Self-monitoring of blood glucose.
Studies have shown that reducing A1c levels can delay and/or reduce the overall risk of microvascular and macrovascular complications associated with both type 1 and type 2 diabetes (1-5). Implementation of intensive diabetes management [using insulin pumps or multiple daily injections along with increased frequency of self-monitoring of blood glucose (SMBG)] is expensive although there is a significant reduction in risk of long-term complications and cost (6,7). Although the benefits of optimal glucose control seem clear, the risk of severe hypoglycaemia can be a barrier to achieving this goal (1,4,5). In fact, there is nearly a threefold increase in hypoglycaemia with intensification of treatment in type 1 diabetes (1). This is further complicated by the results of recent clinical trials in type 2 diabetes [ACCORD (8), ADVANCE (9) and VADT (10)]. The results of these trials have shown conflicting outcomes in the intensively treated arm. This paradox has created a need for new technology that will facilitate optimal glucose control by recommending appropriate insulin doses while decreasing the risk of hypoglycaemia. There is no doubt of the role of SMBG in insulin-requiring patients with diabetes as it helps guide patients and the providers to adjust their insulin dose on a daily basis. There is enough data documenting the beneficial effects of increased SMBG in such individuals. However, the story for patients with type 2 diabetes not on insulin therapy is different. There is no consensus on frequency and timing of SMBG and its exact impact on glucose control in non-insulin-requiring individuals with type 2 diabetes is debatable. Part of the reason for this controversy may be related to increasing healthcare cost and thus payers finding ways not to reimburse SMBG, since there is conflicting data and the evidence of SMBG improving long-term outcomes in such individuals is not fully evaluated. The prevalence of diabetes is rising worldwide and there are more than 24 million people, with both type 1 and 2 diabetes (diagnosed and undiagnosed), in the USA (11-15). With a limited number of endocrinologists or diabetes specialists available in the USA, most clinical diabetes care is provided by primary care physicians (16). Tools to help patients adjust their insulin dose at home should help in improving their glucose control. Several technologies such as continuous glucose monitors (sensors) and glucometers (SMBG) are on the market and have been shown to help patients improve glucose excursions, reduce glucose variability, decrease time spent in hypoglycaemia and hyperglycaemia and improve A1c levels (17-19). Other software available on insulin pumps can also guide patients with adjustment of insulin dose, especially meal-time boluses (20). We hope that the future might see many such technologies being used on a regular basis to guide providers and patients for better long-term outcomes.
Garg
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Barbara Davis Center for Childhood Diabetes University of Colorado Health Sciences Center, Aurora, CO 80010, USA. satish.garg@uchsc.edu
Hirsch
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D015190:Blood Glucose Self-Monitoring; D003920:Diabetes Mellitus / Q000517:prevention & control; D006801:Humans