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September 20, 2007

A1c (Glycohemoglobin, HgbA1c)

Question from Elizabethtown, Kentucky, USA:

We just returned from my son's quarterly endocrinology appointment. His A1c was 11.7, which climbed from 9.6. We are floored by this and the doctor seemed to be stumped. His blood glucose readings have all been in the range of 90 mg/dl [5.0 mmol/L] to 140 mg/dl [7.8 mmol/L] over the past two months although, in June, he went up to 260 mg/dl [14.4 mmol/L] sometimes, with a couple high days in the 400s mg/dl [over 22.2 mmol/L]. Last month, he had one high day in the 500s mg/dl [27.8 mmol/L] because his pump tubing was kinked, but dropped back into normal range once he changed his set for his insulin pump. We downloaded all the readings from his meter and pump to make sure that he recorded everything correctly and he has. His activity level is extremely high as he has physical conditioning at school for 90 minutes, followed by high school soccer practice for two hours. He is running approximately 1.5 miles every day. We cannot figure out how his A1c can be so high. We even made sure that his meter was calibrated correctly and the doctor took a second A1c reading on a different machine to make sure the machine was not malfunctioning. How can this be? What do you recommend to help him bring it down? These have been the best readings he has had since being diagnosed and he was very proud of the was he has been controlling his levels, but, today, walked out of the doctor's office very discouraged by the A1c. We return in three months, but they have ordered another A1c in a month to see if it is coming down.

Answer:

If the A1c test were done correctly and repeat check shows similar values, then there are high blood sugars not being recognized, according to what you have written. I would watch him carefully and make sure that the full bolus doses are being given. I would also download his pump twice-a-week for the same reasons to make sure that it is delivering what is scheduled and that there are no gaps. Such a dramatic rise in A1c without obvious illness usually means missing insulin and/or major overeating so that close and direct surveillance by parents should figure out if this is the case.

SB