[acb-diabetics] why self montering is so important in all cases of diabetes

[Patricia LaFrance-Wolf]

Issue 543

 

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

 

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

 

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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.

 

South Med J. 2010;103(9):911-916

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