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VOLUME 8 NUMBER 3 • SEPTEMBER 2011
DIABETES EDUCATOR’S FOCUS
SA JOURNAL OF DIABETES & VASCULAR DISEASE
1. SMBG should be used only when individuals with diabetes (and/or their
care-givers) and/or their healthcare providers have the knowledge,
skills and willingness to incorporate SMBG monitoring and therapy
adjustment into their diabetes care plan in order to attain agreed
treatment goals.
2. SMBG should be considered at the time of diagnosis to enhance the
understanding of diabetes as part of their education and to facilitate
timely treatment initiation and titration optimisation.
3. SMBG should also be considered as part of ongoing diabetes self-
management education to assist people with diabetes to better
understand their disease and provide a means to actively and effectively
participate in its control and treatment, modifying behavioural and
pharmacological interventions as needed, in consultation with their
healthcare provider.
4. SMBG protocols (intensity and frequency) should be individualised to
address each individual’s specific educational, behavioural, clinical and
provider requirements for data on glycaemic patterns and monitor
impact of therapeutic decision making.
5. The purpose(s) for performing SMBG and using SMBG data should be
agreed between the person with diabetes and the healthcare provider.
These agreed upon purposes/goals and actual review of SMBG data
should be documented.
6. SMBG use requires an easy procedure for patients to regularly monitor
the performance and accuracy of their glucose meter.
Table 1.
IDF 2009 guidelines: recommendations for SMBG use in non-
insulin-treated diabetes
Recommends SMBG
for patients:
on intensified insulin therapy
•
on basal and premixed insulin
•
with T2DM on diet/oral agents in case of special circumstances of:
•
–
newly diagnosed diabetes
–
acute illness
–
therapy modification
–
pregnancy
–
unexplained or unnoticed hypoglycaemia
–
coronary artery disease
–
neuropathy
Table 3.
National Institute of Health and Clinical Excellence (NICE)
guidelines.
risk. Both genetic factors and blood glucose variability play
important roles.
24,25,32
In 2010, three publications contributed to our knowledge
on SMBG. The Bonomo
et al.
trial
25
in 273 patients showed
an improvement in glycaemic control, measured by HbA
1c
level, when the patients were compliant with the intensive
SMBG strategy. Although general compliance was not that
good, there was still a benefit shown. It was also noticed that
glycaemic control could be improved by SMBG if there was a
good understanding of testing and interpretation by both the
patient and healthcare professional.
The Duran
et al.
trial
26
confirmed that SMBG was of
benefit in 161 newly diagnosed type 2 diabetics who were
observed for one year. SMBG is now recommended for all
newly diagnosed type 2 diabetic by the International Dia-
betes Federation (IDF).
28
The Kemph trial was a 12-week
lifestyle intervention study, which showed glucometabolic
improvements of 0.3%, as measured by HbA
1c
levels, with
SMBG and structured lifestyle interventions.
27
The IDF published guidelines in 2009 for SMBG in type
2 diabetes and made clear recommendations regarding its
use.
28
These are summarised in Table 1.
28
The European con-
sensus statement on the frequency and timing of SMBG in
type 2 diabetes is summarised in Table 2.
29
This can be com-
pared to the NICE guidelines from the UK, which are sum-
marised in Table 3.
30
In February 2011, the STeP (Structure Testing Program)
study on 483 patients was published in
Diabetes Care
.
33
The
aim was to assess blood glucose testing in poorly controlled
non-insulin-treated type 2 diabetics. Both patients and phy-
sicians participated in a collaborative programme to gather,
interpret and appropriately use structured SMBG data. The
patients were followed for 12 months and the primary end-
point was change in HbA
1c
levels at 12 months.
STeP was a two-arm prospective, randomised trial in 34
primary-care practices in the United States on 483 non-
insulin-treated type 2 diabetics. It was important to note
that the sites were randomised, not the individual patients.
There were two groups; the active control group (ACG) had
usual care with quarterly physician visits. Point-of-care HbA
1c
monitoring was done, and SMBG was freely available. A
structured testing group (STG) received the same care as the
ACG, but also used the Accu-Check 360 degree View blood
glucose analysis system.
The results were analysed both as intention-to-treat (ITT) and
as a per-protocol analysis. The ITT analysis included all patients
Table 2.
Consensus on the frequency and timing of SMBG testing by
treatment.
Treatment
Frequency
Timing
Intensified
insulin
4–8 tests
per day
•
Primarily pre-prandial and bedtime
•
7–10 tests per week postprandial
•
Nocturnal once per week
•
Should follow ISPAD guidelines
if aged
<
18 years
Conventional
insulin
2–4 tests
per day
•
Primarily pre-prandial
•
Postprandial 1–2 times every day
•
Nocturnal once weekly or fortnightly
Oral glucose-
lowering
6–8 tests per
week
•
Equal pre- and postprandial tests
•
Infrequent testing should be done in
pairs (pre
+
postprandial)
•
7-point monitoring over a single day
once per week or month
Newly-
diagnosed
T2DM
3–5 tests per
week
•
To improve patient awareness and
compliance to lifestyle modification
and treatment
Gestational
dabetes
4–8 tests per
day
•
High frequency recommended
during
pregnancy
•
Postprandial testing performed
at 1 hour postprandial
