New Diabetes Guidelines Already Outdated?

Anne L. Peters, MD


April 12, 2018

Today I am going to talk about the American College of Physicians (ACP) guidelines for glycated hemoglobin (A1c) treatment targets in patients with type 2 diabetes.[1] Before I continue, I should tell you that I disagree with what they say. All of the major organizations that involve endocrinologists in this country also disagree with what they have to say. But I am not just going to be argumentative. I am going to discuss ways in which I believe they are correct and ways in which I believe they are incorrect.

The first point in the guideline is that you should individualize targets, and I can't agree more. Every patient deserves an individualized target.

The next three recommendations, however, go way off the rails. [Editor's Note: These recommend setting most A1c targets between 7% and 8%, scaling back treatment when A1c drops below 6.5%, and avoiding A1c targets altogether in elderly and chronically ill patients where harms might outweigh benefits.][1] I say this because the ACP used six other guidelines to create their own, and I believe that they looked at studies incorrectly and drew conclusions that are not germane to the way we treat patients with type 2 diabetes today.

To set the record straight, they are very concerned about hypoglycemia risk and weight gain. I am also very concerned about hypoglycemia and weight gain. And in all of the older studies, these were major risks.

But we now have drugs that do not cause hypoglycemia and weight gain. We actually have drugs for the treatment of type 2 diabetes that reduce both cardiovascular risk and progression of nephropathy. So, I think the way the world looks for the treatment of type 2 diabetes now is quite different from the world when the studies they are quoting were conducted.

We know irrefutably that reducing the A1c to below 7% is associated with a reduction in diabetic retinopathy, nephropathy, and neuropathy.

You may say that we do not have lots of good, long-term data about these new treatments, but I believe that we actually have a lot of data to inform us.

So, what do I think? Well, I think less is better, and that's actually one of their points. They say that if someone's A1c is too low, and the patient is getting hypoglycemic and gaining weight, back off. I could not agree more. You do not want to cause hypoglycemia, and you do not want to cause weight gain; you also do not want to set unreasonable expectations for an older patient.

However, we know irrefutably that reducing the A1c to below 7% is associated with a reduction in diabetic retinopathy, nephropathy, and neuropathy. I can tell you that if you ask patients what their goal is, many will say, "I do not want to go blind," or, "I do not want to have an amputation." I have seen patients suffer terribly from diabetic neuropathy.

If I have a 50- or 60-year-old with new-onset disease, who I believe does not have a number of limiting comorbidities, that patient may well live longer than 10 years, longer than 20 years, maybe even longer than 30 years. That patient may say, "I want my target to be less than 7% so that I avoid those complications."

As patients reach their 80s and 90s, it seems fine to reduce those targets, and I do that all the time. I have lots of patients with a target A1c of 7.5% because that is appropriate for them.

When you look at a population and make recommendations, you are really looking across an age span. Again, if we are talking about diabetic microvascular complications, you want a lower target A1c.

I would also argue that we cannot actually know how long someone is going to live. Not that long ago, I had a clinic where 5 out of the 10 patients I saw that morning were cognitively functioning mid-90-year olds. That was pretty impressive. I do not have an A1c target of less than 7% in those individuals, but had I changed my target 15 years before, I may have missed out in preventing the complications that they do not now have.

I believe that we have to think about what we are trying to do. We are trying to avoid hypoglycemia and weight gain; we are trying to avoid polypharmacy inasmuch as it may be bad for the patient. But we now have agents that can control diabetes without the hypoglycemia and weight gain that we saw previously, as well as having a cardiovascular benefit.

I know cost matters. But ideally, when you are writing guidelines, I believe you should be looking at what is best for the patient in terms of preventing complications. And in an ideal world, if we can give patients a medication that has already been proved to have dual benefit in terms of A1c and cardiovascular disease reduction, we may not want to cut back on that agent as patients get older.

Think about the medications you are using; think about the patients, risks and benefits, and individualized targets; and remember, preventing microvascular complications is linked to glucose levels. Mortality, cardiovascular disease, and so on, are more related to a host of other risk factors, and tight control early helps reduce those complications as well. For many patients, you will not reduce that risk by lowering glucose levels. You will reduce that risk by other means, perhaps by using a diabetes medication that does both.

This is Dr Anne Peters for Medscape. Thank you.


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