Revision of HBA1c targets?

[catherinecherub]

A NHS prescribing advisory body has called for a change in diabetes guidance to include a minimum HBA1c target, reflecting the weight of trial data suggesting lowering blood sugar below a certain level may be harmful to patients.

http://www.pulsetoday.co.uk/section.asp?navcode=1064

Here we go again. We will all be advised to aim for higher minimum levels and then some research will come along and suggest we should have stayed as we were. Who really knows the answer?

 

[clearviews]

I totally agree with CC,
This stuff does not give us much confidence that anyone knows what is good for us, diabetics that is.

I choose to believe that if I aim to be as close to a non-diabetic's A1c as I can, it would be better for my outcome. I think that I don't want to be as close as I can to a healthy diabetic. I want more. I want it all!!!! That is what I want. What is a non diabetic A1c again?
Alison

 

[clearviews]

PS to CC
I want your A1c.................. I really, really want the same A1c as you.
Alison

 

[hanadr]

The article quotes information on drug and insulin blood glucose control. They have nothing on diet control.
Since the only difference between a drug and a poison, is the dose, It's not surprising that if you give someone large doses of several different blood glucose lowering preparations, it harms them. No One has yet collected data on tight control by diet [although I believe DUK is doing so at the moment]
So there's still no valid reason for those of us on the 5% sofa to get off it.Provided we are diet controlling or using a combination of minimal medication and diet.
I'm trying to get off the 5% sofa and on to the 4% one
Hana

 

[catherinecherub]

I wasn't thinking of myself Hana. There are forum users who are doing all they can to lower their levels with the help of drugs and insulin as they cannot do it by diet alone. Where does that leave them?

 

[Anonymous]

Once again a post written without thought for the diabetics who, because they are too far along the diabetic pathway cannot control their diabetes without medications.

Since the only difference between a drug and a poison, is the dose, It's not surprising that if you give someone large doses of several different blood glucose lowering preparations, it harms them.

How frightening is this statement to diabetics who must take medication even when they try to reduce their carbs and still cannot control their blood sugar levels.
The difference here is well documented and trialed dosages of drugs that are life savers not poisons as you imply. There are many diabetics who are living healthy fulfilling lives on what you call ‘large' dosages of life saving drugs who would be dead or full of complications now without them.
For those lucky enough to be able to control by diet only then reducing Hba1c levels to a comfortable lifestyle level is of course worthwhile.

 

[iHs]

I don't think that there will be many D consultants who will be happy to go by a hba1c 7.5% for people dependant on insulin as being all ok. For a few years when first diagnosed, possibly yes but once 5 years have gone by, then they will get a good get your act together lecture and be told to get their bg levels a bit lower.

 

[RichardNY]

Life dont talk to me about life :lol:

Indeed who does know and as silver fox points out some people are way along the path sometimes even before they get a diagnoses, already have complications and need additional help. Diabetes is a very individual disease with detection rates varying wildly something that is just not limited to T2 peeps like me which I was absolutely amazed at :shock: but a couple of local T1 friends have blown that assumption out of the water that only T2's go undetected. Then there are the cases of diabetes that defy a definition such as this brave little lass http://www.cravenherald.co.uk/news/8099201.Alice_raises___16_500_to_make_wishes_come_true/

With such a myriad of people medications, ages, progression and personal effort or none effort on the part of the individual, I'll look at my peers around me and see who gets good results and can halt control or slow down the progression and follow that doctrine. I'll do that until the next report like Catherine says that calls for tighter control from diabetics.

You do what you can with what you have and hopefully to the best of your ability.
You have to rely to some extent on your diabetic care team.
You have to rely on how good your local GP/Hospital is and the individuals you meet.

Whilst diet is a good way for T2's to help with control it is not always possible. Articles like this are something that as a diabetic you need to take in your stride and remind yourself that you are doing your best and even the medical community is just as capricious as diabetes itself.

A dads army summary :-
Corporal Jones-'Don't Panic Mr Mainwaring, don't panic'
Private Fraser-'We're doomed, I say. Doomed'.

I like to think of myself of a Corporal Jones type but now and again succumb to a 'whiff' of the Fraser's :shock:


All the best peeps.

