‘Brittle’ diabetes encompasses harder-to-control blood sugar
DEAR DR. ROACH: I am 74 years old and have been a brittle Type 1 diabetic for 50 years. I have no history of heart disease. My doctor of 40 years recently retired and had me control my hemoglobin A1C to a range of 5.9-6.2. My new doctor, who is in her mid-30s, wants me to elevate my hemoglobin A1C to 8.0. Is this the new way of controlling blood sugar? I am confused! Can you please explain the difference in opinion? -- E.S.
ANSWER: “Brittle” diabetes is when it is hard to control too-high and too-low blood sugars.
The A1C is a blood test that looks at average blood sugar over the past few months. A normal A1C is between 4 and 5.6%. People with normal A1C levels are at very low risk of complications from diabetes, especially of the kidneys (leading to dialysis), eyes (which ultimately leads to blindness) and nerves (diabetic neuropathy is painful and predisposes to injury).
On the other hand, low A1C levels put people at higher risk for low blood sugar (hypoglycemia), which can be very dangerous. People with Type 2 diabetes and blockages in blood vessels (or at very high risk) were shown to have higher risk of heart attack. For this reason, recent guidelines for older adults with Type 2 diabetes have had more relaxed goals, in the range of 7 to 8, although these do need to be individualized. For Type 1 diabetes, most guidelines still recommend an A1C goal of less than 7%. However, for a person with Type 1 diabetes who also has other medical problems that are likely to impact mortality, and for those at high risk for severe hypoglycemia, a more relaxed goal is not un- reasonable.
Hypoglycemia is too-low blood sugar, with risk of confusion. This is a big problem in people with brittle diabetes.
A lower A1C is associated with a lower risk of damage to small blood vessels, which is what is responsible for nerve damage, eye disease and most diabetic kidney disease. If you have been able to keep your A1C in the range of 5.9 to 6.2, which is not an easy feat, and have not had any serious episodes of low blood sugar recently, I would wonder why your new doctor feels your blood sugar needs to be substantially higher than it is.
Finding the right balance between good control and freedom from hypoglycemia isn’t always easy, but these are the risks and benefits your doctors have been considering.
DEAR DR. ROACH: I have a relative who has had inflammatory bowel disease for 12 years. In November, he was started on Xeljanz. For the past several months, he has had a persistent elevation of alkaline phosphatase. It’s less than 1.5 times the upper limit of normal. Isoenzymes were fractionated, revealing it to be 100% of intestinal origin. Could this be a harbinger of intestinal perforation? -- I.G.
ANSWER: Tofacitinib (Xeljanz) is a biological medication for inflammatory bowel disease, specifically, ulcerative colitis. It can affect the liver, and a serious but rare side effect is perforation of the intestine. However, this was seen in people taking Xeljanz for rheumatoid arthritis, often in connection with NSAID drugs. There was no increased rate of intestinal perforation in people taking the drug for ulcerative colitis.
An increase of less than 1.5 times the upper limit of normal is a very mild increase. Three times the upper limit of normal is a cause for more concern. About 20% of people with ulcerative colitis will have a transient increase in liver enzymes, and about half of those will be of the alkaline phosphatase.
Based on this information, I think intestinal perforation is unlikely.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Dr., Orlando, FL 32803.