ACP Guidelines Recommend Less-Intensive Treatment Targets for Type 2 Diabetes

The American College of Physicians (ACP) recently issued new guidelines aimed at assisting clinicians in making decisions about targets when using pharmacologic therapy in adults with type 2 diabetes.

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Based on evaluation of existing guidelines and clinical studies, the ACP has recommended that clinicians use less intensive treatment target strategies. Studies showed no evidence that lowering HbA

levels less than 7% provided any additional benefit. The guidelines also suggested de-intensifying treatment for patients with HbA

levels persistently below 6.5%.

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“The evidence shows that for most people with type 2 diabetes, achieving an A1C between 7% and 8% will best balance long-term benefits with harms such as low blood sugar, medication burden, and costs,” said Jack Ende, MD, President, ACP, in a press release.

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The ACP published the 4 evidence-based statement guidelines to assist health care providers in making treatment decisions:

1. Clinicians should personalize goals for glycemic control in patients with type 2 diabetes on the basis of a discussion of benefits and harms of pharmacotherapy, patients’ preferences, patients’ general health and life expectancy, and costs of care.
2. Clinicians should aim to achieve an HbA_1clevel between 7% and 8% in most patients with type 2 diabetes.
3. Clinicians should consider de-intensifying pharmacologic therapy in patients who achieve HbA_1clevels less than 6.5%.
4. Clinicians should treat patients with type 2 diabetes to minimize symptoms related to hyperglycemia and avoid targeting an HbA_1clevel in patients with a life expectancy less than 10 years due to advanced age (80 years or older), residence in a nursing home, or chronic conditions because the harms outweigh the benefits in this population.

The authors analyzed 5 large, long-term controlled trials from existing guidelines that investigated intensive versus less intensive treatment target strategies in adults. Throughout the studies, patients randomly assigned to more intensive therapy required more antiglycemic medications at higher doses, leading to more adverse events than the less intensive groups.

According to the guidelines, the studies demonstrated that no evidence has consistently shown that intensive glycemic control to HbA

levels below 7% reduces clinical microvascular events, and that only reductions were seen in surrogate microvascular complications.

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“Although ACP’s guidance statement focuses on drug therapy to control blood sugar, a lower treatment target is appropriate if it can be achieved with diet and lifestyle modifications such as exercise, dietary changes, and weight loss,” said Dr. Ende.

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Although several guidelines differ on recommended treatment target strategies, all guidelines consistently recommend individualizing HbA

targets on the basis of patient characteristics, such as comorbid conditions and risk for hypoglycemia.

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Reference

1. Qaseem A, Wilt TJ, Kansagara D, et al. Hemoglobin A_1ctargets for glycemic control with pharmacologic therapy for nonpregnant adults with type 2 diabetes mellitus: a guidance statement update from the American College of Physicians.Ann Intern Med. 2018. Doi: 10.7326/M17-0939
2. ACP recommends moderate blood sugar control targets for most patients with type 2 diabetes [news release]. Philadelphia. ACP’s website.https://www.acponline.org/acp-newsroom/acp-recommends-moderate-blood-sugar-control-targets-for-most-patients-with-type-2-diabetes. Accessed March 6, 2018.