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National

Blood glucose monitoring

Type 2 diabetes prescribing
Scottish Government Effective Prescribing & Therapeutics Division
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Self-management by regular blood glucose monitoring is not routinely recommended in people with T2DM1 as it does not significantly improve glycaemic control, health-related quality of life, or hypoglycaemia rates.

However, self-monitoring of blood glucose is recommended for those who:

  • are on insulin
  • have had prior hypoglycaemic episodes
  • drive or operate machinery and use oral medications that increase their risk of hypoglycaemia (see DVLA guidance)
  • are pregnant, or planning to become pregnant
  • those undergoing significant changes in pharmacotherapy, e.g. on high dose oral steroids or oral hypoglycaemic agents such as sulfonylureas that require dose adjustment

National therapeutic indicator

Proportion of individuals prescribed SMG, potentially unnecessarily

The most up to date national therapeutic indicator data is available here.

This indicator should have a low value, because self-monitoring glucose (SMG) is not generally recommended in management of T2DM, unless therapy includes insulin and/or sulfonylureas.

For those who require self-monitoring of blood glucose, there is no evidence to suggest greater clinical benefit from using more expensive test strips over less costly ones and therefore NHS Boards should select appropriate formulary products.

The Scottish Therapeutic Utility (STU) indicators can be used to identify individuals with T2DM who would benefit from review.

 

Intermittently scanned (flash) glucose monitoring 

The Scottish Health Technologies Group (SHTG) advice49 in 2018 recommended the availability of flash glucose monitoring for individuals with diabetes who are actively engaged in the management of their condition and who intensively manage their disease with multiple daily insulin injections* or insulin pump therapy, with some restrictions.

*NICE define multiple daily injections as ‘two or more daily insulin injections, which could either be a basal-bolus regimen or more than one daily insulin injection.’

NICE guidance2 supports the pre-existing guidance from SHTG and recommends offering intermittently scanned continuous glucose monitoring (isCGM), commonly referred to as 'flash', to adults with T2DM on multiple daily insulin injections if any of the following situations apply:

  • recurrent hypoglycaemia or severe hypoglycaemia
  • impaired hypoglycaemia awareness
  • a condition or disability (including learning disability or cognitive impairment) where the individual cannot self-monitor blood glucose using capillary blood glucose monitoring but could use an isCGM device (or have it scanned for them)
  • would otherwise be advised to self-measure at least eight times a day (SHTG recommend at least six times per day)

Additionally, adults with insulin-treated type 2 diabetes who would otherwise need help from a care worker or healthcare professional to monitor their blood glucose, should be offered isCGM.

 

Good practice point

Those prescribed flash glucose monitors only require two sensors per 28 days (26 within a year).

If the sensors become detached or are faulty, people should contact the manufacturer directly for replacements. 

It is good practice to utilise prescribing data to identify patients who may be over-ordering and/or put in place mechanisms which prevent this, such as annual serial prescription for 26 sensors, to reduce inappropriate prescribing and associated costs.

 

For all individuals requiring glucose monitoring there should be a documented plan outlining frequency and duration of testing, along with what to do with results.  Most people require diabetes assessments every three to six months and this should be tailored according to the individual needs to improve care. Use of diabetes digital resources to support self-management are recommended, such as My Diabetes My Way (a list of further resources is available in lifestyle interventions and remission).

 

Blood ketone testing in T2DM

  • People with type 1 diabetes (insulin dependent) will test for ketones if their blood glucose levels are significantly low to alert to the risk of ketoacidosis.
  • Blood ketone testing in T2DM is not normally necessary and individuals are not routinely provided with self-monitoring equipment.
  • However due to the risk of eDKA, if a person displays symptoms of DKA (including rapid weight loss, nausea or vomiting, abdominal pain, fast and deep breathing, sleepiness, a sweet smell to the breath, a sweet or metallic taste in the mouth, or a different odour to urine or sweat) ketone testing should occur 45,46
  • Clinicians should be aware of this recommendation and have access to the necessary equipment.