Guidelines on Self Monitoring of Blood Glucose (SMBG)
in Adults with Diabetes
Introduction
Self-monitoring of blood glucose (SMBG) refers to the use of regular blood testing to
understand patients’ diabetes control and to inform changes to improve patients’ control or
wider regime. SMBG can support the empowerment model of care, whether a person has Type
1 or Type 2 diabetes. However it should only be offered to a person with diabetes through a
health care professional (HCP) supported education process and based on an individual care /
action plan developed in agreement with the person with diabetes.
Blood glucose monitoring meter technology continues to advance and there is a constant
stream of new models introduced to the market. This leads to confusion for patients and
practices alike when prescribing strips and lancets. In addition, the costs associated with
prescribing strips and lancets continue to increase significantly.
Therefore, these guidelines have been developed with the following aims:
1. To help inform a discussion between individuals with diabetes and their healthcare
professional where the risks, benefits and options for SMBG are fully explored. This
provides an opportunity to review use and reduce waste.
2. To act in addition to NICE guidance in relation to the frequency of SMBG in order to provide
consistent advice and education to patients across Medway Clinical Commissioning Group
(MCCG) and Swale Clinical Commissioning Group (SCCG).
3. To inform HCPs and patients of MCCG’s and SCCG’s preferred list of blood glucose meters
which should be prescribed first line. This will reduce the confusion to patients and
practices that arises with the vast supply of meters available whilst still allowing for some
degree of patient choice.
4. To ensure clinical and cost effective prescribing of blood glucose monitoring strips and
lancets. This will ensure resources are directed to where they are needed for best possible
patient care, whilst reducing waste and taking account of the best available evidence.
This guidance has been ratified by member organisations of the Medway Integrated Diabetes
Service, including HCPs from Medway NHS Foundation Trust, Medway Community Healthcare
and HCPs in Primary Care.
This document aims to provide guidance. There will be occasions when a patient and / or HCPs
will agree to differ from this guidance e.g. risk of hypoglycaemia or if occupation or lifestyle
requires more frequent SMBG. However, reasons for acting outside of this guidance should be
justified and documented appropriately.
Approved by: Medway CCG Commissioning Committee
th
Date of approval: 17 February 2016
Page 1 of 8
Date for review: February 2018
Current guidelines from the Driver and Vehicle Licensing Agency (DVLA) should always be
observed (refer to the link for the most up to date guidance).
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/457961/aagv
1.pdf
Who should be testing their blood glucose levels?
People with Type 1 Diabetes
All patients with Type 1 diabetes should be encouraged to test their blood glucose levels.
Ideally this should, on average, be performed four times daily. However, patients with good
glycaemic control may test less often and patients undergoing treatment / lifestyle changes or
experiencing an inter-current illness may need to test more frequently (up to 10 times daily).
See Appendix 2 for further information.
Advise adults with type 1 diabetes to aim for:
 A fasting plasma glucose level of 5 – 7 mmol/litre on waking and
 A plasma glucose level of 4 – 7 mmol/litre before meals at other times of the day
Precautions which drivers treated with insulin should take whilst driving are detailed in the
DVLA leaflet entitled ‘A Guide to Insulin Treated Diabetes and Driving’ available via
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/457961/aagv
1.pdf
Evidence: NICE Guideline (NG17) Type 1 diabetes in adults: diagnosis and management –
August 2015
http://www.nice.org.uk/guidance/ng17/resources/type-1-diabetes-in-adults-diagnosis-andmanagement-1837276469701
People with Type 2 Diabetes
Take the Driver and Vehicle Licensing Agency (DVLA) At a Glance Guide to the Current Medical
Standards of Fitness to Drive into account when offering self-monitoring of blood glucose
levels.
Do not routinely offer self monitoring of blood glucose levels for adults with type 2 diabletes
unless the person:
 Is on insulin or
 Experiences symptomatic hypoglycaemia or
 Is on oral medication that may increase their risk of hypoglycaemia while driving or
operating machinery or
 Is pregnant, or is planning to become pregnany. For more information, see the NICE
Guideline on Diabetes in Pregnancy
Consider short-term self-monitoring for adults with type 2 diabetes who starts treatment with
oral or intravenous corticosteroids.
Be aware that adults with type 2 diabetes who have acute intercurrent illness are at risk of
worsening hyperglycaemia. Review treatment as necessary.
