A1c And Cardiovascular Disease Outcomes
Cardiovascular Disease and Type 1 Diabetes
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. In the 9-year post-DCCT follow-up of the EDIC cohort, participants previously randomized to the intensive arm had a significant 57% reduction in the risk of nonfatal myocardial infarction , stroke, or cardiovascular death compared with those previously randomized to the standard arm . The benefit of intensive glycemic control in this cohort with type 1 diabetes has been shown to persist for several decades and to be associated with a modest reduction in all-cause mortality .
Cardiovascular Disease and Type 2 Diabetes
The glycemic control comparison in ACCORD was halted early due to an increased mortality rate in the intensive compared with the standard treatment arm , with a similar increase in cardiovascular deaths. Analysis of the ACCORD data did not identify a clear explanation for the excess mortality in the intensive treatment arm .
If already on dual therapy or multiple glucose-lowering therapies and not on an SGLT2 inhibitor or GLP-1 receptor agonist, consider switching to one of these agents with proven cardiovascular benefit.
Acp Recommends Moderate Blood Sugar Control Targets For Most Patients With Type 2 Diabetes
Philadelphia, March 6, 2018 Patients with type 2 diabetes should be treated to achieve an A1C between 7 percent and 8 percent rather than 6.5 percent to 7 percent, the American College of Physicians recommends in an evidence-based guidance statement published today in Annals of Internal Medicine.
An A1C test measures a persons average blood sugar level over the past two or three months. An A1C of 6.5 percent indicates diabetes.
ACPs analysis of the evidence behind existing guidelines found that treatment with drugs to targets of 7 percent or less compared to targets of about 8 percent did not reduce deaths or macrovascular complications such as heart attack or stroke but did result in substantial harms, said Dr. Jack Ende, president, ACP. The evidence shows that for most people with type 2 diabetes, achieving an A1C between 7 percent and 8 percent will best balance long-term benefits with harms such as low blood sugar, medication burden, and costs.
ACP recommends that clinicians should personalize goals for blood sugar control in patients with type 2 diabetes based on a discussion of benefits and harms of drug therapy, patients preferences, patients general health and life expectancy, treatment burden, and costs of care.
More than 30 million Americans have diabetes, and 90 percent to 95 percent of them have type 2 diabetes. Type 2 diabetes most often develops in people over age 45, but more and more children, teens, and young adults are also developing it.
Journal Your Blood Sugar Levels
If your blood sugar levels are well-managed, you may not be monitoring them as often as you should. Even if youre checking your levels regularly, you may not be tracking them. Keep an electronic or written blood sugar log along with what you were eating and doing at the time of the test. This helps you identify how your blood sugar responds to certain foods, heavy or light meals, stress, and exercise. Think about setting a long-term goal to regularly monitor and identify patterns that can help you make changes as needed.
Setting long-term health goals can help you manage your diabetes. When setting goals, make sure theyre achievable and realistic, or you may give up. A good way to start is by setting S.M.A.R.T. goals, which are:
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Be Compassionate With Yourself
If you find it difficult to keep your blood sugar within target range or meet other treatment goals, try not to be too hard on yourself.
Type 2 diabetes is a complex condition that can change over time, even when you follow your recommended treatment plan.
Other life changes and challenges can also pose barriers to meeting your treatment goals.
If youre struggling to meet your goals, let your healthcare provider know.
In some cases, they might recommend changes to your lifestyle habits, prescribed medications, or other parts of your treatment plan. Over time, they might make adjustments to your blood sugar targets, too.
Type 2 Diabetes Blood Sugar Levels
Consistently testing and tracking the blood sugar levels that you and your doctor have agreed on can tell you how well your type 2 diabetes plan is working. Your doctor will work with you to determine the target levels that are best suited for you. What Do My Blood Sugars Tell Me? Checking your blood sugar levels is important, but keeping track of them in a written logbook or software will help you spot trends of blood sugar levels that are too high or too low. If you see a trend like this, be sure to discuss it with your doctor. Keep in mind that if you have recently started a new type 2 diabetes therapy, it may take some time to see the results. Be sure to discuss with your doctor how long it should take before you see an improvement in your blood sugar levels. If your doctor recommends blood sugar guidelines for you, he or she may ask you to check your blood sugar levels every day. Self-monitoring measures blood sugar levels at the time of the test, so its important that your doctor also tests your A1C to see how well your blood sugar is being managed over time The A1C test measures your average blood sugar level over the previous 2 to 3 months, and results are given as a percentage, called your A1C level. The higher your A1C level, the more sugar you have in your blood Whether youre making changes to your treatment or wondering about what might come next, were here to listen. Learn more Continue reading > >
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New Type 2 Diabetes Treatment Approaches
Bile acid sequestrants may lower glucose as well as LDL cholesterol levels, in individuals with diabetes. Kalin et al. , Schwarz et al. , and Zieve et al. administered 3.75 g colesevelam daily versus placebo to 59 type 2 diabetic individuals, finding a placebo-adjusted reduction in fasting glucose of 23 and 18 mg/dl at 4 and 8 weeks, respectively. At 12 weeks, fasting glucose had fallen from 170 to 165 mg/dl, and the glucose level 1 h following a sucrose-containing meal decreased from 269 to 251 mg/dl with colesevelam, while with placebo fasting glucose increased from 188 to 190 mg/dl and postprandial glucose increased from 285 to 288 mg/dl. There was a 0.2% reduction in A1C versus a 0.3% increase among individuals receiving placebo from the 8% baseline. LDL cholesterol fell from 123 to 108 mg/dl with colesevelam, whereas it increased from 120 to 122 with placebo. Kawabata et al. administered the similar anion-exchange resin colestimide, 3 g daily, to 27 type 2 diabetic individuals, finding a decrease in A1C from 7.7 to 6.8%, in fasting glucose from 164 to 152 mg/dl, and LDL cholesterol from 130 to 103 mg/dl.
