Blood glucose meter

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Blood glucose meter with lancing device, lancets and blood glucose test strips in a case (2016)

A blood glucose meter ( english blood glucose monitoring system , BGMS ) is an electronic device for determining the blood sugar , so the glucose concentration in the blood of the people . A large number of devices and systems with different equipment features and of different quality can be found on the market. The test blood sample can be from a vein , an artery or capillary removed be. In this case it is applied to a blood sugar test strip (sensor) and then examined with the help of the measuring device. The latest development are sensors that are inserted into the subcutaneous fat tissue in order to deduce blood sugar from the glucose level measured in it.

The self-monitoring of blood sugar (blood sugar self-control ; English: self-monitoring blood glucose , SMBG ) is an important element of modern therapy for diabetes mellitus . Patients use it to monitor their blood sugar level in order to use this as a basis to adapt their therapy to the changed metabolic situation. This requires certain skills, namely a good understanding of certain basics of metabolism, nutrition and treatment with insulin or other drugs (this is also referred to as empowerment of the patient). This knowledge is imparted to those affected in individual or group training courses in hospitals , in rehab clinics and in diabetological practices and outpatient departments.

history

Beginnings of blood sugar self-control

At the beginning of the self-monitoring of blood sugar there were rapid tests with which one could determine the sugar content in the urine of the patient since the late 1920s . The first chemical set that patients themselves could use was the "Clinitest" from the US manufacturer Miles Laboratories, which had been available since 1945. It was a copper reduction sample in the form of a tablet that worked without external heat energy. The urine sugar content was read off from a color scale based on the discoloration of the sample. A similar method has been available for measuring ketone in urine since 1950 . Since then there has been no need for a laboratory to determine the sugar content of urine.

The next step was the “Clinistix” urine sugar test strip coated with the enzyme glucose oxidase, which also came from Miles and was available in Germany from 1956. The strip only provided qualitative evidence: it turned blue when there was sugar in the urine, otherwise it remained colorless. There were comparable products from the manufacturers Eli Lilly and Boehringer Mannheim . The prevalence was very low, however, because it was controversial whether patients should even measure their urine or blood sugar themselves and draw conclusions for their therapy. It was not until the late 1950s that pharmaceutical companies began investing in products that patients could use to measure their own blood sugar. In 1978 there was a first statement on this by the then newly established committee for lay work of the German Diabetes Society .

The first paper test strip that could directly measure the glucose level in the blood was a further development by Clinistix in 1965 under the name "Destrostix".

Development of blood glucose meters

The interest in a direct measurement of glucose in the blood grew out of dissatisfaction with the results of the urine tests. The kidney threshold at which sugar from the blood enters the urine can change over the course of the disease, and there is no precise relationship between the concentration of glucose in the blood and in the urine. In addition, the HbA1c had become the measure of the quality of the diabetes control since the 1970s .

The first electronic blood glucose meters ("Ames Reflectance Meter" [ARM], 1969; "Eyetone", 1972; "Reflomat", 1974) were intended for doctors. The reflectance meter weighed 1.2 kg, mainly because of the heavy housing and batteries. The blood sugar was measured with a photocell using the light reflected from a test strip and output in mg / dl. At a price of 1500 DM, both devices were considered too expensive for diabetics. It was not until the 1980s that laypeople recommended blood sugar self-monitoring, also to save laboratory costs. In 1985 Bayer launched the Glucometer II , which continued Miles' products. At that time it was sold over a million times worldwide and cost 496 DM. It was also the first measuring device that could save values ​​in order to read them out in the doctor's office. The training of the patients in the use of the devices was entrusted to diabetes advisors. Corresponding training and further education has existed since 1983. During this time, only a minority of patients practiced self-control of urine sugar or blood sugar. Since the 1990s, ever smaller and more precise devices have come onto the market, which have been widely used since then and are part of the standard therapy for diabetes mellitus. During this time, new methods were also sought for the administration of insulin. The first report on the successful treatment of a diabetic with an infusion device "Infusaid" that can be implanted in the abdominal cavity, a forerunner of the insulin pump , dates back to 1984.

In the course of time, various measurement methods were used.

