Ask the Pharmacist – June 6, 2018

Q) My doctor keeps nagging me about my blood sugars but this same doctor is fine with my dad’s numbers and they’re higher than mine. Why the double standard?

A) One of the essential things about medical knowledge is that it should continue to evolve as we learn more and more from the experiences of our patients.

One of the practical applications of this is that it is neither reasonable nor good medical practice to demand the same standards from 30 year olds as we do from our oldest clientele.

 When it comes to the measurement of blood sugars, experts are determining that demanding the same low numbers from our elderly can increase the risk of adverse events while not providing the same benefits that these figures can provide to the younger crowd.

A1C is the gold standard for measuring how well a diabetic is controlling their blood sugars. This simple blood test works by measuring how much glucose (i.e. sugar) attaches or binds to the hemoglobin (this is the part of your red blood cells that carries oxygen throughout your body).

The more glucose that is floating around in your bloodstream, the more of it attaches to your hemoglobin. By measuring this, doctors can get a great idea of what your average blood sugar has been over the last 3 months, which is a much better indicator of your control than a fasting glucose test or even multiple results from your own personal glucose meter.

Your personal results are still very useful since they can point to specific times in the day when sugars tend to trend too high or too low which the A1C cannot detect. While a “normal” A1C is below 5.7, for years health care professionals have pushed for their diabetics to aim for an A1C of less than 7.

This number makes sense for many as we know that higher blood sugar levels are associated with an increased risk of being plagued by what we call micro-vascular complications. These are a direct result of the destructive effects that elevated sugars have on the small blood vessels within the body and include such negative outcomes as nephropathy (kidney damage), neuropathy (pain from nerves that have been damaged) and retinopathy (damage to the retina that lines the back of the eye).

As an example of how prevalent these problems can be, take a look at retinopathy. It is responsible for causing 10,000 new cases of blindness every year in the U.S. alone. Most type 1 diabetics will have retinopathy within 20 years and some type 2’s (non-insulin dependent) will show evidence of retinopathy years before they are actually diagnosed as a diabetic.

 For nephropathy, the incidence of microalbuminuria in type 2 diabetics is 2% a year and 25% within 10 years of diagnosis. Microalbuminuria is a term used when small amounts of protein are leaked into the urine and typically, over time, it leads to overt kidney disease.

 For diabetics who are expected to live for decades to come, these complications could greatly decrease the quality of their lives for many years. Aiming for an A1C of less than 7 or even under 6.5 for those with a long life expectancy and no significant evidence of cardiovascular disease makes perfect sense.

Trials have shown that the risks of developing these complications are even lower with A1C’s of 6.4 as compared to A1C’s at 6.9. But over half of type 2 diabetics are over the age of 65 or have many accompanying chronic conditions (such as heart disease or high blood pressure) and many have had diabetes at this point for many years.

In order for some of these to get under a 7 for their A1C would require the use of more and more drugs with the attendant risks this entails such as the potential for interactions with their other medications or the potential for their sugars to “crash” at certain points of the day, a condition known as hypoglycemia.

Hypoglycemia has been associated with cognitive decline, heart rhythm abnormalities, seizures and most particularly an increased risk of falling and the physical destruction that may arise from that.

For some seniors, achieving an A1C of less than 7 is simply not worth it and instead a more reasonable and safe goal would be to keep it under 8.5% since the risk of hypoglycemia in these people outweighs the risk of micro-vascular complications. 

Please note however, if you are a senior and your easily keeping your sugars under 7 without a steadily increasing list of drugs or dosages, continue to aim for this. The higher target should only apply to those who are really struggling to achieve this. In all, this makes sense. 

Our health goals for everything in life (sleep, exercise, weight….) logically differ for everybody depending on age, sex, health status and whatnot and there is no reason that blood sugar control in diabetes should be any different. 

The whole point of health care is to come up with a plan that optimizes your health, not that of the ever fictitious “average” person.


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