Michael Kleerekoper, MD, MACE, has joined the faculty at the University of Toledo Medical School where he is Professor in the Department of Internal Medicine and section chief of the Endocrinology Division. The author of numerous journal studies, Dr. Kleerekoper serves on the editorial boards for Endocrine Today, Endocrine Practice, Journal of Clinical Densitometry, Journal of Women's Health, Osteoporosis International and Calcified Tissue International. Dr. Kleerekoper is also a founding board member of the newly formed Academy of Women’s Health.

Monitor HbA1c, but be careful

The American Diabetes Association now recommends measurement of HbA1c as the most appropriate test to use for the diagnosis of diabetes. Details can be found in the January issue of Diabetes Care. This recommendation makes perfect sense for several reasons, not the least of which is that the patient does not need to be fasting for the test so it can be done in your office at the time of the patient visit – there are several point of care (POC) systems available for this.

Not so fast!

The current issue of the journal Clinical Chemistry, the journal of the American Association for Clinical Chemistry, has an article and an editorial pointing out that only two of the available POC systems for HbA1C measurement are reliable. The variability issues with the POC systems also affect serial monitoring which is clinically as important as initial screening.

Not what you wanted to hear! I must quickly add that the available laboratory methods for HbA1c are all felt to be reliable, so if you are not measuring HbA1c in your office follow the recommendation of the ADA: “The test should be performed in a laboratory using a method that is National Glycohemoglobin Standardization Program (NGSP) certified and standardized to the Diabetes Control and Complications Trial (DCCT) assay.”

If you do measure HbA1c in your office, please read the Clinical Chemistry articles and make changes as appropriate.

An HbA1c level >6.5% is diagnostic but is not necessarily an indication to begin pharmacologic therapy. That decision will depend on many other factors including personal medical history, family history, BMI, blood pressure, fasting glucose and lipid profile. A fasting glucose <126 mg/dL in the presence of an elevated HbA1c in a previously undiagnosed patient should not negate the diagnosis of diabetes but should point you and the patient in the direction of lifestyle modification as the first line of intervention. This is of course essential for all patients with type 2 diabetes no matter how far from 'normal' the lab results are.

The number and classes of drug therapies for type 2 diabetes has expanded substantially over the last decade and continues to grow. The number of persons newly diagnosed with diabetes appears to be expanding even faster, with the most rapid expansion being in waist circumference. The only thing 'wearing thin' is the number of excuses we hear for not being able to lose weight to help control or stave off diabetes and other preventable conditions. Many are unfortunately legitimate – many more are just excuses!