Where Should Blood Sugar Control Really Be for Type 2 Diabetes

Hemoglobin A1C (A1C) is a way of looking at the average blood sugar levels over the preceding two to three months in people living with diabetes. And the American College of Physicians has published a new recommendation suggesting that some people with type 2 diabetes can safely raise their A1C level.

The update suggests the 29.1 million Americans with diabetes should aim for an A1C between 7 and 8 percent, an increase from the 6.5 to 7 percent that national guidelines from the American Diabetes Association (ADA) and the American Association of Clinical Endocrinologists (AACE) recommend.

This change has come with critics, though, including myself. The ADA, AACE and the Endocrine Society have published statements challenging a broad relaxation the A1C target. I strongly agree with these national organizations, which are the voice of doctors who are specialists in treating diabetes. If a person’s blood sugar levels, as reflected in their A1C, are too high, they could be at increased risk over many years for:

• Heart attack
• High blood pressure
• High cholesterol
• Kidney failure
• Leg amputation from infection
• Stroke
• Vision loss

Evidence shows that controlling your A1C to no greater than 7 percent lowers your risk for these diabetes-related complications. So, if the new guidelines are too loose, what targets for diabetes control are best for people with type 2 diabetes? And how can we make it easier for people to achieve their goal?

What’s a safe A1C for me?

Every person living with type 2 diabetes should have their own targets for blood sugar levels and A1C. You should speak with a doctor about what targets are best for you. During your visit, many things are taken into consideration including:

• How many diabetes medications you are taking
• Your age
• Your physical activity levels
• Whether you already have any diabetes complications

Generally, if you haven’t had diabetes for many years and you either have no, or very few, diabetes complications, you should aim for an A1C under 7 percent. However, people who are 65 years or older, have had trouble with severe low blood sugar reactions, or have had advanced diabetes complications might benefit from a more relaxed target A1C closer to 8.

Tips for managing your blood sugar and A1C levels

1. Ask your doctor or diabetes educator about new ways to monitor and treat diabetes

Checking your own blood sugar levels with a fingerstick is becoming easier, as researchers continue to develop new ways to do so. Some of the latest innovations include:

• The FreeStyle Libre: This is the first blood glucose meter that can read your blood sugar levels by waving the meter over an adhesive patch that sticks to your arm, rather than pricking your finger to get a drop of blood. This device records your blood sugar level every five minutes and shows you a graph of the results on its screen.
• New medications: Several new classes of medications have come out relatively recently and can help people with type 2 diabetes maintain their target blood sugar levels. Some of these newer medications also provide protection against cardiovascular and kidney complications that can arise because of diabetes.

2. Make sure you receive diabetes self-care education from a certified diabetes educator

Many health care organizations offer diabetes education, which your doctor can refer you to and is covered by most insurance plans.  Diabetes education is recommended when you are first diagnosed with diabetes, before and during pregnancy with diabetes, and any time your blood sugars are poorly controlled. People who receive diabetes education learn important information, such as lifestyle and medication tips, which helps them successfully take control of their diabetes.

Anyone in the MedStar Health system can access the MedStar Diabetes Institute’s Diabetes Self-Management Education program through their own primary care provider. Furthermore, people with type 2 diabetes and an A1C of 9 percent or higher, can participate in our three-month Diabetes “Boot Camp” upon a referral from your provider, which helps patients lower their A1C by an average of 3 percent. Protocol for the program can be found here.

For those with type 2 diabetes, have you spoken with your doctor about your specific average blood sugar level goal?

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What Is The A1C Range For Diabetes?

Content

• Overview
• What is diabetes?
• Types of diabetes
• What is the A1C test?
• When is the A1C test given?
• What other tests are used to diagnose diabetes?
• Can the A1C test diagnose gestational diabetes?
• What is the A1C range for diabetes?
• Target A1C levels for people with diabetes
• What factors can affect your A1C results?
• When to see your doctor
• The lowdown

Diabetes is a life-long disease that should be carefully treated. While there is no cure for diabetes, it’s possible to live a long, healthy life by making healthy lifestyle choices, taking any necessary medications, and working closely with your healthcare provider to find a personalized treatment plan that works best for you.

