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Additionally, time below target and time above target are useful parameters for the evaluation of the treatment regimen Table 6. CGM is rapidly improving diabetes management.
As stated in the recommendations, time in range TIR is a useful metric of glycemic control and glucose patterns, and it correlates well with A1C in most studies 23 — New data support the premise that increased TIR correlates with the risk of complications.
CGM, continuous glucose monitoring; CV, coefficient of variation; TAR, time above range; TBR, time below range; TIR, time in range. Adapted from Battelino et al. For many people with diabetes, glucose monitoring is key for achieving glycemic targets. Major clinical trials of insulin-treated patients have included BGM as part of multifactorial interventions to demonstrate the benefit of intensive glycemic control on diabetes complications BGM is thus an integral component of effective therapy of patients taking insulin.
In recent years, CGM is now a standard method for glucose monitoring for most adults with type 1 diabetes Both approaches to glucose monitoring allow patients to evaluate individual responses to therapy and assess whether glycemic targets are being safely achieved.
The international consensus on TIR provides guidance on standardized CGM metrics see Table 6. To make these metrics more actionable, standardized reports with visual cues, such as the ambulatory glucose profile see Fig. BGM and CGM can be useful to guide medical nutrition therapy and physical activity, prevent hypoglycemia, and aid medication management.
While A1C is currently the primary measure to guide glucose management and a valuable risk marker for developing diabetes complications, the CGM metrics TIR with time below range and time above range and GMI provide the insights for a more personalized diabetes management plan.
The incorporation of these metrics into clinical practice is in evolution, and remote access to these data can be critical for telemedicine. A rapid optimization and harmonization of CGM terminology and remote access is occurring to meet patient and provider needs 35 — Key points included in standard ambulatory glucose profile AGP report.
Reprinted from Holt et al. With the advent of new technology, CGM has evolved rapidly in both accuracy and affordability. Reports can be generated from CGM that will allow the provider and person with diabetes to determine TIR, calculate GMI, and assess hypoglycemia, hyperglycemia, and glycemic variability.
As discussed in a recent consensus document, a report formatted as shown in Fig. Note the goals of therapy next to each metric in Fig. Overall, regardless of the population being served, it is critical for the glycemic targets to be woven into the overall patient-centered strategy. For example, in a very young child, safety and simplicity may outweigh the need for perfect control in the short run.
Simplification may decrease parental anxiety and build trust and confidence, which could support further strengthening of glycemic targets and self-efficacy. Similarly, in healthy older adults, there is no empiric need to loosen control. However, the provider needs to work with an individual and should consider adjusting targets or simplifying the regimen if this change is needed to improve safety and adherence.
Hyperglycemia defines diabetes, and glycemic control is fundamental to diabetes management. Follow-up of the DCCT cohorts in the Epidemiology of Diabetes Interventions and Complications EDIC study 3839 demonstrated persistence of these microvascular benefits over two decades despite the fact that the glycemic separation between the treatment groups diminished and disappeared during follow-up.
Patient and disease factors used to determine optimal glycemic targets. Characteristics and predicaments toward the left justify more stringent efforts to lower A1C; those toward the right suggest less stringent efforts.
Adapted with permission from Inzucchi et al. The Kumamoto Study 40 and UK Prospective Diabetes Study UKPDS 4142 confirmed that intensive glycemic control significantly decreased rates of microvascular complications in patients with short-duration type 2 diabetes.
Long-term follow-up of the UKPDS cohorts showed enduring effects of early glycemic control on most microvascular complications Epidemiologic analyses of the DCCT 32 and UKPDS 45 demonstrate a curvilinear relationship between A1C and microvascular complications.
Given the substantially increased risk of hypoglycemia in type 1 diabetes and with polypharmacy in type 2 diabetes, the risks of lower glycemic targets may outweigh the potential benefits on microvascular complications. Three landmark trials Action to Control Cardiovascular Risk in Diabetes [ACCORD], Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation [ADVANCE], and Veterans Affairs Diabetes Trial [VADT] were conducted to test the effects of near normalization of blood glucose on cardiovascular outcomes in individuals with long-standing type 2 diabetes and either known cardiovascular disease CVD or high cardiovascular risk.
These trials showed that lower A1C levels were associated with reduced onset or progression of some microvascular complications 46 — The concerning mortality findings in the ACCORD trial discussed below and the relatively intense efforts required to achieve near euglycemia should also be considered when setting glycemic targets for individuals with long-standing diabetes, such as those populations studied in ACCORD, ADVANCE, and VADT.
Findings from these studies suggest caution is needed in treating diabetes to near-normal A1C goals in people with long-standing type 2 diabetes with or at significant risk of CVD. These landmark studies need to be considered with an important caveat; glucagon-like peptide 1 GLP-1 receptor agonists and sodium—glucose cotransporter 2 SGLT2 inhibitors were not approved at the time of these trials.
As such, these agents with established cardiovascular and renal benefits appear to be safe and beneficial in this group of individuals at high risk for cardiorenal complications. Prospective randomized clinical trials examining these agents for cardiovascular safety were not designed to test higher versus lower A1C; therefore, beyond post hoc analysis of these trials, we do not have evidence that it is the glucose lowering by these agents that confers the CVD and renal benefit As such, on the basis of physician judgment and patient preferences, select patients, especially those with little comorbidity and a long life expectancy, may benefit from adopting more intensive glycemic targets if they can achieve them safely and without hypoglycemia or significant therapeutic burden.
CVD is a more common cause of death than microvascular complications in populations with diabetes. There is evidence for a cardiovascular benefit of intensive glycemic control after long-term follow-up of cohorts treated early in the course of type 1 diabetes.
