Should Geezers run Higher A1c's?

Thank you so much for these links.

I’m no longer on the sulfonylureas. I’m only on Tresiba 80 units/night.

I’ve never had a hypo. My lowest readings were mid 60s. I felt no symptoms then, but I don’t want to risk hypos. My goal is to stay in or above the 90s.

So far, so good.

Edd, there is no reason why you shouldn’t have a CGM. Your physician sounds like a control freak. I am glad that you have been firm with her, because she really doesn’t seem to have your best interest at heart, even though she may think that she does.

I am glad to see you here.

I hope that you will consider getting a different physician.

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Since we are talking about “Geezers” here, I suspect that the original poster is on Medicare. If so, she/he would not be eligible for CGM coverage under Medicare. There was a recent announcement that Medicare will not longer require 4 BG tests per day as a requisite for CGM coverage. https://www.medtechdive.com/news/cms-opens-up-cgm-coverage-abbott-dexcom/602047/?fbclid=IwAR07wU0V6gUmvGA69lomm3IcXK34i6x1ezNxAh1YDLQcyyDDbUj2aCaR_QY

But the current guidelines still require intensive insulin therapy which is defined as 3 or more injections per day or an insulin pump. This is Dexcom’s list of requirements for CGM coverage by Medicare (but you can now remove the 4 tests per day requirement). https://www.dexcom.com/faqs/medicare

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That’s kind of you to say. :slight_smile:

I just try buying an at home A1C test out of stock , pick up or mail order. Just like everything else I guess. Plus Walgreens wanted $43.00 . Nancy50

You have to tell the doctor what you are doing. I wouldn’t vary the dose to what you eat. That isn’t the job of Tresiba, basal. You could mess up badly one night. When the basal is set right, there is very little change and none for what you eat

You would be better adding a meal time insulin, bolus.
I would ask to attend an insulin course at the hospital, or where they are run in your area.

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This is the conventional wisdom, basal is not meant to be used for fine control, it is background insulin. Fast acting mealtime (bolus) insulin is meant for fine control. The idea is to return your higher post meal blood glucose levels to normal or near normal levels as soon possible without the need to raise slow acting (basal) insulin rate to compensate over a longer period of time, overnight in your case.

The problem is that the conventional wisdom is not always applicable in T2s. There is a third type insulin often involved, the insulin ones body may still produce. And then there is the problem of insulin resistance. Add all this together in highly varying combinations and the conventional wisdom often flies out the window.

Basal only insulin regimes tend to work well when beta cells first become over taxed due to insulin resistance, it gives them the little bit of help they need.

All of this was a long way of say if it works for you, it works, why change.

I went back and re-read your original post and found this statement to be quite interesting. Maybe I have been under a rock but switching from glimepiride to insulin (Tresiba) to prevent lows seems counterintuitive. While glimepiride is a long acting sulfonylurea not recommended in elderly because of possible hypoglycemia I don’t see how insulin is safer in that respect. I would have expected other oral or injectable agents to be tried before insulin.

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I’ll let you read the “CONSENSUS STATEMENT” Gary and see if they think it’s a good idea.

close the popup

I would do a ‘miss a meal’ basal test and see what is my true base level

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I get what you are saying Jack. What he is doing is not ideal. Bolus insulin and a lower basal rate is the conventional wisdom for a reason.

The more I think about it Jack the more I realize that you are correct and how what Edd is doing could go wrong.

Edd currently has his basal set too high, he is having morning lows in the 60s if he does not reduce his basal when he goes to bed with near average bg reads. he did not say so but I gather he is injecting his full basal when his bedtime reads are higher. Edd has said he has had no lows but 60 is low and if he was 60 fasting what was he at 3 am, possibly lower?

Edd appears to be a numbers man and he is working it pretty well but we all know that diabetes plus insulin doesn’t always add up as it should.

Ideally Edd should be following the conventional wisdom and be compensating for what he eats with bolus insulin and be back to near normal while he is still awake so he has a chance to correct for dosing errors instead of compensating at bedtime with the wrong insulin and possibly suffering worse lows while he is asleep and can do nothing about it. If bolus insulin is done right a smaller basal will be needed to cover background needs.

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I am a 70 y.o.with type one for 42 years. I am also a retired physician (not an internist or endo). I think an important point has been entirely missed. The greatest risk to intensive treatment of diabetes with insulin is hypoglycemia. The consequences of severe hypoglycemia increases with age. Older brains probably suffer more damage from low sugars. Also hypoglycemic events such as falls and auto accidents become more severe with age. The real question as to how low a patient should keep their a1c depends not just on their age but also on their past history of hypoglycemia. Have there been consequences in the past? Do they have a history of hypoglycemic unawareness? Do they have a reliable support system? The benefits of lowering an a1c must be weighed against the risk of increasing the risk of a serious hypoglycemic event. A good endo would discuss this decision with the patient. It is true that sometimes physicians worry more about the adverse consequences of their treatment than of the disease but both need to be considered. I am concerned about the tone of some of the posts that a lower a1c is always better. There are studies that show hypoglycemic events do increase significantly with lower a1c. The point is the risk vs.benefits of glucose management in that particular patient must always be considered and discussed with them.

