Tag Archives: hemoglobin A1c

The Top-Viewed Posts of 2010

Well, it’s that time of year: A time for reflection, a time for too much fattening food and drink, and probably way too much togetherness with relatives you spend the rest of the year trying to avoid. Here at Notes From the Road, we’d like to take a moment to reflect on the bounty that medicine has provided us in 2010 by sharing our most-viewed posts, as nearest as we can determine.

Via Flickr Creative Commons user yoppy

10. Would an Artificial Pancreas be a Diabetes “Cure?” By Miriam E. Tucker

The Juvenile Diabetes Research Foundation’s announcement yesterday of a partnership with Animas Corp. and DexCom Inc. to develop a first-generation automated insulin delivery system brought to my mind a question that is often debated in diabetes circles: Would a fully automated “artificial pancreas” represent a “cure” for type 1 diabetes? (Read more.)

9. Placebos vs. Antidepressants: Not Quite a Draw By Bob Finn

There’s a fascinating study in today’s Journal of the American Medical Association. It’s a meta-analysis of randomized controlled trials comparing antidepressants vs. placebo. And it showed that the placebo effect is so strong in depression that placebos work as well as paroxetine (Paxil) and imipramine (Tofranil) for all patients except those with major depressive disorder that’s classified as “very severe.” Placebo tied active medication for “mild,” “moderate,” and even “severe” depression. (Read more.)

8. Tocilizumab Approval Causes Buzz by Diana Mahoney

One year after asking the Roche group to submit additional data for its monoclonal antibody tocilizumab, the FDA has approved the biologic agent for the treatment of moderate to severe rheumatoid arthritis. (Read more.)

7. Head Injuries Predict Persistent, Bad Headaches by Sherry Boschert

Like many of the neurologists attending the annual meeting of the American Headache Society, I slipped into the hotel lobby during breaks in the program to watch World Cup soccer in bits and pieces. The images of players heading the ball caught my eye in a new way after hearing a couple of presentations about the associations between head injuries and persistent, more frequent, and disabling headaches. (Read more.)

6. Using Hemoglobin A1C to Diagnose Diabetes: What’s Your Take? By Miriam E. Tucker

The American Diabetes Association’s decision earlier this month to officially endorse hemoglobin A1c as a diagnostic test for diabetes is either timely, inappropriate, or long overdue, depending on whom you talk to. (Read more.)

5. Can Hemoglobin A1C Go Too Low? By Miriam E. Tucker

A new study showing increased mortality among type 2 diabetes patients at hemoglobin A1c levels below 7.5% raises a new question: Should diabetes guidelines be revised to include a minimum hemoglobin A1c level? (Read more.)

4. New Clues to the Root of Basal Cell Carcinoma by Doug Brunk

Findings from a novel investigation published in the Jan. 5, 2010, edition of Cancer Prevention Research are helping researchers better understand what causes basal cell carcinoma tumors. (Read more.)

3. Rheumatoid Arthritis 5.0 by Mitchel Zoler

Rheumatologists have remade rheumatoid arthritis, a pretty big deal for them if only because it’s “the major systemic rheumatic disease that we as a specialty treat,” said Dr. Michael E. Weinblatt, a Harvard rheumatologist, at the end of a 90-minute session on Sunday afternoon that unveiled a new definition of rheumatoid arthritis to the world. (Read more.)

2. Doctors Attend to Burning Man by Sherry Boschert

Next week more than 40,000 people from around the world will migrate to Black Rock Desert in Nevada to create a week-long community where clothing is optional, illicit drugs are common, and fantastical artwork is everywhere. Dr. Marc Nelson will be one of them at an event called Burning Man. (Read more.)

1. Doctors: Help Them Understand That “It Gets Better” By Mark Lesney

Any growing tolerance of a person’s right to his or her own sexuality that is evidenced in the mainstream culture has yet to impact the Lord of the Flies scenarios that exist for gay, lesbian, bisexual, transgendered, or questioning students in many schools across the country—something that is comically but bitingly portrayed in the Fox hit series “Glee.” (Read more.)

Thanks for following us in 2010. We hope you’ll be back for more in 2011.

— Alicia Ault (on Twitter @aliciaault)

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Filed under Dermatology, Endocrinology, Diabetes, and Metabolism, Family Medicine, IMNG, Pediatrics, Primary care, Psychiatry, Rheumatology

Transatlantic Disagreements on Diabetes

Not surprisingly, the Avandia news was the big buzz at the meeting of the European Association for the Study of Diabetes (EASD) in Stockholm. Attendees I spoke with expressed surprise that although the U.S. Food and Drug Administration and the European Medicines Agency had made announcements on same day, their decisions were different: The EMA had suspended Avandia entirely from the European market while the FDA decided to keep it on the U.S. market with tight restrictions.

How could the European and American agencies have reviewed the same data yet come to different conclusions regarding risk/benefit? And which decision was right? There was much speculation and debate in the hallways at EASD.

European Union flag photo by openDemocracy via Flickr Creative Commons

Simultaneously, another transatlantic debate was taking place at the meeting.  This one, though less likely to make headlines, also has major implications for clinical practice worldwide.

Back in January 2010, the American Diabetes Association recommended the use of hemoglobin A1c for diagnosing diabetes, listing convenience and stability of the test among the advantages. The move was controversial, with many scientists citing data suggesting that sizable proportions of people with diabetes will be missed by using that test rather than either fasting glucose or an oral glucose tolerance test (OGTT), considered the gold standard.

At the EASD meeting, investigators from the U.K., Spain, Norway, France, Portugal, and the Republic of Korea presented data showing a lack of correlation between the tests, and either advised against or at least recommended caution in the use of A1c as a diagnostic.

