ADA cut target HbAIC for children to 7%

Oct 31, 2021Aug 23, 2021 kaitiscotland1 Comment

More Stringent HbA1C Targets for Children and Adolescents with Type 1 Diabetes

Mar 2, 2021 Editor: David L. Joffe, BSPharm, CDE, FACA
Author: Adrian Gavre, PharmD Candidate, Philadelphia College of Osteopathic Medicine

What do the new ADA guidelines for HbA1C have to say about treating children and adolescents with type 1 diabetes?

Recently, the American Diabetes Association (ADA) recommended lowering the target hemoglobin A1C (HbA1C) guidelines for children with type 1 diabetes (T1D).

A study conducted by Redondo et al. has shown that stricter controls of HbA1C within this population resulted in improved patient outcomes. Specifically, it was revealed that chronically elevated blood glucose levels in children could lead to increased rates of several serious effects, such as abnormal brain development; cardiac issues including stroke, coronary, peripheral heart disease; and other diabetic complications, nephropathy, neuropathy, and retinopathy. Better control of blood glucose levels lowered these events’ incidence and improved mortality rates in children and adolescents with T1D. http://imasdk.googleapis.com/js/core/bridge3.476.0_en.html#goog_25686799Volume 0%

Regarding abnormal brain development, one meta-analysis (n=1619) showed that patients with T1D had lower inhibition, working memory, and executive function compared to control subjects. In a study regarding microvascular diseases, patients with lower HbA1C had a significantly lower risk of microvascular diseases than patients with higher HbA1C (mean Hba1C 8.06% vs. 9.76%). A study conducted by the Swedish National Diabetes Register found a risk over fourfold for all-cause mortality, over sevenfold for cardiovascular mortality, and elevenfold for cardiovascular disease in patients diagnosed with T1D under age ten compared to the control group.

Due to this study’s results, the ADA 2020 Standards of Medical Care recommends that children and adolescents with T1D target an HbA1C goal of less than 7%. This is a change from their 2019 guidelines, which had a target HbA1C goal of less than 7.5%.

The study suggests that more intensive insulin therapy is the preferred strategy to treat children and adolescents with T1D. Instead of simply treating a patient’s hyperglycemia with insulin, it would be more beneficial to more aggressively bring blood glucose levels to a normal range. More aggressive blood glucose treatment seems to be the best strategy that results in a lower incidence of diabetes-related complications and long-term organ damage.

However, caution should be used in this approach as more aggressive insulin therapy and lower HbA1C targets often result in a higher incidence of hypoglycemia. Symptoms of hypoglycemia are severe and can include dizziness, seizures, coma, and death. Despite this, the study has found that the incidence of hypoglycemia in children and adolescents with T1D has been steadily declining over the past three decades. The Danish Adult Diabetes Database (DADD) found an annual decrease of 8.4% in hypoglycemia incidence in children under 15 with type 1 diabetes from 1995-2016. Another similar study showed no significant difference in hypoglycemia rates in children who had an A1C <7% compared to children who had an A1C between 8-9% (n=1,770). Over this time, the lowered hypoglycemia rates coincide with innovations in drug therapies and technologies, such as insulin analogs, insulin pumps, and continuous glucose monitoring.

These innovative technologies make it easier than ever to keep a patient’s HbA1C within a prespecified range and reduce the risk of hypoglycemia. The ADA still recommends a target of 7.5% for patients too young to properly articulate hypoglycemic symptoms, or patients who do not have access to these innovative technologies. An HbA1C score of less than 8% is acceptable for patients with a severe history of hypoglycemia or a shortened life expectancy due to other pre-existing conditions.

Practice Pearls:

The ADA recently recommended lowering the target HbA1C from 7.5% to 7% for children with type 1 diabetes.
Lowering the target HbA1C in children and adolescents with type 1 diabetes reduces the risks of developing diabetic complications such as nephropathy, neuropathy, and retinopathy, abnormal brain development, and cardiac disorders, and improves mortality.
Although more aggressive insulin regimens can result in hypoglycemia, hypoglycemia rates in children and adolescents with type 1 diabetes have decreased over the past three decades due to innovative new technologies and therapies such as insulin analogs, insulin pumps, and continuous glucose monitoring.

