Self-Monitoring Eases Doctors' Reluctance to Start Insulin

Dr. Charles Harold Schikman, from North Shore University Health System Skokie Hospital, in Skokie, Illinois, stated that, "There is a reluctance to put patients on insulin. Doctors tend to be benevolent and wait too long to transition to insulin and injection therapy, but this tool was a catalyst to overcome clinical inertia and get doctors to be more aggressive and intensify treatment earlier in these poorly controlled non-insulin treated Type 2 patients."

"Patients with Type 2 diabetes will often go for a long time with high hemoglobin A1cs before insulin is started," Dr. Schikman said. "We wanted to see how we could decrease this clinical inertia."

He and his colleagues randomized 483 patients with poorly controlled insulin-naive Type 2 diabetes, all with hemoglobin A1c at least 7.5%, to either usual care or structured testing using the Accu-Chek 360 View Blood Glucose Analysis System, a paper tool that patients fill out to record their glucose profiles. In addition, all patients received free blood glucose meters and test strips.

Intermittently, patients in the structured testing group used the Accu-Chek to record their blood sugars before and 2 hours after each meal and at bedtime, as well as their meal size and energy levels, over 3 consecutive days. Once every 3 months, they brought the information to their doctor.

The participating physicians were taught how to identify normal patterns and when to make therapeutic interventions - ranging from recommending lifestyle changes to prescribing insulin. Patients in the active control group checked their blood sugars as they usually did but did not record them in a systematic way. 

At 12 months, an intent-to-treat analysis showed that patients in the structured group had a significantly greater mean improvement in HbA1c than patients in the control group (-1.2% vs -0.9%; p = 0.04), lower average preprandial and postprandial glucose levels at all meals and bedtime (p <0.001), and significant reductions in mean amplitude of glucose excursions, from a mean of 38.5 mg/dL at month 1 to 34.3 mg/dL at month 12 (p = 0.0003).

Physicians who participated in the structured arm of the study were more likely to recommend a medication change (60% vs 23%, p<0.0001), a lifestyle change (41% vs 9%, p<0.0001) or both (76% vs 28%, p<0.001), compared with those who participated in the active control arm.

The study also found that all patients, regardless of study arm, who had a recommended treatment change at 1 month achieved significantly greater HbA1c reductions at 12 months than those who did not (-1.3 vs -0.8, p<0.002). And patients in the structured group had significantly more treatment change recommendations at the 1 month visit than control patients: 179 patients (75.5%) vs 61 patients (28.0%; p <0.0001).

"The doctors loved the tool and wanted to continue using it after the 12-month study," Dr. Schikman said. "It really changed the way they treated Type 2 diabetes."

Results of the program "structured self-monitoring of blood glucose" were reported at the 20th annual meeting and clinical congress of the American Association of Clinical Endocrinologists in San Diego.