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Jensch H, Setford S, Thomé N, Srikanthamoorthy G, Weingärtner L, Grady M, Holt E, Pfützner A. Dynamic Interference Testing-Unexpected Results Obtained with the Abbott Libre 2 and Dexcom G6 Continuous Glucose Monitoring Devices. SENSORS (BASEL, SWITZERLAND) 2025; 25:1985. [PMID: 40218498 PMCID: PMC11991141 DOI: 10.3390/s25071985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2025] [Revised: 03/12/2025] [Accepted: 03/21/2025] [Indexed: 04/14/2025]
Abstract
BACKGROUND Sensors for continuous glucose monitoring (CGM) are now commonly used by people with type 1 and type 2 diabetes. However, the response of these devices to potentially interfering nutritional, pharmaceutical, or endogenous substances is barely explored. We previously developed an in vitro test method for continuous and dynamic CGM interference testing and herein explore the sensitivity of the Abbott Libre2 (L2) and Dexcom G6 (G6) sensors to a panel of 68 individual substances. METHODS In each interference experiment, L2 and G6 sensors were exposed in triplicate to substance gradients from zero to supraphysiological concentrations at a stable glucose concentration of 200 mg/dL. YSI Stat 2300 Plus was used as the glucose reference method. Interference was presumed if the CGM sensors showed a mean bias of at least ±10% from baseline with a tested substance at any given substance concentration. RESULTS Both L2 and G6 sensors showed interference with the following substances: dithiothreitol (maximal bias from baseline: L2/G6: +46%/-18%), galactose (>+100%/+17%), mannose (>+100%/+20%), and N-acetyl-cysteine (+11%/+18%). The following substances were found to interfere with L2 sensors only: ascorbic acid (+48%), ibuprofen (+14%), icodextrin (+10%), methyldopa (+16%), red wine (+12%), and xylose (>+100%). On the other hand, the following substances were found to interfere with G6 sensors only: acetaminophen (>+100%), ethyl alcohol (+12%), gentisic acid (+18%), hydroxyurea (>+100%), l-cysteine (-25%), l-Dopa (+11%), and uric acid (+33%). Additionally, G6 sensors could subsequently not be calibrated for use after exposure to dithiothreitol, gentisic acid, l-cysteine, and mesalazine (sensor fouling). CONCLUSIONS Our standardized dynamic interference testing protocol identified several nutritional, pharmaceutical and endogenous substances that substantially influenced L2 and G6 sensor signals. Clinical trials are now necessary to investigate whether our findings are of relevance during routine care.
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Affiliation(s)
- Hendrick Jensch
- Pfützner Science & Health Institute, Haifa-Allee 20, 55128 Mainz, Germany; (H.J.); (N.T.); (G.S.); (L.W.)
- Lifecare Laboratories, 55128 Mainz, Germany
| | - Steven Setford
- LifeScan Scotland Ltd., Inverness IV2 2ED, UK; (S.S.); (M.G.)
| | - Nicole Thomé
- Pfützner Science & Health Institute, Haifa-Allee 20, 55128 Mainz, Germany; (H.J.); (N.T.); (G.S.); (L.W.)
- Lifecare Laboratories, 55128 Mainz, Germany
| | - Geethan Srikanthamoorthy
- Pfützner Science & Health Institute, Haifa-Allee 20, 55128 Mainz, Germany; (H.J.); (N.T.); (G.S.); (L.W.)
- Lifecare Laboratories, 55128 Mainz, Germany
| | - Lea Weingärtner
- Pfützner Science & Health Institute, Haifa-Allee 20, 55128 Mainz, Germany; (H.J.); (N.T.); (G.S.); (L.W.)
- Lifecare Laboratories, 55128 Mainz, Germany
| | - Mike Grady
- LifeScan Scotland Ltd., Inverness IV2 2ED, UK; (S.S.); (M.G.)
| | | | - Andreas Pfützner
- Pfützner Science & Health Institute, Haifa-Allee 20, 55128 Mainz, Germany; (H.J.); (N.T.); (G.S.); (L.W.)
