1. Avoid routine multiple daily self-glucose monitoring in adults
with stable type 2 diabetes on agents that do not cause
hypoglycaemia
Once target control is achieved and the results of self-monitoring become quite predictable,
there is little gained in most individuals from repeatedly confirming. There are many
exceptions, such as for acute illness, when new medications are added, when weight
fluctuates significantly, when A1c targets drift off course and in individuals who need
monitoring to maintain targets. Self-monitoring is beneficial as long as one is learning and
adjusting therapy based on the result of the monitoring.
Materiality/usage patterns
Total utilisation of blood glucose test strips is growing at a rate of approximately 6.3% per
annum. Approximately 35% of all blood glucose test strips dispensed are for people with
type 2 diabetes not using insulin.1 In 2011-12, the Australian Government spent
approximately $143.5 million subsidising glucose test strips for people living with diabetes,
through both the PBS ($17 million) (Medicare Australia 2012) and the NDSS ($126.5
million). 2
Figure 1: Total Prescriptions (and NDSS equivalent supplies) for blood glucose test strips
Source: Department of Health and Ageing 2012, ‘Pharmaceutical Benefits Scheme Products
Used in the Treatment of Diabetes’, Report to the Pharmaceutical Benefits Advisory Committee
Lessons from research and guidelines
While self-monitoring of blood glucose (SMBG) can improve glycaemic control, the clinically
meaningful effects are negligible to small, particularly over the longer term. It is only
recommended when there is appropriate education and willingness to self-adjust drug
treatments based on readings. This makes the benefits of multiple daily tests even more
questionable, particularly for those not using insulin.
Paper
Approach
Conclusions
Malanda et al 20123
Systematic reviews of RCTs,
12 included
Farmer et al 20124
Meta-analysis based on
individual participant data of
RCTs published since 2000
with at least 80 participants
Department of Health and
Ageing and University of
South Australia 20125
Literature review
Clar et al 20106
Systematic review from 1996
to April 2009, 30 RCTs
identified
McIntosh et al 20107
Systematic review from
January 1990 to March 2009
included RCTs and
observational studies, 25
selected.
International Diabetes
Guidelines
When diabetes duration is
over one year, the overall
effect of self-monitoring of
blood glucose on glycaemic
control in patients with type 2
diabetes who are not using
insulin is small up to six
months after initiation and
subsides after 12 months.
Furthermore, based on a
best-evidence synthesis,
there is no evidence that
SMBG affects patient
satisfaction, general wellbeing or general healthrelated quality of life
Not convincing for a clinically
meaningful effect compared
with management without
self-monitoring, although the
difference in HbA(1c) level
between groups was
statistically significant
Studies and other recent
evidence suggest that there
is some initial benefit gained
from blood glucose
monitoring when a person is
first diagnosed with type 2
diabetes. However, over
time, that benefit is reduced
as a person’s diabetes
stabilises. Further, while
regular testing may assist in
identifying hyperglycaemia,
regular engagement with
healthcare professionals and
periodic testing of a patient’s
HbA1c is of greater benefit
for patients not using insulin
SMBG is of limited clinical
effectiveness in improving
glycaemic control in people
with T2DM on oral agents, or
diet alone, and is therefore
unlikely to be cost-effective.
SMBG may lead to improved
glycaemic control only in the
context of appropriate
education and if patients are
able to self-adjust drug
treatment.
Associated with a modest,
statistically significant
reduction in haemoglobin
A1c concentrations,
regardless of whether
patients were provided with
education. Did not
demonstrate consistent
benefits in terms of quality of
life, patient satisfaction,
prevention of hypoglycemia
or long-term complications of
diabetes, or reduction of
mortality.
SMBG should be used only
Consistent with
inclusion?
