Expert Analysis from AADE 16
SAN DIEGO – The former president of the Endocrine Society told diabetes educators that it’s time to replace the much-used hemoglobin A1c level with a measurement that better reflects how diabetes patients are faring.
The problem is that the HbA1c is “woefully inadequate,” said Robert Vigersky, MD , the medical director of Medtronic Diabetes and president of the Endocrine Society in 2009-2010. “It doesn’t tell you about time-in-range or the frequency, duration, and severity of hypoglycemia or hyperglycemia. And there’s nothing about glycemic variability.”
These measurements are important, he told an audience at the annual meeting of the American Association of Diabetes Educators. For example, “there are several new classes of medication and new technologies. Some decrease HbA1c with no effect on hypoglycemia. Some affect hypoglycemia with no effect on HbA1c. How do we think about these globally and compare them to one another?”
To shed more light on the true condition of patients, he said, it’s time to “change the conversation from HbA1c alone to one that is more glucose-centric. It’s about thinking about glucose as a vital sign, not HbA1c. This may help health care providers, regulators, and payers better understand what is best for patients.”
He is also thinking about going beyond sugar levels. “Maybe a future composite metric will have more than just glucose numbers,” he said.
Indeed, last hear Dr. Vigersky proposed a composite metric known as “the hypoglycemia-A1C score” that can also take factors like weight, quality of life and costs into account ( J Diabetes Sci Technol. 2015 Feb 19;9[5]:1148-51 ).
But he acknowledged there are challenges. For one, there are at least a dozen different ways to measure hypoglycemia, he said, “and every paper cherry-picks the method they want to show their data in the best light.”
It’s also not clear how best to represent the data once researchers figure out which statistics should be included. Should the overall measurement be a single number? Or should there be multiple numbers? In that case, should the numbers be represented graphically?
Dr. Vigersky said he is working on an approach that illustrates various measurements through a pentagon shape. Its appearance reflects measurements such as mean glucose and duration of high glucose.
However, he predicted the future will produce a simpler measurement: “a multicomponent single value.”
What’s next? “We need to educate the payers about how we can’t stay with HbA1c. This will take an effort with professional societies. Once everyone agrees, we need to get some consensus about what the elements of the composite metric are.”
Dr. Vigersky is hopeful that the HbA1c is on its way out, although he acknowledges that it won’t be a rapid process. “It took 20 or more years for everyone to buy into A1C and understand what it represented,” he said. “Changing the conversation isn’t going to happen overnight. But unless we start to address it, it will never happen.”
Dr. Vigersky reported having no relevant financial disclosures.
