By Richard S. Beaser, M.D., and Richard Jackson, MD
What are the goals of therapy?
Most people today use the A1C as the primary yardstick of control, using a methodology whereby the range in people who do not have diabetes is 4% to 6%. Glucose goals are theoretically “normal” or “near-normal” levels that can be thought of as estimations of levels that would help achieve the desired A1C goals. So what should be the goals of therapy? Many groups have their own perspectives on this question! And these perspectives have been evolving over the last few years, as we try to balance the ideal with the practical….
The new wording by the ADA — setting a general goal but stating that ultimately it should be individualized — is also reflected in the goals set by the Clinical Oversight Committee of Joslin Diabetes Center (Table 2-5). Joslin’s goals also use the <7% A1C target as a practical level for patients using medications that may cause hypoglycemia to avoid the risk of that complication, but state that achieving normal blood glucose is recommended if it can be done practically and safely.
The European community has treatment goal recommendations (Table 2-6) that are two tiered, reflecting differences in goals to reduce macrovascular and microvascular risk. In 2001, the American Association of Clinical Endocrinologists (AACE) recommended targets for A1C of <6.5%, preprandial plasma glucose <110 mg/dl and a postprandial plasma glucose <140mg/dl. While each association or institution may differ slightly from the others, the trends and implications are clear. Recommendations for target A1C are drifting downward based on assessment of newer data and buoyed by safer and more effective treatment tools. The target should be at least under 7%, perhaps lower based on the actual targeted recommendations by some, and an assessment of safety and practicality by others.
Achieving Individualized Goals
Clearly, any goal represents a standard of care that must then be individualized for each patient, balancing the risk of therapy against the benefit that the patient would receive from achieving this level of control. While trying to reach recommended goals of therapy is an important objective of therapy, for some people with diabetes doing so may be extremely difficult, impractical, or unsafe. However, because such goals may be unrealistic does not mean that the patient or healthcare professional should fail to be aggressive in their treatment approach. As noted above, studies such as the DCCT/EDIC suggest that any improvement in control is beneficial. Clearly, however, the obstacles to achieving ADA, Joslin, European or AACE goals should be reviewed among the healthcare providers and the patient and his or her family, and realistic alternative targets of therapy should be established. Keep in mind, also, that compromised goals at one point in time may be adjusted to be more aggressive in the future to accommodate changes such as improved patient attention to self-care, availability of others to help, or newer, safer or more physiologic therapies that allow lower glucose targets to be achieved safely.
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