- Lifecare Laboratories, 55128 Mainz, Germany
- Department of Biotechnology, Technical University Bingen, 55411 Bingen am Rhein, Germany
- Institute of Internal Medicine and Laboratory Medicine, University for Digital Technologies in Medicine and Dentistry, L-9516 Wiltz, Luxembourg
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Zoet S, Urgert T, Veldhuis A, van Beijnum BJ, Laverman GD. Quantification of the relation between continuous glucose monitoring observation period and the estimation error in assessing long-term glucose regulation. BMJ Open Diabetes Res Care 2025; 13:e004768. [PMID: 40011057 PMCID: PMC11865789 DOI: 10.1136/bmjdrc-2024-004768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2024] [Accepted: 02/09/2025] [Indexed: 02/28/2025] Open
Abstract
INTRODUCTION The integration of continuous glucose monitoring (CGM) into clinical practice has rapidly emerged in the last decade, changing the evaluation of long-term glucose regulation in patients with diabetes. When using CGM-derived metrics to evaluate long-term glucose regulation, it is essential to determine the minimal observation period necessary for a reliable estimate. The approach of this study was to calculate mean absolute errors (MAEs) for varying window lengths, with the goal of demonstrating how the CGM observation period influences the accuracy of the estimation of 90-day glycemic control. RESEARCH DESIGN AND METHODS CGM data were collected from the DIABASE cohort (ZGT hospital, The Netherlands). Trailing aggregates (TAs) were calculated for four CGM-derived metrics: time in range (TIR), time below range (TBR), glucose management indicator (GMI) and glycemic variability (GV). Arbitrary MAEs for each patient were compared between the TAs of window lengths from 1 to 89 days and a reference TA of 90 days, which is assumed to reflect long-term glycemic regulation. RESULTS Using 14 days of CGM data resulted in 65% of subjects having their TIR estimation being below a MAE threshold of 5%. In order to have 90% of the subjects below a TIR MAE threshold of 5%, the observation period needs to be 29 days. CONCLUSIONS Although there is currently no consensus on what is an acceptable MAE, this study provides insight into how MAEs of CGM-derived metrics change according to the used observation period within a population and may thus be helpful for clinical decision-making.
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Affiliation(s)
- Stennie Zoet
- Faculty of Electrical Engineering, Mathematics and Computer Science, University of Twente, Enschede, The Netherlands
- Department of Internal Medicine, Ziekenhuisgroep Twente, Almelo, Overijssel, The Netherlands
| | - Thomas Urgert
- Faculty of Electrical Engineering, Mathematics and Computer Science, University of Twente, Enschede, The Netherlands
- Department of Internal Medicine, Ziekenhuisgroep Twente, Almelo, Overijssel, The Netherlands
| | - Anouk Veldhuis
- Department of Health and Information Technology, Ziekenhuisgroep Twente, Almelo, Overijssel, The Netherlands
| | - Bert-Jan van Beijnum
- Faculty of Electrical Engineering, Mathematics and Computer Science, University of Twente, Enschede, The Netherlands
| | - Gozewijn D Laverman
- Faculty of Electrical Engineering, Mathematics and Computer Science, University of Twente, Enschede, The Netherlands
- Department of Internal Medicine, Ziekenhuisgroep Twente, Almelo, Overijssel, The Netherlands
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Csermely A, Borella ND, Turazzini A, Pilati M, Sheiban SS, Bonadonna RC, Trevisan R, Trombetta M, Lepore G. Different Times for Different Metrics: Predicting 90 Days of Intermittently Scanned Continuous Glucose Monitoring Data in Subjects With Type 1 Diabetes on Multiple Daily Injection Therapy. Findings From a Multicentric Real-World Study. J Diabetes Sci Technol 2025:19322968241308564. [PMID: 39764582 PMCID: PMC11705298 DOI: 10.1177/19322968241308564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2025]
Abstract
AIMS According to the 2023 International Consensus, glucose metrics derived from two-week-long continuous glucose monitoring (CGM) can be extrapolated up to 90 days before. However, no studies have focused on adults with type 1 diabetes (T1D) on multiple daily injections (MDIs) and with second-generation intermittently scanned CGM (isCGM) sensors in a real-world setting. METHODS This real-world, retrospective study included 539 90-day isCGM data from 367 adults with T1D on MDI therapy. For each sensor metric, the coefficients of determination (R2) were computed for sampling periods from 2 to 12 weeks versus the whole 90-day interval. Correlations were considered strong for R2 ≥0.88. RESULTS The two-week sampling period displayed strong correlations for time in range (TIR, 70-180 mg/dl; R2 = 0.89) and above range (TAR, >180 mg/dl; R2 = 0.88). The four-week sampling period showed additional strong correlations for time in tight range (TITR, 70-140 mg/dl; R2 = 0.92), for the coefficient of variation (CV; R2 = 0.88), and for the glycemia risk index (GRI; R2 = 0.92). The six-week sampling period displayed an additional strong correlation for time below range (TBR, <70 mg/dl; R2 = 0.90). After stratification by clinical variables, lower R2 values were found for older age quartiles (>40 years), higher CV (>36%), lower sensor use (≤94%), and higher HbA1c (>7.5%). CONCLUSION In patients with T1D on MDI, two- to six-week intervals of isCGM use can provide clinically useful estimates of TIR, TAR, TITR, TBR, CV, and GRI, which can be extrapolated to longer (up to 90 days) time intervals. Longer intervals might be needed in case of older age, higher glucose variability, lower sensor use, and higher HbA1c.
