Targets for different medication levels

[LittleGreyCat]

There are targets to achieve in BG control depending on medication.
NICE says roughly:

Metformin and exercise 6.5%

Metformin and one second stage 7.0%

3rd stage (possibly including insulin) 7.5%

All very well, but sometimes my logic blows a fuse.

Last HbA1c was 7.0% on Metformin and exercise.
So I am well away from my target.
However I am on target for Metformin + another drug.
Under those circumstances should I start a second drug? I am already hitting the target.
Or should I regard the target as really 6.5% with a second drug.

I suspect that I would have to be well up towards the 7.5% to justify a second drug to bring me back to 7%.
Likewise well over 7.5% to justify going onto 3rd stage medication. to bring me back to 7.5%.

However it still niggles me to have the targets relaxed each time, instead of always aiming for the same reading.
Probably pragmatic, just jars against my logic a bit.

 

[KK123]

Hi @LittleGreyCat, I note that diet doesn't even come into it then 'target' wise? This must mean their targets are based on an assumption that people will be consuming the 'eatwell' plate and will automatically be on medication in the first place, (I'm guessing you are talking type 2). If people ARE eating to the eatwell plate then the targets above probably shoot straight to number 3 quite quickly. Do you include diet in your efforts at all? x

 

[LittleGreyCat]

Hi @LittleGreyCat, I note that diet doesn't even come into it then 'target' wise? This must mean their targets are based on an assumption that people will be consuming the 'eatwell' plate and will automatically be on medication in the first place, (I'm guessing you are talking type 2). If people ARE eating to the eatwell plate then the targets above probably shoot straight to number 3 quite quickly. Do you include diet in your efforts at all? x

Some very hard work on LCHF/keto to keep my numbers within range.

 

[KK123]

Some very hard work on LCHF/keto to keep my numbers within range.

Thank you for replying. It's very hard isn't it, deciding whether you need further medication or not. I do think though that when you have done everything you can, surely accepting extra help medicinally is not a bad thing? x

 

[Brunneria]

Is NICE still giving targets in % ?
How outdated.

this link gives the targets in mmol/mol with the % as an afterthought (in brackets)
https://pathways.nice.org.uk/pathways/type-2-diabetes-in-adults#path=view:/pathways/type-2-diabetes-in-adults/managing-blood-glucose-in-adults-with-type-2-diabetes.xml&content=view-node:nodes-hba1c-targets

 

[Antje77]

However it still niggles me to have the targets relaxed each time, instead of always aiming for the same reading.
Probably pragmatic, just jars against my logic a bit.

It's because the 2nd and 3rd stage medications hold risks for hypo's, which metformin does not. It is feared that people on hypo-risk medication with a lower hba1c came to have this low hba1c by having lots of hypo's, pushing the average glucose down.

Of course this is not always the case, but those guidelines are made with people who do not test multiple times a day in mind.
Guidelines are only that, guidelines. They're not the law, and targets can be set on a case by case basis.
Why not speak with your HCP about your thoughts and how they feel about it?

 

[LittleGreyCat]

It's because the 2nd and 3rd stage medications hold risks for hypo's, which metformin does not. It is feared that people on hypo-risk medication with a lower hba1c came to have this low hba1c by having lots of hypo's, pushing the average glucose down.

Of course this is not always the case, but those guidelines are made with people who do not test multiple times a day in mind.
Guidelines are only that, guidelines. They're not the law, and targets can be set on a case by case basis.
Why not speak with your HCP about your thoughts and how they feel about it?

Waiting for an appointment and meanwhile exploring options so that I go into the discussion moderately well informed.

 

[Riva_Roxaban]

Is NICE still giving targets in % ?
How outdated.

At the private pathology lab where I get my hba1c blood test done, they come back as 5.7% / 38 mmol/mol so it is still used here.

 

[Brunneria]

At the private pathology lab where I get my hba1c blood test done, they come back as 5.7% / 38 mmol/mol so it is still used here.

the UK adopted mmol/mol as ‘the default setting’ in 2011
https://www.diabetes.org.uk/about_us/news_landing_page/change-in-how-hba1c-results-are-reported

The official unit has been mmol/mol since then, but the % is often added in brackets, for those who still think in ‘old money’.

