Average Daily Risk Range (ADRR) in Young Children With Type 1 Diabetes

Abstract

Hemoglobin A1c (A1c) is widely regarded as the gold standard for evaluating glycemic control in youth with type 1 diabetes.1 However, A1c represents average glucose levels over the past 6-12 weeks and may not adequately represent the degree of blood glucose (BG) excursions experienced, particularly hypoglycemic episodes.2,3 Greater frequency of BG excursions, even excursions lasting brief periods of time, is related to increased risk for development of diabetesrelated complications. 4 Thus, standardized evaluation of the risk for BG excursions and BG variability may be a critical component in fine-tuning diabetes treatment regimens.In response to the need for more sensitive measures to assess BG variability, Kovatchev and colleagues created the average daily risk range (ADRR).5 ADRR is calculated using ≥14 days of BG values with a minimum of 3 checks/day and is designed to be equally sensitive to hyperglycemic and hypoglycemic episodes. ADRR has been found to be a valid and reliable measure of glycemic variability in adults and has been shown to prospectively predict both hypoglycemia and hyperglycemia within 4 months of ADRR determination. 5 In adult samples, ADRR has been positively and statistically significantly associated with A1c and other indices of glycemic variability, including mean amplitude of glycemic excursions and standard deviations of mean BG levels. 6 ADRR may also be a valuable tool in evaluating BG variability and classifying risk of hypoglycemic and hyperglycemic episodes in young children with type 1 diabetes. Minimizing glycemic variability in young children with type 1 diabetes can be challenging due to greater insulin sensitivity and less insulin resistance than pubertal children, susceptibility to hypoglycemia, highly variable and unpredictable eating and activity schedules, and difficulty communicating symptoms of glycemic excursions to caregivers. Abstract Objective: The objective was to examine the utility of the average daily risk range (ADRR) in young children with type 1 diabetes. Methods: Self-monitored blood glucose (BG) data and A1c values were collected from 134 children (ages 2-6). Other measures of BG variability and diabetes care were calculated using self-monitored BG data. ADRR, A1c, and other glycemic indices were compared to assess their distinctiveness and utility as measures of BG variability and glycemic control. Results: Of young children's ADRR values, 72% were in the "high-risk" range using adult guidelines. ADRR and A1c were highly correlated with indicators of hyperglycemia but only weakly correlated with measures of hypoglycemia. ADRR was moderately correlated with minimum BG value in the past 30 days but not percentage of BG values below 70 mg/dL. A1c was not correlated with either measure of hypoglycemia. Conclusions: ADRR values confirm the high degree of BG variability present in young children with type 1 diabetes, particularly as compared with adults. New ADRR risk guidelines are needed for pediatric patients. ADRR and A1c are adequate indicators of hyper...

Evaluation of the Average Daily Risk Range as a Measure of Glycemic Variability in Youths with Type 1 Diabetes

“…1,13 In the current study, 56% of youths had ADRR scores in the high-risk category. This percentage was lower than the percentage of very young children with T1DM with ADRR scores in the high-risk category as reported by Monaghan et al 9 (73.1%) and Patton et al 10 (69%), but much higher than the percentage of adults with T1DM with ADRR scores in the high-risk category as reported by Kovatchev et al 8 (28%). Unlike the previous adult study, 8 when tested against a variety of other measures of GV, the ADRR scores in this sample of youths was not equally accurate in predicting the percentage of episodes of hyper-or hypoglycemia.…”

“…This outcome is similar to the results of a previous cross-sectional study of ADRR scores in very young children with T1DM, which also found that scores did not correlate with the percentage of concurrent moderate hypoglycemic episodes. 9 Although our findings demonstrate that the ADRR does not predict future episodes of hypoglycemia, we did identify more accurate measures of future risk for hypoglycemia in youths, which were LBGI, the percentage of moderate hypoglycemic events in Month 1, and CoV. Likewise, we determined that the adult risk categories, when used in youths, appear limited to only predicting a youth's likelihood of future hyper-or euglycemia and not episodes of hypoglycemia.…”

“…The ADRR has been used previously as a measure of GV in pediatric samples, [9][10][11] but here we present the first data exploring the validity of the ADRR in a large clinical sample of 1-18-year-old youths with T1DM. The ADRR showed good concurrent validity with youths' mean blood glucose, SD, CoV, percentage of moderate hyperglycemia in Month 1, and HBGI.…”

“…8 Since then, the ADRR has been used in pediatric diabetes samples to measure GV. [9][10][11] However, the ADRR score has never been examined in a pediatric sample to determine if, as a continuous score, the ADRR is equally sensitive to predicting hyper-and hypoglycemia in youths, if the original risk categories of Kovatchev et al 8 are valid to predict future episodes of glycemic excursions in youths, or how the ADRR compares with other measures of GV in predicting hyper-and hypoglycemia in youths. There is also limited research comparing the ADRR to other measures of GV in pediatric patients.…”

“…There is also limited research comparing the ADRR to other measures of GV in pediatric patients. 9 Thus, the current study explores these questions and yields useful normative and validity data for the ADRR in youths with T1DM.…”