Intended for healthcare professionals

Rapid response to:

Research

Impact of self monitoring of blood glucose in the management of patients with non-insulin treated diabetes: open parallel group randomised trial

BMJ 2007; 335 doi: https://doi.org/10.1136/bmj.39247.447431.BE (Published 19 July 2007) Cite this as: BMJ 2007;335:132

Rapid Response:

Don't take my parachute away!

In this week's BMJ Farmer and colleagues report the results of their
trial in well-controlled type 2 diabetes who were not taking insulin. They
claim no benefit of an effect of self-monitoring of blood glucose (SMBG)
on glycemic control, with and without diabetes education, compared with
usual care. This study reminds me of a previous study published in BMJ:
Parachute use to prevent death and major trauma related to gravitational
challenge: systematic review of randomized controlled trials Smith GC et
al. BMJ 2003;327:1459-1461, that asserted that the effectiveness of
parachutes has not been subjected to rigorous evaluation by using
randomized controlled trials. What is wrong with the academicians these
days? Have we exhausted all research areas of medicine and we are turning
against the well-established medical milestones of the past half century
of research.

If we applied the message of this study, we would not have had DCCT or
UKPDS trials. Those 2 trials are considered the jewels and of all diabetes
trials. They clearly showed that intensive treatment (which is impossible
to do without intensive monitoring) clearly reduces risks of diabetes
complications. Why do we want to steal from our patients the empowerment
of knowledge about their glucose values?

Without measurement of blood glucose, we will never know when our patients
have nocturnal hyper-, or hypoglycemia, postprandial hyper- or
hypoglycemia. For example: when I see persistent morning hyperglycemia, I
would know that my patient has nocturnal hepatic glucose production. This
would guide me to add metformin or insulin to night-time antidiabtes
regimen.

When my patient has severe hyperglycemia throughout the day, I would
suspect either inadequate doses of oral agents or insulin deficiency. SMBG
readings will guide my next therapeutic steps.

The patient would also know the effect of food items, and physical
activity on own blood glucose readings and develop a sense of empowerment.
By claiming that SMBG is of no value just because it will save some short-
term costs, we will put blindfolds on both patients and physicians; and
then we ask them to accomplish the unattainable, namely, glycemic control
in the dark.

Parachutes work to save life, whether there were randomized double-blind
clinical trials to prove it or not. Doing studies to prove it would end a
few lives.

Competing interests:
None declared

Competing interests: No competing interests

26 July 2007
Shirwan A. Mirza, MD, FACP, FACE
Clinical Assistant Professor/Consultant Diabetologist
Auburn, New York