Guidelines Ease Up on Glycemic Control for Some Patients With Type 2 Diabetes
Authors: Mike Mitka
Journal: JAMA (2012)

PHYSICIANS ARE BEING TOLD TO loosen up on glycemic control when treating certain patients with type 2 diabetes. Aggressive glucose management has been a mainstay of diabetes treatment, intended to reduce microvascular risks such as diabetic nephropathy, neuropathy, and retinopathy. Physicians treating patients with diabetes have traditionally set a goal of achieving and keeping glycated hemoglobin (HbA1c) levels below 7.0%. But recent trials have suggested that achieving such a level may put certain patients with diabetes at risk for cardiovascular complications and mortality. Acknowledging these recent studies, the American Diabetes Association and the European Association for the Study of Diabetes released a consensus report April 19 calling for a more patientcentered treatment approach that takes into account patient needs, preferences, and tolerances (Inzucchi SE et al. Diabetes Care. doi:10.2337/dc12-0413 [published online April 19, 2012]). The report notes that lowering HbA1c to less than 7.0% is still recommended for most patients with diabetes. However, less stringent goals of between 7.0% to slightly higher than 8.0% are appropriate for patients with a history of severe hypoglycemia; limited life expectancy; advanced complications; extensive comorbid conditions; or difficulty attaining that 7.0% target despite intensive self-management education, repeated counseling, and effective doses of multiple glucose-lowering agents, including insulin. The report authors added that a goal of 6.5% might be considered in selected patients with short disease duration, long life expectancy, and no significant cardiovascular disease if it can be achieved without significant hypoglycemia or other adverse effects of treatment. These multiple targets emerged in part because of a 2010 study that found a U-shaped risk curve: those with the lowest rate of all-cause mortality had an HbA1c of 7.5%, while those with higher and lower HbA1c levels saw an increased risk for all-cause mortality and cardiac events (Currie CJ et al. Lancet. 2010;375[9713]:481-489). The other study that raised questions about aggressive glucose management for all was the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial of 2008. That trial found that patients randomized to intensive therapy targeting a 6.0% or lower HbA1c level were 22% more likely to experience a nonfatal myocardial infarction, nonfatal stroke, or death from cardiovascular causes when compared with patients randomized to standard therapy with a target HbA1c level of 7.0% to 7.9% (N Engl J Med. 2008;358[24]:25452559). “In terms of choosing a target, the studies have been murky; no study says it should be 7% for everybody,” said Vivian Fonseca, MD, president of the American Diabetes Association. “The goal of 7% came from a study of patients with type 1 diabetes, and achieving an HbA1c of 7% seemed to balance the benefits and risks of glycemic control.” Beyond suggesting alternative HbA1c levels for various types of patients with diabetes, the consensus report also notes that lifestyle interventions, weight management, diet, and exercise remain key factors for minimizing diabetes complications. Another important element of the report addresses the growing array of pharmacological agents available for diabetes treatment and their possible adverse effects. Metformin remains the optimal first-line drug for glucose management. If metformin does not enable a patient to achieve or maintain a personalized target HbA1c level, adding another 1 or 2 oral or injectable agents is considered reasonable. But the report authors cannot say with certainty which additional medications are best because of a “distinct paucity of