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Affiliation(s)
- Alessandro Csermely
- Division of Endocrinology, Diabetes and Metabolic Diseases, Department of Medicine, University Hospital of Verona, Verona, Italy
| | - Nicolò D. Borella
- Division of Endocrinology, Diabetes and Metabolic Diseases, Department of Medicine, University Hospital of Verona, Verona, Italy
| | - Anna Turazzini
- Division of Endocrinology, Diabetes and Metabolic Diseases, Department of Medicine, University Hospital of Verona, Verona, Italy
| | - Martina Pilati
- Division of Endocrinology, Diabetes and Metabolic Diseases, Department of Medicine, University Hospital of Verona, Verona, Italy
| | - Sara S. Sheiban
- Division of Endocrinology, Diabetes and Metabolic Diseases, Department of Medicine, University Hospital of Verona, Verona, Italy
| | - Riccardo C. Bonadonna
- Division of Endocrinology, Diabetes and Metabolic Diseases, Department of Medicine, University Hospital of Verona, Verona, Italy
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Roberto Trevisan
- Unit of Endocrine Diseases and Diabetology, Department of Medicine, ASST Papa Giovanni XXIII, Bergamo, Italy
- Department of Medicine, University of Milano-Bicocca, Milan, Italy
| | - Maddalena Trombetta
- Division of Endocrinology, Diabetes and Metabolic Diseases, Department of Medicine, University Hospital of Verona, Verona, Italy
| | - Giuseppe Lepore
- Unit of Endocrine Diseases and Diabetology, Department of Medicine, ASST Papa Giovanni XXIII, Bergamo, Italy
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Lin BS, Liu ZG, Chen DR, Yang YL, Yang DZ, Yan JH, Zeng LY, Yang XB, Xu W. Relationship between hemoglobin glycation index and risk of hypoglycemia in type 2 diabetes with time-in-range in target. World J Diabetes 2024; 15:2058-2069. [PMID: 39493564 PMCID: PMC11525731 DOI: 10.4239/wjd.v15.i10.2058] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2024] [Revised: 08/13/2024] [Accepted: 09/06/2024] [Indexed: 09/26/2024] Open
Abstract
BACKGROUND In patients with type 2 diabetes mellitus (T2DM), the risk of hypoglycemia also occurs in at a time-in-range (TIR) of > 70%. The hemoglobin glycation index (HGI) is considered the best single factor for predicting hypoglycemia, and offers new perspectives for the individualized treatment of patients with well-controlled blood glucose levels that are easily ignored in clinical settings. AIM To investigate the relationship between HGI and hypoglycemia and the implications of HGI on hypoglycemia in T2DM with TIR > 70%. METHODS All participants underwent a 7-days continuous glucose monitoring (CGM) using a retrospective CGM system. We obtained glycemic variability indices using the CGM system. We defined HGI as laboratory hemoglobin A1c minus the glucose management indicator. Patients were categorized into low HGI (HGI < 0.5) and high HGI groups (HGI ≥ 0.5) according to HGI median (0.5). Logistic regression and receiver operating characteristic curve analyses were used to determine the risk factors for hypoglycemia. RESULTS We included 129 subjects with T2DM (54.84 ± 12.56 years, 46% male) in the study. Median TIR score was 90%. The high HGI group exhibited lower TIR and greater time below range with higher hemoglobin A1c than the low HGI group; this suggests more glycemic excursions and an increased incidence of hypoglycemia in the high HGI group. Multivariate analyses revealed that mean blood glucose, standard deviation of blood glucose and HGI were independent risk factors for hypoglycemia. Receiver operating characteristic curve analysis indicated that the HGI was the best predictor of hypoglycemia. In addition, the optimal cut-off points for HGI, mean blood glucose, and standard deviation of blood glucose in predicting hypoglycemia were 0.5%, 7.2 mmol/L and 1.4 mmol/L respectively. CONCLUSION High HGI was significantly associated with greater glycemic excursions and increased hypoglycemia in patients with TIR > 70%. Our findings indicate that HGI is a reliable predictor of hypoglycemia in this population.
