Diabetes is a complex disease, with multiple strategies involved in disease management. Along with lifestyle modifications and medications, diabetes management also includes blood glucose monitoring for those patients who must maintain more precise control over their glucose levels.
Glucose meters are useful for patients with both type 1 and type 2 diabetes. There are several brands and types of meters on the market, and patients can easily become overwhelmed by the choices. The best choice is dependent on many factors, including accessibility, affordability, and preference of features. Often patients’ insurance plans will dictate the selection, as possibly only one brand will be on the formulary. Medicare covers most of the cost of select diabetic testing supplies with a doctor’s prescription.
Diabetic patients often need to check their blood sugar to get an idea of how well their pharmacologic interventions are working, with sometimes patients needing those blood sugar checks to determine how much insulin to inject themselves with. By checking their blood sugar often, patients can measure the effectiveness of their lifestyle modifications. Then, by gaining insight into how much a particular meal affects their blood sugar, they can learn what foods they can and should avoid.
Basic Fingerstick Method
Today, the traditional fingerstick method is still the predominantly used glucose monitoring method. A sample of blood is placed onto the test strip, which is inserted into and read in 5 seconds by a handheld meter. These meters, which can store on average 250 to 300 readings, are small enough to fit in a purse and usually come in a small carrying case.
The case can hold a supply of lancets, which are the needles used to prick the finger; the lancing pen; the meter; alcohol swabs; and a vial of test strips. The lancing pen is loaded with a lancet with which the puncture depth can be selected. It is recommended to select the level with the least discomfort that yields a drop of blood large enough to drench the test strip. If the sample is not large enough, an error message will display in the meter.
With this traditional fingerstick method, the most common complaint pharmacists receive from patients is that they don’t want to prick their fingers anymore. Even though the sample required is very small, it is a highly disliked procedure among patients, and particularly among elderly individuals or pediatric patients for whom this method can be especially difficult.
The cost of the meters typically range from $10 to $25. However, the hidden cost is the price of the test strips, which range from about $50 to $125 per 100 strips. Depending on how many times per day patients are required to test their blood sugar, this cost can easily add up and become a burden on their overall disease management.
Each brand has its own test strips; unfortunately, a strip from one brand will not fit or work with a meter from another brand. These meters vary based on the number of readings they store and how fine the gauge is on the lancet they come with, as well as other factors. However, patients can use a lancing device and lancets of a different brand than the meter and test strip; only the test strips and meters have to match.
A common prescribing error occurs when the physician is unaware of the brand the patient has previously used and writes a prescription for continuing test strips of another brand, which will not work with the patient’s meter. If the patient is new to the pharmacy, the pharmacy will fill the brand written by the physician. Fortunately, it is common practice for pharmacists to ask patients which brand of machine they use prior to dispensing their diabetic supply prescriptions.
The meters, test strips, and lancets are each sold separately. The different brands available include OneTouch Ultra, OneTouch Delica, Contour, Bayer Ascencia, Freestyle, Easy Touch, Relion, True Metrix, and CareTouch—to name a few. These basic meters are accurate and simple enough for anyone to use.
When patients are first prescribed a meter, pharmacists can take the opportunity to counsel the patients on how to use a control solution to maintain their meter and talk them through the initial setup. It is a good tip for patients to always keep the meter case packed with supplies like alcohol swabs, strips, lancets, and control solution.
This feature allows a meter to transmit glucose readings to a smartphone. Many basic fingerstick-style glucose monitors and those with advanced features offer this technology, which can be beneficial in tracking glucose levels and conveniently storing the readings in one place to present during doctors’ visits. It can also present readings in chart form to show trends, which may help a patient realize how certain behaviors or food choices influence their blood sugar reading. Generally, this feature is appropriate for patients who like to track their health and disease management using their phone.
Continuous Glucose Monitoring Method
Continuous glucose monitoring (CGM) systems now provide the long-awaited option for diabetes patients to not have to prick their fingers for each test. This new technology, which can take readings every 5 minutes, includes the Bluetooth feature, and offers even further insight into managing blood glucose levels. Patients can also see instant changes in their sugar levels in correlation to their food choices, stress, sleep, and other lifestyle choices.
This meter also comprises a sensor device, which is affixed to the patient’s arm, and a reader device to which the sensor sends the reading. Utilizing this type of meter not only helps to manage one’s glucose levels, but it can be set up to give an alert on a preselected glucose level. In other words, you can get alerts when your sugar is too high or too low.
Among the CGM readers, there are variations in use, such as how the Freestyle Libre CGM reader requires smartphone scanning while the Dexcom reader does not. Additionally, the Dexcom reader can be used for patients aged 2 years and older, while the Freestyle Libre 14-day system is approved for patients aged 18 years and older. Further, there is a Freestyle Libre 2 available, which is a new version that is approved for patients aged 4 years and older. However, the Dexcom CGM monitor is more ideal for those using insulin pumps.
The major drawbacks to the CGM method are its cost and patients’ ability to troubleshoot when problems arise with the readers’ functionality. Common feedback pharmacists receive is that the sensor does not stay on, which is particularly concerning since once it falls off, it should not be reinserted into the patient’s body. Initially, this was a major concern, but systems now come with adhesive bandages that have significantly improved the use of the patch. Each sensor should be replaced every 10 days or 2 weeks, depending on the instructions.
The sensors cost on average $75 to $100 for a pack of 2. Unless covered by insurance, this can be quite costly to maintain. With a doctor’s prescription, pharmacists can tell patients if their meter will be covered on Medicare or their insurance plan. Additionally, in terms of patient selection for each meter, the CGM meter is particularly practical for use in the pediatric population.
Pharmacists can help patients with type 1 and type 2 diabetes navigate through the diabetes management choices available for them or counsel patients on best practice for their chosen meters. Furthermore, frequent glucose testing or monitoring can lead to patients having a clear awareness of the impact of their lifestyle choices on their disease state, which can help them make decisions around how to bring down A1C levels.
About the Author
Ferkhanda Najib, Pharm D, is a client relations pharmacist and vaccine coordinator for Community Care Rx, a full-service, long-term care pharmacy with offices in Hempstead, NY and Totowa, NJ.