A New Set of Type 2 Care Guidelines, and Where They Fall Short
By Ben Pallant and Payal Marathe
Recommendations from the American College of Physicians focus on relaxing A1c goals without considering up-to-date CGM and therapy options
A new set of recommendations could have substantial and potentially counterproductive effects on type 2 diabetes care. The guidelines from the American College of Physicians (ACP), an influential organization with over 150,000 members, call for the majority of people with diabetes and their providers to raise their A1c goals, in most cases to 7-8%. This contradicts the recommendations of other leading professional organizations, which suggest an A1c target of at least <7%. The ACP guidelines do not address many of the newer, highly-effective therapies and technologies available today, and they overlook the fact that A1c can be an insufficient – and even potentially misleading – measure. Given that well over 20 million people in the US have diagnosed diabetes (an estimated 7.2 million more have diabetes but don’t know it) – including 1.4 million people diagnosed in 2015 according to new CDC data – and given that over 30% of people with diabetes have A1c levels over 9%, these new guidelines may be unproductive for many.
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The ACP offered four “Guidance Statements” for type 2 diabetes care. These statements boil down to:
A1c targets for people with type 2 diabetes should be personalized based on:
overall health and life expectancy, and
the pros and cons of therapy options including side-effects-versus-benefits consideration as well as financial or emotional burdens.
For most people with type 2 diabetes, an A1c target of 7-8% will probably be appropriate.
For people with type 2 diabetes who have an A1c of 6.5% or lower, clinicians should consider reducing or stopping medications.
For people with type 2 diabetes and a life expectancy of less than 10 years (due to age or health conditions), diabetes management should generally avoid setting any kind of A1c goal, and should instead focus on avoiding symptoms of high and low blood sugar.
The overall message of these recommendations seems to be that many people with type 2 diabetes should have a more relaxed (that is, higher) A1c target, especially if it helps avoid side effects or other negative consequences like high cost.
Given other recommendations by leading professional organizations, as well as past studies such as the UKPDS that show that lower A1c levels reduce complications, these recommendations might best be taken with a grain of salt.
For instance, in response to the third guidance statement, leading University of Washington researcher Dr. Irl Hirsch mused, “Why if I have someone with an A1c below 6.5% on metformin, an SGLT-2 inhibitor, and a GLP-1 agonist (especially with known CV disease) would I want to de-intensify therapy? I think a greater emphasis on glucose with individualized targets are needed, not a global statement that all patients with type 2 diabetes who are successful with pharmacotherapy need to be de-intensified.” In other words, this third guideline is useful for some patients on some therapies.
Renowned UNC researcher Dr. John Buse also emphasized, in response to the fourth guideline, just how challenging it is to estimate life expectancy for any one person.
If you haven’t discussed an A1c goal with your healthcare provider, we recommend doing so, along with discussing goals for hypoglycemia, weight management, and spending on diabetes therapies. One indisputable aspect of the ACP guidelines is that management should be individualized! (Several years ago, diaTribe shared a five-question guide on individualizing therapy. While a lot has changed since then, the key points still apply.) Better individualization is a great way to make people with diabetes and their healthcare providers more successful – ACP wisely recognizes that this may mean raising A1c targets in some cases.
The ACP publication with these new guidelines looks at A1c targets as a trade-off. In principle, this makes a lot of sense – trying to single-mindedly push A1c lower can come with undesired consequences like side effects from using more medications, extra daily stress and burden, and increased cost. And in many cases, avoiding these consequences is certainly important in deciding, “What diabetes management strategy is best for me?”
But the ACP makes little or no mention of two key areas of information. As diaTribe has written about before, A1c is an insufficient – and potentially misleading – measure when it comes to diabetes management. It turns out that many different factors can influence A1c, including individual variability, meaning that two people with identical A1c levels might actually have a very different average blood glucose. And this is not to mention that most commonly used A1c tests are only accurate to the nearest 0.5%, meaning that an A1c result of 7.0% could represent a “true” value of anywhere from 6.5% to 7.5%.
More importantly, the ACP guidelines do not mention continuous glucose monitoring (CGM) or any of the newest classes of type 2 diabetes drugs, including SGLT-2 inhibitors, GLP-1 receptor agonists, and DPP-4 inhibitors (except to say the guideline “does not cover use of specific medications outside of their use to achieve HbA1C targets”). These newer medicines are notable for lowering A1c without increasing the risk of low blood sugar (hypoglycemia) unlike insulin (especially mealtime insulin) and sulfonylureas, which come with increased risk of hypoglycemia and weight gain. Many newer medications also have relatively mild side effects and, in some cases, are even associated with desirable “side effects” like weight loss. The ACP’s guidelines did recognize that individual preferences should be an important factor but didn’t indicate how this should actually be done. These new therapies offer a great example of how different outcomes – and cost – can be important considerations for each individual. Additionally, CGM has the potential to help people with diabetes recognize or avoid hypoglycemia. This is especially meaningful given that two different CGM systems – the Dexcom G5 and Abbott FreeStyle Libre – are now covered by Medicare, making them available to many more people with type 2 diabetes who use insulin.
In short, it is increasingly the case that there isn’t a clear tradeoff of “lower A1c means more negative consequences like hypoglycemia.” Virtually all of the research that the ACP turns to in order to support its guidelines was conducted before these newer drug classes and technologies were approved, suggesting that the recommendation to aim for an A1c level of 7-8% may be outdated. In fact, a group from the renowned Joslin Diabetes clinic, led by Dr. Medha Munshi, published a piece last year titled “Liberating A1C goals in older adults may not protect against the risk of hypoglycemia,” showing that higher A1c levels did not result in reduced hypoglycemia in a study of older people with diabetes using insulin.
The ACP is not the only group of health professionals to have guidelines for type 2 diabetes care. The ACP’s recommendations conflict with two key sets of guidelines from the American Diabetes Association (ADA) and the American Association of Clinical Endocrinologists (AACE). The ADA recommends aiming for an A1c of 7% or less, while AACE states that an A1c of 6.5% or less is ideal as long as it can be achieved in a safe and affordable manner. Leaders of both of these organizations expressed disagreement with the new ACP guidelines in an NPR piece published alongside the new recommendations. In the piece, Dr. George Grunberger, former AACE President, said "My concern is this will be a message to many practicing physicians saying, 'Well, don't worry about it so much, because it's OK.'" The head of the American Diabetes Association, Dr. Will Cefalu, said, “We stand by our guidelines,” emphasizing that the ACP recommendations seem to overlook the value of newer therapies.
It does seem, however, that the one key matter on which all three of these organizations, do agree is that there is no one-size-fits all strategy for diabetes care. Different solutions may be best, and different outcomes may matter most, depending on the person, so diabetes care should be personalized based on these factors. Unfortunately, an over-emphasis on A1c targets and failure to acknowledge the most advanced tools to help people manage diabetes seems to have lead the ACP to recommend less up-to-date standards.