Continuous Glucose Monitoring– Derived Data ReportdSimply a Better Management Tool Diabetes Care 2020;43:2327–2329 | https://doi.org/10.2337/dci20-0032 The introduction of A1C into routine diabetes care some 30 years ago pro- vided the first reliable marker of glycemic control, clearly related to devastating chronic complications of diabetes. A1C became the standard metric to judge the quality of diabetes care and the primary outcome for all diabetes intervention trials investigating novel medications and new technologies. This dependence on A1C as our sole glycemic management guide and primary outcome measure was questioned by some investigators (1); however, the A1C was familiar and con- venient and became the key diabetes pay-for-performance quality metric in the U.S. After decades of the “A1C era” in diabetes care, it is now evident that the management of diabetes guided by A1C has not yielded our desired re- sults, and despite novel medicines and diabetes technology the mean A1C has actually deteriorated in the last decade (2–5). As national A1C levels were slip- ping, an impactful article entitled “Re- surgence in Diabetes-Related Complications ” was published (6), pointing out that while health care access, delivery, and preven- tive services are far from ideal, we also need to focus on innovative strategies to safely achieve glycemic targets. It seems fair to ask, what went wrong? Wasn’t the introduction of continuous glucose monitoring (CGM) going to transform diabetes management (7)? While it often takes 17 years to get approved therapies or technology inno- vations adopted and implemented in clinical practice (8), we believe that in the case of CGM, effective implementa- tion will also involve a refinement of our management philosophy. Our current training on use of the CGM glucose profile and data report is to always address any noted patterns of hypogly- cemia first. This is a sound principle, and using CGM we have been extremely successful in minimizing hypoglycemia as demonstrated in randomized clinical trials (9–11) and cohort studies (12). Unfortunately, in routine clinical care, we often forget the word first in the CGM teaching principle of “address hypogly- cemia first.” We are happy we prevented or reversed the feared and potentially dangerous condition of hypoglycemia, but then we often do not aggressively shift our focus to minimize the hyper- glycemia usually also present. Maybe this is because the hyperglycemia is generally much less symptomatic and is a long- term issue that does not evoke the same urgency of attention as hypoglycemia. We seem surprised when the A1C actu- ally drifts up or the CGM time in range (TIR) 70–180 mg/dL seems stuck at 50% when the international consensus tar- get for TIR is over 70%. The “zero-harm strategy” (13) of “no hypoglycemia” ad- vocated by many may finally prove harm- ful by also being associated with a general increase in hyperglycemia and chronic complications of diabetes (3,6). The big question for every endocrinologist, pri- mary care physician, nurse practitioner, pharmacist, or diabetes educator is, with the availability of CGM, are we all ready to adopt a balanced diabetes manage- ment philosophy of aggressively mini- mizing hyperglycemia (time above range [TAR]) and hypoglycemia (time below range [TBR]) while maximizing TIR? Would such a TIR-centric approach to the day-to-day management of diabetes finally prevent or minimize acute and chronic diabetes complications (14)? In this issue of Diabetes Care, an im- portant report by Dr. Elena Toschi and colleagues from the Joslin Diabetes Cen- ter starts with an exemplary observation: “Current guidelines for older adults with T1D [type 1 diabetes] recommend less stringent hemoglobin A 1c (A1C) targets to mitigate hypoglycemia... . However, studies have shown that liberalization of A1C may not protect against the risk of hypoglycemia in the older population” (15). Exactly! One becomes tempted to think that the current guidelines for particularly 1 University Children’s Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia 2 Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia 3 International Diabetes Center at Park Nicollet and HealthPartners, Minneapolis, MN Corresponding author: Tadej Battelino, tadej.battelino@mf.uni-lj.si T.B. and R.M.B. contributed equally to this commentary. © 2020 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. More information is available at https://www.diabetesjournals.org/content/license. See accompanying article, p. 2349. Tadej Battelino 1,2 and Richard M. Bergenstal 3 Diabetes Care Volume 43, October 2020 2327 COMMENTARY Downloaded from http://diabetesjournals.org/care/article-pdf/43/10/2327/630674/dci200032.pdf by guest on 01 September 2022