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Blood Glucose Self-Monitoring in Type 1 and Type 2 Diabetes: Reaching a Multidisciplinary Consensus

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Blood Glucose Self-Monitoring in Type 1 and Type 2 Diabetes: Reaching a Multidisciplinary Consensus 5.p8-16_Consensus.sbg 6/4/04 10:53 am Page 1 Consensus Blood glucose self-monitoring in type 1 and type 2 diabetes: reaching a multidisciplinary consensus ARTICLE POINTS David Owens, Anthony H Barnett, John Pickup, David Kerr, Phyllis The provision of Bushby, Debbie Hicks, Roger Gadsby and Brian Frier 1home blood glucose monitoring materials is Introduction key to empowerment and In the light of evidence that emerged from the UKPDS (1998) and the delivery of good the DCCT (1993), individual patients must be made aware of the glycaemic control safely. importance of blood glucose monitoring. A multidisciplinary group of healthcare professionals met to discuss blood glucose self-monitoring The NSF for 2Diabetes outlined in type 1 and type 2 diabetes. This article outlines the consensus that the importance of they reached and provides a general basis upon which individual regular monitoring patient care plans may be formulated. Advice is given on home blood of HbA1c levels. glucose monitoring systems for people with different regimens for type 1 and type 2 diabetes. General 3recommendations and specific n the UK in 2001, approximately £90 with suitable training (National Diabetes considerations million was spent on blood glucose Support Team, 2003). are given for blood Itesting strips for people with The recently published NSF for glucose monitoring in diabetes (National Prescribing Centre, Diabetes (England and Wales) type 1 diabetes and 2002). This amount is estimated to be recommends that diabetes services type 2 diabetes. 40% more than the amount spent on oral should be: agents to lower blood glucose levels The article concludes (Tiley, 2002). Therefore the cost of ‘...person-centred, developed in partnership, with advice on home 4 home blood glucose monitoring is of equitable, integrated and outcome- blood glucose monitoring orientated.’ for different diabetes legitimate concern to healthcare providers (Burrill, 2002). regimens, and these are Important elements of the document outlined in a table. Several primary care trusts (PCTs) in include Standard 3, which specifies that: England have recently instructed general practitioners (GPs) to reduce the ‘...all children, young people and adults provision of blood glucose monitoring with diabetes will receive a service that David Owens, CBE, MD, FRCP, strips, in some cases suggesting no more CBiol, FIBiol, Professor and encourages partnership in decision- Consultant Diabetologist, than one test per day for all people with making, supports them in managing their Llandough Hospital, Penarth; diabetes irrespective of the type of Anthony H Barnett, BSc, MD, FRCP, diabetes and helps them adopt and Professor of Medicine, University diabetes or clinical need. The National maintain a healthy lifestyle.’ of Birmingham, and Consultant Diabetes Support Team (NDST) has Physician, Birmingham Heartlands and Solihull NHS Trust; John Pickup responded by making reference to the This recommendation relates to both DPhil, FRCPath, Professor of National Institute for Clinical Excellence outpatient and inpatient care. Standards 4 Diabetes and Metabolism, Guy’s and 5 clearly state that all people with Hospital London; David Kerr, MD, (NICE) guidelines published in September FRCP, Consultant Physician, 2002, reaffirming that self-monitoring diabetes will receive support to optimise Bournemouth Diabetes and should be used as part of integrated self- their blood glucose control (DoH, 2001). Endocrine Centre; Phyllis Bushby, Diabetes Specialist Nurse, care (NDST, 2003). It is well accepted that in people with Sherwood Forest Hospitals NHS However, the NICE guidance makes no type 1 or type 2 diabetes good glycaemic Trust; Debbie Hicks, Senior Diabetes Specialist Nurse, Hull and recommendations for frequency of testing control is essential to minimise the risk East Yorkshire Hospital NHS Trust; according to treatment regimen (NICE, of long-term vascular complications Roger Gadsby, GP, Nuneaton, Senior Lecturer in Primary Care, 2002). In addition, the NDST statement (DCCT Group, 1993; UKPDS, 1998). University of Warwick. Brian Frier also highlighted the benefits that self- Management of diabetes according to the MD FRCP, Professor and standards established by the NSF for Consultant Diabetologist, Lothian monitoring of blood glucose offers people University Hospitals NHS Trust. with diabetes when used appropriately Diabetes is dependent upon the control 8 Diabetes and Primary Care Vol 6 No 1 2004 5.p8-16_Consensus.sbg 6/4/04 10:53 am Page 2 BLOOD GLUCOSE SELF-MONITORING IN TYPE 1 AND TYPE 2 DIABETES Table 1: Recommendations regarding blood glucose monitoring in type 1 