Less Aggressive HbA1c Targets Recommended by American College of Physicians
Once again, the ACP finds its advice in conflict with guidance from other major societies, this time the American Diabetes Association.
The American College of Physicians (ACP) is taking yet another contrarian stance against guideline recommendations from other major professional societies, this time with glycemic treatment targets for individuals with type 2 diabetes.
In a new guidance statement, which was published online today in the Annals of Internal Medicine, the ACP states that while clinicians should “personalize glycemic control” in patients with type 2 diabetes, they should aim to achieve an HbA1c level between 7% and 8%. They also suggest physicians scale back pharmacologic therapy in patients who achieve HbA1c levels of less than 6.5%.
The new recommendations are based on their review of five large, long-term randomized controlled trials: ACCORD, ADVANCE, UKPDS (two studies), and VADT. For the ACP, there is insufficient evidence to support the more aggressive HbA1c target of less than 7% and further studies are needed to address the knowledge gap.
The ACP recommendations clash with those from the American Diabetes Association (ADA), as well as differ from those of other organizations, including the American Association of Clinical Endocrinologists/American College of Endocrinology, US Department of Veterans Affairs/Department of Defense, and United Kingdom’s National Institute for Health and Care Excellence (NICE), among others.
For the ADA, a reasonable HbA1c goal for “many” nonpregnant adults in less than 7% based on the evidence available to date, including the UKPDS. In that trial, intensive glycemic control using either a sulphonylurea or insulin reduced the risk of any diabetes-related endpoint compared with less stringent HbA1c control.
“The ADA believes all people diagnosed with type 2 diabetes can be healthy and should have the opportunity to reduce their risk of serious diabetes complications through appropriate blood glucose targets,” said the organization in a statement to TCTMD. “Individualization of targets is the key factor, and by lumping ’most’ people with type 2 diabetes into a 7-8% target range, ACP’s new guidance may cause potential harm to those who may safely benefit from lower evidence-based targets.”
AACE/ACE recommends an HbA1c target of less than 6.5% for most nonpregnant adults, while NICE believes a target of less than 6.5% is reasonable in those managed with diet and lifestyle or with lifestyle and a single drug. Guidelines from the Department of Veterans Affairs/Department of Defense suggest a target of 6% to 7% in those with a life expectancy between 10 and 15 years. All the guidelines stress the importance of individualized care for determining the risks and benefits of tighter versus weaker glycemic control, however.
The ACP guidance also advises clinicians to minimize symptoms related to hyperglycemia and avoid targeting an HbA1c level in patients 80 years and older, those in a nursing home, or those with chronic conditions such as dementia, cancer, end-stage kidney disease, severe chronic obstructive pulmonary disease, or congestive heart failure.
Again, the ADA takes issue with these broad strokes, stating that each patient should be evaluated individually regardless their age, living situation, or existing comorbidities.
“A person living in a nursing home or with a chronic condition may yet have some years to live, and would likely prefer to live them without diabetes complications,” according to the ADA. “It’s important to note that the average life expectancy for an 80-year-old man is more than 8 years, and it’s nearly 10 years for a woman the same age. And that’s an average—for some individuals, it’s even longer.”
The ADA said they support simplifying or deintensifying treatment, but only if this can be achieved within the individualized HbA1c targets. The key, however, is to scale back treatment based on patient factors, such as hypoglycemia, and “not on a number,” said the ADA.
This is not the first time the ACP has bucked recommendations from other professional organizations. In 2017, they, along with the American Academy of Family Physicians, published their own guidelines for the treatment of hypertension and adopted a less aggressive systolic blood pressure treatment target than other organizations. In late 2017, the American College of Cardiology/American Heart Association issued their long-awaited hypertension guideline with its more aggressive, and somewhat controversial treatment targets, and the ACP and AAFP refused to endorse their recommendations.
Qaseem A, Wilt TJ, Kansagara D, et al. Hemoglobin A1c targets for glycemic control with pharmacologic therapy for nonpregnant adults with type 2 diabetes mellitus: a guidance statement update from the American College of Physicians. Ann Intern Med. 2018;Epub ahead of print.
- The authors report no relevant conflicts of interest.