Y
Y
Y
Y
Y
Y
Federation 20098
Allemann et al 20099
Systematic review and metaanalysis to 2009, 15 trials
included.
when individuals with
diabetes (and/or their caregivers) and/or their
healthcare providers have
the knowledge, skills and
willingness to incorporate
SMBG monitoring and
therapy adjustment into their
diabetes care plan in order to
attain agreed treatment goal
SMBG compared with nonSMBG is associated with a
significantly improved
glycaemic control in noninsulin treated patients with
type 2 diabetes. The added
value of more frequent
SMBG compared with less
intensive SMBG remains
uncertain
N
2. Don’t routinely order a thyroid ultrasound in patients with
abnormal thyroid function tests if there is no palpable
abnormality of the thyroid gland
Thyroid ultrasound is used to identify and characterize thyroid nodules, and is not part of the
routine evaluation of abnormal thyroid function tests (over- or underactive thyroid function)
unless the patient also has a palpably large goitre or a nodular thyroid. Incidentally
discovered thyroid nodules on ultrasound are common. Overzealous use of ultrasound will
frequently identify nodules, which are unrelated to the abnormal thyroid function, and may
divert the clinical evaluation to assess the nodules, rather than the thyroid dysfunction, may
lead to further unnecessary investigation, unwarranted patient anxiety and increased costs.
Imaging may be needed in thyrotoxic patients; when needed, a radionuclide thyroid scan,
not an ultrasound, is used to assess the aetiology of the thyrotoxicosis and the possibility of
focal autonomy in a thyroid nodule or nodules.
Materiality/usage patterns
There is no specific MBS item for thyroid ultrasounds. Instead it is covered by the MBS items
for neck ultrasounds. While not all neck ultrasounds ordered by endocrinologists will be
thyroid scans (some will be assessing parathyroids), Figure 2 below shows the usage of
neck ultrasounds ordered by all medical practitioners over the 2004 to 2014 financial year
period while Figure 3 shows similar usage patterns just for endocrinologists over the shorter
time period for which such specialised data is available over 2010 to 2014.
Note that the data has not been separated out into data on the number of tests ordered as a
first test by endocrinologists compared with those that need to be ordered as a follow up –
which could better reveal the extent to which inappropriately ordered ‘first tests’ lead to
additional follow up tests. We have requested customised data on this from the Department
of Health but the data has not been received in time for the finalisation of this document.
Bearing these caveats in mind, the figures show that there has been a significant increase in
the number of neck ultrasounds ordered. For all tests over the 2004 to 2014 period the
compounded growth rate has been 9.3% p.a. while the growth rate for the number of such
tests ordered by endocrinologists has been more than 12.5% p.a.
Total benefits paid out for these tests amounted to $9.8 million in 2004 but had grown to
almost $28.3 million by 2014 which is an annual growth rate of more than 11%. This growth
if anything may underestimate the opportunity costs from inappropriate testing as it does not
include the costs for specialty consultations, subsequent surgery and other activity based on
the initial inappropriate investigation. Nor have costs in terms of mental health burdens and
anxieties caused by false positive results been taken into account.
Figure 2: No. of services - MBS items 55032, 55033, 55011, 55013
Source: MBS website data
Figure 3: No. of services ordered by endocrinologists - MBS items 55032, 55033, 55011, 55013
Source: MBS website data
Lessons from research and guidelines
There is insufficient evidence to evaluate the comparative benefit of a thyroid ultrasound for
use beyond the boundaries of established indications, frequency, intensity, or dosage.
Guidelines recommend that thyroid ultrasounds are useful in detection of nodules and
cancer but not in the absence of any palpable abnormalities. There is also evidence that
inappropriate thyroid investigations leads to the over detection and treatment of thyroid
cancers including the lack of benefits from the use of RAIs for small papillary cancers.
Paper
Approach
Conclusions
Ahn et al 201410
Observational study
Brito et al 201211
Clinical review
Bahn et al 201112
Guidelines
In 2011, the rate of thyroidcancer diagnoses in the
Republic of Korea was 15
times that observed in 1993,
yet thyroid-cancer mortality
remains stable — a
combination that suggests
that the problem is
overdiagnosis attributable to
widespread thyroid-cancer
screening.
New imaging methods allow
the detection and biopsy of
thyroid nodules as small as 2
mm. There is an expanding
gap between the incidence of
thyroid cancer and stable
death rates from papillary
thyroid cancer which is
evidence of overdiagnosis.
Patients having
thyroidectomy experience
physical complications,
financial and psychosocial
burdens, and need lifelong
thyroid replacement therapy.
