Important Updates to Diabetes Treatment Recommendations

Every year, the American Diabetes Association (ADA) reviews the current scientific literature and releases an updated version of its Clinical Practice Recommendations. This year, there have been several important revisions to the guidelines, including the adoption of more individualized recommendations for the frequency of blood glucose monitoring and the switch to a less stringent target for systolic blood pressure (the top number) .


Blood glucose monitoring
The previous recommendation for people with Type 1 or Type 2 taking multiple doses of insulin or using insulin pump therapy had been to check blood glucose levels “three or more times daily.” Some insurance companies had interpreted this to mean that allotting three blood glucose test strips per day was sufficient for everyone with diabetes.

The new guidelines for glucose monitoring have been revised to highlight the need for people taking multiple doses of insulin or using an insulin pump to check their blood glucose frequently. In these people, monitoring is now recommended at least before meals and snacks, occasionally after eating, before exercising, at bedtime, when low blood glucose is suspected, and before critical tasks such as driving.

“We’re trying to say it’s very situation-dependent…both by the patient and the patient’s context,” Richard Grant, MD, MPH, incoming chair of the ADA Professional Practice Committee, noted in an interview with Medscape Medical News.

For people with Type 2 diabetes who are taking basal insulin only or noninsulin treatments, monitoring blood glucose is still recommended as a potentially helpful tool when coupled with education about how to use the results. Monitoring “is really not any use if it’s not being acted on…. If no one looks at the results, there’s no sense testing,” noted Dr. Grant.

Blood pressure control
Goals for systolic blood pressure have been updated to reflect new evidence suggesting that there may be little benefit — but an increase in risk — in controlling blood pressure tighter than 130/80 mmHg. For most people with diabetes and high blood pressure, the new target is now below 140/80 mmHg. The looser target may allow people to take fewer blood pressure medicines, saving money and reducing the potential for side effects, according to Dr. Robert Ratner, chief scientific and medical officer for the ADA.

Representatives of the ADA note that controlling blood pressure is still vitally important for reducing the risk of cardiovascular and kidney disease, and state that the loosening of the systolic target should not be taken to mean that blood pressure control is unimportant. “We really tried to communicate that it’s crucially important that everyone with type 2 diabetes have a [systolic] blood pressure down to 140. It’s a very important threshold. Changing the recommendation is not meant to imply that excellent blood pressure control is not as much of a priority as it was,” according to Dr. Grant.

The revised recommendations note that lower systolic targets may be appropriate for certain people (such as younger individuals) if they can be achieved without “undue treatment burden.”

For more information on these and other changes to the Clinical Practice Recommendations — 2013, read the article “New Diabetes Guidelines Ease Systolic Blood Pressure Target” or see the updated guidelines in the journal Diabetes Care. (A summary of all the revision can be found here.)

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  • Joe

    It seems that whenever I get my glucose under control, my BP shoots up, as does my cholesterol. When I get those under control, my glucose is through the roof. And my “good” cholesterol is always low no matter what I do.

  • Ferne

    Wait another day and there will be something different again. Medicare has guidelines for how often we can check our blood sugar and I expect in the future with the new health care there will be more rules and regulations. I’m afraid what the doctor orders won’t be accepted in the new healh care. These are rather scary times and it’s not going to be the medical profession making the rules.

  • Dick

    It seems to me that it follows, that if you are type 2 diabetic and trying to control your BG level with only diet and exercise (i.e. w/o medication)it would be extremely helpful to test more than the one time per day that Medicare allows. You need at least two tests to check before and after a meal.

    When I see a postprandial high, I know that I should go to the treadmill (which is my “insulin)to bring my BG down before my next meal.

  • Al Busa

    With insurance companies limiting type 2’s to only 2 test strips per day (under Medicare guide lines) it is very hard to keep ones glucose levels in control. ADA should fight for limits that we need.

  • Maridel Jackson

    I am only on metformin, but Medicare only allows one test a day now unless you are willing to go through the hoops. It would seem that they want all of us to have to be on insulin to test more often. That means more expense for Medicare, when, if we who are not on insulin yet could just test at least twice a day, we could keep in better control and not have to go on insulin so we could test more often. Makes sense to me, but who am I?

  • F.Allgaier

    No one said the Medicare Poeple are the sharpest Knives in the Drawer

  • Patricia

    It makes no sense that if you are Type 2, on no meds and are trying to control BS thru diet and exercise that you are only allowed to test 1 x a day. If anyone making these rules up actually had Diabetes themselves I bet they would be singing a different tune!!

  • Louise

    I’m type 2 and I test as many times as needed… I’m on metforin and take it twice a day with glipizide. just trying to take care of myself. my bloodpressure is good so is my cholesterol in the last year I lost 40lbs but some time bloodsugar is high because I don’t eat enough food… I’m not hungry. tried nutribullet for shakes fine for about45 mintues then blood sugar drops to low. any suggestion.anybody?????

  • Eileen

    Insurance doesn’t tell you can’t test as often as want even 10-12 times a day, nor dictate your care. Insurance only works within the limits of the policy YOU chose. If you want 10 test strips a day you just pay the difference between the limits of your policy and what you desire. Just like if you have coverage for $200 for eyeglasses and the ones you want cost $400. You can have whatever you want but you pay the difference. Lifestyle preference and medical necessity are not the same thing

  • r mcgauley

    i agree its important yo test more than once a day, or as needed. i have been buying additional needed strips over the counter. so far target is the best, though their prices are going up too, probably because they can.