  • In reflectometric measurement, the enzymatic conversion of glucose creates or changes a color. The change in color can be converted into the blood glucose value.
  • The first devices for domestic use determined the sugar content photometrically . For this purpose, a drop of blood was placed on a sample strip in a beam path inside the device. The sugar content was then determined using the characteristic light absorption of the test strip chemistry that reacts with the glucose . The light absorption depends on the glucose concentration.
  • With the amperometric measurement, the blood is applied to a small test strip and sucked into the test strip via a capillary to a test field that is not visible from the outside. There the glucose reacts with an enzyme , e.g. B. glucose oxidase , and closes the contact between different electrodes . The blood glucose meter applies a defined electrical voltage to these contacts and measures the strength of the current that is passed through the blood over time. The device then determines the blood sugar value from the current strength curve. This biosensor method, which has been used in consumer devices since the 1990s, has become the standard procedure. It has the advantage of being able to run automatically, whereas previous methods required application and wiping away of the blood sample.

The amount of blood required for a measurement became smaller and smaller over time. In 1965, the Destrostix test strip still required a 50–100 µl blood sample, the Reflomat needed 20–30 µl blood in 1974, the Glucometer Elite only needed 5 µl in 1993, while modern blood glucose meters only need 0.3 µl. The accuracy and the speed of a measurement have also continued to improve. In 1991, the "HemoCue B" still needed 20–240 seconds for a measurement, depending on the concentration of glucose in the blood. Today's blood glucose meters give a value just five seconds after starting the test.

Continuous blood glucose monitoring

The most recent development are continuously measuring glucose sensors that can be read out using a measuring device. The sensors are placed in the subcutaneous fatty tissue and remain there for a certain time (depending on the type: a few days to several weeks). If the value is only read out on request, one speaks of a flash measurement (English: flash glucose meter , FGM). In addition, there is the real continuous glucose meter (CGM), which also enables an active warning function if the measured values ​​fall below a certain threshold. Other approaches work with non-invasive procedures, especially optical.

The first CGM was the " Medtronic Minimed CGM" in 1999, but it was not yet suitable for controlling blood sugar. The Dexcom devices have been approved by the American FDA since 2006 , Abbott followed in 2008. In these systems, a sensor is inserted into the subcutaneous fat tissue that measures the glucose concentration and continuously sends it to a receiver via a Bluetooth connection, which records it. The first "long-term CGM" in which the sensor is placed under the skin by means of a surgical procedure and remains there for up to 180 days was the Eversense XL from Roche and Senseonics in Germany in 2018. An alarm can be triggered on CGM devices can be configured to warn the patient when blood glucose levels are too high or too low. However, the measured glucose values ​​from the adipose tissue only follow the values ​​in the blood with a certain delay; So it is not an exact real-time measurement of blood sugar, the devices only show the trend, so they do not replace the measurement of blood sugar on the fingertip for setting, but only supplement it. CGM measurement systems have been part of the standard care in statutory health insurance in Germany since 2016 (English: real-time CGM, in German: CGM in real time, abbreviation: rtCGM). In July 2019, Abbott's Freestyle Libre 2 (iscCGM, a Flash-CGM) was included in the list of medical aids for statutory health insurance , while it is not yet adopted by all private health insurers .

FGM systems cannot offer this alarm function because they are not read out continuously, but only when requested by the user. Furthermore, the models differ according to whether and at what time intervals they have to be calibrated using a conventional blood sugar measurement on the fingertip and how long the sensors can be worn. The aim is to integrate continuous blood sugar measuring devices with an insulin pump in a so-called "closed loop system". In this respect, one speaks of an artificial pancreas . The first commercial system was the "Biostator" in the mid-1970s; it is still used in research today, but it can only be used as a stationary device. The first hybrid closed-loop system to be approved by the FDA was the Medtronic Minimed 670G in 2016. It has been approved for the treatment of type 1 diabetics in the US and Europe since 2018. The coupling of continuous blood sugar measurement and the insulin pump makes it possible to interrupt the delivery of the insulin basal rate from the pump when the measured glucose values ​​have fallen below a certain threshold value. This is to avoid severe hypoglycaemia (one also speaks of sensor-supported pump therapy, SuP, with hypoglycemia switch-off). The bolus injections must continue to be given by the patient. According to a study from 2019, the blood sugar could be kept in the target range for six months with a hybrid closed-loop system than with a normal, fully manual ICT . It is currently not possible to make a definite statement about the benefits of the treatment in avoiding long-term damage.

In addition to the officially approved systems for the recruitment of diabetics, there are also unofficial closed-loop solutions that are developed by technically experienced users on the basis of free software (OpenAPS, AndroidAPS, APS stands for "Artifical Pancreas System", ie: "Artificial pancreas." "). These so-called "looper" are looking for better or cheaper offers and also make them accessible to third parties. In July 2016, the OpenAPS community consisted of around 100 users worldwide. The use of such applications is at your own risk, there is no liability for economic or health damage, and doctors are not allowed to recommend or support them.