While there are many options to treat and manage your diabetes, the A1C test is one option that can help you keep your blood sugar levels under control long term.

If you’re exhibiting symptoms of diabetes, are at risk of developing diabetes, or have already been diagnosed with diabetes, here’s what you should know about how the A1C test could benefit you before scheduling an appointment with your healthcare provider.

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Diabetes is a serious condition that affects how your body produces or uses insulin. Insulin is a hormone that is created by your pancreas. It is used to help the glucose (sugar) found in your bloodstream from the foods you eat enter your cells and be turned into energy. 

When your body stops making insulin or can’t use the available insulin as it should, too much sugar builds up in your bloodstream. This can lead to symptoms such as feeling thirsty or tired in the short term. Over time, however, high blood sugar can lead to more serious health complications, including kidney disease, vascular and neurological issues, eye problems, and heart disease. 

While type 1, type 2, and gestational diabetes are all related to how your body makes and responds to insulin, each type of diabetes is unique.

Likewise, not every diabetic’s experience will be the same. They may exhibit many of the same symptoms, but the types of diabetes are often diagnosed and treated differently. Some key differences in the types of diabetes include:

Type 1

Type 1 diabetes is an autoimmune disease that occurs in individuals whose immune system attacks the insulin-secreting cells in the pancreas, leading to low/lack of insulin production. It most commonly occurs in children, adolescents, and young adults. However, it can occur at any age. 

Symptoms of type 1 diabetes can appear very suddenly and develop over a short period. They include:

Treatment for type 1 diabetes could include:

• Eating a healthy diet

• Exercising regularly

• Maintaining a healthy weight

• Taking medications, such as insulin — This is the principal treatment for type 1 diabetes, and often the person will be insulin-dependent for a lifetime.

Type 2

Type 2 diabetes occurs in individuals whose bodies don’t process insulin as they should, mainly due to insulin resistance. Unlike type 1 diabetes, symptoms of type 2 diabetes develop slowly over time, and initially, they could be very mild and could go unnoticed. Similar to type 1 diabetes, symptoms include:

Treatment for type 2 diabetes depends on your overall health, other medical conditions, and personal preferences. Treatment options could include:

• Eating a healthy diet

• Exercising regularly

• Maintaining a healthy weight

• Taking medications if necessary, such as medications to help with insulin resistance (metformin), or insulin 

Gestational diabetes

This type of diabetes only occurs during pregnancy. It usually exhibits no signs at all, which is why healthcare providers perform routine blood tests between the 24th and 28th week of pregnancy to check for it. 

Gestational diabetes is most commonly treated by making lifestyle changes, such as eating a healthy diet and exercising regularly, although some individuals may have to take medications as well.

Gestational diabetes usually disappears on its own after delivery, although an increased risk of developing type 2 diabetes often exists in the years after.

The A1C test is used to give an indication of your average blood sugar levels over the past three months. A1C tests are used to diagnose prediabetes, type 1 diabetes, and type 2 diabetes. For individuals who have already been diagnosed with type 1 or type 2 diabetes, the A1C test can help monitor the condition by determining if your treatment plan is working. 

The A1C test is sometimes referred to as the hemoglobin A1C test or the glycohemoglobin test. Hemoglobin is a part of your red blood cells responsible for bringing oxygen to the cells in your body. Glucose, or sugar, binds with hemoglobin to your red blood cells. The A1C test measures the percentage of hemoglobin in your red blood cells coated with glucose.

Therefore, the test is also known as hemoglobin A1C, glycated hemoglobin, and HbA1c.

Your healthcare provider will present your A1C levels in the form of a percentage. A higher percentage directly corresponds with how high and poorly controlled your blood glucose levels have been. The normal range for an A1C is considered anything lower than 5.7 percent. 

