Home blood glucose monitoring in type 2 diabetes
BMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7469.754 (Published 30 September 2004) Cite this as: BMJ 2004;329:754All rapid responses
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The editorial by Reynolds and Strachan (1) is a sensible review of a
contentious topic but was bound to stir up some opposing responses. Here
in North Derbyshire we have been concerned for some time that at least
some of the expenditure on blood glucose testing strips was inappropriate
and not leading to health gain.
However, Diabetes UK seems to advocate that all people with type 2
diabetes should self-monitor their blood glucose and have accused PCTs of
rationing testing strips. Application of evidence-based medicine and
rational use of scarce resources is not rationing. Spend on inappropriate
use of blood glucose testing strips could be better spent on the very same
people to improve outcomes and reduce risk.
Of great concern is that if health professionals and patients
inadvertently concentrate their efforts on blood-glucose management, the
much more beneficial intervention, in terms of both macro- and
microvascular end-points, of tight blood pressure control may be ignored.
With these isues in mind, about 18 months ago a local guideline on
self-monitoring of blood glucose in type 2 diabetes was introduced with
the agreement of local stakeholders (2). A key aspect is that the need
and frequency of testing should be determined by answering the question
“how is this test going to alter what I do?”
By applying the guideline and auditing the results, one of our
practices found that in a year they had reduced the prescribing of blood
glucose testing strips in type 2 diabetes by 82%. The process was easier
than they expected with feedback being generally good and patients being
relieved at not having to self-test. Some resistance occurred if the new
arrangement conflicted with previous advice given but it still provided an
opportunity for review.
At the same time by concentrating their efforts on other aspects of
diabetes management they have arguably improved the care of these
patients. In a year the percentage of patients with a HbA1c level <7.5
has increased from 67% to 81%. The percentage of patients with a blood
pressure <140/80 has increased from 55% to 76% and those with a
cholesterol <5 from 62% to 66%.
While this is a small audit, it does suggest that good management of
type 2 diabetes does not necessarily depend on self-monitoring of blood
glucose. Reducing the use of self-monitoring is possible in general
practice and acceptable to both patients and staff, and can divert
resources to improve quality of diabetes care. It may be worth auditing
the use of blood glucose testing strips in your area.
References:
1.Rebecca M. Reynolds and Mark W. J. Strachan. Home blood glucose
monitoring in type 2 diabetes. BMJ 2004;329:754-755.
2.Peter Burrill. Is self-monitoring a waste of resource for type 2
diabetes patients? Pharmacy in Practice 2004; 14(1): 25-27
Competing interests:
None declared
Competing interests: No competing interests
In their recent editorial Reynolds and Strachan draw attention to the
lack of evidence supporting conflicting ‘consensus statements’ on the use
of blood glucose home monitoring among people with non-insulin treated
type 2 diabetes.[1] Costs of blood glucose monitoring vary widely across
England with a 4.9 fold difference in prescribing of blood testing strips
between the highest and lowest primary care trusts, however the overall
trend is upwards with an annual increase in costs of £17 million a year up
to an annual cost of £118 million in 2003. [2] What kind of evidence do we
need to support, focus or discourage this rapidly increasing activity?
Reynolds and Strachan identify several deficiencies in the available
studies including poor designs, poorly specified interventions and
participant groups and lack of evaluation on impact on glycaemic
control.[3] They call for further large randomised trials to examine the
role of home blood glucose monitoring in non-insulin treated type 2
diabetes. We would like to draw attention to the DiGEM trial which the
Health Technology Assessment Programme has commissioned us to conduct, and
which addresses some of these research gaps.
The diabetes glucose and education monitoring (DiGEM) trial (ISRCTN
47464659) tests the hypothesis that home blood glucose monitoring will be
most effective in improving glycaemia and well being if it is taught as
part of a well specified skills based self management programme, linking
blood glucose results to behavioural change through goal setting, action
planning and motivated self - monitoring..
