Case presentation: 29-year-old woman with 15-year history of type 1 diabetes (DM1) currently on treatment with Glargine, and Aspart pre-meals. She is on continuous glucose monitor (CGM) intermittently. We describe her glycemic control for the past 5 years at 3 three different times. On initial visit, she presented with fatigue and polyuria, A1c of 10.8% and fasting glucose (FG) of 184 mg/dl. CGM indicated hyperglycemia with levels above 300 and time-in-Range (GTR) of 17%. BMI 27.9. Insulin regimen was changed to the current one. We also encourage self-monitoring of glucose, nutrition control and regular physical activity. On second-year follow-up, she reported good compliance with treatment and recommendations but still limited physical activity. Her glycemic control had significantly improved by that time. A1c was 7.1%, FG was 107 mg/dl and she had no symptoms of hyperglycemia. CGM indicated less hyperglycemia mostly below 200 and a GTR of 22%. Insulin doses were adjusted accordingly. On the most recent follow-up, A1c was 7.7 and FG 151 but CGM indicated less glucose variability and GTR of 58%. She continued to report good compliance but this time also an improvement on physical activity.
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Perú has one of the lowest incidence of DM1 in South America reported by the Diamond study. Tight glycemic control reduces the risk of vascular complications in DM1 however only few patients achieved this goal in Latin America. This could be related to the limited access to diagnostic tests and treatment. Our patient´s A1c improve significantly and reached a value around the goal suggested by ADA (7%). One of the limitations of A1c is that it doesn’t indicate glucose variability. FG is a common parameter used during follow-up visits in our country. Even though, our patient FG levels improved, this value is not useful to assess glycemic control overtime. CGM has become an important devise to obtain information regarding glucose variability and GTR making management more precise, even when use intermittently. We consider our patient had a better control over time as evidence by the GTR and less glucose fluctuations.
DM1 is a chronic disease and patients can get overwhelmed trying to reach a specific target. What are our realistic goals in DM1 control? Perhaps, instead of pursuing a specific number of A1c we should focus in increasing GTR. New technologies such as CGMs, help to improve glycemic control. Compliance with treatment and self-glucose monitoring are still the most important aspect in management of diabetes. Our patient reports good quality of life, family support and has no complications despite time since diagnosis.
Peruvian Air-Force Central Hospital
LIMA, Lima, Peru
Medical Doctor, Endocrinologist, with special interest in the field of Prevention and Education in Diabetes.