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Clinical Benefit of Self-Monitoring of Blood Glucose Is Uncertain for Non–Insulin-Treated Patients With Type 2 Diabetes

  1. Katherine R. Gerrald, PharmD, BCPS,
  2. Robb M. Malone, PharmD, CDE, CPP and
  3. Betsy Bryant Shilliday, PharmD, CDE, CPP
Clinical Diabetes 2010 Jul; 28(3): 121-123. https://doi.org/10.2337/diaclin.28.3.121
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Allemann S, Houriet C, Diem P, Stettler C: Self-monitoring of blood glucose in non-insulin treated patients with type 2 diabetes: a systematic review and meta-analysis. Curr Med Res Opin 25:2903–2913, 2009

SUMMARY

Design. A comprehensive systematic review and meta-analysis.

Objective. To assess the effect of self-monitoring of blood glucose (SMBG) on A1C in non–insulin-treated patients with type 2 diabetes.

Subjects. The analysis included 3,270 non–insulin-treated patients with type 2 diabetes in Canada, the United States, Europe, and Asia. In the 15 studies included, mean age ranged from 50 to 67 years, with 38–74% female patients. Mean duration of diabetes ranged from 0 to 12.5 years. Mean BMI ranged from 27.1 to 34.2 kg/m2, and baseline A1C ranged from 6.7 to 11.9%.

Methods. Studies included randomized, controlled trials of non–insulin-treated type 2 diabetic patients comparing treatment strategies including SMBG to less frequent or no SMBG. To be included, trials also had to report data on A1C. Two independent reviewers assessed study quality, with any discrepancies resolved by a third reviewer. The authors used heterogeneity statistics (I2) to determine the appropriate model for analysis, with high heterogeneity (I2 > 80%) indicating that no pooled analysis should be done. The primary endpoint was A1C, and secondary outcomes were fasting glucose and the occurrence of hypoglycemia.

The primary analysis was comparing patients performing SMBG with a non-SMBG control group. Secondarily, the authors compared more frequent SMBG with less frequent SMBG. Univariate meta-regression was used to assess the influence of other factors on the main outcomes of interest. Variables examined in the meta-regression included self-management instruction, use of a treatment algorithm, industry sponsorship, country of study origin, baseline mean A1C, study duration, and key domains of internal validity (intention to treat, allocation concealment, blinding of outcome assessors).

Results. Of the 15 studies that met inclusion criteria and were included in the final analysis, 12 trials of 2,934 patients contributed to the primary analysis comparing SMBG to no SMBG. The frequency of SMBG examined varied widely but involved at least six tests per week. This comparison showed that SMBG was associated with lower A1C levels (weighted mean difference −0.31%, 95% confidence interval [CI] −0.44 to −0.17, I2 = 33.3%).

The stratified analysis for SMBG versus no SMBG showed modestly larger improvement in A1C with SMBG in non-industry–sponsored trials (−0.51 vs. −0.3%), trials performed in the United States or Canada (−0.8 vs. −0.27%), trials with a mean baseline A1C ≥ 8% (−0.38 vs. −0.21%), those that did not have intention-to-treat analyses (−0.49 vs. −0.23%), those without adequate allocation concealment (−0.44 vs. 0.2%), and those whose assessors were not blinded (−0.37 vs. −0.19%). The effect of SMBG was unaffected by study follow-up, education aimed at self-management, or the use of treatment algorithms.

Four trials that included 637 patients contributed to the secondary analysis comparing more frequent SMBG with less intensive SMBG. Overall, more frequent SMBG did not result in significantly lower A1C levels (WMD −0.21%, 95% CI −0.57 to +0.15), with two trials showing moderate to large effects (change in A1C −0.4 and −0.84%) and two showing no benefit (−0.03 and +0.20%). Both studies showing benefit compared individualized SMBG regimens with additional education or monitoring; one trial that showed no benefit compared fixed intervals (once daily, twice a week and twice daily, once a week vs. once a week testing).

Conclusion. SMBG was associated with a statistically significant but clinically modest reduction in A1C when compared to no SMBG. However, more frequent SMBG compared to less frequent SMBG did not improve A1C in patients with type 2 diabetes who were not being treated with insulin.

COMMENTARY

Glycemic control is essential to reducing microvascular complications that arise from uncontrolled diabetes.1,2 However, the utility of SMBG in contributing to improved glycemic control has not been well proven in patients with type 2 diabetes who are not using insulin.