Richard.

 

[hanadr]

It's obvious, that anyone who MUST use a lot of medication, needs to be careful. Because they could be heading for trouble. Perhaps they will have to slacken their control.
As to being far down the road,
>>Once again a post written without thought for the diabetics who, because they are too far along the diabetic pathway cannot control their diabetes without medications.<<
I'm actually diagnosed longer than many people who take loads of medication and now take FAR LESS than at diagnosis.
So I hope that wasn't another personal "snipe"
Hana

 

[Anonymous]

It's obvious, that anyone who MUST use a lot of medication, needs to be careful. Because they could be heading for trouble. Perhaps they will have to slacken their control.
As to being far down the road,
>>Once again a post written without thought for the diabetics who, because they are too far along the diabetic pathway cannot control their diabetes without medications.<<
I'm actually diagnosed longer than many people who take loads of medication and now take FAR LESS than at diagnosis.
So I hope that wasn't another personal "snipe"
Hana

You may have been diagnosed a long time but how long had you been diabetic before you were diagnosed ? Many have had diabetes a long time before the diagnosis and are into complications before they go to see the doctor because they don't like to 'bother' the doctor !
These are the ones who need medication from day 1 and, however hard they try, cannot control their levels. Not everyone is lucky enough to be diagnosed in the early stages where diet and exercise can turn round their health and help them control their blood sugar levels.
This was not a 'snipe' just a personal observation about the feelings of others.

 

[cocacola]

Can someone please explain this report in plain English?

 

[IanD]

Can someone please explain this report in plain English?

But it also showed there was a U-shaped association between increased all-cause mortality above and below an HbA1c of 7.5%. Changes above or below an HbA1c of 7.5% was associated with a greater risk, regardless of whether treatment was intensified with oral hypoglycaemic agents or insulin injections.

They have found that using high medication to achieve HBA below 7.5 may be counter-productive because of the adverse effects of the medication. At higher HBAs, the adverse effect of diabetes becomes more significant.

There is a line of thought that diabetes (particularly T1, with DAFNE) can be controlled by medication, while eating normally. That is where Hana & I & others take issue. A reduced carb diet will not have such adverse effects. Hana's husband has been T1 for many years.

 

[Sid Bonkers]

I'm actually diagnosed longer than many people who take loads of medication and now take FAR LESS than at diagnosis.
So I hope that wasn't another personal "snipe"
Hana

I too take far less medication than at diagnoses Hana, but I dont make statements like medicine is poison etc etc etc. Can you not accept that every diabetic is different and some will need more medication than others? You take metformin because you cant manage your diabetes without it, others need more and different medication to manage theirs.

You are no better than any other diabetic, better controlled than some perhaps but not better and that is the insinuation that I get when I read some of your posts.

Oh and this is not "a personal snipe" merely an observation.

 

[cugila]

Can someone please explain this report in plain English?

CC
For what it's worth........here is my 'unbiased' observations on the article. I hope it is a little clearer.

Basically, a body that advises the NHS has stated that they think the Diabetes guidance should show a minimum HbA1c level that we should not go below. They maintain that it can harm patients if they drop below this level. This is based on trial data that they have used which is quoted in the report as posted. If you want more specific information about them you will need to research those trials.

Apparently there is more evidence coming to light that dropping levels below 7.5% increases the risks of developing Cardiovascular events, such as strokes, heart attacks etc.

There was an analysis of a UK primary care trial published which has also cast doubt on the clinical value (i.e. does it do any good) of having an HbA1c level below 7%. The data that was used in the paper showed that keeping a level of around 7.5% was associated with the lowest risk of all causes mortality (deaths) and macrovascular disease events.

Macrovascular disease is of the large blood vessels, including the Coronary Arteries, the Aorta, and the larger Arteries in the brain and limbs. This is different to Microvascular Disease which is associated with Diabetes and chronic Hyperglycaemia. The connection between that and HbA1c levels is apparently still not clear.

The ‘u’ shaped association referred to was actually saying that there was a greater risk of these events at both higher and lower levels than the quoted 7.5% HbA1c. It does not matter what the treatment regime was, so if you were on oral medications or Insulin it made no difference to the results.

