The Pharmaceutical Journal
Vol 269 No 7207 p97-101
20 July 2002

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Letters to the Editor

Diabetes

Self-testing beneficial most of the time

From Ms K. Thomson

On behalf of Diabetes UK, I should like to respond to Peter Burrill's article (PDF 50K) on self-monitoring of glycaemic control (PJ, 15 June, p847). The reason for our not giving a specific recommendation about frequency of self-monitoring is that it depends on the individuals, their circumstances, degree of control and stage of life. Teenagers, pregnant women and people with poor control or hypoglycaemic unawareness may need to test more frequently than others. People who are about to drive may need to test before embarking on a journey. People who take a lot of exercise, are ill or have had changes in their treatment need to test more frequently at these times. There is a raft of factors that need to be considered, not least an individual's needs and desires.

Ninety per cent of the care people with diabetes receive is self-care. The focus of care therefore needs to be on improving the capacity of people with diabetes to manage their diabetes. The role of health care professionals is how to build that capacity and provide some expert advice to enable individuals to manage their own diabetes effectively. All people with diabetes should receive information and education which enables them to adjust insulin or other medication appropriately for themselves. Self-monitoring is key as a tool to support this process of self-care.

For those who are treated solely with a healthy eating and increased physical activity regimen, it might be argued that there is little reason for them to monitor their glucose levels, since there is no "medication" to adjust. Self-monitoring can be important, however, in the early stages of the condition in reminding people that they do indeed have diabetes. It can give people a sense that at least they know what is going on with their diabetes and could show when their blood glucose reaches dangerously high levels, or prompt them to take a healthy life style decision, because their levels are a bit high.

For some, self-monitoring may have a negative impact: finger-pricking, or simply not understanding why they are self-monitoring, can cause distress and in such circumstances may be counter-productive. In the research cited, although a link appears to have been established between frequency of testing and depressive symptoms, direct causation does not appear to have been established. Could it be that the depressive symptoms are related to people feeling a lack of control over their diabetes? The solution for individuals may be to reduce the frequency of testing, or stop altogether, or it might be to receive information as to why self-monitoring can be helpful and how to act on the results. We would agree with Mr Burrill that people with diabetes should be involved in such decisions.

Of course people with diabetes, as well as health service managers, want resources to be used to greatest effect but decisions about "disinvesting" in current care methods need to be taken in conjunction with the needs and views of people with diabetes uppermost.

In conclusion, Diabetes UK believes that while self-monitoring may not be beneficial to all people with diabetes all the time, it is beneficial to most people most of the time. People with diabetes need appropriate education to ensure that they are able to make use of the results of their self-monitoring to adjust treatment in line with varying trends and activities. This could be done in association with the diabetes care team or carried out by themselves, whereby they would gain a sense of control over their diabetes.

Karen Thomson

Policy Officer
Diabetes UK

Can we have evidence, please!

From Ms I. Gummerson, MRPharmS

In his letter, John Logan (PJ, 29 June, p903) states: "Another major benefit [of allowing prescription exemptions only on the basis of low income] would be to remove the incentive for patients with marginal diabetes ... to press for a positive diagnosis in order to benefit from life-long total exemption."

By "marginal diabetes" he cannot mean type 1 or type 2 diabetes. He must mean people with impaired fasting glucose (IFT) and impaired glucose tolerance (IGT). Anyone identified as having these conditions should be given diet and lifestyle advice to delay the progression of the condition. I have no evidence and would be interested to hear Mr Logan's evidence that people with IFG or IGT are asking for a firm diagnosis of diabetes so that they can start on hypoglycaemic medication.

He must mean this, since people whose diabetes is diet-controlled are not exempt. Even when people are diagnosed with type 2 diabetes, for the first few months it is normal to try diet and lifestyle modification before introducing medication, unless the glucose levels are exceptionally high.

All diabetes must be taken seriously; pharmacists must never "collude" with misguided professionals who tell their patients they only have "mild" diabetes.

Mr Logan goes on to say: "... and, no less importantly, to remove the temptation for purveyors of official prescribing guidance to urge doctors not 'normally' to treat such conditions."

I have not seen any evidence that official prescribing guidance urges doctors to treat IFT or IGT. Again could he show the evidence of this?

Talking about exemption, it could become a public health issue if people who are, say, just above the low income "cut off" point feel they cannot afford the prescription charges or the prepayment certificate charge. In 20 years, more people would be going blind and would have more severe coronary heart disease.

Irene Gummerson

Wakefield, West Yorkshire

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