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Self monitoring of blood glucose in type 2 diabetes mellitus

Self monitoring of blood glucose in type 2 diabetes mellitus

Wednesday 17th August 2016

The most recent guidance from the National Institute for Health and Care Excellence (NICE) on the management of type 2 diabetes in adults recommends that there are specific patient groups who would benefit from self monitoring of their blood glucose levels in order to appropriately manage their condition.

These patients include; those who are being treated with insulin, patients who have suffered hypoglycaemic episodes, if a patient is on oral medication which may increase their risk of hypoglycaemia during operating machinery or whilst driving, and also patients who are pregnant or planning on falling pregnant. Self testing is also recommended if a patient with type 2 diabetes mellitus is started on corticosteroids, or to confirm suspected hypoglycaemia. [NICE 2015]

Additional guidance has also been issued by the Driver & Vehicle Licensing Agency (DVLA). Their literature on Assessing fitness to drive outlines their recommendations for self monitoring of blood glucose levels in type 2 diabetes patients who are being treated with insulin or tablets which may induce hypoglycaemia, failure to comply with these regulations may lead to a patient being deemed unfit to drive. [DVLA 2016]

NICE [2015] have recommend that patients who have been self monitoring their blood glucose levels, should have at least an annual assessment. Not only should clinicians look at a persons self monitoring technique and how it is interpreted,but they should also assess how this self monitoring is benefiting the patient, its effect on quality of life, and finally there is a new recommendation that clinicians should make an assessment of the equipment being used for self monitoring.

In 2013, the International Organisation for Standardisation (ISO) documented performance standards which they expect blood glucose monitoring systems should meet, manufacturers will have to adhere to these standards as of May 2016. [Sutheran and Reynolds 2016]

The 2013 ISO guidance includes "tighter accuracy standards", this data is obtained by comparing results from different blood glucose monitoring systems with results from laboratory measurements. The ISO also now recommend evaluation of clarity of instructions of use as well as how the test copes when measuring blood glucose in a specimen that contains levels of substances which may interfere with the result, for example the concentration of red blood cells within the sample, or common medications. [Diabetes Digital Media Ltd 2016]

In line with the NICE guidance for assessing equipment used by diabetic patients, it is important that clinicians are familiar with the ISO standards before deciding on the best blood glucose meter to prescribe for the patient. However more typically a group of clinicians and pharmacy staff will evaluate the guidance as a group before producing prescribing guidelines for their local trust.

"The rationale for the use of self monitoring of blood glucose in insulin-treated type 2 diabetes is compelling and is supported by data from large prospective and observational trials" [Czupryniak et al. 2014]. There has been evidence of a reduction in microvascular complications, and reductions in HBA1C levels in patients with good compliance in monitoring their blood glucose levels.

The majority of studies including type 2 diabetics who are not on insulin therapy have so far failed to find any improvement in metabolic control or positive changes in health behaviours with self monitoring of their blood glucose. However, it is hypothesised that the inconsistencies in results from studies of this particular patient group may be due to there being many differences in the study designs. [Czupryniak et al. 2014]

The main downside to regular self monitoring of blood glucose levels is cost to the health service, with a substantial proportion of the cost relating to the cost of the disposable test strips [Sutheran and Reynolds 2016], for example a paper in 2002 stated that "If a patient is testing four times daily for every day of the year then the yearly cost of glucose monitoring per patient is £423.98" [Tiley 2002]. However after in terms of cost Vs benefit it has been shown that "the financial cost of frequent self monitoring of blood glucose levels is significantly lower than the cost of longterm diabetes complication treatments" [Sutheran and Reynolds 2016].

In conclusion, there is undoubtably an important role for self monitoring of blood glucose in type 2 diabetics, however there is also a duty for clinicians to monitor how the patient interprets these results, that the patient is using their self monitoring system correctly and that it meets all of the ISO standards. There is an added responsibility for clinicians to not only provide the right blood glucose monitoring system for their patients but also to compare the devices on the market rather than simply choosing devices based on familiar brands, it is important that prescribers seeks good value for money in these difficult economic times for the NHS.

References

Czupryniak, L. et al. 2014. Self-Monitoring of Blood Glucose in Diabetes: From Evidence to Clinical Reality in Central and Eastern Europe—Recommendations from the International Central-Eastern European Expert Group. Diabetes Technology & Therapeutics [Online]16. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4074758/pdf/dia.2013.0302.pdf [Accessed: 14th July 2016]

Diabetes Digital Media. 2016. ISO Standards for Blood Glucose Meters [Online]. diabetes.co.uk. Available at http://www.diabetes.co.uk/blood-glucose-meters/iso-accuracy-standards.html [Accessed: 14th July 2016]

DVLA. 2016. Assessing fitness to drive - a guide for medical professionals [Online]. gov.uk. Available at https://www.gov.uk/government/publications/assessing-fitness-to-drive-a-guide-for-medical-professionals [Accessed: 14th July 2016]

NICE. 2015. Type 2 diabetes in adults: management [Online]. NICE.org.uk . Available at https://www.nice.org.uk/guidance/ng28/chapter/1-Recommendations [Accessed: 14th July 2016]

Sutheran, H.L. and Reynolds, T. 2016. Technical and clinical accuracy of three blood glucose meters: clinical impact assessment using error grid analysis and insulin sliding scales. Journal of Clinical Pathology [Online]. Available at http://jcp.bmj.com/content/early/2016/02/05/jclinpath-2015-203339.abstract [Accessed: 14th July 2016]

Tiley, S. 2002. Home Blood Glucose Monitoring—What Cost?. Practical Diabetes International [Online]19. Available at http://onlinelibrary.wiley.com/doi/10.1002/pdi.413/full [Accessed: 14th July 2016]