No More Finger Pricks for Some With Diabetes
The glucose test may not keep you healthier, so why are many still doing it?
If you have type 2 diabetes, chances are you prick your finger once a day or so to check your blood sugar.
But a growing body of evidence shows that for most type 2 diabetes patients, routinely tracking your blood sugar, or glucose, doesn’t make any difference for your health.
The exception is patients taking insulin or a sulfonylurea drug such as glipizide (which goes by the brand name Glucotrol) or glimepiride (Amaryl), which stimulates beta cells in the pancreas to produce insulin. That’s according to Dr. Jack Ende, president of the American College of Physicians, a professional organization of internal medicine specialists.
Both insulin and the sulfonylureas can lead to hypoglycemia, or too-low blood sugar, so it’s important to perform self-monitoring, said Ende, an assistant dean at the University of Pennsylvania’s Perelman School of Medicine in Philadelphia.
Good News for Many with Diabetes
“If you’re diet-controlled alone, or you’re just on metformin (a widely prescribed diabetes medication), which does not cause hypoglycemia, and you’re not interested in testing, there’s really no reason to do it,” he said. “It’s expensive [test strips alone cost around $1 each]. It’s burdensome.”
But, Ende said, he has some patients who, even though they’re controlling their blood sugar by diet alone, continue to prick their finger regularly to check their glucose.
“It helps them stay on the diet,” he explained. “It’s a motivating technique,” kind of like hopping on the scale every morning if you’re trying to lose weight.
More than 29 million Americans have diabetes, although a quarter of them don’t know it, according to the Centers for Disease Control and Prevention. Of those who have been diagnosed, 90 to 95 percent have type 2 diabetes, which used to be called “adult-onset” diabetes. The remainder have type 1 diabetes, formerly known as “juvenile” diabetes.
Most Americans being treated for type 2 diabetes are not on insulin. Yet more than 75 percent of them regularly track their blood glucose levels, said endocrinologist Dr. Laura Young, a coauthor of the latest study to raise questions about the value of self-monitoring in these patients.
Guidelines Don’t Call for Tracking
That’s a high proportion, considering that no treatment guidelines recommend routine tracking for such patients. Whether patients who are not on insulin monitor their blood glucose has a lot to do with who’s taking care of them, said Young, a physician researcher at the University of North Carolina (UNC) School of Medicine who specializes in caring for diabetes patients. “There are some — probably the minority, predominantly primary care — providers who say, ‘You’re doing fine, your numbers are fine, you don’t need to check,’” Young said.
On the other hand, some health-care providers think self-testing makes patients feel empowered, enhancing their motivation to maintain control of their blood sugar, Young said. “I think for some people (patients), that is definitely the case,” she said. “I think it’s short-sighted for us to think it’s going to work for everybody. Type 2 diabetes is a multi-faceted disease.”
What Top Groups Recommend
Here’s what some organizations say about self-monitoring of blood glucose:
- In its 2017 “Standards of Care,” the American Diabetes Association (ADA) notes “the evidence is insufficient regarding when to prescribe SMBG [self-monitoring of blood glucose] and how often testing is needed for patients who do not use intensive insulin regimens…” The ADA goes on to say that “a key consideration is that performing SMBG alone does not lower blood glucose levels. To be useful, the information must be integrated into clinical and self-management plans.”
- In a recommendation updated in February, the Society of General Internal Medicine advises against daily home finger glucose testing in type 2 diabetes patients who aren’t using insulin. Such testing doesn’t benefit patients who aren’t on insulin or sulfonylureas, the group says.
- Since 2013, The Endocrine Society has recommended against “multiple daily self-glucose monitoring” by adults with stable type 2 diabetes who are not being treated with anything that could cause hypoglycemia.
Latest Research Shows No Significant Differences
In their new study, published online first this month in JAMA Internal Medicine and presented at the American Diabetes Association’s Scientific Sessions, Young and her collaborators enrolled 450 type 2 diabetes patients being treated at 15 primary care practices in central North Carolina.
The patients, none of whom were on insulin, were randomly assigned to three groups. One group did not test their blood sugar; one tested once daily; and one tested once daily and received messages via their glucose meter tailored to their results. The messages were intended to educate and motivate patients.
A year later, the researchers measured the patients’ hemoglobin A1C levels, which show the average blood sugar level for the previous three months. The scientists also assessed the patients’ “health-related quality of life” with a 36-item survey developed by RAND.
They found no significant differences across the three groups on either count. Also, there were no notable differences in hypoglycemia, hospitalizations, emergency department visits or the number of patients who had to begin using insulin to improve blood sugar control.
‘To Test or Not to Test?’
“Our study results have the potential to transform current clinical practice for patients and their providers by placing a spotlight on the perennial question, ‘to test or not to test?’” Dr. Katrina Donahue, one of Young’s coauthors, said in a UNC press release. Donahue directs research at UNC Family Medicine.
Still, Young said, “I worry about making a blanket statement saying that nobody should test. I think it needs to be a discussion between patient and provider.”
Young recently saw a patient whose A1C was fine, and she told the woman she didn’t have to keep checking her blood sugar every day. “She looked at me in disbelief,” Young recalled. “She didn’t embrace the message the way I would have expected.”
Because she and her coauthors hadn’t yet reported their findings, she couldn’t share the results with the patient. But she plans to revisit the topic with her, Young said.
For some patients, testing “has become so ingrained into their life, they feel they would be naked without it,” she said. On the other hand, “I think there will be a portion of the population that feels relieved” by her findings.
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