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Can A1c be TOO low?

Discussion in 'Parents of Children with Type 1' started by DsMom, May 29, 2011.

  1. DsMom

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    Read a sad article about someone who lost her dad to T1. She talked about how his A1c was usually under 5 and never over 6. It seemed that he had frequent hypo seizures, which ultimately did claim his life.

    My question, is there an A1c # that is too low or unsafe for someone with T1?? We all of course try to shoot for that great number--but at what point is it going overboard?
     
  2. Amy C.

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    If the reason for the low A1c was the low blood sugars, then yes, that A1c was too low.

    I don't look at an A1c in a vacuum, but with the supporting evidence of the blood sugar readings.
     
  3. emm142

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    It's not so much that an a1C can be too low. More that in someone with diabetes, a low a1C can indicate that too many low blood sugars are happening.
     
  4. mmgirls

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    Yes, remember that an A1C is just an average.

    ALthough I have met adult T1's with A1C in the 5's, BUT they CGM and test at least 6 times a day.

    Without CGM I would think that a person would have to test more than 6 times a day, and be very dedicated to counting carbs and making better food choices.

    A low A1C with recurrent severe hypos is never good.
     
  5. bnmom

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    At our endo appt in January they said Bobby's A1C was 5.8...and in my head I'm thinking woo hoooo, nailed it! score!

    Then the NP asked if Bobby was experiencing a lot of lows. I said no - couple here and there, but not many. Then she said 'well with that score he has to be experiencing a lot of lows, so if you don't know about them they must be happening during the night'

    That totally popped my balloon...and freaked me out even more about nighttime.

    So, I don't know what number they'll be happy with - guess we'll find out when we hit it :p
     
  6. Tuff

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    Our endo says he sees red flags when he sees A1C's below 6.5 as he says there are too many lows at that level and therefore the child wouldn't be safe. Personally I would love an A1c of 6.5 for my son but I understand his point.
     
  7. Lisa P.

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    An A1C that is lower than what the endo expects is a red flag that simply needs to be explained.

    A1C is a great tool, it gives you information to help know what to look for and make adjustments if necessary.

    Having a low A1C questioned is a good thing. Then you set up a plan, and you determine whether the low number reflects lows (particularly those scary undetected lows that can go on for so long and then cause huge trouble seemingly out of the blue -- the low A1C stops that bolt from the blue, it makes you look at the holes you didn't look at before). If it doesn't reflect lows, then it's all good. If it does, you've detected a dangerous and hidden trend. Win/win.

    What I do have an issue with is endos or CDE who say they automatically want to see a number above X. That's too arbitrary for me, because frankly we could have a 30 every other day and with our highs we could still have an in-range A1C. And I know folks on here with A1Cs below 6 and I believe they don't get lows. So you have to use the number, like a PP said above, in context. And you have to use it, not just hear it and do the happy snoopy dance or hide under a rock in shame. :p It's just a number (I know, I have to work on seeing it as a grade myself. . . :eek:)
     
  8. CallMeSpunky

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    I think if the parent or pwd is certain that A1C was achieved through good control and not a high abundance of lows, then go for it.

    My sons are in the 6s since pumping and lower 6s since using a cgm, we have lows like all do, but I know that the average was achieved through being able to run him in the low 100s comfortably rather than the upper 100s.

    Its a tool as a pp said, each person is different. 2 different people can have the same A1C yet very different numbers. Just my opinion.
     
  9. etringali

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    We've had A1c's in low 6's. Dr was concerned at potential for too many lows, but as we are frequent testers and have a CGM she wasn't too worried, just told us to be alert for lows.
     
  10. wilf

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    With an A1C of 5.8, your son is almost certainly still honeymooning. A1Cs in the 5s are possible without many lows during the honeymoon, but still take hard work so good for you! That having been said, nighttime testing is a good idea and most of us on here do it.

    You goal should be to achieve the lowest A1Cs possible without your son experiencing unacceptable lows and without you obsessing about the D to the exclusion of the important things in life.. :cwds:
     
  11. wilf

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    In answer to the OP, there was obviously something going badly wrong in the case you read about. Bad seizures are a huge red flag, and should have led to major changes in the insulin regimen. For someone with frequent seizures to have an A1C in the 4s and 5s speaks to some combination of personal recklessness and medical malpractice. It's very unfortunate, but also extremely rare for something like this to occur.