Another trend is the integration of measurement and analysis functions in “smart” devices and wearables that combine a large number of functions. Smartphones can be used as receivers and monitors for continuous blood glucose meters or their sensors via the NFC interface , provided the NFC interface is approved by the manufacturer of the mobile device. On the other hand, Apple patented a non-invasive blood sugar measurement function for the Apple Watch in the summer of 2018 , which is primarily intended for the early detection of diabetes. The measurement of glucose in the tear fluid using a “smart” contact lens was not further developed by Google in 2018 because it had proven to be too imprecise.

use

The currently common blood glucose meters are usually carried by the patient in a case that also offers space for the lancing device and blood glucose test strips. For a measurement, a test strip (sensor) is inserted into the device and a drop of blood is obtained by puncturing the fingertip with a lancet, which is then applied to the test strip. The measurement then runs automatically and the device displays the result on a screen. In addition, the measured value is stored in the device and is available for later retrieval or statistical evaluation, if necessary in conjunction with a corresponding program that runs on a desktop computer or a mobile device. In addition, the diabetic often keeps a blood sugar diary to document the course and the relevant events, either on paper or digitally in a mobile device.

With a blood glucose meter that records values ​​continuously (CGM), correspondingly more measured values ​​are available than with a conventional method because the measurement and logging take place every ten or five minutes. The measured values ​​are read out on the screen of the control device or visualized and evaluated on a desktop computer.

  • Different blood glucose meters in practice

  • Blood glucose meter, lancing device with lancets in a drum, test strips in a small box (2011)

  • Applying a drop of blood from the fingertip to the blood sugar test strip (2015)

  • Reading of a sensor that is placed in the subcutaneous fatty tissue and worn there for a while (2018)

  • Monitor of a flash measuring device, which also offers an elementary diary function (2018)

Quality of the measuring devices

Incorrect measurement results often result from incorrect handling, be it that the hands were not washed thoroughly before the measurement and z. For example, sugar residues were still adhering to the blood collection point, the fingertip was “milked out” too much and more or less tissue fluid ( lymph ) was added or the test strips were not properly sealed and stored. These influences must be considered in order to analyze faults in the measuring device.

In a test published in July 2012 by Stiftung Warentest , 12 of 16 blood glucose meters available in Germany were rated “good”, three were “satisfactory” and one was “poor”. The accuracy of the measurement entered the final score in the test with 60 percent. It was always “good” with the established measuring devices, two were “very good”. Even among the so-called “B devices”, whose blood sugar test strips are sold more cheaply, there were devices with “good” measurement accuracy. The Working Group on Diabetological Technology (AGDT) of the German Diabetes Society has issued an opinion on this distinction between A and B devices.

Cost and importance of blood sugar self-regulation

For the treatment of diabetes mellitus type 1 , while insulin-treated type 2 diabetics , and also in the treatment of gestational diabetes , the blood glucose self-monitoring has become indispensable. Self-measurement is recommended for both insulin-dependent and non-insulin-dependent diabetics as an “important element of diabetes therapy” in all recognized training programs. In a statement by the German Diabetes Society and other associations, it is emphasized that self-monitoring of blood sugar levels is a "decisive prerequisite for the motivation, training and therapy of the patient" even in non-insulin-dependent type 2 diabetics.

Cost regulation of the statutory health insurance in Germany

This section presents the situation in Germany . Help us to describe the situation in other countries.

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The costs for blood sugar self-tests by the patient are reimbursed by the statutory health insurance companies in Germany for diabetics who require insulin. The ordinance practice differs depending on the federal state. In diabetics with intensified insulin therapy and a requirement of 5 measurements per day, i. H. 150 test strips per month, costs around 75 euros.

In order to reduce costs, the Association of Substitute Health Insurance Funds contracted with the German Pharmacists' Association on August 1, 2013 that pharmacies should in future switch a certain quota of prescriptions from blood sugar test strips for those insured with replacement health insurance to products in the economically more favorable price group (B) for health insurers. The drug supply contract of the substitute health insurance funds as of November 1, 2016 provides for a quota of 50% for the period from April 1, 2016 to September 30, 2016 and a quota of 55% from October 1, 2016.

