Self Monitoring of Blood Glucose

Self-monitoring of blood glucose (SMBG)
in type 2 diabetes
These slides should be used in conjunction with
the accompanying notes
1
Options for local implementation

NPC. Key therapeutic topics 2010/11 Medicines management options for local
implementation. Second update July 2011
Review and, where appropriate, revise local use

of SMBG in type 2 diabetes mellitus to ensure
that it is in line with NICE guidance
These slides should be used in conjunction with the accompanying notes
Key questions
What does NICE say about SMBG in type 2 diabetes?
What is the evidence for SMBG in type 2 diabetes?
Are there specific groups of patients with type 2
diabetes who would benefit from SMBG?
How are we doing with prescribing?
Type 2 diabetes management is multifactorial

Smoking
Education
Control blood
pressure
Lifestyle
Control blood
glucose
Aspirin
Metformin
Statin
Individualised care
of patients:
based on
evidence for each
intervention
What does NICE say about SMBG in type 2 diabetes?

NICE Clinical Guideline 87; May 2009
Make available to:
Those on insulin
Those on oral medication to provide information on hypoglycaemia
Assess changes during medication or lifestyle changes, or illness
Ensure safety during activities, including driving.
Assess at least annually in a structured way:
Self-monitoring skills
Quality and appropriate frequency of testing
The use made of results obtained
The impact on quality of life
The continued benefit
The equipment used.
What is the evidence for SMBG in

type 2 diabetes?
HTA report on SMBG in type 2 diabetes

Clar C, et al. HTA 2010; Vol. 14: No. 12
Identified 30 RCTs, although few of high quality
Concluded that evidence suggests SMBG is of limited clinical

effectiveness in improving glycaemic control in people with type 2
diabetes on oral agents, or diet alone, and is therefore unlikely to be
cost-effective
SMBG may lead to improved glycaemic control only in the context of

appropriate education both for patients and healthcare
professionals on how to respond to the data, in terms of lifestyle and
treatment adjustment
SMBG may be more effective if patients are able to self-adjust drug

treatment
Further research is required on the type of education and feedback

that are most helpful, characteristics of patients benefiting most from
SMBG, optimal timing and frequency of SMBG, and the
circumstances under which SMBG causes anxiety and/or depression.
More evidence for SMBG in type 2 diabetes?

Polonsky, WH, et al. Diabetes Care 2011;34:2627, MeReC Rapid Review No. 2534
US 12-month RCT of 483 poorly controlled insulin-nave type 2

diabetic patients (mean HbA1c 8.9%)
Compared a comprehensive, structured SMBG intervention
package (which encouraged patients and doctors to work together
to collect, interpret, and appropriately use SMBG data) with
enhanced usual care
Primary end point: HbA1c at 12 months
Significantly greater reductions in mean HbA1c with structured
SMBG compared with enhanced usual care
mean reduction in HbA1c 1.2% vs. 0.9%, respectively, P=0.04
Unclear whether 0.3% difference in HbA1c between groups is

clinically significant and enough to justify the additional resources
needed to provide the intervention
8
Are there specific groups of patients

with type 2 diabetes who would benefit
from SMBG?
NHS Diabetes Report on SMBG in non-insulin

treated patients with type 2 diabetes
NHS Diabetes. March 2010.
http://www.diabetes.nhs.uk/publications_and_resources/reports_and_guidance/
10
SMBG should be available (with appropriate structured education) to

people receiving sulfonylureas to identify hypoglycaemic episodes
SMBG should only be provided routinely to people not treated with

insulin or sulfonylureas where there is agreed purpose
SMBG should be used only within a care package, accompanied by

structured education, with regular review
individuals with non-insulin treated diabetes who are motivated by

SMBG activity and use information to maximise effect of lifestyle and
medication should be encouraged to continue to monitor
staff training in the use of SMBG to support changes in lifestyle and

self-adjustment of medications is required
savings from reduction in SMBG should be used to provide structured

education and training of professionals.
How are we doing with prescribing?

http://www.ic.nhs.uk/pubs/prescribingdiabetes0410
COST
11
Key messages
Management of type 2 diabetes requires individualised

multifactorial care
In patients with established type 2 diabetes whose blood glucose is

relatively well-controlled with oral drugs who monitor blood glucose
infrequently, little is to be gained in promoting SMBG, even with an
education programme
Reserve SMBG for people treated with insulin and in some specific
circumstances
such as patients at risk of hypoglycaemia during intercurrent illness, fasting
or when using sulfonylureas
Attention and resources may be best directed to interventions likely to

make a difference to patients symptoms and risk of macrovascular and
microvascular complications
such as support and advice around nutrition, exercise, smoking cessation,
foot care, management of blood pressure and lipids
12

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Self-monitoring of blood glucose (SMBG)

Options for local implementation

Review and, where appropriate, revise local use

These slides should be used in conjunction with the accompanying notes

These slides should be used in conjunction with the accompanying notes

Type 2 diabetes management is multifactorial

These slides should be used in conjunction with the accompanying notes

What does NICE say about SMBG in type 2 diabetes?

Make available to:

Assess at least annually in a structured way:

These slides should be used in conjunction with the accompanying notes

What is the evidence for SMBG in

These slides should be used in conjunction with the accompanying notes

HTA report on SMBG in type 2 diabetes

Identified 30 RCTs, although few of high quality

Concluded that evidence suggests SMBG is of limited clinical

SMBG may lead to improved glycaemic control only in the context of

SMBG may be more effective if patients are able to self-adjust drug

Further research is required on the type of education and feedback

More evidence for SMBG in type 2 diabetes?

US 12-month RCT of 483 poorly controlled insulin-nave type 2

Unclear whether 0.3% difference in HbA1c between groups is

These slides should be used in conjunction with the accompanying notes

Are there specific groups of patients

These slides should be used in conjunction with the accompanying notes

NHS Diabetes Report on SMBG in non-insulin

SMBG should be available (with appropriate structured education) to

SMBG should only be provided routinely to people not treated with

SMBG should be used only within a care package, accompanied by

individuals with non-insulin treated diabetes who are motivated by

staff training in the use of SMBG to support changes in lifestyle and

savings from reduction in SMBG should be used to provide structured

How are we doing with prescribing?

These slides should be used in conjunction with the accompanying notes

Management of type 2 diabetes requires individualised

In patients with established type 2 diabetes whose blood glucose is

Attention and resources may be best directed to interventions likely to

These slides should be used in conjunction with the accompanying notes

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