  • n armstrong

    My insurance company will not cover my type one diabetes or any of my medication. Thay will only cover type 2. Is there any way to get help for my meds

  • Carla

    Stop whining and pay for the testing yourself! Insurance was never intended to cover everything. Everyone has to make choices as to priorities in life.

  • jim snell

    I need to respond to Carla:

    if test strips were sold for a reasonable price with discounts for those needing more aggressive testing for safe insulin dosing as well as checking peak readings on ingested food to track and police that aspect to ensure better health and not rot out, it might be reasonable for the patient to buy some portion of the strips.

    Typically OTC at drugstore strip price varies from $50 to $ 77 per barrel of 50 strips.

    Mail order can get one down to 20 to 30 $ per barrel of 50.

    So for 2 strips a day that works out to $1.54 per strip at drug store and $ 0.60 per strip mail order.

    That works out for the ideal morning wake-up, before and after meals – 3 meals means 5 strips
    and one final strip at midnight/late to ensure system is under control means 7 strips per day.

    For 31 days that means 217 strips per month. That works out to a measley $334.18 or mail order
    Is 130.20 plus appropriate taxes. If one has a CGMS ( that generally are not paid for) that requires an additional at min 2 strips a day plus any extra tests to catch CGMS off track with a weird reading.
    It takes 10 tests a day when I am using a CGMS that does not save any strips as dosage for insulin must always be done on the caveman meter – no exception due to the delays of the CGMS and is only authorized as a logging tracking device only.
    Having spent many thousands of dollars in purchasing and using a CGMS whose sensors run $ 300 a month for last 2 years plus supporting test strips, I find the well intentioned comments in this blog most irritating.

    The hope is the more aggressive testing strategies are only required for a short run leading to treatments that stop the rot and facilitating reduced diagnostic testing and hopefully for a non insulin type 2 get the number of strips down.

    One test a day for a type 2 diabetic is like licking one’s fingers and sticking in the air to measure wind speed.

    Without careful checking of blood glucose using the only available tool – the cost effective caveman finger prick machine multiple times a day at the right times can a person properly police and control his diabetes. For folks on insulin, all my reading suggests folks are using 6 to 10 strips a day.

    Any other arguments are sophistry and disgraceful. I can die from this mess if not looked after but some enterprising folks in this country are suggesting free birth control for women.

    The argument made by Carla can be equally applied to other interest groups in our country.

  • Deb

    Carla, I presume you have diabetes or have someone in your life who does. But apparently you do not understand how the other “half” lives. My husband is on insulin, so our insurance pays for him to test 3 times a day. I am on metformin and trying very hard to manage my diabetes with that and diet alone, and our insurance pays for one strip a day for me. Without testing the effect different meals have on different days and at different times it is a crapshoot. (Though I really like jim’s description better!) I bought a box of test strips to supplement, but on a fixed income I don’t have the wherewithal to do that but a couple of times a year.
    By the way, I didn’t CHOOSE my insurance. It’s Medicare plus what my husband’s retirement plan pays part of. We’re lucky that we have that. Plenty of people don’t have any supplemental insurance at all.

  • Gary

    When I picked up my strips under new Medicare guidelines at Walgreens this past week, I had to go through a computerized set of mandated instructions (called guidelines – with penalties for non compliance of course ) and sign and sign and agree on their screen in order to get my strips. Then they gave me a mandatory log that is subject to audit by medicare. It was explained to me that this was to prevent fraud by either me or my doctor. It appears that they expect me to use the allotted one strip per day exactly as the doctor filled out on his application to medicare for my prescription. That means once every day. This means that the government now has police control of my relationship with my doctor. Quoting Walgreens’ form, “In case of a Medicare audit, you will need to provide your signed Test Log sheets to Walgreens upon request.” The next step would be for the Medicare gestapo to demand my actual testing unit to see if the log matches exactly to the testing unit data. This greatly reduces the effectiveness of flexibility in testing using the strips in a way that gives a more complete picture of what is happening on a given day. The Walgreens form goes on to say that “If you follow the above guidelines, Medicare will cover …” Also, I found out that the infusion center at Deaconess Hospital in Spokane has been forced to close with less than a months notice (two weeks it appears). Obamascare??

  • jim snell


    Good grief! What state was this in and which dme center monitors approves your bills? Washington State I assume.

    What senseless idiot mandates this? On its surface this seems discrimminatory behaviour against a diabetic and interfereing with the patient – Doctor Relationship – unless I am missing something here?


    Some of these stories are incredible. I am not diabetic but I study about diabetes and testing once a day is rediculous. Even for insulin users testing three time is not enough per guidance from medicare. But I would like to said this is not from the implementation of Affordable Healthcare (OBAMACARE). Petition your elected officials because they make laws that mandate medicare and private insurances.

  • jim snell

    What utter crap. This is America and we went to the moon in 1970’s and haven’t been back.

    that some utter three degree’d arrogant fool signed up for 1 strip a day for type 2 and 3 for a type 1 on insulin is outrageous ignorant and stupid policy from stone henge times at a day and age of exploding diabetes world wide. What assinine fool would restrict the only tool and its strips that help a person manage his diabetes in the closeminded foolish chase to save a few pennies testing while cursing many to rot out most expensively!!

    This is a disgrace and a time warp back to the worst of the dark ages and non thinking.

    Now when I go out to get mail order for my strips and check the limited list of 18 approved contracts we have to buy from – I have asked 4 so far. Freestyle lite – don’t carry it . get lost.

    I want this arroganty ship of fools thrown out of office immediately.