Reducing your a1c too quickly

I posted this question on another thread but didn’t get a response so trying again as probably nobody noticed
I saw on TUDiabetes the moderator say that when you reduce your a1c from running high for many years you should do it slowly like 0.5 per cent per month - no idea where he got that from or he is just making it up
My last a1c test was done in April and it was 8.5 - my August one was 6 and my October one should be 5 - so I guess I’ve followed that pattern almost but is there any documented studies of effects of reducing a1c fast
I saw one on eye problems but I couldn’t figure out whether it applies if you had some small signs of retinopathy it can speed up or it can just appear and go fast
I had my eye test yesterday and I have no signs of haemmorhage or have or anything else in the eye

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There is some evidence hat retina problems are more likely if a1c is reduced super quickly… how quickly is too quickly isn’t really something anyone really seems to know…

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I am guessing that is not exactly a study that would draw many participants…

Hopefully there are no issues for me. I got mine from 12.5 to 5.5 in 11 weeks… I’ve seen that tossed around other facebook groups but none have been supported (and admittedly, I haven’t looked).

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How long were you at 12.5 ?

No idea… that’s what it was when I was diagnosed this May. I had clear symptoms for 6 months (very bad for 2 weeks) and intermittent for 3 years.

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I would think the rapid drop from diagnosis to getting yourself in order wouldn’t count as not long enough - although I’ve never thought about how high an undiagnosed type 2 can go and for how long without identification - can it be decades ? I’ve probably been 8 ish for 25 yrs

My eye doctor said no need to see him for a year or so as long as I kept my a1c at 5 - Maybe I need to ignore him and go back in 3 months just to be safe

I’d just follow their recommendations as far as frequency of exams personally

It seems that your doctor is pleased with your progress, a 5 A1c is impressive. One year is the eye exam standardl for a diabetic that exhibits no problem, especially someone with an excellent A1c.

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If it helps you sleep better than definitely see him in 3 months. Peace of mind is hard to come by. If it is good then maybe push the next app out to 6 months. If still good then push the next appt to 9 months. After that, a yearly check is probably prudent while no problems are showing up.
I like to take things slow…

Better advice thanks - have to stop being paranoid for a second !

@Robellengold, the main issue in responding to your question is the lack of available data. This 2010 article makes directly applicable points:

HbA1C and duration of diabetes (glycemic exposure) explained only about 11% of the variation in retinopathy risk for the entire study population, suggesting that the remaining 89% of the variation in risk is presumably explained by other factors independent of HbA1C

a potential determinant of microvascular complications not captured by HbA1C could be greater magnitude and frequency of glycemic excursions.4 This hypothesis is provisionally supported by experimental evidence that prior episodes of transient hyperglycemia trigger persistent increases in proinflammatory gene expression during subsequent periods of normal glycemia by inducing stable epigenetic changes

Realizing that the aspects of glycemia that explain the approximately 89% of microvascular complications are unknown […] Given the lack of studies specifically aimed at reducing glycemic variability to determine the effect of such reductions on clinical end points, new treatment guidelines targeting glycemic variability per se cannot be justified.

Recent evidence suggests a role for both blood pressure and lipids in the pathogenesis of diabetic microvascular complications. Thus, it seems prudent to integrate earlier use of medications and other approaches to control blood pressure and lipid levels, as well as to include frequent follow-up assessments of retina and renal status into an overall treatment strategy.

In other words:

  • only 11% of the risk of retinopathy is explained by A1c and duration of diabetes

  • glucose variability is likely a partial culprit but we have no idea how and what to do about it

  • Blood pressure and cholesterol must be controlled as they are likely significant factors too.

Everyone is afraid of glucose variability as a possible cause of complications. Changing your A1c so radically fast would increase variability and possibly result in short-term issues – that’s the fear. But there is no data or proof :frowning:

So, my conclusion is that nobody can tell you if this will be a problem – it is was me, I’d probably schedule a visit at 6 months just in case your quick improvement causes issues in the short term. You will probably have to pay out of pocket though, since the regular diabetes schedule is 1 year.

[EDIT] There is limited data that tends to show glucose variability as a risk factor, such as:

But people have attacked the validity of the measures of variability used in DCCT, so this study may not be convincing.

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Thanks - good articles - it’s interesting that nearly all the articles I read when they say ‘nornal’ they mean 6.5 to 7 - or diabetic normal - which still creates risk - you have to keep checking yourself to be clear
when I told my eye doctor my risk now should be the same as his but I will continue to get it checked his initial response was to laugh and say diabetics always have heightened risk of retinopathy so when I told him my a1c was probably better than his ( given he was overweight) - he didn’t know how to take it I think - apart from what came before and what may be lurking there - there really is no difference between a diabetic and a non diabetic when their a1c is 5 per cent and they don’t have excursions over 140 - it’s just that very few in the medical community accept that can be achieved so think normal still has the heightened risk associated - luckily insurance companies also feel that way so the checks and balances many of which everyone should get when they get older are available to us

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Unfortunately he is right-- even with absolutely perfect control type 1 diabetics are still at a higher risk of microvascular complications such as retinopathy. Those risks can be tremendously reduced with tight control, but not completely eliminated.

One theory is that this is due to the reduced c-peptide hormone, which in normal non diabetics leads to vasodilatation and generally healthier microvascular systems

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@Robellengold, no excursion over 140 is really more than terrific! You have likely decreased your risk of retinopathy by an extraordinary degree!

But – you probably do have an increased risk compared to him :slight_smile: :

http://www.sciencedirect.com/science/article/pii/S0168822711006747

epidemiological and prospective data have revealed that the stressors of diabetic vasculature persist beyond the point when glycemic control has been achieved. These kinds of persistent adverse effects of hyperglycemia on the development and progression of complications has been defined as “metabolic memory”

Metabolic memory is also called glycemic memory. It is only a theory, but with some support in several studies.

Ah you can’t win them all I guess - although it says tight glycemic control - even DCCT studies that test out tight glycemic control mean a1c of 7 which is loose for those on this site ! Would definitely impact the results

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@Robellengold It’s so much more complicated than just glycemic control.

For instance, for 25 of my 46 year stint with T1 I have no idea what my control was. Never had an A1c, had plenty of severe hypoglycemic episodes, ate lots of bread and cakes and junk. If my A1c was under 8 or 9 during this time I would be shocked.

But I am completely free of diabetic complications. So there has to be something else at play here. My guess is it has a strong genetic component.

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There is a possibility that this idea came from some overly-cautious doctor, who was afraid that if someone’s A1C was dropped radically, it would come at the expense of them having a lot of lows, so they advised a gradual drop.

That’s just a guess, but a lot of these bits of advice come down that way. I’ve never heard any science to support the idea that you need to make slow improvements. I don’t really know if it is true, I’ve never seen that supported.

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There is some evidence (and plenty of observation) that lowering A1c – that is, in general, tightening control – too rapidly can result in a period of proliferative retinopathy, which later stabilizes if good control is maintained. (This was certainly my own experience.)

Not the most scientific of papers, but this discusses some of the research and touches on the pros and cons of rapidly improving control within one year:
http://www.diabeticretinopathy.org.uk/retinopathyprogression.htm#co

And the Canadian contribution :maple_leaf: – "In type 1 diabetes, rapid improvement of glycemia may be associated with transient early worsening of retinopathy, but this effect is offset by long-term benefits."
http://guidelines.diabetes.ca/browse/chapter30#bib39

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