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					                          Managing Type 2 Diabetes in the Primary Care Setting: The Importance of Self-Monitoring of Blood Glucose (SMBG)




Managing Type 2
Diabetes in the
Primary Care Setting:
The Importance of Self-
Monitoring of Blood
                                                                                                                 Lawrence Blonde, MD,

Glucose (SMBG)                                                                                                   FACP, FACE
                                                                                                                 Director, Ochsner Diabetes
                                                                                                                 Clinical Research Unit,
                                                                                                                 Section on Endocrinology,




D
                                                                                                                 Diabetes, and Metabolic
                  iabetes is a serious disease with far-reaching consequences.1,2                                Diseases, Ochsner Clinic
                  In 2002, the disease and its complications cost the United States                 Foundation, New Orleans, La
                  about $132 billion. Direct costs had doubled since 1997 and costs
                  are expected to continue to increase. Type 1 and type 2 diabetes
                  currently affect over 18 million Americans, or 6.3% of the popula-
                                                                                                     Learning
     3
tion. Additionally, an estimated 5.2 million people remain undiagnosed, and more                       Objectives
than 40 million Americans have pre-diabetes, a precursor condition characterized                     Upon completion of this course,
by plasma glucose levels that are above normal but below the values diagnostic of                    you should be able to:
diabetes.3,4 Primary healthcare professionals will care for the majority of the dramat-
                                                                                                        Discuss the current prevalence
ically enlarging type 2 diabetes patient population, ranging from teenagers to the
                                                                                                        of type 2 diabetes
elderly. They face a tremendous challenge in diagnosing and managing patients with
type 2 diabetes in order to reduce the risk of costly, life-threatening complications,                  Summarize the current guide-
and help their patients maintain a high quality of life.                                                lines for glycemic control in
                                                                                                        patients with type 2 diabetes

                                                                                                        Describe the ability of self-
What Contributes to the Development              illness, some medications, and other factors.          monitoring of blood glucose
Of Diabetes?                                     The insulin resistance is often accompanied            (SMBG) to empower patients
Unlike type 1 diabetes, which is associated      by abnormalities such as hypertension, cen-            and facilitate improved
with a marked deficiency of insulin, patients    tral obesity, a characteristic dyslipidemia with       glycemic control
with type 2 diabetes have two defects. They      high triglycerides, low HDL, and the pres-
                                                                                                     For information on how to earn
have at least a relative deficiency of insulin   ence of smaller denser and more atherogenic
                                                                                                     CME/CE credit, see inside front
secretion, but they also have a resistance to    LDL particles and high levels of PAI1, as well
the action of both endogenous and exog-          as other indications of a hypercoagulable           cover. To view disclosure infor-
enous insulin. The insulin resistance has        state. Thus, these patients often have mul-         mation, see page 5.
both genetic and acquired components.            tiple components of the insulin resistance or       Participation in this self-study
Other than a few rare mutations, the com-        metabolic syndrome.5                                activity should be completed in
mon forms of the genetic abnormalities                                                               about 1 hour.
are largely unidentified. Acquired insulin       The Importance of Glycemic Control
resistance is related to overeating and the      Appropriate treatment of type 2 diabetes            Course ID: AB0333
resultant obesity, physical inactivity, aging,   requires addressing all abnormalities in

                                                                                                                CME-TODAY                     17
Managing Type 2 Diabetes in the Primary Care Setting: The Importance of Self-Monitoring of Blood Glucose (SMBG)

                                            TABLE 1. SUMMARY OF DIABETES RISK-REDUCTION TRIALS
TRIAL                              MEASURE EVALUATED                   RELATIVE RISK                       RELATIVE RISK                      RELATIVE RISK
                                                                       REDUCTION IN                        REDUCTION IN                       REDUCTION IN
                                                                       EYE DISEASE                         KIDNEY DISEASE                     CARDIOVASCULAR DISEASE
UK Prospective                     A1C reduction of 0.9%;              Retinopathy, 21%                    Albuminuria, 33%                   Myocardial infarction, 16%
Diabetes Study                     blood pressure of 144/82
                                                                       Cataract extraction, 24%            N/A                                Stroke, 44%
                                   mm Hg compared with
                                                                       Retinopathy progression, 34%
                                   average blood pressure of                                                                                  Heart failure, 56%
                                   154/87 mm Hg                        Vision deterioration, 47%

Hypertension Optimal               Diastolic treatment goal:           N/A                                 N/A                                Cardiovascular events, 51%
Treatment Study                    80 mm Hg
Heart Outcomes                     Ramipril in patients with           N/A                                 N/A                                Stroke, myocardial infarction,
Prevention                         diabetes                                                                                                   or cardiovascular death,
Evaluation Study                                                                                                                              25% to 30%
Captopril                          Captopril in patients with          N/A                                 N/A                                Cardiovascular death, 48%
Prevention Project                 diabetes
Reprinted with permission from Gavin JR III, Peterson K, Warren-Boulton E. Reducing cardiovascular disease risk in patients with type 2 diabetes: a message from the national
diabetes education program. Am Fam Phys. 2003;68(8):1569-1578.