Even if you’re not experiencing signs of diabetes, it’s a good idea to have a baseline A1C test performed if you’re:

Your healthcare provider will recommend how frequently you have an A1C test performed based on your conditions and circumstances. This could include:

• One time a year, if you’re diagnosed with prediabetes

• Two times a year, if your blood sugar levels are within the target range and you don’t take insulin

• Four times a year, if you’re having trouble managing your blood sugar levels and if you take insulin

While the A1C test is one of the most common tools used to diagnose diabetes, your healthcare provider could also use several other tests. These include:

Fasting plasma glucose (FPG) test

This is the quickest and simplest blood test used to measure your blood sugar levels at a certain point when the blood sugar level isn’t elevated due to eating. Hence, the test requires fasting for 8 to 12 hours to be performed, preferably first thing in the morning.

Random plasma glucose (RPG) test

This is a blood test that healthcare providers sometimes use to diagnose diabetes when you have symptoms, but they don’t want to wait until after you have fasted as it measures the blood sugar level at any point in time.  

The glucose challenge test and the oral glucose tolerance test (OGTT) are routine blood tests given to every pregnant woman between the 24th and 28th week of pregnancy to determine gestational diabetes. 

While the A1C test cannot be used to diagnose gestational diabetes, your healthcare provider can have the test performed early in your pregnancy to see if you had undiagnosed diabetes before becoming pregnant.

Because the A1C test includes your blood sugar levels over the past three months, that time frame can include the time you weren’t pregnant.

Additionally, the A1C test can be used after your baby is born to check for type 2 diabetes. Even if your blood sugar levels are within the normal range, it’s important to check your A1C at least every three years after having gestational diabetes. 

Just as your experience with diabetes will be different from others diagnosed with the same condition, your A1C results will likely be different from someone else’s. Anything lower than 5.7 percent is considered within the normal range.

If your A1C is between 5.7 and 6.5 percent, your levels are within the prediabetes range. If your A1C is higher than 6.5 percent, you’re within the diabetic range. The goal, then, for most adults with diabetes is to consistently maintain an A1C level of less than 7 percent. 

Managing your blood sugar levels will also require checking your blood sugar at home with a blood sugar meter or another device. This device will display your blood sugar levels in milligrams of sugar per deciliter (mg/dL)

When you use a self-monitoring device, the result will reflect your blood sugar levels at the time that you take the test. Because of this, certain factors can impact your results, such as eating. 

Checking your blood sugar levels at home can help you track your long-term blood sugar level goals and see if you are on track for meeting your A1C goals. A1C levels and their corresponding estimated average blood glucose (eAG) levels are as follows:

• A1C: 6 percent, eAG: 126 mg/dL

• A1C 7 percent, eAG 154 mg/dL

• A1C 8 percent, eAG 183 mg/dL

• A1C 9 percent, eAG 212 mg/dL

• A1C 10 percent, eAG 240 mg/dL

• A1C 11 percent, eAG 269 mg/dL

• A1C 12 percent, eAG 298 mg/dL

The A1C test level that your healthcare provider sets for you will be based on your specific circumstances. If you’re diagnosed with diabetes, your healthcare provider may set an A1C goal for you based on:

• Age

• Other health conditions you may have

• If you’re pregnant

• Your diabetes treatment plan

• Complications you may be experiencing from diabetes

• How long you’ve had diabetes

You can expect your healthcare provider to recommend maintaining an A1C below 6.5 percent if you:

• Are young or have a longer life expectancy

• Were recently diagnosed with diabetes

• Are otherwise in good health

• Are successfully managing your condition

Alternatively, your healthcare provider may recommend maintaining an A1C that’s between 7.0–8.5 percent¹ if you:

• Are older or have a shorter life expectancy

• Have had diabetes for a long time

• Have a difficult time managing your diabetes, even with medication

• Have other serious health conditions

• Have experienced complications from diabetes such as hypoglycemia or metabolic decompensation

Your A1C goals may need to be adjusted over time. It’s important to work closely with your healthcare provider to help manage your diabetes and live a long, healthy life.

Certain factors can cause your A1C levels to increase or decrease. These include:

• Severe anemia, liver disease, or kidney failure

• Early or late pregnancy

• Blood transfusions or loss

• Certain medications, such as opioids

• Having a less common type of hemoglobin than hemoglobin A, which is the most common variant, can lead to false results. This could occur in some people with certain blood disorders or people of Mediterranean, African, or Southeast Asian descent

If you have one or more of these factors, talk to your doctor about whether you may need other blood glucose tests to monitor your diabetes.

