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Dr.R.V.S.N. Sarma, M.D., M.Sc.,

Paradigm shift in Diabetic care. Dr.R.V.S.N. Sarma, M.D., M.Sc.,. Once there was a tiger which boasted that it can run faster than any one. One day he chased a rabbit and failed to catch it. “All right” said the tiger; “of course I failed on my boast.

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Dr.R.V.S.N. Sarma, M.D., M.Sc.,

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  1. Paradigm shift in Diabetic care Dr.R.V.S.N. Sarma, M.D., M.Sc., Dr.Sarma@works

  2. Once there was a tiger which boasted that it can run faster than any one. One day he chased a rabbit and failed to catch it. “All right” said the tiger; “of course I failed on my boast. But, remember the rabbit was running for its life and I, for my dinner.” Now, decide who is the rabbit and who is the tiger - among we and our patient ! How true ? Dr.Sarma@works

  3. “The greatest burden on doctors will be not the management of diabetes, but the associated macro and micro- vascular complications of it.” ..1926 “The goal of therapy in diabetes should be to make serious efforts to keep the blood sugar levels as close normal as possible.” ….. 1929 Dr.E.P.Joslin Dr.Sarma@works

  4. I am making India the capital of the world shortly ! Already I have a big… family of 200 millions on the globe. I am happily troubling 12% urban and 8.2% of rural Indians. In my name I am sweet but my effects are very hot ! I am not easily controlled (< 45%) Be serious Doctor Dr.Sarma@works

  5. Haemoglobin Structure of Hb Dr.Sarma@works

  6. Fetal Hemoglobin – Hb F Adult Hemoglobin – Hb A Sickle cell disease – Hb S Hemoglobinopathies – Hb C, Hb E Glucose in the blood reacts with the Hemoglobin A to form Glycated Hb. Different Hbs Dr.Sarma@works

  7. Different types of Glycation products are formed from the HbA0 depending on the carbohydrate moiety – namely HbA1a1 - Fr 1,6 diphos –N-term. valine HbA1a2 - Gl 6 phos –N-terminal valine HbA1b - Other CHO – N-term. valine HbA1c - Glucose –N-terminal valine Normally less than 6% of Hb is HbA1c Glycated Hb - GHb (Previously called glycosylated Hb.) Dr.Sarma@works

  8. Less than 6% - Normal 6 to 7.5% - Good control of DM 7.6 to 9% - Unsatisfactory control More than 9% - Very poor control Reference values ofHbA1c Values depend on the method of estimation They vary from lab to lab. Note if all GHb is measured instead of HbA1c Dr.Sarma@works

  9. Acute hyperglycemia Severe aneamia Gestational diabetes Life span of the RBC Abnormal Hb like S-Hb, Hb C Serum opalescence -↑TG On the method of estimation Factors affecting HbA1c Dr.Sarma@works

  10. There are many methods of estimation HPLC (High Performance Liquid Chromatography) – Gold standard. Immuno-turbimetric meth. – HbA1cAb Affinity chromatography Electrophoretic methods Method based on chemical reactions. Estimation of HbA1c Dr.Sarma@works

  11. HbA1cis ‘weighted’ Dr.Sarma@works

  12. How well it measures ? Lowering Hb A1c reduces risk of complications Dr.Sarma@works

  13. Advantages of HbA1c • Index of long-term control over 120 days and not a snap shot like PG • Can be done at any time of day • Not influenced by diet, exercise, emotional disturbances on test day • Useful index in clinical trials • Useful if missed drugs / default diet • Useful in DD of stress hyperglycemia Dr.Sarma@works

  14. Limitations of HbA1c • Cannot be an emergency room test to titrate Insulin or OHA dosage • Cannot register hypoglycemia • More sensitive to sin than repentance – if it is elevated it confirms poor control, if it is boarder line, it cannot assure good control in the recent past. • Not sensitive enough for use in GDM •  Anaemia, Uraemia, Pregnancy Dr.Sarma@works

  15. Mean BG mg % 80.5 147.1 213.7 280.3 HbA1C % 5 7 9 11 Correlation of MPG - HbA1c Mean Plasma Glucose = (33.3 x HbA1C%) - 86 (Nathan et. al. NEJM, vol. 310, No 6, Feb 9, 1994) Dr.Sarma@works

  16. Glycosylation of hair • Hair glycosylation using thiobarbituric acid TBA • Glycosylation of hair is  in diabetes mellitus • Both insulin dependent , non-insulin dependent • Glycosylation of hair is proportionate to HbA1c • Due to the presence of hexosyl lysome in hair • Long hair sample provides a long term record. • May have forensic application & in population • studies. BMJ, 1996, vol. 288 pp. 669-670 Dr.Sarma@works

  17. Blood Glucose Monitoring Dr.Sarma@works

  18. MAGE “Blood Glucose 80 min. after breakfast correlates with MAGE ( Mean Amplitude of Glycaemic Excursions ) throughout the day” Molnar et. al. Dr.Sarma@works

  19. SMBG • On intensive insulin therapy • Diabetes in pregnancy • IDDM who lack warning symptoms • of hypoglycaemia • Insulin - requiring diabetics • Diabetics with unusually high/low • RTMG. • Insulin - resistant diabetics on large • insulin doses • Motivated diabetics for tight control. Dr.Sarma@works

  20. New era in monitoring control Dr.Sarma@works

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