The design is a three arm randomised parallel group study comparing
the effectiveness of three monthly HbA1c measurements, self-testing and
self-testing linked to self-management in lowering HbA1c. Participants
include those currently managed with lifestyle or oral glucose lowering
medication and the recruitment target is 150 per group. Secondary study
analyses will explore the extent to which changes in beliefs about self-
management of diabetes between experimental groups lead to changes in
outcomes, in accordance with self-regulation theory.[4] The trial is
planned to report in 2007 and will provide the largest trial dataset so
far in this area.
[1] Reynolds RM, Strachan MWJ. Home blood glucose monitoring in type
2 diabetes. BMJ 2004; 329(7469):754-755.
[2] Farmer AJ, Neil A. Variations in glucose self-monitoring during
oral hypoglycaemic therapy in primary care (letter). Diabet Med 2004 (in
press).
[3] Coster S, Gulliford MC, Seed PT, Powrie JK, Swaminatham R. Self-
monitoring in Type 2 diabetes mellitus: a meta-analysis. Diabet Med 2000;
17:755-761.
[4] Leventhal H, Nerenz DR, Steele DJ. Illness representations and
coping with health threats. Baum A, Taylor SE, Singer JE eds. Handbook of
psychology and health. Hillsdale, NJ: Erlbaum, 1984: 219-52.
Competing interests:
We are carrying out a trial of blood glucose self-monitoring
Competing interests: No competing interests
Reynolds and Strachan [1] take a narrow view of the value of home
blood glucose monitoring (HBGM) in type 2 diabetes. They emphasize the
lack of evidence for the effectiveness of this technique and advocate
large randomised clinical trials to examine this question. While waiting
for the answer from evidence-based medicine, the default position is to
prevent people with type 2 diabetes from monitoring their own condition.
Moreover HBGM might lead to “distress, worry and depressive symptoms”.
The evidence for this paternalistic and dated view comes from a large
observational study, [2] the authors of which take pains to stress that
"the cross-sectional nature of our analysis does not allow any causal
inference for the associations emerged."
Reynolds and Strachan ignore the well-designed randomised controlled
trial of non-insulin treated patients with type 2 diabetes, [3] which
showed a 1% improvement in HbA1c after 6 months HBGM versus non-testers.
In contrast to the findings of Franciosi et al [2], well-being markedly
improved in the group testing blood glucose, particularly in the scores
for depression and lack of well-being.
It is not surprising that patients who have responded to the article on
eBMJ have defended the importance of HBGM as a way of finding out about
their own diabetes. People with type 2 diabetes in our active patients
group object strongly to any threat to cut off their supplies of blood
glucose testing strips and are affronted at the suggestion that they
should confine their monitoring to urine tests. These observations are
backed up by objective qualitative studies. [4,5]
Properly used, the educational value of HBGM is huge, especially soon
after diagnosis when patients are discovering how different foods and
activities may affect their blood glucose. Rather than removing this
valuable tool, we should be providing patients with better education to
allow them to decide when to test and how to make use of the results.
1. Reynolds RM, Strachan MWJ. Home blood glucose monitoring in type 2
diabetes. BMJ 2004;329:754-5
2. Franciosi M et al. Impact of blood glucose monitoring on metabolic
control and quality of life in type 2 diabetic patients. Diabetes Care
2001;24:1870-7.
3. Schwedes U, Siebolds M, Mertes G. Meal-Related Structured Self-
Monitoring of Blood Glucose: Effect on diabetes control in non-insulin-
treated type 2 diabetic patients. Diabetes Care 2002; 25:1928-32.
4. Peel E, Parry O, Douglas M, Lawton J. Blood glucose self-
monitoring in non-insulin-treated type 2 diabetes: a qualitative study of
patients' perspectives. Br J Gen Pract. 2004;54:183-8.
5. Lawton J, Peel E, Douglas M, Parry O. 'Urine testing is a waste
of time': newly diagnosed Type 2 diabetes patients' perceptions of self-
monitoring. Diabet Med. 2004;21:1045-8.
