Getting Practical with Monitoring in Type 2 Diabetes
Abstract & Commentary
By Joseph E. Scherger, MD, MPH, Clinical Professor, University of California, San Diego. Dr. Scherger reports no financial relationship to this field of study.
Synopsis: A meta-analysis of the medical literature shows that self-monitoring of blood glucose by type 2 diabetics not on insulin does not improve control of the disease compared with regular monitoring of hemoglobin A1c (HbA1c). Patients spend considerable time and resources with daily monitoring of their blood sugars. Physicians increasingly rely on quarterly HbA1c levels as a marker of control.
Source: Welschen LM, et al. Self-monitoring of blood glucose in patients with type 2 diabetes who are not using insulin: a systematic review. Diabetes Care. 2005;28:1510-1517.
Welschen and colleagues performed an extensive meta-analysis of studies looking at the benefits of home glucose testing in type 2 diabetic patients not on insulin. Six different studies qualified for the analysis. Regular blood glucose monitoring had minimal impact on the level of control of blood sugar and HbA1c. In fact, blood glucose monitoring was no better than urine glucose monitoring. In patients who did not monitor their blood glucose, there were no serious episodes of hypoglycemia. They conclude that intensive monitoring of blood glucose in patients with type 2 diabetes not using insulin results in a small decrease in HbA1c but does not change fasting blood glucose levels.
Commentary
Daily blood glucose monitoring by the patient is expensive and time consuming. Welschen et al estimate an average cost of $2000 per year for monitoring blood glucose multiple times a day. What is the practical benefit? For most patients, not much. Sure you might argue that blood glucose monitoring keeps the patients focused on their disease and the level of control. A lot of time passes between quarterly measurements of HbA1C. But is it really the blood glucose that we should be focusing on intensively with most of these patients? The morbidity and early mortality in type 2 diabetics comes from cardiovascular disease, which is more related to blood pressure, body fat, and lipid levels.
The best management of type 2 diabetes strives for HbA1C levels below 7, and preferably below 6.5. Equally important is striving for and maintaining a healthy body weight through quality nutrition and regular exercise. Blood pressure and lipid levels rank right up there with glucose control in monitoring importance. There is plenty for type 2 diabetics to do every day other than monitor their blood sugars.
It would be wrong to use this study to do away with self-monitoring of blood glucose in type 2 diabetics not on insulin. Welschen et al do not suggest this. They admit that more casual or infrequent measuring of blood glucose has not been studied. My interpretation of these results is that self-monitoring of blood glucose in these patients is discretionary. We should individualize our care of this diverse group of patients, and encourage the patient’s active participation in monitoring their chronic illness. For some, a frequent look at their blood glucose levels with a full knowledge of recommended targets will help them achieve their goals as validated by excellent HbA1c levels. Others might say that they know what they need to do, and are committed to achieving excellent HbA1c levels, but I’d rather do without those finger sticks every day. Both patients are right! Now that the standard of care in diabetes is focused on the HbA1c level, with blood glucose used for diagnosis, we may become more relaxed about blood glucose measurement (not more relaxed in the management of the disease!).
I welcome this study as validation of a practice change that I have been making for some time. How nice it is to have my guilt relieved for not promoting home blood glucose monitoring in all my type 2 diabetics! My preference is focusing on the lifestyle changes necessary to truly reduce the disease and prolong life. I often say to patients, a test never makes anyone better, changing lifestyle does.
A meta-analysis of the medical literature shows that self-monitoring of blood glucose by type 2 diabetics not on insulin does not improve control of the disease compared with regular monitoring of hemoglobin A1c (HbA1c). Patients spend considerable time and resources with daily monitoring of their blood sugars. Physicians increasingly rely on quarterly HbA1c levels as a marker of control.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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