Higher A1C desired for advanced aged?

I moved and changed States and healthcare institutions. I’m 81, insulin dependent Type 2 (dx 40 years). With Victoza I have lost about 45 pounds and over time reduced my dose of Lantus significantly. My A1Cs were running 5.7 and my endocrinologist of 40 years was content. New PCP is a gerontologist and wants my A1C higher as ‘older’ diabetics do better with higher A1Cs?

I have had neuropathy (numbness and only occasional and very brief episodes [TG] of sharp pain). On metformin and B12 but neuropathy progressive.

Comments?

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@Penningdcp
I’ve read a little about this and my previous Endo stated a higher A1c is allowed for by ADA and various others docs and orgs. What I’ve read and that Endo indicated an A1c of 7 or slightly higher (up to 7.3) is OK for older folks (60s+). My recollection is it is to keep older folks from pushing the envelop and possibly going low too often in order get their A1c down into the 5’s or 6’s. I’d recommend asking your new PCP for the rationale of why the higher A1c is recommended and for the studies that support it with the intent of reviewing and drawing your own conclusions. I’d also ask why the emphasis is on A1c, vice GMI and TIR (presuming a CGM is in use, your post didn’t indicate if used one). My perspective (I’m slightly younger at 67) is that A1c is good, but it’s a lagging indicator, where GMI and TIR are more current and probably more accurate indicators. I’m no doc, so my opinion is worth what your paying. Trust your own research and fact based research.

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I think your PCP may be worried about lows and possible falls, if you have lost the ability to detect lows, etc. Do you have a lot of lows? Do you have the option of seeing someone at a diabetes clinic? They may be able to reassure your PCP that you are doing an awesome job managing your diabetes.

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Another point in this discussion, if you research the history of the “<7” A1c recommendation, you’ll find there was a lot of “heated discussion” by doctors, the ADA, other orgs, and the government about what to endorse and whether the studies that supported the conclusion were soundly based. Respected people lined up on both sides, but all most hear about is what the winners said/say. The primary concern was that people would focus on getting as low (i.e. as far below 7) as they could, despite the health consequences of their actions. The linked article is one of many discussing the rationale, particularly for T2s: Is less than 7 percent a reasonable A1C goal?

Again, I recommend people do their own research, discuss with their Endo’s, PCPs, and other health providers, and develop their own conclusions based on facts. Many of the health providers out their today were only trained on the “<7” side of the argument and may not have researched it themselves.

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Thanks, Tom, for your thoughts. No CGM in place as Medicare required insulin 4 times daily and I am using long acting Lantus (now Trujeo) once daily. I was experiencing overnight lows (4.9-5.3 at 4:30 am) on the Lantus but now the Trujeo provides a more even coverage for 24 hours. I liked Abbott’s Libre that my private insurance partly covered but went lost access when I went on Medicare. The gerontologist said she would like to see my BG around 125 - said cognition can be impacted (at my age) when control is tighter🤔 worth more discussion at next visit.

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Tom, Thanks for the link to the article! Looks like a good resource. Also, Jan, thanks for your thoughts as well.

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@Penningdcp I understand Medicare used to require insulin 4x/day, but I believe this changed last year. If a CGM would be helpful, I encourage you to check it again. I understand Medicare also now covers Libre, so if you liked it before and now use Medicare, that may be an option as well. Lastly, if Trujeo ever stops working for you and want to give Lantus a second look, try splitting the dose morning/evening. I was on Lantus prior to my Omnipod, had similar problems as you with morning lows, so split my Lantus dose half morning and half night; ended up needing increase my doses one unit for each injection, but no more morning lows either. Of course, run any/all of this by your doc. There are lots of conversations here on FUD about all, just use the search tool. Best of luck!

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I just went on Medicare, and have a Dexcom G6. Medicare covers it, just under Part B as Durable Medical Equipment. That means you have to get your Dexcom supplies through a supplier contracted by Medicare (there’s a list on the Medicare site). https://www.medicare.gov/coverage/therapeutic-continuous-glucose-monitors

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Most of us are T1Ds and our condition is very different; I would die for a 5.7 A1C. Your previous endo was happy, your new one isn’t - that’s a clear conflict. You have two experts presenting different opinions, it’s not just reasonable but essential to get an explanation; since they have different opinions you have no choice but to chose who is correct!

