American College of Physicians: Internal Medicine — Doctors for Adults ®

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ACP DiabetesMonthly



In the News for the month of September 2013




Highlights

Metformin use associated with cognitive impairment

Metformin is associated with cognitive impairment in people with type 2 diabetes, but the effect may be mitigated by vitamin B12 and calcium supplements, a new study found. More...

Linagliptin may be effective for elderly patients, study finds

Linagliptin appeared efficacious in patients age 70 years or older with type 2 diabetes who didn't achieve glycemic control from other regimens, and it had a safety profile similar to placebo, reported an industry-funded trial. More...

Healthy diet may decrease CKD risk in type 2 diabetes

Patients with type 2 diabetes who eat a healthy diet may have a lower risk of developing chronic kidney disease (CKD), according to a recent study. More...


Test yourself

MKSAP Quiz: Elevated hemoglobin A1c

This month's quiz asks readers to evaluate a 48-year-old woman with type 2 diabetes after laboratory study results show a hemoglobin A1c value of 8.5%. More...


From ACP InternistWeekly

Oral fluoroquinolones associated with increased dysglycemia risk in diabetics

Diabetic patients taking oral fluoroquinolones could have a higher risk for severe dysglycemia, according to a recent study. More...

New score predicts dementia risk for type 2 diabetics

A dementia risk score specific to patients with type 2 diabetes was derived and validated by a recent study. More...


From ACP Internist

Diabetes debates defy easy resolution

Learn what speakers at the American Diabetes Association's 73rd Scientific Sessions said about use of sulfonylureas, diabetes and osteoporosis, and concentrated insulin in the September ACP Internist. More...


From Annals of Internal Medicine

Meta-analysis assesses sodium-glucose cotransporter 2 (SGLT2) inhibitors

Sodium-glucose cotransporter 2 inhibitors appear to be an effective option to lower blood sugars in type 2 diabetes, but there is insufficient evidence on their safety and long-term effects, a recent meta-analysis found. More...


From ACP Journal Club

Review: In patients with chronic diabetic foot ulcers, hyperbaric oxygen reduces major amputations

According to a review of treating chronic diabetic foot ulcers with hyperbaric oxygen (HBO), HBO resulted in more healed ulcers and fewer major amputations, but no difference in minor amputations. More...


Tool of the month

Ask many questions

The questions you ask during visits with patients with type 2 diabetes, especially those who have been recently diagnosed, will inform your treatment plan. More...


Keeping tabs

Spotlight on cardiovascular risk

Several recent studies addressed the effects of diabetes and diabetes treatments on cardiovascular risk. More...


Physician editor: David V. O'Dell, MD, FACP



Highlights


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Metformin use associated with cognitive impairment

Metformin is associated with cognitive impairment in people with type 2 diabetes, but the effect may be mitigated by vitamin B12 and calcium supplements, a new study found.

Australian researchers recruited participants from the Prospective Research in Memory (PRIME) clinics study, the Australian Imaging, Biomarkers and Lifestyle (AIBL) study of aging, a clinic for the elderly, and a private geriatrician's practice. Participants with mild cognitive impairment, those with Alzheimer's disease (AD) or those who were cognitively intact were included; those with stroke or neurodegenerative diseases other than AD were excluded. After exclusions, 1,354 people (mean age, 74 years) were in the final analysis—1,228 with no diabetes, 104 with type 2 diabetes, and 22 with impaired glucose tolerance. Researchers performed subgroup analyses on the latter two groups of participants.

After adjustments for sex, age, depression and education, participants with type 2 diabetes had worse cognitive performance than those without diabetes (adjusted odds ratio [AOR], 1.51; 95% CI, 1.03 to 2.21; P=0.03). Diabetes participants who took metformin had worse cognitive performance than diabetes participants who didn't (AOR, 2.23; 95% CI, 1.05 to 4.75; P=0.04). Diabetes participants who had vitamin B12 levels below 250 ρmol/L also had worse cognitive performance than those whose levels were higher (AOR, 2.29; 95% CI, 1.12 to 4.66).

Each one-year increase in age was associated with an 8% higher risk of decreased cognitive performance. A secondary or tertiary level of education was the greatest predictor of better cognitive performance in diabetes participants. Once adjustments were made for age, sex, depression history, education level, use of serum vitamin B12 and metformin, the diabetic and impaired glucose tolerance participants who took calcium supplements performed better on cognitive measures than those who didn't take them (AOR, 0.41; 95% CI, 0.19 to 0.92; P=0.03). Results were published online Sept. 5 by Diabetes Care.

