Self-monitoring blood glucose (SMBG) is an integral part of self-management in patients with type 1 diabetes. However, the use of SMBG in patients with type 2 diabetes has caused some debates in the field. A recent publication found a considerable amount of patients with type 2 diabetes not on insulin were testing their blood glucose levels too often,1 which was deemed as a low-value care and should not be routinely tested as recommended by the American Academy of Family Physicians, the Society of General Internal Medicine, and the Endocrine Society at the Choosing Wisely® campaign.2-4 The study was published in JAMA Internal Medicine.
The results were obtained from a retrospective analysis on commercial health insurance data and Medicare claims data collected from January 1 2013 to June 30 2015.1 Subjects included in the analysis were type 2 diabetic patients who do not require insulin.1 A total of 370,740 patients were included in the analysis, where 86,747 (23.4%) of them made 3 or more claims for test strips in one year.1 The study also found those patients taking agents not considered to be a risk for causing hypoglycemia and patients not claiming any antidiabetic medications used a median of 2 strips per day (interquartile range, 1.2-2.4).1 The median claims cost for test strips was US$325.54 (interquartile range, $0.00-$534.76) per person per year.1
The author concluded that around 14% of the patients with type 2 diabetes not on insulin were having SMBG inappropriately despite a lack of clinical evidence and being positioned as a low-value service by the Choosing Wisely® campaign.1
There were speculations that the study results may be subjected to selection bias as it consisted of a selected population of privately insured patients.1 Debates surrounding the use of SMBG were also sparkled as Lisa Harris, Certified Diabetes Nurse Educator and Registered Nurse at the Rush University Medical Center in Chicago, Illinois, argued in an interview with Healthline, “testing your blood sugar can be extremely informative for people when they’re trying to prevent the need for further medication, like insulin.”5
A randomized controlled trial on SMBG with nurses or physicians’ guidance versus usual care found a beneficial effect on reducing HbA1c level and blood pressure.6 The findings may suggest the real problem could be the lack of actionable guidance after SMBG, instead of SMBG itself.
Currently, in Hong Kong, the Centre for Health Protection suggested SMBG should be tested two to four times per week at various times during the day.7 As the debates surrounding SMBG continue, the role of SMBG will be more apparent as more research evidence becomes available. Considering patient characteristics can vary between individuals, this debate will undoubtedly shed light on how to optimize health outcomes in type 2 diabetic patients using personalized strategy to manage their disease.
1. Platt KD, Thompson AN, Lin P, et al. Assessment of Self-monitoring of Blood Glucose in Individuals With Type 2 Diabetes Not Using Insulin. JAMA Intern Med. 2019;179(2):269-272.
2. Don’t routinely recommend daily home glucose monitoring for patients who have Type 2 diabetes mellitus and are not using insulin. 2018. Choosing Wisely®. (Accessed March 14, 2019, at https://www.choosingwisely.org/clinician-lists/aafp-daily-home-glucose-monitoring-for-patients-with-type-2-diabetes/.)
3. Don’t recommend daily home finger glucose testing in patients with Type 2 diabetes mellitus not using insulin. 2017. Choosing Wisely®. (Accessed March 14, 2019, at https://www.choosingwisely.org/clinician-lists/society-general-internal-medicine-daily-home-finger-glucose-testing-type-2-diabetes-mellitus/.)
4. Avoid routine multiple daily self-glucose monitoring in adults with stable type 2 diabetes on agents that do not cause hypoglycemia. 2013. Choosing Wisely®. (Accessed March 14, 2019, at https://www.choosingwisely.org/clinician-lists/endocrine-society-multiple-daily-self-glucose-monitoring-for-stable-type-2-diabetes/.)
5. Vieira G. 2018. How Often Should a Person with Type 2 Diabetes Test Their Blood Sugar? Healthline. (Accessed March 14, 2019, at https://www.healthline.com/health-news/do-some-type-2-diabetes-patients-do-fewer-blood-tests#How-often-is-enough?)
6. Wild SH, Hanley J, Lewis SC, et al. Supported telemonitoring and glycemic control in people with type 2 diabetes: the Telescot diabetes pragmatic multicenter randomized controlled trial. PLoS Med. 2016;13(7):e1002098.
7. Self Monitoring of Diabetes. Centre for Health Protection. (Accessed March 14, 2019, at https://www.chp.gov.hk/en/static/90083.html.)