In the DCCT, there was a trend toward lower risk of CVD events with intensive control. The benefit of intensive glycemic control in this cohort with type 1 diabetes has been shown to persist for several decades 51 and to be associated with a modest reduction in all-cause mortality In type 2 diabetes, there is evidence that more intensive treatment of glycemia in newly diagnosed patients may reduce long-term CVD rates.
Thus, to prevent both microvascular and macrovascular complications of diabetes, there is a major call to overcome therapeutic inertia and treat to target for an individual patient 57 ACCORD, ADVANCE, and VADT suggested no significant reduction in CVD outcomes with intensive glycemic control in participants followed for shorter durations 3.
All three trials were conducted in relatively older participants with a longer known duration of diabetes mean duration 8—11 years and either CVD or multiple cardiovascular risk factors. The glycemic control comparison in ACCORD was halted early due to an increased mortality rate in the intensive compared with the standard treatment arm 1.
Analysis of the ACCORD data did not identify a clear explanation for the excess mortality in the intensive treatment arm Longer-term follow-up has shown no evidence of cardiovascular benefit, or harm, in the ADVANCE trial The end-stage renal disease rate was lower in the intensive treatment group over follow-up.
However, year follow-up of the VADT cohort 61 did demonstrate a reduction in the risk of cardiovascular events Heterogeneity of mortality effects across studies was noted, which may reflect differences in glycemic targets, therapeutic approaches, and, importantly, population characteristics Mortality findings in ACCORD 59 and subgroup analyses of VADT 63 suggest that the potential risks of intensive glycemic control may outweigh its benefits in higher-risk individuals.
In all three trials, severe hypoglycemia was significantly more likely in participants who were randomly assigned to the intensive glycemic control arm. As discussed further below, severe hypoglycemia is a potent marker of high absolute risk of cardiovascular events and mortality Therefore, providers should be vigilant in preventing hypoglycemia and should not aggressively attempt to achieve near-normal A1C levels in people in whom such targets cannot be safely and reasonably achieved.
: HbAc importance in diabetes control| HbA1c test - a blood test to diagnose and monitor diabetes | healthdirect | Strategies for weight management include lifestyle change, pharmacologic therapy, and metabolic surgery. It makes sense that keeping blood sugar under control should prevent diabetes-related damage — but how low to push blood sugar is an open question. Abe M , Hamano T , Hoshino J , et al. Literature review current through: Jan Thus, to prevent both microvascular and macrovascular complications of diabetes, there is a major call to overcome therapeutic inertia and treat to target for an individual patient 57 , If you have diabetes, ask your doctor if tight blood sugar control is right for you. Total Views 3, |
| Helpful Links | Moreover, Increase focus and attention studies have HbA that ij use of Hair growth for thinning hair can improve the mean amplitude HbAc importance in diabetes control glycemic excursion MAGE and congrol in better glycemic control in persons with type 2 HbAc importance in diabetes control [ Roasted Pumpkin Seeds28 diaetes, 29 imporatnce, 30 ]. Conclusions This study focused on the long-term risk of diabetes-related complications among individuals with T2D. Use of continuous glucose monitoring leads to diagnosis of hemoglobin C trait in a patient with discrepant haemoglobin A1c and self-monitoring blood glucose. Nevertheless, both metabolic syndrome and metabolic diseases indicate serious physiological dysfunction, which has been associated with worse outcomes, including higher odds of mortality [ 3839 ]. Bergenstal RM. Lipska KJKrumholz HM. |
| Talk to us about diabetes | may worsen glycemic control un precipitate Hair growth for thinning hair ketoacidosis Liver support pills nonketotic hyperglycemic hyperosmolar state, life-threatening diabetse that require immediate medical care to prevent complications and death. Hypoglycemia prevention is ln Roasted Pumpkin Seeds component of diabetes management. The identification window for each person was the overlap between his or her period of continuous insurance coverage and the time horizon requirements for the pre- and post-period. Yuan L, Li F, Jing T, et al. HbA1c levels are an indicator of how well your blood sugar has been controlled over the past two to three months. |
| Introduction | Elevated HbA1c has also been regarded as an independent risk factor for coronary heart disease and stroke in subjects with or without diabetes. The valuable information provided by a single HbA1c test has rendered it as a reliable biomarker for the diagnosis and prognosis of diabetes. This review highlights the role of HbA1c in diagnosis and prognosis of diabetes patients. The new NEJM report suggests that tight blood sugar control also has cardiovascular benefits. The report is a year follow-up of the Veterans Affairs Diabetes Trial. This trial enrolled 1, military veterans with type 2 diabetes who were an average of 60 years old. In each group, the target blood sugar level was achieved with a combination of oral diabetes medications and insulin injections, if needed. During the five-and-a-half-year trial, the intensive-therapy group had an average HbA1c level near 6. The standard-therapy group had an average HbA1c level near 8. More than 1, of the trial participants were followed for another five years. During this time, researchers compared how many participants had a cardiovascular event, such as heart attack or stroke, between the intensive therapy and standard therapy groups. The results were heartening, both for doctors who have championed tight blood sugar control and for people with diabetes who have worked hard to achieve it. That translates into nearly 9 fewer heart attacks and strokes per 1, people. The study had another positive finding. It reinforced what Dr. The active part of the VA trial lasted for about five-and-a-half years. Within three years, the average HbA1c level in the intensive-therapy group had crept upward, reducing the difference in levels between the intensive and standard groups from 1. And yet, the intensive therapy group continued to reap cardiovascular benefits years later. Although tight blood sugar control can help prevent diabetes-related damage, it has some drawbacks. People aiming for tight control can experience bouts of low blood sugar hypoglycemia , which can be very dangerous. Tight control can also