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Affiliation(s)
- Bei-Si Lin
- Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Sun Yat-sen University, Guangdong Provincial Key Laboratory of Diabetology, Guangzhou 510630, Guangdong Province, China
| | - Zhi-Gu Liu
- Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Sun Yat-sen University, Guangdong Provincial Key Laboratory of Diabetology, Guangzhou 510630, Guangdong Province, China
| | - Dan-Rui Chen
- Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Sun Yat-sen University, Guangdong Provincial Key Laboratory of Diabetology, Guangzhou 510630, Guangdong Province, China
| | - Yan-Ling Yang
- Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Sun Yat-sen University, Guangdong Provincial Key Laboratory of Diabetology, Guangzhou 510630, Guangdong Province, China
| | - Dai-Zhi Yang
- Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Sun Yat-sen University, Guangdong Provincial Key Laboratory of Diabetology, Guangzhou 510630, Guangdong Province, China
| | - Jin-Hua Yan
- Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Sun Yat-sen University, Guangdong Provincial Key Laboratory of Diabetology, Guangzhou 510630, Guangdong Province, China
| | - Long-Yi Zeng
- Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Sun Yat-sen University, Guangdong Provincial Key Laboratory of Diabetology, Guangzhou 510630, Guangdong Province, China
| | - Xu-Bin Yang
- Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Sun Yat-sen University, Guangdong Provincial Key Laboratory of Diabetology, Guangzhou 510630, Guangdong Province, China
- Department of Endocrinology and Metabolism, The Third Affiliated Hospital (Zhaoqing Hospital), Sun Yat-sen University, Zhaoqing 526000, Guangdong Province, China
| | - Wen Xu
- Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Sun Yat-sen University, Guangdong Provincial Key Laboratory of Diabetology, Guangzhou 510630, Guangdong Province, China
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Svensson CH, Fabricius TW, Verhulst CEM, Kristensen PL, Tack CJ, Heller SR, Amiel SA, McCrimmon RJ, Evans M, Holst JJ, de Galan BE, Pedersen-Bjergaard U. Association between recent exposure to continuous glucose monitoring-recorded hypoglycaemia and counterregulatory and symptom responses to subsequent controlled hypoglycaemia in people with type 1 diabetes. Diabetes Obes Metab 2024; 26:3213-3222. [PMID: 38774963 DOI: 10.1111/dom.15649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 04/25/2024] [Accepted: 04/26/2024] [Indexed: 07/10/2024]
Abstract
AIM Experimental hypoglycaemia blunts the counterregulatory hormone and symptom responses to a subsequent episode of hypoglycaemia. In this study, we aimed to assess the associations between antecedent exposure and continuous glucose monitoring (CGM)-recorded hypoglycaemia during a 1-week period and the counterregulatory responses to subsequent experimental hypoglycaemia in people with type 1 diabetes. MATERIALS AND METHODS Forty-two people with type 1 diabetes (20 females, mean ± SD glycated haemoglobin 7.8% ± 1.0%, diabetes duration median (interquartile range) 22.0 (10.5-34.9) years, 29 CGM users, and 19 with impaired awareness of hypoglycaemia) wore an open intermittently scanned CGM for 1 week to detect hypoglycaemic exposure before a standardized hyperinsulinaemic-hypoglycaemic [2.8 ± 0.1 mmol/L (50.2 ± 2.3 mg/dl)] glucose clamp. Symptom responses and counterregulatory hormones were measured during the clamp. The study is part of the HypoRESOLVE project. RESULTS CGM-recorded hypoglycaemia in the week before the clamp was negatively associated with adrenaline response [β -0.09, 95% CI (-0.16, -0.02) nmol/L, p = .014], after adjusting for CGM use, awareness of hypoglycaemia, glycated haemoglobin and total daily insulin dose. This was driven by level 2 hypoglycaemia [<3.0 mmol/L (54 mg/dl)] [β -0.21, 95% CI (-0.41, -0.01) nmol/L, p = .034]. CGM-recorded hypoglycaemia was negatively associated with total, autonomic, and neuroglycopenic symptom responses, but these associations were lost after adjusting for potential confounders. CONCLUSIONS Recent exposure to CGM-detected hypoglycaemia was independently associated with an attenuated adrenaline response to experimental hypoglycaemia in people with type 1 diabetes.
