICAL?
There are several groups of patients with diabetes who are strongly encouraged to utilize SMBG:

 any patient with type 1 diabetes

 any patient with type 2 diabetes on insulin

 patients with type 2 diabetes taking medication that increases the risk of hypoglycemia (e.g. insulin
secretagogues such as sulfonylureas or meglitinides)

 any patient who is not achieving glycemic control

 pregnant patients with diabetes

 patients newly diagnosed with diabetes

 patients starting a new medication known to cause hyperglycemia (e.g., steroids)

 patients experiencing an illness known to cause hyperglycemia (e.g., infection)

 patients who are acutely ill

PRACTICE TIP
Most individuals with diabetes should have A1C measured every 3 months to ensure that glycemic goals
are being met and maintained. If glycemic targets have been consistently achieved and lifestyle and
treatment are stable, then A1C measurement at least every 6 months is acceptable.3

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Times to Conduct SMBG

WHEN IS THE MOST APPROPRIATE TIME TO PERFORM SMBG?
The 2013 CDA guidelines recommend most patients with diabetes perform SMBG.3 They advise patients to
perform preprandial readings and postprandial readings.3 For most patients, the postprandial readings are
ideally taken two hours after they finish their meal.

PRACTICE TIP
Most patients with diabetes should check their blood glucose readings just prior to a meal or two hours
after a meal.

Other common times to perform SMBG are in patients:

 when patients feel symptoms of hypoglycemia (e.g., shaking, sweating, increase in heart rate, etc.)
to confirm symptoms with a blood glucose reading

 prior to and during exercise in patients taking medications that can cause hypoglycemia such as
insulin secretagogues and insulin (this is especially important in patients with type 1 diabetes)

Frequency of SMBG
WHAT IS THE RECOMMENDED FREQUENCY FOR SMBG?
The frequency for SMBG must be individualized for each patient. When determining the frequency of
testing, the CDA guidelines advise clinicians to adjust the frequency based on:3

 the type of diabetes

 the treatment prescribed

 the need for information about blood glucose levels and the individual’s capacity to use the
information from testing to modify behaviours or adjust medication

Patients with Type 1 Diabetes

 The CDA guidelines recommend that SMBG should be undertaken at least three times daily and
include fasting and postprandial readings in all individuals with type 1 diabetes.3

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Patients with Type 2 Diabetes on Multiple Daily Insulin Injections

 The CDA guidelines recommend that SMBG should be undertaken at least three times daily and
include fasting and postprandial readings in all individuals with diabetes using multiple daily insulin
injections.3

Patients with Type 2 Diabetes with Once Daily Basal Insulin and Oral Hypoglycemics
 The CDA guidelines recommend that SMBG should be undertaken at least once daily at variable
times throughout the day (including at breakfast in order to adjust the basal insulin dose).3

Patients with Type 2 Diabetes on Antihyperglycemics or Lifestyle Modification Alone

 SMBG recommendations should be individualized depending on type of antihyperglycemic agents,
level of glycemic control and risk of hypoglycemia. When glycemic control is not being achieved,
SMBG should be instituted and should include periodic pre- and postprandial measurements, and
training of healthcare providers and patients should be trained on methods to modify lifestyle and
medications in response to SMBG values. If achieving glycemic targets or receiving medications not
associated with hypoglycemia, infrequent SMBG is appropriate. Table 1 lists some guidelines from
the International Diabetes Federation (IDF).

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Table 1: IDF Recommendations for

SMBG
WHAT ARE THE INTERNATIONAL DIABETES FEDERATION
RECOMMENDATIONS FOR SMBG IN TYPE 2 DIABETES?
Table 1 summarizes the International Diabetes Federation recommendations for SMBG testing in non-
insulin treated patients with type 2 diabetes.