Redondo, M, et al. “The Evolution of Hemoglobin A1c Targets for Youth With Type 1 Diabetes: Rationale and Supporting Evidence.“

Adrian Gavre, PharmD Candidate, Philadelphia College of Osteopathic Medicine  

Dr Gil Wilshire: Resource for women with polycystic ovary syndrome

Oct 25, 2021Aug 23, 2021 kaitiscotlandLeave a comment

*Dr Gil Wilshire has treated thousands of women with polycystic ovary syndrome over 30 years*

Dr Wilshire is a USA gynaecologist who recommends low carbing, also known as a reduced carbohydrate therapeutic diet, for his patients who wish to improve their weight, symptoms and fertility.

His You Tube Videos are collected here for your interest. Please feel free to recommend them to women you know who are afflicted. This is thought to be about one in ten women.

Don’t over treat blood pressure in the over 75s

Oct 19, 2021Aug 21, 2021 kaitiscotland2 Comments

The lowest mortality in people over the age of 75 occurred in those with a systolic blood pressure of 140-160 and a diastolic pressure of 80-90.

These figures are different than for the middle aged, young retirees and those with diabetes, who are often told to shoot for systolic BPs of 130 to 140.

It was reported Age and Ageing that an analysis of a primary care database that strict blood pressure control can actually be detrimental. Frail older adults do particularly poorly when their blood pressures are too low.

My comment: I remember doing four house calls in a row one warm summer’s day to see older adults, all at different addresses, who had collapsed from over treated blood pressure. None came to serious harm but they could have had fractures, sustained head injuries or collapsed in the street. I have read that a higher blood pressure in older life helps to perfuse the kidneys better. For many patients, they see nurses at nurse led clinics and lower blood pressures are not remarked on. They are told “good, come back in six months or a year”. They only see GPs when the blood pressure is considered to be too high. Instead, patients may be better to have realistic targets set by their GP depending on their age and ongoing health issues and check their blood pressure at home where it is less likely to be artificially raised by anxiety that is common in the health care setting.

Saving lives from cardiac arrest in young athletes

Oct 13, 2021Aug 21, 2021 kaitiscotland1 Comment

Adapted from BMJ Oct 10 2020

Ventricular fibrillation with cardiac arrest is the most common cause of death in young athletes.

Unless there has just been physical contact with another player it is best to assume that someone who collapses on a playing field should be considered to have had a cardiac arrest until proven otherwise.

Breathing can continue for half a minute after cardiac arrest and jerking of the limbs is common.

In this situation, begin chest compressions immediately and send for an automated defibrillator and ambulance crew.

My comments: Chest compressions are done to the Bee Gees “Staying Alive”. Don’t waste your time with rescue breaths as these don’t improve survival. Defibrillation is the key and survival reduces by 10% per minute post collapse.

From British Journal of Sports Medicine.

Omega 3 fatty acids are an easy way improve life expectancy

Oct 7, 2021Aug 21, 2021 kaitiscotland1 Comment

A study reported in the American Journal of Clinical Nutrition has found that the highest levels of omega 3 fatty acids found in red blood cells were strongly associated with corresponding increased life expectancy.

This was a longitudinal study over 11 years. People in the top 5th of the erythrocyte fatty acid group had a life expectancy of 5 years more than the people in the bottom 5th.

This is actually as strong an association with mortality and cardiovascular events as traditional factors such as blood pressure, serum lipids and diabetes.

It is never too late to stop smoking

Oct 1, 2021Aug 21, 2021 kaitiscotland1 Comment

There are far fewer smokers now and many have transferred from cigarettes to the more benign vaping devices. Everyone knows not to start or stop if they possibly can, particularly people with diabetes, cardiovascular and lung disease. But is there a point when stopping becomes pointless?

Researchers performed a prospective cohort study with 517 Russian smokers who had been diagnosed with early stage, non small cell lung cancer.

Life lasted a whopping 21.6 months longer in those who stopped smoking soon after diagnosis.