Part 2 Routinely Identifying Postprandial Hyperglycemia Challenges Tools

Part 2 Routinely Identifying Postprandial Hyperglycemia - Challenges & Tools An Educational Service from GLYCOMARK is a registered trademark of Glyco. Mark, Inc. 1 © Glyco. Mark, Inc. All rights reserved NOTE: Please see slide notes below each page for study and slide details

Looking Beyond a “Good” A 1 C of 7% mg/d. L 400 A 1 C may not reflect postprandial extremes due to blood glucose averaging and individual variability 300 A 1 C 7% 200 180 70 50 185 154 123 Range of Estimated Average Glucose Fingerstick tests may miss glucose peaks due to timing Breakfast Lunch Dinner Bedtime 2 D Nathan et al, Translating the A 1 C Assay into Average Glucose Values, Diabetes Care, Vol. 31, No. 8, Aug

Postprandial Hyperglycemia Assessment Tools Tool Description Drawbacks Hb. A 1 C Mean of last 60 -90 days • Can mask extremes; cannot change quickly • Interferences (hemoglobinopathies) • Individual variability in glycosylation rates Fructosamine Mean of last 3 -4 weeks • Can mask extremes • Individual variability in glycosylation rates Oral Glucose Tolerance Multiple data points Test (75 gr load) on one day • Good measure of postprandial glucose but time -consuming for patients and providers • Only measures one day in time so could be skewed by illness or stress Continuous Glucose Monitors 24/7 continuous blood glucose measurements • Excellent tool but cost and reimbursement is issue for T 2 D and some T 1 D • Time-consuming training and report review • Some patients will not wear sensor 24/7 Frequent Fingerstick Blood Glucoses Single data points • • 1, 5 -Anhydroglucitol (1, 5 -AG; GLYCOMARK) 1 -2 week measure of average peak blood glucose • Not accurate in advanced kidney or liver disease • Individual variability in renal thresholds especially during pregnancy 3 Can miss peaks due to timing Patient adherence to frequent PPG testing Cost and insurance limits on BG strip quantity Unreadable/inaccurate glucose logbooks

1, 5 -Anhydroglucitol (1, 5 -AG) • Provides an estimated average peak glucose (e. APG) over the previous 1 -2 weeks • Used when continuous glucose monitor or frequent postprandial fingerstick glucose tests not available • Non-fasting serum or plasma test that can be used as routine marker for PPH • Typically ordered when A 1 C is 6 -8% and to monitor therapy change impact on PPH 4

1, 5 -Anhydroglucitol (1, 5 -AG) A monosaccharide similar to glucose 1, 5 -anhydroglucitol 1, 5 -anhydro-D-glucitol 1 -deoxyglucose D-glucose HO HO O O OH OH OH HO OH 5 HO OH

1, 5 -Anhydroglucitol Found in Most Foods Highest content - soybeans, grains, rice, pasta, beef, pork, tea 6

Physiology of 1, 5 -Anhydroglucitol (1, 5 -AG) Why 1, 5 -AG decreases with hyperglycemia 1, 5 -AG Food intake (5 -10 mg) Normoglycemia 1, 5 -AG Food intake (5 -10 mg) 1, 5 -AG Digested Blood stream Most 1, 5 -AG is reabsorbed in renal tubules Hyperglycemia Tissue pool of 1, 5 -AG Excess glucose blocks 1, 5 -AG reabsorption Blood stream Liver Production Kidney Serum 1, 5 -AG stays HIGH Urinary 1, 5 -AG excretion limited (5 -10 mg) 7 Tissue pool of 1, 5 -AG Kidney Serum 1, 5 -AG is LOW Large amounts of 1, 5 -AG excreted in urine

1, 5 -Anhydroglucitol – The “Good” Sugar Inverse relationship to glucose >20µg/m. L Median - No diabetes 300+ mg/d. L 1, 5 -AG 20+µg/ml Normoglycemia x a n. M a e M <140 mg/d. L 8 <14µg/m. L normally found in diabetes e s o c u l G <10µg/m. L frequent peaks over 180 mg/d. L Extreme hyperglycemic <6µg/m. L excursions frequent peaks over 200 mg/d. L 1 µg/ml

1, 5 -AG Correlation with CGM Mean Postmeal Maximum Glucose (MPMG) Patients sorted by glycemic excursions as measured by CGMS (AUC-180) and subdivided into two populations – bottom 50 th percentile (Group 1) and top 50 th percentile (Group 2) CGM MPMG (mg/d. L) P < 0. 05 Group 1 Group 2 A 1 C (%) Not statistically different Group 1 Group 2 1, 5 -AG (µg/m. L) P < 0. 05 Group 1 Group 2 Authors’ Conclusions • 1, 5 -AG reflects CGM glycemic excursions (MPMG and AUC/180) more robustly than fructosamine or A 1 C • 1, 5 -AG reflected varying postmeal glucose levels, despite similar A 1 Cs • 1, 5 -AG may be a useful adjunct to A 1 C in moderately controlled T 2 D where SBGM is infrequent and often only in fasting state 9 Dungan, K. , Buse, J. et al. Diabetes Care, June 2006

A 1 C Can Mask Hyperglycemic Excursions 1, 5 -AG marker measures blood glucoses >180 mg/d. L 7 Days of Continuous Glucose Monitoring 6 spikes Renal Threshold 18 spikes 52 year old female A 1 C 7. 43% Ave. CGM Max Glucose 195 mg/d. L 1, 5 -AG 12. 4 µg/m. L 49 year old male A 1 C 7. 27% Ave. CGM Max Glucose 235 mg/d. L 1, 5 -AG 10 Dungan, K. , Buse, J. et al. Diabetes Care, June 2006 4. 5 µg/m. L

For more information • For a listing of postprandial hyperglycemia outcome studies, please visit www. glycomark. com/postprandialhyperglycemia • For a listing of studies about the 1, 5 -anhydroglucitol biomarker for postprandial hyperglycemia, please visit www. glycomark. com/product/studies • For a 3 -minute overview about the 1, 5 -anhydroglucitol biomarker, please visit www. glycomark. com/movie 11