One caveat is that this
inference about
overdiagnosis of thyroid
cancer is based on
epidemiological and
observational evidence.
The use of thyroid
ultrasonography in all
patients with GD (Graves’
Disease) has been shown to
identify more nodules and
cancer than does palpation
and 123I scintigraphy.
However, since most of
these cancers are papillary
microcarcinomas with
minimal clinical impact,
further study is required
before routine ultrasound
(and therefore surgery) can
be recommended’
Consistent with
inclusion?
Y
Y
Y
3. Don’t routinely measure 1,25-dihydroxyvitamin D unless the
patient has hypercalcemia or decreased kidney function
Serum levels of 1,25-dihyroxyvitamin D have little or no relationship to vitamin D stores but
rather are regulated primarily by parathyroid hormone levels, which in turn are regulated by
calcium and/or vitamin D. In vitamin D deficiency, 1,25-dihydroxyvitamin D levels go up, not
down.
Unregulated production of 1,25-dihydroxyvitamin D is an uncommon cause of
hypercalcemia; this should be suspected if blood calcium levels are high and parathyroid
hormone levels are low and confirmed by measurement of 1,25-dihydroxyvitamin D. The
enzyme that activates vitamin D is produced in the kidney, so blood levels of 1,25dihydroxyvitamin D are sometimes of interest in patients on dialysis or with end-stage kidney
disease. There are few other circumstances, if any, where 1,25-dihydroxyvitamin D testing
would be helpful.
Materiality/usage patterns
As MBS restrictions have only recently (in October 2014) been introduced which break out a
separate 1,25-dihyroxyvitamin D testing item, there is no useful dataset yet on long term
usage patterns for this test item.
Lessons from research and guidelines
Guidelines recommend against using the serum 1,25-dihydroxyvitamin D (as opposed to the
25-hydroxyvitamin D) test for testing for vitamin D deficiency. The former test can be
inaccurate because those with vitamin D deficiency can exhibit normal or even elevated
levels of serum 1,25-dihydroxyvitamin D.
Paper
Approach
Conclusions
Holick et al 201113
Guideline
Holick et al 200714
Review article
Recommends using the
25(OH)D] level to evaluate
vitamin D status in patients
who are at risk for vitamin D
deficiency. Recommends
against using 1,25(OH)2D
assay for this purpose and
are in favour of using it only
in monitoring certain
conditions, such as acquired
and inherited disorders of
vitamin D and phosphate
metabolism.
Serum 1,25(OH)2D does not
reflect vitamin D reserves,
and its measurement is not
useful for monitoring the
vitamin D status of patients.
Serum 1,25(OH)2D is
frequently either normal or
even elevated in those with
vitamin D deficiency, due to
secondary
hyperparathyroidism.
Since the kidneys
tightly regulate the
production of 1,25dihydroxyvitamin
Consistent with
inclusion?
Y
Y
D, serum levels do not rise in
response to
increased exposure to
sunlight or increased intake
of vitamin D.1-3 Furthermore,
in a vitamin D–
insufficient state, 1,25dihydroxyvitamin D levels
are often normal or even
elevated
4. Don’t order a total or free T3 level when assessing thyroxine
dose in hypothyroid patients
T4 is converted into T3 at the cellular level in virtually all organs. Intracellular T3 levels
regulate pituitary secretion and blood levels of thyroid-stimulating hormone (TSH), as well
as the effects of thyroid hormone in multiple organs; a normal TSH indicates an adequate T4
dose. Conversion of T4 to T3 at the cellular level may not be reflected in the T3 level in the
blood. Compared to patients with intact thyroid glands, patients taking T4 may have higher
blood T4 and lower blood T3 levels. Thus the blood level of total or free T3 may be
misleading (low normal or slightly low); in most patients a normal TSH indicates a correct
dose of T4.
Materiality/usage patterns
Figure 5: No. of services - MBS item 66719 (2004 to 2014)
Source: MBS website data
MBS data (which does not include services provided to public patients in public hospitals or
services that qualify for a benefit from the Department of Veterans' Affairs) shows an
increase in the number of T3 level tests ordered over the 2004 to 2014 period. This has
been at an average rate of 8.4% p.a. A breakdown is not available for the number of these
tests ordered for hypothyroid patients. Nonetheless, the increase suggests there is a prima
facie case for better selectivity in use of the ordering of these tests.