                                                                                                                        order to reduce the associated microvas-
     TABLE 2. SUMMARY OF RECOMMENDATIONS FOR ADULTS WITH DIABETES
                                                                                                                        cular (eye and kidney disease), neuro-
 GLYCEMIC CONTROL                                                                                                       logic, and macrovascular complications.
 AIC                                          <7.0%*                                                                    Patients need therapy aimed at achieving
 Preprandial plasma glucose                   90–130 mg/dL (5.0–7.2 mmol/l)                                             recommended targets for increased blood
                                                                                                                        pressure and dyslipidemia in addition to
 Postprandial plasma glucose†                 <180 mg/dL (<10.0 mmol/l)                                                 hyperglycemia if complications are to be
 Blood pressure                               <130/80 mm Hg                                                             averted (Table 1).6-13
 LIPIDS‡
 LDL                                          <100 mg/dL (<2.6 mmol/l)                                                  A key component of good management
                                                                                                                        is glycemic control. The American Dia-
 Triglycerides                                <150 mg/dL (<1.7 mmol/l)                                                  betes Association (ADA) advocates a goal
 HDL                                          >40 mg/dL (>1.1 mmol/l)§                                                  A1C of <7%. The latest ADA Standards
 Key concepts in setting glycemic goals:                                                                                of Care indicate that more stringent
 • Goals should be individualized                                                                                       goals (Table 2) (i.e., a normal A1C of
 • Certain populations (children, pregnant women, and elderly) require special                                          <6%) can be considered in individual
   considerations                                                                                                       patients.14 The American College of
 • Less intensive glycemic goals may be indicated in patients with severe or frequent                                   Endocrinology (ACE) advocates a target
   hypoglycemia                                                                                                         of ≤6.5%.15 Ideally, one should strive for
 • More stringent glycemic goals (i.e., a normal A1C, <6%) may further reduce                                           A1C values as close to normal as can be
   complications at the cost of increased risk of hypoglycemia (particularly in those with                              achieved without an unacceptable inci-
   type 1 diabetes)                                                                                                     dence of adverse events, especially hypo-
 • Postprandial glucose may be targeted if AIC goals are not met despite reaching                                       glycemia, because there is no evidence
   preprandial glucose goals                                                                                            for a glycemic threshold for diabetic
                                                                                                                        complications. Obviously, all goals should
 *Referenced to a non-diabetic range of 4.0%–6.0% using a DCCT-based assay. †Postprandial glucose
                                                                                                                        be individualized and certain populations,
 measurements should be made 1–2 h after the beginning of the meal, generally peak levels in patients                   including children, pregnant women, and
 with diabetes. ‡Current NCEP/ATP III guidelines suggest that in patients with triglycerides >200 mg/dL,                the elderly, require special considerations.
 the “non-HDL cholesterol” (total cholesterol minus HDL) be utilized. The goal is <130 mg/dL. §For women,               Less intensive glycemic goals may well
 it has been suggested that the HDL goal be increased by 10 mg/dL.
                                                                                                                        be indicated in those with or at risk for
 Adapted from the American Diabetes Association.14
                                                                                                                        severe or frequent hypoglycemia.
                                                           Source of Evidence: Standards of medical care in
                                                           diabetes. Diabetes Care. 2004 Jan;27(suppl 1):S15-35.        Benefits of Glycemic Control
                                                                                                                        Achieving glycemic goals established
                                                           Strength of Evidence A                                       by the ADA, ACE, and other organiza-
 Practice Recommendation: Lowering glycated
 hemoglobin (A1C) has been associated with                                                                              tions will significantly reduce the risk
 a reduction in microvascular and neuropathic              Web Site: www.guideline.gov/summary/
                                                                                                                        of microvascular disease, and there is
 complications of diabetes.                                summary.aspx?ss=15&doc_id=4679&nbr=3413
                                                                                                                        increasing evidence that it will also

18             CME-TODAY
                          Managing Type 2 Diabetes in the Primary Care Setting: The Importance of Self-Monitoring of Blood Glucose (SMBG)

reduce macrovascular complications in                                                        FIGURE 1. IMPROVEMENT IN QUALITY-OF-LIFE ENDPOINTS
type 1 and type 2 diabetes patients. The




                                                                                                                                                                   ++
epidemiologic analysis of the landmark
United Kingdom Prospective Diabetes                                                0.4                                                                                   Improved
                                                                                                             Placebo
Study (UKPDS) of individuals with type
                                                                                                                                     †              †
2 diabetes demonstrated that for each 1                                                                      Glipizide GITS
percentage-point reduction in A1C, there
                                                                                   0.3
                                                                                                    *




                                                 Change From Baseline (SD Units)
was a 14% reduction in myocardial infarc-
                                                                                   0.2
tion and all-cause mortality, a 21% reduc-
tion in diabetes-related death, and a 37%
                                                                                   0.1
reduction in microvascular disease.7 In
UKPDS 35, the risk of diabetic complica-
tions was strongly associated with previ-                                            0
ous hyperglycemia. Thus, the benefits of
glycemic control are well-demonstrated.                                            -0.1

