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Evidence-based Laboratory Medicine and Test Utilization: David B. Sacks, David E. Bruns, David E. Goldstein, Noel K. Maclaren, Jay M. McDonald, and Marian Parrott Guidelines and Recommendations for Laboratory Analysis in the Diagnosis and Management of Diabetes Mellitus Clin Chem 2002; 48: 436-472 [Abstract] [Full text] [PDF]

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Diabetic Self-Monitoring for Glucosuria by Dipstick is Cost-Effective

Darryl E. Palmer-Toy, MD, PhD   (23 April 2002)

Diabetic Self-Monitoring for Glucosuria by Dipstick is Cost-Effective 23 April 2002
Darryl E. Palmer-Toy, MD, PhD, Pathologist Massachusetts General Hospital Send letter to journal: Re: Diabetic Self-Monitoring for Glucosuria by Dipstick is Cost-Effective dpalmertoy{at}partners.org Darryl E. Palmer-Toy, MD, PhD	In their otherwise excellent review of laboratory issues in diabetes mellitus, I was disappointed to see the NACB contend that dipstick urinary glucose testing is inferior to blood glucose for self-monitoring [Sacks et al, 2002]. There is substantial evidence that urine glucose monitoring is cost-effective alternative to blood testing. Some potential drawbacks of monitoring glucosuria are obvious: urine glucose does not reflect blood glucose in real time, relatively high level of blood glucose (180 mg/dL) must be reached before glucosuria occurs, and most importantly, hypoglycemia cannot be detected. Other problems are more subtle, such as the difficulties that people with diabetic retinopathy may have in reading dipstick color changes [Bresnick et al, 1984]. Yet several studies have not demonstrated any clinical advantage of testing blood rather than urine of non-insulin dependent diabetics, In a randomized crossover trial of 150 consecutive newly diagnosed, non-insulin dependent, British diabetics, no significant difference was seen in glycemic control (measured by glycated hemoglobin), change in body mass index, or quality of life score between those monitoring by urine or blood glucose [Miles et al, 1997]. Other randomized controlled clinical trial from Russia (Starostina et al., 1994), America (Allen, DeLong, and Feussner, 1990), and France (Fontbonne et al, 1989) all failed to show any benefit of blood testing over urine testing. Among diabetics in poorer countries, DUA has demonstrated comparable performance to fingerstick blood glucose monitoring in identifying "clinically significant" hyperglycemia (defined as >180 mg/dL) at a fraction of the cost [Feleke and Abdulkadir, 1998]. Given the tremendous financial and administrative downside of point- of-care-testing for blood glucose, the authors should be reticent to turn their backs on this old friend. Sacks DB, Bruns DE, Goldstein DE, Maclaren NK, McDonald JM, Parrott M. Guidelines and Recommendations for Laboratory Analysis in the Diagnosis and Management of Diabetes Mellitus Clin Chem 2002 48: 436- 472. Bresnick GH, Groo A, Palta M, Korth K. Urinary glucose testing inaccuracies among diabetic patients. Effect of acquired color vision deficiency caused by diabetic retinopathy. Arch Ophthalmol 1984;102(10):1489-96. Miles P, Everett J, Murphy J, Kerr D. Comparison of blood or urine testing by patients with newly diagnosed non-insulin dependent diabetes: patient survey after randomised crossover trial. BMJ 1997 Aug 9;315(7104):348-9 [Erratum in: BMJ 1998 Jan 17;316(7126):195] Starostina EG, Antsiferov M, Galstyan GR, Trautner C, Jorgens V, Bott U, Muhlhauser I, Berger M, Dedov II. Effectiveness and cost-benefit analysis of intensive treatment and teaching programmes for type 1 (insulin-dependent) diabetes mellitus in Moscow—blood glucose versus urine glucose self-monitoring. Diabetologia 1994 Feb;37(2):170-6. Allen BT, DeLong ER, Feussner JR. Impact of glucose self-monitoring on non-insulin-treated patients with type II diabetes mellitus. Randomized controlled trial comparing blood and urine testing. Diabetes Care 1990 Oct;13(10):1044-50 Fontbonne A, Billault B, Acosta M, Percheron C, Varenne P, Besse A, Eschwege E, Monnier L, Slama G, Passa P. Is glucose self-monitoring beneficial in non-insulin-treated diabetic patients? Results of a randomized comparative trial. Diabete Metab 1989 Sep-Oct;15(5):255-60 Feleke Y, Abdulkadir J. Urine glucose testing: another look at its relevance when blood glucose monitoring is unaffordable. Ethiop Med J 1998 Apr;36(2):93-9.