Metabolic Control Matters. These words by Dr Richard Eastman, director of the the diabetes program of the National Institutes of Health were meant to introduce the results of the Diabetes Control and Complications Trial 1, a 10 year study in almost 1500 patients that demonstrated a tight correlation of excellent control of blood glucose and a dramatic reduction in the risk of the complications of diabetes. This study leaves little room for doubt: if you want to prevent the devastating complications of diabetes you need to bring your blood glucose as close to normal as possible.
Unfortunately, normalizing your blood glucose is often a difficult task. It requires knowledge on your part and on your doctor’s, dedication and persistance and a willingness to put up with the pain and inconvenience of self-monitoring of blood glucose (SMBG). I have chosen to focus on the topic of SMBG because it is the most difficult and painful part of intensive diabetes therapy for most patients, but if SMBG is not performed well and frequently, the program of intensive diabetes therapy often fails.
Within the DCCT, patients in the intensive group were advised to measure their blood glucose 4-5 times per day. In actuality, they performed SMBG 3-4 times per day and they achieved near-normal values for their blood glucoses. This can be contrasted with many areas in the Scandanavian countries, which demonstrate the importance of SMBG. A few years ago, virtually all of the patients in Scandanavia with IDDM took 2 shots of insulin each day. Their hemoglobina A1c was about 9%, corresponding to average blood sugars of about 220. Over the years, virtually all of the patients with IDDM in Scandanavia have switched to 3-4 shots of insulin per day, similar to that of the DCCT. In reseach studies, in which these patients monitored 3-4 times per day, they achieved hemoglobin A1c values of about 7%, similar to the DCCT2. In most diabetes clinics, however, in which the patients monitor only 4 times per week, the hemoglobin A1c remains about 9%, the same as on 2 shots per day. In the Scandanavian countries, all medical supplies are provided by the government, so it is not the expense that stops them from monitoring. It the discomfort of the lancets and the inconvenience of the procedure of SMBG.
If the European experience can be extrapolated to the US, the main reasons that people don’t monitor their blood glucose as often as needed are the discomfort of the procedure and the inconvenience and even embarassment of measuring their blood sugar. Some progress has been made on each of these and much more will be demonstrated soon.
The discomfort of the procedure is entirely related to the process of getting the blood from the finger. Because most current strips require that the blood be placed onto the strip in a single complete action, the blood must be “drawn” from a finger. That’s too bad, because the finger is one of the most sensitive places in the body and the pain of a lancet is greatest in this location.
Current lancets are mostly 21 gauge, as shown in figure 1, magnified 10 times. There are some 23 gauge lancets on the market, but these are not appreciably less painful than the 21 gauge lancets. Virtually all of the available lancets provide enough blood for SMBG at least 90% of the time.
Most patients feel that the most convenient form of SMBG is one in which they did not have to prick their finger at all and did not have to get blood from a body part. The day of minimally invasive SMBG is coming, but we still have a wait (discussed further in the article.). In the meantime, patients feel that less blood and less time are important features of SMBG and some of the newer meters fulfill some of their wishes. Early in SMBG, virtually all of the meters required at least 1-2 minutes to do a BG reading. The fastest of the meters take only 20 seconds (ExacTech Companion 2). Meters were initially very large, but now many of the meters are tiny (Tracer, OneTouch Easy, Glucometer III, Companion II). Initally most meters required a full drop of blood (30 ml) but now some require only 1/3 (Companion II) to 1/6 (Glucometer III) of that amount.
In an attempt to reduce pain still further, newer lancets have been produced. Gainor Medical released a 25 gauge lancet a few years ago. The thinnest lancet now on the market, however, is the new B-D Ultra-Fine lancet, which is 29 gauge. As seen in figure 1, this lancet’s cutting area is only 20% of the 21 gauge lancets’ like the Monolet.