Blood glucose control is a cornerstone of managing type 2 diabetes.
But guidelines from different medical organizations vary in their recommendations
for appropriate target HbA1C levels.
To help physicians navigate these conflicting recommendations, the American College
of Physicians, or ACP, issued a guidance statement on HbA1c targets
for glycemic control with medication.
They recommend that "Clinicians should aim to achieve an HbA1c level between 7%
and 8% in most patients with type 2 diabetes."
But just days after the guidance was published, four medical associations --
the American Diabetes Association, the American Association of Clinical Endocrinologists,
the Endocrine Society, and the American Association of Diabetes Educators --
issued a joint press release, saying they strongly disagree
with the proposed new guidance.
That's because the targets recommended by the ACP are higher
than those organizations recommend.
[Elizabeth L. Tung] For the most part in the U.S.,
I think that most people probably follow the American Diabetes Association
or the American College of Endocrinologists, and, essentially,
those guidelines recommend an HbA1c of less than 7 or less than 6.5.
Those groups have expressed concerns
that the new ACP guidance does not recognize the long-term benefits
of intensive glycemic control.
[Elizabeth L. Tung] There are these legacy effects that essentially say: in the long run,
if you have intensive glycemic control today, you have significant benefits in mortality,
in microvascular outcomes, et cetera.
Younger patients are more likely to realize the long-term benefits
of earlier stricter glucose control, so for them,
the ACP guidance could have unintended consequences.
And the incidence of type 2 diabetes is increasing in younger age groups in the US.
[Neda Laiteerapong] They are the one group that have not had improvements
in their glycemic control level over the last decade.
And if physicians start to go, "Oh I can go between seven and eight for most
of my patients," and they happen to see a younger cohort of people,
then all of a sudden you could have long-term ramifications of increased risk of microvascular
and macrovascular complications down the line,
and we won't see those effects for 10 or 20 years.
In loosening the recommended target HbA1c levels,
the ACP considered the potential benefits and harms of intensive glycemic control.
On the benefits side, there's a reduction in microvascular complications,
such as diabetic nephropathy and retinopathy, and with newer medications,
a potential reduction in macrovascular complications
like myocardial infarction and stroke.
But the effects on microvascular outcomes are not without controversy.
[Elizabeth L. Tung] The argument that the ACP makes is
that you don't actually see clinical benefits of intensive glycemic control
in the major clinical trials, clinical benefits meaning an actual improvement
in end-stage kidney disease or other major outcomes.
And, instead, what you see is improvements in your surrogate markers --
for instance, in your albumin levels.
The ACP weighed this against the potential harms of intensive glycemic control,
which include hypoglycemia and the burden of more medication.
[Elizabeth L. Tung] The different guideline writers are viewing it
from differing perspectives.
And so, ultimately, you have the ADA and ACE on the one hand,
and I think they're really concerned about the ideal glycemic target.
This is what is ideal for this patient, and if we can achieve it safely, let's do it.
Whereas I think the ACP almost approaches it from maybe a more realist,
or potentially even a more pessimistic perspective, and they're essentially saying
who can actually achieve it safely?
And if most people can't, then why are we targeting that ideal?
Intensive glycemic control can be difficult to achieve safely for patients,
especially older patients or those with comorbidities.
Of the estimated 23 million adults with diagnosed diabetes,
3 million are under 45 years old, while 10 million are 65 or older.
And more than half of people with diabetes have at least one other chronic condition.
[Neda Laiteerapong] If you actually look at the recommendations for how
to individualize glycemic goals, it's not just age, it's not just duration of diabetes,
it's not just comorbidities or complication history; also included are risk
for hypoglycemia, resources and support, patient engagement and their personal level,
personal preference for where they want their glycemic goal to be,
so it's a lot more complicated than physicians are given credit for.
The different guidelines all recognize that patients have individual circumstances.
So the need to personalize treatment goals is an area of consensus.
But even with that consensus, some physicians may be penalized on quality measures
if their patients do not achieve established A1C goals of their system or institution,
which may be at the more strict targets.
That's where the new guideline could have major implications.
The "ACP suggests that any physician performance measures developed to evaluate quality
of care should not have a target HbA1c level below 8% for any patient population."
[Neda Laiteerapong] So, for physicians who are being penalized for an A1C above seven percent,
what this guideline means to them is that they can hold up the guideline
to their healthcare system or their clinic manager and say, "hey, take a look at this,"
and I think it's really reinforcing for physicians
and hopefully it'll change how physicians are being measured on their quality.
[Ed Livingston] Hi, I'm Ed Livingston, Deputy Editor for Clinical Reviews and Education
for JAMA and host of the JAMA Clinical Reviews podcast.
[Jennifer Abbasi] And I'm Jennifer Abbasi, a Senior Staff Writer with JAMA Medical News.
[Ed Livingston] There's a lot that wasn't covered in this video,
but what we did in the JAMA Clinical Reviews Podcast was review the literature base
supporting diabetes control recommendations in great detail,
finding that that evidence base is surprisingly weak.
[Jennifer Abbasi] And in the Medical News article we took a deeper dive
into the perspectives you heard in the video, and we discussed how new drugs
and devices could change things in the not-so-distant future.
[Ed Livingston] Links to the podcast and these articles are in the description below.