ACP guidance on type 2 diabetes treatment

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Patients with type 2 diabetes should be treated to achieve an A1C between 7% and 8% rather than 6.5% to 7%, the American College of Physicians (ACP) recommends in an evidence-based guidance statement.

An A1C test measures a person’s average blood sugar level over the past two or three months. An A1C of 6.5% indicates diabetes.

“ACP’s analysis of the evidence behind existing guidelines found that treatment with drugs to targets of 7% or less compared to targets of about 8% did not reduce deaths or macrovascular complications such as heart attack or stroke but did result in substantial harms,” said Dr Jack Ende, president, ACP. “The evidence shows that for most people with type 2 diabetes, achieving an A1C between 7% and 8% will best balance long-term benefits with harms such as low blood sugar, medication burden, and costs.”

ACP recommends that clinicians should personalise goals for blood sugar control in patients with type 2 diabetes based on a discussion of benefits and harms of drug therapy, patients’ preferences, patients’ general health and life expectancy, treatment burden, and costs of care.

The rationale in guidelines that recommended lower treatment targets (below 7% or below 6.5%) is that 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.

If patients with type 2 diabetes achieve an A1C of less than 6.5%, 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.

“Results from studies included in all the guidelines demonstrate that health outcomes are not improved by treating to A1C levels below 6.5%,” Ende said. “However, reducing drug interventions for patients with A1C levels persistently below 6.5% 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 patients 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.

“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,” said Ende.

Noting the policy implication of its recommendations, ACP suggests that any physician performance measures developed to evaluate quality of care should not have a target A1C level below 8% for any patient population and should not have any A1C targets for older adults (age 80 and older) or younger individuals with limited life expectancy because of other serious diseases and illnesses.

More than 30m Americans have diabetes, and 90% to 95% of them have type 2 diabetes. Type 2 diabetes most often develops in people over age 45, but more and more children, teens, and young adults are also developing it.

ACP’s guidance statements involve a review and methodological critique of existing and sometimes conflicting guidelines rather than a systematic review of available evidence.

Abstract
Description: The American College of Physicians developed this guidance statement to guide clinicians in selecting targets for pharmacologic treatment of type 2 diabetes.
Methods: The National Guideline Clearinghouse and the Guidelines International Network library were searched (May 2017) for national guidelines, published in English, that addressed hemoglobin A1c (HbA1c) targets for treating type 2 diabetes in nonpregnant outpatient adults. The authors identified guidelines from the National Institute for Health and Care Excellence and the Institute for Clinical Systems Improvement. In addition, 4 commonly used guidelines were reviewed, from the American Association of Clinical Endocrinologists and American College of Endocrinology, the American Diabetes Association, the Scottish Intercollegiate Guidelines Network, and the US Department of Veterans Affairs and Department of Defense. The AGREE II (Appraisal of Guidelines for Research and Evaluation II) instrument was used to evaluate the guidelines.
Guidance Statement 1: Clinicians should personalize goals for glycemic control in patients with type 2 diabetes on the basis of a discussion of benefits and harms of pharmacotherapy, patients’ preferences, patients’ general health and life expectancy, treatment burden, and costs of care.
Guidance Statement 2: Clinicians should aim to achieve an HbA1c level between 7% and 8% in most patients with type 2 diabetes.
Guidance Statement 3: Clinicians should consider deintensifying pharmacologic therapy in patients with type 2 diabetes who achieve HbA1c levels less than 6.5%.
Guidance Statement 4: Clinicians should treat patients with type 2 diabetes to minimize symptoms related to hyperglycemia and avoid targeting an HbA1c level in patients with a life expectancy less than 10 years due to advanced age (80 years or older), residence in a nursing home, or chronic conditions (such as dementia, cancer, end-stage kidney disease, or severe chronic obstructive pulmonary disease or congestive heart failure) because the harms outweigh the benefits in this population.

Authors
Amir Qaseem, Timothy J Wilt, Devan Kansagara, Carrie Horwitch, Michael J Barry, Mary Ann Forciea

American College of Physicians material
Annals of Internal Medicine abstract


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