Table 1: The International Diabetes Federation (IDF) Recommendations for SMBG in Non-Insulin
Treated Type 2 Diabetes8

 SMBG should be used only when individuals with diabetes (and/or their caregivers) and/or their
healthcare providers have the knowledge, skills, and willingness to incorporate SMBG monitoring
and therapy adjustment into their diabetes care plan in order to attain agreed-upon treatment
goals.

 SMBG should be considered at the time of diagnosis to enhance the understanding of diabetes
as part of individual’s education and to facilitate timely treatment initiation and titration
optimization.

 SMBG should also be considered as part of ongoing diabetes self-management education to

assist people with diabetes to better understand their disease and provide a means to actively
and effectively participate in its control and treatment, modifying behavioural and pharmacological
interventions as needed, in consultation with their healthcare provider.

 SMBG protocols (intensity and frequency) should be individualized to address each patient’s
specific educational/behavioural/clinical requirements (to identify/prevent/manage acute hyper-
and hypoglycemia) and provider requirements for data on glycemic patterns and to monitor
impact of therapeutic decision making.

 The purpose(s) of performing SMBG and using SMBG data should be agreed-upon by both the
person with diabetes and the healthcare provider. These agreed-upon purposes/goals and actual
review of SMBG data should be documented.

 SMBG use requires an easy procedure for patients to regularly monitor the performance and
accuracy of their glucose meter.

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Evaluation of SMBG Frequency

WHAT IS A PRACTICAL METHOD OF EVALUATING SMBG FREQUENCY?
Clinicians and patients commonly question the frequency of blood glucose monitoring conducted in clinical
practice. Common questions from patients include:

 Am I testing the right amount?

 What is testing too little?

 What is testing too much?

PRACTICE TIP
Test with purpose; don’t have patients test solely for the reason of testing.

Many diabetes professionals have seen patients who test frequently but when asked what they do with the
result, many will reply they record it but do not adjust any component of their diabetes self-management
plan as a result of the readings. A key message when discussing SMBG is to let patients know that it is
important that they test for a purpose.

From a clinical practical standpoint, SMBG is only effective if patients and their clinicians understand the
goals of SMBG and patients don’t fall into the pattern of testing solely for the sake of testing instead of
making clinical adjustments to their lifestyle and medication regimen based on SMBG results.

Table 2: Factors to Increase or

Decrease SMBG Frequency
ARE THERE TIMES WHEN A PATIENT SHOULD ADJUST SMBG TESTING
FREQUENCY?
Many patients with type 1 and type 2 diabetes should consider adjusting their SMBG frequency under
certain conditions that can affect glycemic control. Table 2 lists some of the factors that diabetes educators
can consider for increasing or decreasing SMBG frequency.

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Table 2: Factors To Increase or Decrease SMBG Frequency8

Factors to Decrease
Factors to Increase SMBG Frequency
SMBG Frequency

 symptoms of hypoglycemia

 infections, travelling, or under unusual stress

 adjustments in medication, nutrition, and/or physical activity  A1C numbers are in the
target range
 entering a new life experience (e.g., going away to school, starting a new
job, or changing hours)  stable pre- and
postprandial numbers
 experiencing a worsening of A1C values
 patient not willing or
 are unclear or require additional information about the nature of their disease
able to perform
and/or the impact of their treatment on their glucose control
frequent blood glucose
 pregnant or becoming pregnant tests

 new diagnosis with diabetes (< 6 months)

 occupation that requires strict avoidance of hypoglycemia

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Tables 3, 4, 5: Blood Glucose Targets

WHAT ARE THE RECOMMENDED BLOOD GLUCOSE TARGETS FOR SMBG?
The targets for patients with diabetes must be individualized. Table 3 lists SMBG glycemic targets for most
patients with diabetes. Tables 4 and 5 list the common SMBG glycemic targets in children and pregnant
patients, respectively.