Working closely with your healthcare provider is the best way to manage your diabetes and maintain normal A1C goals. Even if you haven’t been diagnosed with diabetes, it’s important to have your A1C levels checked if you have certain risk factors. Be sure to schedule an appointment with your healthcare provider if you:

• Have symptoms of high or low blood sugar

• Are having a difficult time managing your diabetes or maintaining normal A1C levels

• Are experiencing complications from diabetes

• Have questions about your condition or treatment plan

Signs of diabetes include:

• Being very thirsty

• Frequent urination

• Blurry vision

• Fatigue

Signs of low blood sugar include:

The A1C test is a blood test commonly used to diagnose and monitor diabetes. It works by measuring the percentage of hemoglobin in your blood coated with glucose and indicating your average blood sugar levels from the previous three months. A1C test results are presented in percentage form. 

Generally speaking, people with an A1C of less than 5.7 percent are within a normal blood sugar range, while anyone between 5.7 and 6. 5 percent is considered prediabetic. Most adults who have already been diagnosed with diabetes are encouraged to maintain an A1C of less than 7 percent. 

Of course, this varies on your overall health, other medical conditions, genetics, and lifestyle choices, among other factors. It’s important to work closely with your healthcare provider and have your A1C checked regularly if you are at risk of developing diabetes or have already been diagnosed. Doing so can help you determine if your current treatment plan is working as well as if any changes need to be made.

Modern strategy of hypoglycemic therapy in type 2 diabetes mellitus: the role and place of combination therapy | Nedosugova L.V.

The spread of type 2 diabetes mellitus (T2DM) in the world exceeds all theoretical forecasts. If 15 years ago, WHO experts assumed that by 2025 the number of patients with diabetes in the world would be 380 million people [1], then, according to the International Diabetes Association (IDF), in 2011 the number of patients with diabetes has already reached 366 million, and , according to WHO experts, by 2030 the number of patients with T2DM will be 552 million people [2]. Life expectancy in patients with T2DM is on average 5 years shorter than in the general population, and this is primarily due to the rapid progression of atherosclerosis, which leads to cardiovascular mortality in T2DM patients 4–5 times more often [3]. Overall, more people with diabetes die from atherosclerosis-related diseases than from all other causes combined [4]. The cause of such a pronounced lesion of the vascular bed is currently considered to be hyperglycemia. Meta-analysis of 20 different studies including 95,783 patients followed up for 12 years led to the conclusion that glucose is the same risk factor for the development of atherosclerosis and acute cardiovascular mortality as the level of total cholesterol and blood pressure [5].

