Diabetes Care Volume 41, Supplement 1, January 2018 S55

American Diabetes Association

6. Glycemic Targets: Standards of
Medical Care in Diabetesd2018
Diabetes Care 2018;41(Suppl. 1):S55–S64 | https://doi.org/10.2337/dc18-S006

The American Diabetes Association (ADA) “Standards of Medical Care in Diabetes”

6. GLYCEMIC TARGETS
includes ADA’s current clinical practice recommendations and is intended to provide
the components of diabetes care, general treatment goals and guidelines, and tools to
evaluate quality of care. Members of the ADA Professional Practice Committee, a
multidisciplinary expert committee, are responsible for updating the Standards of
Care annually, or more frequently as warranted. For a detailed description of ADA
standards, statements, and reports, as well as the evidence-grading system for ADA’s
clinical practice recommendations, please refer to the Standards of Care Introduction.
Readers who wish to comment on the Standards of Care are invited to do so at
professional.diabetes.org/SOC.

ASSESSMENT OF GLYCEMIC CONTROL

Patient self-monitoring of blood glucose (SMBG) and A1C are available to health
care providers and patients to assess the effectiveness and safety of a manage-
ment plan on glycemic control. Continuous glucose monitoring (CGM) also has
an important role in assessing the effectiveness and safety of treatment in sub-
groups of patients with type 1 diabetes and in selected patients with type 2 di-
abetes. Data indicate similar A1C and safety with the use of CGM compared with
SMBG (1).

Recommendations
c Most patients using intensive insulin regimens (multiple-dose insulin or in-
sulin pump therapy) should perform self-monitoring of blood glucose (SMBG)
prior to meals and snacks, at bedtime, occasionally postprandially, prior to
exercise, when they suspect low blood glucose, after treating low blood
glucose until they are normoglycemic, and prior to critical tasks such as
driving. B
c When prescribed as part of a broad educational program, SMBG may help to
guide treatment decisions and/or self-management for patients taking less fre-
quent insulin injections B or noninsulin therapies. E
c When prescribing SMBG, ensure that patients receive ongoing instruction and
regular evaluation of SMBG technique, SMBG results, and their ability to use
SMBG data to adjust therapy. E Suggested citation: American Diabetes Associa-
tion. 6. Glycemic targets: Standards of Medical
c When used properly, continuous glucose monitoring (CGM) in conjunction with
Care in Diabetesd2018. Diabetes Care 2018;
intensive insulin regimens is a useful tool to lower A1C in adults with type 1 41(Suppl. 1):S55–S64
diabetes who are not meeting glycemic targets. A © 2017 by the American Diabetes Association.
c CGM may be a useful tool in those with hypoglycemia unawareness and/or Readers may use this article as long as the work
frequent hypoglycemic episodes. C is properly cited, the use is educational and not
c Given the variable adherence to CGM, assess individual readiness for continuing for profit, and the work is not altered. More infor-
CGM use prior to prescribing. E mation is available at http://www.diabetesjournals
.org/content/license.
S56 Glycemic Targets Diabetes Care Volume 41, Supplement 1, January 2018