In the case of patients with type 2 diabetes mellitus who do not require insulin, the G-BA ruling of March 2011 only reimburses the costs in exceptional cases and only to a limited extent: According to this, the maximum per treatment situation should only be in the case of an unstable metabolic situation, when setting up for the first time or when switching therapy with a high risk of hypoglycemia 50 test strips per quarter remain prescribable. This decision was examined by the Federal Ministry of Health on May 23, 2011 in accordance with Section 94 SGB ​​V , there was no objection, announced in the Federal Gazette on June 16, 2011 and entered into force on October 1, 2011. The evaluation by the IQWiG in 2009, which the Federal Joint Committee referred to, “did not provide any evidence of any benefit for patients with type 2 diabetes mellitus who are not treated with insulin, neither for self-monitoring of blood sugar nor for self-monitoring of urine. (...) The epidemiological studies on the subject did not provide any evidence of an association between self-monitoring of blood sugar levels and morbidity and mortality. ”The German diabetes associations diabetesDE , DDG , VDBD, BVND and DDS criticize this assessment and call for the ability to prescribe blood sugar test strips to be retained .

The increasing cost pressure at the end of 2012 meant that the established manufacturers also started to lower the price of some test strips. In November 2012 took place at the private plans a nationwide grouping of these test strips into the lower rate group (B). The remuneration prices for the primary health insurance funds are negotiated regionally, i.e. based on the respective federal state . The negotiations take place between the primary health insurers and the State Pharmacy Association (LAV). Depending on the federal state, the price reduction implemented by the manufacturer Roche also results in a lowering of the selling prices. For example, the sales price in Hessen is calculated as follows: pharmacy purchase price (AEP) + 5% + sales tax . This gross amount flows into the doctor's expenditure volume.

criticism

The use of blood sugar self-control in diabetes therapy was initially criticized by the patient because of the excessive demands it caused by the psychological stress associated with the ongoing measurements.

From a cultural-anthropological perspective, it was pointed out that the obligation of patients to self-monitor blood glucose levels using self-operated measuring devices had in turn strengthened the doctors' control over patient compliance . Thanks to the log function of the devices, the doctor can understand in great detail how complex the patient is with his therapy and whether he is able to follow the therapeutic recommendations. At the same time, the desired degree of “ empowerment ” has remained rather low for many patients, because knowledge about their illness was “written into the devices” and the use and purpose of using blood glucose meters could therefore no longer be questioned. In this respect, one cannot speak of empowerment in a therapeutic context. This is all the more true as measuring devices are increasingly working fully or partially automatically with the help of IT and carry out therapy according to rules that are increasingly difficult for the patient to understand.

literature

  • SF Clarke, JR Foster: A history of blood glucose meters and their role in self-monitoring of diabetes mellitus . In: British Journal of Biomedical Science . tape 69 , no. 2 , March 6, 2012, ISSN  0967-4845 , p. 83–93 , doi : 10.1080 / 09674845.2012.12002443 (English).
  • Martina Lenzen-Schulte: Type 1 diabetes: DIY diabetes therapy . In: Deutsches Ärzteblatt . tape 116 , no. 29-30 , 2019, pp. A 1378-A 1381 ( aerzteblatt.de ).
  • Cecilia C Low Wang, Avni C Shah: Medical management of type 1 diabetes . Editor: American Diabetes Association. 7th edition. American Diabetes Association, Arlington, VA 2017, ISBN 978-1-58040-677-2 , Chapter: Tools of Therapy, Monitoring (English, e-book without pagination).
  • David Olczuk, Ronny Priefer: A history of continuous glucose monitors (CGMs) in self-monitoring of diabetes mellitus . In: Diabetes & Metabolic Syndrome: Clinical Research & Reviews . tape 12 , no. 2 , April 1, 2018, p. 181–187 , doi : 10.1016 / j.dsx.2017.09.005 (English, elsevier.com [accessed on March 15, 2019]).
  • Aaron Pfaff: The metabolic self-control - from the determination of urine sugar to digital blood sugar measurement . In: Anna Palm, Sabine Wöhlke (ed.): Human-technology interaction in medicalized everyday life . Universitätsverlag Göttingen, Göttingen 2018, ISBN 978-3-86395-358-4 , p. 129–143 ( oapen.org [accessed March 15, 2019]).
  • Helmut Schatz, Andreas FH Pfeiffer: Compact diabetology. Basics and practice . 5th, completely revised and updated edition. Springer, Berlin 2014, ISBN 978-3-642-41358-2 , pp. 10-16, 68, 94-96 .