Prof. George Alberti summarized an expert committee’s recommendation to the World Health Organization that glucose testing should remain the preferred diagnostic method, with A1c as an alternative provided that certain conditions are met. Both the WHO and the EASD are expected to issue positions soon.

American Flag photo by ayblazerman via Flickr Creative Commons

I asked Dr. M. Sue Kirkman, clinical affairs vice president at ADA, to comment. She said that the ADA had been aware of data showing that the A1c may be less sensitive and therefore would identify fewer people with diabetes than does the fasting glucose, which in turn detects fewer cases than does the OGTT.

She noted that the ADA didn’t advise against glucose tests. “If people want to use glucose tests, they certainly can. But the reality is that a quarter of people with type 2 diabetes in the U.S. are undiagnosed. If you have a test that doesn’t require fasting, that you do when the patient’s in your office—especially in populations with less access to medical care—we think in the real world you can actually diagnose more people.”

While there’s disagreement over diagnostics, at least there’s one point of agreement: Few if any of those patients will be treated with Avandia.

—Miriam E. Tucker (@MiriamETucker on Twitter)





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Filed under Cardiovascular Medicine, Drug And Device Safety, Endocrinology, Diabetes, and Metabolism, Family Medicine, IMNG, Internal Medicine, Primary care

Using Hemoglobin A1c to Diagnose Diabetes: What’s Your Take?

Photo courtesy of Flickr Creative Commons user Scribbletaylor

The American Diabetes Association’s decision earlier this month to officially endorse hemoglobin A1c as a diagnostic test for diabetes is either timely, inappropriate, or long overdue, depending on whom you talk to.

In its 2010 Standards of Medical Care in Diabetes, the ADA for the first time officially endorsed the use of HbA1c as one of four options for diagnosing diabetes, with a cut-point of 6.5% or greater. Recommendations for use of the three previous diagnostic criteria remain unchanged, including a fasting plasma glucose of 126 mg/dL or above, a 2-hour plasma glucose of 200 mg/dL or greater on the oral glucose tolerance test, or a random glucose of 200 mg/dL or greater in someone with classic symptoms of hyperglycemia.
Although some experts have been urging use of the HbA1c to diagnose diabetes for many years—citing its greater convenience, among other advantages—the lack of global standardization precluded a recommendation for doing so until recently, according to Dr. Silvio Inzucchi of Yale University, New Haven, Ct., who chaired the ADA ad hoc working group that wrote the guideline.

Use of HbA1c for diabetes diagnosis was initially endorsed as a consensus opinion last summer by an international expert committee. The ADA working group reviewed that paper and arrived at similar conclusions (except that ADA did not say HbA1c is the “preferred” test).

“There is an inherent attractiveness to using the A1c, since it measures glucose exposure over a long period of time, not just the specific instance of when the blood test is obtained. … In all, the recent guidelines gives practicing clinicians another tool to screen patients who are at risk for diabetes,” Dr. Inzucchi said.

But Dr. Zachary T. Bloomgarden of Mount Sinai School of Medicine, New York, said ADA’s move is “overall, not to my mind satisfactory.”  Although he says he believes HbA1c could be used to screen people who would then undergo further testing, he says its use as a stand-alone diagnostic test could lead to overdiagnosis of “high glycators” or underdiagnosis of “low glycators,” each of whom comprise about 10% of the population.

At the other extreme is Dr. Mayer Davidson of the University of California, Los Angeles, who has been advocating use of the HbA1c to diagnose diabetes for more than a decade.  In fact, he says he believes it should be the only test: “Unfortunately, the ADA kept the glucose criteria, which will lead to the confusing situation of people who have diabetes by one criterion but not by the other when both are measured, which is likely to occur frequently.”

So will the new endorsement change clinical practice? In a 2005 survey of 258 internists, 93.4% reported that they routinely screened for diabetes, 49% reported using HbA1c for screening, and 58% said they used it for diagnosis of diabetes. Interestingly, 49% mistakenly thought HbA1c was already an approved screening test (J. Clin. Endocrinol. Metab. 2008;93:2447-53).

–Miriam E. Tucker (@MiriamETucker on Twitter)

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Filed under Endocrinology, Diabetes, and Metabolism, Family Medicine, Geriatric Medicine, IMNG, Internal Medicine, Polls, Primary care

Glycemic targets: How low to go?

Photo by Uwe Hermann under a Creative Commons license.

Photo by Uwe Hermann under a Creative Commons license.

From the 2009 UCSF Diabetes Update and Advances in Endocrinology and Metabolism meeting.

Some recent reports from major trials and long-term follow-up of large diabetes treatment studies have sparked a lot of discussion about how low to try and push hemoglobin A1c levels in people with diabetes. Clinicians may be wondering whether intensive glucose control is safe and worth the effort, and in which patients, after tasting the alphabet soup of  recent findings — from the 10-year follow-up of the UKPDS to the ACCORD and ADVANCE studies, the VADT, and Steno-2, plus the 2009 joint statement on all this from the American Diabetes Association, American Heart Assocation, and American College of Cardiology.

Dr. Elizabeth Murphy, chief of endocrinology at San Francisco General Hospital, put it all in perspective. What to do differently? Not much. Aim for a hemoglobin A1c level below 7% for most patients. Consider lower targets for younger, healthier, newly diagnosed patients. Consider higher targets if the patient is expected to live less than 5 years, or has severe hypoglycemia, advanced complications, or other significant comorbid conditions. The American Association of Clinical Endocrinologists still recommends A1c targets below 6.5%, she added.

At conferences like this, spoon-feeding the blood sugar data helps the medicine go down…

— Sherry Boschert
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Filed under Endocrinology, Diabetes, and Metabolism, Family Medicine, Internal Medicine