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Self-monitoring of blood glucose in type 2 diabetes: Is the debate (finally) ending?

2012; Elsevier BV; Volume: 97; Issue: 1 Linguagem: Inglês

10.1016/j.diabres.2012.03.013

1872-8227

Antonio Ceriello,

Diabetes Treatment and Management

The usefulness of the self-monitoring of blood glucose (SMBG) in the management of type 2 diabetes not on insulin therapy is still a matter of debate, and in my opinion, of confusion. For example, in a very recent meta-analysis the authors conclude "Evidence from this meta-analysis of individual patient data was not convincing for a clinically meaningful effect of clinical management of non-insulin treated type 2 diabetes by self-monitoring of blood glucose levels compared with management without self-monitoring, although the difference in HbA1c level between groups was statistically significant" [[1]Farmer A.J. Perera R. Ward A. Heneghan C. Oke J. Barnett A.H. et al.Meta-analysis of individual patient data in randomised trials of self monitoring of blood glucose in people with non-insulin treated type 2 diabetes.BMJ. 2012; 344: e486https://doi.org/10.1136/bmj.e486Crossref PubMed Scopus (116) Google Scholar]. Even the conclusions of the authors of this meta-analysis could be anyhow questionable (a significant reduction of HBA1c is not clinically relevant?), in this meta-analysis no one of the study evaluating structured SMBG has been included. As underlined in the review by Parkin [[2]Parkin C.J. Results that matter: structured vs. unstructured self-monitoring of blood glucose in type 2 diabetes.Diabetes Res Clin Pract. 2012; 97: 6-15Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar] in this issue of the journal, performing a structured SMBG makes the difference: the difference is in how the data coming from the SMBG are used. It is clear that only when a consistent action follows the data coming from the SMBG an improvement of the metabolic control can be achieved. This concept has been stressed by a consensus coming from The Coalition for Clinical Research—Self-Monitoring of Blood Glucose Scientific Board [[3]Klonoff D.C. Blonde L. Cembrowski G. Chacra A.R. Charpentier G. Colagiuri S. et al.Consensus report: the current role of self-monitoring of blood glucose in non-insulin-treated type 2 diabetes.J Diabetes Sci Technol. 2011; 5: 1529-1548Crossref PubMed Scopus (84) Google Scholar]. These experts came from the United States, Brazil, Canada, France, Germany, Italy, and the United Kingdom. In addition, three consultants from Australia, Germany, and the United States contributed to the group's final report. This coalition was organized by Diabetes Technology Society. Self-monitoring of blood glucose was studied from eight perspectives related to patients with NIT T2DM: (a) epidemiological studies; (b) randomized controlled trials (RCTs) and meta-analyses; (c) targets, timing, and frequency of SMBG use; (d) incidence and role of SMBG in preventing hypoglycemia with single-drug regimens and combination regimens consisting of antihyperglycemic agents other than secretagogues and insulin; (e) comparison of SMBG with continuous glucose monitoring; (f) technological capabilities and limitations of SMBG; (g) barriers to appropriate use of SMBG; and (h) methods and end points for appropriate future clinical trials. The panel emphasized recent studies, which reflect the current approach for applying this intervention. Among the participants there was consensus that SMBG is an established practice for patients with NIT T2DM, and to be most effective, it should be performed in a structured format where information obtained from this measurement is used to guide treatment [[3]Klonoff D.C. Blonde L. Cembrowski G. Chacra A.R. Charpentier G. Colagiuri S. et al.Consensus report: the current role of self-monitoring of blood glucose in non-insulin-treated type 2 diabetes.J Diabetes Sci Technol. 2011; 5: 1529-1548Crossref PubMed Scopus (84) Google Scholar]. The role of structured SMBG in the management of type 2 diabetes not on insulin treatment has been further confirmed in a recent large observational study in the real world [[4]Lalic N. Tankova T. Nourredine M. Parkin C. Schweppe U. Amann-Zalan I. Value and utility of structured self-monitoring of blood glucose in real world clinical practice: findings from a multinational observational study.Diabetes Technol Ther. 2012; ([Epub ahead of print])PubMed Google Scholar] and in a very large trial, the PRISMA Study [[5]Scavini M. Bosi E. Ceriello A. Giorgino F. Porta M. Tiengo A. et al.Prospective, randomized trial on intensive SMBG management added value in non-insulin-treated T2DM patients (PRISMA): a study to determine the effect of a structured SMBG intervention.Acta Diabetol. 2011; ([Epub ahead of print])PubMed Google Scholar], very recently completed and first presented in the February 2012 at ATTD meeting in Barcelona and accepted as poster at the ADA 2012. The PRISMA study is a 12 month, multicenter, parallel group, randomized, controlled trial in patients with non-insulin treated T2D, comparing intensive structured SMBG (intensive structured monitoring, ISM, 4-point daily glucose measurements 3 times per week) and discretionary, unstructured SMBG (active control, AC). Inclusion criteria were age 35–75 years, T2DM for 1–10 years and glycated hemoglobin (HbA1c) 7–9%. The main primary outcome was the change of HbA1c from baseline to month 12. The PRISMA study enrolled 1024 patients from 39 diabetes clinics in Italy. The ISM group (n = 501) and AC group (n = 523) were comparable for demographics and baseline HbA1c. In the intention-to-treat population (n = 938) the reduction of HbA1c from baseline to month 12 was significantly higher in the ISM than AC group; moreover, in the ISM group significantly more changes in medication prescription occurred in comparison with AC group. This study, when published, probably will end the debate about the usefulness of SMBG in type 2 diabetes not on insulin therapy. Finally, a potential role of SMBG as tool to guide the decision making process for personalizing the therapy in type 2 diabetes has been suggested [[6]Ceriello A. Gallo M. Armentano V. Perriello G. Gentile S. De Micheli A. Personalizing treatment in type 2 diabetes: a self-monitoring of blood glucose inclusive innovative approach.Diabetes Technol Ther. 2012; ([Epub ahead of print])Google Scholar]. A strong correlation exists between improved blood glucose control, obtained from the earliest stages of diabetes, and the prevention of complications. However, tight glycometabolic control does not always translate into an advantage for every patient. Since the characteristics of individual patients play an important role in diabetes care, there is a need to develop personalized action plans. A Panel of Experts of the Associazione Medici Diabetologi (AMD, an Italian Scientific Society of specialists in diabetes) tailored therapeutic algorithms for some of the commonest type 2 diabetes phenotypes, taking into consideration age, BMI, presence of micro- and macro-vascular complications, hypoglycaemia risk, and the co-existence of chronic renal failure. Particular emphasis was placed on exploiting information supplied through the rational use of home-based blood glucose monitoring as a tool for optimizing diabetes management, according to the prevalence of fasting/pre-prandial or post-prandial hyperglycaemia. In other words, for the first time, the use of SMBG as a tool for selecting which strategy to employ for optimizing management and/or any therapeutic changes is proposed. In my opinion structured SMBG is a valid tool for the better management of type 2 diabetes not on insulin therapy, but only if both patients and health care professionals are trained on how to respond to the data for SMBG to be effective. The authors declare that they have no conflict of interest.