The researchers noted that there wasn't enough information in their study to determine how duration and dose of metformin, or severity and duration of diabetes, affected results. They pointed out that while calcium supplements seem to be linked to better cognitive outcomes, these supplements also have been associated with higher risk for myocardial infarction in postmenopausal women and in chronic kidney disease patients, and thus their safety still needs to be determined. Vitamin B12 supplements are a promising potential option for people with diabetes who take metformin, they said. The authors conclude by recommending increased monitoring of the cognitive abilities of diabetic patients older than 50 years who take metformin.


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Linagliptin may be effective for elderly patients, study finds

Linagliptin appeared efficacious in patients age 70 years or older with type 2 diabetes who didn't achieve glycemic control from other regimens, and it had a safety profile similar to placebo, reported an industry-funded trial.

Researchers conducted a double-blind, parallel-group, multinational phase 3 study in 241 community-living outpatients with hemoglobin A1c (HbA1c) of 7.0% or more who were receiving metformin, sulfonylureas, basal insulin or combinations of these drugs at baseline. Patients were instructed to continue their previous medications. They were stratified by HbA1c level of <8.5% or ≥8.5% and insulin use, and then randomized in a 2:1 ratio to once daily oral linagliptin (n=162) or matching placebo (n=79) for 24 weeks. Results were published online Aug. 13 by The Lancet.

The mean HbA1c at baseline was 7.8% (SD, 0.8%). At week 24, mean change in HbA1c with linagliptin was 0.64% lower than with placebo (95% CI, −0.81 to −0.48; P<0.0001). Overall safety and tolerability were similar between the linagliptin and placebo groups.

Serious adverse events occurred in 6.3% patients in the placebo group (n=5) and 8.6% patients in the linagliptin group (n=14); all were deemed unrelated to linagliptin. Hypoglycemia was the most common adverse event in both groups but did not differ between groups (24.1% [n=39] in the linagliptin group, 16.5% [n=13] in the placebo group; odds ratio, 1.58; 95% CI, 0.78 to 3.78; P=0.2083). There were no deaths.

The researchers noted that the study population was characteristic of elderly patients with type 2 diabetes who are encountered in clinical practice: More than half of the study population had diabetes for 10 years in more; 87% had cardiovascular disease and 79% had renal impairment; and there was a generally high use of concomitant drugs.

They concluded, "Linagliptin might be a useful glucose-lowering drug for elderly patients with type 2 diabetes, a prevalent population for which other treatment options are understudied and have important limitations."

However, an accompanying editorial stated that the study missed crucial opportunities to examine the management of older patients with type 2 diabetes, especially those who are frail.

"Their description of HbA1c targets is vague and there is no mention of how these targets were discussed, managed, or achieved," the editorial stated. "Attempts to lower HbA1c towards 7.0% (53 mmol/mol) or less in an older cohort of patients with diabetes might seem unnecessary or even dangerous since higher target levels are now recommended" by international consensus groups and position papers.


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Healthy diet may decrease CKD risk in type 2 diabetes

Patients with type 2 diabetes who eat a healthy diet may have a lower risk of developing chronic kidney disease (CKD), according to a recent study.

Researchers used data from ONTARGET (Ongoing Telmisartan Alone and in Combination With Ramipril Global Endpoint Trial) to examine whether healthy diet and alcohol, protein, and sodium intake were associated with incidence or progression of CKD in patients with type 2 diabetes. Patients in ONTARGET were recruited from January 2002 to July 2003 and were followed through January 2008. Those included in the current study had no macroalbuminuria at baseline. The authors defined CKD as new microalbuminuria or macroalbuminuria or a decrease in glomerular filtration rate (GFR) or over 5% annually after 5.5 years of follow-up. Diet was assessed using the modified Alternate Healthy Eating Index (mAHEI), where higher scores indicated a healthier diet. The study results were published online Aug. 12 by JAMA Internal Medicine.

