HbA1c and Glucose Management Indicator Discordance: A Real-World Analysis

Perlman, Jordan E.; Gooley, Theodore A.; Mcnulty, Bridget K.; Meyers, Jedidiah; Hirsch, Irl B.

doi:10.1089/dia.2020.0501

Cited by 60 publications

(52 citation statements)

References 19 publications

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“…Key elements of the analysis of glucose combined with insulin data are shown in Figure 1. This includes summaries of glucose metrics (panel A) showing results for mean glucose, variability (%Coefficient of Variation [%CV]), 52 estimates of Hemoglobin A1c (HbA1c) calculated from glucose data such as the glucose management indicator (GMI) 53 or alternative approaches with better accuracy, [54][55][56][57] percentages of time in several ranges (time in range [%TIR]), time below range (%TBR, levels 1, 2, and combined), time above range (%TAR, levels 1, 2, and combined); insulin metrics 38 such as total daily dose, basal insulin dose, average bolus doses for the three major meals, and correction boluses to correct for elevated glucose levels shown as a stacked bar chart 51 (panel B); a combined graphical display of glucose patterns (10th to 90th percentiles) superimposed on the desired target range and average insulin doses and timing shown below the time axis (panel C) [40][41][42][43][44][45][46][47][48][49] ; user experience including metrics for extent of usage of CGM and connected insulin pens, frequency of alerts for hypo-and hyperglycemia by time of day, number of bolus doses and missed boluses, frequency of major and minor overrides of bolus doses estimated by a bolus dose calculator, information regarding meals, physical activity, and sleep patterns to the extent that they are available (panel D); and clinical interpretation and insights (panel E). These insights will be driven by the logic built into an analytical software program.…”

Section: Resultsmentioning

confidence: 99%

Standardizing Reporting of Glucose and Insulin Data for Patients on Multiple Daily Injections Using Connected Insulin Pens and Continuous Glucose Monitoring

Rodbard

Garg

2021

Diabetes Technology & Therapeutics

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Background: Recent development and availability of several connected insulin pens with digital memory are likely to expand the availability of glucose and insulin metrics that previously had been available only for the much smaller number of people using insulin pumps. It would be highly desirable to standardize data presentations to avoid the chaotic emergence of multiple formats that might reduce the clinical utility of connected pens. Methods: We reviewed the literature and analyzed data displays from multiple blood glucose monitoring, continuous glucose monitoring (CGM), insulin pump, and automated insulin delivery systems, and methods for combination of glucose and insulin data. We examined multiple forms of presentation and now propose a prototype for a standardized method for data analysis and display, focusing on the content and format of a onepage dashboard summary for patients on multiple daily injection (MDI) insulin regimens. Results: We propose the following metrics to be included in the one-page report: (A) glucose metrics: simplified glucose distribution in the form of a stacked bar chart showing percentages of time below-, above-, or within-target ranges overall and (optionally) by date, by time of day, or day of the week; (B) insulin metrics: types and doses, and timing of basal and bolus insulin; (C) an enhanced ambulatory glucose profile or ''AGP+'' showing glucose data points and/or distributions (10th to 90th percentiles), dosages and timing of basal and bolus insulins and (optionally) graphical display of risk of hypoglycemia and hyperglycemia; and (D) user experience regarding technology usage, frequency of alerts for hypo-and hyperglycemia, and information regarding lifestyle, meals, exercise, and sleep, if available; and (E) clinical insights and interpretation. Conclusion:We propose a prototype for a dashboard summary report of glucose, insulin, meals, and activity data intended for providers and patients on MDI using connected pens and CGM. Our goal is to stimulate development of a standardized approach.

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Section: Resultsmentioning

confidence: 99%

Standardizing Reporting of Glucose and Insulin Data for Patients on Multiple Daily Injections Using Connected Insulin Pens and Continuous Glucose Monitoring

Rodbard

Garg

2021

Diabetes Technology & Therapeutics

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“…Indeed, in a study of 64 dialysis patients with diabetes who underwent concurrent glycemic assessment by HbA1c and CGM, mean blood glucose levels estimated from HbA1c levels were lower than the CGM‐measured glucose values 23 . Even in the absence of CKD, the association of mean glucose to HbA1c may show wide variation 15,24 . Furthermore, there are racial differences in glycation, such that HbA1c levels tend to overestimate mean glucose concentrations in Black persons compared with White persons 25 .…”

Section: Discussionmentioning

confidence: 99%

Continuous glucose monitoring in an end‐stage renal disease patient with diabetes receiving hemodialysis

Narasaki

Park

You

et al. 2021

Seminars in Dialysis

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Diabetes is the leading cause of end‐stage renal disease (ESRD) and contributes to heightened morbidity and mortality in dialysis patients. Given that ESRD patients are susceptible to hypoglycemia and hyperglycemia via multiple pathways, adequate glycemic monitoring and control is a cornerstone in diabetic kidney disease management. In ESRD, existing glycemic metrics such as glycated hemoglobin, self‐monitored blood glucose, fructosamine, and glycated albumin have limitations in accuracy, convenience, and accessibility. In contrast, continuous glucose monitoring (CGM) provides automated, less invasive glucose measurements and more comprehensive glycemic data versus conventional metrics. Here, we report a 48‐year‐old male with ESRD due to diabetes receiving thrice‐weekly hemodialysis who experienced decreased patient‐burden, greater glucose monitoring adherence, improved glycemic parameters, and reduction in hypoglycemia after transitioning to CGM. Through this case, we discuss how CGM is a practical, convenient patient‐centered tool that may improve metabolic outcomes and quality of life in ESRD patients with diabetes.

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“…In a study of 621 encounters, 91% with patients having type 1 diabetes, HbA1c estimated from continuous glucose monitoring analysis was within 0.1% of measured HbA1c in 11% of patients, but there were discrepancies of 0.5% or more in half, of 0.7% or more in one third, and of 0.9% or more in one quarter of patients 8 . It is important for the clinician to realize that HbA1c may not show the same relationship with mean glycemia in all persons 9 .…”

Section: Limitations Of Hba1c In Reflecting Mean Glycemiamentioning

confidence: 94%

Use of HbA1c in clinical practice: New insights

Bloomgarden

2021

Journal of Diabetes

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HbA1c and Glucose Management Indicator Discordance: A Real-World Analysis

Cited by 60 publications

References 19 publications

Standardizing Reporting of Glucose and Insulin Data for Patients on Multiple Daily Injections Using Connected Insulin Pens and Continuous Glucose Monitoring

Standardizing Reporting of Glucose and Insulin Data for Patients on Multiple Daily Injections Using Connected Insulin Pens and Continuous Glucose Monitoring

Continuous glucose monitoring in an end‐stage renal disease patient with diabetes receiving hemodialysis

Use of HbA1c in clinical practice: New insights

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