Table 3: Recommended Targets for Glycemic Control for Most Patients with Type 1 and Type 2
Diabetes9 (see Module 1.3 for more comprehensive targets, including A1C)

FPG or preprandial PG
2-hour postprandial PG (mmol/L)
(mmol/L)

Type 1 and type 2 5.0-10.0 (5.0-8.0, if A1C targets are not

4.0-7.0
diabetes being met)

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Table 4: Recommended Glycemic Targets for Children and Adolescents with Type 1 Diabetes10

2-hour
Age AIC Fasting/preprandial
postprandial Considerations
(years) (%) PG (mmol/L)
PG (mmol/L)

Extra caution is required to minimize

hypoglycemia, because of the potential
See NOTES association between severe hypoglycemia
<6 < 8.0 6.0-10.0
below. and later cognitive impairment. Consider
target of < 8.5% if excessive hypoglycemia
occurs.

Targets should be graduated to the child’s

See NOTES age.
6-12 ≤7.5 4.0-10.0
below. Consider target of < 8.0% if excessive
hypoglycemia occurs.

13-18 ≤ 7.0 4.0-7.0 5.0-10.0 Appropriate for most adolescents.

NOTES:

Postprandial monitoring is rarely done in young children, except for those on pump therapy for whom targets are
not available.
In adolescents (where it can be safely achieved), consider aiming toward normal PG range (i.e., A1C ≤ 6.0%,
fasting/preprandial PG 4.0-6.0 mmol/L, and two-hour postprandial PG 5.0–8.0 mmol/L).

Table 5: Recommended Glycemic Targets during Pregnancy11

Fasting and preprandial plasma glucose < 5.3 mmol/L

1-hour postprandial plasma glucose < 7.8 mmol/L

2-hour postprandial plasma glucose < 6.7 mmol/L

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Blood Glucose Profile

HOW DO I DEVELOP A BLOOD GLUCOSE PROFILE?
One of the key principles in SMBG is pattern monitoring and adjustment. Patients will commonly have
blood glucose readings outside the target range, but the pattern of readings is usually much more
important than a single blood glucose value. For example, a patient with excellent blood glucose control
with one high reading of 12.4 mmol/L two hours after eating a birthday meal is of much less significance
than a patient who normally has 2-hour postprandial readings of 11.8 mmol/L or higher.

The problem is without having a pattern of readings, it is hard for a patient or health professional to
evaluate if a reading outside of the target range is a normal occurrence or just a single reading outside the
range. To recognize patterns, a blood glucose profile will help interpret blood glucose values.

Developing a Blood Glucose Profile

To develop a blood glucose profile, a day is divided into eight distinct blood glucose testing times. These
eight times are before and after each meal, at bedtime, and throughout the night. To develop a pattern, the
patient tests at different testing times each day to provide a record of how well controlled his blood glucose
is throughout the day.

A standard protocol for many patients with type 2 diabetes who are not using insulin is to test twice daily to
develop the pattern. Once the pattern has been established, the patient can adjust the testing frequency
based on the regimen and the level of glycemic control. Figure 1 illustrates a testing regimen that a patient
with newly diagnosed type 2 diabetes can follow to develop a blood glucose profile.

The most accurate blood glucose profile will be developed over a period of time where the patient’s meals
and exercise routine are kept relatively stable.

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Table 6: SMBG Testing Pattern to

Develop a Blood Glucose Profile
HOW CAN I DEVELOP AN SMBG TESTING PATTERN TO DEVELOP A BLOOD
GLUCOSE PROFILE?
Table 6 is an example of an SMBG testing pattern that can be used to develop a blood glucose profile.

Table 6: SMBG Testing Pattern to Develop a Blood Glucose Profile

Breakfast Lunch Dinner Bed At night

2 hr 2 hr 2 hr
Before Before Before
after after after

Monday X X

Tuesday X X

Wednesday X X

Thursday X ±X

Friday X X

Saturday X X

Sunday X X

Monday X ±X

Tuesday X X

Wednesday X X

Thursday X X

Friday X ±X

Saturday X X

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Sunday X X

Legend:
 Areas marked with an "X” are times when the patient should consider doing a test. This profile
allows for at least three to four readings in each of the eight time slots over a two-week period.

