How often should a T1D check her/his blood glucose level?

Type 1 and LADA
#1

Last July (2014), the official publication of the American Diabetes Association (ADA), Diabetes Care, published a position paper written on behalf of the authors of the Type1 Diabetes Sourcebook. The title of the piece, Type 1 Diabetes Through the Life Span: A Position Statement of the American Diabetes Association, reflects its comprehensive nature. It was written by Jane L. Chang, M. Sue Kirkman, Lori M.B. Laffel, and Anne L. Peters.

In this climate of Medicare and other payer cutbacks with blood glucose test strip allowances, this position is a breathe of fresh air. Here are their recommendations for frequency of blood glucose testing:

Recommendations

  • Patients with type 1 diabetes should perform SMBG [self monitoring of blood glucose] prior to meals and snacks, at a minimum, and at other times, including postprandially to assess insulin-to-carbohydrate ratios; at bedtime; midsleep; prior to, during, and/or after exercise; when they suspect low blood glucose; after treating low blood glucose until they have restored normoglycemia; when correcting a high blood glucose level; prior to critical tasks such as driving; and at more frequent intervals during illness or stress. (B)

  • Individuals with type 1 diabetes need to have unimpeded access to glucose test strips for blood glucose testing. Regardless of age, individuals may require 10 or more strips daily to monitor for hypoglycemia, assess insulin needs prior to eating, and determine if their blood glucose level is safe enough for overnight sleeping. (B)

These authors/doctors get it. There is abundant medical rationale to test at least ten times per day, sometimes more. I realize that not every T1D wants make room in her/his life for this frequency of checking but some of us do. I'm glad to see this position declared in black and white!

Now I know that this position paper only speaks to type 1 diabetes. I think that a similar position could be taken on behalf of people with T2D. Continual learning about the effects of different foods on post-prandial blood glucose requires lots of strips. Anyone that uses insulin faces the same challenges as the typical T1D.

So, the next time that some bean-counter payer pushes back on the number of test strips that you need, this is a great piece from which to cut and paste.

By the way, the Type 1 Diabetes Sourcebook target diabetes clinicians as its audience. It's interesting to note that this book was sponsored jointly by the ADA and the JDRF.

#2

Fantastic, and totally concur.

I wonder, have people found that once they get a CGM, insurance puts pressure on them to scale back their test strip use? The CGMs needs calibration, but presumably reduce the need for quite as many finger-stick tests, and they are expensive for the insurance companies, as are the (from their perspective perhaps redundant) test strips.

#3

With the Dex G4 505 update the CGM may be approaching the current meter level of accuracy. I'd have to see the numbers before I'd want to depend on the CGM alone, as a habit, to use for dosing. I'll make smaller moves without benefit of a fingerstick, like when the CGM gives me a low alarm and I don't want to wake all the way up during the night.

I still like the idea of having some counterbalancing separate technology for BG confirmation. Maybe not 14 strips/day, maybe as few as two to four. My fingertips would like that.

#4

I totally agree! I wrote this, spelling out what seems like a reasonable day, and came up with about a dozen:

• wake up, test bg
2) before eating test BG
3) before driving to work test bg
4) 2 hours after eating test bg
5) lunch test BG
6) 2 hours post lunch test bg
7) drive home test BG
8) get home, run 3 miles...oh wait, don't forget to test your bg!
9) post-exercise maybe, maybe not, maybe eat dinner and, you guessed it, test BG
10) 2 hours post dinner, test BG ****AGAIN****
12) stay up late? Maybe squeeze in another one, what if you have errands to run, what if you want to exercise more (when it's nicer out, I'll run 6-7 miles during the week, more on the weekends...a lot of times, I'll run a long run on Saturday and then a 20ish mile bike ride for fun, speed and recovery on Sunday...there's several extra strips in there...).