A series of large randomized trials [6-10] have proven the importance of tight glycemic control in reducing the risk of developing diabetic vascular complications, which requires aggressive treatment of T2DM using effective and safe hypoglycemic drugs and their combinations already at the diagnosis of the disease, allowing to achieve the target level of glycemia, which, as proven by long-term observations, can prevent the rapid progression of atherosclerosis in these patients [11, 12].
However, the intensification of hypoglycemic therapy is limited by the risk of developing hypoglycemic conditions, weight gain and, as a result, increased mortality from acute vascular accidents. Hypoglycemic episodes were 3 times more common in the intensive care group compared with standard therapy in the ACCORD study [13] and 2 times more often in the VADT study [14], which was accompanied by a 22% increase in overall mortality in the ACCORD study and an increase in cases cardiovascular events in the next 3 months. after severe hypoglycemia in the elderly in the VADT study.
In connection with the above, at the end of 2011, the Russian Association of Endocrinologists proposed to individualize the target levels of glycemic control [15] depending on the patient’s age, life expectancy (LE), the risk of developing hypoglycemic conditions, and the presence/absence of severe cardiovascular complications (Table 1). 1).
T2DM is characterized by two major pathogenetic defects: decreased insulin sensitivity (or insulin resistance) and inadequate insulin secretion to overcome the barrier of insulin resistance. Insulin resistance often precedes the development of DM for many years and is genetically determined, although exacerbated by external factors such as obesity, decreased physical activity, pregnancy, and excess contrainsular hormones. Initially, existing insulin resistance is compensated by hyperinsulinemia, which maintains normal carbohydrate tolerance. Impaired carbohydrate tolerance is observed with an increase in insulin resistance or a decrease in the compensatory capabilities of insulin secretion, or with the progression of both defects [16, 17]. According to modern concepts, T2DM manifests itself in a situation where the secretory capabilities of β-cells are unable to overcome the barrier of insulin resistance. The main role in this failure of the insular apparatus is assigned to genetic disorders [17], however, the so-called “glucose toxicity phenomenon” plays an important role in reducing the secretory reserves of the insular apparatus, due to which apoptosis and death of β-cells develop. According to statistics, by the time of the disease manifestation, only 50% of the initial number of β-cells are functioning in patients, which confirms the theory of the gradual progression of carbohydrate metabolism disorders: from normoglycemia in conditions of insulin resistance and hyperinsulinemia to the manifestation of diabetes through successive stages of impaired fasting glycemia and impaired tolerance to glucose [18].
Based on the foregoing, a completely logical conclusion suggests itself that the main strategic direction in the treatment of T2DM should be the impact on insulin resistance as the main pathogenetic link in the development of the disease. By reducing insulin resistance, or, in other words, increasing insulin sensitivity, we reduce the load on the insular apparatus, thereby preserving its secretory capabilities and removing the negative effect of hyperinsulinemia on increased appetite, weight gain, and the state of the cardiovascular system. The easiest way to increase insulin sensitivity is to reduce weight through lifestyle and dietary changes, which, unfortunately, allows achieving the target level of glycemia in less than 30% of patients with newly diagnosed T2DM [6]. In such situations, agents are needed that affect the main pathogenetic link of the syndrome – insulin resistance.
Currently, the most accessible and effective drug is metformin (the original metformin drug is Glucophage®), the main mechanism of action of which is to reduce insulin resistance by increasing the activity of the insulin receptor tyrosine kinase in peripheral tissues. As a result, the utilization and oxidation of glucose in peripheral tissues improves [19, 20], and lipolysis and oxidation of free fatty acids as an alternative energy substrate are suppressed [21, 22]. It is with an increase in insulin sensitivity of the liver tissue that a decrease in gluconeogenesis and glycogenolysis is associated [23, 24]. Thus, the hypoglycemic effect of metformin is not so much hypoglycemic as antihyperglycemic, because. leads to a decrease in hepatic glucose production and fasting glucose levels. An increase in the sensitivity of peripheral tissues to insulin is also associated with a decrease in the need for insulin and an improvement in the functionality of β-cells due to a decrease in glucose toxicity [25]. In addition, as recent studies show, metformin can increase the level of glucagon-like peptide-1 (GLP-1), which, as you know, stimulates insulin secretion by improving glucose absorption in the more distal parts of the small intestine, where L-cells are mainly localized. secreting GLP-1 [26].
In case of metformin intolerance or contraindications, the latest 2011 IDF algorithm suggests, as an alternative option for patients who are not overweight, the use of sulfonylurea drugs (SUM) as the first line of treatment, based on the assumption that the main pathogenetic defect in the development of T2DM without obesity is inadequate secretion of insulin. This option of starting drug treatment is justified not only by the need for a pathogenetic approach to therapy, but also by a sufficient evidence base for the effectiveness and safety of the use of PSM, as well as the relative cheapness and availability of such an alternative treatment option.
