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Part 2 Routinely Identifying Postprandial Hyperglycemia - Challenges & Tools
An Educational Service from GLYCOMARK
GLYCOMARK is a registered trademark of GlycoMark, Inc.© GlycoMark, Inc. All rights reserved
NOTE: Please see slide notes below each page for study and slide details
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Looking Beyond a “Good” A1C of 7%
70
180200
300
400
50
mg/dL
Breakfast Lunch Dinner Bedtime
185
154
123
Range ofEstimatedAverageGlucose
A1C may not reflect postprandial extremes due to blood glucose averaging and individual variability
D Nathan et al, Translating the A1C Assay into Average Glucose Values, Diabetes Care, Vol. 31, No. 8, Aug 2008
Fingerstick tests may miss glucose peaks due to timing
A1C 7%
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Postprandial Hyperglycemia Assessment ToolsTool Description Drawbacks
HbA1C Mean of last 60-90 days
• Can mask extremes; cannot change quickly• Interferences (hemoglobinopathies)• Individual variability in glycosylation rates
Fructosamine Mean of last 3-4 weeks
• Can mask extremes• Individual variability in glycosylation rates
Oral Glucose Tolerance Test (75 gr load)
Multiple data points on one day
• Good measure of postprandial glucose but time-consuming for patients and providers
• Only measures one day in time so could be skewed by illness or stress
Continuous Glucose Monitors
24/7 continuous blood glucose measurements
• Excellent tool but cost and reimbursement is issue for T2D and some T1D
• Time-consuming training and report review• Some patients will not wear sensor 24/7
Frequent Fingerstick Blood Glucoses
Single data points • Can miss peaks due to timing• Patient adherence to frequent PPG testing
• Cost and insurance limits on BG strip quantity • Unreadable/inaccurate glucose logbooks
1,5-Anhydroglucitol(1,5-AG; GLYCOMARK)
1-2 week measure of average peak blood glucose
• Not accurate in advanced kidney or liver disease• Individual variability in renal thresholds
especially during pregnancy
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1,5-Anhydroglucitol (1,5-AG)
• Provides an estimated average peak glucose (eAPG) over the previous 1-2 weeks
• Used when continuous glucose monitor or frequent postprandial fingerstick glucose tests not available
• Non-fasting serum or plasma test that can be used as routine marker for PPH
• Typically ordered when A1C is 6-8% and to monitor therapy change impact on PPH
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1,5-Anhydroglucitol (1,5-AG)A monosaccharide similar to glucose
O
OH
OH
HO
HO OH
O
OH
OH
HO
HO
1,5-anhydroglucitol1,5-anhydro-D-glucitol
1-deoxyglucoseD-glucose
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1,5-Anhydroglucitol Found in Most Foods
Highest content - soybeans, grains, rice, pasta, beef, pork, tea
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Physiology of 1,5-Anhydroglucitol (1,5-AG)Why 1,5-AG decreases with hyperglycemia
1,5-AGFood intake(5-10 mg)
Blood stream
Urinary 1,5-AG excretion limited(5-10 mg)
1,5-AG Food intake(5-10 mg)
Blood stream
Large amounts of 1,5-AG excretedin urine
Normoglycemia Hyperglycemia
Excess glucoseblocks 1,5-AG reabsorption
Most 1,5-AG is reabsorbed
in renal tubules
Serum 1,5-AG stays
HIGH
Serum 1,5-AG is LOW
1,5-AG Digested
1,5-AGDigested
Tissue pool of 1,5-AG
Tissue pool of 1,5-AG
Kidney Kidney
LiverProduction
LiverProduction
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1,5-Anhydroglucitol – The “Good” SugarInverse relationship to glucose
Mean Max Glucose
1,5-AG
<140 mg/dL
300+ mg/dL
20+µg/ml
1 µg/ml
Extremehyperglycemic
excursionsNormoglycemia
<10µg/mLfrequent
peaks over180 mg/dL
<6µg/mL frequent
peaks over200 mg/dL
>20µg/mL Median - No
diabetes
<14µg/mL normally found in diabetes
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180230
0
50
100
150
200
250
Patient Group 1 Patient Group 2
CGM Postmeal Glucose (mg/dL)(P<0.05)
7.20 7.38
0.00
2.00
4.00
6.00
8.00
Patient Group 1 Patient Group 2
A1C (%)8.00
5.58
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
9.00
Patient Group 1 Patient Group 2
GlycoMark 1,5-AG (mg/ml)(P<0.05)
Dungan, K., Buse, J. et al. Diabetes Care, June 2006
Authors’ Conclusions•1,5-AG reflects CGM glycemic excursions (MPMG and AUC/180) more robustly than fructosamine or A1C•1,5-AG reflected varying postmeal glucose levels, despite similar A1Cs•1,5-AG may be a useful adjunct to A1C in moderately controlled T2D where SBGM is infrequent and often only in fasting state
Patients sorted by glycemic excursions as measured by CGMS (AUC-180) and subdivided into two populations – bottom 50th percentile (Group 1) and top 50th percentile (Group 2)
1,5-AG Correlation with CGMMean Postmeal Maximum Glucose (MPMG)
CGM MPMG (mg/dL)P < 0.05
A1C (%)P < 0.05Not statistically different
Group 1 Group 2 Group 1 Group 2 Group 1 Group 2
1,5-AG (µg/mL)
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A1C Can Mask Hyperglycemic Excursions
0
50
100
150
200
250
300
350
400
2/15 2/16 2/17 2/18 2/19 2/20 2/21 2/22
Time (days)
Glu
co
se (m
g/d
L)
0
50
100
150
200
250
300
350
400
2/8 2/9 2/10 2/11 2/12 2/13 2/14 2/15
Time (days)
Glu
co
se (
mg
/dL
)
Renal Threshold
52 year old female A1C 7.43%
7 Days of Continuous Glucose Monitoring
49 year old male A1C 7.27%
Ave. CGM Max Glucose 195 mg/dL
Ave. CGM Max Glucose 235 mg/dL
1,5-AG marker measures blood glucoses >180 mg/dL
Dungan, K., Buse, J. et al. Diabetes Care, June 2006
6 spikes
18 spikes
1,5-AG 12.4 µg/mL
1,5-AG 4.5 µg/mL
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For more information
• For a listing of postprandial hyperglycemia outcome studies, please visit www.glycomark.com/postprandialhyperglycemia
• For a listing of studies about the 1,5-anhydroglucitol biomarker for postprandial hyperglycemia, please visit www.glycomark.com/product/studies
• For a 3-minute overview about the 1,5-anhydroglucitol biomarker, please visit www.glycomark.com/movie
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