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[HbA.sub.1c] will be the test for most.

My major concern with this study is that the wrong question is being asked. The key question in clinical practice is, "Which glycemic measure best predicts the risk of microvascular complications, in particular retinopathy?" For that, other evidence suggests that hemoglobin [A.sub.lc] is the best predictor of microvascular risk, that it's at least as good as fasting glucose, and that a 2-hour glucose tolerance test is a very poor predictor of microvascular risk.

If you put all of that into clinical practice, many primary care physicians find that the ability to measure [HbA.sub.lc] at any time of the day, and to combine it with assessment of other cardiovascular risk factors, makes pragmatic sense. That's where the practice is going.

We need more evidence on whether using [HbA.sub.lc] and fasting glucose together improves our ability to predict risk of microvascular complications. We are forgetting that we can repeat tests over time as people progress with their disease. Each factor will progress.

[HbA.sub.lc] is more expensive than fasting glucose, so the cost-benefit ratio must be determined. If we start to introduce wide-scale [HbA.sub.lc] testing, how much extra cost will there be to detect more patients with diabetes? The difference is probably $l-$2 per test per patient. It's a cost that we probably would be willing to make. And it's more convenient for patients.

I think [HbA.sub.lc] will become the preferred test for diabetes in the vast majority of individuals, although there is a subgroup of people in whom glucose measures will still be used.

NAVEED SATTAR, M.D., is professor of metabolic medicine at the University of Glasgow, Scotland. He said he has no relevant conflicts of interest.
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Title Annotation:VIEW ON THE NEWS
Author:Sattar, Naveed
Publication:Internal Medicine News
Date:Jul 1, 2011
Words:289
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