A total of 6,213 patients from ONTARGET with type 2 diabetes but no macroalbuminuria were included in the current study. Overall, 1,971 (31.7%) had incidence or progression of CKD by 5.5 years of follow-up and 516 (8.3%) died. Nine hundred seventy-nine patients (15.8%) developed new microalbuminuria (n=678) or new macroalbuminuria (n=301), and GFR declined more than 5% per year in 1,270 patients (20.4%). End-stage renal disease occurred in 33 patients (0.5%). Compared to those in the least healthy tertile of mAHEI score, participants in the healthiest tertile had a lower risk for CKD and death (adjusted odds ratios, 0.74 [95% CI, 0.64 to 0.84] and 0.61 [95% CI, 0.48 to 0.78], respectively). CKD risk was also lower in patients who ate more than three servings of fruit per week and in those who ate more total and animal protein compared with those who ate less. Sodium intake and CKD did not appear to be associated, but moderate alcohol intake appeared to reduce the risk for CKD (odds ratio, 0.75 [95% CI, 0.65 to 0.87]) and death (odds ratio, 0.69 [95% CI, 0.53 to 0.89]).

The authors noted that their study was observational and pointed out that albuminuria was measured only three times, which may have led to misclassification, and that protein intake may have been underreported, among other limitations. However, they concluded that a healthy diet lowers risk for CKD, slows progression of early kidney disease, and reduces risk for death in patients with type 2 diabetes. "Neither a low protein nor a low sodium diet, the 2 main nutritional recommendations in individuals with CKD, reduced the incidence and progression of the disease," the authors wrote. They stated that "it may be legitimate" to recommend that patients with type 2 diabetes and vascular disease eat a healthy diet and avoid "extremes of protein and salt intake."

An accompanying editorial noted that the study didn't adjust for overall energy intake, given that people who eat fewer calories also often eat less sodium and protein and are also "likely sicker and less physically active than those consuming a higher amount of calories," the editorialists wrote. The editorialists also noted that the effects of different fat sources were not evaluated.

Dietary restrictions can be especially frustrating for patients in this population, the editorialists stressed. "Perhaps the best dietary advice we can give to patients with type 2 diabetes and kidney disease is the same as the advice for those who want to avoid chronic kidney disease, and the same advice for preventing and treating hypertension, and the same dietary advice for everyone," they wrote. "Eat a diet rich in fruits and vegetables, low-fat dairy products, and whole grains while minimizing saturated and total fat."



Test yourself


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MKSAP Quiz: Elevated hemoglobin A1c

A 48-year-old woman is evaluated after laboratory study results show a hemoglobin A1c value of 8.5% (estimated average plasma glucose level of 197 mg/dL [10.9 mmol/L]). The patient has type 2 diabetes mellitus. Her blood glucose logs indicate an average fasting and preprandial blood glucose level of 132 mg/dL (7.3 mmol/L) for the past 3 months. She also has a history of iron deficiency anemia secondary to menorrhagia and has recently started iron replacement therapy. Other medications are neutral protamine Hagedorn (NPH) insulin at bedtime and metformin three times daily with meals.

On physical examination, temperature is 36.9 °C (98.4 °F), blood pressure is 127/78 mm Hg, pulse rate is 77/min, and respiration rate is 14/min; BMI is 26. All other findings from the physical examination are unremarkable.

mksap.gif

Results of laboratory studies are normal except for a repeat hemoglobin A1c value of 8.5% and a fasting plasma glucose level of 130 mg/dL (7.2 mmol/L); a blood glucose level obtained simultaneously on the patient's glucose monitor is 134 mg/dL (7.4 mmol/L).

Which of the following best explains the discrepancy between her average blood glucose levels as measured on the glucose monitor and her hemoglobin A1c values?

A. Inaccurate glucose monitor
B. Iron therapy
C. Nocturnal hypoglycemia
D. Postprandial hyperglycemia

Click here or scroll to the bottom of the page for the answer and critique.


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From ACP InternistWeekly


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Oral fluoroquinolones associated with increased dysglycemia risk in diabetics

Diabetic patients taking oral fluoroquinolones could have a higher risk for severe dysglycemia, according to a recent study.

Researchers performed a population-based inception cohort study of diabetic outpatients in Taiwan from January 2006 to November 2007 who were new users of oral levofloxacin, ciprofloxacin, moxifloxacin, cephalosporins and macrolides. The main outcome measures were emergency department visits or hospitalization for dysglycemia 30 days after antibiotic therapy was initiated. The study results were published online Aug. 14 by Clinical Infectious Diseases.

