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REPRINTED FROM AUSTRALIAN FAMILY PHYSICIAN VOL. 43, NO. 9, SEPTEMBER 2014 611
CLINICAL HbA1c, blood glucose monitoring and insulin therapy
meals, during the day and overnight. The result of achieving lower glycaemic levels in the will exceed 7%). The source of glycaemic
is reported either as a percent of the total short and long term for that patient (Table 2). variability should be addressed (eg variable
haemoglobin or as a molar proportion (mmol/ The general target for glycaemic control is an lifestyle, therapeutic non-adherence,
mol). There is a simple relationship between HbA1c ≤7%, equivalent to an avBG of 8 mmol/L incorrect use of insulin or incorrect BGM
the two measures of HbA1c and the avBG: for and a prepBG of 7 mmol/L. technique).
each 1% change in the HbA1c percentage, the The Australian Diabetes Society 2. Is prepBG consistent with the HbA1c? If not:
HbA1c changes by 11 mmol/mol and the avBG recommends individualising targets for HbA1c • Is the BG profile misleading?
changes by 2 mmol/L (Table 1). Laboratories on the basis of duration of diabetes, presence –– Compare the patient’s records with
report HbA1c measurement in terms of of cardiovascular disease and hypoglycaemic readings held in the meter memory.
both percentage and mmol/mol. This article risk (Table 3).5 –– Check BGM technique.
illustrates the principles of interpretation using –– Compare the patient’s BGM values
the HbA1c percentage measurement. HbA1c, blood glucose immediately before and after fasting
• The avBG over 24 hours is given by the monitoring and insulin blood is taken for laboratory glucose
formula: therapy analysis (Table 5).7
avBG mmol/L = 2HbA1c% – 6 Blood glucose monitoring (BGM) assesses the • Is there hidden hyper- or hypoglycaemia
• The prepBGs (before breakfast, lunch and relevant blood glucose at each step: fasting, that explains lower or higher observed BGM
the evening meal) are approximately 1 before the evening meal and, if needed, before values than those expected from the HbA1c?
mmol/L lower than avBG, which reflects the midday meal, after the evening meal or –– Check blood glucose levels at midday,
both basal and prandial glycaemia: during the night. In practice, the steps are after the evening meal and during the
Preprandial mmol/L = 2HbA1c% – 7 (Table 4 ): night (eg 0200).
For example, if the HbA1c is 6%, the HbA1c 1. Is prepBG highly variable? (eg average • Is the HbA1c misleading?
in mmol/mol is 42 mmol/mol, the avBG is swings wider than ± 3 mmol/L around –– Consider whether patient-related factors
6 mmol/L and the prepBG is 5 mmol/L. the mean allowing for an exceptional but could be causing HbA1c values to be
explicable prepBG). If so, adjusting insulin different from that expected from avBG5
Setting glycaemic targets therapy to achieve prepBG ≤7 mmol/L is (eg shortened red cell survival causing
Targets should be set in collaboration with likely to cause hypoglycaemia and overall anaemia and lower HbA1c values). Ask
the patient, balancing the benefits and costs glycaemic targets will not be met (HbA1c the laboratory if their assay could cause
the discrepancy you observe. If so, ask for
the HbA1c to be measured by a different
24 Hour Blood Glucose Profile method that will give the actual value.
Prandial
3. Are the fasting blood glucose and the
evening prepBG on target? If not:
20 20
• Add or adjust the nighttime and/or morning
Plasma glucose (mmol/l)
Plasma glucose (mmol/l)
Daytime basal
basal insulin accordingly.
Increment
4. Is the HbA1c on target (after 6 weeks of
fasting blood glucose and prepBG being on
target)? If not:
10 10
Fasting
• Look for and correct any hidden hypers after
meals and/or during the night.
5. Is the ongoing 3-monthly HbA1c on target?
If not:
0600 1000 1400 1800 2200 0200 0600 • Re-assess the blood glucose profile and
Time of day (hours) return to step 1 (as above).
Hirsch IB et al. Clin Diab 2005; 23: 78-86
*In a person with diabetes (average BGL 16.9 mmol/L) Adapted from Phillips PJ. Medicine Today 2008; 9(10): 43-48
*This is the average BG profile of a cohort of patients with type 2 diabetes about to start insulin therapy.
Generally there are three components to the BG profile:
Case. HbA1c, BGM and
• The fasting baseline insulin in practice
• A gradual rise in the pre-prandial BG between breakfast and the evening meal
• The prandial increments above the pre-prandial BGs
Over the past 2 years Mr JR’s HbA1c has
increased from 7.4 to 8.9%.
