ACP backs less intensive HbA1c targets for type 2 diabetes
medwireNews: The American College of Physicians (ACP) has issued four recommendations relating to glycated hemoglobin (HbA1c) targets in patients with type 2 diabetes.
One of these recommendations is to treat the majority of adult patients to an HbA1c target of between 7% and 8%.
This is in opposition to the more stringent 6.5% to 7.0% target that some guidelines advocate, on the basis that the cumulative effect will be to reduce the risk for complications over the long term. But the ACP’s statement says that “the evidence for reduction is inconsistent, and reductions were seen only in surrogate microvascular end points, such as progression of proteinuria or receipt of retinal photocoagulation.”
In this vein, another of the recommendations is to step down pharmacologic therapy for patients who have achieved an HbA1c target of 6.5% or below.
It is important to be clear about what our treatment goals are for intensive glucose management.
The advice comes from the ACP’s Clinical Guidelines Committee, which produces guidance statements on specific topics for which there are several conflicting guidelines available.
As such, the publication in the Annals of Internal Medicine rates the six major identified guidelines using the Appraisal of Guidelines for Research and Evaluation II instrument and provides an overview of the main clinical trials on which those guidelines’ recommendations are based.
The identified English-language guidelines comprise four from the USA – developed by the AACE/ACE, ADA, ICSI, and VA/DoD – and two from the UK, developed by NICE and SIGN. The trials on which the guidelines base their advice are the UKPDS, ACCORD, ADVANCE, and VADT.
The recommendations’ authors, Amir Qaseem (ACP, Philadelphia, Pennsylvania, USA) and colleagues, stress that the “[e]vidence from trials included here is insufficient to evaluate the effect of HbA1c targets between 6.5% and 7% on clinical outcomes, and further research would be needed to close this gap.”
Of the other two statements, one is general advice to personalize patients’ glycemic control targets according to a range of factors including the benefits and harms of pharmacotherapy and their general health and age.
The other looks at the issues of age and comorbidities in more detail, advising that physicians should not aim for specific targets in patients with a life expectancy of less than 10 years, instead treating to minimize the symptoms of hyperglycemia. In this population, say Qaseem and team, the cardiovascular and mortality benefits of having controlled HbA1c levels are small and outweighed by adverse effects including hypoglycemia and treatment burden.
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