This question is particularly relevant because of the rising prevalence of type 2 diabetes in the United States and the tremendous economic burden it carries in both direct and indirect medical costs. It has been estimated that the cost of SMBG in the United States is $500 million per year.3

Many studies have been undertaken to investigate whether SMBG improves glycemic control. However, these studies have differed in trial design, methodology, and results.4–18 Meta-analyses that have attempted to combine these results have generally shown beneficial effect of SMBG with reductions in A1C ranging from −0.16 to −0.4% depending on the trials included and the duration of follow-up.19–21

Previous meta-analyses assessing this subject are difficult to rely on because of the heterogeneity among studies included, resulting from differences in the type of monitoring used, the frequency of the monitoring, and duration of follow-up. One strength of this meta-analysis is that comparisons of SMBG with no SMBG and comparisons of more frequent with less intensive SMBG were separated, thereby reducing overall heterogeneity and allowing for a more accurate assessment of the SMBG versus non-SMBG comparison.

The meta-analysis supports the benefits of SMBG in patients with type 2 diabetes that is not treated with insulin by showing an average A1C reduction of 0.31% in those patients who performed SMBG. Despite these results, we must consider the clinical significance of this reduction, its cost-effectiveness, the impact of the intervention on patients' quality of life, and the possible psychological effects.

Cost-effectiveness and self-care considerations are crucial considerations when assessing any intervention, but particularly so in disease states associated with significant medical expenditures. Costs per life-year gained have ranged from $8,000 to $39,000, with the higher amount being determined from a hypothetical A1C reduction of 0.39%3 and the lower amount being per quality-adjusted life-year gained projected from actual patient data showing a 0.32–1% reduction.22 It is important to note that these cost analyses do not take into account the time it takes for patients to perform SMBG, which can be significant. If a time of 3 minutes is allotted for each SMBG test, a patient testing six times per week would spend > 15 hours annually on SMBG.23

Results of the stratified analysis shown here demonstrate that comparable effects were seen whether SMBG was complemented by education or not. This education is defined as instruction on self-management in case of undesirably high glucose values. However, it is not reported whether that education included adjusting lifestyle (e.g., diet and exercise) or medications. SMBG readings can serve as immediate feedback to patients to reflect the impact of dietary, exercise, or health changes on glucose control.

Another important outcome to measure with this controversy is the impact of the intervention on psychological indices. This was not addressed by the present analysis. However, it has been investigated in at least one randomized, controlled trial.18 That trial found that newly diagnosed patients who were randomized to the SMBG group had more depressive symptoms, indicated by a 6% higher score on a 12-question depression subscale of a well-being questionnaire. One survey conducted by Franciosi et al.24 showed that SMBG was associated not only with a higher A1C, but also with a higher psychological burden.

This is a concerning outcome because there is a known link between chronic disease diagnoses and depression.25 However, improvements in not only glucose control, but also outlook on life, have been seen when SMBG is coupled with structured counseling, although this is not supported by the current meta-analysis.26

In summary, SMBG improves A1C compared with no SMBG, but the overall net benefit and cost-effectiveness of SMBG in non–insulin-treated patients with type 2 diabetes remains controversial. Furthermore, more frequent SMBG in patients with type 2 diabetes who are not using insulin is not necessarily better than less frequent monitoring, although this point requires further research.

The American Diabetes Association recommends that, for patients who are on non-insulin therapies, SMBG may be useful as a guide to the success of therapy and that care for such patients should include initial instruction on SMBG technique and education on using the data to adjust diet, exercise, or therapy to achieve their goals.27 In our opinion, SMBG at a modest frequency (2–3 times per week) in non–insulin-treated patients with type 2 diabetes may help patients correlate their lifestyle to glucose control if they are educated on interpreting the results and are willing to make lifestyle or therapeutic modifications. SMBG does not appear to be a therapeutic intervention in itself, but rather is one part of a comprehensive treatment plan.

Footnotes

  • Katherine R. Gerrald, PharmD, BCPS, is an assistant professor of pharmacy at Presbyterian College School of Pharmacy in Clinton, S.C., and was the ambulatory care pharmacy resident at University of North Carolina (UNC) Health Care at the time the article was written. Robb M. Malone, PharmD, CDE, CPP, and Betsy Bryant Shilliday, PharmD, CDE, CPP, are assistant professors of medicine at the UNC School of Medicine and assistant professors of pharmacy with the UNC Eshelman School of Pharmacy in Chapel Hill.

