Glycaemic control, glucose variability and the Triangle of Diabetes Care

Abstract

The discovery of insulin turned a diagnosis of type 1 diabetes from a terminal condition to one that can be managed in a way that allows a full and fulfilling life. Optimal management of glycaemia plays a key role within the long-term management of diabetes. Indeed, the Diabetes Control and Complications Trial and the UK Prospective Diabetes Study established beyond doubt that intensive management of blood glucose (HbA1c) reduced the risk of long-term (especially microvascular) complications of the disease in type 1 and type 2 diabetes, respectively. Long-term observational follow up years or decades beyond these trials revealed a longer-term macrovascular benefit from these interventions. There is more to glycaemic control than the prevailing level of HbA1c, however. Variability of blood glucose within and between days promotes hypoglycaemic and hyperglycaemic episodes that may increase the risk of diabetes complications or adverse clinical outcomes and which certainly impair patients' quality of life and confidence in managing their insulin regimen. The Triangle of Diabetes Care has emerged as a useful concept here, bringing together the need to improve glucose levels, but also to avoid hypoglycaemia and to reduce glucose variability. Continuous glucose monitoring is a particularly valuable tool for addressing glycaemic variability, but patients and healthcare professionals can be swamped by the large amount of data that it generates. Advanced glucose profiling provides a means of producing a straightforward, visual representation of daily glucose profiles over a number of days that can help to pinpoint the changes in the insulin regimen needed to optimise blood glucose control.Br J Diabetes 2016;16(Suppl1):S3-S6

Efficacy and safety of a morning injection of insulin glargine 300 units/mL versus insulin glargine 100 units/mL in adult patients with type 1 diabetes: A multicentre, randomized controlled trial using continuous glucose monitoring

“…Therefore, a patient may appear to be well controlled according to HbA1c levels, yet have frequent episodes of hyperglycaemia and hypoglycaemia as the result of large variation in blood glucose levels on a daily basis . Reducing excessive fluctuations in blood glucose levels (glycaemic variability) is becoming increasingly recognized as an important aspect of appropriate glycaemic control, especially in type 1 diabetes (T1D) . Continuous glucose monitoring (CGM) metrics, such as the amount of time during a 24‐hour period when glucose is within a target range (ie, time in range), are becoming key to optimal diabetes management.…”

“…4 Reducing excessive fluctuations in blood glucose levels (glycaemic variability) is becoming increasingly recognized as an important aspect of appropriate glycaemic control, especially in type 1 diabetes (T1D). 5 Continuous glucose monitoring (CGM) metrics, such as the amount of time during a 24-hour period when glucose is within a target range (ie, time in range), are becoming key to optimal diabetes management. Time in range, evaluated together with time in hyperglycaemia and hypoglycaemia and with glucose variability, provides a more accurate reflection of overall glycaemic control than HbA1c.…”

Day‐to‐day fasting self‐monitored blood glucose variability is associated with risk of hypoglycaemia in insulin‐treated patients with type 1 and type 2 diabetes: A post hoc analysis of the SWITCH Trials

“…High day‐to‐day glycaemic variability exposes patients to risk of hypoglycaemia and is a frustrating issue for patients, particularly for patients treated with insulin . Although there may be debate about the most accurate metric for measuring glycaemic variability, one can expect that improved and simpler techniques will become more widely adopted when continuous glucose monitoring is more widely applied in research and clinical practice.…”

“…[13][14][15] High day-to-day glycaemic variability exposes patients to risk of hypoglycaemia and is a frustrating issue for patients, particularly for patients treated with insulin. 16 Although there may be debate about the most accurate metric for measuring glycaemic variability, 9 one can expect that improved and simpler techniques will become more widely adopted when continuous glucose monitoring is more widely applied in research and clinical practice. Nonetheless, the consolidated evidence to date supports the importance of both the magnitude and duration of glucose variability 9 with respect to increased risk of hypoglycaemia, regardless of the method of variability measurement.…”

Glucose Control in Diabetic Patients Attending Parirenyatwa Group of Hospitals in Zimbabwe

“…Good glycaemic control is defined as HbA1c less than 7% (53 mmol/mol), while HbA1c greater than or equal to 7% represents poor glycaemic control in patients with diabetes mellitus [12,13]. There is evidence that good glycaemic control in diabetic patients can be achieved when patients are educated about the disease and become compliant [11,14].…”