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Affiliation(s)
- Cecilie H Svensson
- Department of Endocrinology and Nephrology, Nordsjællands Hospital, Hillerød, Denmark
| | - Therese W Fabricius
- Department of Endocrinology and Nephrology, Nordsjællands Hospital, Hillerød, Denmark
| | - Clementine E M Verhulst
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Peter L Kristensen
- Department of Endocrinology and Nephrology, Nordsjællands Hospital, Hillerød, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Cees J Tack
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Simon R Heller
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Stephanie A Amiel
- Department of Diabetes, School of Cardiovascular and Metabolic Medicine and Science, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | | | - Mark Evans
- Welcome/MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Jens J Holst
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, Novo Nordisk Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
| | - Bastiaan E de Galan
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
- Division of Endocrinology, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Ulrik Pedersen-Bjergaard
- Department of Endocrinology and Nephrology, Nordsjællands Hospital, Hillerød, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Eliasson B, Allansson Kjölhede E, Salö S, Fabrin Nielsen N, Eeg-Olofsson K. Associations Between HbA1c and Glucose Time in Range Using Continuous Glucose Monitoring in Type 1 Diabetes: Cross-Sectional Population-Based Study. Diabetes Ther 2024; 15:1301-1312. [PMID: 38598054 PMCID: PMC11096286 DOI: 10.1007/s13300-024-01572-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 03/21/2024] [Indexed: 04/11/2024] Open
Abstract
INTRODUCTION Continuous glucose monitoring (CGM) introduces novel indicators of glycemic control. METHODS This cross-sectional study, based on the Swedish National Diabetes Register, examines 27,980 adults with type 1 diabetes. It explores the relationships between HbA1c (glycated hemoglobin) and various CGM-derived metrics, including TIR (time in range, representing the percentage of time within the range of 4-10 mmol/l for 2 weeks), TAR (time above range), TBR (time below range), mean glucose, standard deviation (SD), and coefficient of variation (CV). Pearson correlation coefficients and linear regression models were utilized for estimation. RESULTS The analysis included 46% women, 30% on insulin pump, 7% with previous coronary heart disease and 64% with retinopathy. Mean ± SD values were age 48 ± 18 years, diabetes duration 25 ± 16 years, HbA1c 58.8 ± 12.8 mmol/mol, TIR 58.8 ± 19.0%, TAR 36.3 ± 20.0%, TBR 4.7 ± 5.4%, mean sensor glucose 9.2 ± 2.0 mmol/l, SD 3.3 ± 1.0 mmol/l, and CV 36 ± 7%. The overall association between HbA1c and TIR was - 0.71 (Pearson's r), with R2 0.51 in crude linear regression and 0.57 in an adjusted model. R2 values between HbA1c and CGM mean glucose were 0.605 (unadjusted) 0.619 (adjusted) and TAR (unadjusted 0.554 and fully adjusted 0.568, respectively), while fully adjusted R2 values were 0.458, 0.175 and 0.101 between HbA1c and CGM SD, CGM CV and TBR, respectively. CONCLUSIONS This descriptive study demonstrates that the degree of association between HbA1c and new and readily available CGM-derived metrics, i.e., time in range (TIR), time above range (TAR), and CGM mean glucose, is robust in assessing the management of individuals with type 1 diabetes in clinical settings. Metrics from CGM that pertain to variability and hypoglycemia exhibit only weak correlations with HbA1c.
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Affiliation(s)
- Björn Eliasson
- Department of Medicine, Sahlgrenska University Hospital, 413 45, Göteborg, Sweden.
- Centre of Registers, Västra Götalandsregionen, Göteborg, Sweden.
| | - Elin Allansson Kjölhede
- Department of Medicine, Sahlgrenska University Hospital, 413 45, Göteborg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Göteborg, Sweden
| | - Sofia Salö
- Novo Nordisk Scandinavia AB, Malmö, Sweden
| | | | - Katarina Eeg-Olofsson
- Department of Medicine, Sahlgrenska University Hospital, 413 45, Göteborg, Sweden
- Centre of Registers, Västra Götalandsregionen, Göteborg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Göteborg, Sweden
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