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American College of Physicians Recommending Controversial Increase in A1c of 7% to 8%

Mar 10, 2018
 

Organization says adults with type 2 diabetes can aim for an easier-to-achieve blood sugar target than what’s been used to guide treatment in the past.

By Steve Freed, R.Ph., CDE, Publisher

The recommendations include, (1) Personalize goals for blood sugar control based on a discussion of benefits and harms of drug therapy, patient preferences, patient health and life expectancy, treatment burden and costs of care, (2)  Aim to achieve an HbA1C level between 7% and 8% in most patients, (3) Consider deintensifying drug therapy in patients with A1C levels less than 6.5%, (4) Treat patients to minimize low blood sugar symptoms and avoid targeting an A1C level in patients with a life expectancy less than 10 years because the harms outweigh the benefits and finally the guidance also states that a lower treatment target is appropriate if achievable with diet and lifestyle modifications and that clinicians should emphasize to patients the importance of exercise, weight loss, smoking cessation, and other lifestyle changes.

These recommendations are inconsistent with guidelines from most national and international organizations, such as the American Diabetes Association, American Association of Clinical Endocrinologists and even world organizations and are certainly not consistent with all of the 2018 Standards of Diabetes Care from every other organization.

They reviewed these five clinical trials: ACCORD (Action to Control Cardiovascular Risk in Diabetes), ADVANCE ((Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation), and Affairs Diabetes Trial), Both UKPDS (United Kingdom Prospective Diabetes Study) trials. We know that for most of these studies the participants were usually older and had elevated A1c’s and many had cardiovascular disease and other complications to start with.

Looking back to the Diabetes Complications and Control Trial (DCCT), which was a major clinical study conducted from 1983 until 1993, which discovered for the first time that keeping blood glucose levels as close to normal as possible slows the onset and progression of the eye, kidney, and nerve damage caused by diabetes. In fact, it demonstrated that any sustained lowering of blood glucose helps, even if the person has a history of poor control.

The DCCT involved 1,441 volunteers, ages 13 to 39, with type 1 diabetes and 29 medical centers in the United States and Canada. Volunteers had to have had diabetes for at least 1 year but no longer than 15 years. They also were required to have no, or only early signs of, diabetic eye disease.

The study compared the effects of standard control of blood glucose versus intensive control on the complications of diabetes. Intensive control meant keeping hemoglobin A1C levels as close as possible to the normal value of 6 percent or less. The A1C blood test reflects a person’s average blood glucose over the last 2 to 3 months. Volunteers were randomly assigned to each treatment group.

The DCCT study found that Intensive blood glucose control reduces risk of

  • eye disease by 76%
  • kidney disease 50%
  • nerve disease by 60%

Then they continued the study for 10 years more, which was the EDIC study and they found that those who were in the intensive control group had a reduction of cardiovascular disease by 42% and nonfatal heart attack, stroke or death from cardiovascular causes by 57%.

We know that the DCCT study was for type 1 diabetes, but the complications we know come from elevated blood sugars, regardless whether you have type 1 or type 2 diabetes. In many other studies, we have seen that blood sugars destroy our organs over time. Therefore, recommending higher blood sugars by the ACP will only confuse medical professionals.

It has been known from the 1000’s of studies done for just about every drug that we should be lowering blood sugars as close to normal as possible when done safely without hypoglycemia is the worldwide recommendation from every reputable organization.

The Chief Scientific Officer of the American Diabetes Association has responded to the American College of Physicians recommendations with this comment:  “The ADA believes all people diagnosed with type 2 diabetes can be healthy and should have the opportunity to reduce their risk of serious diabetes complications through appropriate blood glucose targets,” stated ADA’s Chief Scientific, Medical and Mission Officer William T. Cefalu, MD. “Individualization of targets is the key factor in designing the most appropriate regimen for patients with Type 2 diabetes. However, by lumping ‘most’ people with type 2 diabetes into a 7 to 8 percent target range, ACP’s new guidance could cause increased complication rates for those who may safely benefit from lower evidence-based targets. Multiple clinical trials confirm increased additional risk of complications among patients who are above an A1C of 7 percent.”

Practice Pearls:

  • The relaxation of the A1C goal by a large organization such as ACP sends a mixed message to our patients, and potentially sends us backward in the fight against small vessel complications in type 2 diabetes.
  • To truly find out if having an A1c of 8% is beneficial, why not just find patients who have had A1c’s of 7-8% for 15, 20, 30 and 40 years and see if they have any complications or are still alive?
  • Should we abandon the information from the thousands of studies showing that normal blood sugars are good?

References:

Annals of Internal Medicine (ACP) March 2018

DCCT and EDIC: The Diabetes Control and Complications Trial and Follow-up Study (PDF, 106 KB)