Approved by: Medway CCG Commissioning Committee
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Date of approval: 17 February 2016
Page 2 of 8
Date for review: February 2018
If adults with type 2 diabetes are self-monitoring their blood glucose levels, carry out a
structured assessment at least annually. The assessment should include:
 Self-Monitoring skills – specifically important if patients are testing infrequently
 The quality and appropriate frequency of testing
 Checking that the person knows how to interpret the blood glucose results and what action
to take
 The impact on the quality of life
 The continued benefit
 The equipment used
Therapies, ability to cause hypoglycaemia and necessity to perform SMBG
Table 1: Varying therapies, ability to cause hypoglycaemia and the necessity to routinely
monitor blood glucose levels.
Therapy (drug or nonpharmacological)
Causes Hypoglycaemia
Non-drug therapy i.e. diet control
and physical activity
Biguanides (Metformin)
Sulphonylureas
No
Yes
Thiazolidinediones
Meglitinides
Acarbose
Dipeptidyl peptidase-4 inhibitors
Glucagon-like peptide-1 agonists
Sodium-glucose co-transporter-2
inhibitors
No
Yes
Yes
No
No
Yes (in combination with
insulin or sulphonylurea)
Insulin
Yes
Necessary to
routinely
perform
SMBG?*
No
No
Yes (See criteria
below)
No
Yes
Yes
No
No
Yes
(combination
therapy).
Yes
*The necessity to perform SMBG may differ in times of inter-current illness, medication and
lifestyle changes (for example, extreme exercise or increased alcohol intake) or to ensure safety
during activities such as driving (in line with current DVLA requirements).
Patients prescribed therapies that do not require routine monitoring of blood glucose levels
should be advised that glycaemic control is best monitored through HbA1c testing.
Approved by: Medway CCG Commissioning Committee
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Date of approval: 17 February 2016
Page 3 of 8
Date for review: February 2018
Evidence
NICE Guideline 28 - Type 2 diabetes in adults: management December 2015
http://www.nice.org.uk/guidance/ng28/resources/type-2-diabetes-in-adults-management1837338615493
[Self Monitoring of blood glucose in type 2 diabetes: a systematic review
CClar et al Health Technology Assessment 2010 Vol 14 No12]
Beneficial
 SMBG can motivate and improve diabetes self management in some people with
diabetes by informing them in real time of the impact of any lifestyle changes.
 SMBG can provide reassurance, empower people with diabetes to take control of their
health care and understand the relationship between how they feel and their blood
glucose readings
 SMBG when used as part of a structured education programme can lead to substantial
improvement in HbA1c
Not Beneficial
 SMBG in some individuals can cause a deterioration in psychosocial outcomes including
anxiety and depression
 Where there is a lack of interest in the results from healthcare professionals
 Where there is a failure to act on the results either by the person with diabetes or the
health care professional who is reviewing diabetes therapies
Choice of Meter
In order to reduce the confusion to patients and practices that arises with the vast supply of
meters available and in order to ensure clinical and cost effective prescribing of strips and
lancets, NHS Medway CCG and NHS Swale CCG have developed a preferred list of blood glucose
meters suitable for prescribing in the local health economy. The preferred list of meters is
available in Appendix 1.
The meters on the preferred list have been selected by a multi-disciplinary group and choices
were based on the following criteria:







Achievement against updated International Organisation for Standardisation (ISO)
standards, updated 2014. All meters included on the preferred list were required to
achieve a level of 98% or more against the ISO standards.
Patient convenience which included reviewing sample volume required; spoken instructions
and readings for the visually impaired; ease of disposal.
Ease of use
Units of display fixed at mmol/L rather than possible to switch to mg/dL.
Service available from the manufacturing company e.g. education, technical advice
provided.
Capability to also do ketone testing.
Cost effectiveness.
Approved by: Medway CCG Commissioning Committee
th
Date of approval: 17 February 2016
Page 4 of 8
Date for review: February 2018
The use of any glucose meter should be agreed between the individual patient and HCP as part
of an individual care/action plans. The HCP should have a good understanding of each and
every meter included on the preferred list to ensure informed choice. The patient should have
all available meters demonstrated. The HCP undertaking to teach the patient about their
chosen meter and interpretation of blood glucose readings must be aware that they also adopt
responsibility for treatment adjustment until such time as the patient feels confident and
competent to undertake this process for themselves.
If a patient requires a meter due to clinical need, there is no requirement for them to purchase
a meter. Meters will be provided free of charge from either the diabetes specialist clinic or GP
practice, and a appropriate meter from the Medway and Swale CCGs formulary will be given.
Occasionally, for specific individuals, the diabetes specialist service will initiate an alternative
meter to meet specific patient needs and will inform the GP of this in order to support on-going
prescribing of consumables.
Insulin Pump Patients will have a specific insulin bolus advisor meter to work with their pump.