When a comparison was made it showed that those in the reference group who had HbA1c of 6.4% had a 52% higher risk, those with a 10.6% HbA1c had a 79% higher risk of dying from any cause.Because of this it was suggested that GP’s might wish to discuss with their patients the implications of the study.

That means those who maintain low levels of HbA1c would be advised that it may not be beneficial for them because of the risks, and that those with higher levels of HbA1c should consider increasing the medication to lower levels, again because of the risks. Each Patient should come to an agreement as to what they believe is their own HbA1c target level in discussion with the GP.

At the moment this is all just speculation as in the conclusion it clearly states that if the evidence so far from all quarters is confirmed then that would give credence to the thought that HbA1c levels should have a minimum figure set......not necessarily the figure quoted, it is just a baseline so far.

It also has to be remembered that all of this is in relation to HbA1c levels and Cardiovascular events.........it is not specifically about glycaemic levels and glycaemic control. I am sure we all have our own ideas about what a good HbA1c level is in that respect. That's just it, it is all a balance......the body has to be looked at holistically, everything has to be considered.....not just Diabetes.

Ken

 

[cugila]

They have found that using high medication to achieve HBA below 7.5 may be counter-productive because of the adverse effects of the medication. At higher HBAs, the adverse effect of diabetes becomes more significant.

Sorry Ian.
I must have missed something here......where exactly does it say that ? :?
What is high medication, I didn't see that mentioned anywhere. I take two Metformin along with my Byetta....is that high then ?

Ken

 

[catherinecherub]

My interpretation of this report took it to mean all types of control that we employ. When it says,

"Changes above or below an HBA1c of 7.5 was associated with greater risk regardless of whether treatment was intensified with oral hypoglycemic agents or insulin injections" surely that means even if you are controlling with diet and exercise or adding meds and or insulin?

Interesting to note we have got people expressing paranoia, A Type2 giving a biased view of Dafne, (a course for Type 1's) and one who thinks that meds are poison.

You have to be in control of your own diabetes and if this includes medication then so be it. It has to be whatever you have to do regardless of other people's take on what you are doing. Nobody else can manage it for you, know your medical history, lifestyle, complications etc. It is pure arrogance to deem to know the right way for all and sundry.

As for being a better diabetic, as mentioned in another post, how do you class that then? Am I a better diabetic if I follow a specific eating plan, take less meds, belong to more support groups? It may mean that I am more involved but does that make me better?

 

[hanadr]

To answer silver fox's point.
I had background retinopathy at diagnosis and was diagnosed in a hospital following a stroke. I'd had no symptoms of diabetes, but I must have had the condition a fair time. It runs in my family and I've only known how strong that trend is for the last 2 or 3 years, otherwise I might have been looking for it sooner. I do not know what my blood tests would have been, because I was never told. They must be in some hospital notes somewhere. I do know that all the time Iwas in hospital beeing treated for stroke injury, my BG was being tested by nurses 4 times a day and Iwas being given3 x 500mg Metformin and 40mg Gliclazide[half a tablet] per day and my BG was almost always over 20 and NEVER in single figures.
Nowadays on 2 x 500mg Metformin and no Gliclazide with low carb and a lot of exercise, I haven't seen an 8 for so long I can't remember it.
This isn't easy to maintain. I still have a taste for things Iknow I must not eat and going out to walk dogs a minimum of 3 miles each evening isn't always what I want to do. They used to make do with a mile. I also wish for a lie-in sometimes instead of getting up before 6 and going to the gym 3 mornings a week and walking the other days
Hana

 

[phoenix]

Hi, whilst Ken has been writing his summary, I've been drawing graphs.
Using the limited figures given, a graph of the deaths in the lancet study would look a bit like this
(it really is only to give a idea its not accurate)

There are several possibilities as to why this higher rate of death at lower rates might be.
For example in the lancet study. (and I'm sure there are lots of other interpretations)

