Diabetes Type 1 and 2

DM: Blood Glucose Self-Monitoring (2007)

• Intervention
  What is the relationship between self-monitoring of blood glucose and metabolic outcomes in persons with type 2 diabetes?

  • Conclusion

    Sixteen type 2 diabetes studies that involved SMBG and glycemic control were reviewed. SMBG, compared to non-SMBG, is associated with greater improvement in A1C when it is a part of a structured education program where subjects use the information to make changes in their management program.  Evidence on frequency and duration of SMBG is inconclusive.

  • Grade: II
    • Grade I means there is Good/Strong evidence supporting the statement;
    • Grade II is Fair;
    • Grade III is Limited/Weak;
    • Grade IV is Expert Opinion Only;
    • Grade V is Not Assignable.
    • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
    • Moderate (B) means we are moderately confident in the effect estimate;
    • Low (C) means our confidence in the effect estimate is limited;
    • Very Low (D) means we have very little confidence in the effect estimate.
    • Ungraded means a grade is not assignable.
  • Evidence Summary: What is the relationship between self-monitoring of blood glucose and metabolic outcomes in persons with type 2 diabetes?
    • Detail
    • Quality Rating Summary
      For a summary of the Quality Rating results, click here.
    • Worksheets
      • Allen BT, DeLong ER, Feussner JR. Impact of glucose self-monitoring on non-insulin-treated patients with type II diabetes mellitus. Randomized controlled trial comparing blood and urine testing. Diabetes Care. 1990; 13: 1044-1050.
      • Bonora E, Calcaterra F, Lombardi S, Bonfante N, Formentini G, Bonadonna RC, Muggeo M.  Plasma Glucose Levels Throughout the Day and HbA1c Interrelationships in Type 2 Diabetes:  Implications for treatment and monitoring of metabolic control.  Diabetes Care 2001;24: 2023-2029.
      • Coster S, Gulliford MC, Seed PT, Powrie JK, Swaminathan R. Self-monitoring in type 2 diabetes mellitus: a meta-analysis. Diabetic Medicine. 2000; 17: 755-761.
      • Davidson MB, Castellanos M, Kain D, 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 Medicine 2005;118(4):422-5. 
      • Franciosi M, Pellegrini F, DeBerardis G, Belfiglio M, Cavaliere D, DiNardo B, Greenfield S, Kaplan SH, Sacco M, Tognoni G, Valentini M, Nicolucci A, for The 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 2001;24(11):1870-7. 
      • Franciosi M, Pellegrini F, DeBerardis G, Belfiglio M, DiNardo B, Greenfield S, Kaplan SH, Rossi MCE, Sacco M, Tognoni G, Valentini M, Nicolucci A. for The QuED Study Group- quality of care and outcomes in Type 2 diabetes.  Self-monitoring of blood glucose in non-insulin-treated diabetic patients: a longitudinal evaluation of its impact on metabolic control. Diabetes Medicine 2005; 22: 900-906. 
      • Harris MI.  Frequency of blood glucose monitoring in relation to glycemic control in patients with type 2 diabetes.  Diabetes Care 2001;24(6):979-982.
      • Hoffman RM, Shah JH, Wendel CS, Duckworth WC, Adam KD, Bokhari SU, Dalton C, Murata GH.   Evaluating Once- and Twice-Daily Self-Monitored Blood Glucose Testing Strategies for Stable Insulin-Treated Patients with Type 2 Diabetes.  The Diabetes Outcomes in Veterans Study.  Diabetes Care 2002;25: 1744-1748.
      • Jaworska J, Dziemidok P, Kulik TB, Rudnicka-Drozak E.  Frequency of self-monitoring and its effect on metabolic control in patients with type 2 diabetes.  Ann Univ Mariae Curie Sklodowsk (Med) 2004; 59(1): 310-6.
      • Karter AJ, Ackerson LM, Darbinian JA, D’Agostino RB Jr, Ferrara A, Liu J, Selby JV. Self-monitoring of blood glucose levels and glycemic control: the Northern California Kaiser Permanente Diabetes registry. Am J Med. 2001; 111:1-9.
      • Martin S, Schneider B, Heinemann L, Lodwig V , Kurth HJ, Kolb H, Scherbaum WA, for the ROSSO Study Group.  Self-monitoring of blood glucose in type 2 diabetes and long-term outcome: an epidemiological cohort study.  Diabetologia 2006; 49: 271-278.
      • Meier JL, Swislocki ALM, Lopez JR, Noth RH, Bartlebaugh P, Siegel D.  Reduction in self-monitoring of blood glucose in persons with type 2 diabetes results in cost savings and no change in glycemic control.  Am J Manag Care 2002; 8:557-565.
      • Murata GH, Shah JH, Hoffman RM, Wendel CS, Adam KD, Solvas PA, Bokhari SU, Duckworth WC.  Intensified Blood Glucose Monitoring Improves Glycemic Control in Stable, Insulin-Treated Veterans With Type 2 Diabetes: The Diabetes Outcomes in Veterans Study (DOVES).  Diabetes Care 2003;26: 1759-1763.
      • Sarol Jr JN, Nicodemus Jr NA, Tan KM, 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).  Current Medical Research and Opinion 2005;21(2):173-184.
      • Schwedes U, Siebolds M, Mertes G, For the SMBG Study Group.  Meal-Related Structured Self-Monitoring of Blood Glucose:  Effect on diabetes control in non-insulin-treated type 2 diabetic patients.  Diabetes Care 2002;25: 1928-1932.
      • Wen L, Parchman ML, Linn WD, Lee S.  Association between self-monitoring of blood glucose and glycemic control in patients with type 2 diabetes mellitus.  Am J Health Syst Pharm 2004; 61:2401-5.
  • Search Plan and Results: Self-Monitoring of Blood Glucose 2006
     