be difficult to achieve, sometimes requiring multiple medications that may have harmful side effects of their own. Earlier research had suggested that people with long-standing diabetes and established heart disease may not benefit from tight blood sugar control as much as those with newly diagnosed diabetes. The veterans enrolled in this trial had had poorly controlled diabetes for several years before the study began. So not only did intensive treatment reduce cardiovascular disease risk, it did so in older people with long-standing diabetes, many of whom already had heart trouble. Good blood sugar control is important for everyone with diabetes. If you have diabetes, ask your doctor if tight blood sugar control is right for you. Urmila Parlikar , Director, Editorial Operations, Harvard Health Publishing. As a service to our readers, Harvard Health Publishing provides access to our library of archived content. Please note the date of last review or update on all articles. Several randomized clinical trials have demonstrated a beneficial effect of intensive glycemia-lowering therapy on macrovascular outcomes in type 2 diabetes [ 2,3 ], with other trials not supporting a significant beneficial effect [ 4 ] and one trial suggesting harm [ 5 ]. Glycemic goals are discussed in more detail separately. See "Overview of general medical care in nonpregnant adults with diabetes mellitus", section on 'Glycemic management' and "Treatment of type 2 diabetes mellitus in the older patient", section on 'Controlling hyperglycemia' and "Glycemic control and vascular complications in type 2 diabetes mellitus", section on 'Choosing a glycemic target'. Cardiovascular risk factor management — In addition to glycemic management, vigorous cardiac risk reduction smoking cessation; blood pressure control; reduction in serum lipids with a statin; diet, exercise, and weight loss or maintenance; and aspirin for those with established atherosclerotic cardiovascular disease [ASCVD] or after shared decision-making should be a top priority for all patients with type 2 diabetes. However, in spite of evidence that aggressive multifactor risk reduction lowers the risk of both micro- and macrovascular complications in patients with diabetes [ 6,7 ], a minority of adults with diabetes fully achieve recommended goals for A1C, blood pressure control, and management of dyslipidemia [ 8 ]. See "Overview of general medical care in nonpregnant adults with diabetes mellitus", section on 'Aspirin' and "Treatment of hypertension in patients with diabetes mellitus" and "Low-density lipoprotein cholesterol-lowering therapy in the primary prevention of cardiovascular disease" and "Management of low density lipoprotein cholesterol LDL-C in the secondary prevention of cardiovascular disease" and "Overview of general medical care in nonpregnant adults with diabetes mellitus", section on 'Multifactorial risk factor reduction'. DIABETES EDUCATION — Patients with newly diagnosed diabetes should participate in a comprehensive diabetes self-management education program, which includes individualized instruction on nutrition, physical activity, optimizing metabolic control, and preventing complications. In clinical trials comparing diabetes education with usual care, there was a small but statistically significant reduction in A1C in patients receiving the diabetes education intervention [ 9 ]. In two meta-analyses, use of mobile phone interventions for diabetes education was successful in significantly reducing A1C Medical nutrition therapy — Medical nutrition therapy MNT is the process by which a dietary plan is tailored for people with diabetes, based on medical, lifestyle, and personal factors. It is an integral component of diabetes management and diabetes self-management education. For all patients, the goals of MNT include avoidance of weight gain, consistency in day-to-day carbohydrate intake at meals and snacks, and balanced nutritional content. MNT may be customized to achieve body weight reduction and is reviewed in detail elsewhere. See 'Diet' below and "Medical nutrition therapy for type 2 diabetes mellitus". Weight management — For patients with type 2 diabetes, body weight management should be considered as a therapeutic target in addition to glycemia. Patients should receive counseling regarding changes in diet and physical activity to achieve weight loss or to prevent weight gain. Weight loss improves glycemia through mitigation of insulin resistance and impaired beta cell function, two major metabolic perturbations evident in type 2 diabetes [ 12,13 ]. For patients who have difficulty achieving weight loss, weight maintenance rather than gain is an alternative goal. Strategies for weight management include lifestyle change, pharmacologic therapy, and metabolic surgery. Lifestyle change includes diet and physical activity, as well as behaviors that facilitate these changes, and is an essential component of any weight management plan. We emphasize lifestyle change as our initial approach to body weight reduction and reserve pharmacotherapy and metabolic surgery for patients who do not achieve targeted weight loss with lifestyle change alone. We tailor our specific recommendations to patients' goals and preferences and encourage "intensive" lifestyle modification, where available, for highly motivated patients. Diet — Diagnosis of type 2 diabetes is often a powerful motivator for lifestyle change. Dietary modification is a highly effective strategy for weight loss and for management of glycemia and hypertension in patients who are willing to commit to it, with metabolic benefit likely outlasting the effect of weight loss per se. The improvement in glycemia is related both to the degree of caloric restriction and weight reduction [ 12,14,15 ]. Body weight loss of 5 to 10 percent may also improve nonalcoholic steatohepatitis, sleep apnea, and other comorbidities of type 2 diabetes [ 16 ]. Consumption of sugar-sweetened beverages, including natural fruit juice, should be specifically queried and strongly discouraged in order to manage glycemia, weight, and reduce risk for CVD and fatty liver [ 17 ]. See "Medical nutrition therapy for type 2 diabetes mellitus", section on 'Designing a nutrition care plan' and "Management of nonalcoholic fatty liver disease in adults", section on 'Initial lifestyle interventions'. In a two-year analysis of the DiRECT trial, only 11 percent of intervention participants had weight loss of 15 kg or more compared with 24 percent in the one-year analysis [ 18 ]. However, 36 percent of participants maintained diabetes remission, compared with 3 percent of control patients. Several studies have evaluated the long-term efficacy of diet alone or with exercise in patients with