The study included 78,433 diabetic patients who were taking a fluoroquinolone, 12,564 taking ciprofloxacin, 4,221 taking moxifloxacin, 11,766 taking levofloxacin, 20,317 taking cephalosporins, and 29,565 taking macrolides. Two hundred fifteen hyperglycemic events and 425 hypoglycemic events occurred during the study period. Those taking moxifloxacin had an absolute risk of 6.9 per 1,000 persons for hyperglycemia and 10.0 per 1,000 persons for hypoglycemia; for those taking macrolides, the risks were 1.6 and 3.7 per 1,000 persons, respectively. Adjusted odds ratios for hyperglycemia with levofloxacin, ciprofloxacin and moxifloxacin compared to macrolides were 1.75, 1.87, and 2.48, while adjusted odds ratios for hypoglycemia were 1.79, 1.46, and 2.13, respectively. Hypoglycemia risk was significantly higher with moxifloxacin than with ciprofloxacin, as well as with moxifloxacin and concomitant insulin.

The authors noted that data on rare events were obtained from an electronic database and might therefore be incomplete. Among other limitations, they also pointed out that reverse causality could have been present, since severe infection can cause dysglycemia. However, they concluded that based on their results, diabetic patients taking fluoroquinolones, especially moxifloxacin, could potentially be at higher risk for severe dysglycemia. "Clinicians should consider these risks when treating patients with diabetes and prescribe fluoroquinolones cautiously," the authors wrote.


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New score predicts dementia risk for type 2 diabetics

A dementia risk score specific to patients with type 2 diabetes was derived and validated by a recent study.

Researchers used longitudinal data from the Kaiser Permanente Northern California Diabetes Registry, including almost 30,000 diabetics age 60 and older, to create a prediction model for development of dementia over 10 years. The model was then validated in a separate cohort of more than 2,000 similar patients from Washington State. Results were published by The Lancet Diabetes and Endocrinology on Aug. 20.

The researchers developed a risk score including the factors that most predicted development of dementia in the studied patients: microvascular disease, diabetic foot, cerebrovascular disease, cardiovascular disease, acute metabolic events, depression, older age and less education. Point values were assigned to each factor, and patients were stratified into 14 risk categories, to create what the researchers called the type 2 diabetes-specific dementia risk score (DSDRS).

Patients with the lowest scores had a 10-year dementia risk of 5.3% compared to 73.3% in the highest-risk group. The C-statistic (a statistical measure indicating the predictive strength of a model, with 0.5 being the same as chance and values approaching 1.0 indicating a stronger predictive ability) for the DSDRS was 0.733 to 0.744, which is higher than other commonly used scores like the Framingham score, the researchers noted. The C-statistic for age alone was almost as high, however. This may lead to uncertainty about the value of the score, an accompanying editorial acknowledged, but use of the full score would show, for example, that a 60-year-old with diabetes complications and cardiovascular disease has similar dementia risk to an 80-year-old without those comorbidities.

Because the score uses easily gathered information, it may be useful in primary care to identify the diabetes patients who should be watched most vigilantly for cognitive deterioration and protected from hypoglycemia (which has been associated with cognitive impairment by other research), the study authors concluded. Ideally, this first dementia risk score for diabetes patients could eventually lead to development of measures to predict dementia earlier in life, which would allow more preventive action and motivate lifestyle changes, the accompanying editorial concluded.



From ACP Internist


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Diabetes debates defy easy resolution

The ever-changing nature of medical evidence and expert opinion (with no clear consensus, in some cases) was apparent at the American Diabetes Association's 73rd Scientific Sessions.

Learn what speakers at the meeting said about use of sulfonylureas, diabetes and osteoporosis, and concentrated insulin in the September ACP Internist.



From Annals of Internal Medicine


.
Meta-analysis assesses sodium-glucose cotransporter 2 (SGLT2) inhibitors

Sodium-glucose cotransporter 2 (SGLT2) inhibitors (a new class of drugs that reduces renal glucose reabsorption, leading to increased glucose excretion) appear to be an effective option to lower blood sugars in type 2 diabetes, but there is insufficient evidence on their safety and long-term effects, a recent meta-analysis found.

