醫聲論壇

請問有人有遇到空腹血糖200多, 可是HbA1c都完全正常的嗎?這個病人不是只有抽一次血喲, 是每次抽血都這樣,怎麼會有這種情形呢?病人否認抽血前一天有吃什麼宵夜或喝酒.

換家檢驗單位啦

最近一個月才有高血糖的問題ㄇ?

有無 Anemia or other systemic disease?

有三多的症狀嗎?

再驗個CBC吧!

某些 Anemia disease 會這樣
我有患者就這樣
A1c 一直只有 4.0.

ccc 寫:某些 Anemia disease 會這樣
我有患者就這樣
A1c 一直只有 4.0.

請問Hb多少以下
影響較明顯?

這個就不是很清楚了

Most physicians periodically determine glycosylated hemoglobin ( Hb A1c ) to estimate plasma glucose control during the preceding 1 to 3 months. 因此HbA1c是看過去3 個月的平均血糖, 而空腹血糖則是指Patient( subject )確實空腹 12 個小時的時候的血糖, 因此一般狀況下, 空腹血糖 200 mg/dl多, 而Hb A1c 卻正常? 就不太可能存在了 !!必定有某一環節出錯 ?!!!

板凳到
請哪位META大解說一下

http://david007.myweb.hinet.net/mt/HbA1c.htm

Joelin 文章標題 : Re: 請問空腹血糖和HbA1c的問題

http://david007.myweb.hinet.net/mt/HbA1c.htm
___________________________________________________

但是沒有回答到為何空腹血糖 200多, 而HbA1c 卻是正常阿 ???

A-HSIEN 寫:

ccc 寫:某些 Anemia disease 會這樣
我有患者就這樣
A1c 一直只有 4.0.

請問Hb多少以下
影響較明顯?

我個人是不認為 anemia 的病人其 HbA1C 會相對較低
因為 HbA1C 是 HbA1 中 糖化 (glycated) 的比例
所以如果是一般的 anemia，應當還是依一般的比例去分配

除非
病患的 anemia 是 β-thalassemia --> HbA1 比例降低，而HbA2比例上升
因為HbA1比例降低，所以 HbA1C 在整體 Hb 的比例當然也會降低

http://en.wikipedia.org/wiki/Thalassemia


-------
好巧不巧，只要在 google 上鍵入 thalassemia 及 HbA1C
我們就可以找到一篇台灣人發表的 paper... http://www.clinchem.org/cgi/content/full/47/4/756
裡面的結論我就直接摘錄的......

We conclude that Hb variants can contribute to mismanagement of patients with DM because of falsely low HbA1c values measured by HPLC.

不知以上可以帶給大家一些解答嗎？

pedi 寫:不知以上可以帶給大家一些解答嗎？

給你

WINDOW 寫:

pedi 寫:不知以上可以帶給大家一些解答嗎？

給你

感恩

我 google :
http://pmj.bmj.com/cgi/content/extract/79/933/421

Causes of high/low HbA1c levels
High
Newly diagnosed diabetes mellitus.
Uncontrolled diabetes mellitus.
Non-diabetic hyperglycaemia: acromegaly, phaechromocytoma, thyrotoxicosis, Cushing’s syndrome.
Splenectomy.
Alcoholism.

Low
Haemolytic anaemia: congenital (for example, spherocytosis and elliptocytosis), haemoglobinopathies, acquired haemolytic anaemias—for example, drug induced (dapsone, methyldopa).
Chronic blood loss.
Chronic renal failure (variable).

joelin 寫:(偽可愛) 我 google :

Causes of high/low HbA1c levels
High
Newly diagnosed diabetes mellitus.
Uncontrolled diabetes mellitus.
Non-diabetic hyperglycaemia: acromegaly, phaechromocytoma, thyrotoxicosis, Cushing’s syndrome.
Splenectomy.
Alcoholism.

Low
Haemolytic anaemia: congenital (for example, spherocytosis and elliptocytosis), haemoglobinopathies, acquired haemolytic anaemias—for example, drug induced (dapsone, methyldopa).
Chronic blood loss.
Chronic renal failure (variable).

感恩

感謝Pedi和Joelin大大的詳細解答.
這個病人沒有anemia, Hgb=14, MCV 也是正常的,年紀比較大了，所以也沒做過G6PD的篩檢，下次會再仔細問一下他的病史和家族史。
一年多來的抽血紀錄都差不多, 血糖200~220, HbA1c=5~6, 唯一比較特別的是urine ob++, proteinuria 300
medication: dail 由2#bid-->4#bid, glucophage 2#bid, 血糖卻幾乎沒什麼變化,最好的紀錄是降到180~190, 之後又回到200多, 下次也許會試試glucophage 也加量吧

pedi 寫:不知以上可以帶給大家一些解答嗎？

贊贊贊！！！

這種狀況我們以前也有遇過，chia大也可以問一下患者是否有G6PD deficiency蠶豆症

In healthy individuals, hemoglobin A1c comprises less than 7% of the total hemoglobin that is present. Conditions that can falsely elevate levels of hemoglobin A1c include kidney failure, hypertriglyceridemia, and folate and vitamin B12 deficiencies that are accompanied by slower rates of red blood cell turnover. Conditions that cause more rapid turnover of red blood cells, such as blood loss, sickle cell disease, or glucose-6-phosphate dehydrogenase (G6PD) deficiency, can falsely decrease levels.