                                                                                   -0.2
  Exercise 1
  Which of the following is correct regarding                                      -0.3                                                                                  Worsened
  optimal glycemic control of diabetes?                                                   Quality–of–Life   Mental            Cognitive       General        Symptom
                                                                                          Analog Rating     Health            Function    Perceived Health    Distress
  a. Optimal glycemic control means main-
     taining blood glucose levels as close to    Mean changes from baseline to week 15 for the global scales of quality-of-life for patients randomized to
     non-diabetic levels as possible without     diet and placebo or diet and glipizide gastrointestinal therapeutic system (GITS).
     an unacceptable incidence of adverse        * indicates P <.05; † indicates P <.01; and ‡ indicates P <.001.
     events like hypoglycemia                    Source: Testa MA, Simonson DC. Health, economic benefits, and quality of life during glycemic control in patients
  b. Optimal glycemic control is likely          with type 2 diabetes mellitus. JAMA. 1998;280:1490-1496.
     to reduce the risk of macrovascular
     complications in type 1 and type 2                 that provides a complete picture of                                       The ADA recommendations on SMBG
     diabetes patients                                  glucose levels                                                            include the following statements: “SMBG
  c. Optimal glycemic control has been shown            In the management of type 2 diabetes,                                     is an integral component of diabetes
     to reduce the risk of eye, kidney, and             physicians and patients may be reluc-                                     therapy and it should be included in the
     nerve complications of diabetes                    tant to initiate insulin therapy when it                                  management plan. Clinicians are advised
  d. All of the above                                   is needed                                                                 to instruct the patient in SMBG and rou-
                                                                                                                                  tinely evaluate the patient’s technique
  Answer on page 24.                            Monitoring Therapy: A1C and Self-                                                 and ability to use data to adjust therapy.
                                                Monitoring of Blood Glucose (SMBG)                                                Frequency and timing of SMBG should be
                                                Assessment of glycemia is obviously a                                             dictated by the particular needs and goals
How Do We Achieve Glycemic Targets?             crucial component of optimal diabetes                                             of the patients. Daily SMBG is especially
A recent study assessing NHANES 2000            care. A1C levels provide the “big picture”                                        important for patients treated with insulin
data noted that only 37% of participants        and correlate with end-organ impact;                                              to monitor for and prevent asymptomatic
with diabetes achieved an A1C of <7%,           they have been used as a surrogate for                                            hypoglycemia. For most patients with
and 37% were above 8%.16 This finding           the development of complications. SMBG                                            type 1 diabetes and pregnant women tak-
is discouraging—especially given the dra-       values are also important and provide                                             ing insulin, SMBG is recommended 3 or
matic increase in the number of people          the day-to-day data on patterns of glyce-                                         more times daily.” The ADA indicates that
with diabetes—and suggests that the             mia that are used to select and manage                                            optimal frequency and timing of SMBG
burden of both micro- and macrovascu-           antihyperglycemic therapy. Thus, SMBG                                             for patients with type 2 diabetes is not
lar complications will increase, adversely      allows the design and implementation                                              known but should be sufficient to facilitate
affecting the national healthcare picture.      of treatment programs that more closely                                           reaching glucose goals. When adding to
There are likely many factors contributing      mimic the non-diabetic physiology.                                                or modifying therapy, type 1 and type 2
to the failure of many people with diabe-                                                                                         diabetic patients should test more often
tes to achieve glycemic targets:                Current SMBG recommendations for                                                  than usual.14
   Physicians and other primary healthcare      patients with type 1 diabetes are explicit
   professionals often have time constraints    and are based on the research protocols                                           Recently, an AAFP Panel on Self-Moni-
   and competing priorities during visits       of the DCCT and the Stockholm Diabetes                                            toring of Blood Glucose, a group that
   Patients may have difficulty adhering to     Intervention Study.8,17 For many years,                                           included experts in diabetes care, epide-
   recommendations for lifestyle changes,       there were no widely accepted guidelines                                          miology, and family medicine, addressed
   medications, or performance of SMBG          for patients with type 2 diabetes and, for                                        this need and published their findings
   Insurers sometimes fail to adequately        the most part, decisions were left up to the                                      in a monograph.18 The panel made the
   support self-monitoring at a frequency       treating physician.                                                               following recommendations about the

                                                                                                                                                CME-TODAY                     19
Managing Type 2 Diabetes in the Primary Care Setting: The Importance of Self-Monitoring of Blood Glucose (SMBG)

frequency of SMBG in patients with type
                                                 FIGURE 2. RELATIONSHIP BETWEEN IMPROVEMENTS IN A1C AND QUALITY OF LIFE
2 diabetes. Patients who use multiple
daily injections of insulin should per-                                          0.4
form SMBG as often as those who have
type 1 diabetes (at least three times per                                                Favorable QOL Response
                                                                                 0.2
day). Many patients taking oral antidia-