The Diabetes Nurse Specialist (DSN) will inform the patient’s GP via letter with details as
required. For NICE guidance on use of insulin pumps see the following link:
http://www.nice.org.uk/guidance/ta151/resources/continuous-subcutaneous-insulin-infusionfor-the-treatment-of-diabetes-mellitus-82598309704645
Adults Newly Diagnosed With Diabetes
If a glucose meter is required, one should be provided in accordance with this guidance.
Existing Patients
It is appreciated that some patients already use meters that are not on the recommended list of
products. These patients should be encouraged to change to a meter on the formulary and any
issues discussed with their HCP. The patient should then be supplied with a meter in
accordance with this guidance, unless there are extenuating circumstances. Should the HCP
decide that extenuating circumstances apply, then prescriptions for the appropriate strips and
lancets should continue to be issued, the reasons for supply outside of the guidance should be
documented on the patient’s medical record.
The list of preferred choice blood glucose meters for Medway and Swale CCG (Appendix 2) will
be reviewed every two years by MCCG and SCCG in collaboration with the local diabetes health
community.
Frequency of testing.
Once an informed discussion has taken place between the HCP and the patient and a meter has
been selected, strips and lancets relevant to that system should be supplied. The HCP should
confirm that the patient is aware of the frequency of testing to be undertaken (this will be
governed by the choice of treatment and the objective of care being set) and will ensure that
an appropriate number of strips and lancets are provided to support this. Recommended
Approved by: Medway CCG Commissioning Committee
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Date of approval: 17 February 2016
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Date for review: February 2018
frequency for testing is stated in Appendix 2 (note that this is guidance only and should be
reviewed and tailored to the individual’s needs).
Current DVLA driving regulations should be adhered to and these are entitled ‘DVLA at a glance
guide to the current medical guidelines’ available online via
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/457961/aagv
1.pdf
Inclusion of clear directions on the prescription will result in the strips being labelled with
frequency of testing. Patients requesting in excess of their usage should be referred to their
practice nurse or diabetes clinic for review. Ensure patients’ medical certificates are still in
date as these expire and need to be renewed, to avoid prescription chargesReferences
List of appendices
Appendix 1 – NHS Medway and Swale CCGs Preferred List of Blood Glucose Monitoring Meters
Appendix 2 – Recommended regimes for self-monitoring of blood glucose in people with
diabetes.
Approved by: Medway CCG Commissioning Committee
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Date of approval: 17 February 2016
Page 6 of 8
Date for review: February 2018
Appendix 1: NHS Medway and Swale CCGs Preferred List of Blood Glucose Monitoring Meters.
Meter
Strips
*GlucoMen Areo (First line Choice)
GlucoMen GM®
GlucoMen Areo strips (50 strips £9.95)
GlucoMen GM Glucose Test Sensor (50 strips £9.95)*
Lancets
Who Is This Meter Suitable For?
People with Type 2 diabetes
Glucoject Lancets
(Compatible with Icodextrin peritoneal dialysis)
One Touch Lifescan Verio®
One Touch Verio (50 strips £15.12)
Bayer Contour XT® and Contour Next USB®
Contour Next Strips
(50 strips £15.04)*
BG Star Test Strips
(50 strips £14.73)*
(Compatible with Icodextrin peritoneal dialysis)
BG Star®
AccuChek Mobile®
Roche AccuChek Mobile Cassette. (100 strips £31.54)*
One Touch Comfort
Lancets
Microlet Lancets
People with Type 2 diabetes
People With Type 2 diabetes
BG Star Ultrathin
Lancets
People With Type 2 diabetes
Fastclix Lancets
Suitable for patients with Type 1 and 2
diabetes - professional drivers only.
(As this meter holds up to six test strips and lancets
in a canister, it may also be considered for patients
with a genuine need for testing blood glucose levels
in locations where there is no means for safe disposal
of lancets).
Other meters are available and test strips can be issued if the meter has been recommended by a HCP in exceptional circumstances. If carbohydrate counting is required, the
patient will be issued a suitable meter after they have been through the structured educational training session – practices will be notified of meter issued.
Meters for DSN initiation only
Meter
GlucoMen LX+®
FreeStyle Optium Neo®
GlucoRx Nexus Voice®
Strips
GlucoMen LX Glucose Test Sensors (50 strips £15.20)*
GlucoMen LX Ketone Test Sensor (10 strips £20.32)*
FreeStyle Optium test Strips (50 Strips £15.64) *
FreeStyle OPtium B-Ketone strips (10 strips £21.04) *
GlucoRx Nexus
(50 strips £9.95)*
Lancets
GlucoJect Lancets
Who Is This Meter Suitable For?