As noted above, in the majority of people with T2DM, lifestyle interventions fail to achieve target carbohydrate metabolism, either due to inadequate weight loss, weight gain, disease progression, or a combination of these and other factors. Therefore, it is recommended to start metformin therapy along with lifestyle changes immediately after diagnosis. In the absence of specific contraindications, metformin is recommended primarily due to its effect on glycemia, lack of weight gain and hypoglycemic conditions, generally good tolerability with a low incidence of side effects, high adherence, and relatively low cost. The dose of metformin should be gradually (over 1-2 months) increased to the maximum effective and tolerated.
Second line therapy
At the same time, even the maximum doses of metformin do not always make it possible to achieve the target level of glycemia and reduce the level of Hb A1c <7.0% during the first 2–3 months. treatment as recommended by the authors of the latest IDF algorithm (2011). If persistent hyperglycemia persists, the question of the rapid addition of other hypoglycemic drugs should be addressed. A clear consensus on a second drug added to metformin does not yet exist, and the choice is between SSM and DPP-4 or TZD inhibitors and α-glucosidase blockers as an alternative (Fig. 1). In particular, when the risk of hypoglycemia is especially dangerous (for example, in patients engaged in heavy physical labor), it is advisable to additionally prescribe DPP-4 inhibitors or the TZD class of drugs – pioglitazone. In cases where one of the main goals of treatment is weight loss, and the level of Hb A1c is <8.0%, it is preferable to prescribe α-glucosidase blockers.
As a second line of drugs, if it is impossible to achieve the target level of glycemic control with the use of SSM, the use of metformin is suggested, if it has not been previously prescribed, or DPP-4 inhibitors, or TZD, or α-glucosidase blockers as an alternative option (Fig. 1).
Third line therapy
If lifestyle modification, metformin, and the second drug did not lead to the achievement of the target parameters of carbohydrate metabolism control, the next step is to start or intensify insulin therapy (Fig. 1). If the A1c level is close to the target (< 8.0%), a third oral antidiabetic drug can be added as an alternative. As an additional hypoglycemic agent, the 2011 IDF algorithm suggests either α-glucosidase blockers or DPP-4 inhibitors, or TZD, or, as an alternative, GLP-1 agonists (exenatide, liraglutide) when one of the main goals of treatment is to reduce weight, and the level of Hb A1c <8.0%. However, this approach is more expensive and not always effective compared to switching to insulin therapy or its intensification.
Fourth line therapy
Intensive insulin therapy usually consists of additional injections of short-acting or ultra-rapid-acting insulin before individual meals to reduce postprandial glycemic fluctuations (Fig. 1). When switching to intensive insulin therapy with short-acting or rapid-acting insulin injections, insulin secretogens (PSM or glinides) should be discontinued, since they have a synergistic effect with injected insulin.
However, endocrinologists often face the problem of not being able to achieve the target level of glycemic control within 2-3 months. treatment. This is due to the fact that the initial level of Hb A1c in patients can range from 6.5 to 10% or more, which, of course, complicates the ability to quickly and effectively achieve the goal.
Stratification of treatment tactics
according to the Algorithm of the RAE 2011
In this regard, the Russian Association of Endocrinologists (RAE) at the end of 2011 proposed a differentiated approach to prescribing and correcting hypoglycemic therapy depending on the initial level of Hb A1c, followed by a change in treatment if the goal is not achieved no earlier than after 6 months. from the start of therapy. Indeed, if the initial level of Hb A1c does not exceed 7.5%, it is quite possible to achieve the target level of <6.5% with monotherapy with metformin, pioglitazone, DPP-4 inhibitors (dipeptidyl peptidase) or α-glucosidase, as shown in Figure 2. A double combination in case of ineffective monotherapy involves the addition of drugs that somehow stimulate insulin secretion either due to a direct effect on the β-cell (PSM, glinides and GLP-1 analogues), or indirectly, due to blockade of the cleavage of native GLP-1 by inhibitors of the DPP-enzyme. 4. In any case, this combination affects both pathogenetic links in the development of T2DM: insulin resistance and inadequate secretion of insulin, resulting in adequate glycemic control not only in terms of fasting glycemia, but also after meals, leading to rapid achievement of the goal.
Which combination is preferred in patients with baseline Hb A1c between 6.5% and 7.5%? Based on the tolerability and safety criteria, the possible risk of hypoglycemia when using secretogens in patients with initially low levels of Hb A1c exceeds the severity of side effects from the gastrointestinal tract and edematous syndrome associated with the use of incretins and TZD, respectively. That is why the authors of the RAE algorithm suggest, first of all, the combination of metformin with DPP-4 inhibitors or GLP-1 analogues, and secondly, metformin with secretogens (PSM or glinides), as the most rational combinations. If lifestyle modification, metformin, and the second drug did not lead to the achievement of the target parameters of carbohydrate metabolism control, the next step is to start or intensify insulin therapy (Fig. 2). If the A1c level is close to the target (<7.5%), a third oral hypoglycemic agent can be added. However, this approach is more expensive and not always effective compared to switching to insulin therapy or its intensification [27].
Case Management
with A1c level from 7.6 to 9%
The vast majority of patients with T2DM have an A1c level of >7.6% at the time of disease diagnosis. To date, there are no drugs that can achieve the target level of control in monotherapy for 2-3 months. (Table 2).