In 2004 the total cost of these tests was more than $28 million. This had grown to almost
$62.7 million in 2014 which is an annual average growth rate of around 8%.
The variation in usage per capita is noticeable but not significant ranging from 5351 per
100,000 in NT to 10,685 per 100,000 in Queensland.
Lessons from research and guidelines
Guidelines states that the serum T3 measurement has limited utility in assessing
hypothyroidism and can lead to both false positives and false negatives.
Paper
Approach
Conclusions
Garber et al 201215
Guidelines
Serum T3 measurement,
whether total or free, has
limited utility in
hypothyroidism because
levels are often normal due
to hyperstimulation of the
remaining functioning thyroid
tissue by elevated TSH and
to up-regulation of type 2
iodothyronine deiodinase.
Moreover, levels of T3 are
low in the absence of thyroid
disease in patients with
severe illness because of
reduced peripheral
conversion of T4 to T3 and
increased inactivation of
thyroid hormone.
Consistent with
inclusion?
Y
5. Don’t prescribe testosterone therapy unless there is evidence of
proven testosterone deficiency
Many of the symptoms attributed to male hypogonadism are commonly seen in normal male
aging or in the presence of comorbid conditions. Testosterone therapy has the potential for
serious side effects and represents a significant expense. It is therefore important to confirm
the clinical suspicion of hypogonadism with biochemical testing. Current guidelines
recommend the use of a total testosterone level obtained in the morning. A low level should
be confirmed on a different day, again measuring the total testosterone. In some situations,
for example conditions in which sex hormone-binding globulin concentrations are altered, a
calculated free or bioavailable testosterone may be of additional value.
Materiality/usage patterns
Over two decades, total annual expenditure on testosterone products increased ninefold to
$12.7 million according to PBS data and fivefold to $16.3 million according to IMS, a source
of commercial pharmaceutical data. When adjusted for inflation and population growth, total
annual expenditure on testosterone products increased 4.5-fold according to PBS data and
2.5-fold according to datafrom January 1992 to December 2010. Differences in total
testosterone prescribed per capita between the states and territories with the highest and
lowest rates of prescribing were roughly twofold at the beginning and at the end of this
period.1
Figure 6: No. of scripts – testosterone products (2005 to 2011)
Handelsman, D. 2012, ‘Pharmacoepidemiology of testosterone prescribing in Australia, 1992–2010’,
Med J Aust 2012; 196 (10): 642-645.
1
Source: Australian Statistics on Medicines, various years, PBS
PBS statistics show that there has been a steep increase in number of scripts written for testosterone
products which increased by 5.23% p.a. between 2001 and 2011 (with the steeper increases starting
from around 2005). The increase in injections and transdermal prescriptions has more than made up
for declines in number of scripts written for other testosterone products.
Lessons from research and guidelines
Guidelines recommend that testosterone therapy should be considered in men who are
androgen deficient. There is ongoing controversy over potential adverse effects associated
with use of this therapy. Treatment should be preceded by consideration of the benefits
versus risks in individuals.
Research
Paper
Approach
Conclusions
Corona et al 201416
An up to date meta-analysis
of randomised controlled
trials involving 75 studies
with 3,016 men treated with
T and 2,448 with placebo for
a mean duration of 34
weeks.
Testosterone is not related to
any increase in CV risk, even
when composite or single
adverse events were
considered. In RCTs
performed in subjects with
metabolic derangements a
protective effect of TS on CV
risk was observed
Finkle et al 201417
Cohort study of the risk of
acute non-fatal myocardial
infarction (MI) following an
initial testosterone
prescription (n = 55,593).
Y
Baillargeon et al 201418
Case-control study of men 66
years of age and older in
which testosterone therapy
was not associated with risk
of myocardial infarction.
Retrospective national cohort
study of men with low
testosterone levels who
underwent coronary
angiography (8709
participants)
In older men, and in younger
men with pre-existing heart
disease, the risk of non-fatal
MI was higher in the 90 days
following prescription of
testosterone compared with
the preceding period..
