ACP recommends less intensive glucose control in most cases of type 2 diabetes

Most patients with type 2 diabetes should aim for an HbA1c target between 7% and 8% rather than 6.5% to 7%, according to a new evidence-based guidance statement from ACP.

The guidance statement was based on a search of the literature for English-language national guidelines that addressed HbA1c targets for type 2 diabetes in nonpregnant outpatient adults. Guidelines from the National Institute for Health and Care Excellence, the Institute for Clinical Systems Improvement, the American Association of Clinical Endocrinologists/American College of Endocrinology, the American Diabetes Association, the Scottish Intercollegiate Guidelines Network, and the U.S. Department of Veterans Affairs/Department of Defense were reviewed. The authors of the guidance statement used the Appraisal of Guidelines for Research and Evaluation II (AGREE II) method to evaluate the guidelines. The ACP guidance statement was published by Annals of Internal Medicine on March 6.

ACP recommends that clinicians personalize goals for glycemic control in patients with type 2 diabetes according to a discussion of benefits and harms of pharmacotherapy, patients' preferences, patients' general health and life expectancy, treatment burden, and costs of care. “The benefits and harms of more versus less intensive glycemic control may be finely balanced for many persons and vary according to expected duration of treatment, comorbid conditions, risk factors for hypoglycemia, and choice of medication,” the guidance authors wrote. “The choice of glycemic target also depends on consideration of other variables, such as risk for hypoglycemia, weight gain, and other drug-related adverse effects, as well as the patient's age, life expectancy, other chronic conditions, functional and cognitive impairments, fall risk, ability to adhere to treatment, and medication burden and cost.”

ACP recommends that clinicians aim for an HbA1c level between 7% and 8% in most patients with type 2 diabetes. The authors of the guidance statement noted concerns that targeting HbA1c levels below 7% may increase risk for death, weight gain, hypoglycemia, and other adverse effects. They also noted that while guidelines recommending lower targets do so based on the rationale that intensive glycemic control reduces microvascular events over years of treatment, the evidence to support this potential benefit is inconsistent. More stringent targets may be appropriate for patients with a long life expectancy who are interested in more intensive glycemic control with pharmacologic therapy, despite risk for harms, the authors wrote. In patients with type 2 diabetes who have achieved HbA1c levels below 6.5%, ACP recommends that clinicians consider deintensifying pharmacologic therapy.

Finally, ACP recommends that clinicians should treat patients with type 2 diabetes to minimize symptoms related to hyperglycemia and avoid targeting a specific HbA1c level in patients with a life expectancy of less than 10 years because of advanced age, residence in a nursing home, or chronic conditions. ACP concluded that the harms of therapy outweigh the benefits in these cases. “Setting stringent targets in these populations is not an optimal approach, and clinicians should instead focus on treating to reduce symptoms from both disease and treatment,” the authors wrote.