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March 7, 2018

A key physician group just changed diabetes treatment guidelines—and some providers are firing back

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    The American College of Physicians (ACP) in guidance released Tuesday recommends that clinicians set higher blood sugar targets for most non-pregnant adults with Type 2 diabetes—prompting criticism from health care providers and medical groups that specialize in diabetes care.

    Guidance details

    ACP based its guidance statement on a review of six existing guidelines on the topic from various medical groups and organizations. All of the reviewed guidelines recommend individualizing HbA1c target levels based on the patient, but they each varied slightly in their HbA1c target levels. For instance, guidelines from the:

    • American Association of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE) recommend an HbA1c target of 6.5%, if it can be reached safely;
    • American Diabetes Association (ADA) recommend an HbA1c target of 7%;
    • Department of Defense and Veteran Affairs recommend an HbA1c of 6% to 7%;
    • Institute for Clinical Systems Improvement recommend HbA1c levels of less than 7% to less than 8%;
    • National Institute for Health and Care Excellence recommend an HbA1c target of 6.5% or 7%; and
    • Scottish Intercollegiate Guidelines Network (SIGN) recommend an HbA1c target of 7%.

     ACP also examined five clinical trials used to develop the six guidelines.

    Guidance statement details

    Based on the review, ACP, which represents internists, is now recommending that providers set HbA1c target levels between 7% and 8% for most non-pregnant adults with Type 2 diabetes. According to STAT News' "Morning Rounds," the group previously recommended HbA1c target levels of between 6.5% and 7% for adults with Type 2 diabetes.

    ACP said clinical trials "showed that treating to targets of 7% or less compared with targets around 8% did not reduce death or macrovascular events over about five to 10 years of treatment, but did result in substantial harms, including but not limited to hypoglycemia."

    ACP also said clinicians should consider scaling back pharmacologic therapies for adults with Type 2 diabetes whose HbA1c levels fall below 6.5% because of potential cardiovascular harms.

    In addition, ACP said for some patients—those who are 80 years or older, residing in a nursing home, or diagnosed with a chronic condition—clinicians should design care plans to "minimize symptoms related to hyperglycemia," instead of setting HbA1c target levels, because the harms outweigh the benefits.

    ACP also reaffirmed its position that "clinicians should reevaluate HbA1c levels and revise treatment strategies on the basis of changes in the balance of benefits and harms due to changed costs of care and patient preferences, general health, and life expectancy."

    Experts raise concerns

    Medical groups and providers who specialize in diabetes care are pushing back against ACP's new guidelines.

    Ajay Rao, an assistant professor at the Lewis Katz School of Medicine at Temple University, said ACP's new recommendation "is inconsistent with guidelines from most national and international organizations," as well as the most recent 2018 Standards of Diabetes Care from ADA. Rao said lowering HbA1c target levels "sends a mixed message to our patients, and potentially sends us backward in the fight against small vessel complications in Type 2 diabetes."

    George Grunberger, a past president of the American Association of Endocrinologists who served on the committee that developed diabetes recommendations for ACE, said ACP's guidelines are based on a misinterpretation of old studies that were not designed to examine ideal blood sugar levels. He said the risks of high blood sugar levels outweigh those of low blood sugar levels, and that the new recommendation could cause some practicing physicians not to worry about keeping those levels under control.

    Experts from the AACE and ADA also said the new guidelines could cause confusion among providers.  

    William Cefalu—chief scientific, medical, and mission officer at ADA—said, "HbA1c targets should not vary between types of clinicians or clinical settings."

    Yehuda Handelsman, medical director and principal investigator of the Metabolic Institute of America who has served as president of AACE, said the "new guidance will surely add confusion," as the ADA and AACE guidelines are "quite similar [to ACPs] as both endorse personalized treatment, focusing on lower HbA1c goals and recommending newer medications with lower risk of hypoglycemia."

    David Lam of Icahn School of Medicine at Mount Sinai also said ACP's recommendations could "change how some providers care for patients who are able to achieve this level of control," but he added, "It is important to also consider what potential impact the subsequent increase in HbA1c level may have on the patient's quality of life and their perception of overall health."

    In terms of ACP's recommendations to avoid setting HbA1c levels for certain type 2 diabetes patients, Lam said, "While many providers likely already adjust their A1C goals in this subset of patients, this guideline may further change the care in this group of patients" (Minerd, MedPage Today, 3/5; Joseph, "Morning Rounds," STAT News, 3/6; Larkin, Reuters, 3/5; Busko, Medscape, 3/5; Harris, "Shots," NPR, 3/5;  ACP clinical guidelines, 3/6).

    More on how to improve your diabetes program

    Our briefing dives deeper into the five areas diabetes management programs often fail when expanding, and provides solutions to engage patients, improve outcomes, and reduce spending.

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