Figure 1. Components of 24-hour blood glucose profile
On your advice, Mr JR has decided to
Adapted with permission from Phillips PJ. Getting A1c under 7% – the KISS (‘keep insulin
safe and simple’) approach in type 2 diabetes. Med Today 2008; 9(10):43-48. start insulin treatment. Mr JR’s prepBG
profile is shown in Table 6.
612 REPRINTED FROM AUSTRALIAN FAMILY PHYSICIAN VOL. 43, NO. 9, SEPTEMBER 2014
HbA1c, blood glucose monitoring and insulin therapy CLINICAL
Question 4
Table 3. Individualising glycaemic targets5
What is your response?
Clinical situation HbA1c target (%)
Answer 3 General target ≤7.0
Mr JR’s prepBG is on target, but his evening Pregnancy or planning pregnancy ≤6.0
prepBG is high. Short duration diabetes and no CVD:
• Low risk of hypoglycaemia ≤6.0
Answer 4 • At risk of hypoglycaemia† 6.5–7.0
Start a second morning basal dose of 10 units Longer duration diabetes or CVD ≤7.0
and titrate the basal insulin before breakfast and High risk of hypoglycaemia ≤8.0
bed to achieve prepBGs before breakfast and the Limited life expectancy Symptomatic control
evening meal 6–7 mmol/L. Derived from the Position Statement of the Australian Diabetes Society6
†Sulphonylurea therapy ≤6.5; insulin therapy ≤7.0
Three months later Mr JR’s HbA1c is 7.1%.
CVD, cardiovascular disease
His prepBG profile is shown in Table 6.
REPRINTED FROM AUSTRALIAN FAMILY PHYSICIAN VOL. 43, NO. 9, SEPTEMBER 2014 613
CLINICAL HbA1c, blood glucose monitoring and insulin therapy
Question 5 • Glycaemic targets should be negotiated • Interpreting the HbA1c and blood glucose
How do you interpret the blood glucose profile? with each patient and guided by guidelines profile requires assessment of the variability
published by the Australian Diabetes Society of prepBG; the consistency of the values of
Question 6 with the usual target being HbA1c ≤7%. the blood glucose profile and the HbA1c;
How do you respond?
614 REPRINTED FROM AUSTRALIAN FAMILY PHYSICIAN VOL. 43, NO. 9, SEPTEMBER 2014
HbA1c, blood glucose monitoring and insulin therapy CLINICAL
whether the morning and evening prepBG 4. Phillips PJ. Getting A1c under 7& – The KISS (‘keep
insulin safe and simple’) approach in type 2 diabe-
and HbA1c are on target; and ongoing tes. Med Today 2008;9:43–48.
3-monthly HbA1c values. 5. Phillips PJ. HBa1C and monitoring glycaemia. Aust
Fam Physician 2012;41: 37–401.
Authors 6. Craig ME, Twigg SM, Donaghue KC, et al for the
Australian Type 1 Diabetes Guidelines Expert
Patrick J Phillips MBBS, MA, FRACP,
Advisory Group. National evidence-based clinical
MRACMA, GradDipHealthEcon, Consultant guidelines for Type 1 diabetes in children, adoles-
Endocrinologist, Queen Elizabeth Specialist cents and adults. Australian Caberral: Department
Centre, Adelaide, SA. pat.phillips@me.com of Health & Ageing, 2011.
Stephen Leow MBBS, General Practitioner with 7. Phillips PJ. Guessing glycaemia. Med Today
2003;4:79–80.
a special interest in diabetes, Adelaide, SA 8. NPS MedicineWise. HBA1c unit converter tool
Competing interests: None. for type 1 diabetes. Available at http://www.
nps.org.au/conditions/hormones-metabolism-
Provenance and peer review: Not commis-
and-nutritional-problems/diabetes-type-1/
sioned; externally peer reviewed. for-individuals/tests-and-monitoring/hba1c-unit-
converter [Accessed 29 July 2014].
References
1. Phillips PJ, Twigg SM. Type 2 diabetes – which
BGLs matter? The fasting, pre- and postprandial
glycaemia debate. Aust Family Physician 2008;137:
929–31.
2. Hirsch IB, Bergenstal RM, Parkin CG, Wright Jr E,
Buse JB. A real-world approach to insulin therapy
in primary care practice. Clin Diab 2005;23:78–86.
3. Phillips PJ. KISS: Keep insulin safe and simple.
Part 1: Initiating insulin in type 2 diabetes. Med
Today 2007;8:23–34.
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