Doctors' group issues controversial advice for type 2 diabetes

A large organization of internal medicine physicians said Tuesday that adults with type 2 diabetes can aim for an easier-to-achieve blood sugar target than what’s been used to guide treatment in the past.

However, that advice is already controversial.

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 per cent and 8 per cent, rather than the traditional 6.5 per cent to 7 per cent.

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 per cent and 8 per cent in most patients.
• Consider deintensifying drug therapy in patients with A1C levels less than 6.5 per cent
• 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 per cent in newly diagnosed or early-stage diabetes has immediate and long-term benefits,” he said.

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 per cent or 6.5 per cent 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 per cent 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 foetal health.”