Web links

Commons : Glucose meters  - collection of pictures, videos, and audio files

Individual evidence

  1. ↑ a b c d e f S. F. Clarke, JR Foster: A history of blood glucose meters and their role in self-monitoring of diabetes mellitus . In: British Journal of Biomedical Science . tape 69 , no. 2 , March 6, 2012, ISSN  0967-4845 , p. 83-93, 85, 86, 88 , doi : 10.1080 / 09674845.2012.12002443 .
  2. ↑ a b c Aaron Pfaff: The metabolic self-control - from the determination of urine sugar to digital blood sugar measurement . In: Anna Palm, Sabine Wöhlke (ed.): Human-technology interaction in medicalized everyday life . Universitätsverlag Göttingen, Göttingen 2018, ISBN 978-3-86395-358-4 , p. 129-143, 129-134, 137-139, 140 ( oapen.org [accessed March 15, 2019]).
  3. ↑ Published in Diabetes Journal 11/1978, 449, quoted from Aaron Pfaff: The metabolism self-control - from the determination of urine sugar to digital blood sugar measurement . In: Anna Palm, Sabine Wöhlke (ed.): Human-technology interaction in medicalized everyday life . Universitätsverlag Göttingen, Göttingen 2018, ISBN 978-3-86395-358-4 , p. 129-143, 135 ff . ( oapen.org [accessed March 15, 2019]).
  4. ^ IW Campbell, H. Kritz, C. Najemnik, G. Hagmueller, K. Irsigler: Treatment of type I diabetic with subcutaneous insulin resistance by a totally implantable insulin infusion device ("Infusaid") . In: Diabetes Research (Edinburgh, Scotland) . tape 1 , no. 2 , July 1, 1984, ISSN  0265-5985 , p. 83-88 , PMID 6442226 .
  5. ↑ a b David Olczuk, Ronny Priefer: A history of continuous glucose monitors (CGM) in self-monitoring of diabetes mellitus . In: Diabetes & Metabolic Syndrome: Clinical Research & Reviews . tape 12 , no. 2 , April 1, 2018, p. 181–187 (4–6 online) , doi : 10.1016 / j.dsx.2017.09.005 ( elsevier.com [accessed March 15, 2019]).
  6. ↑ Stefanie Blockus: Under the Skin. Continuous blood sugar measurement with Eversense XL . In: c't . No. 1 , 2019, p. 94-95 .
  7. ↑ Arne Hillienhof: Glucose Monitoring: private insurance supplies sometimes bad. In: Deutsches Ärzteblatt. September 27, 2019, accessed on September 27, 2019 (printed edition: Volume 116, Issue 39, Page A 1694).
  8. ↑ a b Helmut Schatz, Andreas FH Pfeiffer: Diabetology compact. Basics and practice . 5th, completely revised and updated edition. Springer, Berlin 2014, ISBN 978-3-642-41358-2 , pp. 68, 95 f .
  9. ↑ a b c Artificial pancreas improves blood sugar control in type 1 diabetes. In: Deutsches Ärzteblatt. October 18, 2019, accessed October 29, 2019 .
  10. ^ Sue A. Brown, Boris P. Kovatchev, Dan Raghinaru, John W. Lum, Bruce A. Buckingham: Six-Month Randomized, Multicenter Trial of Closed-Loop Control in Type 1 Diabetes . In: New England Journal of Medicine . tape 0 , no. 0 , October 16, 2019, ISSN  0028-4793 , doi : 10.1056 / NEJMoa1907863 .
  11. ^ Dana Lewis, Scott Leibrand, #OpenAPS Community: Real-World Use of Open Source Artificial Pancreas Systems . In: Journal of Diabetes Science and Technology . tape 10 , no. 6 , November 2016, ISSN  1932-2968 , p. 1411-1411 , doi : 10.1177 / 1932296816665635 , PMID 27510442 .
  12. ↑ Stefanie Blockus: The compiled pancreas. Type 1 diabetics make artificial pancreases . In: c't . No. 9 , 2019, pp. 162 .
  13. ↑ Martina Lenzen-Schulte: Type 1 diabetes: diabetes therapy made by yourself . In: Deutsches Ärzteblatt . tape 116 , no. 29-30 , 2019, pp. A 1378-A 1381 ( aerzteblatt.de ).
  14. ↑ Ben Schwan: Glucose sensor uses the iPhone's NFC capabilities. In: heise online. February 7, 2018, accessed May 14, 2019 .
  15. ↑ Ben Schwan: Apple patents non-invasive blood sugar measurement technology - also for computer clocks. August 24, 2018, accessed October 24, 2018 .
  16. ↑ Tilman Wittenhorst: Smart lens with glucose measurement: Google research laboratory stops diabetic project. In: Heise Online. November 17, 2018, accessed November 20, 2018 .
