What is the Optimal HbA1c Target for Type 2 Diabetes Patients?

What is the Optimal HbA1c Target for Type 2 Diabetes Patients?

Blood glucose control is a
cornerstone of managing type 2 diabetes. But guidelines from different medical
organizations vary in their recommendations for appropriate target HbA1C levels. To help physicians navigate these conflicting
recommendations, the American College of Physicians, or ACP, issued a
guidance statement on HbA1c targets for glycemic control with medication. They recommend that “Clinicians should
aim to achieve an HbA1c level between 7% and 8% in most patients with type 2 diabetes.” But just days after the guidance was
published, four medical associations — the American Diabetes Association, the American
Association of Clinical Endocrinologists, the Endocrine Society, and the American
Association of Diabetes Educators — issued a joint press release,
saying they strongly disagree with the proposed new guidance. That’s because the targets
recommended by the ACP are higher than those organizations recommend. [Elizabeth L. Tung] For the
most part in the U.S., I think that most people probably
follow the American Diabetes Association or the American College of
Endocrinologists, and, essentially, those guidelines recommend an HbA1c
of less than 7 or less than 6.5. Those groups have expressed concerns that the new ACP guidance does not
recognize the long-term benefits of intensive glycemic control. [Elizabeth L. Tung] There are these legacy
effects that essentially say: in the long run, if you have intensive glycemic control today,
you have significant benefits in mortality, in microvascular outcomes, et cetera. Younger patients are more likely
to realize the long-term benefits of earlier stricter glucose
control, so for them, the ACP guidance could have
unintended consequences. And the incidence of type 2 diabetes is
increasing in younger age groups in the US. [Neda Laiteerapong] They are the one
group that have not had improvements in their glycemic control
level over the last decade. And if physicians start to go, “Oh I
can go between seven and eight for most of my patients,” and they happen
to see a younger cohort of people, then all of a sudden you could have long-term
ramifications of increased risk of microvascular and macrovascular complications down the line, and we won’t see those effects
for 10 or 20 years. In loosening the recommended
target HbA1c levels, the ACP considered the potential benefits
and harms of intensive glycemic control. On the benefits side, there’s a
reduction in microvascular complications, such as diabetic nephropathy and
retinopathy, and with newer medications, a potential reduction in
macrovascular complications like myocardial infarction and stroke. But the effects on microvascular
outcomes are not without controversy. [Elizabeth L. Tung] The argument
that the ACP makes is that you don’t actually see clinical
benefits of intensive glycemic control in the major clinical trials, clinical
benefits meaning an actual improvement in end-stage kidney disease
or other major outcomes. And, instead, what you see is
improvements in your surrogate markers — for instance, in your albumin levels. The ACP weighed this against the potential
harms of intensive glycemic control, which include hypoglycemia and
the burden of more medication. [Elizabeth L. Tung] The different
guideline writers are viewing it from differing perspectives. And so, ultimately, you have
the ADA and ACE on the one hand, and I think they’re really concerned
about the ideal glycemic target. This is what is ideal for this patient, and
if we can achieve it safely, let’s do it. Whereas I think the ACP almost
approaches it from maybe a more realist, or potentially even a more pessimistic
perspective, and they’re essentially saying who can actually achieve it safely? And if most people can’t, then
why are we targeting that ideal? Intensive glycemic control can be
difficult to achieve safely for patients, especially older patients
or those with comorbidities. Of the estimated 23 million
adults with diagnosed diabetes, 3 million are under 45 years old,
while 10 million are 65 or older. And more than half of people with diabetes
have at least one other chronic condition. [Neda Laiteerapong] If you actually
look at the recommendations for how to individualize glycemic goals, it’s not
just age, it’s not just duration of diabetes, it’s not just comorbidities or
complication history; also included are risk for hypoglycemia, resources and support,
patient engagement and their personal level, personal preference for where they
want their glycemic goal to be, so it’s a lot more complicated than
physicians are given credit for. The different guidelines all recognize that
patients have individual circumstances. So the need to personalize treatment
goals is an area of consensus. But even with that consensus, some physicians
may be penalized on quality measures if their patients do not achieve established
A1C goals of their system or institution, which may be at the more strict targets. That’s where the new guideline
could have major implications. The “ACP suggests that any physician performance
measures developed to evaluate quality of care should not have a target HbA1c level
below 8% for any patient population.” [Neda Laiteerapong] So, for physicians who are
being penalized for an A1C above seven percent, what this guideline means to them is
that they can hold up the guideline to their healthcare system or their clinic
manager and say, “hey, take a look at this,” and I think it’s really reinforcing
for physicians and hopefully it’ll change how physicians
are being measured on their quality. [Ed Livingston] Hi, I’m Ed Livingston, Deputy
Editor for Clinical Reviews and Education for JAMA and host of the JAMA
Clinical Reviews podcast. [Jennifer Abbasi] And I’m Jennifer Abbasi, a
Senior Staff Writer with JAMA Medical News. [Ed Livingston] There’s a lot
that wasn’t covered in this video, but what we did in the JAMA Clinical Reviews
Podcast was review the literature base supporting diabetes control
recommendations in great detail, finding that that evidence
base is surprisingly weak. [Jennifer Abbasi] And in the Medical
News article we took a deeper dive into the perspectives you heard in the
video, and we discussed how new drugs and devices could change things
in the not-so-distant future. [Ed Livingston] Links to the podcast and
these articles are in the description below.

3 Replies to “What is the Optimal HbA1c Target for Type 2 Diabetes Patients?”

  1. Why not target a normal A1C of of 4.6 to 5.5. that A1C can easily be achieved on a ketogenic diet. There are studies stating that A1C levels over 5.4 carries increased risk of heart desease. https://diabetes.diabetesjournals.org/content/59/8/2020

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