    • American Diabetes Association(R) Inc., 2010

    REFERENCES

    1. ↵
      1. U.K. Prospective Diabetes Study Group
      : Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 352:837–853, 1998
      OpenUrlCrossRefPubMedWeb of Science
    2. ↵
      1. DCCT Research Group
      : The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 329:977–986, 1993
      OpenUrlCrossRefPubMedWeb of Science
    3. ↵
      1. Neeser K,
      2. Erny-Albrecht K,
      3. Weber C
      : Cost-effectiveness of self-monitoring of blood glucose in type 2 diabetic patients not receiving insulin: response to Davidson. Diabetes Care 29:480, 2006; erratum 29:959, 2006
      OpenUrlFREE Full Text
    4. ↵
      1. Fontbonne A,
      2. Billault B,
      3. Acosta M,
      4. Percheron C,
      5. Varenne P,
      6. Besse A,
      7. Eschwege E,
      8. Monnier L,
      9. Slama G,
      10. Passa P
      : Is glucose self-monitoring beneficial in non–insulin-treated diabetic patients? Results of a randomized comparative trial. Diabetes Metab 15:255–260, 1989
      OpenUrlWeb of Science
      1. Wing RR,
      2. Epstein LH,
      3. Nowalk MP,
      4. Scott N,
      5. Koeske R,
      6. Hagg S
      : Does self-monitoring of blood glucose levels improve dietary compliance for obese patients with type II diabetes? Am J Med 81:830–836, 1986
      OpenUrlCrossRefPubMedWeb of Science
      1. Davidson MB,
      2. Castellanos M,
      3. Kain D,
      4. Duran P
      : The effect of self monitoring of blood glucose concentrations on glycated hemoglobin levels in diabetic patients not taking insulin: a blinded, randomized trial. Am J Med 118:422–425, 2005
      OpenUrlCrossRefPubMedWeb of Science
      1. Estey AL,
      2. Tan MH,
      3. Mann K
      : Follow-up intervention: its effect on compliance behavior to a diabetes regimen. Diabetes Educ 16:291–295, 1990
      OpenUrlFREE Full Text
      1. Allen BT,
      2. DeLong ER,
      3. Feussner JR
      : Impact of glucose self-monitoring on noninsulin-treated patients with type II diabetes mellitus: randomized controlled trial comparing blood and urine testing. Diabetes Care 13:1044–1050, 1990
      OpenUrlAbstract/FREE Full Text
      1. Sonksen PH,
      2. Judd SL,
      3. Lowy C
      : Home monitoring of blood-glucose: method for improving diabetic control. Lancet 1:729–732, 1978
      OpenUrlPubMed
      1. Walford S,
      2. Gale EA,
      3. Allison SP,
      4. Tattersall RB
      : Self-monitoring of blood-glucose: improvement of diabetic control. Lancet 1:732–735, 1978
      OpenUrlPubMedWeb of Science
      1. Cohen M,
      2. Zimmet P
      : Self-monitoring of blood glucose levels in non-insulin-dependent diabetes mellitus. Med J Aust 2:377–380, 1983
      OpenUrlPubMedWeb of Science
      1. Rutten G,
      2. van Eijk J,
      3. de Nobel E,
      4. Beek M,
      5. van der Velden H
      : Feasibility and effects of a diabetes type II protocol with blood glucose self-monitoring in general practice. Fam Pract 7:273–278, 1990
      OpenUrlAbstract/FREE Full Text
      1. Muchmore DB,
      2. Springer J,
      3. Miller M
      : Self-monitoring of blood glucose in overweight type 2 diabetic patients. Acta Diabetol 31:215–219, 1994
      OpenUrlCrossRefPubMedWeb of Science
      1. Jaber LA,
      2. Halapy H,
      3. Fernet M,
      4. Tummalapalli S,
      5. Diwakaran H
      : Evaluation of a pharmaceutical care model on diabetes management. Ann Pharmacother 30:238–243, 1996
      OpenUrlPubMedWeb of Science
      1. Schwedes U,
      2. Siebolds M,
      3. Mertes G,
      4. SMBG Study Group
      : Meal-related structured self-monitoring of blood glucose: effect on diabetes control in noninsulin-treated type 2 diabetic patients. Diabetes Care 25:1928–1932, 2002
      OpenUrlAbstract/FREE Full Text
      1. Guerci B,
      2. Drouin P,
      3. Grange V,
      4. Bougne`res P,
      5. Fontaine P,
      6. Kerlan V,
      7. Passa P,
      8. Thivolet C,
      9. Vialettes B,
      10. Charbonnel B,
      11. ASIA Group
      : Self-monitoring of blood glucose significantly improves metabolic control in patients with type 2 diabetes mellitus: the Auto-Surveillance Intervention Active (ASIA) study. Diabetes Metab 29:587–594, 2003