                                                  QOL Global Outcome (z Score)
betic agents who have not achieved their
A1C goal may require SMBG multiple                                                 0
times per day (two to four). The SMBG
monograph also recommends:
                                                                                 -0.2
   All patients who have diabetes should
   own a glucose meter and know
   how to use it                                                                 -0.4
   Patients whose diabetes is not well-
   controlled should test multiple times                                                                                                     Unfavorable QOL Response
                                                                                 -0.6
   per day for several days to produce suf-
   ficient data for clinical decision-making
                                                                                 -0.8
SMBG provides the most reliable data to                                                           >1.5            1.5 to 0.5   0.5 to -0.5   -0.5 to -1.5   <-1.5
                                                                                 Worsened                                                                           Improved
assess the combined effect of medications,                                       HbA1C Levels                      HbA1C Change from Baseline, %                    HbA1C Levels
diet, exercise, and physiology on patients’
daily glycemia. SMBG also provides impor-        Calibration of baseline to week 15 change in the quality-of-life (QOL) global outcome factor scores to change
tant feedback that may motivate patients         in hemoglobin A1C (HbA1C) expressed as 5 categories. Coordinates shown are mean (±SE) QOL change scores
to better adherence.                             within each HbA1C change category with corresponding log-linear fitted function for the 5 mean coordinates
                                                 (P <.001). Full regression sum of squares for QOL changes as a function of actual change in HbA1C was
                                                 statistically significant at P =.008.
                                                 Source: Testa MA, Simonson DC. Health, economic benefits, and quality of life during glycemic control in
  Exercise 2                                     patients with type 2 diabetes mellitus. JAMA. 1998;280:1490-1496.
  Which of the following suggestions
  were made by the AAFP Panel on Self-         less frequent monitoring (P<0.0001).19                                          and UKPDS. But Testa and Simonson21
  monitoring of Blood Glucose?                 Even those with nonpharmacologically                                            have shown that quality of life can also
  a. All patients who have diabetes            treated type 2 diabetes who practiced SMBG                                      be improved by alleviating the short-term
     should own a glucose meter and            (at any frequency) had a 0.4 percentage                                         symptoms of hyperglycemia. In this ran-
     know how to use it                        point lower A1C level than those not prac-                                      domized, placebo-controlled study, the
  b. Type 2 diabetes patients who use          ticing at all (P<0.0001).                                                       quality of life and economic benefit—in
     multiple daily injections of insulin                                                                                      terms of lost workdays, bed days, and
     should perform SMBG as often as           Schwedes and colleagues20 showed                                                restricted activity days, were compared
     those who have type 1 diabetes            that meal-related (pre- and 1-hour post-                                        between a group using placebo and diet
     (at least three times per day)            prandial) SMBG within a structured                                              to control glucose levels and a group
  c. Many type 2 diabetes patients taking      counseling program improved glycemic                                            using the glipizide gastrointestinal thera-
     oral antidiabetic agents who have         control in individuals with non–insulin-                                        peutic system (GITS) and diet. The bet-
     not achieved their A1C goal may           treated type 2 diabetes. Self-monitoring                                        ter control attained from glipizide GITS
     require SMBG multiple times per day       also resulted in a marked improvement                                           produced a clear advantage in quality-of-
     (two to four)                             of general well-being, with significant                                         life endpoints (Figure 1).
  d. All of the above                          improvements in the subitems of depres-
                                               sion (P<0.032) and lack of well-being                                           Quality of life rises with A1C improve-
  Answer on page 24.                           (P<0.02).                                                                       ments from baseline (Figure 2). The
                                                                                                                               economic impact of improved glycemic
                                               Quality of Life and Economic Benefit                                            control is also clear. At the beginning of
There is increasing evidence for the benefit   Of Improved Glucose Control                                                     the study, health-related absenteeism,
that can be accrued from the performance of    It’s logical to assume that improved                                            bed days, and days of restricted activity
SMBG. A report of 24,312 adults with dia-      glucose control leads to improved qual-                                         were similar between the placebo and
betes in a large, group-model managed care     ity of life. The advent of new oral agents                                      glipizide GITS groups. As glycemic con-
organization (MCO) noted that those with       and the development of better tools for                                         trol improved over time in the glipizide
type 1 diabetes who performed SMBG three       SMBG have prompted studies of both                                              GITS group, differences became appar-
or more times per day and those with phar-     quality of life and economic benefit.                                           ent in all endpoints, including produc-
macologically treated type 2 patients who                                                                                      tivity and retention of employment.
performed SMBG one or more times per           One measure of quality of life would
day had A1C levels that were 1% and 0.6%       be the delay or prevention of long-term                                         In considering economic benefit, we
less, respectively, than those who performed   complications, as shown by the DCCT                                             should also look at the overall cost of

