Intended for healthcare professionals

Research

Efficacy of self monitoring of blood glucose in patients with newly diagnosed type 2 diabetes (ESMON study): randomised controlled trial

BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39534.571644.BE (Published 22 May 2008) Cite this as: BMJ 2008;336:1174

Mean weekly glycemia: a SMBG-derived method for near-real-time evaluation of glycemic control and of adequacy of treatment strategy

Papers by Simon et al. and O’Kane et al. dealt with ideal type 2
diabetic patients, followed every three months for a whole year. The study
on efficacy of self monitoring of blood glucose (SMBG) by O’Kane et al.
included only “five star” diabetic patients that we all would like to have
as our patients: no comorbidities of any kind, no insulin treatment, no
cognitive deficits, no serious diseases. The study on cost-effectiveness
by Simons et al. only included patients from the DiGEM Study managed with
diet or oral hypoglycemic agents alone, also excluding insulin treated
patients. Conclusions of both studies are therefore applicable to this
divine segment of “pure” diabetic population, which by no means reflect
the real world situation.

The real danger of this rather simplistic
analysis is the extrapolation of these conclusions to the diabetic
population as a whole. Both studies present the same pitfall of utilizing
a prefixed frequency of testing for the whole 12 months period of the
studies (8 tests /week in the efficacy study and 6 tests/week in the cost
effectiveness study), regardless of the level of glycemic control, which
conflicts with the very basic concept of SMBG according to which the
frequency of testing should never be predefined, except during the
realization of 6 or 7 points glycemic profiles for a very short period of
a few days. It seems a total nonsense to force patients with reasonably
stable glycemic control to test themselves in a predetermined frequency
for a whole year.

At the Diabetes Education and Control Group of the
Kidney and Hypertension Hospital, Federal University of Sao Paulo, Brazil,
we just started a proof-of-concept study on the use of Mean Weekly
Glycemia (MWG) as a practical, point-of-care, low cost method for the near
-real-time evaluation of glycemic control and of adequacy of therapeutic
regimen. The majority of our population consists of diabetic low income,
less educated type 2, insulin treated patients with different
comorbidities, between 50 and 70 years, with A1C levels ranging from 8% up
to 15% and with different degrees of renal failure. These patients are
seen every week for educational activities and weekly adjustments of
therapeutic strategy as needed. Patients receive a glucose meter and
strips (Lifescan One Touch Ultra), with instructions to perform a full 6
points glycemic profile (7 points in insulinized patients) during three
days in a week (Mondays, Tuesdays and Wednesdays). At each visit, results
from glucose monitors are downloaded with the help of the One Touch
Diabetes Management Software Pro v3.1.1. for calculations of mean glycemia
and standard deviation of data from any specified period of time. Results
from the three glycemic profiles per week are used as representative of
MWG value. Results are projected in a screen and presented to each
patient, showing and commenting on his/her successes and failures in the
week, compared with their performance in previous weeks. Treatment
adjustments are implemented as needed , with the reasons for changes fully
explained to the patient, taking in consideration the glucose trend and
the standard day data modes provided by the software.

Therefore, MWG is a practical option for short term, near-real –time
evaluation of glycemic control that allows a fully rational approach to
adjustments in therapy on a weekly basis, instead of having to wait 3
months as suggested by almost all international guidelines on the
treatment of diabetes. A1C is the gold standard for long term evaluation
of glycemic control, but does not provide the need information on what
kind of pharmacological agents would be more indicated for each particular
patient at any particular time and situation. MWG, on the other hand, has
the advantage of being able to provide these very crucial information and
thus give a definite contribution to combat therapeutic inertia.
Correlations between MWG and A1C levels at weeks 0,4, 6 and 8 after the
implementation of the MWG evaluation method will be carried out. Patients
who do respond to this approach (an average of 60% of our patients) will
achieve within normal range glucose readings in 4 to 6 weeks. After this
period, patients are instructed to perform tests only occasionally, 2
times per week, in different times of the day, or when they feel that
something is wrong.

AUGUSTO PIMAZONI, MD

Coordinator, Diabetes Education and Control Group

Center of Hypertension and Cardiovascular Metabology,
Kidney and Hypertension Hospital,
Federal University of Sao Paulo, Brazil

E-mail: pimazoni@uol.com.br

Competing interests:
None declared

Competing interests: No competing interests

20 April 2008
AUGUSTO PIMAZONI, MD
Coordinator, Diabetes Education and Control Group
Center of Hypertension and Cardiovascular Metabology - Kidney and Hypertension Hospital - Brazil