New type 2 diabetes guideline recommends more moderate HbA1c target

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The ACP has concluded that patients with type 2 diabetes should be treated to achieve an A1C between 7% and 8%, rather than 6.5% to 7%.
The ACP has concluded that patients with type 2 diabetes should be treated to achieve an A1C between 7% and 8%, rather than 6.5% to 7%.

The American College of Physicians (ACP) has developed guidance recommendation statements for clinicians in selecting targets for the pharmacologic treatment of type 2 diabetes, as published in the Annals of Internal Medicine.

The Clinical Guidelines Committee of the ACP, led by Amir Qaseem, MD, PhD, MHA, analyzed national guidelines that addressed hemoglobin A1c (HbA1c) targets for treating type 2 diabetes in nonpregnant outpatient adults. Based on its review, the ACP recommends that patients with type 2 diabetes should be treated to achieve an A1C between 7% and 8%, rather than 6.5% to 7%.

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

A summary of the guidelines is as follows:

  1. Clinicians should personalize goals for glycemic control in patients with type 2 diabetes on the basis of a discussion of benefits and harms of pharmacotherapy, patients' preferences, patients' general health and life expectancy, treatment burden, and costs of care.

  2. Clinicians should aim to achieve an HbA1c level between 7% and 8% in most patients with type 2 diabetes.

  3. Clinicians should consider deintensifying pharmacologic therapy in patients with type 2 diabetes who achieve HbA1c levels less than 6.5%.

  4. Clinicians should treat patients with type 2 diabetes to minimize symptoms related to hyperglycemia and avoid targeting an HbA1c level in patients with a life expectancy less than 10 years due to advanced age (80 years or older), residence in a nursing home, or chronic conditions (such as dementia, cancer, end-stage kidney disease, or severe chronic obstructive pulmonary disease or congestive heart failure) because the harms outweigh the benefits in this population.

“ACP believes that clinicians should reevaluate HbA1c levels and revise treatment strategies on the basis of changes in the balance of benefits and harms due to changed costs of care and patient preferences, general health, and life expectancy,” the authors stated. “In persons who reach HbA1c levels less than 6.5% with drug treatment, de-escalation of therapy (by reducing dosage or number of drugs) is warranted to reduce harms, patient burden, and costs of treatment.”

References

  1. Qaseem A, Wilt TJ, Kansagara D, et al. 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. Ann Intern Med. 6 March 2018. doi: 10.7326/M17-0939
  2. ACP recommends moderate blood sugar control targets for most patients with type 2 diabetes [press release]. American College of Physicians Newsroom. March 6, 2018. Accessible at: https://www.acponline.org/acp-newsroom/acp-recommends-moderate-blood-sugar-control-targets-for-most-patients-with-type-2-diabetes
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