American College of Physicians Releases 4 Guidelines for HbA1c Targets in T2D

The American College of Physicians (ACP) has released 4 updated guidance statements regarding glycated hemoglobin A1c (HbA1c) targets for non-pregnant adult patients with type 2 diabetes (T2D), published online in the Annals of Internal Medicine.

“ACP’s analysis of the evidence behind existing guidelines found that treatment with drugs to targets of 7 percent or less compared to targets of about 8 percent did not reduce deaths or macrovascular complications such as heart attack or stroke but did result in substantial harms,” said Jack Ende, MD, MACP, president of ACP. “The evidence shows that for most people with type 2 diabetes, achieving an A1C between 7 percent and 8 percent will best balance long-term benefits with harms such as low blood sugar, medication burden, and costs.”

The guidance statements are as follows:

Guidance Statement 1: Clinicians should create personalized goals for glycemic control in patients with type 2 diabetes. These goals should be based on clinician-patient discussion of benefits and harms of pharmacotherapy, patient preferences, the patient’s general health and life expectancy, treatment burden, and costs of care.

Guidance Statement 2: Clinicians should aim to help their patients with type 2 diabetes achieve an HbA1c level between 7% and 8%.

Guidance Statement 3: If a patient with type 2 diabetes achieves an HbA1c level <6.5%, clinicians should consider de-intensifying pharmacologic therapy.

Guidance Statement 4: In treating patients with type 2 diabetes, clinicians should aim to minimize symptoms related to hyperglycemia. Clinicians should avoid targeting a specific HbA1c level in patients with a life expectancy of <10 years due to advanced age (80 or older); residence in a nursing home; or chronic conditions such as dementia, cancer, end-stage kidney disease, severe chronic obstructive pulmonary disease, or congestive heart failure because the harms outweigh the benefits in these patients.

In order to create these guidelines, the researchers searched The National Guideline Clearinghouse and the Guidelines International Network library for national guidelines that addressed HbA1c targets for treating T2D in non-pregnant outpatient adults.

They used the AGREE II (Appraisal of Guidelines for Research and Evaluation II) instrument to evaluate 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 US Department of Veterans Affairs and Department of Defense.

Disclosures

Dr Barry reports grants and personal fees from Healthwise, a nonprofit company, outside the submitted work. Authors not named here have disclosed no conflicts of interest. Authors followed the policy regarding conflicts of interest described at www.annals.org/article.aspx?articleid=745942. Disclosures can also be viewed at www.acponline.org/authors /icmje/ConflictOfInterestForms.do?msNum=M17-0939. All financial and intellectual disclosures of interest were declared, and potential conflicts were discussed and managed.

Dr Vijan was recused from voting on the recommendations for an active direct financial conflict. Dr. Manaker was recused from voting on the recommendations for an active indirect financial conflict. A record of disclosures of interest and management of conflicts of interest is kept for each CGC meeting and conference call and can be viewed at www.acponline.org /clinical_information/guidelines/guidelines/conflicts_cgc.htm.

Reference

Qaseem A, Wilt TJ, Kansagara D, et al. for the Clinical Guidelines Committee of the American College of Physicians. Hemoglobin A1c targets for glycemic control with pharmacologic therapy for nonpregnant adults with type 2 diabetes mellitus: a guidance statement update from the American College of Physicians. [published online March 6, 2018] Ann Intern Med. doi:10.7326/M17-0939.