Charles Fox,
Anne Kilvert, Northampton General Hospital
Julia Lawton, University of Edinburgh
Competing interests:
None declared
Competing interests: No competing interests
Managing the expenditure of testing strips used in home blood glucose
monitoring (HBGM) has been a politically sensitive and emotive issue for
some Primary Care Trusts (PCT). Representations made from individual
patients and the voluntary sector, asked them to justify their reasoning
and disparaged policies as draconian and clinically inappropriate. The
price of one test strip can be up to 30p and a day’s metformin dose is
10.8p [1], with many patients and clinicians being unaware of the higher
cost of monitoring compared to therapy. It is often the case in practice
that HBGM results are meaningless, as patients test at inappropriate times
or have not quality controlled their meter.
In a primary care practice of 756 patients with diabetes, the annual
cost of strips used for blood testing is £59,456, which is 30.6% of the
total prescription costs used in glycaemic management. Over 8% of test
strip expenditure is accounted for by patients treated by diet alone or
with drugs that do not cause hypoglycaemia. Analysis of glycaemic control
by comparing the HbA1c results of patients, treated either by diet,
glitazones and/or metformin, in those who do perform HBGM (n=70, mean
7.1%, SD +/- 1.6) and do not (n=189, mean 6.7%, SD +/- 1.1), found the
latter group had significantly better control (p < 0.05). This confirms
there is no advantage to HBGM over that which can be achieved through
laboratory based testing taken during planned reviews [2].
Reticence should not hinder examination of this issue to ensure cost-
effective prescribing through medicines management. Identifying situations
where testing is needed for safety or has a health gain and when testing
is a waste of resources is an obligation for both clinicians and those
responsible for policy. Unlike test strips, meters are not available on
NHS prescription. Clinicians have no control on who has access to meters
as they are purchased privately from retail chemists who may gain in
generating test strip prescriptions. Meter manufacturers provide
discounted vouchers as a loss leader to encourage meter use and meters are
given free to some specialist centres who have no incentive to restrict
supply, as test strips costs are ultimately born by primary care.
The options available to government include allowing meters to be
obtainable on prescription and confining test strips to those on insulin
or sulphonylureas. In the absence of a clear national directive, as noted
by Reynolds and Strachan [3], we suggest PCT/LHB’s develop a local
strategy which discourages the ineffective use of HBGM and produce
supporting material that balances the information available, so helping
patients make an informed choice.
References
1
Prescription Pricing Authority. The Electronic Drug Tariff, Part VIII -
Basic Prices of Drugs Product List, Part VIII products M.
http://www.ppa.org.uk/edt/October_2004/mindex.htm (accessed 14 October
2004).
2
Selvin E, Marinopoulos S, Berkenblit G, Rami T, Brancati FL, Powe NR,
Golden SH. Meta-analysis: glycosylated hemoglobin and cardiovascular
disease in diabetes mellitus. Ann Intern Med. 2004 Sep 21;141(6):421-31.
3
Reynolds RM, Strachan MWJ. Home blood glucose monitoring in type 2
diabetes. BMJ 2004; 329: 754-755.
Competing interests:
None declared
Competing interests: No competing interests
Sir-The article by Reynolds and Strachan(1), views glucose self
monitoring in the same light as drug therapy.The cost of monitoring
happens to be included in the drug tariff, but we must not confuse a test
with a treatment.
The value of self monitroing has been highlighted by others as part of
structured care(2).It empowers patients, and promotes involvement in their
care.
As with all tests, it is our response to the results that will determine
outcome,not the test itself.
We do not count the cost of INR monitoring to achieve appropriate levels
of anticoagulation in stroke prevention,nor do we link outcomes in this
scenario to the process of care.
Home blood glucose should be included in the package of care in type 2
diabetes as part of a structured care programme.
References:
1.Rebecca M. Reynolds and Mark W. J. Strachan. Home blood glucose
monitoring in type 2 diabetes.
BMJ 2004;329:754-755.
