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 That advice is already controversial, however.
Based on its review of six sets of guidelines from other
organizations, the American College of Physicians (ACP) said doctors
can tell patients to aim for a so-called glycosylated hemoglobin, or
HbA1C, level between 7 percent and 8 percent, rather than the
traditional 6.5 percent to 7 percent.
The HbA1C level reflects the person's average blood glucose level
for the last several months.
In new guidance published in Annals of Internal Medicine, the ACP’s
Dr. Amir Qaseem and colleagues made four major recommendations.
Clinicians treating patients with type 2 diabetes should:
- Personalize goals for blood sugar control based on a discussion of
benefits and harms of drug therapy, patient preferences, patient
health and life expectancy, treatment burden and costs of care.
- Aim to achieve an HbA1C level between 7% and 8% in most patients.
- Consider deintensifying drug therapy in patients with A1C levels
less than 6.5%
- Treat patients to minimize low blood sugar symptoms and avoid
targeting an A1C level in patients with a life expectancy less than
10 years because the harms outweigh the benefits.
The guidance also states that a lower treatment target is
appropriate if achievable with diet and lifestyle modifications and
that clinicians should emphasize to patients the importance of
exercise, weight loss, smoking cessation and other lifestyle
changes.
Three clinicians commented in emails to Reuters Health. None
disagreed with the guidance to personalize treatment and relax goals
for older patients at high risk for hypoglycemia (low blood sugar)
and those with limited life expectancy.
All were concerned about the change in A1C targets.
Dr. Ajay Rao, an assistant professor in the Section of
Endocrinology, Diabetes and Metabolism at the Lewis Katz School of
Medicine at Temple University in Philadelphia said the recommended
range “is inconsistent with guidelines from most national and
international organizations,” and is not consistent with the most
recent 2018 Standards of Diabetes Care from the American Diabetes
Association.”
“There is clear evidence that targeting an A1C of 7 percent in newly
diagnosed or early-stage diabetes has immediate and long-term
benefits,” he said.
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The relaxation of the A1C goal “by a large organization such as ACP
sends a mixed message to our patients, and potentially sends us
backward in the fight against small vessel complications in type 2
diabetes,” he concluded.
Dr. Akanasha Goyal, an endocrinologist at NYU Langone Health in New
York City, stated, “Overall, reducing (high blood sugar) is known to
be the primary and most effective means of preventing complications
of diabetes.”
“Stringent A1C goals of lower than 7 percent or 6.5 percent are
appropriate for patients who are younger, have few comorbidities and
do not have diabetes complications . . . as long as we don’t cause
hypoglycemia or side effects from the medications,” she said.
Dr. Rekha Kumar, an endocrinologist at NewYork-Presbyterian/Weill
Cornell Medical Center in New York City, said, “The overarching
statement that blood glucose targets in type 2 diabetes should be
less stringent is controversial.”
“In young patients in whom an Hba1c target can be achieved with a
balance of low glycemic diet, exercise, and conservative
pharmacotherapy, I don’t see a harm in tighter control,” she stated.
“I also don’t think pharmacotherapy should also be reduced in all
patients who achieve a blood glucose average of 6.5 percent or
under, especially because this A1C target may have been achieved on
the two new classes of medicines that treat type 2 diabetes - the
GLP-1 receptor agonists and SGLT-2 inhibitors - which have shown a
reduction in cardiovascular mortality.”
“Generalizing the less stringent targets to the overall type 2
diabetes population may lead patients and providers to not always
optimize use of (these) newer medicines,” she noted.
“There are also populations of patients, such as those trying to
conceive, who would still benefit from tighter control of blood
sugar,” Dr. Kumar concluded, “and we should not overlook the
importance of this due to the implications for maternal and fetal
health.”
SOURCE: http://bit.ly/2wYH0qu Annals of Internal Medicine, online
March 5, 2018.
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