Paradigm shift in Diabetic care. Dr.R.V.S.N. Sarma, M.D., M.Sc.,. Once there was a tiger which boasted that it can run faster than any one. One day he chased a rabbit and failed to catch it. “All right” said the tiger; “of course I failed on my boast.
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Dr.R.V.S.N. Sarma, M.D., M.Sc.,
One day he chased a rabbit and failed to catch it.
“All right” said the tiger; “of course I failed on my boast.
But, remember the rabbit was running for its life and I, for my dinner.”
Now, decide who is the rabbit and who is the tiger - among we and our patient !How true ?
“The greatest burden on doctors will be not the management of diabetes, but the associated macro and micro- vascular complications of it.” ..1926
“The goal of therapy in diabetes should be to make serious efforts to keep the blood sugar levels as close normal as possible.” ….. 1929Dr.E.P.Joslin
I am making India the capital of the world shortly ! management of diabetes, but the associated macro and micro- vascular complications of it.” ..1926
Already I have a big… family of 200 millions on the globe.
I am happily troubling 12% urban and 8.2% of rural Indians.
In my name I am sweet but my effects are very hot !
I am not easily controlled (< 45%)Be serious Doctor
Haemoglobin management of diabetes, but the associated macro and micro- vascular complications of it.” ..1926
Structure of Hb
Fetal Hemoglobin – Hb F management of diabetes, but the associated macro and micro- vascular complications of it.” ..1926
Adult Hemoglobin – Hb A
Sickle cell disease – Hb S
Hemoglobinopathies – Hb C, Hb E
Glucose in the blood reacts with the
Hemoglobin A to form Glycated Hb.Different Hbs
Different types of Glycation products are formed from the HbA0 depending on the carbohydrate moiety – namely
HbA1a1 - Fr 1,6 diphos –N-term. valine
HbA1a2 - Gl 6 phos –N-terminal valine
HbA1b - Other CHO – N-term. valine
HbA1c - Glucose –N-terminal valine
Normally less than 6% of Hb is HbA1c
Glycated Hb - GHb
(Previously called glycosylated Hb.)
6 to 7.5% - Good control of DM
7.6 to 9% - Unsatisfactory control
More than 9% - Very poor controlReference values ofHbA1c
Values depend on the method of estimation
They vary from lab to lab.
Note if all GHb is measured instead of HbA1c
Life span of the RBC
Abnormal Hb like S-Hb, Hb C
Serum opalescence -↑TG
On the method of estimationFactors affecting HbA1c
HPLC (High Performance Liquid Chromatography) – Gold standard.
Immuno-turbimetric meth. – HbA1cAb
Method based on chemical reactions.Estimation of HbA1c
Lowering Hb A1c reduces risk of complications
Advantages of HbA HbA1c
Limitations of HbA HbA1c
Mean HbA BG mg %
Correlation of MPG - HbA1c
Mean Plasma Glucose =
(33.3 x HbA1C%) - 86
(Nathan et. al. NEJM, vol. 310, No 6, Feb 9, 1994)
BMJ, 1996, vol. 288 pp. 669-670
“Blood Glucose 80 min. after breakfast correlates with MAGE
( Mean Amplitude of Glycaemic
Excursions ) throughout the day”
Molnar et. al.