20           CME-TODAY
                        Managing Type 2 Diabetes in the Primary Care Setting: The Importance of Self-Monitoring of Blood Glucose (SMBG)

treatment. The same study showed that          whole blood values, so it is incumbent
improved glycemic control reduced the          on patients and their providers to know         Exercise 3
use of non–study-related healthcare ser-       to which their unit is calibrated. Plasma       There is a wide choice of home glucose
vices resulting in a savings of $11 per        calibration is more easily compared             meters available in the marketplace today.
month per patient.                             with laboratory methods. Meters can             Which of the following is not an accurate
                                               also report glucose levels either in            statement about meters?
In a cost-effectiveness study from the         milligrams/deciliter or millimoles/liter.       a. Meters employ one technology:
UKPDS, the cost of intensive treatment         Plasma glucose is rapidly becoming                 absorptive photometry
(sulfonylureas and insulin) versus con-        the preferred standard and, in the U.S.,        b. Meters provide glucose values
ventional treatment (diet alone) in type 2     glucose levels are most commonly                   calibrated to either whole blood
diabetes patients was weighed against the      presented in mg/dL.                                or plasma, but not both
cost of treating complications.22 Intensive                                                    c. Meters can report glucose levels
control increased treatment cost by £695       Meters employ one of two technologies:             either in milligrams/deciliter or
per patient over the course of the study.       Reflectance Photometry: the meter                 millimoles/liter
However, this was offset by a reduction         measures light reflected from the              d. Newer meters are fully automatic and
in the cost of complications of £950 per        strip. Increasing glucose concentra-              need only a drop of peripheral blood
patient, indicating an economic benefit to      tions produce increasing amounts of
improved control. Additionally, intensive       dye resulting in less light reflected.         Answer on page 24.
control netted a mean of 1.14 event-free        The meter then uses custom algo-
years over a patient’s lifetime.                rithms to convert this signal into
                                                glucose results.                             Problems with meters often lie more with
Another study by Testa and Simonson23           Electrochemical measurements are             users than with the units themselves.
demonstrated that variability in daily          made when current is generated by            Patients must be thoroughly trained in
QOL ratings of an individual with diabe-        the glucose in the solution being            cleaning and lancing the skin to obtain a
tes was explained by both the absolute          tested. Increasing glucose concentra-        small amount of blood, applying it to the
level and the day-to-day variation in           tions produce increasing currents that       test strip, and reading the results. They
blood-glucose levels. This study provides       are measured by the meter. Custom            must make sure not to reuse strips, use
additional evidence of the benefits of          algorithms are used to convert the           outdated strips, or expose test strips to
both improving A1C values and reducing          measured current into glucose results.       adverse humidity and temperature con-
fluctuations in daily glucose profiles. This                                                 ditions. Control solutions are available
cannot be achieved without the regular         Meters should be chosen on the basis of       for patients to verify that the strips have
performance of SMBG and utilization of         the following criteria:                       not deteriorated. Physicians must also
the resultant values to adjust therapy.          Accuracy: Manufacturers may calibrate       recognize that patients sometimes report
                                                 meters using different reference stan-      lower values than their meter reveals,
ADA preprandial and peak postpran-               dards, but should correlate with the        either because they don’t remember the
dial plasma-glucose goals are 90 to 130          reference method                            value or they “fudge” the value because
and <180 mg/dL, respectively.14 ACE              Precision: How reproducible are the         they want to please the provider. The vast
advocates for preprandial and 2-hour             results of each meter                       majority of modern meters have memory
postprandial values of <110 mg/dL and            Reliability: How consistent are repeated    and download capabilities.
<140 mg/dL, respectively.15                      results with multiple test strips
                                                 Ease of use: In general, the fewer
Home Glucose Meters and Software                 demands made on the user, the better          Exercise 4
In the U.S., there is a wide choice of           and the more likely patients will be to       There are a number of possible problems
home glucose meters from more than               use the meter                                 that arise with meters. Which of the fol-
a dozen manufacturers. While older               Safety: A meter should accept strips          lowing are true statements?
devices were more difficult to use, cur-         designed exclusively for it; some meters      a. Problems with meters lie mainly with
rent meters are fully automatic and              will reject out-of-date test strips and          the units themselves
require only a drop of peripheral blood          test solutions                                b. Patients must be thoroughly trained in
from the patient. Some of the newest             Memory and data management: Result               cleaning and lancing the skin to obtain
meters, such as the OneTouch Ultra,              storage and download capabilities                a small amount of blood, applying it to
take only 5 seconds to provide a result,         maximize the value of monitoring data            the test strip, and reading the results
require only a 1-µL blood sample, and            Power: Meters should use commonly             c. Patients sometimes report lower values
its strips automatically draw up blood           available batteries and have low-battery         than their meters indicate
by capillary action and indicate to the          indicators                                    d. Careful handling of test strips is neces-
user if the sample is adequate.                  Durability: Construction should be               sary in order to get an accurate reading
                                                 strong enough to survive typical use             from the meter
Meters provide glucose values calibrated         and abuse
to either whole blood or plasma, but             Ease of maintenance: Meters should be         Answer on page 24.
not both. Plasma values are higher than          easy to clean and disinfect, if necessary

                                                                                                            CME-TODAY                         21
Managing Type 2 Diabetes in the Primary Care Setting: The Importance of Self-Monitoring of Blood Glucose (SMBG)