newly diagnosed type 2 diabetes see "Medical nutrition therapy for type 2 diabetes mellitus". In the United Kingdom Prospective Diabetes Study UKPDS , for example, all patients were given a low-calorie, low-fat, high complex carbohydrate diet [ 21 ]. Furthermore, the mean glucose value was substantially higher with diet alone than with diet plus an oral hypoglycemic drug or insulin. The likelihood of a successful glycemic response to diet is determined in large part by the initial fasting blood glucose. Pharmacologic therapy — Pharmacotherapy targeted solely for weight management is effective in patients with type 2 diabetes. Although metformin is usually started for the management of hyperglycemia, it is also frequently an effective medication to promote modest weight loss. When additional body weight reduction is a primary goal of therapy, we choose medications that promote weight loss and lower glucose. Glucagon-like peptide 1 GLP-1 receptor and dual GLP-1 and glucose-dependent insulinotropic polypeptide GIP agonist therapies promote weight loss and help prevent weight gain due to other glucose-lowering pharmacotherapies. We add these medications sequentially to metformin if additional glucose lowering or weight loss is a treatment goal. See "Glucagon-like peptide 1-based therapies for the treatment of type 2 diabetes mellitus" and "Obesity in adults: Drug therapy". Surgical therapy — Weight loss surgery in patients with obesity and type 2 diabetes results in the largest degree of sustained weight loss and, in parallel, improvements in blood glucose management and the most frequent sustained remissions of diabetes. Weight loss surgery is an option to treat poorly managed type 2 diabetes when other modalities have failed. This topic is reviewed in detail separately. See "Management of persistent hyperglycemia in type 2 diabetes mellitus", section on 'Bariatric metabolic surgery'. Exercise — Regular exercise is beneficial in type 2 diabetes, independent of weight loss. It leads to improved glycemic management due to increased responsiveness to insulin; it can also delay the progression of impaired glucose tolerance to overt diabetes [ 22,23 ]. These beneficial effects are directly due to exercise, but concurrent weight reduction plays a contributory role. In one study, however, only 50 percent of patients with type 2 diabetes were able to maintain a regular exercise regimen [ 24 ]. See "Exercise guidance in adults with diabetes mellitus". Shorter-duration, intensive exercise may be appropriate for physically fit individuals [ 25 ]. Resistance training may be particularly important for individuals with type 2 diabetes who do not have overweight or obesity, in whom relative sarcopenia may contribute to diabetes pathophysiology [ 26 ]. Intensive lifestyle modification — In patients with established type 2 diabetes, intensive behavioral modification interventions focusing on weight reduction and increasing activity levels are successful in reducing weight and improving glycemic management while, at the same time, reducing the need for glucose-lowering and other medications [ 15,18, ]. The intensive intervention included caloric restriction maximum 30 percent calories from fat, minimum 15 percent protein, and the remainder from carbohydrates, in the form of liquid meal replacements, frozen food entrees, or structured meal plans , moderate-intensity physical activity goal minutes weekly , and weekly group or individual sessions with registered dietitians, behavioral psychologists, and exercise specialists. The primary outcome was a composite of death from cardiovascular causes, nonfatal myocardial infarction, nonfatal stroke, and hospitalization for angina. Although the anticipated follow-up period was After a median follow-up of 9. The improvement in weight and glycemia did not reduce the occurrence of cardiovascular events. Possible reasons for this finding include the lower-than-expected rates of cardiovascular events in both groups, improved overall cardiovascular risk factor treatment with medical therapy antihypertensives, statins in the standard diabetes education arm, enrollment of a relatively healthy patient population, gradual weight loss in the control group such that the differential weight loss between the two groups was only 2. A sustained weight loss of greater than that achieved in the trial may be required to reduce the risk of CVD. In an observational post hoc analysis of the Look AHEAD trial, weight loss of 10 percent or greater in the first year was associated with a reduction in the primary outcome 1. However, this post hoc analysis is problematic. Moreover, the degree of weight loss is difficult to achieve and maintain through lifestyle intervention alone. Weight loss, weight loss maintenance, and exercise remain important components of diabetes management due to overall health benefits. The following summarizes several other major observations from the Look AHEAD trial [ 27,31, ]:. The difference was attenuated but remained significant throughout the trial 6 versus 3. Changes in waist circumference and physical fitness were also significantly better in the intervention group throughout the study. By study end, mean A1C was significantly lower in the intervention group 7. Psychological interventions — Patients with type 2 diabetes often experience significant stress, a condition often called diabetes distress, related to the many self-care responsibilities required for glycemic management lifestyle modifications, medication, and blood glucose monitoring [BGM] [ 42 ]. Concurrent depression similarly may interfere with self-care. See "Overview of general medical care in nonpregnant adults with diabetes mellitus", section on 'Comorbid conditions'. Psychotherapy reduces psychological distress and improves glycemic management in some [ 43,44 ], but not all [ 45 ], studies. In a meta-analysis of 12 trials of patients with type 2 diabetes randomly assigned to psychological intervention or usual care, mean A1C was lower in the intervention group pooled mean difference Measures of psychological distress were also significantly lower in the intervention group, but there were no differences in weight management. Pregnancy planning — All women of childbearing age with diabetes should be counseled about the potential effects of diabetes and commonly used medications on maternal and fetal outcomes and the potential impact of pregnancy on their diabetes management and any existing complications. See "Pregestational preexisting diabetes: Preconception counseling, evaluation, and management". When to start — Early institution of treatment for diabetes, at a time when the A1C is not substantially elevated, is associated with improved glycemic management