diabetes PAGE POINTS General recommendations Specific considerations Diabetes UK have 1re-emphasised in a G Blood glucose monitoring should be regarded Factors which indicate a need position statement that as an integral part of treating all people with for more frequent testing: people with diabetes type 1 diabetes. G Hypoglycaemia unawareness should have access to G People with type 1 diabetes should be educated G Frequent hypoglycaemia home blood glucose to monitor blood glucose and adjust treatment G Exercise monitoring which is appropriately. G Certain employments based on individual G As the majority of people with type 1 diabetes G Intercurrent illness clinical need and not on are liable to instability of glycaemic control, G Driving an ability to pay. during such times or periods of instability, G Children monitoring should ideally take place 4 or more G Pregnancy There is a lack of times per day to prevent hypoglycaemia G Breastfeeding 2randomised controlled and control hyperglycaemia. G Outpatient procedures clinical trials in support of G Drug/alcohol abuse the role of blood glucose G Change of insulin regimen monitoring in the treatment of type 1 and G Advanced complications type 2 diabetes, and results (autonomic neuropathy, from meta-analyses are nephropathy). inconclusive. of blood glucose. The utilisation of home multidisciplinary group that home blood Home blood glucose monitoring has an blood glucose monitoring, in addition to glucose monitoring has an important and 3 important and essential regular HbA measurement, is not essential role to play in ensuring the 1c role to play in ensuring however, clearly defined. safety and efficacy of glucose lowering the safety and efficacy Similarly, Diabetes UK have therapies in order to prevent the onset of glucose lowering re-emphasised in a position statement and limit the progression of therapies in order to that people with diabetes should have complications related to hyperglycaemia. prevent the onset and access to home blood glucose In the quest for normoglycaemia, the limit the progression of monitoring which is based on individual evidence suggests an increasing risk of complications related to clinical need and not on an ability to pay hypoglycaemia. From the patients’ hyperglycaemia. (Diabetes UK, Accessed March, 2004). perspective, this most feared However, no detailed recommendations complication of diabetes is a major Home blood glucose on monitoring have been produced. limiting factor in the achievement of 4monitoring empowers people with diabetes to Therefore, guidance is needed. good glycaemic control, especially for understand and thereby There is a lack of randomised people on insulin therapy. better manage their own controlled clinical trials in support of the The measurement of HbA1c has an glycaemic control. role of blood glucose monitoring in the integral part to play in the management treatment of type 1 and type 2 diabetes, of diabetes, providing an overall and results from meta-analyses are indication of ambient blood glucose levels inconclusive (Coster et al, 2000). This over time, whereas home blood glucose deficiency is an important contributor to monitoring provides people with diabetes the variation in practice both in primary the opportunity to manage their and secondary care. Some clinical studies requirements on a day-to-day basis. have suggested that home blood glucose monitoring in type 2 diabetes confers no The need for home blood significant benefit in improving glycaemic glucose monitoring control (Patrick et al, 1994; Gallichan, Home blood glucose monitoring 1997). However, there is an increasing empowers people with diabetes to body of evidence indicating the benefits of understand and thereby better manage home blood glucose monitoring their own glycaemic control. It also (Nyomba et al, 2003; Muhrata et al, 2003). forms the basis upon which the clinician It is the collective view of this can interpret the individual patient’s Diabetes and Primary Care Vol 6 No 1 2004 9 5.p8-16_Consensus.sbg 6/4/04 10:53 am Page 3 BLOOD GLUCOSE SELF-MONITORING IN TYPE 1 AND TYPE 2 DIABETES glycaemic profile, including both either state. Reliance on subjective PAGE POINTS preprandial and postprandial blood signs/symptoms (without testing) has glucose levels reflecting lifestyle and been shown on occasions to be Individual patients 1should be made aware different treatment modalities (Blonde et disturbingly unreliable (Pramming et al, of the importance of al, 2002). 1990). blood glucose monitoring It is known that people with poor G Alterations in treatment. Any change in in recognition of the glycaemic control are more likely to blood glucose lowering therapies evidence emanating from suffer from the long-term vascular requires detailed monitoring of blood the DCCT and UKPDS. complications of diabetes and have an glucose to improve safety whilst increased risk
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