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Doctors often rely on guidelines from national medical organizations to help them care for patients. Earlier this year, the American College of Physicians (ACP) published new guidelines to help doctors and their patients with Type 2 diabetes set goals for hemoglobin A1C (HbA1c), a common measure of how well blood sugars are controlled.
Elizabeth Tung, MD, MS, and her colleagues Andrew Davis, MD, MPH, and Neda Laiteerapong, MD, MS, from the University of Chicago Medicine, wrote a summary and discussion of the new guidelines for today’s issue of the Journal of the American Medical Association. We spoke to Tung about the new guidelines, why they have been controversial, and what they mean for patients with Type 2.
There were four major recommendations. The main one that has been controversial is a recommendation to target HbA1c levels between seven and eight percent. Previous guidelines from groups like the American Diabetes Association (ADA) recommended less than seven, or even less than 6.5, but these new guidelines said it's okay to have more relaxed targets for the general United Sates population. Another recommendation was to consider de-intensifying treatment at HbA1c levels less than 6.5, meaning patients could take fewer medications once they hit that level.
The other recommendations weren’t as controversial. One was to personalize HbA1c levels. Pretty much all of the guidelines now say doctors need to target levels based on the patient in front of them, so that's not necessarily going to be the same for everyone. The last recommendation was for patients with life expectancy less than 10 years—say people at an extremely advanced age or nursing home patients—the guidelines said their diabetes should be treated to minimize symptoms rather than targeting a specific HbA1c level.
The ACP is taking the position that there are not obviously clear benefits to tight blood sugar control, based on major clinical trials that have examined the risks and benefits. At the same time, some of these studies have actually documented some harms. Mostly notably, the ACCORD trial in 2008 showed higher risk of death for patients with tight glycemic control. There's been some criticism of that finding, but other studies have found increased risk for other things, like more low blood sugar events and more hospitalizations from low blood sugars. It's a lot easier for older patients or patients with a lot of complications to end up with these extremely low blood sugars. So, the idea behind these new recommendations is that maybe it’s not always worth it to target a lower HbA1c that could increase the risk of these bad things happening.
People who disagree with the ACP’s position say that many patients can handle lower HbA1c levels, and a more relaxed target can increase complications in the long run. This would especially harm younger and healthier patients with diabetes who have the most to gain from preventing complications.
Doctors don't have a ton of time when we see patients, so we often base our care off of whatever guideline has consensus in the medical community. Previously the ADA recommendation was to target an HbA1c level less than seven percent, which was probably what most physicians were shooting for most of the time. In certain cases, for the older patient with severe illnesses, advanced age, or who has had diabetes for a long time, we would relax those targets. But for the most part, I actually did target an HbA1c of less than seven. So, the notion that I'm now supposed to target an HbA1c level between seven and eight would make a big difference for how I practice.
The controversy has made me realize that I need to personalize goals for patients more often. It just hasn't been on my radar that it's so important to do that. I think the fact that we can't really agree if the optimal goal is less than seven, like the ADA says, or between seven and eight, like the ACP says, means that either recommendation could be correct, depending on the patient sitting in front of me.
Patients are their own best advocates. They do have choice in deciding if they want to target a higher goal or a lower goal. A lot of it has to do with their preferences, or the amount of risk they can tolerate. If a patient previously had a goal of less than seven and decides to relax it between seven and eight, they should probably think along the lines of forgoing potential benefits of tighter blood sugar control but minimizing risk for severe lows. Alternatively, a patient may choose a lower goal to make sure they have the best chance for no complications down the road, but with the understanding that there may be some risks. It’s a very personal decision and we're not having these kinds of conversations with our patients enough.
I think the fact that we can't agree on a narrow target means that in the future, recommendations will probably need to be more focused on what the best targets are for different groups of people. Right now, they're saying shoot for seven to eight in most patients, but “most patients” is a very vague term. It doesn't provide a lot of guidance to doctors about who that is, and how to adjust for the diversity of patients we see.
A lot of people have also been talking about how HbA1c may not be enough to determine a person's risk in the future. So, the question then becomes: can there be technology-based decision support tools to help us consider an array of things, and is that a better way to target a person's sugars? Complexity isn't necessarily always better, and I think a lot of doctors like guidelines because they’re simple. But maybe it's possible to use software and electronic health records to automatically generate personalized goals for patients. Who knows what the future will hold?
Elizabeth Tung, MD, MS is a researcher and practicing internist in the Section of General Internal Medicine. Her research focuses on disparities in chronic disease management, with a special interest in race, place, and poverty.Learn more about Dr. Tung