1) people who are very ill and particularly with end stage renal problems have a lower HbA1c, this could skew the data.(it was death from all causes).
2) insulin is prescribed quite later or when other methods have 'failed' in type 2 diabetes in the UK.
a)it might be a case of too little too late, the insulin reduces the HbA1c but sometimes well after the complications have developed
b) it could mean that the medication itself was the problem(as Ian) suggests
3) The quality of data used in the study might itself be a problem (doctors records)

Just to show how confusing the data is (and why you can't make a blanket interpretation)
This slide shows some of the data from the ACCORD study. In this one there was a higher mortality rate in the intensive arm... this is the one medicated to achieve a lower HbA1c, but even in this arm there were fewer deaths than in other studies. Also in this intensive arm there was a reduced risk of non fatal complications.


Moral: people need to have targets based upon their indivdual circumstances. For some low levels will not be appropriate.

There is a line of thought that diabetes (particularly T1, with DAFNE) can be controlled by medication, while eating normally. That is where Hana & I & others take issue. A reduced carb diet will not have such adverse effects. Hana's husband has been T1 for many years

I really don't know what grounds you have for this statement. Using injected insulin in a way that attempts to mimick the natural functions of endogenous insulin seems to me to be a very sensible practice, where is the evidence for adverse effects?

 

[jopar]

There is a line of thought that diabetes (particularly T1, with DAFNE) can be controlled by medication, while eating normally. That is where Hana & I & others take issue. A reduced carb diet will not have such adverse effects. Hana's husband has been T1 for many years.

This isn't easy to maintain. I still have a taste for things Iknow I must not eat and going out to walk dogs a minimum of 3 miles each evening isn't always what I want to do. They used to make do with a mile. I also wish for a lie-in sometimes instead of getting up before 6 and going to the gym 3 mornings a week and walking the other days
Hana

Two quotes that says a lot indeed...

Sadly IanD is protraying a very missleading notion of T1 and DAFNE course, which suggests that if T1 choose to follow his say so, then we could stop insulin :lol: :lol: Total lack of understanding here.. Ian I think that you will find that Edvidence from DAFNE is suggesting that yes it's possible without adverse effects, and a improvement to the whole of the T1 quaility of life apart from improved diabetic control. I know I've been on DAFNE And Hana has just declared how hard going is it all is to follow there say so :roll:

This report just highlights how difficult it is for diabetic patient and there medical team to decide what is the patient best move forward, is it to leave there control in status quo or to increase medication further which will lead to the best outcome overall benefit of the patient...

T2 will always be difficult as in the main it hits later in life, when many life style choose have become ingrained, bad eating habbits are harder to break, it's more diffiuclut to maintain motivation or physically difficult to maintain a good level of exercise there are many factors involved in their outcomes...

Does the likes of Hana and Ian know better than our HCP, who after all actually know us, and have all our medical details and a very high degree of knowledge surrounding diabetes and the medication we take?

What happens when they can't no longer control their diabetes with exercise and mim medication alone, will they increase to a suitable amount or will they continue to be spitefull making accusations against their hcp's and make statmenets such as binging on insulin about those of us who decide we rather listen to our HCP's than them..

 

[noblehead]

There is a line of thought that diabetes (particularly T1, with DAFNE) can be controlled by medication, while eating normally. That is where Hana & I & others take issue. A reduced carb diet will not have such adverse effects. Hana's husband has been T1 for many years.

Ian, not quite sure what you mean by 'eating normally', surely eating normal is choosing a diet that best suits your own personal needs, so 'eating normally' is open to interpretation. The DAFNE approach doesn't advocate any type of diet or eating plan, it merely provides the education and guidance to better understand our own insulin to carb ratio, and by doing so achieve the best possible blood glucose control. The people who attend the course vary in their daily carbohydrate intake, some may eat a high, medium or low-carb diet, it doesn't matter whatsoever, what is important is that you correctly match your insulin to suit. Here is a extract from the DAFNE handbook given to all patients on the course:

''The DAFNE approach aims to help you to manage your blood glucose control by matching insulin to the carbohydrate foods you choose to eat. This, and not healthy eating, is the main consideration when attempting to achieve normal/near-normal blood glucose levels. Healthy eating becomes a personal choice''.


Nigel