{"id":1145,"date":"2016-10-31T15:28:13","date_gmt":"2016-10-31T15:28:13","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/?p=1145"},"modified":"2017-08-21T10:44:52","modified_gmt":"2017-08-21T10:44:52","slug":"primary-care-corner-with-geoffrey-modest-md-glucometers-lower-a1cs-in-non-insulin-using-diabetics-a-little","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/10\/31\/primary-care-corner-with-geoffrey-modest-md-glucometers-lower-a1cs-in-non-insulin-using-diabetics-a-little\/","title":{"rendered":"Primary Care Corner with Geoffrey Modest MD: Glucometers Lower A1c&#8217;s in Non-Insulin Using Diabetics, a Little"},"content":{"rendered":"<p><strong>By Dr. Geoffrey Modest <\/strong><\/p>\n<p>BMJ just published a meta-analysis of randomized controlled trials (RCTs), finding that non-insulin using diabetic\u00a0patients who\u00a0self-monitored their blood sugars had improved glycemic control\u00a0(see\u00a0doi:10.1136\/bmjopen-2015-010524 ). This analysis included several new studies, not available in prior reviews.<\/p>\n<p>Details:<\/p>\n<ul>\n<li>15 RCTs were identified with 3383 patients<\/li>\n<li>Results:\n<ul>\n<li>Those using SMBG (self-monitoring of blood glucose) had:\n<ul>\n<li>Lower\u00a0HbA1c by\u00a0\u22120.33 (\u22120.45 to \u22120.22); p&lt;0.001 [the quality of evidence was rated as moderate]<\/li>\n<li>Lower\u00a0BMI by\u00a0\u22120.65 (\u22121.18 to \u22120.12); p=0.02\u00a0[the quality of evidence was rated as low]<\/li>\n<li>Lower\u00a0total cholesterol (TC)\u00a0by\u00a0\u22120.12 (\u22120.20 to \u22120.04); p=0.003\u00a0[the quality of evidence was rated as high]<\/li>\n<li>Lower\u00a0waist circumference by -2.22 (-4.40 to\u00a0-0.03); p=0.047\u00a0[no comment, but i assume that is in\u00a0centimeters;\u00a0the quality of evidence was rated as moderate]<\/li>\n<li>No significant difference in fasting\u00a0plasma glucose, systolic or diastolic BP, HDL, LDL, triglycerides, or\u00a0weight<\/li>\n<li>Subgroup analyses: no difference if Asian countries or\u00a0US\/Europe; A1C was improved in both short-term (&lt;6 month, by -0.36%) or long-term studies\u00a0(&gt;12\u00a0month, by -0.28%). BMI and\u00a0TC changes were only significant in the &lt;6 month group. and though\u00a0waist circumference was improved overall, it was\u00a0not significantly improved in the subgroups, but was near-significant (p=0.06)\u00a0only in the &gt;12 month group (by -3.15); also similar A1C reductions were found in patient with newly diagnosed type 2 diabetes (T2DM) vs duration &gt;12 months [no further analysis for really long-termers]; SMBG was significantly more effective in patients with lower A1C (&lt;8%) vs higher<\/li>\n<\/ul>\n<\/li>\n<li>Adverse events: most common was the incidence of\u00a0hypoglycemia (higher in SMBG group), though their rate (episodes\/patient) was lower<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>Commentary:<\/p>\n<ul>\n<li>Prior concern about SMBG reflect its high cost (21% of diabetic prescription costs in the US) and several studies suggesting its\u00a0lack of efficacy in non-insulin using T2DM\u00a0patients (e.g. Farmer AJ BMJ 2012;344:e486), even though currently\u00a063.4% of T2DM\u00a0use SMBG daily<\/li>\n<li>The analysis, as with pretty much all meta-analyses, is limited by the quality of the studies included,\u00a0their size, differences in\u00a0methodology in general, degree\u00a0of\u00a0patient education,\u00a0frequency of testing, and inherent\u00a0biases associated with the\u00a0more intensive medicalization in those doing SMBG<\/li>\n<li>The decrease in A1C of -0.33%\u00a0is often not considered to be clinically significant (typically\u00a0defined as a change of 0.5%)<\/li>\n<li>So, this study does suggest efficacy of SMBG monitoring, albeit perhaps of marginal clinical significance. As an intervention, it does medicalize patients\u00a0much more than just taking a pill. And this has the potential for\u00a0both positive and negative effects: the positive side is that it may empower patients in involving them more in taking ownership and\u00a0treating their condition, and for some patients, this involvement might be important in helping them deal psychologically\u00a0with a potentially devastating disease; the negative side is that for some patients it might create lots of anxiety and perhaps over-focus\/dwelling on their medical problems and perhaps reinforce a more passive, &#8220;sickness&#8221; mentality which could decrease\u00a0their ability to function.<\/li>\n<li>This last difference exposes one of the contradictions of RCTs: they look at a large group of individuals, with some exclusions, but cannot really replicate the actual patient one is treating.\u00a0It may well be that some patients who want to control their bodies and illnesses more, actually do much better with SMBG than decreasing their A1C by the\u00a00.33% as above, perhaps using the daily blood sugar\u00a0feedback as a motivation for more lifestyle changes (and, even if the A1C does not plummet, these lifestyle changes might have much broader healthful consequences). Others who may become more anxious or are not interested in this level of involvement, may get no benefit, or the experience might actually\u00a0be negative. And the sum of these patients in the larger RCTs\u00a0may then reveal only a mediocre outcome, obscuring the potential benefit for perhaps a lot of people. The real trick might be to figure out who is motivated by the SMBG and use this tool to help them with their diabetes management. And perhaps not using or\u00a0stopping SMBG in those who do not really benefit. So, yet again, one size just does not fit all&#8230;.<\/li>\n<\/ul>\n","protected":false},"excerpt":{"rendered":"<p>Primary Care Corner with Geoffrey Modest MD: Glucometers Lower A1c&#8217;s in Non-Insulin Using Diabetics, a Little  [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/10\/31\/primary-care-corner-with-geoffrey-modest-md-glucometers-lower-a1cs-in-non-insulin-using-diabetics-a-little\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":148,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[14283],"tags":[],"class_list":["post-1145","post","type-post","status-publish","format-standard","hentry","category-archive"],"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/1145","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/users\/148"}],"replies":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/comments?post=1145"}],"version-history":[{"count":0,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/1145\/revisions"}],"wp:attachment":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/media?parent=1145"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/categories?post=1145"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/tags?post=1145"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}