I think that BG testing should be a civil right. Given our general societal dependence on cars, testing our BG at any time is essential. At the same time, even if you're not driving, SAHM (as if they don't drive, ha ha...), or retired or whatever, that level of testing should be available. It should never be mandatory but it should be provided by any health insurance contract providing "reasonable and customary" coverage of medical expenses or any "single-payer" governmental or quasi-governmental entity charged with providing for public health. Great post Terry! I also really like to see ADA/ JDRF pooling their considerable resources.

#5

When I used the 7+ I actually used significantly MORE strips because It was glitching out so often I was constantly saying, “hmm that can’t be right I better check”

#6

I'm still using a lot of strips. I like a double test/average for CGM cals. If I'm below 65, I'll stick 2-3 times per hour until "gluconormal." I love their terminology!

I love this bit of word-smithing: "determine if their blood glucose level is safe enough for overnight sleeping."

What bureaucrat could resist that line?

The truth is so obvious.

#7

Back in the '90s my company started using a pharmacy benefits manager who tried to cut my supply, in contradiction to my understanding with my doctor.

I was pissed. I called the doctor to got him to rewrite the order and increase the number per day. I told the corporate pharmacist if they ever messed with my doctor's clearly written legible prescription, I would file a complaint with their professional licensing bureau.

They never tried those shenanigans again.

It is a right. Not only that, its cheaper.

#8

I thought my 10 strips/day prescription was unusual, you guys have no problems getting insurance to cover that many and more, and perhaps on top of a CGM?

I once briefly had a new endocrinologist who told me he thought only 4 tests strips/day were warranted for diabetics. I tried to walk him through a typical day--do you not want me testing before this meal? Do you not want me testing before or after this run? Do you not want me testing if I feel low mid-afternoon?--but he didn't seem to get it. I found it kind of mind-boggling, frankly.

I've also had a past insurance company that capped me at 6/day. It didn't occur to me I'd had much leverage, and I've noticed doctors often aren't keen to push back hard.

#9

Agreed, I was pretty unimpressed by the Seven+. I'm hoping the G4, which I should get soon, will be a significant improvement.

#10

On 'routine' days, I test 10x.

On 'good' days 5 or 6. I call them 'flatline' days.

On 'bad' days, well....more - My personal 'best' is 26 times!
There was a couple days where I was sick, suffering a severe reaction to steroids. I finally went to the ER with a nose bleed that would not stop, BG in the 300's and a BP 250+/160ish!

I had to remove the CGM due to x-rays, Cat Scan, etc. Had to disconnect the pump on a couple occasions too.

And true to their word (after a huge fiasco earlier in the year) they only asked me for my BG numbers and never made any suggestions or tried to advise me on how to manage it. Just offered me their support in any way I thought might be helpful. :-)

I guess there are some small benefits of having the Chief of Medicine as one's personal physician.

p.s. I had a really 'cool' adrenaline dump due to the IV BP reducing meds they gave me. It was painfully reminicent of a couple severe hypo's I've had.

#11

I had the same experience, some time in there, it must have been the late 90s or early to mid-2000s. I decided to arrange a 4 way call, BCBS, the pharmacy (Walgreens), the doc and I. I assumed that I wouldn't get the doc on the line but was hopeful maybe it would be a nurse but, shockingly, the doc took the call and used his leverage and I haven't had much trouble since then. Although for a few years, BCBS' (lol on the plural) seemingly "captive" pharmacy prime care, sent letters saying "Medicare says you only need 4 strips/day", they never did anything about it but the threat was sort of menacing. The letters were signed by a doc, some Vietnamese guy, so I looked around on the internet to see if I could d/l pics of his house to include with any subsequent correspondence I'd have to send them. I'd also scoped out the approaches to BCBS HQ with a notion of hitting golf balls through their windows but they seemed to have gotten to google so the pics aren't online (it's Chicago, so there's this deal with multiple layers and all that, I'd just have to use a longer club from what I can see online...). I'm not really a total psycho but it makes me feel better.