What Are Blood Sugar Targets
A blood sugar target is the range you try to reach as much as possible. These are typical targets:
- Before a meal: 80 to 130 mg/dL.
- Two hours after the start of a meal: Less than 180 mg/dL.
Your blood sugar targets may be different depending on your age, any additional health problems you have, and other factors. Be sure to talk to your health care team about which targets are best for you.
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The United Kingdom Prospective Diabetes Study
The care of patients with type 2 diabetes mellitus has been profoundly shaped by the results of the United Kingdom Prospective Diabetes Study . This landmark study confirmed the importance of glycemic control in reducing the risk for microvascular complications and refuted previous data suggesting that treatment with sulfonylureas or insulin increased the risk of macrovascular disease. Major findings of the UKPDS are displayed in the images below.
Significant implications of the UKPDS findings include the following:
Microvascular complications are reduced by 25% when mean HbA1c is 7%, compared with 7.9%
A continuous relationship exists between glycemia and microvascular complications, with a 35% reduction in risk for each 1% decrement in HbA1c a glycemic threshold below which risk for microvascular disease is eliminated does not appear to exist
Glycemic control has minimal effect on macrovascular disease risk excess macrovascular risk appears to be related to conventional risk factors such as dyslipidemia and hypertension
Sulfonylureas and insulin therapy do not increase macrovascular disease risk
Metformin reduces macrovascular risk in patients who are obese
Vigorous blood pressure control reduces microvascular and macrovascular events beta blockers and angiotensin-converting enzyme inhibitors appear to be equally effective in this regard
Type 2 Diabetes Treatment By Cytokine Modulation
Morino et al. induced heat-shock protein-72, by combined mild electrical stimulation and hyperthermia in both high-fat fed and db/db mice, finding a 20% reduction in fasting glucose, a 38% decrease in fasting insulin, and a doubling of serum adiponectin and of uncoupling protein-1 mRNA expression in brown adipose tissue and with a 34 and 44% respective reduction in visceral and subcutaneous fat, reduction in adipocyte size, and improvement in fatty liver, suggesting a potential therapeutic approach for insulin-resistant states including type 2 diabetes and the metabolic syndrome. In a related study, Kolonics et al. studied BGP-15 , a hydroxylamine derivative that increases heat-shock proteins and restores constitutive nitric oxide synthase activity in hyperglycemia, and was found to double insulin-stimulated glucose uptake in two animal models. In 42 nondiabetic individuals with insulin resistance given the agent for 28 days, whole-body glucose utilization similarly increased 1.61.75 mg · kg1 · min1. In vitro, nitric oxide synthase and mitochondrial function improved, suggesting this to be a candidate pharmacologic insulin sensitizer.
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American College Of Physicians Guidance Statement
According to a 2018 guidance statement by the American College of Physicians , Clinicians should aim to achieve an HbA1c level between 7% and 8% in most patients with type 2 diabetes. The ACP said that this higher target is aimed at helping patients benefit from glycemic control while avoiding the adverse effectsassociated with low blood sugar, medication burden, and costsof stricter targets. The ACP stated that evidence does not indicate that medication therapy to reduce the HbA1c level to 7% or less results in reduced mortality or in decreased macrovascular complications, such as heart attack or stroke, compared with a reduction to about 8%.
However, experts from the American Diabetes Association and the American Association of Clinical Endocrinologists have expressed skepticism about the higher target, noting that the guidance statement does not take into account the cardiovascular disease benefits of newer drugs, which themselves frequently reduce HbA1c levels. In response, a coauthor of the ACP statement observed that other guidelines have also not specifically accounted for these newer medications in their recommended HbA1c levels and that research on such drugs has primarily been in patients either with cardiovascular disease or at high risk of developing it.
