Glucose monitoring (Guidelines)

Testing up to 4 times per day is appropriate for:

• patients with type 2 diabetes using or being considered for insulin injectable therapy
• patients advised on an individual basis by an appropriate health care professional
• patients requiring short-term glucose testing.

Patients who require to test more frequently than 4 times daily:

• patients with type 1 diabetes
• children
• if there is evidence of impaired hypoglycaemia awareness
• during pregnancy (including gestational diabetes)
• for patients managed with a continuous subcutaneous insulin infusion (CSII by pump)
• if control is poor or unstable; reduce testing frequency again when control is improved
• for specific patients as advised by the specialist team
• if patients are carbohydrate counting
• in other selected circumstances, eg for occupational reasons.

NB when prescribing Free Style Libre, continue to supply blood glucose monitoring strips (on repeat or acute prescription) for the patient to order when needed. 

Please refer to Formulary choices for blood monitoring.

The different meters on the market all require different testing strips/devices. Stocking many types of meter is potentially wasteful and can be confusing for patients and health-care professionals. The guidance given below is intended to help match glucose meters to individual requirements bearing in mind that many of the type 2 diabetes population do not require a multi-function meter, therefore it is suggested that the following meters listed below be used in NHS Highland.

 All meters are subject to inaccuracies arising from:

• Poor technique: lack of hand washing can lead to contaminated samples giving an inaccurate result. Wash hands with soap and water before taking a sample. Using just hand sanitiser may alter the blood glucose result.
• Insufficient blood on the test strip: all of the advised meters use a capillary fill system so the strip ‘sucks up’ the blood rather than it being applied to the top of the strip. If the blood is incorrectly applied the meter will not work.
• Temperature: meters and strips are designed to be most accurate at room temperature. If the meter is too cold it may not function.
• Humidity will also affect test strips. They should be stored in the container with the top closed and used within manufacturers’ recommended time after opening.
• Disposal of blood glucose meters Spirit Healthcare are able to collect old blood glucose meters (both their own meters and other companies' meters).  They recycle the meters and ensure none go to landfill.  The email address to contact is: cs@spirit-healthcare.co.uk

Avoid comparing results from different meters as different meters will provide varying readings leading to confusion.

What is FreeStyle Libre?

The Abbott FreeStyle Libre (FSL) flash glucose monitoring system is a factory-calibrated glucose sensor that measures interstitial fluid (not blood) glucose levels in individuals with diabetes mellitus. It is worn on the back of the arm and sensors last 14 days. Interstitial glucose readings are taken using an associated reader device or a compatible smartphone which is held over the sensor and downloads the last eight hours-worth of data, providing a graphical display of interstitial glucose levels. This reduces the need to perform fingerprick glucose measurements. However, glucose monitoring is still required to confirm hypoglycaemia or suspected spurious results, and to enable accurate calculation of insulin correction doses.

Who can prescribe the Freestyle Libre?

GPs can prescribe FSL, and should do so, only for individuals identified by the secondary care diabetes team as being eligible based on clinical need and criteria as proposed by the Scottish diabetes Group/MCN Leads and endorsed by a Scottish Health Technology Group Assessment on the cost effectiveness of FSL.

Who is eligible to receive prescriptions for FSL?

• Individuals with diabetes who are attending diabetes specialist services and treated with intensive insulin therapy, with multiple daily insulin injections, or insulin pump therapy, who are already performing multiple (5 or more) fingerprick blood glucose tests per day.
• Individuals with recently developed impaired awareness of hypoglycaemia who are not yet candidates for (more costly) continuous glucose monitoring systems.
• Women planning pregnancy (this would be switched to Dexcom continuous glucose monitoring during pregnancy).
• Those who required a third party to perform monitoring, or where dexterity or disability denote that conventional testing is difficult or impossible.

What other criteria must be met for the FSL to be prescribed?

• Deemed by the team to have the required knowledge and skills to effectively self-manage their diabetes. This may include having undertaken a recognised diabetes structured education programme (eg HEIDI), and/or 1 to 1 carbohydrate counting.
• Completion of the on-line Libre Academy modules at: https://freestylediabetes.co.uk/freestyle-libre/academy. Agreement to attend a locally provided flash glucose monitoring education session, or an on-line equivalent, if appropriate.
• To agree to measure/“swipe” a minimum of six times per day.
• To use sensors as recommended.
• To agree to share glucose monitoring data with the diabetes clinic and complete any associated clinical questionnaires.

How will ongoing effectiveness of the device be assessed?

Ongoing prescription of FSL will require effective use of the technology to improve self management as determined by the specialist diabetes team at their review appointments, eg reduction in hypoglycaemia, improvement in HbA1c, reduction in hospital admissions.

What are the associated costs?

FSL was added to the NHS prescribing tariff in November 2017 at a reduced acquisition cost compared to when purchased privately. The annual prescribing cost for FSL and associated sensors is £910 per patient, roughly equivalent to 8 or more glucose test strips per day. This is a significant saving compared to private purchase by patients. However, prescription should be limited to those identified by the specialist team as being suitable.