#12

my "one month supply" is 300 strips but I probably only refill it about every 2 months. My prescription coverage is kind of complicated... I have 2 different prescription plans, each of which insists it is my primary and can't be billed as a secondary. They also have almost total opposite drugs, strips, etc, in their "formulary." So basically I keep the different "primary" coverage on file at the two different local pharmacies, and then when I need a med I have to research which plan will cover it and go to that pharmacy.... the only issue I've ever had with strips is one of the two plans decided that they were only going to cover one-touch strips (which I hate) so I've been billing the generics I prefer to the other plan. I have often wondered how a senior citizen on 2 dozen different meds and maybe having a little more trouble than I do upstairs could possibly keep track of such a complicated arrangement.

#13

The confusion works in the favor of the house. They know that.

#14

My script is for 400 every 28 days.

#15

Thanks for mentioning T2. If you read the position paper and simply replaced T1 with insulin dependent it would appear that all of the evidence and logic applies to anyone who is insulin dependent. Someone with insulin dependent T2 should also testing in all the ways recommended for T1s.

Sadly Medicare policy allows insulin dependent (T1 or T2) 300 strips every three months which works out to a little over 3/day, enough to check your blood sugar before three meals a day. Good luck driving. Sadly the changes in Medicare have drastically cut reimbursement rates and in many cases test accuracy is seriously compromised. I would never undertake a drastic correction without verifying my meter reading, unfortunately that wastes another strip. I really, really don't look forward to Medicare.

#16

On the surface, that might seem to be the case, however in a "long view" of health care, the life expectancy of T1/T2 folks seems to have increased quite a bit due to the advances in medicine, better insulin and blood sugar testing. I don't think anyone knows for sure whether or not it might save an insurance company tons of money to just pay for my complications with 5ish A1Cs vs paying for what my complications might be were I to run my A1C a bit higher, even in the 6.5-7.0 range, not that there's proven to be anything wrong with that?

It seems as if it would be useful to study more precisely and more conclusively whether there is, in fact, an advantage to running one's BG lower, say the 5ish (4ish?, 6ish?) A1Cs vs. the 6-7 A1C. I've used the example in relation to MARD and CGMs but Bill James pointed out that the difference between a .285 hitter and .300 hitter is about 5-6 hits over the course of a season and about $10 million dollars when your trying to sign them. Perhaps we are wasting our time but, for me, charting my course towards normal seems to be a reasonable solution.

#17

I agree, Brian. Anyone that uses insulin needs the same access to test strips as described in this paper. And one strip per day is not a reasonable accommodation for non-insulin dependent diabetes. It totally pre-empts the rational "eat-to-your-meter" tactic.

Fortunately, Medicare permits an appeal with a letter of medical necessity from the patient's doctor. This is where the doctor can use some of the language used in this paper. I'm getting the same number of test strip under Medicare, 14x/day, that I was getting under private insurance and my doctor has not needed to write an appeal on my behalf. I haven't been challenged about this yet, but I expect it. I have the data to prove my usage.

It took the large advocate organizations a few years to push back, but I like this position paper as a start. The diabetes community needs to keep this issue front and center. Medicare's test strip stance is a very poor policy decision. They may have decreased fraud but they've now hurt the very group they initially intended to help.

#18

The studies I have viewed have shown an A1c "sweet spot" for people with diabetes from 6.0-6.5%. That is the point where continuing to decrease A1c does not show much of a reduction in secondary complications.

I'm not sure that I agree with this and science has not looked at your question. My gut tells me it's better for anyone like yourself that can push his A1c into the 5% range without undue hypo risk. Unfortunately, for people to do this they must also sport low glucose variability, something most people with diabetes can not do.

#19

I don't understand the admin edit (censor?) here for, "p***ed." I don't think that the actual word that I wrote offends community sensibility. It's in the common vernacular and I've heard it used in polite company. Please explain.

We can take this offline, of course, but editing my words without any separate communication is not OK with me!

#20

Pancreas:
Immune
System
Spoiled
Everything
Dammit!

That's my definition of P****d.