Editorial
Glycaemic variability. What glycated haemoglobin hides
Variabilidad glucémica. Lo que la glicada esconde
J.C. Arevalo-Lorido
, J. Carretero-Gómez
Corresponding author
Servicio de Medicina Interna, Hospital de Zafra, Badajoz, Spain
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What glycated haemoglobin hides" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "345" "paginaFinal" => "346" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J.C. Arevalo-Lorido, J. Carretero-Gómez" "autores" => array:2 [ 0 => array:4 [ "nombre" => "J.C." "apellidos" => "Arevalo-Lorido" "email" => array:1 [ 0 => "joscarlor@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "J." "apellidos" => "Carretero-Gómez" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Medicina Interna, Hospital de Zafra, Badajoz, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Variabilidad glucémica. Lo que la glicada esconde" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1392 "Ancho" => 2500 "Tamanyo" => 203341 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pathogenic mechanisms that imply glycemic variability with a poor prognosis.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Given the current knowledge on glucose homeostasis, the fact that poor glycemic control influences the prognosis of our patients with diabetes mellitus (DM) seems unquestionable. A multitude of studies throughout the years have shown us how an increase in glycosylated hemoglobin (HbA1c) figures,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> hyperglycemia,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and hypoglycemia,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> all of which are markers of poor glycemic control, affect patients’ prognosis, increasing micro- and macrovascular complications, cardiovascular mortality, and overall mortality.</p><p id="par0010" class="elsevierStylePara elsevierViewall">More recently, glycemic variability (GV), a third measurement related to glycemic control, has also been implicated in poor glycemic control<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and thus a worse prognosis when this variable is elevated.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The concept of GV refers to an individual’s fluctuations in plasma glucose from the highest to the lowest levels over a certain period of time that exceeds the range expected in normal physiological conditions. Therefore, just like HbA1c, patients who have a greater GV could have worse progress.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In this issue, a retrospective study by Jordán-Domingo et al.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> of patients with DM hospitalized in internal medicine wards shows us how measurement of GV during hospitalization along with an elevated mean blood sugar (MBS) level (>140 mg/dL) are significantly related to an increase in mortality at 2.7 years of follow-up. Though it is not a novel finding that elevated MBS is an indicator of poor prognosis, in the case of GV, it is necessary to dig deeper into its true value as an indicator and as a potential causative agent of this poor prognosis. It should be noted that the prognostic information derived from GV has mainly been obtained in the intensive care setting<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and on severe, acute pathologies, such as ischemic cardiopathy,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> in which the stress related to the acute illness could interfere in the interpretation of the results. There is less evidence from patients hospitalized in internal medicine wards,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> which adds to the interest in Jordán-Domingo et al.’s analysis.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The proposed mechanisms by which GV could affect the prognosis are described in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>, though some of them have only been verified in animal models; again, more research in this regard is necessary. In any case, all of them are related to an increase in cellular death and inflammation with endothelial dysfunction.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Therefore, it seems clear that this new variable may be valuable when it comes to establishing treatment guidelines that minimize these mechanisms and thus improve the prognosis of patients with DM. However, at present, there are several issues which much be clarified. The first is the method of measuring GV, knowing full well that some of these indexes have been designed for continuous glucose monitoring data. In the analysis by Jordán-Domingo et al.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> the coefficient of variance of capillary glucose measurements taken during the hospitalization is calculated, with the bias of an absence of postprandial measurements, which could limit its real value. However, there are more indexes such as the standard deviation of measurements, the M index,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> or the J index,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> none of which are considered a gold standard for its universal evaluation.</p><p id="par0030" class="elsevierStylePara elsevierViewall">On the other hand, we likewise do not know if the number of glycemic excursions above or below physiological values is also related to prognosis, what the ideal time for measuring GV is, or what its normal range and target values should be for improving prognosis. These issues will no doubt be elucidated in the future.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare that they do not have any conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Arevalo-Lorido JC, Carretero-Gómez J. Variabilidad glucémica. Lo que la glicada esconde. Rev Clin Esp. 2021;221:345–346.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1392 "Ancho" => 2500 "Tamanyo" => 203341 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pathogenic mechanisms that imply glycemic variability with a poor prognosis.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Glycemic control and excess mortality in type 1 diabetes" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. 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