I can't get my A1C below 8   (October 26, 2011)

I received the following e-mail question:

I have type 1 diabetes and I can't get my A1C below 8. I am on an [brand name deleted] insulin pump and CGM, and under the care of an endocrinologist. What should I do?

My reply:

As you probably know, aiming for an A1C (also called hemoglobin A1c) below 7, or even lower, is generally recommended for most people with diabetes, so you should not be satisfied with levels of 8 or more. With an insulin pump and continuous glucose monitoring (CGM), you should be able to achieve a lower level of A1C. My general recommendations for a situation like this would be as follows.

First, check with your endocrinologist about any possible reasons not to aim to get your A1C lower. These rare reasons to allow the A1C to remain high might include hypoglycemia unawareness, untreatable concomitant disease (e.g., terminal cancer), and perhaps some transient medical conditions (for example, during initial treatment of thyroid or adrenal disease).

Second, you and your diabetes team should be consistent about the method used for measurement of your A1C. In the past, methods of assaying A1C were sometimes influenced by factors such as genetic variants of hemoglobin, but hopefully there's been sufficient standardization that this is less of a worry nowadays - but it's still worth verifying by someone talking with the laboratory manager wherever the test is being done and seeing if it's subject to any unusual factors that might be causing elevated values.

Third, be sure you are on state-of-the-art and reliable equipment. Check with your equipment's manufacturers about any recalls, upgrades, or other equipment failures that you and your physician might not have been aware of. Also, plan to do a lot more fingerstick blood glucose testing to verify that your CGM device is working correctly. And be sure to use a reliable meter - or even two or three.

Next thought: your meal plan probably has become sloppier over time. You (and your partner, if they do the cooking) should have a thorough review of your meal plan by an experienced diabetes dietitian to see if there's advice that might help you.

And while you're at it, you should have a consultation with someone who is a Certified Diabetes Educator. Most CDEs are nurses, but some are dietitians, physicians, or other health care professionals who have earned the credentials by experience and examination. Your visit(s) with a CDE should review everything about your diabetes care plan, and see if there are any unexpected gaps that are somehow screwing you up. If the dietitian is a CDE, the same person can handle both the meal plan previously mentioned plus the general diabetes review.

Most important of all, the algorithms that you are using to adjust your insulin doses may be inappropriate. I just was rereading a textbook from 1983, called Intensive Insulin Therapy, and it was fascinating to see what present day concepts were not known then: nothing about carb counting, very little about setting different basal rates, nothing about the new insulin analogs that can be given at mealtime, and the word "flexible" doesn't even show up in the index, let alone in the algorithms that were described in those days.

They did point out one concept that sometimes is overlooked by non-specialist physicians, namely adjusting insulin doses based on meal size: "Consumption of an unusually large or small meal should be accompanied by a corresponding increase or decrease in insulin dose", but they don't give guidelines on what "large or small" means, nor how to choose a corresponding insulin dose - which is now part of flexible insulin programs using carb counting. Hopefully your physician is up-to-date on the newest algorithms: if he/she is a general endocrinologist who isn't too interested in diabetes, they might not be aware of the latest and greatest advice.

Obviously, I don't know what your algorithms for adjusting insulin doses might be, or anything about the many other factors that might be influencing your diabetes control. I hope that the concepts I mention above are helpful; you have my best wishes for better control!