That is why the authors of the algorithm propose to initially use combined “double” therapy to achieve rapid and effective glycemic control (Fig. 3). This approach is based on the data of numerous studies showing that the simultaneous administration of drugs with different points of application of action provides a more significant decrease in A1c not only in a shorter time, but also at significantly lower dosages than the initial metformin monotherapy followed by the addition of a second drug [28– thirty]. Metformin is the basis of all possible combinations, of which the combination of metformin with incretin mimetics is the safest, due to the absence of the risk of hypoglycemic conditions and weight gain, and the most effective is the combination of metformin with PSM, since these drugs most significantly reduce the level of A1c, and their combination provides good control not only of glycemia, but also of cholesterol and blood lipid spectrum [30].
In case of ineffectiveness of “dual” therapy, it is recommended to add a third drug, based on the principles of efficiency and safety in this case: Metformin is considered the basis of therapy in this situation, while the safest in terms of the risk of developing hypoglycemic conditions is the addition to the combination of metformin with incretin TZD mimetics, and the most effective is the addition of PSM to a combination of metformin with incretin mimetics. Thus, in patients with A1c levels close to 7.5%, it is more appropriate to prescribe a combination of metformin with TZD and incretin mimetics, while in patients with higher A1c levels, it is more logical to use a combination of metformin with SM and incretin mimetics. The next step in achieving the target level of glycemia with the ineffectiveness of the “triple” combination is the appointment of insulin therapy, first in the background, and then in the background-bolus mode, upon transition to which it is necessary to cancel drugs that somehow stimulate insulin secretion.
Case Management
at A1c >9%
In clinical practice, situations are not uncommon in which, already at the stage of T2DM diagnosis, patients have significant hyperglycemia and the Hb A1c level exceeds 9%, but there are no clinical symptoms of the disease, which indicates sufficient secretory activity of the insular apparatus. The tactics of choice in this situation, at the suggestion of the authors of the algorithm, may not be intensive insulin therapy, which is absolutely indicated for A1c > 10% and severe clinical symptoms, but the initial “triple” therapy. In this case, the combination of metformin with PSM and incretin mimetics is considered the most effective, the most safe in terms of the risk of hypoglycemia is the combination of metformin with incretin mimetics and TZD (Fig. 4).
However, practitioners are well aware of the adverse effect of complex hypoglycemic regimens on patient adherence to medical prescriptions in daily practice. According to the results of the DARTS study [31], only 30% of patients are firmly adherent to single-drug therapy and less than 13% adhere to multiple drugs and high doses (separate combination). It is this fact that explains the emergence of official combined hypoglycemic drugs, consisting of a combination of metformin with various drugs of other classes. The most effective is the combination of metformin with PSM, which allows to achieve the most rapid and significant decrease in the level of A1c, while using smaller doses of each of the components, which, of course, reduces the risk of development and severity of side effects (gastrointestinal disorders, weight gain, hypoglycemic conditions) .
One of the drugs of this group, registered in Russia, is Glyukovance®, the only combination drug in Russia that contains the original metformin and glibenclamide in a micronized form, which provides a number of advantages compared to the usual form of glibenclamide, confirmed in clinical trials, including: hours, lower risk of hypoglycemia and safer action compared to the conventional form of glibenclamide [28, 33]. In addition, the faster release of glibenclamide from the Glucovance® tablet is more effective in preventing an increase in glycemia in the first 3 hours after a meal compared to the standard form of glibenclamide [34, 35]. The calibrated particle size technology used in the creation of Glucovance® provides controlled release of drug components in accordance with the physiological needs of the patient [34]. Thus, the target values ​​of glycemia are achieved with the use of lower doses of metformin and glibenclamide in the composition of Glucovance® in comparison with the doses used in monotherapy [33].
The drug is available in two dosages containing 2.5/500 mg of glibenclamide/metformin and 5.0/500 mg of glibenclamide/metformin, respectively, which makes it possible to titrate the dose of glibenclamide to reduce the risk of developing hypoglycemic conditions. Thus, using Glucovance in the treatment of T2DM, it is possible to achieve the target level of glycemic control both in patients with ineffectiveness of higher doses of metformin or in case of its intolerance, and in patients who are initially indicated for “double” therapy with A1c> 8. 0% or ” triple” therapy at the level of A1c> 90% in combination with incretin mimetics or TZD. The use of Glucovans not only provides an effect on both major pathogenetic defects in T2DM, but also allows to achieve an effect at lower doses with a lower risk of side effects and with greater patient compliance with the prescribed therapy [36]. Glucovance can be used in any cohort of patients with T2DM, regardless of the initial HbA1c level, of course, taking into account individual treatment goals that exclude the risk of developing hypoglycemic conditions, in the absence of severe vascular complications, taking into account age and life expectancy.

