A Rosetta Stone for Insulin Treatment: Self-Monitoring of Blood Glucose

In the daily management of type 1 diabetes, self-monitoring of blood glucose (SMBG) is the recommended glycemic monitor, or “Rosetta stone”, that enables improved glycemic control (1). By measuring real-time glucose, informed patients can modify their diabetes management acutely or prospectively to sustain glucose in a narrow range near normal. A recent study from the Veterans Administration demonstrated improved glycemic control with lowered hemoglobin A1c in patients with insulin-treated type 2 diabetes who performed SMBG (2). A wide range of insulins is now available with various durations of action that can help to improve glycemic control. The greatest therapeutic advances entail the use of recombinant DNA-engineered insulin analogs. Novel insulins such as lyspro-insulin [lysine(B28), proline(B29)] have a very rapid onset of action (15–30 min), peak effect (1–2 h), and limited overall duration of action (3–4 h), whereas glargine (A-Gly-30Ba-l-Arg-30Bh-l-Arg-human) has no peak and a duration of action of 24 h or longer.Maintaining blood glucose at or very near the normal range decreases the frequency of new-onset microvascular complications and delays the progression of established microvascular complications in both type 1 and type 2 diabetes (3)(4)(5). In non-insulin-treated patients, before 2002 there were few data to suggest that SMBG improved clinical outcome (6). However a recent study from France found that SMBG lowered hemoglobin A1c in monitored, non-insulin-treated type 2 diabetes (7), as did a study from Germany (8).Accurate and precise blood glucose measurements are no doubt helpful and important to achieve optimal diabetic care (9). However, unless patients alter their care (e.g., acute adjustments in diet, exercise, or insulin dosing) in response to the real-time blood glucose or in anticipation of changes in blood glucose, even the most accurate and precise glucose …