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© 2005 by the American Diabetes Association, Inc.
Letters: Comments and Responses |
Self-Monitoring of Blood Glucose in Patients With Type 2 Diabetes Who Are Not Using Insulin
Response to Kleefstra et al. and Davidson
1 Institute for Research in Extramural Medicine, VU University Medical Center, Amsterdam, the Netherlands
2 Department of General Practice, VU University Medical Center, Amsterdam, the Netherlands
3 Department of Endocrinology, Diabetes Center, VU University Medical Center, Amsterdam, the Netherlands
Address correspondence to Laura M.C. Welschen, Institute for Research in Extramural Medicine, VU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, Netherlands. E-mail: l.welschen{at}vumc.nlwww.emgo.nl
Response to Kleefstra et al. and Davidson
In response to Kleefstra et al. (1), we will try to eliminate the confusion concerning the conclusions of our systematic reviews on self-monitoring of blood glucose (SMBG) in patients with type 2 diabetes who are not using insulin, published in Diabetes Care (2) and the Cochrane Library (3).
In the Cochrane Library, we performed a qualitative analysis, and because of the consistency of the results of rather heterogeneous trials, we concluded that the level of evidence that SMBG might be effective in improving glycemic control was moderate. After a lengthy discussion, we decided not to perform a meta-analysis because of clinical heterogeneity between the studies.
Because we considered this topic to be very important to health care professionals in the diabetes field, we also submitted the review to Diabetes Care. The editor also urged us to perform a meta-analysis, as pointed out in his response letter (4), to which we responded positively. We believed that this offered an interesting opportunity to explore the added value of having a quantitative summary estimate. On the basis of the meta-analysis, we concluded that SMBG significantly lowered HbA1c (A1C) by 0.39%, which is clinically relevant compared with the control groups (5).
However, we respectfully disagree with Davidson's conclusion that the available evidence does not show that SMBG is effective in decreasing A1C levels (4). We believe that the current level of evidence is only moderate, but the direction of the evidence is positive. It is likely that in future studies, this will be shown again, as was also suggested in the point discussion in Diabetes Care accompanying our review (6).
We explicitly mentioned in our discussion of the review in Diabetes Care that the results of the meta-analysis should be interpreted with caution since the methodological quality of the trials was poor in more than half of the studies and the studies were heterogeneous. This implies that there are important limitations on the meta-analysis.
In our two reviews, we used a different approach to reach the same conclusion: there may be a clinically relevant effect of SMBG on A1C, although the evidence for this effect is still moderate. Both reviews give similar recommendations for research and clinical practice and point out the need for a large randomized controlled trial to draw final conclusions on this important topic.
References
- Kleefstra N, Houweling ST, van Ballegooie E, Bilo HJG: Self-monitoring of blood glucose in patients with type 2 diabetes who are not using insulin (Letter). Diabetes Care 28:2596, 2005
[Free Full Text]
- Welschen LM, Bloemendal E, Nijpels G, Dekker JM, Heine RJ, Stalman WA, Bouter LM: Self-monitoring of blood glucose in patients with type 2 diabetes who are not using insulin: a systematic review. Diabetes Care 28:1510–1517, 2005
[Free Full Text]
- Welschen LM, Bloemendal E, Nijpels G, Dekker JM, Heine RJ, Stalman WA, Bouter LM: Self-monitoring of blood glucose in patients with type 2 diabetes who are not using insulin. Cochrane Database Syst Rev 2:CD005060, 2005
- Davidson MB: Self-monitoring of blood glucose in patients with type 2 diabetes who are not using insulin (Letter). Diabetes Care 28:2597, 2005
[Free Full Text]
- Stratton IM, Adler AI, Neil HA, Matthews DR, Manley SE, Cull CA, Hadden D, Turner RC, Holman RR: Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ 321:405–412, 2000
[Abstract/Free Full Text]
- Ipp E, Aquino RL, Christenson P: Point: self-monitoring of blood glucose in type 2 diabetic patients not receiving insulin: the sanguine approach. Diabetes Care 28:1528–1530, 2005
[Free Full Text]
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