Just got back from the endocrinologist. He strongly advised me to bring my A1c to…6.4-6.5. This was sure a shock to someone who works hard and strives for a 5.5-5.8.
He cited the ACCORD study that shows a higher degree of mortality for T1 diabetics with excellent control and one CV event. Seems that for those folks an A1c of 6.5 works best.
Now that I’ve had a CV event I am in a different class. Now the question is how to achieve an A1c of 6.4 when I’ve become comfortable at 5.5.
Donut ?
Simply the first thing that came to mind.
lol
But for real, what about a 20% basal reduction and see what that does?
He says that my basal is fine. I just had to react at 150 instead of 120.
But donuts sound like a great idea! Problem then becomes one of over bolusing.
- My GP / family doctor / PCP made a similar comment after my last A1C was 5.7. But it was more - should you really have an A1C below 6.0? He is a nice guy and is open to discussions so we chatted about how using a CGM was a game-changer, in that with constant monitoring of BG lows are generally avoided. I always thought that the low A1C worry of doctors was that you had too may lows and not more CV stuff.
Here are my “low Stats” where 3.8 mmol/l = 68.4 mg/dl.
What this says is my BG is pretty much above 60 (3.3) about 100% of the time. He bought into this argument and does not bug me about lows or low A1Cs.
From Accord:
“Hypoglycemia requiring assistance and weight gain of more than 10 kg were more frequent in the intensive-therapy group (P<0.001).”
The incidence of key safety outcomes — including severe hypoglycemia, heart failure, motor vehicle accidents in which the patient was the driver, fluid retention, elevated aminotransferase levels, and weight gain — were compared with the use of Fisher’s exact test.
err… so if you had a CGM and were well managed the lows would go away and hopefully that would mean less hypoglycemia and less motor vehicle accidents caused by hypoglycemia.
And that weight gain - I assume it is because they were peeing away the sugar before the A1Cs were lowered.
Was the A1C the only cause of increase CV mortality?
Was it the weight gain that led to the increased mortality was it the lower A1C?
Was it just the luck of the draw?
I would point out some problems I have with ACCORD:
-It was based on Type 2 patients not Type 1 (so it does not apply to you right? 
)
-Only 34% were on insulin - so… this really does not apply. right?
-The median A1C at the start was 8.1% and the intestive group was aiming for < 6.0% although the median was 6.4% at the end of the year for the intensive group.
So for me to belive the results of ACCORD - you need a new study that:
-Is for Type 1 diabetics
-Has a contingent that uses a CGM
-Also looks at micro vascular complications
-[edit] Has a group that starts with an A1C < 7.0.
/RANT OVER
Additional Interesting Discussion of the ACCORD and ADVANCE Trials
http://www.nejm.org/doi/full/10.1056/NEJMe0804182?query=recirc_curatedRelated_article
@Aaron Thank you for the perspective. The problem is that he reclassified me as a patient with a CV event and my low A1c is fire to quite a few more lows than you show. I’m store of I was at 3.3% lows the lower A1c would be fine.
@Eric That’s probably true, but I don’t want to die trying to prove it’s wrong. Like @Chris 's graph shows it’s not something he pulled out of thin air.
Doc, my personal thoughts. My understanding of you as a patient, doesn’t fit into any clean categories. You have Type 1, but you also have some variable characteristics of Type 2 in the insulin resistance that has plagued you at times, additionally, having a cardiovascular event I am sure is both scary and sobering considering that diabetic patients have an increased risk of cardiovascular events leading to death. The other diabetic treatment factor is trying to avoid complications from microvascular damage to the blood vessels and organs.
Assuming that the fear of additional cardiovascular events is warranted, I think you would be well advised to update your A1c goal. With that said, you have to be the one to decide what the goal is, because clearly increasing your blood glucoses will increase the microvascular damage done to your body. That may very well be a risk worth taking, and no one really knows what the full extent of the complicated changes that happen during the course of T1 and T2 diabetes. Unfortunately, this is not the only place in medicine where treatment schemes for one organ cause damage to another. In advanced heart disease the cardiologist and the nephrologist constantly fight to balance their treatments because what is good for one isn’t good for the other.
I believe you have to weigh which events you are most worried about and make a treatment decision. Ask if you need any help.
I guess I’ve been very lucky with diabetes for the past 47+ years, but it sounds like the jig is up. The endo did say that he just wants my lows eliminated. He mentioned that the chemicals released when blood sugar is low can be dangerous to people with CV incidents.
Anecdotally, I have a friend with T2, and she’s had a few CV events. She has heart disease.
Her doctors have been very explicit about avoiding lows because they have triggered CV events for her.
I think concerns about lows and CV events are very valid.
It sounds like you have a physician that is aware of the literature. That is always a good thing, but of course you have to implement the strategy. Never thought I would say this, but a few more donuts won’t kill you. 
They may even be life extending!
In your case I hope so, otherwise so many teeth out there won’t have their dentist to help them.
Did he say what chemicals?
One time my endo said that he wants his patients to avoid hypos because they can trigger coronary events. I searched it out a bit back then and came across an article that explained that hypoglycemia can induce cardiac arrhythmias. So I’d think that the issue isn’t the low A1C itself, it is that A1C is being used as a proxy for hypoglycemic incidents and those are the actual problem. I do believe that raising your average BG and your “in range” target will tend to reduce the number and depth of hypoglycemic incidents. But I’d ask your physician whether the issue is A1C or hypos, and then focus your efforts on the real issue.
Adrenalin and a couple others I don’t remember.
Nah, I just tend to repeat the point in different ways to help it get through. Old teaching habit; sometimes annoying in adult company when I go on and on.
