Meta-analysis and systematic reviews: Attenuation of needle stick pain in blood glucose monitoring in diabetes: An examination of the evidence for alternative site testing

Abstract

Pain and discomfort associated with diabetic home glucose testing (HGT) is often a major barrier to treatment compliance, resulting in suboptimal glycemic control. Since intensive management of diabetes (“tight control”) can result in a significant reduction in microvasular and neurologic complications such as painful peripheral neuropathy, autonomic neuropathy, amyotrophy, and painful skin ulcerations, modified modes of less painful HGT may have clinical merit. The nociceptor density of particular anatomic HGT sites as well as the size and caliber of individual needle sticks has been linked to varying pain levels. Another factor associated with differential HGT pain is the amount of blood required for accurate sampling which may be related to lancet caliber and the “blood yield” of different sites. The advent of alternative site blood glucose monitoring devices (ASD's), may help to decrease pain, thereby enforcing adherence and compliance but do they do so at the expense of sacrificing accuracy? A review of the literature reveals that measurements taken at alternate, less painful sites, such as the earlobe, thigh, forearm, lateral thumb and palm yield values comparable to finger stick values, under stable glycemic conditions. During periods of rapid glycemic change however, blood glucose values obtained at the forearm and thigh may lag behind fingertip values. The palm of the hand has a lower density of pain receptors yet provide samples that corroborate closely with fingertip values under all glycemic conditions including post-exercise. This presentation will provide a comprehensive literature review of the topic along with a detailed consideration of the pain neural mechanisms of particular sites. A survey of existing technologic innovations will be reviewed along with putative neurophysiologic mechanisms of pain reduction. Common mechanisms of diabetic HGT pain will be reviewed. A pictorial overview of practical techniques for mitigating HGT pain will be outlined.