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US doctors group calls for new type 2 HbA1c target

By Editor
7th March 2018
Care planning, Self-monitoring of blood glucose Type 2 diabetes

New guidelines for the desired HbA1c levels for people with type 2 diabetes have been recommended in the US.

The American College of Physicians (ACP) recommendations are part of an evidence-based guidance statement published in the Annals of Internal Medicine.

In America, the current HbA1c recommendation for people with type 2 diabetes is 6.5 per cent, but the ACP thinks most people should be trying to achieve an A1C between seven per cent and eight per cent.

ACP president Dr Jack Ende said: “ACP’s analysis of the evidence behind existing guidelines found that treatment with drugs to targets of seven per cent or less compared to targets of about eight per cent did not reduce deaths or macrovascular complications such as heart attack or stroke but did result in substantial harms.”

It has also been suggested that clinicians should personalise goals for blood sugar control in people who have type 2 diabetes based on a discussion of benefits and harms of drug therapy, patients’ preferences, their general health and life expectancy, treatment burden, and costs of care.

The rationale in guidelines that recommended the lower treatment targets was more intensive blood sugar control would reduce microvascular complications over many years of treatment. However, the evidence for reduction is inconsistent and reductions were seen only in surrogate microvascular complications such as the presence of excess proteins in the urine.

Although ACP’s guidance statement focuses on drug therapy to control blood sugar, a lower treatment target is appropriate if it can be achieved with diet and lifestyle modifications such as exercise, dietary changes, and weight loss

If people with type 2 diabetes achieve an A1C of less than 6.5 per cent, ACP recommends that clinicians consider de-intensifying drug therapy by reducing the dosage of current treatment, removing a medication if the patient is currently taking more than one drug, or discontinuing drug treatment.

Dr Ende added: “Results from studies included in all the guidelines demonstrate that health outcomes are not improved by treating to A1C levels below 6.5 per cent. However, reducing drug interventions for patients with A1C levels persistently below 6.5 per cent will reduce unnecessary medication harms, burdens, and costs without negatively impacting the risk of death, heart attacks, strokes, kidney failure, amputations, visual impairment, or painful neuropathy.”

ACP also recommends that clinicians should treat people with type 2 diabetes to minimise symptoms related to high blood sugar rather than targeting an A1C level in patients with a life expectancy less than 10 years due to advanced age (80 years or older) or chronic conditions (such as dementia, cancer, end stage kidney disease, severe COPD or congestive heart failure, and patients residing in nursing homes), as the harms of A1C targeted treatment outweigh the benefits in this patient population.

Dr Ende said: “Although ACP’s guidance statement focuses on drug therapy to control blood sugar, a lower treatment target is appropriate if it can be achieved with diet and lifestyle modifications such as exercise, dietary changes, and weight loss.”

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