A: Monitoring blood glucose at home three to five times a week at different times per day would likely provide enough information to assess Julio’s response to his current treatment, and would certainly be more helpful than relying on A1C measures alone.

EXPERT OPINION

Patients like Julio with new onset diabetes should be provided with self-management education to learn the knowledge and skills required to control their new chronic condition optimally. As a part of this education patients need to understand how lifestyle factors can lead to changes in their glycemic control. A focus on improved dietary choices (and quantities) as well as increasing regular exercise is a sound foundation for managing the condition. So is the concurrent prescription of metformin. Patients with elevated A1C levels should have additional therapeutic options such as dual oral agents, or if very elevated, the addition of insulin to the regimen.

Julio at this point has been offered diabetes self-management and metformin. The goals of self-monitoring for blood glucose (SBGM) for patients on metformin are different than those on more intense regimens. Blood glucose monitoring in this setting is typically not used in for decision making about intensification or adjustments to metformin. Rather it is used, if at all, as a tool to emphasize and reinforce to patients that they have a chronic condition that may be suboptimally controlled. This direct feedback loop encourages the “right choices” and may help patients achieve their goals. These include an increase in the quantity of movement (i.e., “exercise”), as well as a restriction of calories. 

Monitoring blood glucose at home three to five times a week at different times per day would likely provide enough information to assess Julio’s response to his current treatment, and would certainly be more helpful than relying on A1C measures alone. Over the years, many patients do not advance appropriately on their therapy because their A1C measurements do not reflect their actual level of diabetes control. This is yet another reason why regular SMBG in a patient like Julio with newly diagnosed T2DM is advisable.

Although the literature on the frequency of SMBG for patients not receiving insulin is complex, four meta-analyses and review of the literature suggests that it has a small but significant effect on A1C levels.[i] Another concern not well appreciated is how crude the A1C test is for many patients with diabetes, and making decisions solely on that level could result in wrong management decisions. The A1C test runs low for patients who have various anemias or splenomegaly or are receiving erythropoietin injections, for example, while it runs high in patients with iron deficiency.[ii] Should the A1C be discordant with SMBG levels, the clinician should consider the possibility of a spurious A1C result due to factors such as anemia and hemoglobinopathies. More importantly than the many reasons the test does not reflect glycemic history for many patients, too, we now know that variations in red blood cell survival times and normal differences in glycation rates mean that someone with an A1C of 7% could have a higher average blood glucose than someone with an A1C of 8%.[iii] So a clinician can use glucose testing to better appreciate if the A1C truly reflects mean blood glucose.

Julio’s risk of hypoglycemia depends on the medications used. At this early stage of his disease he is being treated with lifestyle changes and metformin, neither of which raises hypoglycemia risk, and so it is appropriate for him to try to maintain an A1C of <7%. As the disease progresses, he will probably need to have additional medications that will increase his risk of hypoglycemia, at which point SBMG will continue to be critical. If he develops complications and comorbidities that limit life expectancy, it may eventually be necessary to consider treatment as well and lower glycemic goals, although if he continues to be at risk for microvascular complications and has sufficient life expectancy, aiming for an A1C of <7% may continue to be appropriate.

Further intensification of therapy (I.e , the addition of more medication) usually occurs with the draw of the next A1C This next A1C should be done before the next office visit and at three months to allow for that encounter to be a productive one where intensification decisions can be jointly made through a shared decision making model.