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2. Time in range as the emerging metric to complement HbA1c and to target therapies in diabetes

     Glycated hemoglobin or HbA1c or A1c is widely recognized as the metric of choice to determine glucose control in both clinical trials and practices for many years till now and the primary endpoint of many CGM studies too. HbA1c has many limitations that paved the way for the identification of “Time-in-range” (TIR) as a new metric at the ATTD International Consensus Conference in Feb 2019.

What is TIR?

      Time-in-Range (TIR) is defined as the percentage of time an individual spends with their blood glucose levels in the target range. The target range varies depending upon the individual, but general guidelines suggest the range as 70 to 180 mg/dL. The 2019 consensus conference recommends a target range of 70-180 mg/dL [3.9-10.0 mmol/L] for individuals with type 1 diabetes and type 2 diabetes, and 63-140 mg/dL [3.5-7.8 mmol/L] during pregnancy, along with a set of targets for the time per day [% of CGM readings or minutes/hrs]. However, the target range was lowered for pregnant women to 63-140 mg/dL as the blood glucose levels are lower in pregnancy.

      The recommendations also outlined fixing targets for people with diabetes who are older and/or considered high-risk and the time-in-range bar was set at 50% for this category. Furthermore, for patients with diabetes the time spent below 70 mg/dL should be less than 1 hour a day and time spent at or above 180 mg/dL should be less than 6 hours a day. For people with serious hypoglycemia the time spent below 54 mg/dL should be less than 15 minutes a day and the time spent above 250 mg/dL should be less than 1 hour and 15 minutes a day.

      People with diabetes often experience different energy levels, moods, dietary patterns etc when they are in TIR, TAR and TBR. There can be many highs and lows in their glucose profile also. HbA1c, the primary metric for glucose monitoring only denotes the average blood glucose level for three months period and it does not express how much time a patient spent in different blood glucose ranges in 24 hours duration. Thus TIR emerged as a better metric beyond HbA1c in expressing the variations in blood glucose levels that characterize living a life with diabetes.

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