 

[EllieM]

Interesting, my 90 year dad has been T2 for about a decade, and used to be on metformin, then got swapped to gliclazide. After going low carb he got taken off medication altogether, and there's no suggestion that he should go back on with his current hba1c of 53 or 7%. So I'm guessing that his targets are relaxed because of his age and that they really don't want to put a 90 year old on hypo inducing meds. Which makes a lot of sense, because he has a bad habit of falling as it is, and I can't imagine what it would be like if you added hypoglycemia to the mix. So his GP is obviously applying sensible discretion to the guidelines. Unless there is specific mention of higher targets for people over a certain age???

 

[Antje77]

Unless there is specific mention of higher targets for people over a certain age???

They do. From Brunneria's link in post #5:
"Consider relaxing the target HbA1c level on a case-by-case basis, with particular consideration for people who are older or frail, for adults with type 2 diabetes:

• who are unlikely to achieve longer-term risk-reduction benefits, for example, people with a reduced life expectancy"

While it is of course possible your father will live to be 120, it's not very likely. With an hba1c of 53, it's not expected to develop diabetic complications any time soon, if at all, which is the main reason to keep BG down.

 

[optimist1]

Some very hard work on LCHF/keto to keep my numbers within range.

I think the target of <6.5 with low hypo risk, remains the same. It's just the trigger points for a med increase is higher. Given you are doing the right thing on keto and I would double check my carb inputs, they can sneak back in. I wouldn't be happy with an A1c of 7% regardless. My endo put me on GLP-1, because of one of the meds I'm on was increasing my weight and A1c. It was A1c 6.5 / 47 and still fell in the under control area. I'm happy with the now, 5.4% / 36.

 

[LittleGreyCat]

I think the target of <6.5 with low hypo risk, remains the same. It's just the trigger points for a med increase is higher. Given you are doing the right thing on keto and I would double check my carb inputs, they can sneak back in. I wouldn't be happy with an A1c of 7% regardless. My endo put me on GLP-1, because of one of the meds I'm on was increasing my weight and A1c. It was A1c 6.5 / 47 and still fell in the under control area. I'm happy with the now, 5.4% / 36.

I should add (discussed elsewhere) that at the moment my long term Libre use is predicting an HbA1c of 5.9% and I have a provisional diagnosis of anaemia which can lead to inaccurate HbA1c results (abnormally high readings).

So I am either doing pretty well (5.9%) or pretty badly (7%) and have no idea which at the moment.

Going to ask for Vitamin B tests along with my retest of Blood Count.

 

[optimist1]

That is good news. You have turned the corner, to have it under control. I think the Libre should give a good estimate.

 

[Antje77]

That is good news. You have turned the corner, to have it under control. I think the Libre should give a good estimate.

For some the Libre estimate is spot on, for others not so much.

 

[EllieM]

So I am either doing pretty well (5.9%) or pretty badly (7%) and have no idea which at the moment.

You could try asking for a fructosamine test....

And I know there are lots of folk out there with hba1cs in the 5s, and all kudos to them, but I wouldn't describe 7% as bad.

 

[Andydragon]

You could try asking for a fructosamine test....

And I know there are lots of folk out there with hba1cs in the 5s, and all kudos to them, but I wouldn't describe 7% as bad.

Agreed, some would prefer lower but for many it’s a good target for whatever reason… (although not exactly sure what targets should be, I was never given one specifically that I reacall, am sure I was supposed to) but as said, guidelines and not a simple at this level add drug as there are other factors (quick google threw link at bottom for example)

I also wouldn’t take libre as a value I would personally assume I am at. Accuracy of that can be hit or miss. As some have said in other threads for example, pressure on sensor overnight can change readings. It’s going to be closer to finger tests but really shouldn’t assume it will map directly to your hba1c

There is a cost/risk balance to be managed by them, risk of hypo on some plus other side effects. I guess that helps form the guidance in part. It may be for you they feel 7% is okay in respect of medication

the anaemia diagnosis as you say could be impacting the hba1c too

https://www.hey.nhs.uk/wp/wp-content/uploads/2018/05/TYPE-2-DIABETES-HbA1c-TARGETS-v4-March-2018.pdf