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HA1c : Just the Tip of the Iceberg?

In medicine, we necessarily rely on making diagnoses which rely heavily upon objective data, laboratory values, normal values, and labels. Treatments are frequently prescribed based on these cutoff values, and patients and physicians alike rely on follow up laboratory values to assess the success of the treatments and assume future risk based on those values. But, what if those assumptions are wrong or incomplete? In medicine, there are examples of where, in hindsight, common practices were determined to be incorrect or incomplete. It is known that it can take years for physicians to change ingrained habits even after new research shows new information. Sometimes, the hardest changes are those that go against what seems like “common sense” or to follow “logic.” Two examples of this that come to mind are hormone replacement therapy for post menopausal women and blood transfusions in the treatment of childhood acute leukemia. Since men tended to suffer heart attacks a decade earlier than women, it was thought that estrogen protected women against heart attacks, and hormone replacement therapy for menopause was commonplace. Then, the Women’s Health Initiative study was stopped early in 2005 as it showed increased risk of heart disease, stroke, and dementia. Another example of an unexpected result in a medical trial occurred when a cohort of patients being treated for acute leukemia refused transfusions of blood products and actually had improved survival compared to those that had the recommended transfusions. This happened a long time ago, and the trend of patients having improved outcomes with less transfusions has been repeated in cardiac surgeries and other settings as well. But, how does this relate to Rainier Medical? Well, it is the heavy reliance on the hemoglobin A1c (HA1c). A HA1c is a measure of the amount of glucose attached to hemoglobin. This happens when the amount of glucose is above normal in the blood. When I started residency, HA1c was new, and we still used frequent blood sugar testing and glucose tolerance tests when controlling diabetes. However, these days, it seems like the HA1c is much more commonly the main parameter upon which treatment decisions are based. Indeed, people who have diabetes sometimes do not check their blood sugar at home and instead rely on the HA1c, which is not necessarily against medical advice. This leaves me with three concerns which I think are sometimes overlooked:

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