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Researchers find it helps patients do better
Some physicians will tell a Type 2 diabetic patient not to monitor blood glucose at all. Others will recommend monitoring several times weekly, even daily.
There’s no clear answer, and there are no clear guidelines about how often patients should check their blood glucose if their Type 2 disease is under good control. But there is growing evidence that some monitoring may be helpful to patients in ways doctors may not consider: Checks can help patients appreciate how exercise and good food choices can keep them in control of their disease.
Researchers at the Veteran’s Affairs Northern California Health System say they have found a happy medium: twice-a-week monitoring improves glycemic control and is cheaper than daily monitoring.
"The literature suggests that Type 2 diabetics well-controlled with oral agents don’t really benefit at all from testing," says the paper’s lead author, Arthur L.M. Swislocki, MD, staff endocrinologist and assistant chief of the medical service at the VA Northern California Health System in Martinez and an assistant professor of medicine at the University of California, Davis.
Swislocki found, however, that twice-weekly monitoring gives stable Type 2 diabetics a heightened sense of responsibility for managing their disease, helps them maintain their stable blood sugars and saves patients and providers money.
The American Diabetes Association (ADA) Standards of Care recommend monitoring but is uncharacteristically vague about how often it should be done. "The optimal frequency of SMBG [self-monitoring blood glucose] for patients with Type 2 diabetes is not known, but it should be sufficient to facilitate reaching realistic glucose goals. The role of SMBG in stable diet-treated patients with Type 2 diabetes is not known," the ADA reported in a position statement published in Diabetes Care in January.
Richard Kahn, PhD, the ADA’s chief scientific and medical officer, admits the standards are vague because there is no solid evidence for or against monitoring.
In his paper presented to the Endocrine Society’s annual meeting in San Diego in June, Swislocki reported patients who had been using an average of 1.36 test strips a day could reduce their use to less than one daily, while maintaining a stable HbA1c at about 7.8%.
"We find that testing is of value," says Swislocki, who is also an associate professor of medicine at the University of California at Davis. "Our experience of 5,000 patients in our system suggests that those who do blood testing twice a week do better in maintaining their HbA1c."
While Swislocki is the first to admit it may not be the actual testing that is helping maintain stability for these patients, he calls a moderate level of self-monitoring of blood sugars a tool that both educates and motivates the patient.
For example, he says, someone considering going to the freezer for a 300-calorie bowl of ice cream might reconsider, after first seeing how previous trips to the dessert table affected blood sugar levels. "Maybe he’ll decide not to do it."
While the ADA’s standards of care call for Type 1 diabetics to self-monitor as often as five times a day, such extreme vigilance is probably not necessary or even desirable for Type 2 diabetics, says Kahn. "In fact, monitoring itself could be de-motivating, because it hurts," he says. "It depends more on the mindset of the patient."
Kahn says what is important is not the frequency of the monitoring, but what the patient does with the information. "You could monitor 100 times a day and not get any improvement in HbA1cs, or you could have somebody who never monitors but is very conscious of diet and exercise who remains in very good control."
Kahn says Swislocki’s study shows that frequent monitoring more than twice a week produces uncertain benefits. "For people who want to monitor and will take the effort, that is good," he says. "But the people who want to do the monitoring are those who are likely to be better motivated in all areas of managing their diabetes."
Swislocki followed a group of approximately 2,500 Type 2 diabetic patients for a six-month baseline period. Then the patients were switched to the new monitoring schedule for two months, which monitored patients about half as frequently as the baseline. He then studied the results for another six months during the post-implementation period. All patients were diet-controlled or using oral agents. Those who required insulin were excluded.
Swislocki adds the patient population had a lot of comorbidities like cardiovascular disease, hypertension, hyperlipidemia, and gastroesophageal reflux.
Determining the cause of symptoms in a diabetic patient is valuable to health care providers, he adds. "If a guy wakes up in the middle of the night not feeling well, having a blood glucose reading helps us know why, whether it’s acid reflux or hypoglycemia or whatever the reason."
At baseline, before the new schedule was implemented, the patients were testing an average of nearly 10 times a week and had HbA1c readings averaging 7.83%.
Their physicians recommended twice weekly testing. "We made it clear to them that if they wanted to test more often, they were free to do that," says Swislocki. "We set out giving them 50 strips for 90 days."
Swislocki’s team found that patients were relieved and happy to test less frequently "because they find it painful." The results: Patients felt more in control of their disease and reported a better quality of life, Swislocki says.
Meanwhile, the VA saved approximately $8,800 a month in the cost of test strips. "And you have to remember that, being the VA, we pay only 30 or 40 cents per strip," Swislocki says. "The list price is probably something like 65 cents, and the retail price is about $1. So you can multiply that out and calculate the savings."
[For more information, call Arthur Swislocki at (925) 372-2070 and Richard Kahn at (703) 549-1500.]