AUTODETERMINACION DE LA GLUCEMIA EN LA PALMA DE LA MANO

(especial para SIIC © Derechos reservados)

El valor de la glucemia en la palma es igualmente preciso que la medición en el pulpejo del dedo y menos doloroso, de modo que la audoterminación de la glucemia en la palma puede ser una de las opciones para las personas con diabetes.

Autor:
Shu Meguro
Columnista Experto de SIIC

Artículos publicados por Shu Meguro

Coautor
Yoshihito Atsumi*
MD, Tokio, Japón*

Recepción del artículo
11 de febrero, 2007

Aprobación
13 de agosto, 2007

Primera edición
24 de septiembre, 2007

Segunda edición, ampliada y corregida
7 de junio, 2021

Resumen
La autodeterminación de la glucemia ha desempeñado un papel importante en el tratamiento de la diabetes. Sin embargo, aún existen algunas barreras que hacen que los pacientes se rehúsen a adoptar esta autodeterminación. Entre ellas, el miedo al dolor producido por la medición es la más grande. Aunque durante mucho tiempo se ha utilizado la sangre capilar del pulpejo del dedo en la autodeterminación de la glucemia, se ha investigado la medición de la glucemia en sitios alternativos a solicitud de los pacientes que buscan técnicas menos dolorosas. Como se ha discutido la equivalencia de las concentraciones de glucemia medidas en distintos sitios, algunos estudios, incluido el nuestro, sugieren que la medición de la glucemia en el antebrazo muestra un valor impreciso cuando las concentraciones cambian rápidamente. Por el contrario, se ha demostrado que la medición de la glucemia en la palma es equivalente al valor de glucemia en el pulpejo del dedo. En cuanto al dolor, la mayoría de los pacientes respondieron que la medición en la palma era menos dolorosa. Estos hechos implican que la autodeterminación en la palma tiene algunas ventajas sobre otros sitios. Los defectos de la medición en la palma son la dificultosa manipulación del dispositivo y la cicatriz que queda, aunque la manipulación difícil puede resolverse mejorando el dispositivo de medición. Una medición menos desagradable de la glucemia puede aumentar la posibilidad de que el paciente con diabetes enfrente su enfermedad.

Palabras clave
glucosa sanguínea, autoevaluación, testeo en sitios alternativos

Abstract
Self-monitoring of blood glucose (SMBG) has been playing an important role in diabetes management. However, there are still some barriers that make patients retreat from adopting SMBG. Among them, fear of pain caused by measurement is the greatest. Although fingertip capillary blood has been long used for SMBG, blood glucose (BG) testing at alternative sites has been under search by request of patients looking for less painful techniques. As there has been a debate as to the equivalence of BG levels measured at various sites, some studies, including ours, suggest that BG measurement in the forearm shows an imprecise value when BG changes rapidly. Contrary, it has been showed that BG measurement in the palm is equivalent to the BG value in the fingertip. As for pain, most patients answered that measurement in the palm was less painful. These facts imply that SMBG in the palm has some advantages to other sites. The defects of palm measurement are difficult handling of device and scar left in the palm, though difficult handling may be resolved by improving the measuring device. Less unpleasant BG measurement may increase the chance for the patient with diabetes to face up to their disease.

Key words
blood glucose, self-monitoring, alternative-site testing

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Autoevaluación

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Artículos originales > Expertos del Mundo >
página www.siicsalud.com/des/expertocompleto.php/88629

Especialidades
Principal: Diabetología
Relacionadas: Medicina Interna

Enviar correspondencia a:
Shu Meguro, Saiseikai Central Hospital, 1-4-17, Mita, Minato-ku, Tokio, Japón

Patrocinio y reconocimiento:
Agradecemos a Masako Amanuma por pulir el inglés de este artículo y a Yasuko Oshita y todos los miembros de nuestro centro clínico para diabetes por su ayuda en esta investigación.