ECRI, a nonprofit agency that evaluates all     Some newer meters can show blood glu-              significant responsibility to patients and a
health devices—from disposables to com-         cose averages by time of day for the past          number of studies suggest that the resultant
plex anesthesia machines—has a 2002             several days and present the information           patient empowerment enhances adherence.
review of home blood glucose meters that        to users without requiring downloading to
compares all available units according to a     a computer. Individuals who take insulin           From a psychological perspective, patient
comprehensive list of relevant parameters.      can have information immediately available         empowerment fits the model proposed by
You can contact the ECRI Healthcare Prod-       to guide insulin adjustments. Some meters          self-determination theory,24 which focuses
uct Comparison System Hotline at 610-           allow the entry of additional data, such as        on the fact that people feel better when they
825-6000, ext. 5265; 610-834-1275 (fax);        insulin doses administered, meals or snacks        perceive that they’re more in charge of their
or hpcs@ecri.org.                               eaten, grams of carbohydrates consumed,            own destiny. They feel powerful and impor-
                                                and physical activity.                             tant, and validated for their successes. Con-
Minimally Invasive and                                                                             sequently, primary care professionals should
Noninvasive Monitors                            Reimbursement Issues                               try to motivate patients by communicating
Currently there are two such devices            Most healthcare insurance providers reim-          that their own efforts can have a major posi-
approved for use in the U.S.:                   burse the cost of meters and test strips. The      tive impact on their healthcare outcomes.
  Medtronic MiniMed’s Continuous                only significant issue is the frequency of mon-
  Glucose Monitoring System (CGMS),             itoring they support, since the test strips rep-
  using a sensor implanted just under           resent an ongoing expense. Reimbursement             Exercise 5
  the skin, measures glucose levels every       is variable among different insurers. Some           Which of the following is true about
  5 minutes over a 72-hour period, after        insurance providers cover strips for only one        motivating patients with diabetes?
  which time, data must be downloaded           glucose reading a day for non–insulin-using          a. Management of the patient’s diabetes
  into a computer. Currently, this device       type 2 patients. A single daily reading (or             should be viewed by the physician
  cannot provide glucose reading in real        fewer) will be inadequate for many patients             as a collaborative effort
  time, and data cannot be viewed until         with type 2 diabetes to achieve control.             b. Studies suggest that patient empower-
  it is downloaded.                             This is especially true for many newly diag-            ment is a key to adherence
  Cygnus GlucoWatch Biographer. Worn            nosed patients and those who have not yet            c. Both a and b
  like a wristwatch, this device uses a non-    achieved their glycemic targets and who are          d. Neither a nor b
  invasive method to extract glucose con-       modifying their therapy. The AAFP SMBG
  taining interstitial fluid through the skin   monograph notes that many patients tak-             Answer on page 24.
  using an applied electrical potential (a      ing oral antidiabetic agents who have not
  process known as reverse iontophoresis).      achieved their A1C goal may require SMBG
  Glucose in the extracted sample is mea-       multiple times per day (two to four).18            Conclusions
  sured using an electrochemical enzymatic                                                         Type 2 diabetes is dramatically increasing in
  sensor. It requires some time for the         Motivating Your Patients                           incidence and prevalence. Primary health-
  device to warm up and it can then pro-        Diabetes is a serious, complicated disorder        care professionals will continue to need to
  vide 6 glucose measurements per hour          that is increasing at epidemic proportions.        provide the majority of care for the increas-
  for up to 13 hours. The GlucoWatch            Patients and healthcare professionals often        ing numbers of patients with this disorder.
  displays data that the wearer can read        find treatment to be complex and challeng-         In order to help meet this challenge, they
  in real time as it is obtained.               ing. Diabetes self-management training is one      should focus on the following key points:
                                                of the most critical components of care and          Achieving ADA and/or ACE targets for
Neither the CGMS nor the GlucoWatch             is often associated with enhanced adherence.         glycemic control can reduce complications
is currently approved for use alone, but        Self-management of diabetes requires knowl-          in patients with type 2 diabetes just as it
rather should be used to supplement and         edge of the disease, the treatment options,          can for those with type 1 disease
support data obtained from a conventional       and the relationship between glucose levels,         All patients with diabetes should
glucose meter.                                  diet, weight, and exercise. There are many           receive diabetes education focused
                                                other educational needs, including learning          on self-management training
Glucose Monitoring Software                     how to perform SMBG and to use the data              Regular monitoring of both A1C and
Computer software available for modern          obtained appropriately. Primary healthcare           SMBG will be required for patients to
meters allows blood glucose data to be          professionals can provide their patients with        achieve optimal glycemic control
organized and structured into informa-          needed education through referral to certified       All patients should be taught how to per-
tion that individuals with diabetes and         diabetes educators, registered dietitians, and       form SMBG and how to interpret and use
healthcare professionals can analyze and        other certified nutritionists, preferably work-      the results to improve glycemic control
synthesize to facilitate adjustments in         ing in a team diabetes education program             Physicians should obtain and use soft-
therapy and improve glycemic control.           that has achieved ADA Recognition.                   ware designed to analyze SMBG readings;
These programs can average all read-                                                                 such software can also be of value to
ings and in some cases do so by time            Motivational models abound in the literature.        many patients
of day, day of the week, or meal period.        The most important ones focus on a col-              SMBG empowers patients, provides neces-
The software can plot graphs and create         laborative effort between patients and their         sary feedback, and increases the likelihood
charts of glucose trends over time.             healthcare professionals. Such models give           of success -

