Type 2 diabetes: should people self-monitor blood glucose?
Evidence about the routine use of blood glucose self-monitoring in type 2 diabetes informs a new NICE guideline.
Since its publication in 2009, the research has impacted policy, clinical practice and education programmes in the UK and internationally.
Type 2 diabetes is a condition where the body doesn’t produce enough insulin to maintain normal levels of glucose in the blood. 3.9 million people live with diabetes in the UK, a figure that has more than doubled since 1996 and is estimated to grow to 5 million by 2025.
The rapid rise in the number of people with diabetes is associated with an ageing population, poor diet and increased obesity. Those living with the condition have a two-to-four fold increased risk of having a stroke, heart disease or developing other health complications.
Regular blood glucose self-monitoring by people at home has previously been widely used as part of routine management for all people with type 2 diabetes. This can provide reassurance about blood glucose levels for some people. However, whether regular self-monitoring should be used routinely has been widely debated, and it represents a considerable cost to the NHS. For example, by 2010 the amount spent on blood glucose testing strips in England in primary care was approximately £150m. By comparison, approximately £300m was spent on insulin and £250m on antidiabetic drugs.
GP and Professor of General Practice Andrew Farmer, from the Nuffield Department of Primary Care Health Sciences, with a team of researchers from the Centre for Diabetes, Endocrinology and Metabolism and the Health Economics Research Centre at Oxford and the Universities of Sheffield and Cambridge, set out to provide evidence about the best use of routine blood glucose self-monitoring for type 2 diabetes.
The team carried out a clinical trial designed to address some of the limitations of previous research studies and, working with 48 general practices across Oxfordshire and South Yorkshire, recruited 450 patients with type 2 diabetes. Patients were individually randomised to one of three tiers of care - either receiving usual care and a routine blood test every three months at their GP surgery; or blood glucose self-testing at home with standard advice about interpreting the results; or they were enrolled into an intensive programme of self-management where patients self-tested their blood glucose from home, interpreted their own results and made their own decisions about lifestyle management.
The study did not provide evidence to support an additional benefit from routine self-monitoring of blood glucose in addition to good clinical care alone. It also raised concerns about a negative impact on the quality-of-life for some people using routine self-monitoring. The study found no evidence that best practice for using regular self-monitoring increased a person’s understanding of their blood glucose levels, or helped them manage their condition.
Since its publication in 2009, the study findings have impacted policy, clinical practice and education programmes in the UK and internationally. A wide range of clinical guidance now recommends that, for many people, routine self-monitoring adds little to routine care and that where it is indicated, there should be a well-established system for training and support – a position which is supported by Diabetes UK and the National Prescribing Centre.
In December 2015, the National Institute for Health and Care Excellence published an update to the 2008 Guideline for type 2 diabetes, which includes the new recommendation that routine self-monitoring should not be used unless the person is on insulin, has experienced low blood sugar levels, is on treatment that increases risk of hypoglycaemia when driving or is pregnant or planning pregnancy.
2 December 2015