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03-05-2018 | Glycemic control | Article

Editorial board commentary

The pendulum is still in motion: The American College of Physicians provides recommendations for the HbA1c target for adults with type 2 diabetes

Author: Jay Shubrook

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Comment on: ACP backs less intensive HbA1c targets for type 2 diabetes

Strengths:

  1. Looks across many guidelines.
  2. Uses the landmark studies available prior to 2015 to decide on treatment.
  3. Highlights the importance that we are likely over-treating older adults with limited life expectancy.

Limitations:

  1. Does not include recent data on new classes that may have additional cardiovascular (CV) benefit such as sodium-glucose cotransporter (SGLT)-2 inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1RAs).
  2. Does not highlight the benefit of reduction of microvascular complications with more intensive control.

Comments:

It is important to be clear about what our treatment goals are for intensive glucose management. We have solid evidence that microvascular complications are reduced when glucose control is down below 7%. Nephropathy (end-stage renal disease needing dialysis), neuropathy (non-traumatic amputations) and retinopathy  (legal blindness) are important patient-centered complications that are feared. While the data do not show CV benefit with short-term (<5 years ) intensive glucose control there is growing evidence in observational trials that these kinds of benefits take more than 10 years to be realized. With this in mind some of the suggestions of ACP are noteworthy – intensive glucose control is not likely to benefit (reduction in death and CV death) those with less than 10 years life expectancy. This is important as we have an aging population and we should become better about de-escalating therapy in older adults.

What I would have liked to see in the ACP recommendations is a recognition that in the mentioned studies we were using "blunt tools" to try to get a precise outcome. These studies largely used metformin, thiazolidinediones and glucose-independent medications such as insulin and sulfonylureas that have higher rates of hypoglycemia. As we have more use of the GLP-1RAs and SGLT-2 inhibitors and even the weaker dipeptidyl peptidase inhibitors in the elderly we have better tools to achieve these goals. It is possible that the mortality and CV equation will look different with these medications. The early hint of this is randomized controlled trial evidence of reduction in CV outcomes/events in high-risk individuals who were taking GLP1-RAs (liraglutide and semaglutide) and SGLT-2 inhibitors (empaglflozin and canagliflozin).

Finally, we should learn lessons from the varying blood pressure guidelines. When we saw the blood pressure guidelines are relaxed we did no better achieving that treatment goal as we universally relaxed treatment. This for sure was good for those overrated but may end up being bad for the rest. Finally, it would be great to re-evaluate these larger trials with the new medications. I appreciate the renewed focus on our decision-making for diabetes treatment targets – as this epidemic grows targeted evidence-based therapies are important for our patients and our healthcare system.

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