22           CME-TODAY
                     Managing Type 2 Diabetes in the Primary Care Setting: The Importance of Self-Monitoring of Blood Glucose (SMBG)

                                           Bibliography
For More Information
                                            1. American Diabetes Association. Economic consequences of diabetes mellitus in the US in 1997.
Visit These Web Sites:
                                               Diabetes Care. 1998;21:296-309.
American Academy of Family                  2. Narayan KM, Gregg EW, Fagot-Campagna A, et al. Diabetes: a common, growing, serious, costly,
Physicians (AAFP)                              and potentially preventable public health problem. Diabetes Res Clin. 2000;50:S77-S84.
www.aafp.org                                3. Gorman C. Why so many of us are getting diabetes. Time. December 8, 2003.
                                            4. Centers for Disease Control and Prevention. National diabetes fact sheet: general information
American Association of Clinical               and national estimates on diabetes in the United States, 2002.
Endocrinologists                            5. Hellman R. Insulin resistance syndrome and type 2 diabetes. Endocr Pract. 2003;9(suppl 2)73-77.
www.aace.com                                6. Gavin JR III, Peterson K, Warren-Boulton E. Reducing cardiovascular disease risk in patients with type 2
                                               diabetes: a message from the national diabetes education program. Am Fam Phys. 2003;68(8):1569-1578.
American Association of Diabetes
                                                                              ,
                                            7. Stratton IM, Adler AI, Neil HAW et al. Association of glycaemia with macrovascular and microvascular com-
Educators (AADE)
                                               plications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ. 2000;32(7258):405-412.
www.aadenet.org
                                            8. The effect of intensive treatment of diabetes on the development and progression of long-term complications
American College of Physicians                 in insulin-dependent diabetes mellitus. The Diabetes Control and Complications Trial Research Group.
www.acponline.com                              N Engl J Med. 1993;329:977-986.
                                            9. Intensive blood-glucose control with sulfonylureas or insulin compared with conventional treatment and
American Diabetes Association (ADA)            risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS)
www.diabetes.org                               Group. Lancet. 1998;352:837-853.
                                           10. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes:
Centers for Disease Control
                                               UKPDS 38. UK Prospective Diabetes Study (UKPDS) Study Group. BMJ. 1998;31:703-713.
and Prevention (CDC)
                                           11. Hansson L, Zanchetti A, Carruthers SG, et al. Effects of intensive blood-pressure lowering and low-dose
www.cdc.gov/diabetes
                                               aspirin in patients with hypertension: principal results of the Hypertension. Optimal Treatment (HOT)
Diabetes Complications and                     randomized trial. HOT Study Group. Lancet. 1998;351:1755-1762.
Control Trial (DCCT) bibliography          12. Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus:
www.bsc.gwu.edu/bsc/studies/                   results of the HOPE study and the MICRO-HOPE substudy. Heart Outcomes Prevention Evaluation
dcct.html                                      Study Investigators. Lancet. 2000;355:253-259.
                                           13. Niskenana L, Hedner T, Hansson L, et al. Reduced cardiovascular morbidity and mortality in hypertensive
Diabetes Prevention Program (DPP)              diabetic patients on first-line therapy with an ACE inhibitor compared with a diuretic/beta-blocker-based
www.diabetes.niddk.nih.gov/dm/pubs/
                                               treatment regimen: a subanalysis of the Captopril Prevention Project. Diabetes Care. 2001;24:2091-2096.
preventionprogram
                                           14. American Diabetes Association. Standards of medical care in diabetes. Diabetes Care. 2004;27:15S-35S.
                                           15. The American Association of Clinical Endocrinologists. Medical guidelines for the management of
Food and Drug Administration (FDA)
information on glucose meters                  diabetes mellitus: the AACE system of intensive diabetes self-management: 2002 update. Available at:
www.fda.gov/diabetes/glucose.html#12           www.aace.com/clin/guidelines/diabetes_2002.pdf. Accessed: April 5, 2004.
                                           16. Saydah SH, Fradkin J, Cowie CC. Poor control of risk factors for vascular disease among adults with
Juvenile Diabetes Research                     previously diagnosed diabetes. JAMA. 2004;291:335-342.
Foundation                                 17. Reichard P, Britz A, Carlsson P, et al. Metabolic control and complications over 3 years in patients
www.jdf.org                                    with insulin-dependent diabetes mellitus (IDDM): the Stockholm Diabetes Intervention Study
                                               (SDIS). J Intern Med. 1990;228:511-517.
National Diabetes
                                           18. Mayfield J, Havas S, et al. Self-control: a physician’s guide to blood glucose monitoring in the management of
Education Program (NDEP)
                                               diabetes. Am Fam Phys Monograph. Available at: www.aafp.org/x25813.xml. Accessed: May 24, 2004.
www.ndep.nih.gov
                                           19. Karter AJ, Ackerson LM, Darbinian JA, et al. Self-monitoring of blood-glucose levels and glycemic control:
National Diabetes                              the Northern California Kaiser Permanente Diabetes Registry. Am J Med. 2001;111(1):1-9.
Information Clearinghouse                  20. Schwedes U, Siebolds M, Mertes G, for the SMBG Study Group. Meal-related structured self-monitoring
www.diabetes.niddk.nih.gov                     of blood glucose. Diabetes Care. 2002;25:1928-1932.
                                           21. Testa MA, Simonson DC. Health, economic benefits, and quality of life during improved glycemic control in
                                               patients with type 2 diabetes mellitus. JAMA. 1998;280:1490-1496.
                                           22. Gray A, Raikou M, McGuire A, et al. Cost-effectiveness of an intensive blood-glucose control policy in
                                               patients with type 2 diabetes: economic analysis alongside randomised controlled trial (UKPDS 41).
                                               BMJ. 2000;320:1373-1378.
                                           23. Testa MA, Simonson DC. Diabetes. 2003;52(suppl 1):1821P.
                                           24. Glasgow RE, Anderson RM. In diabetes care, moving from compliance to adherence is not enough.
                                               Diabetes Care. 1999;12:2090-2092.


