The need to control A1C levels in individuals with diabetes is a given. How to achieve A1C targets and where to set the goals is more problematic. The ADA, the American College of Physicians (ACP), The Endocrine Society, and other organizations have all looked at the same science and set different goals.
The ACP, for example, calls for pharmacologic targets of an A1C of between 7 and 8 percent. The ADA target is less than 7 percent for most patients.
“The science is quite clear that a treatment target of 7 to 8 percent provides the optimal balance of benefits to harms,” said Timothy J. Wilt, MD, MPH, Professor of Medicine at the University of Minnesota School of Medicine and Core Investigator at the Minneapolis Veterans Administration Center for Care Delivery and Outcomes Research. “That’s where the science is soundest, but also where there appears to be some of the greatest noise. But in reality, there’s a lot of commonality among practice guidelines. We should emphasize that commonality.”
Or maybe the difference is more apparent than real.
“In a sense, we’re all splitting hairs,” said David D’Alessio, MD, Professor of Medicine and Director of the Division of Endocrinology, Metabolism, and Nutrition, and Associate Director of the Duke Molecular Physiology Institute at Duke University. “If you measure an individual every week four weeks in a row, you’re likely to get something like 7.0, 7.1, 6.8, and 7.3. The key is not the target itself but the rationale and the science behind the target.”
Dr. D’Alessio and Dr. Wilt will debate the merits of the competing guidelines from the ADA and the ACP during Monday’s Current Issues session Glycemic Goals and Overtreatment—What’s Driving the Debate? The session will begin at 8:00 a.m. in N-Hall E (North, Exhibition Level).
There are important differences between the definitions used in the two guidelines, Dr. Wilt noted. The ACP target applies to nonpregnant adults in good health with an expected lifespan of at least 10 years who have type 2 diabetes and are treated with medications. The ADA guideline applies to “many nonpregnant adults.” The ADA guideline also notes that more stringent targets may be appropriate for some individuals and less stringent for other individuals.
“We should focus more on the rationale behind the targets,” Dr. Wilt said. “The ACP developed our guidance statements based on the evidence of clinical benefits and harms from large, long-term, treat-to-target randomized trials and the ADA came up with their targets based on their rationale. The whole point of this debate is to flesh out those differences.”
Neither organization recommends blind adherence to treatment recommendations. Clinical judgement is vital. Indeed, Dr. D’Alessio said strict adherence to guidelines is generally bad medicine. Individual patients require individual judgements.
“All of us agree that A1C targets should be individualized, taking into account patient age, comorbidities, medication burden, the balance of benefits versus harms, and costs,” Dr. Wilt said. “Diabetes is common, potentially serious, and carries high costs, both in terms of health-care issues and pharmacological cost. Treatment is the optimal balance of benefits and harms.”
The obvious downside of overly stringent A1C targets is hypoglycemia, Dr. Wilt noted. Other common harms from overtreatment include weight gain, fluid retention, excessive medical visits, additional medications, and higher costs.
But the debate over A1C targets is not likely to end soon. There are entirely new classes of medications that have yet to be evaluated in terms of A1C targets, including SGLT2 inhibitors, GLP-1 agonists, and DPP-4 inhibitors.
“This session will explore different viewpoints for the rationales behind what we do,” Dr. D’Alessio said. “Once you understand the rationale, you can adjust as needed because every patient is a little different.”