Literature
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What is the analysis for glycated hemoglobin A1c

Contents

• What is the best HbA1c value?
• How often should the HbA1c test be done?
• What is the difference between A1c and eAG?

The glycated hemoglobin (hemoglobin A1c, HbA1c) test is a complete blood test used to diagnose diabetes and monitor its treatment. This test is usually done to detect type 1 and type 2 diabetes.

HbA1c test shows the average blood sugar level over the past two to three months. It shows how much hemoglobin has been glycated (i.e., has been combined with glucose).

Hemoglobin is the protein in red blood cells that carries oxygen from the lungs to other parts of the body. Glucose enters the red blood cells and glycates (combines) with hemoglobin molecules. The more glucose in the blood, the more hemoglobin will be glycated.

The average amount of glucose in the blood can be determined by measuring the level of hemoglobin A1c. If your glucose level has been high for the past two to three months, the A1c test will show this with great accuracy.

A high A1c test indicates a high glucose level, which in turn increases the risk of diabetes.

See high blood sugar diet.

According to the National Institutes of Health (USA), the most common complications in patients with high blood glucose levels are:0090

Researchers at Bloomberg University (JHSPH, USA) report in the journal NEJM that glycated hemoglobin can predict disease risk with greater accuracy than conventional fasting glucose .

What is the best HbA1c value?

HbA1c test results show the following:

• between 4% and 5.6% – people are healthy , the risk of developing diabetes is minimal
• between 5.7% and 6.4% – the person has a high risk of developing diabetes
• 6.5% or more – the person has diabetes nemia and host vitamin supplements (vitamins C and E), patients with high blood cholesterol, and people with liver or kidney disease may have poor HbA1c test results. If you are taking vitamin supplements, tell your doctor.

  Non-caregivers (diabetes) with high HbA1c levels have a much higher risk of developing complications.

  The American Diabetes Association considers the maximum glycated hemoglobin for diabetic patients to be 7%.

  How often should the HbA1c test be done?

  If you have type 2 diabetes, you need to have your hemoglobin A1c tested every quarter of (three months) to make sure your level is below 7%.

  If your blood sugar levels are good for a certain amount of time, your doctor may allow you to get tested once every six months.

  What is the difference between A1c and eAG?

  Some doctors may tell you your A1c result as an eAG (mean blood glucose) test. eAG is directly related to A1c.

  • A1c is calculated as a percentage, eg 7%
  • eAG is calculated in millimoles per liter (mmol/l, mmol/L) in blood glucose meters, eg 5.4 ml/dl.
  • A1c having a value of 5 is equal to 4.5 eAG; A1c, having a value of 7, is equal to 8.3 eAG; A1c having a value of 8 is equal to 10.0 eAG; A1c, having a value of 9, is equal to 11.6 eAG.

  A study published in The Lancet in 2010 suggests that for diabetic patients, low HbA1c levels can be just as dangerous as high . It also contributes to the development of cardiovascular diseases and, often, with a fatal outcome. After reviewing the research, the Society of Endocrinologists of the United States stated that any changes in glycemic indicators are dangerous.