The analysis included 45 studies (of more than 11,000 patients) in which SLGT2 inhibitors were compared with placebo and 13 studies (with more than 5,000 patients) comparing them to other drug options. Results were published by Annals of Internal Medicine on Aug. 20.

annals.jpg

SGLT2 inhibitors improved hemoglobin A1c compared to placebo (mean difference, −0.66%; 95% CI, −0.73% to −0.58%), but not significantly compared to active comparators (mean difference, −0.06%; 95% CI, −0.18% to 0.05%). Compared to the other active drugs, SGLT2 inhibitors reduced body weight (mean difference, −1.8 kg; 95% CI, −3.5 to −0.1 kg) and systolic blood pressure (mean difference, −4.45 mm Hg; 95% CI, −5.73 to −3.18 mm Hg), but increased urinary and genital tract infections (odds ratios, 1.42 and 5.06, respectively). Data on cardiovascular outcomes and death were inconclusive and there were more breast and bladder cancer cases than expected in patients taking dapagliflozin (although this could result from detection bias, the analysis said).

The available evidence had a number of limitations, including many studies' use of last-observation-carried-forward (LOCF) methods to impute missing data. (Another article in the same issue of Annals explained more about the limitations of such methods.) Other limitations included industry funding, a lack of head-to-head trials and a focus on short-term efficacy outcomes.

Based on the existing evidence, SGLT2 inhibitors may improve short-term outcomes for patients with type 2 diabetes, but conclusions about safety and long-term outcomes await additional data. Future research should compare the SGLT2 inhibitors to each other and to existing antihyperglycemics, the review authors recommended.



From ACP Journal Club


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Review: In patients with chronic diabetic foot ulcers, hyperbaric oxygen reduces major amputations

Researchers reviewed 13 studies, including seven randomized, controlled trials (RCTs), that compared treatment of chronic diabetic foot ulcers with hyperbaric oxygen (HBO) therapy to treatment without HBO. They found that HBO resulted in more healed ulcers (relative risk [RR], 2.33; 95% CI, 1.51 to 3.60) and fewer major amputations (RR, 0.29; 95% CI, 0.19 to 0.44), but no difference in minor amputations.

The study was published in the February Mayo Clinic Proceedings. The following commentary by M. Hassan Murad, MD, MPH, ACP Member, Qusay Haydour, MD, and Khalid Benkhadra, MD, was published in the ACP Journal Club section of the Aug. 20 Annals of Internal Medicine.

The 7 RCTs summarized by Liu and colleagues show that HBO may increase healing of diabetic foot ulcers and reduce major amputations. Confidence in this evidence is low to moderate, balanced between the inconsistency of results across studies and the small number of events, and the very large (7-fold) effect found for healing rate. Despite the inconsistency, all point estimates for RCTs and observational studies are favorable for HBO and healing (Peto odds ratio 7.57, 95% CI 4.35 to 13.19; Peto odds ratio is a suitable estimate for meta-analyses that include studies with 0 events). Publication bias is a concern when all trials are small and positive. A recent large observational study, however, showed that HBO decreased healing and increased amputations, probably due to selection bias given that the worst, more recalcitrant ulcers are usually referred to HBO. The real effect should be derived from RCTs.

In practice, HBO sometimes works and sometimes not. There are several reasons for the varied responses observed in research and practice. First, a common misconception is that it works alone. HBO is an adjunctive therapy that should be delivered after an individualized approach with other wound care standards (e.g., debridement, revascularization, off-loading). In practice, once patients are referred to HBO, other wound care methods usually stop or decrease in intensity. Second, diabetic foot ulcers have multiple causes (e.g., ischemic, neuropathic, infectious) that affect how we should treat them and how they respond to HBO. Third, HBO is approved by society guidelines and is funded by payers for Wagner III or higher ulcers that have failed 30-day standard therapy. In reality, only recalcitrant cases that have persisted for a much longer time are referred to HBO.

The results of the review by Liu and colleagues are consistent with a beneficial effect in some, but not all, diabetic foot ulcers. We recommend proper evaluation of the patient to establish an individualized diagnostic and treatment strategy that includes HBO. As wound care practitioners say, "Consider the whole patient, not just the hole in the patient."



Tool of the month


.
Ask many questions

The questions you ask during visits with patients with type 2 diabetes, especially those who have been recently diagnosed, will inform your treatment plan.

Some useful questions include:

  • What are your greatest concerns at this time about your diabetes? What is hardest for you in caring for your diabetes right now?
  • What questions do you have today? How can I be most helpful to you? What are your thoughts and feelings about diabetes at this time?
  • How well do you think your treatment plan is working to manage your diabetes? What do you think would help to improve the situation?
  • Have you ever received diabetes self-management education? What was your experience? Are you interested in receiving diabetes self-management education?