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While I don’t doubt the the veracity of this, I’m wondering when, if ever, clinicians will recognize the importance of CGM adoption in the elder cohort and the central role that glucose variability plays in the incidence of severe hypoglycemia.

Instead of the reflexive formulaic response of cautioning any senior with an A1c under 6.5%, practitioners should withhold their warnings until they can discover how much their patient’s glucose swings each day. CGM use can reveal variability through its measurement of standard deviation and coefficient of variation (SD/mean glucose).

Lower variability enables a lower average and leads to a lower A1c. Counseling based on an A1c level alone is flawed. It catches people like me who enjoy an A1c in the low 5% range but only spend minutes per day in the serious hypo range and the CGM provides more than enough warnings to take effective counter-action. These hypos often only require 1/2 to 1 glucose tab to fix.

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Kenneth_Brooks. I think that you have made some very good points, but those of us here, who run very low A1c’s, are very educated about our diabetes and are comfortable with our decisions to live this way.

I haven’t had a non diabetic Alc in close to 20 yrs. My last Alc was 4.8. I am 70 and have been a type 1 since 1959. I am still very aware of any lows. I wouldn’t think of driving a car when I have a lower than 80 glucose level. I also have a very supportive husband.

After the faulty ACCORD study findings were released, my GP at the time insisted that my A1c should be no lower than 6.5.
I thought that was ridiculous, so I found a GP who trusted my experience and knowledge about my disease and just wrote me prescriptions for insulin. I haven’t consulted a physician about my diabetes in 30 yrs. My present GP said recently that I should write a book.

I have only been in the hospital because of diabetes once and that was when I was diagnosed in 1959. I have only had a handful of times when I have needed the help of another person when I was hypoglycemic. What I want from a physician is respect for how I have handled my disease and for the knowledge that I have about it.

We don’t want to be treated like the average diabetic patient is treated.

I don’t think any of us here with low a1c’s are having issues with severe hypoglycemia.

I think that for the average diabetic the discussion about A1c’s and the danger of hypoglycemic events is warranted.

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Agree that having CGMS reduces risk to serious lows, and different A1C targets could be appropriate for each individual based on cgms use and other factors.

I’m ok with stating an “average” A1C goal, as long as each person (and doctor) considers what is best in each situation.

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I believe that reliance on the A1c number for any patient to build essential glucose management tactics is flawed. The A1c number is recognized by experts as a valid representation of a population’s glycemia. In the case of any individual patient, her/his A1c may misrepresent the actual glycemia they experience.

My A1c rides about 0.5% above my actual glucose experience as recorded by a CGM. Ironically, that error protected me from past clinicians who are hyper-phobic of hypoglycemia. What if I were a patient with an A1c that rides 0.5% lower than actual?

That could mean an actual average glucose corresponding to say, a 6.0% A1c, yet the number the doctor sees is 5.5%. That level of A1c is scary enough to the average clinician to advise backing off glucose management practices.

The A1c can serve as a rough gage of glycemia when CGM data is absent. When CGM data is available, I suggest that the A1c should play no determinative role in clinical decisions.

I don’t expect this position to be accepted by clinicians in general but do expect that they will eventually gravitate to this realization over years, even decades.

I do not request that my diabetes clinician order an A1c as I don’t think it’s useful or needed. My doctor has more than enough data from my CGM to understand the glycemia that I live with. I will comply with getting an A1c if my doctor insists, but I’ll only do that with one eye on getting prescription support.

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Kenneth’s argument is not at all related to the ACCORD study, and I think his warning note is highly relevant and persuasive. There is a tendency for these forums to become echo chambers where extreme behavior is rewarded, and his note of caution, that an ever lower A1c is not always better, especially as someone ages, is right on target.

He is not saying to give up on closely managing BG, in fact he keeps an A1c of about 6 using a Tandem APS pump. As he points out, there is currently NO clinical data suggesting A1c lower than this is any better in outcome, but there is clinical data suggesting it is worse.

If you can maintain an A1c less than that without hypoglycemia risk and without becoming a slave to BG management then by all means do it. But a reminder that doing this is not necessary, and possibly even detrimental, is good to see.

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I would love to see the studies. Could you please site them, so I can look at them? I am certainly willing to change my mind, if I see good evidence.

All type 1s should try to get a cgm. It is a life saver.

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The problem as I see it is not the current A1c of 6.5% that he has, but that Edd is inexperienced not following basal titration procedure.

He is trying to use it as a corrective evening bolus, Changing doses between 40 and 80U depending what his evening BG is.
The prescribed 80U seems too much and is causing lows into the 60’s and may need to be titrated down.

Edd isn’t keeping the doctor informed and so she is unable to help titrate his basal and perhaps to introduce a bolus, for meal times and corrections. My concern is that trying to use Tresiba, a 42 hr basal to do this, could lead to a bad dosing error.

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