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[IPk] Normal A1C But Unstable Blood Glucose

Rhoda -  I saw this on Medscape today, and thought of you... (A1C = HbA1c btw)




How would you approach the patient whose A1C is normal (less than 7%) but
whose blood glucose levels still fluctuate widely, often far above normal?
Since the normal A1C indicates the average blood glucose is OK, how
dangerous are the intermittent elevations?


from John B. Buse, MD, PhD, CDE, FACE, 10/21/2003

This clinical scenario is clearly not ideal. In our practice, we call it
"getting a good number the hard way." Equally balanced periods of hypo- and
hyperglycemia can produce a good average A1C but generally are associated
with substantial symptoms -- fatigue, blurred vision, hypoglycemia -- and
high risk of severe hypoglycemic events.[1] There are some epidemiologic
data to suggest that it is associated with a higher risk of complications
than similar A1C with less glycemic instability. This pattern is generally
seen in patients who have type 1 diabetes or in patients with type 2
diabetes who are quite insulin deficient and fairly insulin sensitive, most
often under treatment programs in which they take fixed doses of insulin.

Our therapeutic approach is generally to minimize lifestyle variability as
much as possible and to teach flexibility in insulin dosing using
techniques like carbohydrate counting. This generally involves using more
injections, often glargine for basal insulin needs and a rapid- acting
insulin analog administered based on carbohydrate counting and insulin dose
self-adjustments. Sometimes insulin pump therapy and/or frequent glucose
monitoring are required to mitigate the variability in glucose.

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