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Why Self-Monitoring of Blood Sugars Is Critical in All Patients with Diabetes

Posted: Friday, October 22, 2010

Vigilant monitoring of glycemic levels is the key to success for comprehensive glycemic control in patients with Type 2 diabetes.

Comprehensive glycemic control, as demonstrated by desirable glycated hemoglobin A1c (HbA1c), postprandial glucose (PPG), and fasting plasma glucose (FPG) levels, is imperative for managing patients with Type 2 diabetes. It is important to minimize fluctuations in blood glucose levels, as they are thought to contribute to both the microvascular and macrovascular complications.

The HbA1c measurement itself is not always indicative of the magnitude or frequency of glucose fluctuations during the course of a day. Therefore, treatment should be aimed at reducing not only HbA1c, but also PPG and FPG in order to achieve glycemic control. At the same time, patient safety should be a priority. Glycemic control also means minimizing hypoglycemic episodes, which elevate the risk for additional complications. In addition to being life-threatening, hypoglycemia may cause hypoglycemia unawareness and compromised counter-regulatory mechanisms. It may also lead to serious short- and long-term effects, including cognitive impairment and dementia. As most patients are unable to maintain glycemic control on monotherapy, fortunately, effective combination regimens are available with agents having complementary mechanisms that act upon HbA1c, PPG, and FPG with minimal risk of hypoglycemia or weight gain.

Acute glucose fluctuations above a mean value (HbA1c 7%, which is an estimated average glucose [eAG] of 154 mg/dL) may trigger oxidative stress, which contributes to macrovascular damage through oxidation of low-density lipoprotein, exacerbation of endothelial dysfunction, and other proatherogenic mechanisms leading to the development and progression of vasculopathies; treating to limit this glycemic variability may minimize diabetic complications. Decreasing the frequency and magnitude of glucose fluctuations may prevent not only acute, but also long-term consequences associated with hyperglycemia. Recent studies suggest that monitoring HbA1c levels alone might not be sufficient to address the pathogenesis of adverse events -- rather, acute fluctuations in blood glucose may also be instrumental. Lowering both FPG (i.e., plasma glucose levels following an 8- to 12-hour fast) and PPG (i.e., plasma glucose levels 60, 90, or 120 minutes after beginning a meal) levels has been shown to reduce the risk of complications.

Recent evidence has demonstrated that control of postprandial hyperglycemia is necessary to achieve HbA1c targets. In one study, it was shown that when HbA1c levels were 6.5%, PPG levels contributed to approximately 90% of this value. Consequently, treating postprandial hyperglycemia in addition to FPG in efforts to reach HbA1c goals should be part of the overall strategy for the prevention and management of complications associated with T2DM. It should be noted that when HbA1c values were >9%, the proportion of PPG involvement decreased to 40%, demonstrating the importance of treating FPG. The break point appears to be when HbA1c is <7.3%; at that point, treatment of PPG levels becomes more important than treating FPG levels.

AACE and ACE recommend that, in order to reach target HbA1c levels, measurement of both FPG and PPG levels are necessary. HbA1c measurement alone does not disclose the magnitude or frequency of fluctuations in blood glucose throughout the day. Daily glycemic measures, FPG and PPG, give a series of snapshots that, when used in combination with HbA1c, is a more reliable indicator of blood glucose control. HbA1c should be measured every 2 to 6 months, depending on the blood glucose level, how stable that level is, and whether any changes are made in patient therapy.

The ADA recommends measuring HbA1c at least every 6 months in patients who are both meeting their glycemic goals and have stable blood glucose control, and 4 to 6 times per year in patients whose therapy has changed or who are not meeting their glycemic goals. Optimal PPG, FPG, and HbA1c values are <180 mg/dL (10.0 mmol/L), 70 to 130 mg/dL (3.9 to 7.2 mmol/L), and <7.0%, respectively. The contribution of PPG is greatest in patients with moderate hyperglycemia (<7.3%). Based on the ADA and IDF recommendations, physicians should focus on monitoring HbA1c and promoting patient self-monitoring of blood glucose (SMBG) in an effort to improve those values, reach the glycemic goal, and reduce the proportion of patients with diabetes-associated complications. Because it provides real-time data, SMBG is the optimal method for monitoring PPG and FPG; SMBG also allows for early intervention.

Early comprehensive glucose control is essential for maintaining health and reducing long-term microvascular and macrovascular complications of patients with T2DM. Vigilant monitoring of glycemic levels is the key to improving glycemic control. Current guidelines recommend treatment aimed at controlling both FPG and PPG to maintain HbA1c near target goals; at the same time, hypoglycemia and its associated complications should be avoided. Combination regimens with antidiabetic agents that provide complementary mechanisms of action afford the physician drug treatment options that are safe, with minimal risk of hypoglycemia, and effective for the management of daily glycemic control.

Source: http://www.diabetesincontrol.com/index.php?option=com_content&view=article&id=9929&catid=53&Itemid=8, South Med J. 2010;103(9):911-916

 
 
 
 
 
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