A clinical practice guideline on management of type 2 diabetes was released by the Department of Veterans Affairs (VA) and Department of Defense (DoD) in April and was recently summarized in Annals of Internal Medicine.
The guideline recommends individualized target HbA1c ranges based on patient characteristics and suggests the following ranges if they can be safely achieved: 6% to 7% in patients with a life expectancy of 10 to 15 years or more and no or mild microvascular complications; 7% to 8.5% in most patients with established microvascular or macrovascular conditions, comorbid conditions, or life expectancy of five to 10 years; and 8% to 9% for patients with a life expectancy less than five years, significant comorbid conditions, advanced complications, or difficulties with self-management.
The guideline advocates for patient-centered care and “strongly encourages clinicians to incorporate shared decision making and partner with their patients.” The guideline also recommends assessing individual patient characteristics, including race, ethnicity, and kidney function, when interpreting HbA1c, fructosamine, and other glycemic biomarker testing. Other recommendations in the VA/DoD guideline address nonpharmacologic diabetes treatments, glycemic targets and insulin regimens in the hospital and ICU, and combinations of pharmacologic therapies.
The summary, which was published online Oct. 24 and in the Nov. 7 Annals of Internal Medicine, describes ways in which the VA/DoD guideline differs from recommendations from the American Diabetes Association, the American Geriatrics Society, and the American Association of Clinical Endocrinologists (AACE). Among other differences, the VA/DoD recommends that for a new diagnosis of diabetes, an HbA1c of 6.5% to 6.9% should be confirmed with a fasting blood glucose level (>7.0 mmol/L [126 mg/dL]), due to evidence of strong racial differences in correlation of HbA1c levels and glycemic control.
An accompanying editorial described additional ways that the various guidelines differ, noting that the AACE sets the strictest HbA1c target of the various groups, at 6.5% for most patients. Differentiating glycemic control recommendations by patient subgroup is important and the variables to do so would ideally be identified in observational studies or randomized controlled trials, the editorialists said. “Until groups developing [clinical practice guidelines] reach consensus about important risk subgroups and practice recommendations associated with those subgroups, we will continue to face conflicting recommendations that confuse providers, patients, payers, and policymakers,” they wrote.