should be advised against purchasing or most CGM devices include alarms for hypo-
c When prescribing CGM, robust di-
reselling preowned or secondhand test and hyperglycemic excursions. The inter-
abetes education, training, and sup-
strips, as these may give incorrect results. mittent or “flash” CGM device, very re-
port are required for optimal CGM
Only unopened vials of glucose test strips cently approved for adult use only (18),
implementation and ongoing use. E
should be used to ensure SMBG accuracy. differs from previous CGM devices. Spe-
c People who have been successfully
For Patients on Intensive Insulin Regimens cifically, it does not have alarms, does not
using CGM should have continued
Most patients using intensive insulin require calibration with SMBG, and does
access after they turn 65 years of
not communicate continuously (only on
age. E regimens (multiple-dose insulin or insulin
pump therapy) should perform SMBG demand). It is reported to have a lower
prior to meals and snacks, at bedtime, oc- cost than traditional systems. A study in
Self-monitoring of Blood Glucose
casionally postprandially, prior to exercise, adults with well-controlled type 1 diabe-
Major clinical trials of insulin-treated pa-
when they suspect low blood glucose, af- tes found that flash CGM users spent less
tients have included SMBG as part of
ter treating low blood glucose until they time in hypoglycemia than those using
multifactorial interventions to demon-
are normoglycemic, and prior to critical SMBG (19). However, due to significant
strate the benefit of intensive glycemic
tasks such as driving. For many patients, differences between flash CGM and other
control on diabetes complications. SMBG
this will require testing 6–10 (or more) CGM devices, more discussion is needed
is thus an integral component of effective
times daily, although individual needs on outcomes and regarding specific rec-
therapy (2). SMBG allows patients to eval-
may vary. A database study of almost ommendations.
uate their individual response to therapy
27,000 children and adolescents with For most CGM systems, confirmatory
and assess whether glycemic targets are
type 1 diabetes showed that, after adjust- SMBG is required to make treatment de-
being achieved. Integrating SMBG results
ment for multiple confounders, increased cisions, though a randomized controlled
into diabetes management can be a
daily frequency of SMBG was significantly trial of 226 adults suggested that an en-
useful tool for guiding medical nutrition
associated with lower A1C (–0.2% per ad- hanced CGM device could be used safely
therapy and physical activity, preventing
ditional test per day) and with fewer and effectively without regular confirma-
hypoglycemia, and adjusting medications
acute complications (8). tory SMBG in patients with well-controlled
(particularly prandial insulin doses). Among
type 1 diabetes at low risk of severe hy-
patients with type 1 diabetes, there is a
For Patients Using Basal Insulin and/or Oral poglycemia (1). Two CGM devices are now
correlation between greater SMBG fre-
Agents approved by the U.S. Food and Drug Ad-
quency and lower A1C (3). The patient’s
The evidence is insufficient regarding ministration (FDA) for making treatment
specific needs and goals should dictate
when to prescribe SMBG and how often decisions without SMBG confirmation
SMBG frequency and timing.
testing is needed for patients who do not use (18,20), including the flash CGM device.
Optimization intensive insulin regimens, such as those Although performed with older gener-
SMBG accuracy is dependent on the instru- with type 2 diabetes using oral agents ation CGM devices, a 26-week random-
ment and user, so it is important to evalu- and/or basal insulin. For patients using ized trial of 322 patients with type 1
ate each patient’s monitoring technique, basal insulin, assessing fasting glucose diabetes showed that adults aged $25 years
both initially and at regular intervals with SMBG to inform dose adjustments using intensive insulin therapy and CGM
thereafter. Optimal use of SMBG requires to achieve blood glucose targets results experienced a 0.5% reduction in A1C
proper review and interpretation of the in lower A1Cs (9,10). (from ;7.6% to 7.1% [;60 mmol/mol
data, by both the patient and the pro- For individuals with type 2 diabetes on to 54 mmol/mol]) compared with those
vider. Among patients who check their less intensive insulin therapy, more fre- using intensive insulin therapy with SMBG
blood glucose at least once daily, many quent SMBG (e.g., fasting, before/after (21). The greatest predictor of A1C lower-
report taking no action when results are meals) may be helpful, as increased fre- ing for all age-groups was frequency of
high or low. In a yearlong study of insulin- quency is associated with meeting A1C sensor use, which was highest in those
naive patients with suboptimal initial targets (11). aged $25 years and lower in younger
glycemic control, a group trained in struc- Several randomized trials have called age-groups. Two clinical trials in adults
tured SMBG (a paper tool was used at into question the clinical utility and cost- with type 1 diabetes not meeting A1C
least quarterly to collect and interpret effectiveness of routine SMBG in noninsu- targets and using multiple daily injections
7-point SMBG profiles taken on 3 consec- lin-treated patients (12–15). Meta-analyses also found that the use of CGM compared
utive days) reduced their A1C by 0.3 per- have suggested that SMBG can reduce A1C with usual care resulted in lower A1C levels
centage points more than the control by 0.25–0.3% at 6 months (16,17), but the than SMBG over 24–26 weeks (22,23).
group (4). Patients should be taught effect was attenuated at 12 months in Other small, short-term studies have
how to use SMBG data to adjust food in- one analysis (16). A key consideration is demonstrated similar A1C reductions us-
take, exercise, or pharmacologic therapy that performing SMBG alone does not ing CGM compared with SMBG in adults
to achieve specific goals. The ongoing lower blood glucose levels. To be useful, with A1C levels $7% (53 mmol/mol)
need for and frequency of SMBG should the information must be integrated into (24,25).
be reevaluated at each routine visit to clinical and self-management plans. A registry study of 17,317 participants
avoid overuse (5–7). SMBG is especially confirmed that more frequent CGM use is
important for insulin-treated patients to Continuous Glucose Monitoring associated with lower A1C (26), whereas
monitor for and prevent asymptomatic CGM measures interstitial glucose (which another study showed that children
hypoglycemia and hyperglycemia. Patients correlates well with plasma glucose), and with .70% sensor use (i.e., $5 days per