By Seema Gupta, MD, MSPH

Clinical Assistant Professor, Department of Family and Community Health, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV

Dr. Gupta reports no financial relationships relevant to this field of study.

SYNOPSIS: Researchers could not find any statistically significant differences in glycemic control or health-related quality of life between patients who performed glucose self-monitoring compared with those who did not.

SOURCE: Young LA, Buse JB, Weaver MA, et al. Glucose self-monitoring in non-insulin-treated patients with type 2 diabetes in primary care settings: A randomized trial. JAMA Intern Med 2017;177:920-929.

The efficacy of self-monitoring blood glucose (SMBG) for patients with non-insulin-treated type 2 diabetes mellitus (T2DM) has not been proven clearly. Some investigators have found that more frequent self-monitoring of blood glucose levels was associated with clinically and statistically better glycemic control, regardless of diabetes type or therapy. Others have found that neither SMBG testing nor its frequency was associated with glycemic benefit in T2DM patients, regardless of treatment.1,2 Even meta-analyses of randomized trials have reported conflicting results. Testing such as SMBG actually may promote better awareness of glucose levels for patients, which in turn may lead to improvements in diet, lifestyle, and intensification of pharmacotherapy. However, it is also important to understand that blood glucose monitoring remains a tool, not a therapeutic intervention, which may lead to some collateral consequences, such as adverse effects related to testing, association with higher scores on a depression scale, and higher costs resulting from unnecessary testing.

Young et al aimed to assess whether SMBG is an effective tool for patients with non-insulin-treated T2DM in terms of improving either hemoglobin A1c levels or health-related quality of life (HRQOL). The authors conducted an open-label, randomized trial in 15 primary care practices across central North Carolina. The research involved 450 patients with non-insulin-treated T2DM and with glycemic control (hemoglobin A1c) levels higher than 6.5% but lower than 9.5% within the six months preceding screening. Conducted over a year, the average age of study participants was 61 years, and participants had diabetes for an average of eight years. Interventions included assigning participants into three groups: no SMBG, once-daily SMBG, and once-daily SMBG with enhanced patient feedback, including automatic tailored messages delivered via meter.

Researchers found that there were no significant differences in hemoglobin A1c levels across all three groups (P = 0.74; estimated adjusted mean hemoglobin A1c difference, SMBG with messaging vs. no SMBG, -0.09%; 95% confidence interval [CI], -0.31% to 0.14%; SMBG vs. no SMBG, -0.05%; 95% CI, -0.27% to 0.17%). There also were no significant differences found in HRQOL. There were no notable differences in key adverse events, including hypoglycemia frequency, healthcare use, or insulin initiation. The study authors concluded that in patients with non-insulin-treated T2DM, no clinically or statistically significant differences in glycemic control or HRQOL were observed at one year between patients who performed SMBG compared with those who did not perform SMBG.

COMMENTARY

The moment a patient is newly diagnosed with T2DM, it is often customary to write a prescription for a glucometer with testing strips, along with recommendations on diet, lifestyle modifications, and perhaps pharmacotherapy. Patients often engage, going to great lengths to manage their glucose logs, believing that proactively following these steps leads to improved outcomes. In fact, data show that approximately 75% of T2DM patients check their blood glucose at least once per day.3 Incorporating technology into self-management activities often has been recognized as transformative for patients when managing chronic diseases. However, technology infusion must take a common sense approach. Therefore, the findings of this study have significant consequences and suggest that glucose monitoring in patients with non-insulin-treated T2DM should not be routine. These findings seem to support the recommendations of the Society of General Internal Medicine and the Endocrine Society, which discourage frequent blood glucose monitoring among T2DM patients.4 Once target control is achieved and the results of self-monitoring become quite predictable, there is little gained in most individuals from repeat assessments. Perhaps when it comes to routine SMBG for patients with non-insulin-treated T2DM, it is time we take a “less is more” approach.

REFERENCES

  1. Karter AJ, Ackerson LM, Darbinian JA, et al. Self-monitoring of blood glucose levels and glycemic control: The Northern California Kaiser Permanente Diabetes registry. Am J Med 2001;111:1-9.
  2. Davis WA, Bruce DG, Davis TM. Is self-monitoring of blood glucose appropriate for all type 2 diabetic patients? The Fremantle Diabetes Study. Diabetes Care 2006;29:1764-1770.
  3. Wang J, Zgibor J, Matthews JT, et al. Self-monitoring of blood glucose is associated with problem-solving skills in hyperglycemia and hypoglycemia. Diabetes Educ 2012;38:207-218.
  4. ABIM Foundation. Choosing Wisely. Available at: http://bit.ly/1dtkDI8. Accessed July 6, 2017.