People with Type 1 diabetes
FreeStyle Lancets
People with Type 1 diabetes
GlucoRx Lancets
People with Visual Impairment
* Insulin Pump Patients will have a specific meter to work with the pump they have. DSNs will inform the patient’s GP via letter as required.
*All meters selected have met the criteria set out, which included amongst others: above 98% on the ISO 15 197 report (Updated since 2014) along with patient
acceptability and ease of use.*Prices taken from BNF 68, September 2014 and correct at time of publishing.
* GlucoMen Areo replaces GlucoMen GM meter, the GM test strips will still be available and there is no need to switch patients.
Approved by: Medway CCG Commissioning Committee
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Date of approval: 17 February 2016
Page 7 of 8
Date for review: February 2018
Appendix 2: Recommended regimes for self-monitoring of blood glucose in people with diabetes.
Diabetes Type
Treatment Group
Type 1 Diabetes
All people with Type 1 diabetes
Intensive management
or loss of
hypoglycaemic
awareness
Pre-pregnancy,
Pregnancy in
Type 1 & Type 2
& Gestational Diabetes
Type 2 Diabetes
Frequent testing essential in:
newly diagnosed children, under 5yrs;
insulin pump therapy users; those
unwell or carbohydrate counting
All women with diabetes who are
planning a pregnancy,
pregnant women with diabetes
and gestational diabetes
Insuline therapy +/- Hyproglycaemic
e.g. Sulphonylureas
Monitoring Regime
A management plan should be developed and agreed with the individual



SMBG is an integral part of treating Type 1 Diabetes.
Patients should be educated in SMBG and adjust treatment accordingly.
All patients with Type 1 Diabetes should be able to monitor 4 or more times a day to prevent hypoglycaemia and control
hyperglycaemia. Some patients with Type 1 Diabetes may need to test up to 10 times a day if any of the following apply:
 Desired target for blood glucose control, measured by HbA1c level is not achieved
 Frequency of hypoglycaemic episodes increases
 There is a legal requirement to do so (such as driving, in line with the DVLA)
 During periods of illness
 Before, during and after sport
 When planning pregnancy, during pregnancy and while brestfeeding NICE Guideline on Diabetes in Pregnancy
 If there is a need to know blood glucose levels more than 4 times a day for other reasons.
A management plan should be developed and agreed with the individual

up to 8 or more tests daily
50 strips
250 strips
every 2 Months
[but may need more]
250 strips
250 strips
every Month
[but may need less]
All should perform SMBG at least 4 times a day (in some cases up to 8 times a day), to include both fasting and post prandial
blood glucose measurements. NICE Guideline on Diabetes in Pregnancy
150 strips
for the first
month
150-250 strips every month





Diet and Physical Activity alone
Metformin alone
Combination therapies which do not
include suphonylureas or insulin
Usual Blood Glucose Strip
Requirement*
Initiation
Repeat prescription




Consider SMBG 2 to 4 times a day. This may be reduced to once daily or less if glycaemic control is considered to be stable
in agreement with the patient.
Increase testing during periods of illness, instability or use of corticosteroids.
Testing as per DVLA guidelines.
Any significant lifestyle changes.
Assess patients’ understanding and use of results to adjust diet, lifestyle and treatment. Provide extra training / education
if required.
Glycaemic control can be monitored through HBA1c to agreed individual targets
Consider using SMBG during intercurrent illness especially during the use of steroids.
Patterns of monitoring should be agreed as part of a diabetes management plan
As part of a structured education plan, for a specific period, to motivate people with diabetes to achieve agreed
reductions in HbA1c
100 strips
50 strips to
facilitate
monitoring
agreed
50-150 strips every month
depending on number of
tests per day
No repeat.
Issue 50 strips on request
ONLY where appropriate
ONLY consider repeat
prescription as part of agreed
management plan




SMBG should form part of a wider programme of management where the results are used to inform diet, lifestyle or treatment changes.
Patients who self-monitor must be given adequate training in self-monitoring techniques, including regular quality control of their meters
Patients and health care professionals (HCPs) should be clear about what they hope to achieve by SMBG. Frequency of SMBG should be reviewed regularly and
excess use addressed.
Patients may need extra strips to comply with DVLA guidelines (refer to the link http://www.dft.gov.uk/dvla/medical/aag.aspx for the most up to date
information).
Approved by: Medway CCG Commissioning Committee
th
Date of approval: 17 February 2016
Page 8 of 8
Date for review: February 2018