I suspect you may also be in one of those horrible medical situations, utterly unrelated to diabetes; you had a doc who knew you, who was maybe wise, certainly wise enough to keep you as a client for 40 years, who said one thing. You have a new doc who needs to be onboarded.

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I think there’s this myth that higher A1Cs result in less hypoglycemia. For me it’s the opposite since I require quite a bit more insulin to enter normal BG range. It then drops low with more insulin on board. which is more challenging to correct.

As for A1C, I’ve been in the low 5s (sometimes 4.9) for a while so am happy to describe what I do if that helps. By no means am I an expert, but I feel like over time things have gotten smoother. Trader Joe’s and Costco have been very helpful for that.

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I am 78 and have been a T1D for 48 years. Before getting a CGM my A1C was above 7 and I was having hypoglycemic reactions. I also could not detect a low before having a reaction. 5 years after getting a Dexcom CGM my A1C had dropped to either 5.3 or 5.4. I can also tell if my BG level is in a low state without a test, I always test anyway. Also my previous diabetic complication diabetic retinopathy has now been eliminated. My endocrinologist is always concerned with the low A1C but I always have a close family member that relates I have never had a low BG level after getting the technology change. Actually, the best technology change was having a ‘standalone watch’ that always monitors the Dexcom transmitter for a display of BG levels and warnings.

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Thanks ALL for your feedback. I have an appointment next week with the gerontologist regarding my meds and I will make my case for an appeal to Medicare for a GCM. In this university setting I feel my care may be more specialized but more disjointed in a big institution after having 40 years with an endocrinologist who was teaching in 2 teaching medical schools as well as personalized care in his private practice. I’ll let you know developments.

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you could also ask about the libre2…not quite as accurate, and you have to scan to see your glucose, but it seems to be designed for type2, cheaper cost, and some medicare plans may cover it…dexcom g6 is better, but its usually very expensive…either for you, your insurance company, or both…again with cgms the major benefit is the directional arrows predicting where your glucose is headed

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There was a large trial of T2s and they found that tight control led to MORE deaths, largely because of hypos but they couldn’t say for sure, as it was an association, not causal. I think the key was that certain types of medication were associated with this increased risk – perhaps sulfonyureas?

That said, all these studies I think were conducted prior to Victoza being widely used. I have read those drugs lead to a lower risk of death from cardiovascular causes, so I’d be interested to know how those interplay.

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My dad has T2, and while he is very sick (on hospice) we have noticed that his cognition definitely suffers if he is below 100. He also no longer needs any diabetes medication; his blood sugar is almost always in range with zero medication. It’s strange…

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The body is pretty amazing to the way it adapts to situations throughout our life. I don’t think we are even close to understanding it in a holistic way. We have certainly progressed in my lifetime at understanding the chemistry, but the triggers and changes seem to be pretty complicated.

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I thought there was a lot of pushback on that (mostly because “everyone knows lower A1C is better”,) so I’d want to check closely into current results before trying to draw conclusions based solely on work published 5 years ago.

That said, I find it easy to give credence to the hypothesis that adding more and More and MORE medicine to lower the A1C could reach a point where the extreme medication is more dangerous than the hyperglycemia.

Then of course the conclusion would be “too much medicine is harmful,” not “too low an A1C is harmful.”

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I mean, a body of work supports this notion. Not just the study 5 years ago but a few other big ones from earlier in the decade. It seems pretty clear that for T2s, getting A1C low by adding medications is not a good strategy. (I don’t consider appropriately dosing insulin, rather than underdosing, “adding medication.”) It doesn’t add years to life, doesn’t reduce complications, and does seem to cause harm on average.

Here’s another one from 2019, for instance. Not a randomized controlled trial like the others but observational:

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You can push back on the study, but for an observational study, the n=300,000, and the quality of the researchers gives credence to the results, and hopefully one of the European countries follows up with a more definitive research study to determine causation.

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Only when being careful about what the results were.

In my view, “Lower A1C associated with …” is fine, so long as one doesn’t leap to “Lower A1C is harmful” which I find highly suspect, because I it is pretty clear that a BG that is steady at 80 ± 5 will give a low A1C without causing harm, whereas an excess of medication can reach the point of causing harm.

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