over time and decreased long-term complications [ 46 ]. Pharmacologic therapy should be initiated along with consultation for lifestyle modification focusing on dietary and other lifestyle contributors to hyperglycemia. Weight loss and weight loss maintenance underpins all effective type 2 diabetes therapy, and lifestyle change reduces the risk of weight gain associated with sulfonylureas and insulin. However, for those patients who have clear and modifiable contributors to hyperglycemia and who are motivated to change them eg, commitment to reduce consumption of sugar-sweetened beverages , a three-month trial of lifestyle modification prior to initiation of pharmacologic therapy is warranted. Choice of initial therapy — Our suggestions are based upon clinical trial evidence and clinical experience in achieving glycemic targets and minimizing adverse effects table 1 , with the recognition that there is a paucity of high-quality, head-to-head drug comparison trials and long-duration trials or ones with important clinical endpoints, such as effects on complications. The long-term benefits and risks of using one approach over another are unknown. In selecting initial therapy, we consider patient presentation eg, presence or absence of symptoms of hyperglycemia, comorbidities, baseline A1C level , individualized treatment goals and preferences, the glucose-lowering efficacy of individual drugs, and their adverse effect profile, tolerability, and cost [ 47 ]. We prefer initiating a single agent typically metformin and then sequentially adding additional glucose-lowering agents as needed, rather than starting with combination therapy [ 48 ]. Related Pathway s : Diabetes: Initial therapy for non-pregnant adults with type 2 DM. Asymptomatic, not catabolic — The majority of patients with newly diagnosed type 2 diabetes are asymptomatic, without symptoms of catabolism eg, without polyuria, polydipsia, or unintentional weight loss. Hyperglycemia may be noted on routine laboratory examination or detected by screening. Metformin — In the absence of specific contraindications, we suggest metformin as initial therapy for patients with newly diagnosed type 2 diabetes who are asymptomatic. We begin with mg once daily with the evening meal and, if tolerated, add a second mg dose with breakfast. The dose can be increased slowly one tablet every one to two weeks as tolerated to reach a total dose of mg per day. See 'When to start' above and "Metformin in the treatment of adults with type 2 diabetes mellitus", section on 'Dosing'. Metformin is the preferred initial therapy because of glycemic efficacy see 'Glycemic efficacy' below , promotion of modest weight loss, very low incidence of hypoglycemia, general tolerability, and favorable cost [ 47 ]. Metformin does not have adverse cardiovascular effects, and it appears to decrease cardiovascular events [ ]. See "Metformin in the treatment of adults with type 2 diabetes mellitus", section on 'Cardiovascular effects'. Metformin is far less expensive and has more clinical practice experience than glucagon-like peptide 1 GLP-1 receptor agonists and sodium-glucose cotransporter 2 SGLT2 inhibitors. Although some guidelines and experts endorse the initial use of these alternative agents as monotherapy or in combination with metformin [ 48,52 ], we prefer initiating a single agent typically metformin and then sequentially adding additional glucose-lowering agents as needed, rather than starting with combination therapy. In the clinical trials that demonstrated the protective effects of GLP-1 receptor agonists and SGLT2 inhibitors, these agents were added to background metformin therapy in most participants. Further, the cardiorenal benefits of GLP-1 receptor agonists and SGLT2 inhibitors have not been demonstrated in drug-naïve patients without established CVD or at low cardiovascular risk or without severely increased albuminuria. Although each diabetes medication is associated with adverse events, metformin is associated with less weight gain and fewer episodes of hypoglycemia compared with sulfonylureas, and with less edema, heart failure HF , and weight gain compared with thiazolidinediones. See "Sodium-glucose cotransporter 2 inhibitors for the treatment of hyperglycemia in type 2 diabetes mellitus", section on 'Cardiovascular effects' and "Glucagon-like peptide 1-based therapies for the treatment of type 2 diabetes mellitus", section on 'Cardiovascular effects'. Although virtually all recommendations for initial pharmacologic therapy outside of China, where alpha-glucosidase inhibitors are recommended as an alternate first-line monotherapy [ 53 ] endorse use of metformin , there are, in fact, relatively few relevant direct comparative effectiveness data available. Contraindications to or intolerance of metformin — For patients who have gastrointestinal intolerance of metformin , slower titration, ensuring that the patient is taking the medication with food, or switching to an extended-release formulation may improve tolerability. For patients who still cannot tolerate metformin or have contraindications to it, we choose an alternative glucose-lowering medication guided initially by patient comorbidities, and in particular, the presence of atherosclerotic CVD ASCVD or albuminuric chronic kidney disease. See "Metformin in the treatment of adults with type 2 diabetes mellitus", section on 'Contraindications'. When compared with placebo, the GLP-1 receptor agonists liraglutide , semaglutide , and dulaglutide demonstrated favorable atherosclerotic cardiovascular and kidney outcomes [ ]. The SGLT2 inhibitors empagliflozin , canagliflozin , and dapagliflozin have also demonstrated benefit, especially for HF hospitalization, risk of kidney disease progression, and mortality [ ]. Patients at high CVD risk but without a prior event might benefit, but the data are less supportive. Similarly, patients without severely increased albuminuria have some benefit, but the absolute benefits are greater among those with severely increased albuminuria. To select a medication, we use shared decision-making with a focus on beneficial and adverse effects within the context of the degree of hyperglycemia as well as a patient's comorbidities and preferences. As examples:. SGLT2 inhibitors with cardiovascular benefit empagliflozin or canagliflozin are good alternatives, especially in the presence of HF. Given the high cost of these classes of medications, formulary coverage often determines the choice of the first medication within the class. See "Glucagon-like peptide 1-based therapies for the treatment of type 2 diabetes mellitus", section on 'Cardiovascular effects' and "Glucagon-like peptide 1-based therapies for the treatment of type 2 diabetes