Patients and physicians trying to sort out the debate over the new guidance standards on diabetes care issued by the American College of Physicians (ACP) may find themselves scratching their heads.
While both the ACP and several professional diabetes organizations—including the American Association of Clinical Endocrinologists (AACE), the American Diabetes Association (ADA), the American Association of Diabetes Educators (AADE) and the Endocrine Society—agree with ACP guidance emphasizing individualized care for diabetes patients, they sharply disagree about practice recommendations.
Chief among them is the guidance that patients should aim to reach A1C targets of 7 to 8%, compared with the ADA target of less than 7 % and the AACE target of 6.5 or below.
According to the diabetes organizations, blood glucose levels before a meal in a healthy individual should be between 70 and 99 mg/dl, therefore ACP’s recommendation of blood glucose targets from 154 to 183 mg/dl was ruled “potentially harmful.”
“In ACP’s estimation, the risks outweighed the benefits, while the AACE and ADA feel that the benefits of lower A1C’s are significant and we have tools to be able to achieve those benefits in patients who have type 2 diabetes, ” said Jonathan Leffert, MD, president of AACE and managing partner of North Texas Endocrine Center in Dallas, Texas. “The ACP was also concerned with costs of medication and the risk of hypoglycemia, which seem to drive those guidance statements over and above diabetes control for the patient population.”
Many diabetes clinicians emphasize that the range suggested by ACP guidance is too broad to apply to “most patients with type 2 diabetes” and “has the potential to do more harm than good for many patients for whom lower blood glucose targets may be more appropriate, particularly given the increased risk of serious complications such as cardiovascular disease, retinopathy, amputation and kidney disease.”
“Our concern is that there is a pretty broad difference between 6.5 and 7 to 8 %,” said Dr. Leffert.
But ACP President Jack Ende, MD, professor of medicine and assistant dean for Advanced Medical Practice at the Perelman School of Medicine at The University of Pennsylvania, supports the 7 to 8% A1C target.
“When it comes to clinical benefits there are no data that say that if an A1C is below 6.5 that you’re less likely to go into dialysis or less likely to lose your vision or less likely to develop neuropathy or an amputation,” he said in defense of the group’s position.
The ACP guidance standards also advise clinicians to minimize symptoms related to hyperglycemia and avoid targeting A1C levels in patients with a life expectancy less than ten years due to advanced age (80 years or older), residence in a nursing home, or chronic conditions (such as dementia, cancer, end-stage kidney disease or severe chronic obstructive pulmonary disease or congestive heart failure) since harms outweigh benefits in this population.
And they suggest that patients who have an A1C of 6.5 or below may consider first reducing their medications if cost is an issue.
So what, if anything, should patients do in light of this new guidance? Both physicians urge patients to talk to their doctors, who are most aware of their specific cases.
In the end, Dr. Leffert sees the ACP sending a “bad message” to the 30 million people in this country who have diabetes and the 80 million with prediabetes.
“We talk a lot about issues of diabetes and obesity in this country, and we don't have good control on this as a public health issue,” said Dr. Leffert. “I think we have to push forward to make sure we are identifying people with diabetes, that we are treating people with diabetes in an aggressive way so we can prevent devastating complications but also address the costs.”
“I think the message is not to say everything’s ok if you get to be in the range of 7 to 8%. I think that there is plenty of information that says we can do better and need to continue to work to do better,” he said.