chia8153 寫:感謝大家的熱心回答. 可是這個病人沒有anemia, Hgb=14, 一年多來的抽血紀錄都差不多, 血糖200~220, HbA1c=5~6, 唯一比較特別的是urine ob++, proteinuria 300
medication: dail 由2#bid-->4#bid, glucophage 2#bid, 血糖卻幾乎沒什麼變化,最好的紀錄是降到180~190, 之後又回到200多, 下次也許會試試glucophage 也加量吧

不知道你寫得劑量是否錯誤？這樣的劑量即使再加大也沒什麼意義！
應該考慮加其他種類的藥，例如TZD，ACARBOSE，最好的模式是加胰島素。
每一種降血糖藥物能夠減少的HbA1C有限，加大劑量不僅無法達成目標，反而會造成病患肥胖，
甚至於增加胰島素抵抗性，這樣反而得不償失。

虎克 寫:

chia8153 寫:感謝大家的熱心回答. 可是這個病人沒有anemia, Hgb=14, 一年多來的抽血紀錄都差不多, 血糖200~220, HbA1c=5~6, 唯一比較特別的是urine ob++, proteinuria 300
medication: dail 由2#bid-->4#bid, glucophage 2#bid, 血糖卻幾乎沒什麼變化,最好的紀錄是降到180~190, 之後又回到200多, 下次也許會試試glucophage 也加量吧

不知道你寫得劑量是否錯誤？這樣的劑量即使再加大也沒什麼意義！
應該考慮加其他種類的藥，例如TZD，ACARBOSE，最好的模式是加胰島素。
每一種降血糖藥物能夠減少的HbA1C有限，加大劑量不僅無法達成目標，反而會造成病患肥胖，
甚至於增加胰島素抵抗性，這樣反而得不償失。

dail 由2#bid-->4#bid（4#是指daily dose,等於是一次２＃，bid服用)，glucophage 的max daily dose 應該可以加到４＃,所以還有點加量的空間吧？

chia8153 寫:感謝Pedi和Joelin大大的詳細解答.
這個病人沒有anemia, Hgb=14, MCV 也是正常的,年紀比較大了，所以也沒做過G6PD的篩檢，下次會再仔細問一下他的病史和家族史。
一年多來的抽血紀錄都差不多, 血糖200~220, HbA1c=5~6, 唯一比較特別的是urine ob++, proteinuria 300
medication: dail 由2#bid-->4#bid, glucophage 2#bid, 血糖卻幾乎沒什麼變化,最好的紀錄是降到180~190, 之後又回到200多, 下次也許會試試glucophage 也加量吧

其實，從joelin 大大提供的資料，跟你的資料，我覺得有幾點值得追蹤：
1. chronic blood loss
2. chronic renal failure

因為你提到病人 urine ob++, proteinuria 300，所以上述兩個可能都需要考慮

另外，再提供一篇 paper 給您參考，下面這一篇 paper 裡面描述的也是高血糖，低 HbA1C，又無 anemia (Hb 14.1) renal function 是正常的......答案就給您自行參考了（又是台灣人的 paper）

http://www.sim.org.tw/journal/jour18-1/07.PDF

如果您真的想知道病人是否真是那麼一回事，那就 do something 吧

pedi 寫:

chia8153 寫:感謝Pedi和Joelin大大的詳細解答.
這個病人沒有anemia, Hgb=14, MCV 也是正常的,年紀比較大了，所以也沒做過G6PD的篩檢，下次會再仔細問一下他的病史和家族史。
一年多來的抽血紀錄都差不多, 血糖200~220, HbA1c=5~6, 唯一比較特別的是urine ob++, proteinuria 300
medication: dail 由2#bid-->4#bid, glucophage 2#bid, 血糖卻幾乎沒什麼變化,最好的紀錄是降到180~190, 之後又回到200多, 下次也許會試試glucophage 也加量吧

其實，從joelin 大大提供的資料，跟你的資料，我覺得有幾點值得追蹤：
1. chronic blood loss
2. chronic renal failure