  17. ↑ Blood sugar measuring devices: Impressively accurate. In: test 7/2012. Stiftung Warentest , June 28, 2012, pp. 86-91 , accessed on August 15, 2012 .
  18. ↑ AGDT statement on A and B devices (PDF; 71 kB)
  19. ↑ Bernhard Kulzer: The psychological dimension of diabetes mellitus . In: German Diabetes Health Report 2011 , ed. von diabetesDE, ISSN  1614-824X , pp. 44-47, here 43f.
  20. ↑ For the basic pension entitlement cf. SGB ​​V. Accessed on January 28, 2011 .
  21. ↑ See the corresponding overview of the respective requirements of the responsible associations of statutory health insurance physicians: beta-institut non-profit GmbH: Ordinance on blood sugar test strips. (PDF; 31 kB) February 1, 2010, accessed on January 28, 2011 .
  22. ↑ vdek.com (PDF) accessed on December 21, 2016
  23. ↑ G-BA: Restriction of prescriptions for blood sugar test strips. March 17, 2011, accessed March 17, 2011 .
  24. ↑ See the reasons given by the G-BA: Supporting reasons. (PDF; 111 kB) on the resolution of the Federal Joint Committee on the amendment of the Drugs Directive. (No longer available online.) March 17, 2011, archived from the original on March 28, 2011 ; Retrieved March 28, 2011 .
  25. ^ Decision of the Federal Joint Committee of March 17, 2011. Changes to the Medicines Directive: Annex III - Overview of supply restrictions and exclusions: urine and blood sugar test strips for type 2 diabetes mellitus (PDF; 48 kB) Federal Ministry of Health, 23 May 2011, accessed on 22 September 2014 .
  26. ↑ Announcement (1084 A) of a resolution of the Federal Joint Committee on the amendment of the Drugs Directive (AM-RL): Annex III - Overview of the prescription restrictions and exclusions urine and blood sugar test strips for type 2 diabetes mellitus (PDF; 287 kB) ( No longer available online.) In: Bundesanzeiger No. 90. Federal Ministry of Health, March 17, 2011, p. 2144 , archived from the original on July 25, 2011 ; accessed on September 22, 2014 .
  27. ^ Resolutions of the Federal Joint Committee - Federal Joint Committee. (No longer available online.) In: g-ba.de. Archived from the original on October 4, 2011 ; Retrieved October 4, 2011 .
  28. ^ Final report on sugar self-measurement in type 2 diabetes mellitus (PDF; 117 kB) Institute for Quality and Efficiency in Health Care, October 14, 2009, p. 5 , accessed on September 22, 2014 .
  29. ↑ Joint statement by diabetes DE, DDG, VDBD, BVND and DDS on the amendment of the Drugs Directive and Annex III "Urine and blood sugar test strips for patients with type 2 diabetes mellitus". (No longer available online.) Diabetes DE, DDG, VDBD, BVND and DDS, April 19, 2010, archived from the original on February 1, 2011 ; accessed on January 31, 2011 . Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. @1@ 2Template: Webachiv / IABot / profi.diabetesde.org
  30. ↑ letter Roesler test strips 02-05-11. (PDF) (No longer available online.) In: Diabetes.de.org. Archived from the original on June 8, 2011 ; Retrieved June 8, 2011 .
  31. ↑ Diabetes: Low-cost suppliers of blood sugar test strips conquer the market . In: DiabSite. September 23, 2012. Retrieved October 20, 2012.
  32. ↑ Lauer-Taxe: Sales prices in Hessen  ( page no longer available , search in web archives )  Info: The link was automatically marked as defective. Please check the link according to the instructions and then remove this notice.@1@ 2Template: Toter Link / lauer-fischer.de  
  33. ↑ Hartmut Stolze: Exaggerated demands for metabolic self-control . In: Diabetes Journal 7/1986, 334; quoted from: Aaron Pfaff: Metabolic self-control - from the determination of urine sugar to digital blood sugar measurement . In: Anna Palm, Sabine Wöhlke (ed.): Human-technology interaction in medicalized everyday life . Universitätsverlag Göttingen, Göttingen 2018, ISBN 978-3-86395-358-4 , p. 129-143, 137-139 ( oapen.org [accessed March 15, 2019]).