Normal A1C But Unstable Blood Glucose
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?
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. 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.
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?
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. 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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