mellitus", section on 'Microvascular outcomes'. Choice of agent is primarily dictated by provider preference, insurance formulary restrictions, eGFR, and cost. In the setting of declining eGFR, the main reason to prescribe SGLT2 inhibitors is to reduce progression of DKD. However, kidney and cardiac benefits have been shown in patients with eGFR below this threshold. Dosing in the setting of DKD is reviewed in detail elsewhere. See "Treatment of diabetic kidney disease", section on 'Type 2 diabetes: Treat with additional kidney-protective therapy'. An alternative or an additional agent may be necessary to achieve glycemic goals. GLP-1 receptor agonists are an alternative in patients with DKD as their glycemic effect is not related to eGFR. In addition, GLP-1 receptor agonists have been shown to slow the rate of decline in eGFR and prevent worsening of albuminuria. See 'Microvascular outcomes' below and "Sodium-glucose cotransporter 2 inhibitors for the treatment of hyperglycemia in type 2 diabetes mellitus" and "Glucagon-like peptide 1-based therapies for the treatment of type 2 diabetes mellitus". Of note, we avoid use of SGLT2 inhibitors in patients with frequent bacterial urinary tract infections or genitourinary yeast infections, low bone density and high risk for falls and fractures, foot ulceration, and factors predisposing to diabetic ketoacidosis eg, pancreatic insufficiency, drug or alcohol abuse disorder because of increased risk while using these agents. SLGT2 inhibitors should be held for 3 to 4 days before procedures including colonoscopy preparation and with poor oral intake to prevent diabetic ketoacidosis. See "Sodium-glucose cotransporter 2 inhibitors for the treatment of hyperglycemia in type 2 diabetes mellitus", section on 'Contraindications and precautions'. Repaglinide acts at the sulfonylurea receptor to increase insulin secretion but is much shorter acting than sulfonylureas and is principally metabolized by the liver, with less than 10 percent renally excreted. Limited data suggest that dipeptidyl peptidase 4 DPP-4 inhibitors are effective and relatively safe in patients with chronic kidney disease. However, linagliptin is the only DPP-4 inhibitor that does not require a dose adjustment in the setting of kidney failure. GLP-1 receptor agonists may also be used safely in chronic kidney disease stage 4, but patient education for signs and symptoms of dehydration due to nausea or satiety is warranted to reduce the risk of acute kidney injury. Insulin may also be used, with a greater portion of the total daily dose administered during the day due to the risk of hypoglycemia, especially overnight, in chronic kidney disease and end-stage kidney disease ESKD. See "Management of hyperglycemia in patients with type 2 diabetes and advanced chronic kidney disease or end-stage kidney disease", section on 'Patients not on dialysis'. Without established cardiovascular or kidney disease — For patients without established CVD or kidney disease who cannot take metformin , many other options for initial therapy are available table 1. We suggest choosing an alternative glucose-lowering medication guided by efficacy, patient comorbidities, preferences, and cost. Although historically insulin has been used for type 2 diabetes only when inadequate glycemic management persists despite oral agents and lifestyle intervention, there are increasing data to support using insulin earlier and more aggressively in type 2 diabetes. By inducing near normoglycemia with intensive insulin therapy, both endogenous insulin secretion and insulin sensitivity improve; this results in better glycemic management, which can then be maintained with diet, exercise, and oral hypoglycemics for many months thereafter. Insulin may cause weight gain and hypoglycemia. See "Insulin therapy in type 2 diabetes mellitus", section on 'Indications for insulin'. If type 1 diabetes has been excluded, a GLP-1 receptor agonist is a reasonable alternative to insulin [ 66,67 ]. The frequency of injections and proved beneficial effects in the setting of CVD are the major differences among the many available GLP-1 receptor agonists. In practice, given the high cost of this class of medications, formulary coverage often determines the choice of the first medication within the class. Cost and insurance coverage may limit accessibility and adherence. See "Glucagon-like peptide 1-based therapies for the treatment of type 2 diabetes mellitus", section on 'Patient selection'. Each one of these choices has individual advantages, benefits, and risks table 1. See "Sulfonylureas and meglitinides in the treatment of type 2 diabetes mellitus" and "Sodium-glucose cotransporter 2 inhibitors for the treatment of hyperglycemia in type 2 diabetes mellitus", section on 'Patient selection' and "Dipeptidyl peptidase 4 DPP-4 inhibitors for the treatment of type 2 diabetes mellitus", section on 'Patient selection' and "Thiazolidinediones in the treatment of type 2 diabetes mellitus", section on 'Potential indications'. See "Sodium-glucose cotransporter 2 inhibitors for the treatment of hyperglycemia in type 2 diabetes mellitus", section on 'Weight loss' and "Dipeptidyl peptidase 4 DPP-4 inhibitors for the treatment of type 2 diabetes mellitus", section on 'Patient selection' and "Glucagon-like peptide 1-based therapies for the treatment of type 2 diabetes mellitus", section on 'Weight loss'. The choice of sulfonylurea balances glucose-lowering efficacy, universal availability, and low cost with risk of hypoglycemia and weight gain. Pioglitazone , which is generic and another relatively low-cost oral agent, may also be considered in patients with specific contraindications to metformin and sulfonylureas. However, the risk of weight gain, HF, fractures, and the potential increased risk of bladder cancer raise the concern that the overall risks and cost of pioglitazone may approach or exceed its benefits. |
| What is HbA1c? | Blood Test | Target Levels | Diabetes UK | Sci Rep. Article CAS PubMed Google Scholar Prentice JC, Mohr DC, Zhang L, et al. Study of HbA1c as a reliable indicator for metabolic syndrome in non diabetic patients. San Juan. HbA1c is a biomarker with a central role in the diagnosis and follow-up of patients with diabetes, although not a perfect one. Dulaglutide and cardiovascular outcomes in type 2 diabetes REWIND : a double-blind, randomised placebo-controlled trial. |
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Diabetes and blood sugar control -Role of HbA1C in diabetes managementHbAc importance in diabetes control -
This information can help people with diabetes make informed decisions about their diabetes management and improve their overall confidence in managing their condition.