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Expertos del Mundo

Especialidad principal:
Diabetología

Relacionadas:
Medicina Interna

Artículo completo

Blood Glucose Monitoring in the Palm of the Hand -Less Pain and Equally Accurate

In order to achieve better glycemic control, self-monitoring of blood glucose (SMBG) plays an important role in managing diabetes mellitus. In Japan, the cost of SMBG born by patients on insulin therapy has been reimbursed by public health insurance in these ten years. However, it is still under debate whether public health insurance should cover the cost of SMBG for non-insulin diabetic patients.
There has been a big debate on how to use the blood glucose value effectively as meaningful information in the management of diabetic mellitus. As a member of medical support team consisting of dietitians, nurses, and physicians, we, as physicians, should respond properly to the SMBG values, and it is our responsibility to instruct skills so that patients can better cope with the BG values to make their lives less painful. In addition to this obstacle which makes quality of patients’ life more complicated, there are still other barriers which make patients retreat from adopting SMBG. They are: 1) complicated directions to use the device. 2) fear of being recognized as diabetic patients, 3) anxiety to know exactly the level of blood glucose every day, and 4) the cost. Among them all, the fear of stabbing pain caused by the measurement device is the greatest. Although fingertip capillary blood was long used for SMBG, alternative sites to test blood glucose (BG) have been sought for because of the request from patients for less painful measuring.
It is, however, still debatable whether BG levels measured at different sites are equally correct or not. Some studies have suggested that glucose monitoring at the forearm has shown a delayed value of BG when BG changes rapidly.^1,2 It has been also reported that BG measurement in the palm does not get so much delayed as in the fingertip after having a test meal and physical exercise.³ Another study has shown that palm BG is equivalent to fingertip BG in acute hypoglycemia.⁴
As there was no research comparing BG values collected simultaneously in the fingertip, the forearm, and the palm of the hand in acute hypoglycemia, we have conducted the study to compare BG values collected from several different sites during the induced acute hypoglycemia, and evaluated the difference in the BG values collected at alternative sites.⁵
In this study, we examined 10 healthy volunteers (mean age, 35.1 ± 10.8 years; 6 men, 4 women). Regular insulin (0.1 U/kg/BW) was injected intravenously to them after an overnight fast. Their capillary BG was measured using the Medisafe-Mini (Terumo, Tokyo, Japan), a BG meter widely used in Japan. The Medisafe-Mini system, which employs the glucose oxidase method, consists of 1) a meter, 2) a tip with a test-strip, 3) a lancet and 4) a lancing device. Trained research personnel collected subjects’ blood sample simultaneously in duplicate from fingertips, hypothenar of the hand, and forearm. Sampling was performed right before insulin administration and every 5 minutes until 70 minutes passed after the insulin injection. The forearm skin was not rubbed before BG sampling. All procedures were approved by the Ethics Committee of Saiseikai Central Hospital (Tokyo, Japan) and subjects submitted the written informed consent to participate in the study. All data are given as means + SD. Differences in BG collected from multiple sites were assessed using paired t-test and regression analyses.

The time course of mean BG values after insulin injection is shown in Figure 1. Mean BG values at the forearm were significantly higher than mean BG values at the other sites, which were measured at 15, 20, 25, 30, and 35 minutes after insulin was injected(p < 0.05). Regression coefficients of BG in the fingertip were 0.928 (y = 0.7263x + 22.397) and 0.983(y = 0.9773x + 0.2937) in the forearm and the palm, respectively. Minimum BG value measured during testing was 37 ± 14 mg/dl in the fingertip, 38 ± 16 mg/dl in the palm, and 50 ± 11 mg/dl in the forearm. When BG in the fingertip was below 40 mg/dl, only 23.8% of simultaneously measured BG in the forearm showed a value below 40 mg/dl, while 85.7% of BG in the palm showed a value lower than 40 mg/dl. From the outcome of this study, we concluded that BG value in the palm was as precise as the fingertip measurement, but BG measurement in the forearm may possibly mislead clinical decision depending on circumstances.
As for the degree of pain in various sites, Shikama et al. reported that people felt less painful in the palm of the hand as the site for SMBG (published only in Japanese). It was reported by Johnson and Johnson Co., at the Annual Scientific Meeting of Japan Diabetes Society in 2005, that in case of small events, when asked to compare the degree of pain of SMBG in fingertips and palms, 96% of participants answered that measurement in the fingertip was more painful than in the palm. With the above results in mind, we tried SMBG in the palm on daily clinical practice.
Eighteen patients (mean age 57 years; 12 men, 6 women), who were given the instruction to do the SMBG for the first time, were investigated. They were instructed to try SMBG in both fingertips and palms and asked to compare pain by visual analogue scale. They measured BG in the palm four times daily for 2 weeks and were interviewed after that. Their pain in the palm was 4.4 ± 2.6 when the pain at fingertip is evaluated as 10. After 2 weeks, 13 persons (72%) preferred SMBG in the palm to fingertips. As to drawbacks of palm measurement, the first difficulty mentioned most frequently by patients is the handling of measuring device and the second is the scar left after the measurement. This study was conducted mainly by the nurse in our diabetes group, Oshita Y, and published in Japanese. The drawback of difficult handling of measurement might be solved by improving the measuring device. Actually, we are studying a new SMBG device, which is specifically designed for measuring BG in the palm of the hand. So far, study participants prefer the new SMBG device to conventional one that measures BG at fingertip (data unpublished). Therefore, cosmetic problem left after measurement, such as red mark in the palm, seems to be the greatest trouble with SMBG in the palm.
As results of several investigations, including ours, it has been suggested that SMBG in the palm has some advantages compared to SMBG at other site. Because BG value measured in the palm is equally accurate with fingertip measurement and less painful than fingertip, the palm of the hand must be a suitable BG testing site. As a matter of fact, measurement in the palm has also problems, such as cosmetic and handling inconvenience. It is certain, however, that SMBG measurement in the palm can be one of the alternatives for persons with diabetes. We believe that less unpleasant BG measurement may increase the chance for the patient with diabetes to face up to their disease.

Bibliografía del artículo
1. Jungheim K, Koschinsky T. Risky delay of hypoglycemia detection by glucose monitoring at the arm. Diabetes Care 24:1303-1304, 2001.
2. Jungheim K, Koschinsky T. Glucose monitoring at the arm: risky delay of hypoglycemia and hyperglycemia detection. Diabetes Care 25:956-960, 2002.
3. Bina DM, Anderson RL, Johnson ML, Bergenstal RM, Kendall DM. Clinical impact of prandial state, exercise, and site preparation on the equivalence of alternative-site blood glucose testing. Diabetes Care 26:981-985, 2003.
4. Peled N. Timely detection of hypoglycemia by monitoring blood glucose levels of samples obtained from the palm of the hand. Diabetes Technol Ther 4:83-85, 2002.
5. Meguro S, Funae O, Hosokawa K, Atsumi Y. Hypoglycemia detection rate differs among blood glucose monitoring sites. Diabetes Care 28:708-9, 2005.

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