2.Schwedes V., Siebolds M./ Mertes G. Meal related structured self
monitoring of blood glucose: Effect on diabetes control in non-insulin
treated type 2 diabetic patients.
Diabetes Care Nov.1 2002;25:1928-1932.
Competing interests:
None declared
Competing interests: No competing interests
As a very busy doctor in private practice in country NSW who also
happens to be a type 2 Diabetic it might be of some value to venture some
practical ideas on the topic of home blood glucose monitoring.I happen to
believe strongly that the bar for glycated Hb. as set by the mainstream
diabetic experts is too high and so I am very interested to see the recent
article by Khaw et al referred to in your columns.At the recent Asia
Pacific conference on Nutrition in Brisbane Professor Jenny Brand Miller
of Sydney presented a paper showing that one in four Australians have
degees of post prandial hyperglycaemia which correlates to ischaemic heart
disease.Levels of up to 11 of course are generally not considered "
diabetic".The message was essentially that our post prandial Blood Glucose
level should not go above 7.8 as in the (relatively small) study carried
out that was the sort of cut off point for cardiac trouble.Professor Brand
Miller is well known for her GI Factor work and so the thrust of her talk
was to eat low GI carbohydrates and have your one hour post prandial Blood
Glucose level under 7.8.I test my Blood glucose level 4 to 6 times a day
and by dint of very low carbohydrate eating and a lot of exercise (some of
it ridiculously vigorous for a 64 year old bloke like me) I can scrape my
HbAic in the 5's.I am one of those slim type 2's whose old Mum was a slim
type 2 .Incidentally she lived to 85 with all her brains intact and of
course never heard of Glucometers .Sadly, the advice given to diabetics is
that they can eat lots of carbohydrates and don't forget your pills and
have your HbAic abut 7 and "she'll be right mate", to stray into the
common vernac.If you test your BSL once in a while you will once in a
while know what yor BSL is.Sorry, but that's called "coasting" and the
only time you can coast in life is when you're going downhill( I wish I
was the first person to have thought that one up).But it's seriously true
for my diabetes .And of course for your diabetes .When last have you done
your BSL one hour after that high carb meal followed by Pavlova? I bully
my poor old patients into testing their BSL at least once a day and of
course to scatter the time around.And do some one hour post prandial tests
with the standard high carb food that is put about by most(almost
invariably Non diabetic )nutritionists and doctors .Then I ask them to try
my (almost Paleolithic)diet(sorry Prof.Jenny) and see the result.None of
this can be done without home blood glucose monitoring.Pain that it is.But
you are a type 2 diabetic.You need to make your peace with that and as the
kids say "get over it" and while you are trying to, have a thought of the
other baddies out there that you could get. Good control and a normal
life without any medication can be a standard expectation.Glucometers are
the best Antidote to (most)nutritionists.At least as far as those with
diabetes ( including pre diabetics) are concerned. Let's face it watch
type gadgets to constantly read BSl may not be far away and which diabetic
expert would advise against one?I suspect they will ussher in a sea-change
in our diet and exercise life style.
Competing interests:
None declared
Competing interests: No competing interests
I was recently diagnosed as having type 2 diabetes (May 04)and I was
a surprised and worried. As a long time vegetarian and consumer of
wholefoods I believed my lifestyle precluded me from this kind of
problem.
By being able to monitor my glucose levels regularly I am gradually
finding out the best way to keep my levels low. I find that having the
monitoring machine has helped me deal with the stress I initially felt
when first diagnosed diabetic. I have no need to test every day but the
fact that I can gives me peace of mind by having some control in managing
this insidious disease.
A Riley
Mature student
Age 59
Competing interests:
None declared
Competing interests: No competing interests
The main problem with monitoring blood glucose in people with type 2
diabetes is the lack of clear actions to follow the reading. People can
accept modest readings as being good control. If a person does not have
insulin to adjust, it is unlikely that they will have any medication to
alter and they can only alter lifestyle activities. This may be increasing
their activity to reduce a high reading or modifying their diet.