HbA1c testing plays a critical role in diabetes screening, diagnosis, and management. HbA1c testing is a convenient, non-invasive method for diagnosing diabetes and monitoring blood sugar control over time. By using HbA1c testing and management to set achievable goals and create personalized treatment plans, people with diabetes can take an active role in managing their condition and improve their confidence in their ability to do so.
Healthcare providers can help support people with diabetes by prioritizing HbA1c testing and management in their diabetes care. Know your risk of developing diabetes and cardiovascular disease. Assess how well you control your blood sugar.
The Power of HbA1c for Screening, Diagnosing, and Managing Diabetes with Confidence Mar 29, Blog 0 comments.
Introduction Diabetes is a chronic condition that affects more than million people worldwide. Understanding HbA1c Glycated hemoglobin HbA1c is a type of hemoglobin in your blood.
The Benefits of HbA1c Testing HbA1c testing is an important tool in diabetes screening, diagnosis, and management. Using HbA1c for Diabetes Screening and Diagnosis HbA1c is a reliable indicator of long-term blood sugar control, with higher levels indicating poor blood sugar control.
Using HbA1c to Monitor and Manage Diabetes HbA1c testing is also a valuable tool for monitoring blood sugar control and adjusting diabetes treatment plans. The Role of HbA1c in Managing Diabetes with Confidence Managing diabetes can be challenging and regular HbA1c testing and management can give people with diabetes confidence in their ability to manage their condition.
Conclusion HbA1c testing plays a critical role in diabetes screening, diagnosis, and management. Diabetes Risk Know your risk of developing diabetes and cardiovascular disease. View Test. References American Diabetes Association. Standards of Medical Care in Diabetes— Diabetes Care, 45 Supplement 1 , S3—S International Diabetes Federation.
Inzucchi, Silvio E et al. World Health Organization, Choice of medication is guided by efficacy, patient comorbidities, preferences, and cost. Sulfonylureas remain a highly effective treatment for hyperglycemia, particularly when cost is a barrier.
Side effects of hypoglycemia and weight gain can be mitigated with careful dosing and diabetes self-management education. For patients who are injection averse, initial therapy with high-dose sulfonylurea is an alternative, particularly for patients who have been consuming large amounts of sugar-sweetened beverages, in whom elimination of carbohydrates can be anticipated to cause a reduction in glucose within several days.
See 'Symptomatic catabolic or severe hyperglycemia' above and "Insulin therapy in type 2 diabetes mellitus". Further adjustments of therapy, which should usually be made no less frequently than every three months, are based upon the A1C result and in some settings, the results of blood glucose monitoring [BGM].
See 'Monitoring' above. See "Management of persistent hyperglycemia in type 2 diabetes mellitus" and "Insulin therapy in type 2 diabetes mellitus". Why UpToDate? Product Editorial Subscription Options Subscribe Sign in. Learn how UpToDate can help you. Select the option that best describes you.
View Topic. Font Size Small Normal Large. Initial management of hyperglycemia in adults with type 2 diabetes mellitus. Formulary drug information for this topic.
No drug references linked in this topic. Find in topic Formulary Print Share. View in. Language Chinese English. Author: Deborah J Wexler, MD, MSc Section Editor: David M Nathan, MD Deputy Editor: Katya Rubinow, MD Contributor Disclosures. All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jan This topic last updated: Dec 23, TREATMENT GOALS Glycemic management — Target glycated hemoglobin A1C levels in patients with type 2 diabetes should be tailored to the individual, balancing the anticipated reduction in microvascular complications over time with the immediate risks of hypoglycemia and other adverse effects of therapy.
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Pharmacologic Approaches to Glycemic Treatment: Standards of Care in Diabetes The analyses also controlled for: pre-period comorbidities that are not included in the CCI but which may affect patient outcomes anxiety, depression, and hypoglycemia ; pre-period resource utilization visits to a cardiologist, endocrinologist, neurologist, nutritionist, ophthalmologist, family practitioner, or internist ; and pre-period medication use numbers of prescribed classes of insulins, non-insulin GLAs, and non-GLA drugs.
All analyses were conducted using SAS, version 9. There were individuals included in the study prior to requiring that HbA1c be maintained either above or below target for the entire post-period.
Adding that requirement resulted in a final sample of individuals, illustrating that For the individuals in the final sample, the mean age was Over half of those in the final sample had visited a cardiologist in the pre-period, and, on average, individuals were treated in the pre-period with 1.