      OpenUrlCrossRefPubMedWeb of Science
      1. Barnett AH,
      2. Krentz AJ,
      3. Strojek K,
      4. Sieradzki J,
      5. Azizi F,
      6. Embong M,
      7. Imamoglu S,
      8. Perusicova´ J,
      9. Uliciansky V,
      10. Winkler G
      : The efficacy of self-monitoring of blood glucose in the management of patients with type 2 diabetes treated with a gliclazide modified release–based regimen: a multicentre, randomized, parallel-group, 6-month evaluation (DINAMIC 1 study). Diabetes Obes Metab 10:1239–1247, 2008
      OpenUrlPubMedWeb of Science
    5. ↵
      1. O'Kane MJ,
      2. Bunting B,
      3. Copeland M,
      4. Coates VE,
      5. ESMON Study Group
      : Efficacy of self-monitoring of blood glucose in patients with newly diagnosed type 2 diabetes (ESMON study): randomized controlled trial. BMJ 336:1174–1177, 2008
      OpenUrlAbstract/FREE Full Text
    6. ↵
      1. Coster S,
      2. Gulliford MC,
      3. Seed PT,
      4. Powrie JK,
      5. Swaminathan R
      : Self-monitoring in type 2 diabetes mellitus: a meta-analysis. Diabet Med 17:755–761, 2000
      OpenUrlCrossRefPubMedWeb of Science
      1. Sarol JN Jr,
      2. Nicodemus NA Jr,
      3. Tan KM,
      4. Grava MB
      : Self-monitoring of blood glucose as part of a multi-component therapy among non-insulin requiring type 2 diabetes patients: a meta-analysis (1966–2004). Curr Med Res Opin 21:173–184, 2005
      OpenUrlCrossRefPubMedWeb of Science
    7. ↵
      1. Towfigh A,
      2. Romanova M,
      3. Weinreb JE,
      4. Munjas B,
      5. Suttorp MJ,
      6. Zhou A,
      7. Shekelle PG
      : Self-monitoring of blood glucose levels in patients with type 2 diabetes mellitus not taking insulin: a meta-analysis. Am J Manag Care 14:468–475, 2008
      OpenUrlPubMed
    8. ↵
      1. Tunis SL,
      2. Minshall ME
      : Self-monitoring of blood glucose in type 2 diabetes: cost effectiveness in the United States. Am J Manag Care 14:131–140, 2008
      OpenUrlPubMedWeb of Science
    9. ↵
      1. Russell LB,
      2. Suh D-C,
      3. Safford MM
      : Time requirements for diabetes self-management: too much for many? J Fam Pract 54:52–56, 2005
      OpenUrlPubMedWeb of Science
    10. ↵
      1. Franciosi M,
      2. Pellegrini F,
      3. De Berardis G,
      4. Belfiglio M,
      5. Cavaliere D,
      6. Di Nardo B,
      7. Greenfield S,
      8. Kaplan SH,
      9. Sacco M,
      10. Tognoni G,
      11. Valentini M,
      12. Nicolucci A,
      13. QuED Study Group
      : The impact of blood glucose self-monitoring on metabolic control and quality of life in type 2 diabetic patients: an urgent need for better educational strategies. Diabetes Care 24:1870–1877, 2001
      OpenUrlAbstract/FREE Full Text
    11. ↵
      1. Anderson RJ,
      2. Freedland KE,
      3. Clouse RE,
      4. Lustman PJ
      : The prevalence of comorbid depression in adults with diabetes: a meta-analysis. Diabetes Care 24:1069–1078, 2001
      OpenUrlAbstract/FREE Full Text
    12. ↵
      1. Siebolds M,
      2. Gaedeke O,
      3. Schwedes U,
      4. SMBG Study Group
      : Self-monitoring of blood glucose: psychological aspects relevant to changes in HbA1c in type 2 diabetic patients treated with diet or diet plus oral antidiabetic medication. Patient Educ Couns 62:104–110, 2006
      OpenUrlCrossRefPubMed
    13. ↵
      1. American Diabetes Association
      : Standards of medical care in diabetes—2010. Diabetes Care 33 (Suppl. 1):S11–S61, 2010
      OpenUrlFREE Full Text
    View Abstract
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    Clinical Benefit of Self-Monitoring of Blood Glucose Is Uncertain for Non–Insulin-Treated Patients With Type 2 Diabetes
    Katherine R. Gerrald, Robb M. Malone, Betsy Bryant Shilliday
    Clinical Diabetes Jul 2010, 28 (3) 121-123; DOI: 10.2337/diaclin.28.3.121

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    Clinical Benefit of Self-Monitoring of Blood Glucose Is Uncertain for Non–Insulin-Treated Patients With Type 2 Diabetes
    Katherine R. Gerrald, Robb M. Malone, Betsy Bryant Shilliday
    Clinical Diabetes Jul 2010, 28 (3) 121-123; DOI: 10.2337/diaclin.28.3.121
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