ACP Updates Blood Sugar Control Targets for Type 2 Diabetes

03/07/18

The American College of Physicians (ACP) has issued an updated guidance statement recommending an HbA1c level between 7% and 8% in most patients with type 2 diabetes.

The guidance statement was published in the Annals of Internal Medicine (online March 6, 2018; doi:10.7326/M17-0939).

"Studies have not consistently shown that intensive glycemic control to HbA1c levels below 7% reduces clinical microvascular events, such as loss or impairment of vision, end-stage renal disease, or painful neuropathy, or reduces macrovascular events and death," said Amir Qaseem, MD, PhD, ACP vice president for clinical policy, co-author of the guidance statement (March 6, 2018).

Authors of the guidance statement evaluated six sets of current guidelines from other organizations and reviewed five clinical trials on which those guidelines are based (ACCORD, ADVANCE, VADT, and both UKPDS trials). The resulting four key statements were constructed:

  • Clinicians should personalize goals for glycemic control in patients with type 2 diabetes on the basis of a discussion of the benefits and harms of pharmacotherapy, patient preferences, patient general health and life expectancy, treatment burden, and costs of care.
  • Clinicians should aim to achieve an HbA1c level between 7% and 8% in most patients with type 2 diabetes.
  • Clinicians should consider de-intensifying pharmacologic therapy in patients with type 2 diabetes who achieve HbA1c levels less than 6.5%.
  • 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 (ie, dementia, cancer, end-stage kidney disease, or severe chronic obstructive pulmonary disease/heart failure) because the harms outweigh the benefits in this population.

The guidance statement also noted that a lower treatment target is appropriate if achievable with diet and lifestyle modifications and that clinicians should emphasize the importance of exercise, weight loss, smoking cessation, and other lifestyle changes.

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"The 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," authors of the guidance statement concluded.—Zachary Bessette