Yet another review (and papers in the same edition of the British Medical Journal) saying that self-monitoring in Type 2 diabetes is a waste of time and resources.

The review is by a Public Health doctor who summarises the “evidence” he has found by reading the papers and following their reference links. The papers show that in controlled trials, there is no benefit for self monitoring in terms of falls in HbA1C concentrations when compared with patients who were managed without taking their own blood glucose measurements.

This is not surprising because the HbA1c levels were not high in the first place, so any change could only be marginal.

In addition, in common with all other studies of this type, the approach to self monitoring was that only small changes were made to the tablets or to diet in response to the results of relatively few measurements.

Self monitoring is a potential life-saver in Type 2 diabetes when used intelligently. What is required is a period of intensive monitoring so that the person with diabetes learns exactly the effect of different amounts of different foods on their blood glucose levels and how to keep their fluctuations in blood glucose to a minimum. After this period, much less testing is needed because they know how and when to eat.

The complications of diabetes cost healthcare systems a huge amount of money, and this will go on increasing until people with diabetes take charge of their own condition and (mainly through reducing carbohydrate intake) get it under good control. Self monitoring is an essential part of that process, but education about what to do with the results is the key. Unfortunately, most diabetes professionals don’t seem to have grasped this yet.

The waste of time and resources is in doing these studies and publishing the results.

Read if you want, but don’t get discouraged.

And do go on testing, so you can learn how to improve your control.

Research, doi: ; doi: 10.1136/bmj.39526.674873.BE 10.1136/bmj.39534.571644.BE

http://www.bmj.com/cgi/content/abstract/bmj.39534.571644.BEv1

Following the recent stopping of the Intensive control arm of the ACCORD study of  patients with Type 2 diabetes because of an excess of deaths in this group, the investigators in the Australian ADVANCE study ran a preliminary analysis of their data, and found no increase in deaths in their Intensive control patients. This will come as a relief to any of you who were worried that tight control might actually be bad for you. There are some differences between the studies - the ADVANCE patients did not already have the same degree of cardiovascular risk factors as those in ACCORD, and the US patients were even more intensively treated with insulin.

So the message as far as I’m concerned still is - go for good control.

TW

If anyone was getting depressed about the ACCORD results, they can take heart from another large study from Steno in Denmark, just published in the New England Journal of Medicine, in which lowering of the blood sugar and HbA1c levels resulted in an almost 50% fall in overall death rate,  particularly from heart disease.  Many fewer patients progressed to end-stage kidney failure or required laser treatment to their eyes. Major side effects were rare.

You can find the abstract at: http://content.nejm.org/cgi/content/short/358/6/580?query=TOC

Other large studies from both sides of the Atlantic have reported broadly similar results.

We’ll have to wait and see what comes out of the discussion of the ACCORD results, but it is clear that nobody should panic about this or change their treatments right now.

 TW

You will no doubt be seeing in the newspapers in the next few days that one part of the huge ACCORD trial in patients with Type 2 diabetes has been stopped because of an increased death rate in the group of people assigned to intensive blood glucose control. This is a great shock and no doubt will be taken by some people to indicate that good control of blood glucose may be a bad thing.

No single drug or set of drugs could be identified as being responsible for this, but it all the people in this group were receiving multiple treatments for the diabetes and many of them were using insulin as well as tablets. They did seem to have better blood glucose control in that the haemoglobin A1c levels were significantly lower than in the standard treatment group, but despite this more of them died during thestudy period than in the standard treatment group.

As ever, these results need to be viewed with some care. The group of people included in the study not only had had diabetes for an average of 10 years and were relatively old, but they also had poor control and known heart disease or at least two other risk factors. Although their death rate appeared to be higher in the intensive control group, the rate of non-fatal heart attacks was actually lower and there was no consistent cause of the excess of deaths.

Previous studies have suggested that lifestyle measures leading to better blood glucose control can slow the progress of the condition and reverse some of the complications so this result really does come as a surprise.

The first thing to say is that the results may be a statistical anomaly, which are not that uncommon in large trials of this type (remember the HRT trials?). The second is that it is not the lower blood glucose levels that are likely to be causing the deaths, but rather the treatments. Modern views of diabetes care (not yet promoted by either the American Diabetes Association or Diabetes UK) might say that most of the treatments, and particularly insulin in Type 2 diabetes may well cause more problems than they cure.

You will find a good discussion at: http://www.healthcentral.com/diabetes/c/5068/20145/study-whats/1/

If you want to look at the detail and see what the ACCORD study is all about you can find it at http ://www.nhlbi.nih.gov/health/prof/heart/other/accord/index.htm.

In the meanwhile DON’T CHANGE YOUR TREATMENT! Good glucose control matters.

Tony Woolfson