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A1c Differences In Ethnic Populations And Children
In the ADAG study, there were no significant differences among racial and ethnic groups in the regression lines between A1C and mean glucose, although the study was underpowered to detect a difference and there was a trend toward a difference between the African and African American and the non-Hispanic White cohorts, with higher A1C values observed in Africans and African Americans compared with non-Hispanic Whites for a given mean glucose. Other studies have also demonstrated higher A1C levels in African Americans than in Whites at a given mean glucose concentration . In contrast, a recent report in Afro-Caribbeans found lower A1C relative to glucose values . Taken together, A1C and glucose parameters are essential for the optimal assessment of glycemic status.
A small study comparing A1C to CGM data in children with type 1 diabetes found a highly statistically significant correlation between A1C and mean blood glucose, although the correlation was significantly lower than in the ADAG trial . Whether there are clinically meaningful differences in how A1C relates to average glucose in children or in different ethnicities is an area for further study . Until further evidence is available, it seems prudent to establish A1C goals in these populations with consideration of individualized CGM, BGM, and A1C results. Limitations in perfect alignment between glycemic measurements do not interfere with the usefulness of BGM/CGM for insulin dose adjustments.
When Should I Test My Blood Glucose
A diabetes doctor or nurse will discuss with you whether you need to test your blood glucose at home and if so, how often to test. They will give you appropriate advice according to your individual requirements. The following are some general guidelines.
If your diabetes is treated with insulin, you will be asked to test your blood glucose levels more regularly. If the results are within your agreed target range then you may be able to test your blood glucose less often.
If your blood glucose levels are not in your agreed target range, you may need to adjust your insulin.
If you use a basal bolus insulin regime then your doctor or nurse may ask you to check your blood glucose more often. If you use this regime, you should monitor your blood glucose before meals, before you go to bed, before you drive and occasionally in the middle of the night so that you can assess your overnight insulin requirements.
If you are on a twice-daily insulin mixture, then at first you should test your blood glucose four times a day . This will allow your doctor or nurse to assess the best insulin dose for you.
This may be reduced to before breakfast and before dinner every day, or alternating between this pattern and testing before lunch and before bedtime.
When should I test my blood glucose more often?
Steroid therapy If you are on steroid therapy, you should test your blood glucose more often. Steroids may increase blood glucose levels. Your treatment may need to be changed.
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Maintain A Healthy Weight
You may achieve your weight loss goals by changing your diet in the short term, but maintaining that healthy weight is challenging. Many things other than diet and exercise impact the numbers on your scale such as hormone levels, lifestyle habits such as sleep, and stress. Setting long-term goals to continue to lose a set number of pounds or to maintain a healthy weight can help you stay motivated.
If your weight loss has plateaued or youre gaining weight, consider setting a goal to increase your physical activity. Maybe youd like to run or walk a 5K within the next year or walk a 15-minute mile. Set a goal to reach that milestone.
Stroke Prevention In Diabetes
The 2010 American Heart Association/American Stroke Association guidelines for the primary prevention of stroke include the following recommendations for patients with diabetes:
Regular blood pressure screening
Physical activity 30 minutes or more of moderate-intensity activity on a daily basis
A low-sodium, high-potassium diet to reduce blood pressure a diet emphasizing consumption of fruits, vegetables, and low-fat dairy products may lower stroke risk
A blood pressure goal of less than 130/80 mm Hg
Drug therapy with ACE inhibitors or ARBs
Statin therapy, especially in patients with other risk factors monotherapy with fibrates may also be considered to lower stroke risk
The AHA/ASA guidelines note that the benefit of taking aspirin for the reduction of stroke risk has not been fully demonstrated in diabetic patients.
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Achieving Glycemic Goals In Type 2 Diabetes
Zachary T. Bloomgarden Achieving Glycemic Goals in Type 2 Diabetes. Diabetes Care 1 January 2007 30 : 174180.
This is the fourth in a series of articles on presentations at the American Diabetes Associations 66th Scientific Sessions, Washington, DC, 913 June 2006, addressing aspects of the treatment of type 2 diabetes.
A pilot project is underway to offer the Perspectives on the News commentaries as a monthly Web-based CME activity. Please access www.diabetes.procampus.net to view our initial efforts. We look forward to your comments.
Glucose Assessment By Continuous Glucose Monitoring
6.3 Standardized, single-page glucose reports from continuous glucose monitoring devices with visual cues, such as the ambulatory glucose profile, should be considered as a standard summary for all CGM devices. E
6.4 Time in range is associated with the risk of microvascular complications and can be used for assessment of glycemic control. Additionally, time below target and time above target are useful parameters for the evaluation of the treatment regimen . C
CGM is rapidly improving diabetes management. As stated in the recommendations, time in range is a useful metric of glycemic control and glucose patterns, and it correlates well with A1C in most studies . New data support the premise that increased TIR correlates with the risk of complications. The studies supporting this assertion are reviewed in more detail in Section 7, Diabetes Technology they include cross-sectional data and cohort studies demonstrating TIR as an acceptable end point for clinical trials moving forward and that it can be used for assessment of glycemic control. Additionally, time below target and time above target are useful parameters for insulin dose adjustments and reevaluation of the treatment regimen.
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