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glycemic variability &#40;GV&#41;&#44; a third measurement related to glycemic control&#44; 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&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The concept of GV refers to an individual&#8217;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&#46; Therefore&#44; just like HbA1c&#44; patients who have a greater GV could have worse progress&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In this issue&#44; a retrospective study by Jord&#225;n-Domingo et al&#46;<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 &#40;MBS&#41; level &#40;&#62;140&#8239;mg&#47;dL&#41; are significantly related to an increase in mortality at 2&#46;7 years of follow-up&#46; Though it is not a novel finding that elevated MBS is an indicator of poor prognosis&#44; in the case of GV&#44; it is necessary to dig deeper into its true value as an indicator and as a potential causative agent of this poor prognosis&#46; 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&#44; acute pathologies&#44; such as ischemic cardiopathy&#44;<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&#46; There is less evidence from patients hospitalized in internal medicine wards&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> which adds to the interest in Jord&#225;n-Domingo et al&#46;&#8217;s analysis&#46;<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&#46; 1</a>&#44; though some of them have only been verified in animal models&#59; again&#44; more research in this regard is necessary&#46; In any case&#44; all of them are related to an increase in cellular death and inflammation with endothelial dysfunction&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Therefore&#44; 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&#46; However&#44; at present&#44; there are several issues which much be clarified&#46; The first is the method of measuring GV&#44; knowing full well that some of these indexes have been designed for continuous glucose monitoring data&#46; In the analysis by Jord&#225;n-Domingo et al&#46;<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&#44; with the bias of an absence of postprandial measurements&#44; which could limit its real value&#46; However&#44; there are more indexes such as the standard deviation of measurements&#44; the M index&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> or the J index&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> none of which are considered a gold standard for its universal evaluation&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">On the other hand&#44; we likewise do not know if the number of glycemic excursions above or below physiological values is also related to prognosis&#44; what the ideal time for measuring GV is&#44; or what its normal range and target values should be for improving prognosis&#46; These issues will no doubt be elucidated in the future&#46;</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&#46;</p></span></span>"
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DOI: 10.1016/j.rceng.2020.03.006
Glycaemic variability. What glycated haemoglobin hides
Variabilidad glucémica. Lo que la glicada esconde
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J.C. Arevalo-Lorido
Corresponding author
joscarlor@gmail.com

Corresponding author.
, J. Carretero-Gómez
Servicio de Medicina Interna, Hospital de Zafra, Badajoz, Spain
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