• Monitoring and Evaluation
  What is the relationship between continuous glucose monitoring and metabolic outcomes in persons with type 1 and type 2 diabetes?

  • Conclusion

    Six studies using continuous glucose monitoring (CGM) in subjects with diabetes report improvements in glycemic control. Seven studies report improvements in hyper- and hypoglycemic ranges.   Data derived from CGM can be used to modify food or insulin therapy that will improve metabolic outcomes; however, it is currently unclear if use of information from CGM will improve metabolic outcomes significantly more than use of information derived from SMBG: two RCTs found that both methods significantly improved A1C; one RCT found that only CGM significantly improved A1C; and one RCT found that only CGM significantly reduced hyperglycemia. In a data-gathering study, both methods gave similar mean glucose profiles and associations with A1C. Two RCTs found no significant differences between methods in improving hypoglycemia; however two other RCTs found that CGM reduced duration of hypoglycemia vs. SMBG.  Five studies present pattern information from the wearing of CGM devices.

  • Grade: II
    • Grade I means there is Good/Strong evidence supporting the statement;
    • Grade II is Fair;
    • Grade III is Limited/Weak;
    • Grade IV is Expert Opinion Only;
    • Grade V is Not Assignable.
    • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
    • Moderate (B) means we are moderately confident in the effect estimate;
    • Low (C) means our confidence in the effect estimate is limited;
    • Very Low (D) means we have very little confidence in the effect estimate.
    • Ungraded means a grade is not assignable.
  • Evidence Summary: What is the relationship between continuous glucose monitoring and metabolic outcomes in persons with type 1 and type 2 diabetes?
    • Detail
    • Quality Rating Summary
      For a summary of the Quality Rating results, click here.
    • Worksheets
      • Alemzadeh R, Loppnow C, Parton E, Kirby M. Glucose sensor evaluation of glycemic instability in pediatric type 1 diabetes mellitus. Diabetes Technology & Therapeutics. 2003;5(2):167-173.
      • Bode B, Gross K, Rikalo N, Schwartz S, Wahl T, Page C, Gross T, Mastrototaro J. Alarms based on real-time sensor glucose values alert patients to hypo- and hyperglycemia: the Guardian Continuous Monitoing System.  Diabetes Technology & Therapeutics. 2004:6(2):105-113.
      • Bode BW, Schwartz S, Stubbs HA, Block JE.  Glycemic characteristics in continuously monitored patients with type 1 and type 2 diabetes.  Diabetes Care 2005; 28(10): 2361-2366. 
      • Boland E, Monsod T, Delucia M, Brandt CA, Fernando S, Tamborlane WV.  Limitations of conventional methods of self-monitoring of blood glucose.   Diabetes Care 2001; 24: 1858-1862. 
      • Chico A, Vidal-Rios P, Subira M, Novials A. The continuous glucose monitoring system is useful for detecting unrecognized hypoglycemias in patients with type 1 and type 2 diabetes but is not better than frequent capillary glucose measurements for improving metabolic control. Diabetes Care. 2003;26:1153-1157.
      • Deiss D, Hartmann R, Hoeffe J, Kordonouri O.  Assessment of glycemic control by continuous glucose monitoring system in 50 children with type 1 diabetes starting on insulin pump therapy.  Pediatric Diabetes. 2004;5:117-121.
      • Fiallo-Scharer R, Xing D, Weinzimer S, Buckingham B, Mauras N, Tansey M, Chase P, Beck R, Ruedy K, Kollman C, Tamborlane W.  Eight-Point Glucose Testing Versus the Continuous Glucose Monitoring System in Evaluation of Glycemic Control in Type 1 Diabetes. J Clin Endocrinol Metab 2005;90:3387-3391.
      • Garg SK, Schwartz S, Edelman SV. Improved glucose excursions using an implantable real-time continuous glucose sensor in adults with type 1 diabetes. Diabetes Care. 2004;27:734-738. 
      • Garg S, Zisser H, Schwartz S, Bailey T, Kaplan R, Ellis S, Jovanovic L.  Improvement in glycemic excursions with a transcutaneous, real-time continuous glucose sensor: a randomized controlled trial.  Diabetes Care 2006; 29(1): 44-50. 
      • Kaufman FR, Gibson LC, Halvorson M, Carpenter S, Fisher LK, Pitukcheewanont P. A pilot study of the continuous glucose monitoring system:  clinical decisions and glycemic control after its use in pediatric type 1 diabetic subjects.  Diabetes Care. 2001;24(12):2030-2034.
      • Ludvigsson J, Hanas R. Continuous subcutaneous glucose monitoring improved metabolic control in pediatric patients with type 1 diabetes: a controlled crossover study. Pediatrics. 2003;111(5):933-938.
      • Manuel-y-Keenoy B, Vertommen J, Abrams P, Van Gaal L, De Leeuw I, Messeri D, Poscia A. Postprandial glucose monitoring in type 1 diabetes mellitus: use of a continuous subcutaneous monitoring device. Diabetes Metab Res Rev. 2004;20 (Suppl 2):S24-S31.
      • Schaepelynck-Belicar P, Vague Ph, Simonin G, Lassmann-Vague V. Improved metabolic control in diabetic adolescents using the continuous glucose monitoring system (CGMS). Diabetes Metab. 2003;29:608-612.
      • Schiaffini R, Ciampalini P, Fierabracci A, Spera S, Borrelli P, Bottazzo GF, Crino A. The continuous glucose monitoring system (CGMS) in type 1 diabetic children is the way to reduce hypoglycemic risk. Diabetes Metab Res Rev. 2002;18:324-329.
      • Streja D. Can continuous glucose monitoring provide objective documentation of hypoglycemia unawareness?. Endocrine Practice 2005;11(2):83-90. 
      • Tanenberg R, Bode B, Lane W, Levetan C, Mestman J, Harmel AP, Tobian J, Gross T, Mastrototaro J. Use of the continuous glucose monitoring system to guide therapy in patients with insulin-treated diabetes: a randomized controlled trial. Mayo Clin Proc. 2004;79 (12):1521-1526.
      • Weintrob N, Schechter A, Benzaquen H, Shalitin S, Lilos P, Galatzer A, Phillip M. Glycemic patterns detected by continuous subcutaneous glucose sensing in children and adolescents with type 1 diabetes mellitus treated by multiple daily injections vs continuous subcutaneous insulin infusion. Arch Pediatr Adolesc Med. 2004;158:677-684.
  • Search Plan and Results: Continuous Glucose Monitoring 2006
     