The unadjusted descriptive statistics Table 1 reveal significant differences between the people with sustained glycemic control and those with sub-optimal control. Specifically, individuals with glycemic control were significantly older, more likely to be female, less likely to be insured via a health maintenance organization, and less likely to have either visited an endocrinologist or been diagnosed with hypoglycemia in the pre-period.
In addition, they had significantly more visits to a family practitioner or internist in the pre-period, and they were prescribed significantly fewer classes of insulins and non-insulin classes of GLAs.
Figure 2 shows the findings of the multivariable analyses, which are the main results of this study. In contrast, cerebrovascular disease was found to have no statistically significant relationship with post-period HbA1c.
As a test of the sensitivity of results, the main analyses were repeated twice more. In the first sensitivity analysis Fig. Instead, people were grouped based upon their HbA1c level at index date.
In general, the main findings of the analyses were robust to these alternative specifications. Specifically, in both the main analyses and the sensitivity analyses, having HbA1c below target was associated with statistically significant reductions in the likelihood of being diagnosed with cardiovascular disease, metabolic disease, neuropathy, and nephropathy.
While some of the individuals in the latter group also had sustained HbA1c below target for the entire post-period, this result is consistent with research which has identified a legacy effect for long-term outcomes associated with having HbA1c below target during the first-year post-diagnosis of diabetes [ 22 ].
Results from multivariable logistic regressions which controlled for patient characteristics, pre-period general health and comorbidities, pre-period resource, and pre-period medication use. Sample size: Furthermore, meta-analyses of clinical trials which examined intensive glycemic control found that such control was associated with a reduction in the risk for the composite microvascular outcome [ 23 ] or the specific microvascular endpoint of nephropathy [ 24 , 25 ].
Similarly, a prospective study conducted with 50 neurologically asymptomatic individuals with diabetes found that HbA1c was the most important factor predicting higher risk of subclinical neuropathy [ 29 ]. The results of our study suggest that glycemic control i.
These reductions in macrovascular complications are generally consistent with clinical trial data which examined glycemic control over an extended time horizon. Specifically, 10 years of additional observational follow-up after UKPDS revealed statistically significantly lower rates of both myocardial infarction and all-cause death among those who were initially randomized to the intensive treatment cohort [ 31 ], while 10 years of additional follow-up after VADT revealed a significant reduction in the risk of cardiovascular events in the intervention group relative to the control group [ 31 , 32 ].
In contrast, the original UKPDS, ADVANCE, and VADT clinical trials all concluded that there was no statistically significant relationship between intensive antidiabetic treatment and macrovascular complications [ 8 , 10 , 11 ]. Meanwhile, the ACCORD trial found that the intensively treated group had a reduced risk of nonfatal myocardial infarction but also a higher rate of death, leading to early termination of the trial [ 9 ].
Inconsistencies between the present study and the original clinical trial results discussed above may reflect differences in the time horizon and populations included in these respective studies as well as changes in treatments developed for T2D and the increased emphasis on cardiovascular outcomes over the past 2 decades.
The present macrovascular findings generally support several previous non-clinical studies. A recent study of older veterans with diabetes found that increases in HbA1c time-in-range were associated with decreases in cardiovascular disease [ 33 ]. Additionally, Rawshani et al.
The decreased likelihood of metabolic disease among those with glycemic control in the present study is roughly consistent with previous non-clinical studies that have reported an association between lower HbA1c and a reduced rate of metabolic syndrome [ 35 , 36 , 37 ].
However, it is important to note that metabolic syndrome, defined as the presence of two or more risk factors e. for heart disease or other problems [ 35 , 36 , 37 ], is not the same as the DCSI definition of metabolic disease.
Specifically, the DCSI defines metabolic disease as any diagnosis of diabetes with ketoacidosis, hyperosmolarity, or hypoglycemia [ 18 ]. Nevertheless, both metabolic syndrome and metabolic diseases indicate serious physiological dysfunction, which has been associated with worse outcomes, including higher odds of mortality [ 38 , 39 ].
Like any research, this study has limitations. First, the analyses focused on the benefits of achieving HbA1c goals and did not examine disadvantages that may be associated with intensive treatment. For example, while some previous research has found that reductions in HbA1c are associated with cost savings [ 40 ], other research has shown that the improved health outcomes associated with intensive glycemic control may be accompanied by increases in economic costs [ 41 ].
The analyses included only insured adults with T2D, suggesting that the results may not be generalizable to the entire US population with diabetes andhe study design precluded controlling for or studying socioeconomic status, education level, duration of diabetes, or any other characteristics that were not captured in the insurance claims.
This result is surprising as retinopathy may be the most common microvascular complication of diabetes [ 17 , 43 , 44 ]. While a strength of the current study is that individuals were followed for a relatively long time, there were no interim analyses conducted.
Finally, the focus on diabetes-related complications precluded an examination of any potential cost-efficacy associated with lower HbA1c, and the study does not examine the impact of specific therapy use or treatment patterns on patient outcomes.
This study focused on the long-term risk of diabetes-related complications among individuals with T2D. These findings illustrate some of the negative effects associated with poor glycemic control and highlights the importance of lower HbA1c for adults with T2D.
Future work will examine how specific therapies and treatment patterns affect patient outcomes. Centers for Disease Control and Prevention. National Diabetes Statistics Report, [Internet].
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Mar Hair growth for thinning hair, Blog 0 comments. Diabetes Vitality a chronic HbAf that affects more than impprtance people diabetees. It is a disease that can have serious consequences if not managed properly. The good news is that with proper management, people with diabetes can lead healthy, normal lives. The key to managing diabetes is to keep blood sugar levels under control.
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