In men at the highest risk,
testosterone therapy was
associated with lower
incidence of MI
Among a cohort of men who
underwent coronary
angiography and had a low
serum testosterone level, the
use of testosterone therapy
was associated with
increased risk of adverse
outcomes.
Testosterone therapy
increased risk of a
cardiovascular-related event.
In trials not funded by the
pharmaceutical industry the
risk of a cardiovascularrelated event on testosterone
therapy was greater than in
pharmaceutical industry
funded trials.
Testosterone therapy was
associated with reduced
mortality, compared with no
testosterone therapy
‘Our proposed diagnostic
strategy reflects our
preference to avoid labeling
men with low testosterone
Y
Vigen et al 201319
Xu et al 201320
Systematic review and metaanalysis of placebocontrolled randomized trials
of testosterone therapy
among men lasting 12+
weeks reporting
cardiovascular-related
events.(27 trials included)
Shores et al 201221
Cohort study in male US
veterans with an initial low
measured T concentration.
Bhasin et al 201022
Clinical practice guideline
Consistent with
inclusion?
N
N
Y
N
Y
levels due to S HBG
abnormalities, natural
variations in testosterone
levels, or transient disorders
as requiring testosterone
therapy. Our strategy also
reflects our preference to
avoid treatment in men
without unequivocally low
testosterone levels and
symptoms in whom the
benefits and risks of
testosterone therapy remain
unclear.’
‘It is important to confirm low
testosterone concentrations
in men with an initial
testosterone level in the
mildly hypogonadal range,
because 30% of such men
may have a normal
testosterone level on repeat
measurement.’
The Task Force recommends
against a general policy of
offering testosterone therapy
to all older men with low
testosterone levels. (1 |
+OOO)
Fernández-Balsells et al
201023
Systematic review of studies
from 2003 through August
2008, included 51 studies
The Task Force suggests
that clinicians consider
offering testosterone therapy
on an individualized basis to
older men with low
testosterone levels on more
than one occasion and
clinically significant
symptoms of androgen
deficiency, after explicit
discussion of the uncertainty
about the risks and benefits
of testosterone therapy.
Adverse effects of
testosterone therapy include
an increase in haemoglobin
and haematocrit and a small
decrease in high-density
lipoprotein cholesterol. These
findings are of unknown
clinical significance. Current
evidence about safety of
testosterone treatment in
men in terms of patientimportant outcomes is of low
quality.
Y
6. Don’t screen for gestational diabetes at 26-28 weeks using
fasting plasma glucose, random blood glucose, glucose challenge
test or urinalysis for glucose
The oral glucose tolerance test (OGTT) is currently the gold standard for the diagnosis of
diabetes including gestational diabetes. If a woman has had gestational diabetes, a repeat
OGTT is recommended at 6–8 weeks after delivery. If the results are normal, repeat testing
is recommended between 1 and 3 years depending on the clinical circumstances.
Caveats: This is likely to change with the pending Australasian Diabetes Society statement
on HbA1c for diabetes diagnosis and the very poor compliance with OGTT ordering. New
recommendations to screen for overt diabetes early in pregnancy for those at risk with a
random or fasting glucose followed by an OGTT may challenge this.
In addition, in the case of indigenous populations in remote areas, the random and fasting
glucose tests may be the only practical and accessible alternatives to the OGTT. Thus
limiting diagnosis to OGTT may limit diagnosis in these settings.
Materiality/usage patterns
Figure 7: No of services – MBS item 66545 (2004 to 2014) - Glucose challenge
Source: MBS website data
Figure 8: No of services – MBS item 66548 (2004 to 2014) - 75g oGTT
Source: MBS website data
Figure 7 shows the trend in number of services provided for only one of the glucose tests not
recommended for gestational diabetes, namely the oral glucose challenge test (item 66545).
By contrast the number of services provided for the oral glucose tolerance test which is
recommended has grown significantly since 2004. This does not necessarily rule out
consideration of this item on the shortlist though it does show that the use of inappropriate
tests for gestational diabetes may be declining (and that correspondingly, use of the more
appropriate test is increasing).