  What is the relationship between self-monitoring of blood glucose and metabolic outcomes in persons with type 1 diabetes?

  • Conclusion

    Prospective intervention studies in subjects with type 1 diabetes that included self-management training and adjustment of insulin doses based on Self-Monitoring of Blood Glucose (SMBG) showed significant improvement in glycemic control compared to study control group.  More frequent SMBG (3 to 8 times daily) was also associated with better glycemic control regardless of diabetes type or therapy.

  • Grade: I
    • Grade I means there is Good/Strong evidence supporting the statement;
    • Grade II is Fair;
    • Grade III is Limited/Weak;
    • Grade IV is Expert Opinion Only;
    • Grade V is Not Assignable.
    • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
    • Moderate (B) means we are moderately confident in the effect estimate;
    • Low (C) means our confidence in the effect estimate is limited;
    • Very Low (D) means we have very little confidence in the effect estimate.
    • Ungraded means a grade is not assignable.
  • Evidence Summary: What is the relationship between self-monitoring of blood glucose and metabolic outcomes in persons with type 1 diabetes?
    • Detail
    • Quality Rating Summary
      For a summary of the Quality Rating results, click here.
    • Worksheets
      • Brewer KW, Chase HP, Owen S, Garg SK. Slicing the pie: correlating HbA1C values with average blood glucose values in a pie chart form. Diabetes Care. 1998;21:209-212.
      • DAFNE Study Group. Training in flexible, intensive insulin management to enable dietary freedom in people with type 1 diabetes: dose adjustment for normal eating (DAFNE) randomised controlled trial. Brit Med J. 2002; 325:746-751.
      • The Diabetes Control and Complications Trial 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 1993; 329:977-986.  
      • Fiallo-Scharer R, Xing D, Weinzimer S, Buckingham B, Mauras N, Tansey M, Chase P, Beck R, Ruedy K, Kollman C, Tamborlane W.  Eight-Point Glucose Testing Versus the Continuous Glucose Monitoring System in Evaluation of Glycemic Control in Type 1 Diabetes. J Clin Endocrinol Metab 2005;90:3387-3391.
      • Karter AJ, Ackerson LM, Darbinian JA, D’Agostino RB Jr, Ferrara A, Liu J, Selby JV. Self-monitoring of blood glucose levels and glycemic control: the Northern California Kaiser Permanente Diabetes registry. Am J Med. 2001; 111:1-9.
  • Search Plan and Results: Self-Monitoring of Blood Glucose 2006