“Over the last five years, we have learned more about how much tight glucose control impacts patient health. Much of this evidence came from three large randomized, controlled trials of tight glucose control, which showed less absolute benefit than an earlier trial conducted in the 1980s and 1990s. There has also been increasing evidence of potential harms from low blood sugar reactions, especially in older patients,” says Rodney Hayward, MD, an internist at the University of Michigan in Ann Arbor, whose research was used to draft the new guidelines by the American College of Physicians (ACP). The ACP recommendations counter those of other reputable diabetes groups, including the American Diabetes Association, which recommends a general A1C target of 7 for nonpregnant adults with diabetes, and the American Association of Clinical Endocrinologists, which advises those individuals to strive for an A1C of 6.5. RELATED: How Brooklyn Politician Eric Adams Lowered His A1C and Reversed Diabetes Through Diet Changes
A Closer Look at the Doctors’ Proposed A1C Guidelines
To make the new recommendations, study authors analyzed past studies and guidelines issued by other organizations from around the world. Beyond making the general recommendation for a new A1C target, the group proposed the following three guidelines:
Ease up on diabetes treatment for any patient with an A1C of 6.5 or lower, to avoid his or her blood sugar levels from dipping further.Individualize management goals based on factors like life expectancy, cost of care, and medication risk.Do not set a target A1C level in people who have a life expectancy of less than 10 years due to advanced age (80 years old or older), have certain chronic conditions, or are living in a nursing home.
Six coauthors of the report assessed each guideline using a tool that evaluates research materials based on six criteria, including clarity of presentation and a study’s scope and purpose. While the ACP did not return repeated requests for comment before publication of this story, Jack Ende, MD, president of the ACP who is based in Philadelphia, said in a news release that avoiding treatment in people with an A1C 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,” referencing macrovascular complications. Type 2 diabetes is a widespread problem and is linked to the complications Dr. Ende mentions in the release. There are more than 30 million people in the United States who have diabetes, with 90 to 95 percent of them having type 2 diabetes, according to the Centers for Disease Control and Prevention (CDC). You get diabetes when your cells develop a resistance to insulin, causing your pancreas to create more insulin at a rate that it simply can’t keep up with. High blood sugar (hyperglycemia) can cause a range of serious health complications related to diabetes, like loss of vision, heart disease and kidney disease, and the current A1C target is meant to help mitigate those risks. RELATED: What Is Insulin Resistance? Everything You Ever Wanted to Know More closely associated with type 1 diabetes, but also an issue in people with type 2 diabetes — especially those who are over age 65 — is hypoglycemia, according to an article published in March 2018 in the Journal of Clinical Endocrinology and Metabolism, as previously reported by Everyday Health. Undetected severe low blood sugar, called hypoglycemia unawareness, can lead to serious complications, such as diabetic coma, seizures, or death.
Why the ACP Guidelines Have Sparked Some Controversy
Reaction to the ACP’s new guidelines has been mixed. Utpal Pajvani, MD, PhD, an endocrinologist and assistant professor at Columbia University Medical Center in New York City, praises the recommendation to personalize A1C targets, as well as the guideline to account for patients’ preferences and their potential burden and cost of medication. He adds that the recommendation for not making elderly patients’ A1C targets too stringent has a “great deal of logic” to it, considering the risk for hypoglycemia. But other parts of the guidelines give Dr. Pajvani pause. Pajvani says shifting the A1C target to between 7 and 8 percent, as well as de-intensifying therapy for patients below 6.5 percent, are recommendations that the ACP took from past trials of patients with long-standing type 2 diabetes who also had heart disease, meaning that the findings might not be relevant for all people with type 2 diabetes, specifically those who don’t have heart disease. Pajvani says that one big blind spot in the new guidelines involves the fact that they don’t take into consideration the fact that a lot of treatments endocrinologists use help minimize hypoglycemia and weight gain, and have proven benefits on heart disease, for instance. He adds that since the new guidelines focus so much on “macrovascular complications” like heart attacks, they ignore and gloss over “microvascular risks” — think vision impairment or end-stage renal disease — that could come from relaxing the old A1C targets to 7 to 8 percent. RELATED: What Are the Possible Complications of Type 2 Diabetes, and How Can You Avoid Them? For his part, Dr. Hayward says that it is difficult to see what kind of impact the new guidelines will have on diabetes treatment down the line. He says in the past, shifts in guidelines do not “substantially impact real-world clinical practice.” He hopes the new guidelines will increase awareness among clinicians about the value of “striving for tight glycemic control,” which he says has been “greatly overestimated.” “Fears expressed by some diabetologists that some clinicians may become overly complacent in response to the new guidelines should be taken seriously, but overtreatment of glucose has been well documented and is also a legitimate concern,” Hayward adds. Pajvani maintains the opposite view. “I’m worried about the effects of these guidelines,” he says. “Endocrinologists likely won’t apply these guidelines, but most patients with type 2 diabetes are cared for by primary care physicians and internists.”
