COMMENTARY

Dueling Type 2 Diabetes Guidelines: Sorting It Out

Jay H. Shubrook, DO

Disclosures

April 16, 2018

Hello. I'm Jay Shubrook, DO, professor in the Primary Care Department at Touro University, California. Today we're going to talk about diabetes guidelines that don't seem to all match with each other. How do we make sense of this, and what are we to do?

I can remember a day when I knew metformin was the first option for treatment of type 2 diabetes, but I didn't really know what to do after metformin. There was not was a lot of guidance.

Now, we have many guidelines telling us how we can move forward with the treatment, particularly in terms of pharmacotherapy. However, those guidelines don't all match, and this can be a real challenge particularly in primary care, the front line of treating diabetes.

In this commentary, I hope to review these guidelines, highlight the differences and similarities, and provide some suggestions about how we move forward.

I think it is important to note that all of these algorithms agree that we should be individualizing our therapy.

Earlier this year, the American College of Physicians (ACP) released a guideline for pharmacotherapy of type 2 diabetes.[1] This was a provocative statement that has received a lot of media attention, and has caused some confusion in primary care. There are four major tenets in this guidance:

  • First, ACP recommends that we should be individualizing therapy, particularly A1c goals for adults with type 2 diabetes.

  • Second, the target A1c goal should be between 7% and 8% in most people.

  • Third, we need to deintensify glucose control in patients whose A1c is at 6.5% or lower.

  • Fourth, we need to deintensify treatment for people with limited life expectancy, primarily older adults, those with less than 10 years' life expectancy, or serious comorbid disorders.

This is quite different from the previous guidelines.

The American Diabetes Association (ADA) releases annual standards[2] for the care of people with diabetes. For the past couple of years, their guidance has been relatively similar in terms of A1c goals. First of all, the ADA standards recommend that A1c goal should be less than 7% for most people. However, there will be times when that should be adjusted. For example, more intensive control with a lower A1c goal would be appropriate for someone who is newly diagnosed with a shorter duration of diabetes and no known complications. That might provide long-term benefits because of legacy effects that can occur years down the road as a result of early intensive control.

Conversely, there are people for whom a relaxed A1c goal of less than 8% may be appropriate. This may include those who are at very high risk for hypoglycemia, those who have problems with comorbid conditions, or patients with limited life expectancy. The ADA suggests a more stratified goal for those people.

Finally, there are guidelines from the American Association of Clinical Endocrinologists and American College of Endocrinology (AACE/ACE)[3] that encourage an A1c goal of less than 6.5% for most people. That goal should be deintensified for patients who are at significant risk for hypoglycemia.

Table. Comparison of the ACP, ADA, and AACE/ACE Guidelines

ACP[1] ADA[2] AACE/ACE[3]
  • Clinicians should personalize A1c goals

  • Goal A1c 7%-8% for most

  • Deintensify pharmacologic treatment if 6.5%

  • Limit symptoms of hyperglycemia in those with limited life expectancy, because harms exceed benefits

  • Goal for most < 7.0%

  • May adjust this goal on the basis of patient features:

    • < 6.5% for those who can achieve without hypoglycemia

      • Younger patients

      • Shorter duration

      • Longer life expectancy

      • Treatment with lifestyle or metformin alone

    • < 8.0 % in those at higher risk

      • History of severe hypoglycemia

      • Advanced complications

      • Limited life expectancy

  • A1c < 6.5% in people without complications

  • A1c > 6.5% in people with serious illness and risk for hyperglycemia

AACE/ACE = American Association of Clinical Endocrinologists/American College of Endocrinology; ACP = American College of Physicians; ADA = American Diabetes Association

Do I follow 6.5%? Do I follow 7%? Do I follow between 7% and 8%? Or do I follow less than 8%? This has really been quite confusing. I would say that I probably do all of the above.

I think it is important to note that all of these algorithms agree that we should be individualizing our therapy. Goals for a 30-year-old person newly diagnosed with type 2 diabetes and no known problems are probably going to be more aggressive. Goals for an 85-year-old who resides in an extended care facility should be relaxed. That is a very easy decision in these cases.

I also think we need to have a discussion with our patients. We need to explain the things we need to do, noting how long we anticipate before patients will see a benefit. We know that mortality benefits become clear as a result of blood pressure and lipid control much more quickly than with glucose control. We need to know our patient's resources and capabilities.

I use all of these algorithms. There are times when I shoot for an A1c below 6.5% if I can do it. A lot of times, I aim for less than 7%. I do think that healthcare professionals need to do a better job of deintensifying therapy for those that are very high risk for hypoglycemia and those in whom, despite multiple medications, are not getting to target.

What are the key messages to take home? I think all the guidelines agree we should individualize therapy for our patients. Have a look at our patients. See what we think is possible, both from the standpoint of their actions as well as their complications.

I think that you can use all of the recommendations to decrease A1c without hypoglycemia. You can decide how aggressive you can be without creating hypoglycemia. Put your patient's diabetes into a bigger context. What are their other medical illnesses? What is the likelihood of complications from comorbid illnesses that will make it harder for them to achieve mortality benefits from their antidiabetes medications?

Finally, I think it is very important that we recognize that this is an ongoing discussion. Guidelines should be a live document that responds as we get more information and new data. For example, we have had lots of exciting data about the benefits of some of the newer classes of diabetes medications, such as the sodium-glucose transport protein 2 (SGLT2) inhibitors and glucagon-like peptide 1 (GLP1) receptor agonists, that independently reduce cardiovascular events. As we start to get such data as those, our guidelines will need to evolve.

Another take-home message for today is to know that guidelines are an active document that will continue to evolve. Make sure that you focus on the patients in your care and individualize your patient goals. Discuss your target not only for the short term, but the long term.

Because I have a long-term relationship with my patients, I might adjust my goals depending on the patient's healthcare concerns and other comorbidities. Remember that all of these guidelines are important. But when you're in the room with your patient, this patient is in your care. These guidelines are meant to help and guide you, but ultimately it is really what you and your patient decide.

We look forward to seeing you in future programs.

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