Lessons from research and guidelines
Guidelines recommend the oral glucose tolerance test over the glucose challenge test.
Paper
Approach
Conclusions
NICE24
Guidelines
Offer early self-monitoring of
blood glucose or a 2-hour 75
g oral glucose tolerance test
(OGTT) at 16–18 weeks to
test for gestational diabetes if
the woman has had
gestational diabetes
previously, followed by
OGTT at 28 weeks if the first
test is normal … Do not offer
screening for gestational
Consistent with
inclusion?
Y
American Diabetes
Association 201425
Guidelines
diabetes using fasting
plasma glucose, random
blood glucose, glucose
challenge test or urinalysis
for glucose
GDM screening can be
accomplished with
either of two strategies:
1. “One-step” 2-h 75-g OGTT
or
2. “Two-step” approach with
a 1-h 50-g (nonfasting)
screen followed by a 3-h
100-g OGTT for those who
screen positive
Y
7. Avoid repeated measurement of 25-hydroxyvitamin D in
patients with osteoporosis on stable Vitamin D supplementation
Serum 25OH-D levels should not be retested once a desirable level has been reached
through vitamin D supplementation unless risk factors change.
Materiality/usage patterns
Figure 9: No. of services - MBS item 66608 (2007 to 2014)
Source: MBS website data
MBS data (which does not include services provided to public patients in public hospitals or
services that qualify for a benefit from the Department of Veterans' Affairs) shows a steep
increase in the number of vitamin D tests ordered per year. However, the Department of
Health does not link MBS data on these tests with their clinical purpose. Thus it is impossible
to get a clear picture of the extent to which these tests are being used on those with
osteoporosis but who already are on vitamin D supplementation. All that can be discerned is
that there has been a steep increase in the number of vitamin D tests over time suggesting
that the overordering of vitamin D tests is a ‘live’ issue and attempts to curb its use where
unwarranted and introduce greater selectivity are to be welcomed.
Lessons from research and guidelines
Guidelines recommend against retesting of Serum 25OH-D levels once a desirable level has
been reached through vitamin D supplementation unless risk factors change. It is also
recommended that retesting should not take place before 3 months after administration of
supplements.
Paper
Approach
Conclusions
Consistent with
Royal College of Pathologists
Australia 201326
Guidelines
Nowson et al 201227
Guidelines
Serum 25OH-D levels should
be retested no earlier than 3
months following
commencement of
supplementation with vitamin
D or change in dose. Once a
desirable 25OH-D target
level has been achieved,
especially by the end of
winter, no further testing is
required unless risk factors
change
As it may take up to 2–5
months for serum levels of
25-OHD to plateau, retesting
should not take place before
3 months’
inclusion?
Y
8. Do not measure insulin concentration in the fasting state or
during an oral glucose tolerance test to assess insulin sensitivity
Measurement of insulin either in the fasting state or during an oral glucose tolerance test is
not a clinically useful method (and may be costly because of the insulin assay) to estimate
insulin sensitivity. The hyperinsulinemic-euglycemic (HIEG) clamp is the gold standard for
assessing insulin sensitivity as it is possible to assess tissue specific sensitivity and can be
used in all types of populations. This feature is important because a method of
standardisation must be developed to control for various factors prior to any methods for
measurement.
Materiality/usage patterns
MBS data on the number of serum insulin tests is not available as the relevant MBS item
number for this (66695) bundles together a number of blood assays. Data on usage of the
OGTT is available but not sufficiently fine grained to measure incidence of usage for the
purpose of assessing insulin sensitivity.
Lessons from research and guidelines
Guidelines state that the HIEG clamp is the gold standard for assessing insulin sensitivity
while OGTT indices are not as precise. Guidelines also particularly recommend against the
measurement of serum insulin levels as a method of assessing for risk of DM2 as part of the
assessment of PCOS.
Paper
Approach
Conclusions
Antuna-Puente et al 201128
Clinical review
Teede et al 201129
Clinical guideline
Borai et al 201130
Clinical review
Samaras et al 200631
Clinical review
The HIEG clamp is the gold
standard for assessing
insulin sensitivity. OGTT
indices are not as precise as
the HIEG.
