Kovatchev Boris
1 University of Virginia School of Medicine and School of Engineering and Applied Sciences, UVA Center for Diabetes Technology, Charlottesville, VA, USA.
J Diabetes Sci Technol. 2019 Jul;13(4):627-635. doi: 10.1177/1932296819826111. Epub 2019 Jan 29.
Glycemic variability (GV) a well-established risk factor for hypoglycemia and a suspected risk factor for diabetes complications. GV is also a marker of the instability of a person's metabolic system, expressed as frequent high and low glucose excursions and overall volatile glycemic control. In this review, the author discusses topics related to the assessment, quantification, and optimal control of diabetes, including (1) the notion that optimal control of diabetes, that is, lowering of HbA1c-the commonly accepted gold-standard outcome-can be achieved only if accompanied by simultaneous reduction of GV; (2) assessment and visualization of the two principal dimensions of GV, amplitude and time, which is now possible via continuous glucose monitoring (CGM) and various metrics quantifying GV and the risks associated with hypo- and hyperglycemic excursions; and (3) the evolution of diabetes science and technology beyond quantifying GV and into the realm of GV control via pharmacological agents, for example, GLP-1 receptor agonists and DPP-4 inhibitors, which have pronounced variability-reducing effect, or real-time automated closed-loop systems commonly referred to as the "artificial pancreas." The author concludes that CGM allows close tracking over time, and therefore precise quantification, of glycemic variability in diabetes. The next step-optimal control of glucose fluctuations-is also taken by medications with pronounced GV-lowering effect primarily in type 2 diabetes, and by automated insulin delivery in type 1 diabetes. Contemporary CGM-based artificial pancreas systems use specific GV representations as input signals, and thus their main objective is to minimize GV and, from there, optimize glycemic control.
血糖变异性（GV）是低血糖的一个公认危险因素，也是糖尿病并发症的一个疑似危险因素。GV也是一个人代谢系统不稳定的标志，表现为频繁的高血糖和低血糖波动以及整体不稳定的血糖控制。在这篇综述中，作者讨论了与糖尿病评估、量化和最佳控制相关的主题，包括：（1）只有在同时降低GV的情况下才能实现糖尿病的最佳控制，即降低糖化血红蛋白（HbA1c）——普遍认可的金标准结果这一观点；（2）现在通过持续葡萄糖监测（CGM）以及量化GV和与低血糖及高血糖波动相关风险的各种指标，可以对GV的两个主要维度，即幅度和时间进行评估和可视化；（3）糖尿病科学技术从量化GV发展到通过药物进行GV控制的领域，例如胰高血糖素样肽-1（GLP-1）受体激动剂和二肽基肽酶-4（DPP-4）抑制剂，它们具有显著的降低变异性的作用，或者实时自动闭环系统，通常被称为“人工胰腺”。作者得出结论，CGM能够随着时间进行密切跟踪，从而精确量化糖尿病患者的血糖变异性。下一步——对血糖波动进行最佳控制——主要通过对2型糖尿病具有显著降低GV作用的药物，以及对1型糖尿病进行自动胰岛素输注来实现。当代基于CGM的人工胰腺系统使用特定的GV表示作为输入信号，因此其主要目标是将GV降至最低，进而优化血糖控制。