The one change with good evidence of success is to alter weight, having
weighing scales is an alternative to monitor a persons diabetes. If people
are overweight and wish to improve their diabetes a target weight and
monitoring against this can give considerable improvement.
Having acheived good weight control, this then needs to be maintained
over long periods. The other option is to encourage people to avoid buying
larger clothes.
Competing interests:
None declared
Competing interests: No competing interests
The question (1) as whether type 2 diabetics should test their blood
or urine through home monitoring may be a moot issue. Rather it is
suggested that prevention be established on A1c levels as a consensus
standard. Although this does not preclude home testing. Currently the
American Diabetes Association (ADA) and American Association of Clinical
Endocrinologists (AACE) recommend an A1c of 7% and 6.5%, respectively (2).
At these levels there is a dramatic increased risk of cardiovascular
disease and mortality (3). Since 60% or greater of those with type 2
diabetes have an A1c that is 8% or greater (2) these risks are even more
magnified. Based on a recent study (3), risk of cardiovascular disease
and mortality greatly increases at A1c levels of 5% and greater.
Therefore, I suggest that the ADA, AACE and other organizations recommend
a A1c goal of less the 5% for both diabetics and non-diabetics.
References
1. Reynolds RM. Home glucose monitoring in type 2 diabetes. BMJ
2004;329:754-5.
2. Palumbo PJ. The case for insulin treatment early in type 2
diabetes. Cleveland Clinic Journal of Medicine 2004;71:385-405.
3. Khaw T-T, Wareham N, Bingham S, Luben R, Welch A, Day N.
Association of hemoglobin A1c with cardiovascular disease and mortality in
adults: the European prospective investigation into cancer in Norfolk. Ann
Intern Med 2004;141:413-20.
Competing interests:
None declared
Competing interests: No competing interests
Home blood glucose monitoring in type 2 diabetes
Editor – Reynolds and Strachan, in their recent editorial (1) make
reference to a multidisciplinary group of healthcare professional who had
published consensus advice on home blood glucose monitoring (2) and
rightly stated that “none of these recommendations was supported by
evidence from randomised trials”. I would like to bring your attention to
work of another UK based multidisciplinary group of healthcare
professionals, the Diabetes Monitoring Forum (DMF), who, because of the
lack of this evidence believed that rather than offer a set
recommendations it was perhaps more appropriate to offer patients
different reasons why and when they might test their blood glucose (3).
The forum members decided that they should start to address the regular
call for more guidance on how and when testing may be useful in specific
circumstances so that professionals and people with diabetes may start to
use their existing testing strategy in a more targeted way. The DMF
recognised the lack of evidence but also recognised the lack of a
structured, patient centred approach in practice and developed the
leaflets as a means to provide some structure. This information was
developed according to the particular treatment being prescribed.
Hopefully by offering suggestions in a format that is helpful to
healthcare professionals and people with diabetes, in addition to
supporting education, we will begin to see more appropriate use of blood
glucose testing. There is a clear gap between the practice of teaching
people how to measure their blood sugar levels and then assisting them
towards a meaningful strategy for times/frequency of testing and then
analysing the results to improve self care behaviours. There is now an
urgent need to develop clarity about the place of a planned monitoring
strategy (blood glucose) in a personal management plan.
1 Reynolds RM, Strachan MWJ. Home blood glucose monitoring in type 2
diabetes. BMJ 2004; 329: 754-5
2 Owens D, Barnett AH, Pickup J, Kerr D, Bushby P, Hicks et al. Blood
glucose self-monitoring in type 1 and type 2 diabetes: reaching a
multidisciplinary consensus. Diabet Primary Care 2004;6:8-16
3 Diabetes Monitoring Forum. Reasons for testing your blood glucose.
2004. www.dmforum.org.uk
Competing interests:
The Diabetes Monitoring Forum is supported by an educational grant from Abbott Diabetes Care
Competing interests: No competing interests