                                                                                                                       CME-TODAY                           23
Managing Type 2 Diabetes in the Primary Care Setting: The Importance of Self-Monitoring of Blood Glucose (SMBG)


     Answers
  Exercise 1                                      Exercise 3                                     Answer: b, c, d. Problems with meters
  Which of the following is correct regarding     There is a wide choice of home glucose         are more likely to be related to the way
  optimal glycemic control of diabetes?           meters available in the marketplace            patients use them than due to the units
  a. Optimal glycemic control means main-         today. Which of the following is not           themselves. To ensure data reliability,
     taining blood glucose levels as close to     an accurate statement about meters?            physicians should recommend meters
     non-diabetic levels as possible without      a. Meters employ one technology:               with memory and download capabilities.
     an unacceptable incidence of adverse            absorptive photometry
     events like hypoglycemia                     b. Meters provide glucose values               Exercise 5
  b. Optimal glycemic control is likely              calibrated to either whole blood            Which of the following is true about
     to reduce the risk of macrovascular             or plasma, but not both                     motivating patients with diabetes?
     complications in type 1 and type 2           c. Meters can report glucose levels            a. Management of the patient’s diabetes
     diabetes patients                               either in milligrams/deciliter or              should be viewed by the physician as
  c. Optimal glycemic control has been shown         millimoles/liter                               a collaborative effort
     to reduce the risk of eye, kidney, and       d. Newer meters are fully automatic and        b. Studies suggest that patient empow-
     nerve complications of diabetes                 need only a drop of peripheral blood           erment is a key to compliance
  d. All of the above                             Answer: a. Meters employ one of two            c. Both a and b
  Answer: d. Research has shown that              technologies:                                  d. Neither a nor b
  improved glycemic control can signifi-          • Reflectance Photometry: the meter            Answer: c. No one has discovered the
  cantly reduce the development and/or               measures light reflected from the strip.    secret to universal patient motivation.
  progression of complications in patients           Increasing glucose concentrations pro-      What works well for one patient may
  with both type 1 and type 2 diabetes.              duce increasing amounts of dye result-      not work with another, or may even
                                                     ing in less light reflected. The meter      have an adverse reaction. Diabetes
  Exercise 2                                         then uses custom algorithms to convert      education should be provided to every
  Which of the following suggestions were            this signal into glucose results.           diabetic patient and can contribute to
  made by the AAFP Panel on Self-monitoring       • Electrochemical measurements are             improved adherence. Management of
  of Blood Glucose?                                  made when current is generated by the       a chronic illness like diabetes should
  a. All patients who have diabetes should           glucose in the solution being tested.       be a collaborative effort, in which the
     own a glucose meter and know how to             Increasing glucose concentrations pro-      patient and the healthcare professional
     use it                                          duce increasing currents that are mea-      are partners. As a collaborative effort,
  b. Type 2 diabetes patients who use multiple       sured by the meter. Custom algorithms       diabetes management puts great respon-
     daily injections of insulin should perform      are used to convert the measured cur-       sibility on the patient, and a number of
     SMBG as often as those who have type 1          rent into glucose results.                  studies suggest that patient empower-
     diabetes (at least three times per day)                                                     ment is one key to good adherence.
  c. Many type 2 diabetes patients taking oral    Exercise 4
     antidiabetic agents who have not achieved    There are a number of possible problems
     their A1C goal may require SMBG multiple     that arise with meters. Which of the fol-
     times per day (two to four)                  lowing are true statements?
  d. All of the above                             a. Problems with meters lie mainly with
  Answer: d. The achievement of optimal              the units themselves
  control requires an active cooperative          b. Patients must be thoroughly trained in
  effort to balance medications and life-            cleaning and lancing the skin to obtain
  style changes, guided by a comprehen-              a small amount of blood, applying it to
  sive understanding of what is happening            the test strip, and reading the results
  with the individual patient’s blood             c. Patients sometimes report lower values
  glucose levels. This understanding comes           than their meters indicate
  primarily from test results; the more           d. Careful handling of test strips is neces-
  data points included, the more complete            sary in order to get an accurate reading
  the picture.                                       from the meter




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24            CME-TODAY

				
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