Together, the Endocrine Society, the American Diabetes Association (ADA), the American Association for Clinical Endocrinologists (AACE), and the American Association of Diabetes Educators (AADE) strongly disagree with the American College of Physicians’ (ACP’s) proposed new guidance that suggests higher blood glucose targets for people with type 2 diabetes. While there is agreement on individualization of treatment based on patient-specific factors, with the aim of protecting those at highest risk, the ACP’s recommendation of blood glucose targets for A1C “from 7 to 8 percent” could prevent many patients from receiving the full benefits of long-term glucose control. We are also concerned the broad range suggested by ACP’s guidance is too large 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, which are the result of higher blood glucose (A1C) levels.
While ACP’s guidance is only one additional percentage point, this may equate to a difference of nearly 30 points when blood glucose is measured in mg/dl. This difference in the lower and higher A1Cs in the range ACP suggests also has been shown to have clear differences in microvascular complications from large, multicenter randomized trials of patients newly diagnosed with type 2 diabetes.
The ACP’s new guidance, “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,” were published in the Annals of Internal Medicine on March 5, 2018. They were developed based on analysis of the same international clinical trials for people with type 2 diabetes (ACCORD, ADVANCE, VADT and UKPDS) reviewed by each of the other organizations, including the Professional Practice Committee for the ADA’s 2018 Standards of Medical Care in Diabetes and the recommendations of AACE and AADE. However, ACP’s interpretations of the findings of the studies did not account for the differences in the patient populations of these studies.
In addition, their recommendations do not consider the positive legacy effects of intensive blood glucose control confirmed in multiple clinical trials, particularly for those newly diagnosed with type 2 diabetes, and, therefore, are not reflective of the long-term benefits of lower A1C targets. ACP’s guidance also does not consider the positive impact of several newer medication classes (SGLT2 inhibitors and GLP-1 receptor agonists) demonstrated in more recent clinical trials to improve mortality and morbidity in high-risk patients with type 2 diabetes. These medications have been associated with low risk for hypoglycemia, have favorable effects on weight and demonstrate improved cardiovascular disease outcomes.
The Endocrine Society, ADA, AACE and AADE remain firmly committed to protecting the more than 29 million Americans with type 2 diabetes from its serious complications by recommending individualized care that can improve their lives and reduce their risk of complications. The human impact of one percentage point is serious — to their daily lives, their families, friends and loved ones — and their long-term quality of life and health outcomes.