因為你提到病人 urine ob++, proteinuria 300，所以上述兩個可能都需要考慮

另外，再提供一篇 paper 給您參考，下面這一篇 paper 裡面描述的也是高血糖，低 HbA1C，又無 anemia (Hb 14.1) renal function 是正常的......答案就給您自行參考了（又是台灣人的 paper）

http://www.sim.org.tw/journal/jour18-1/07.PDF

如果您真的想知道病人是否真是那麼一回事，那就 do something 吧

謝謝您的解答!!!
其實這個病人剛開始時讓我最困擾的是不知道血糖到底是要以FBG 還是 HbA1c為準,若以FBG而言, 算是控制很差,若是以HbA1c而言,算是控制相當好. 不過看起來應該還是以FBG為準,他的HbA1c 的標準可能要放更低了.
urine ob的問題曾經轉介過,可是沒查出原因,也許要做renal biopsy, 或轉hema OPD看看囉

血糖200~220是不是都是空腹血糖?
若飯後藥後的血糖偏低,
也許Hba1c看起來會很不錯.

DAWN PHENOMENON
Everyone, diabetic or not, exhibits some Dawn Phenomenon. It is a natural part of our bodies' circadian rhythms. Some have said it is the way our ancestors had the strength to rise and slay a wooly behemoth for breakfast.

Since most of us fast while sleeping, with teenagers a possible exception, our bodies use stored energy during sleep. If you have read our Nutrition Section, you know that the body uses all three macro-nutrients (carbohydrates, proteins, and fats) to store energy.

The most easily used is the storage medium of carbohydrates, called glycogen. Glycogen is made from glucose, and is stored in the liver and muscles. Since it is basically nothing more than a complex matrix of glucose, it is easy for the body to store and use, something the body does all day long. The technical term for the act of creating and storing glycogen is glycogenesis. When the body calls for the conversion of glycogen back to glucose it is called glycogenolysis.

Another macro-nutrient that is available to be converted to glucose is protein. Most of us think of our protein as being stored in muscle, but the body has protective mechanisms to make muscle wasting its last choice. One of the most useful and readily available sources of protein storage is in blood components, i.e., albumin (plasma). The body uses a process performed in the liver to convert amino acids, the building blocks of proteins, into glucose. The name for this process is gluconeogenesis, literally "the creation of new glucose".

So, what does all this have to do with a high fasting BG? Overnight, usually between 4am and 11am, your body releases some hormones. These are Growth Hormone (GH) from the anterior pituitary gland, cortisol from the adrenal cortex, glucagon from your pancreatic alpha-cells, and epinephrine (adrenalin). These hormones cause an increase in insulin resistance, raising your BG. In addition, these hormones trigger glycogenolysis and gluconeogenesis, adding stored or new glucose to your bloodstream.

Dawn Phenomenon, and its associated increase in insulin resistance, is the reason most diabetics are far more sensitive to carbs in the morning.

Dealing with Dawn Phenomenon
There are many ways of defeating Dawn Phenomenon. You will have to experiment with the following suggestions to see what works for you.

Try eating no food after dinner. This works for people whose Dawn Phenomenon isn't very strong. Basically, it lowers their baseline BG, so that when DP does hit them, the increase keeps them below a certain level, usually 120 (6.7).
Try eating a small snack of fat and protein before bed. Most find that a tablespoon of peanut butter, or some cheese and deli meat are effective. The theory here is that the slow-digesting fat and protein holds their BG high enough overnight to avoid Somogyi Effect (see below).
Eventually, you will learn how the two disparate approaches above work for you. Hopefully, you will set personal targets to guide you, eg., if my BG is below XXX (insert your target here), I need a snack. If my BG is over XXX, I don't need a snack.
The prescription medication Metformin HCl (Glucophage) is often very effective in limiting Dawn Phenomenon for Type-2s and insulin resistant Type-1s. Of course, Type-1s can adjust their basal (slow) insulin regimen to account for Dawn Phenomenon.
Lastly, EAT BREAKFAST. The resulting increase in blood glucose from food will often turn off the continued rise. If you don't, some diabetics will continue to rise until 10-11 am.

SOMOGYI EFFECT
Somogyi Effect, named for Dr. Robert Somogyi, its discoverer, is a high morning BG due to a low overnight. It is most commonly seen with insulin using diabetics, but is also seen with overnight reactive hypoglycemics.

The mechanism is a low overnight, which causes the body to react by releasing many of the same hormones seen in DP. The strongest blood glucose increasing hormone, glucagon, plays an important role. It tells your liver to start glycogenolysis and gluconeogenesis to provide enough glucose for your body to survive. This is sometimes referred to as a Liver Dump. Often, this mechanism over-produces, and you wake to a significantly higher BG.

Setting your bedtime BG target a bit higher, will usually prevent you from having a hypoglycemic event overnight.

u22 寫:血糖200~220是不是都是空腹血糖?
若飯後藥後的血糖偏低,
也許Hba1c看起來會很不錯.

TZD / ACARBOSE
比較會降 PC...

該病人 好像沒給 ...

可以check fructosamine 看看