1. Self-monitoring of blood glucose in patients with type 2 diabetes A systematic review Laura M.C. Welschen 1,2, Evelien Bloemendal 1,2, Giel Nijpels 1,2, Jacqueline M. Dekker 2, Robert J. Heine 1,3, Wim A.B. Stalman 1,2, Lex M. Bouter 1 1 Institute for Research in Extramural Medicine 2 Department of General Practice 3 Department of Endocrinology, Diabetes Center VU University Medical Center, Amsterdam, The Netherlands E-mail: l.welschen@vumc.nl@vumc.nl INTRODUCTION Glucose control is the primary target in patients with type 2 diabetes Each 1% reduction in HbA 1c is associated with a 37% decrease in microvascular complications 1 Commonly, a three-monthly visit to the general practitioner is recommended to assess glycaemic control 2 Self-monitoring of blood glucose has been found effective in patients with type 1 diabetes 3,4 What is the effectiveness of self-monitoring of blood glucose as a tool in the self-management of patients with type 2 diabetes? 5,6 1 UKPDS, Stratton et al, BMJ 2000 2 Guidelines Dutch College of General Practitioners 3 DCCT, N Engl J Med 1993 4 Bode et al, Diabetes Res Clin Pract 1999 5 Coster et al, Heakth Techn Assess 2000, Diabet Med 2000 6 Faas et al, Diabetes Care 1997 OBJECTIVE To investigate the effects of self-monitoring of blood glucose on - glycaemic control - quality of life, well-being, patient satisfaction - and hypoglycaemic episodes in patients with type 2 diabetes who are not using insulin RESEARCH DESIGN AND METHODS Systematic review of the literature according to the guidelines of the Cochrane Collaboration Search strategy in MEDLINE, EMBASE and the Cochrane Library (1966-January 2004) Study selection: * randomised controlled trials * patients with type 2 diabetes, not using insulin * self-monitoring of blood glucose compared with usual care and/or self-monitoring of urine glucose * at least one of the following outcome measures: glycaemic control (HbA 1c and/or fasting plasma glucose), quality of life, well- being, patient satisfaction, or hypoglycaemic episodes Methodological quality assessment by means of a score list of internal validity 7 Data extraction Data analysis: meta-analysis if studies were sufficiently homogeneous in their populations, interventions and outcomes 7 van Tulder et al, Spine, 2003 StudyBloodUrineUsual Care Fontbonne 8 1989 6 months N Baseline Change 68 8.2 ± 2.5 % –0.36 ± 2.17 % 72 8.6 ± 2.5 % –0.13 ± 2.2 % 68 8.2 ± 2.5 % –0.5 ± 1.54 % Allen 9 1990 6 months N Baseline Change 27 12.4 ± 3.3 % –2 ± 3.4 % 27 11.7 ± 3.0 % –2 ± 2.4 % Muchmore 10 1994 44 weeks N Baseline Change 12 10.29 ± 1.1 % –1.54 % 12 10.45 ± 1.5 % -0.84 % Schwedes 11 2002 6 months N Baseline Change * 113 8.47 ± 0.86 % –1 ± 1.08 % 110 8.35 ± 0.75 % -0.54 ± 1.41 % Guerci 12 2003 6 months N Baseline Change * 345 9.0 ± 1.3 % –0.9 ± 1.54 % 344 8.9 ± 1.3 % –0.5 ± 1.54 % RESULTS Search strategy  1480 citations Study selection  five randomised controlled trials * Three trials compared self-monitoring of blood glucose with usual care * One trial compared self-monitoring of blood glucose with self- monitoring of urine glucose * One three-armed trial comparing self-monitoring of blood glucose with self-monitoring of urine glucose and usual care Outcome measures: HbA 1c. Few data on quality of life (2 studies), well-being (1 study), patient satisfaction (1 study) and hypoglycaemic episodes (1 study) One trial (Schwedes et al.) had a co-intervention of a standardised counseling program to change diet and lifestyle in the self-monitoring of blood glucose group CONCLUSIONS Three studies showed more improvement in HbA 1c levels in self- monitoring of blood glucose groups than in self-monitoring of urine glucose and usual care groups The two largest studies found a statistically significant effect of self- monitoring of blood glucose on HbA 1c compared with usual care. However, one of these had a co-intervention with education on diet and lifestyle  Self-monitoring of blood glucose might be effective in improving glycaemic control in patients with type 2 diabetes who are not using insulin  A randomised controlled trial is needed, which should include: * a longer follow-up period * measurements of quality of life, well-being, patient satisfaction and hypoglycaemic episodes * a standardised treatment program on diet and lifestyle in both the intervention and the control group FIGURE: HbA 1c Changes * * TABLE: Results HbA 1c (%)(mean ± SD)  heterogeneity in baseline values  no meta-analysis performed Self-monitoring of blood glucose Self-monitoring of urine glucose Usual Care Allen (1990) Muchmore (1994) Guerci (2003) Fontbonne (1989) Schwedes (2002) * Significant difference between groups (p<0.01) BaselineEnd of study 8 9 10 11 7 12 13 HbA 1c (%) *Significant difference between groups (p<0.01) 8 Fontbonne et al, Diabete Metab,1989 9 Allen et al, Diabetes Care, 1990 10 Muchmore et al, Acta Diabetol, 1994 11 Schwedes et al, Diabetes Care, 2002 12 Guerci et al, Diabete Metab, 2003