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Dear Dr. Roach, I am 74 years old and I am a diabetic type 1 fragile for 50 years. I have no history of heart disease. My 40-year-old doctor recently retired and allowed me to control my A1C hemoglobin in the range of 5.9 to 6.2. My new doctor, who is in his mid thirties, wants me to wear my hemoglobin A1C at 8.0. Is this the new way to control blood sugar? I'm confused! Can you please explain the difference of opinion?
E. S.
"Fragile" diabetes is when it is difficult to control a blood sugar that is too high and blood glucose too low.
The A1C is a blood test that examines the average blood glucose in recent months. A normal A1C is between 4 and 5.6%. People with normal A1C levels have a very low risk of diabetes-related complications, particularly kidney (resulting in dialysis), eyes (which ultimately lead to blindness) and nerves (diabetic neuropathy is painful and predisposing to injuries).
On the other hand, low levels of HbA1C increase the risk of hypoglycemia (hypoglycemia), which can be very dangerous. People with type 2 diabetes and blockages in the blood vessels (or at very high risk) had a higher risk of heart attack. For this reason, recent recommendations for older people with type 2 diabetes have more flexible goals, ranging from 7 to 8, although these need to be individualized. For type 1 diabetes, most guidelines still recommend an A1C goal of less than 7%. However, for a person with type 1 diabetes who also has other medical problems that may affect mortality, and for people at high risk of severe hypoglycemia, a more goal flexible is not unreasonable.
Hypoglycemia is too low blood sugar, with a risk of confusion. This is a big problem in people with fragile diabetes.
A low level of HbA1C is badociated with a lower risk of lesions of the small blood vessels, responsible for nerve damage, eye diseases and most diabetic kidney diseases. If you have managed to keep your HbA1C rate between 5.9 and 6.2, which is not an easy task, and you have not had a serious episode Of hypoglycemia recently, I wonder why your new doctor thinks that your blood sugar should be significantly higher than what it is.
Finding the right balance between good control and the absence of hypoglycemia is not always easy, but these are the risks and benefits that your doctor has envisioned.
Dear Dr. Roach, I have a member of my family who has been suffering from an inflammatory bowel disease for 12 years. In November he started in Xeljanz. In recent months, he has had a persistent elevation of alkaline phosphatase. This is less than 1.5 times the upper limit of normal. The isoenzymes were fractionated, revealing that it was 100% of intestinal origin. Could it be an omen of intestinal perforation?
I.G.
Tofacitinib (Xeljanz) is a biologic drug for inflammatory bowel disease, particularly ulcerative colitis. It can affect the liver and perforation of the intestine is a serious but rare side effect. However, this has been observed in people taking Xeljanz for the treatment of rheumatoid arthritis, often in combination with nonsteroidal anti-inflammatory drugs. The intestinal perforation rate has not increased in people taking the drug for ulcerative colitis.
An increase of less than 1.5 times the upper limit of normal is a very slight increase.
Three times the upper limit of normal is a source of concern. About 20% of people with ulcerative colitis will have a transient increase in liver enzymes, and about half of those with
those will be alkaline phosphatase.
Based on this information, I think intestinal perforation is unlikely.
Dr. Roach regretted that he could not reply to individual letters, but would incorporate them in the column whenever possible. Readers can e-mail their questions to [email protected]
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