What if an individual is already self-funding Freestyle Libre?

If an individual with Type 1 diabetes is already self-funding FSL then it is likely that prescription of FSL will be recommended by the specialist team provided that they are satisfied that it has led to improvements in the management of the individual’s diabetes, ie improved HbA1c, reduced hypos, less hospital admissions with DKA (if applicable). However, as above, please do not prescribe FSL unless on the advice of the secondary care diabetes team.

What if an individual is having technical problems with the sensors?

Individuals should contact Abbott directly rather than contacting their GP or the diabetes team.
Abbott UK General Customer Service telephone number: 0800 1701177
8am to 8pm, Monday to Friday; excluding bank holidays

1. Freestyle Libre® flash glucose monitoring (shtg.scot) (Accessed on 18^th Aug 2021)

What is the Freestyle Libre?

The Abbott Freestyle Libre (FSL) flash glucose monitoring system is a factory-calibrated glucose sensor that measures interstitial fluid (not blood) glucose levels in individuals with diabetes mellitus. It is worn on the back of the arm and sensors last 14 days. This reduces the need to perform fingerprick glucose measurements. However, glucose monitoring is still required for driving (correct at the time of writing), testing for hypoglycaemia or suspected spurious results, and to enable accurate calculation of correction doses.

Can I get the Freestyle Libre on prescription?

FSL has been added to the NHS prescribing tariff at a reduced acquisition cost compared to when it is purchased privately. The annual prescribing cost for FSL and associated sensors is £910 per patient. Unfortunately there is not an unlimited budget within the NHS to pay for all the treatments and technologies we would like to prescribe. Work is currently being undertaken within NHS Highland to identify savings from within the diabetes service to enable us to prescribe the FSL. Unfortunately not everyone will be eligible for prescription of FSL and individuals will be required to meet certain criteria, based on those devised by the Scottish Diabetes Group, before FSL can be prescribed.

What are the prescription criteria?

• Individuals with Type 1 DM (T1DM) who are attending secondary care diabetes services and treated with intensive insulin therapy, with multiple daily insulin injections, or insulin pump therapy, who are already performing multiple fingerprick blood glucose tests per day.
• Individuals with recently developed impaired awareness of hypoglycaemia who are not yet candidates for continuous glucose monitoring systems
• Women planning pregnancy or who are currently pregnant
• Individuals who need a third party to perform monitoring, or where dexterity or disability denote that conventional testing is difficult or impossible
• To have attended a recognised diabetes structured education programme (eg HEIDI), and/or be deemed by the team to have the required knowledge and skills to self-manage their diabetes.
• To attend a local education session on the use of the FSL
• Completion of the online Libre Academy modules prior to attending the education session https://freestylediabetes.co.uk/freestyle-libre/academy
• To agree to measure/“swipe” a minimum of six times per day
• To use sensors and strips as recommended
• To obtain my monthly supply of complementary strips from Abbott if a driver
• To agree to share my glucose monitoring data with the diabetes clinic and complete any associated clinical questionnaires.

Individuals will be asked to sign a contact to agree to the above and failure to attend two consecutive clinic appointments will result in a letter being sent to your GP asking them to cease prescribing FSL. Ongoing prescription of the FSL will require effective use of the technology to improve self management as determined by the specialist diabetes team, eg reduction in hypoglycaemia, improvement in HbA1c, reduction in hospital admissions.

What if I am already self funding the Freestyle Libre?

If you have T1DM and have already been self funding the FSL then it is expected that this will be prescribed if you can demonstrate it has led to improvements in the management of your diabetes i.e. improved HbA1c, reduced hypos, less hospital admissions with DKA (if applicable).

Who will actually prescribe the Freestyle Libre?

Your GP will be asked to prescribe the FSL on the recommendation of the secondary care diabetes team.

What if there are any problems with the sensors?

If you experience a technical problem or the sensor is faulty you should contact Abbott directly to obtain a replacement rather than contacting your GP or the diabetes team.
Abbott UK General Customer Service telephone number: 0800 1701177
8am to 8pm, Monday to Friday; excluding bank holidays

What is the Dexcom ONE?

Who can prescribe the Dexcom ONE?

Eligibility and prescription criteria?

How will ongoing effectiveness of the device be assessed?

What are the associated costs?

• Sensor costs £23.  With sensors lasting 10 days the annual costs is about £850.  
• The transmitter costs £18 and lasts 90 days.  Individuals will be alerted via the app when a new transmitter is required and will order these from Alliance Healthcare via their pharmacist.  

What if an individual is having technical problems with the sensors or transmitter?

• Dexcom UK Technical Support:
  Telephone number: 0800 031 57 63 or using the link on their webpage Product Support Request (custhelp.com)
  Office opening times:
  • Monday - Friday 07:00 - 18:00
  • Saturday & Sunday 08:00 - 16:30
  • Excluding public holidays