CLINICAL PRACTICE
UPDATE in
ENDOCRINOLOGY
LMC Endocrinology
Centres
& DIABETES
VOLUME 02 - ISSUE 04
EDITOR
RONALD GOLDENBERG
MD, FRCPC, FACE
LMC
“Doctor, why is my sugar
just like a bouncing ball”
EXECUTIVE DIRECTOR
RONNIE ARONSON
MD, FRCPC, FACE
RONALD GOLDENBERG
MD, FRCPC, FACE
HASNAIN KHANDWALA
MD, FRCPC
KIMBERLY MAH-POY
MD, FRCPC
GLORIA RAMBALDINI
MD, FRCPC
SAMANTHA SANDLER
MD, FRCPC
ROBERT SCHLOSSER
MD, FRCPC
WILLIAM SINGER
MB, FRCPC, FACP
GEORGE STEINER
MD, FRCPC
DENNY K.Y. TRINH
MD, FRCPC
YAW TWUM-BARIMA
MD, FRCPC
NINA WINE
MD, FRCPC
LMC
A few weeks ago, a
patient of mine with
longstanding,
insulinrequiring type 2 diabetes
arrived in the clinic in a
state of distress. Up until
one week prior to her
Ronald Goldenberg,
visit, premeal glucose
MD, FRCPC, FACE
levels had consistently
been in the 4 to 8 mmol/L
range. Her distress was triggered by
monitored glucose levels over the past
week bouncing between 7.2 to 14.5,
which she had recorded in a logbook.
When I scrolled through the memory in
her glucose meter, the actual glucose
values were ranging from 72 to 145, and
she had been adding in the decimal point
in her logbook, assuming the decimal
display in her meter had malfunctioned.
In actual fact, her meter had been
inadvertently switched over from SI units
to conventional units. Therefore, the
sugar levels were ranging from 72 to 145
mg/dl. Converting to
SI units indicated
readings in the 4 to 8
mmol/L range. After
switching the meter
back to SI units, I
reassured her and
arranged follow-up.
Our patients with
diabetes will often
encounter unexplained
glucose fluctuations.
being misled by a glucose meter error.
Our patients with diabetes will often
encounter
unexplained
glucose
fluctuations. In this issue of Clinical
Practice Update, Amberley Fischer
discusses the problem of glycemic
variability, and provides us with a
practical checklist to help troubleshoot
this common clinical problem. The next
time your patient says, “Doctor, why is
my sugar just like a bouncing ball”, you
can refer to the checklist to help you
provide the answer.
The clinical scenario
described is a rare
example
of
one
reason for “glycemic
variability.” In this
case, the patient was
from the Endocrinology & Diabetes Specialists of the LMC Endocrinology Centres
The opinions expressed in this paper are those of the authors and do not necessarily reflect the
opinions of LMC Endocrinology Centres or the editorial board of Clinical Practice Update.
Glycemic Variability in Diabetes:
A Practical Solution to the
“Bouncing Glucose”
It is well appreciated by
health care providers that
tight glycemic control, typically reflected by a near-normal A1C, will help prevent
long-term diabetes complications. The DCCT (Diabetes
Amberley Fischer,
RN, BScN
Control and Complications
Trial) and UKPDS (United Kingdom
Prospective Diabetes Study) demonstrated
that achieving A1C levels below 7% will prevent or delay diabetes complications.
However, glucose levels are not stagnant in
our patients with diabetes - rather, levels
range from hypoglycemia to significant
hyperglycemia. This “glycemic variability”
can be disruptive to a patient's day-to day
life, and may also contribute to increased
diabetes complications. In fact, the DCCT
demonstrated that for any given A1C level,
intensively treated patients had less
retinopathy than conventionally treated
patients. All of us caring for individuals with
diabetes have seen patients with wide and
unexplained swings in glucose. In these situations, health care providers must look
beyond the A1C level to try to determine
what factors contribute to glycemic variability.
…fluctuating blood
glucose levels can be
frustrating for patients
in their effort to achieve
good glycemic control.
From a clinical perspective, it can be difficult
to determine the cause of variable blood glucose levels. Besides contributing to the
development of complications, fluctuating
blood glucose levels can be frustrating for
patients in their effort to achieve good
glycemic control. To help patients achieve
smoother glycemic control, it is necessary to
address the factors that cause glucose fluctuations. Some general subjects to discuss
with the patient include the following:
Insulin/Medications (e.g., timing of
injections, dosing, injection sites)
Diet (e.g., knowledge of carbohydrate
counting)
Exercise (e.g., appropriate insulin
adjustments)
Blood Glucose Monitoring (e.g.,
calibration of meter, technique)
Stress (e.g., hormonal changes
or illness)
Attached is a practical checklist with the
above factors to consider when a patient
tells you “my blood sugars are all over the
map.” The checklist will stimulate the healthcare provider to think about the various
issues contributing to the swings in glucose.
Typically, by using a logical, problem-solving
approach, the cause of glycemic variability
can be discovered. By pinpointing one or
more factors related to glycemic variability,
health care providers may be able to aid
their patients in achieving tighter and
smoother glycemic control, thereby preventing complications and improving their quality of life.
1. Brownlee M, Hirsch IB. Glycemic variability: a haemoglobin A1cindependent risk factor for diabetic complications. JAMA 2006;
295:1707-1708
2. Canadian Diabetes Association 2003 Clinical Practice Guidelines for
the Prevention and Management of Diabetes in Canada. Can J
Diabetes. 2003;27(Suppl2): S27-S31
available on the web at www.clinicalpracticeupdate.com <http://www.clinicalpracticeupdate.com>
2
Supported by an educational grant from members of the pharmaceutical industry