 The "At Night” testing does not have to be done consistently for patients. If a patient is up at night
for whatever reason, he should consider testing to determine his control when he is usually
sleeping.

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Key Learning Points

1. SMBG allows for real-time assessment of blood glucose and allows for immediate adaptation of
behaviour to reduce blood glucose excursions.

2. CDA guidelines recommend SMBG for most patients with diabetes.

3. Benefits of SMBG include:

 better A1C control

 empowering the patient to self-regulate their condition

 educating the patient on the benefits that medications and lifestyle changes can have on blood
glucose levels

 monitoring for any changes in their diabetes

 improving safety by identification of hypoglycemic reactions

4. The recommended testing frequency is:

 for patients with type 1 diabetes: test ≥ 3 times per day

 for patients with type 2 diabetes using multiple daily dose insulin: test ≥ 3 times per day

 for patients with type 2 diabetes using insulin once daily with oral medication: test ≥ once per day

 for patients using only oral medications or lifestyle modifications: no set testing frequency; clinicians
should adjust frequency based on glycemic control and type of therapy

5. SMBG should include preprandial (fasting readings) and 2 hour postprandial readings.

6. Blood glucose targets for most patients using SMBG are:

 preprandial: 4.0-7.0 mmol/L

 2 hour postprandial: 5.0-10.0 mmol/L (5.0-8.0 if A1C targets are not being met)

7. Developing blood glucose profile can help for pattern recognition and for adjusting therapies.

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References
1. Banerji MA. The Foundation of Diabetes Self-management: Glucose Monitoring. The Diabetes
Educator. 2007;33(Supplement_4):87S-90.

2. Renard E. Monitoring glycemic control: the importance of self-monitoring of blood glucose. The
American Journal of Medicine. 2005;118(9, Supplement 1):12-19.

3. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Monitoring Glycemic
Control . Can J Diabetes2013;37(suppl 1):s35-s39. Accessed Sep. 4, 2016

4. Blonde L, Karter AJ. Current evidence regarding the value of self-monitored blood glucose testing. The
American Journal of Medicine. 2005;118(9, Supplement 1):20-26.

5. Towfigh A, Romanova M, Weinreb JE, et al. Self-monitoring of blood glucose levels in patients with
type 2 diabetes mellitus not taking insulin: a meta-analysis. Am J Manag Care. 2008;14(7):468-475.

6. Canadian Optimal Medication Prescribing and Utilization Service (COMPUS). Systematic Review of the
Use of Blood glucose Test Strips for the Management of Diabetes Mellitus. Optimal Therapy Report.
2009;3(2). Available at: http://www.cadth.ca/media/pdf/BGTS_SR_Report_of_Clinical_Outcomes.pdf.
Accessed Sept. 4, 2016

7. Welschen LMC, Bloemendal E, Nijpels G, et al. Self-monitoring of blood glucose in patients with type 2
diabetes who are not using insulin. Cochrane Database Syst Rev. 2005;(2):CD005060.

8. International Diabetes Federation. Self-Monitoring of Blood Glucose in Non-Insulin Treated Type 2

Diabetes. Available at: http://www.idf.org/webdata/docs/SMBG_EN2.pdf. Accessed Sept. 4, 2016.

9. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Targets for Glycemic
Control. Can J Diabetes 2013;37(suppl 1):s31-s34. Accessed Sept. 4, 2016

10. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Type 1 Diabetes in
Children and Adolescents. Can J Diabetes 2013;37(suppl 1):s15-s16. Accessed Sept. 4, 2016

11. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Diabetes and
Pregnancy. Can J Diabetes 2013;37(suppl1):s168-s183. Accessed Sept. 4, 2016

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CE Test
In order to receive CE credits for this course, you must complete the CE test online at
www.HealtheLearning.ca.

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