    My sense is that if you have an older child who can feel their lows and are diligent and using a CGM and things are going optimally then A1Cs in high 5s are about the lowest that is safely possible, and that if you are not using a CGM for an older child who can feel their lows but are equally diligent and things are going optimally then A1Cs in mid 6s are about the lowest that is safely possible.

    The lowest safe A1Cs for toddlers and young children, for children who can not feel their lows, and during puberty will be considerably higher.

    Obviously in seeking to get the best possible A1Cs we have think about overall quality of life - there is a balance to be struck between working hard to have good numbers, and ensuring that we spend most of our time on the things that really matter (and not the diabetes).. :cwds:
     
  12. Darryl

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    A low A1C in itself is good for long term health, but only to the extent that the low A1C can be maintained without unacceptable levels of hypoglycemia. Frequent seizures from hypoglycemia - or even one - would be enough cause to raise the average blood sugar target.

    Personally I think it would it would be risky to have an A1C under 6.5% (average BG around 140) without using a CGM or testing very often. On the other hand, an average BG of 140 is above was the body was designed to tolerate. It is worth trying to attain a lower A1C than 6.5%, but it does take using a CGM or testing often (or being in the honeymoon) to shoot for a lower target safely.
     
  13. betty6333

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    Yup. I am on the same page with this. We use a CGM with our son and without it, I would not want my sons a1c under 6.5 or so. His diabetes is just too unpredictable. YDMV of course! BUT for my son we have seen how variable BG can be. My son does not wake up for lows. Before the CGM he had many many lows and he did not wake for them. Knowing what we know now I wish we had had the CGM MUCH sooner than we got it. We have used it about 3 years now.... and for us... it is worth every single penny...
     
  14. dejahthoris

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    I read in the Pink Panther book they recommend a higher a1c for smaller children. Does that mean you are less in danger of a low as you get older?
     
  15. Tuff

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    No it means that toddlers aren't usually able to feel or at least verbalize their lows and so it isn't safe for them to aim for lower A1C's. The goal is that hopefully they will learn to recognize their lows as they get older and you can aim for lower A1C's then. Unfortunately it doesn't always work that way as a lot of older children don't feel all of their lows either - especially at night.
     
  16. Darryl

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    Younger children have more sensitivity to insulin, and may be less able to self-identify symptoms than older kids, so all else being equal they may need a higher A1C, but at the same time the youngest children have to live the longest with higher than normal blood sugars.

    In my opinion, the first step with a young child should be to explore the option of using a CGM. If a CGM can be used, then the safe A1C level (or more precisely, the safe target BG level) will be lower than if not using a CGM. Then there is the practical reality of monitoring BG using the CGM and determining what target level results in an acceptable level of hypoglycemia. This target may need to be changed over time, or at different times of day (i.e., one target at night, one target during the day), or even from day to day depending on that day's basal insulin needs and overall variability (on calm days, the target can be somewhat lower).

    It is somewhat archaic, in my opinion, to specify that a child should be at a certain minimum A1C depending on their age, or for an endo to assume that just because A1C is lower than such a target, that it is "too low" unless there are unacceptable hypos.

    It may not sound so important on the surface to "tailor" target A1C to the individual child, or to adjust this target often to optimize the overall A1C, but then again every 1% difference in overall A1C results is a 50% to 70% difference in long term complication risk. It is worth thinking about it in more detail than the pink panther book might suggest for all children of a given age.
     
  17. Tuff

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    I don't know if this is true but our endo has always claimed that the younger kids that run higher for several years show zero increase in risk of complications because they are so resilient. Have other endos said this to anyone?
     
  18. hawkeyegirl

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    I've heard people on this board say that endos have told them this, and I have yet to see anyone produce a study showing that it is true. My gut instinct tells me that it's more a product of the fact that a child diagnosed very young will have diabetes for so many years that a couple of years of higher a1cs at the beginning doesn't have a big effect. That being said, I didn't intentionally run Jack higher when he was little.

    ETA: Just found the study Jeff posted. I was aware that kids who are diagnosed very young seem to have some innate protective capacity against kidney disease, but had never seen that particular chart. That's big, obviously, but there are many other complications that can befall T1s.
     
  19. wilf

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    If by "run higher" he meant up around 9, that's one thing and it may be true.

    But if he's suggesting "run higher means they can run at 12 or higher with no repercussions then that is utter nonsense. Wishful thinking.
     
  20. Tuff

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    I have always wondered if the endos just said this to reassure parents of toddlers who need to run higher for safety reasons. Jeff's post about the study is encouraging even if it is just about the kidneys.
     

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