In a controversial new clinical guideline, the American College of Physicians (ACP) recommends less restrictive HbA1c targets for glycemic control in most patients with type 2 diabetes; between 7% and 8% rather than 6.5% or 7% as recommended by other groups (Ann Intern Med 2018; doi:10.7326/M17-0939).
ACP based this advice on evidence about the benefits and harms of lower HbA1c targets from clinical trials considered by the other groups in setting their HbA1c targets. “ACP’s analysis of the evidence behind existing guidelines found that treatment with drugs to targets of seven percent or less compared to targets of about eight percent did not reduce deaths or microvascular complications such as heart attack or stroke but did result in substantial harms,” said Jack Ende, MD, president of ACP.
ACP emphasized that glycemic control should be individualized based on discussions about the benefits and harms of pharmacotherapy, patients’ preferences and general health and life expectancy, as well as the burden of treatments and costs. The association also advised physicians to consider deintensifying treatments in patients who have achieved HbA1c levels below 6.5%. Finally, ACP suggested that doctors focus treatments to minimize hyperglycemic symptoms but not target HbA1c levels in patients with type 2 diabetes expected to live less than 10 more years due to age or other medical conditions.
ACP arrived at these recommendations after reviewing guidelines from six other organizations: the National Institute for Health and Care Excellence, the Institute for Clinical Systems Improvement, the American Association of Clinical Endocrinologists (AACE)/American College of Endocrinology, the American Diabetes Association (ADA), the Scottish Intercollegiate Guidelines Network, and the Department of Veterans Affairs and Department of Defense. ACP evaluated these guidelines based on the Appraisal of Guidelines for Research and Evaluation II instrument, which asks questions about factors like scope and purpose, stakeholder involvement, rigor of development, and editorial independence.
AACE, ADA, the American Association of Diabetes Educators, and the Endocrine Society issued a joint statement indicating that they “strongly disagree” with ACP’s recommendations. While noting that ACP’s HbA1c recommendation is just 1% higher than that of other guidelines, “this equates to a difference of nearly 30 points when blood glucose is measured in mg/dL ... blood glucose targets from 154 to 183 mg/dL is potentially harmful and not in the best interest of patients,” the statement averred.