Previous studies have noted
that fasting blood glucose
level alone appears to lack
sensitivity in screening for
prediabetes or DM2 in
PCOS, with national and
international groups
recommending screening all
women with PCOS with an
OGTT It is important to note
that assessment of IR or
measurement of serum
insulin levels has no current
role in clinically assessing for
risk of DM2.
Where possible the HEC
(hyperinsulinaemic
euglycaemic clamp), as the
most accurate technique
available, remains the first
choice but simpler and
inexpensive methods may be
appropriate provided the
investigator is aware of their
limitations.
Serum insulin levels are poor
measures of insulin
resistance. Furthermore,
Consistent with
inclusion?
Y
Y
Y
Y
there is no clinical benefit in
measuring insulin resistance
in clinical practice.
Measurements of fasting
serum insulin levels should
be reserved for large
population-based
epidemiological studies,
where they can provide
valuable data on the
relationship of insulin
sensitivity to risk factors for
diabetes and cardiovascular
disease
References:
Department of Health and Ageing 2012, ‘Pharmaceutical Benefits Scheme Products Used in the
Treatment of Diabetes’, Report to the Pharmaceutical Benefits Advisory Committee.
2 Department of Health and Ageing 2012, ‘Pharmaceutical Benefits Scheme Products Used in the
Treatment of Diabetes’, Report to the Pharmaceutical Benefits Advisory Committee.
3 Malanda et al, Self-monitoring of blood glucose in patients with type 2 diabetes mellitus who are not
using insulin, Cochrane Database of Systematic Reviews 2012, Issue 1.
1
Farmer et al, ‘Meta-analysis of individual patient data in randomised trials of self monitoring of blood
glucose in people with non-insulin treated type 2 diabetes’, BMJ. 2012 Feb 27;344:e486. doi:
10.1136/bmj.e486.
5 Department of Health and Ageing and University of South Australia 2012, Pharmaceutical Benefits
Scheme Products Used in the Treatment of Diabetes, Part 1: Blood Glucose Test Strips.
6 Clar et al,’ Self-monitoring of blood glucose in type 2 diabetes: systematic review’, Health Technol
Assess. 2010 Mar;14(12):1-140. doi: 10.3310/hta14120.
7 Mcintosh et al 2010, ‘Efficacy of self-monitoring of blood glucose in patients with type 2 diabetes
mellitus managed without insulin: a systematic review and meta-analysis’, Open Med.
2010;4(2):e102-13. Epub 2010 May 18.
8 International Diabetes Federation 2009, Guideline: Self-Monitoring of Blood Glucose in Non-Insulin
Treated Type 2 Diabetes.
9 Allemann et al, ‘Self-monitoring of blood glucose in non-insulin treated patients with type 2 diabetes:
a systematic review and meta-analysis’, Curr Med Res Opin. 2009 Dec;25(12):2903-13. doi:
10.1185/03007990903364665.
10 Ahn et al, Korea's Thyroid-Cancer “Epidemic” — Screening and Overdiagnosis, New England
Journal of Medicine 2014; 371:1765-1767.
11 Brito et al, Thyroid cancer: zealous imaging has increased detection and treatment of low risk
tumours, BMJ 2013; 347 doi: http://dx.doi.org/10.1136/bmj.f4706
12 Bahn et al, Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the
American Thyroid Association and American Association of Clinical Endocrinologists. Thyroid.
2011;21:593-646
13 Holick et al, Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society
clinical practice guideline. J Clin Endocrinol Metab. 2011 Jul;96(7):1911–30.
14 Holick, ‘Vitamin D deficiency’, N Engl J Med 2007;357:266-81.
15 Garber et al, Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American
Association of Clinical Endocrinologists and the American Thyroid Association. Endocr Pract. 2012;
Sep 11:1–207
16 Corona G et al. Cardiovascular risk associated with testosterone-boosting medications: a
systematic review and meta-analysis. Expert Opin Drug Saf 2014; 13: 1327-1351
17 Finkle et al, Increased risk of non-fatal myocardial infarction following testosterone therapy
prescription in men, PLoS One. 2014 Jan 29;9(1):e85805. doi: 10.1371/journal.pone.0085805.
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