American College of Physicians Advises Moderate Blood Sugar Control Target in Type 2 Diabetes

Highlights:

Latest American College of Physicians (ACP) guidelines recommend achieving moderate rather than severe blood sugar control in type 2 diabetes, with a HbA1c target between 7-8 percent
Currently followed HbA1c target for control of blood sugar is 6.5 to 7 percent
HbA1c less than 7 percent may be associated with side effects such as low blood sugars and medication costs

Treatment of type 2 diabetes should aim to achieve moderate blood sugar control with HbA1c between 7-8 percent, as per latest advisory released by the ACP in an evidence-based guidance statement that appears in March in the journal Annals of Internal Medicine.

"ACP's analysis of the evidence behind existing guidelines found that treatment with drugs to targets of 7 percent or less compared to targets of about 8 percent did not reduce deaths or macrovascular complications such as heart attack or stroke, but did result in substantial harms," said Dr. Jack Ende, president, ACP. "The evidence shows that for most people with type 2 diabetes, achieving an A1C between 7 percent and 8 percent will best balance long-term benefits with harms such as low blood sugar, medication burden, and costs."

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‘Severe blood sugar control with HbA1c less than 7 may be associated with complications such as low blood sugar, medication costs and pill burden.’

The Basis of Latest Recommendations Versus Current HbA1 Target Below 7

Earlier guidelines of achieving HbA1c target below 7 in type 2 diabetes were based on evidence that it would reduce the risk of microvascular (small vessel) such as kidney, nerve and eye complications over the longer term.

However, available evidence suggests otherwise and a reduction was noted only in microvascular complications such as the presence of increased amounts proteins in the urine.

The ACP further advises that physicians should personalize goals for blood sugar control in type 2 diabetes patients based on a discussion of risks versus benefits of long-term drug therapy, patients' preferences, patients' general health condition and life expectancy, pill burden, and costs of diabetes care.

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HbA1c improves the effectiveness of diabetes treatment; because the patient can understand how best he has controlled his condition and take further necessary steps.

Treat with Aim to Reduce Diabetic Symptoms, Not Just HbA1c Reduction

The ACP suggests that physicians should consider de-intensifying treatment in patients who have achieved HbA1c of 6.5 or less by areduction in dosage of current treatment, removing a drug, if the patient is currently taking more than one drug, or totally discontinuing drug treatment.

"Results from studies included in all the guidelines demonstrate that health outcomes are not improved by treating to A1C levels below 6.5 percent," Dr. Ende said. "However, reducing drug interventions for patients with A1C levels persistently below 6.5 percent will reduce unnecessary medication harms, burdens, and costs without negatively impacting the risk of death, heart attacks, strokes, kidney failure, amputations, visual impairment, or painful neuropathy."

Additionally, in patients with a life expectancy less than 10 years due to advanced age (80 years or older) or younger patients with chronic underlying medical illnesses (such as dementia, cancer, severe COPD or congestive heart failure, end-stage kidney disease, and patients residing in nursing homes), the risks of A1C targeted treatment outweigh the benefits in this patient population.

"Although ACP's guidance statement focuses on drug therapy to control blood sugar, a lower treatment target is appropriate, if it can be achieved with diet and lifestyle modifications such as exercise, dietary changes, and weight loss," said Dr. Ende.

ACP suggests that any physician performance measures developed to check diabetes control should not have a target A1C level above 8 percent for any patient population and should not have any A1C targets for older adults with decreased life expectancy or those with chronic illnesses.

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About HbA1c in Brief

HbA1c or glycosylated hemoglobin refers to glucose that has combined with a protein in the red blood cells called hemoglobin. As the average lifespan of a human red blood cell is about 8 -12 weeks, measurement of glycosylated hemoglobin gives a measure of the blood control over an eight to 12 week period rather than day to day variations and measurements. A HbA1C of 6.5 percent and above indicates diabetes.

In conclusion, these latest ACP guidelines become all the more pertinent due to the high global prevalence of type 2 diabetes (over 400 million) and increasing incidence in teens and young adults and need for optimal blood sugar control weighed against the risks of adverse effects of long-term drug treatment, not to mention additional healthcare costs.

References:

Amir Qaseem, Timothy J. Wilt, Devan Kansagara, Carrie Horwitch, Michael J. Barry, Mary Ann Forciea. Hemoglobin A1c Targets for Glycemic Control With Pharmacologic Therapy for Nonpregnant Adults With Type 2 Diabetes Mellitus: A Guidance Statement Update From the American College of Physicians. Annals of Internal Medicine, 2018; DOI: 10.7326/M17-0939
Global Report On Diabetes - (http://apps.who.int/iris/bitstream/10665/204871/1/9789241565257_eng.pdf)

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