Keeping tabs


.
Spotlight on cardiovascular risk

Several recent studies addressed the effects of diabetes and diabetes treatments on cardiovascular risk.

Two manufacturer-sponsored studies, published by the New England Journal of Medicine on Sept. 2, analyzed dipeptidyl peptidase 4 inhibitors (DPP-4) in patients with type 2 diabetes and cardiovascular risk factors. In the first study, 5,380 patients who had either an acute myocardial infarction (MI) or hospitalization for unstable angina in the preceding three months were randomized to either alogliptin or placebo and followed for up to 40 months. Although alogliptin significantly lowered glycated hemoglobin (7.70% vs. 8.06% for placebo), the treated and placebo groups had similar rates of death from cardiovascular causes, nonfatal MI or nonfatal stroke (11.3% vs. 11.8%; hazard ratio, 0.96).

In the second study, more than 16,000 type 2 diabetes patients with a history or increased risk of cardiovascular events were randomized to saxagliptin or placebo and followed for a median of 2.1 years. Both groups had similar rates of cardiovascular death, MI or ischemic stroke (7.3% with saxagliptin vs. 7.2% with placebo). However, significantly more saxagliptin patients were hospitalized for heart failure (3.5% vs. 2.8%; hazard ratio [HR], 1.27), a finding that researchers described as unexpected and requiring confirmation. The results also show the need for other approaches to reduce cardiovascular risk in diabetic patients, the authors said.

An accompanying editorial agreed, noting that these studies, and the current evidence generally, show that clinicians shouldn't use glycated hemoglobin levels as a predictor of cardiovascular risk or rely on antidiabetic therapies as preventive treatment for cardiovascular events, but rather aggressively manage standard cardiovascular risk factors.

Another study, published by the Journal of the American Medical Association on Aug. 28, did offer a potential future method for predicting cardiovascular risk in patients with type 2 diabetes. An analysis of data from several large studies, including the Nurses' Health Study and the Health Professionals Follow-up Study, identified a gene associated with development of coronary heart disease (CHD) in type 2 diabetes patients. Diabetics who had a variant on chromosome 1q25 had a significantly increased risk of CHD compared to those without the variant. No such association was seen in people without diabetes, leading study authors to conclude that there is an interaction between the gene and diabetes, which could be functionally related to glutamic acid metabolism.


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MKSAP Answer and Critique



The correct answer is D. Postprandial hyperglycemia. This item is available to MKSAP 16 subscribers as item 41 in the Endocrinology section. Information about MKSAP 16 is available online.

The discrepancy in this patient's glucose monitor readings and hemoglobin A1c values is most likely due to postprandial hyperglycemia. She tests her blood glucose level only in a fasting state and before each meal and does not obtain postprandial or other measurements. Although her records indicate an average level that is close to the target of 130 mg/dL (7.2 mmol/L), her blood glucose level may actually exceed 200 mg/dL (11.1 mmol/L) for several hours after meals. These periods of hyperglycemia will contribute to her elevated hemoglobin A1c value. The hemoglobin A1c level represents the average of her fasting, preprandial, postprandial, nocturnal, and other blood glucose levels during the past 3 months.

Although blood glucose monitors occasionally may produce inaccurate readings, this occurrence is extremely rare and also is unlikely in this patient because the simultaneous laboratory plasma glucose level and glucose monitor reading are within 10% of each other.

Hemoglobin A1c levels vary directly with erythrocyte survival. Levels are falsely high when erythrocyte survival is prolonged (decreased erythrocyte turnover), as occurs in patients with untreated iron, vitamin B12, or folate deficiency anemia. Conversely, hemoglobin A1c levels may be falsely low in patients with the shorter erythrocyte survival associated with rapid cell turnover, as occurs in patients with hemolytic anemia; those being treated for iron, folate, or vitamin B12 deficiency; and those being treated with erythropoietin. This patient's history of recent iron deficiency anemia treated with iron is likely to falsely lower, not elevate, her hemoglobin A1c level.

If the patient were having prolonged periods of nocturnal hypoglycemia, she would have a lower-than-expected hemoglobin A1c value.

Key Point

  • Average glucose monitor readings that do not include postprandial blood glucose levels are likely to differ from average plasma glucose levels derived from hemoglobin A1c values.

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