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Blood Glucose Test Strips: To Reimburse or Not to Reimburse?

T1D patients with certain characteristics would benefit the most from reimbursement of blood glucose test strips.

Use of short-acting and long-acting insulin analogs, technological advancement, and improvements in insulin pumps and more frequent glucose monitoring have led to achievement of target HbA1c levels in diabetes mellitus patients. The downside of these therapies is an increase in hypoglycemia rates because of wrong matching of food intake and insulin dose especially for T1D patients.

Hypoglycemia is the major limiting factor for blood glucose control in diabetes mellitus patients, especially those on daily insulin injections. After a hypoglycemia episode,

patients might fear a repeat of such an experience, which causes laxity in monitoring and thus poor glycemic control. ADA guidelines recommend performing SMBG for patients who are on insulin therapy. Frequent SMBG is recommended for patients on multiple-daily insulin or insulin pump therapy. SMBG is a very important part of diabetes self-management that leads to achievement of glycemic targets and hence avoid diabetic complications, which can be very debilitating. With self-monitoring, patients can detect hypoglycemia or even high blood glucose levels and adjust their insulin doses accordingly.

Many studies have proven that for type 1 and type 2 diabetes being treated with insulin, SMBG done frequently is associated with better glycemic control. For type 1 and type 2 diabetes patients on insulin, intensive glycemic control coupled with daily glucose monitoring ≥4 times/day will help delay onset and slow worsening of both microvascular and macrovascular complications as shown by the Diabetes Control and Complication Trial.

A prospective cohort study was carried out and its main aim was to identify factors that independently led to greater benefit of the national reimbursement policy for blood glucose test strips in adult patients with type 1 diabetes at 12 months after registration for the reimbursement program, in terms of glycemic control and rate of severe hypoglycemia. The study looked at 466 adult patients with T1D in South Korea who registered for a national reimbursement program for blood glucose test strips and were then followed for 12 months. Those factors that led to a reduction of HbA1c by more than five percent and a decrease in rate of severe hypoglycemia at 1 year from baseline were examined.

After 1 year of follow-up, 33.9% of the 466 patients were able to achieve a HbA1c reduction that was greater than five percent from baseline. Factors that were independently associated with a HbA1c reduction greater than five percent from baseline included lower total insulin dose at baseline (p=0.048), higher HbA1c at baseline (p<0.001), and an increase in self-monitoring of blood glucose (SMBG) frequency during follow-up (p=0.001)

Rate of severe hypoglycemia went down in 47 of the 111 patients (42.3%) who had had at least one episode of severe hypoglycemia at baseline. Factors that were associated with a decreased severe hypoglycemia rate after one year were increased frequency of SMBG measurements and experiences of SH at baseline (p=0.029), lower baseline HbA1c, presence of hypoglycemic unawareness (p=0.044), and increased frequency of SMBG during the study period. Higher SMBG frequency at baseline (p<0.001) was independently associated with a decreased rate of SH during follow-up.

In conclusion, factors such as frequent SMBG at baseline, lower total insulin dose at baseline, and higher HbA1c at baseline, were independently associated with reduced HbA1c and decreased rate of severe hypoglycemia. Therefore, patients with these characteristics would benefit the most from reimbursement of blood glucose test strips.

Practice Pearls:

  • Hypoglycemia is the major limiting factor for blood glucose control in diabetes mellitus patients.
  • SMBG is a very important part of diabetes self-management that leads to achievement of glycemic targets and hence avoid diabetic complications.
  • Factors independently associated with a HbA1c reduction >5% from baseline include lower total insulin dose at baseline, higher HbA1c at baseline, and increase in SMBG frequency.
  • Frequent SMBG is independently associated with a decreased rate of severe hypoglycemia.

References:

Jin SM. Baek JH.  Suh S. Jung CH. Lee WJ. Et al. Factors Associated with Greater Benefit of a National Reimbursement Policy for Blood Glucose Test Strips in Adult Patients with Type 1 Diabetes: A Prospective Cohort Study. Journal of Diabetes Investigation. 10 August 2017.  DOI: 10.1111/jdi.12728

Juvenile Diabetes Research Foundation Continuous Glucose Monitoring Study Group. Factors Predictive of Use and of Benefit from Continuous Glucose Monitoring in Type 1 Diabetes. Diabetes Care. 2009;32(11):1947-1953. doi:10.2337/dc09-0889.

Josephat Macharia, PharmD candidate, Lecom School of Pharmacy class of 2018