Paradigm shift in Diabetic care
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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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Paradigm shift in Diabetic care

Dr.R.V.S.N. Sarma, M.D., M.Sc.,

Dr.Sarma@works


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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.

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 ?

Dr.Sarma@works


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“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.” ….. 1929

Dr.E.P.Joslin

Dr.Sarma@works


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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

Dr.Sarma@works


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Haemoglobin management of diabetes, but the associated macro and micro- vascular complications of it.” ..1926

Structure of Hb

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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

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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.)

Dr.Sarma@works


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Less than 6% - Normal HbA

6 to 7.5% - Good control of DM

7.6 to 9% - Unsatisfactory control

More than 9% - Very poor control

Reference values ofHbA1c

Values depend on the method of estimation

They vary from lab to lab.

Note if all GHb is measured instead of HbA1c

Dr.Sarma@works


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Acute hyperglycemia HbA

Severe aneamia

Gestational diabetes

Life span of the RBC

Abnormal Hb like S-Hb, Hb C

Serum opalescence -↑TG

On the method of estimation

Factors affecting HbA1c

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There are many methods of estimation HbA

HPLC (High Performance Liquid Chromatography) – Gold standard.

Immuno-turbimetric meth. – HbA1cAb

Affinity chromatography

Electrophoretic methods

Method based on chemical reactions.

Estimation of HbA1c

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HbA HbA1cis ‘weighted’

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How well it measures ? HbA

Lowering Hb A1c reduces risk of complications

Dr.Sarma@works


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Advantages of HbA HbA1c

  • Index of long-term control over 120 days and not a snap shot like PG

  • Can be done at any time of day

  • Not influenced by diet, exercise, emotional disturbances on test day

  • Useful index in clinical trials

  • Useful if missed drugs / default diet

  • Useful in DD of stress hyperglycemia

Dr.Sarma@works


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Limitations of HbA HbA1c

  • Cannot be an emergency room test to titrate Insulin or OHA dosage

  • Cannot register hypoglycemia

  • More sensitive to sin than repentance – if it is elevated it confirms poor control, if it is boarder line, it cannot assure good control in the recent past.

  • Not sensitive enough for use in GDM

  •  Anaemia, Uraemia, Pregnancy

Dr.Sarma@works


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Mean HbA BG mg %

80.5

147.1

213.7

280.3

HbA1C %

5

7

9

11

Correlation of MPG - HbA1c

Mean Plasma Glucose =

(33.3 x HbA1C%) - 86

(Nathan et. al. NEJM, vol. 310, No 6, Feb 9, 1994)

Dr.Sarma@works


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Glycosylation of hair HbA

  • Hair glycosylation using thiobarbituric acid TBA

  • Glycosylation of hair is  in diabetes mellitus

  • Both insulin dependent , non-insulin dependent

  • Glycosylation of hair is proportionate to HbA1c

  • Due to the presence of hexosyl lysome in hair

  • Long hair sample provides a long term record.

  • May have forensic application & in population

  • studies.

BMJ, 1996, vol. 288 pp. 669-670

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Blood Glucose Monitoring HbA

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MAGE HbA

“Blood Glucose 80 min. after breakfast correlates with MAGE

( Mean Amplitude of Glycaemic

Excursions ) throughout the day”

Molnar et. al.

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SMBG HbA

  • On intensive insulin therapy

  • Diabetes in pregnancy

  • IDDM who lack warning symptoms

  • of hypoglycaemia

  • Insulin - requiring diabetics

  • Diabetics with unusually high/low

  • RTMG.

  • Insulin - resistant diabetics on large

  • insulin doses

  • Motivated diabetics for tight control.

Dr.Sarma@works


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New era in monitoring control HbA

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