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Defining the risk of microvascular complications associated with diabetes mellitus is clinically important for identifying at-risk individuals and evaluating treatment efficacy. The standard measure of mean glycemia, glycohemoglobin A1c (Hb A1c),3 is associated with incident microvascular complications among diabetic patients, but this biomarker fails to explain all of the observed risk (1). This has led to the hypothesis that microvascular complications may result not only from chronic sustained hyperglycemia but also from glycemic excursions (1). Therefore, identifying biomarkers that are associated with glycemic excursions has direct clinical significance.For example, in the landmark Diabetes Control and Complications Trial (DCCT) of conventional diabetes therapy vs intensive insulin therapy targeting low Hb A1c, matching attained Hb A1c across the 2 treatment arms did not produce similar reductions in incident microvascular complications (2). The higher rate of microvascular complications observed in the conventional therapy arm of DCCT may have been due to larger glycemic excursions, as this group had fewer insulin injections per day (3). Indeed, in DCCT, greater variability in an individual's Hb A1c measurements was associated with a higher risk of microvascular complications and added risk information beyond standard glycemic measures (4). Mechanistically, both hyperglycemia and glycemic excursions result in oxidative stress, likely through overproducing superoxide by the mitochondrial electron-transfer chain (5, 6), which generates advanced glycation end products, activates protein kinase C and nuclear factor-κB, enhances polyol activity, and increases hexosamine pathway flux (1, 7).1,5-Anhydroglucitol (1,5-AG) is a candidate biomarker for glycemic excursions (8). 1,5-AG is a dietary monosaccharide, similar to glucose, that is freely filtered in the renal glomerulus and subsequently competes with glucose for reabsorption in the renal tubules. In the presence of high blood …

Moving Beyond Mean Glycemia: 1,5-Anhydroglucitol and Microvascular Complications of Diabetes