The American College of Physicians has issued new guidance on managing Type 2 diabetes—including relaxing the long-term blood sugar target called hemoglobin A1C.
The A1C is a blood test that gives doctors an estimate of your blood sugar level average over the past few months. For most adults, the American Diabetes Association recommends a target A1C of below 7 percent. This goal may be altered based on individual circumstances.
However, the new ACP guidance suggests that A1C should be between 7 and 8 percent for most adults with Type 2 diabetes. For adults who achieve an A1C below 6.5 percent, the group suggests stepping down diabetes treatment to keep that level from going even lower.
The American College of Physicians, which is a national organization of internal medicine doctors, also says that management goals should be personalized based on the benefits and risks of medications, patient preference, general health status and life expectancy.
And, though the doctors’ group has relaxed the suggested A1C targets, that doesn’t mean Type 2 diabetes isn’t a serious problem.
“These changes should in no way be interpreted as diabetes is unimportant,” said Dr. Jack Ende, ACP’s president.
More than 29 million Americans have diabetes. Over time, high blood sugar levels can lead to vision loss, nerve problems, heart attacks, strokes and kidney failure.
“Diabetes is such a prevalent problem, and there are so many guidelines and conflicting information out there, we wanted to do an assessment that would give our members the best possible advice,” Ende said. “Also, A1C targets are being used now as a performance measure.”
And, when insurers expect all patients to fall under a certain A1C, that’s “not always consistent with the best possible evidence,” he explained.
For instance, it’s not always safe to manage an 80-year-old with memory problems to the same A1C target as a 50-year-old. Diabetes therapies can cause low blood sugar levels, which can also cause health problems.
The American Diabetes Association also recognizes the importance of individualizing diabetes treatments, according to Dr. William Cefalu, its chief scientific, medical and mission officer. However, he expressed concern about loosening the A1C target.
“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,” Cefalu said.
“Individualization of targets is the key factor,” he said. “By lumping most people with Type 2 diabetes into a 7 to 8 percent target range, ACP’s new guidance may cause potential harm to those who may safely benefit from lower evidence-based targets.”
If someone is safely achieving an A1C of 6.5 percent or less, there’s no reason to arbitrarily reduce their medication, Cefalu said. If people are experiencing low blood sugar levels, then medications should likely be adjusted. But, he said, there’s no lower limit on A1C as long as people have minimal risk of low blood sugar.
ACP’s new guidance also suggests that clinicians avoid a target A1C in people with a life expectancy of less than 10 years because they have an advanced age (80 and older), live in a nursing home or have another chronic health condition. Instead, ACP recommends minimizing symptoms of high blood sugar for these patients.
Cefalu said that, on this issue also, ADA recommends individualized therapy. He noted that the average life expectancy for someone who reaches 80 years old is another 8 years for men and 10 years for women.
“Each specific case should be evaluated individually, as a person living in a nursing home or with a chronic condition may yet have some years to live, and would likely prefer to live them without diabetes complications,” he added.
Ende countered that ACP isn’t minimizing the importance of treating Type 2 diabetes and addressing its risk factors by prescribing statins and controlling blood pressure in people with the disease. However, he said there’s evidence that lowering A1C too much may cause harm.
Cefalu said he’d like to see A1C targets be consistent from clinician to clinician.
“Everyone agrees that care should be individualized and that the focus should be on patients,” he noted. “However, the details are critical and specific for each patient.”
The new guidance for physicians on Type 2 diabetes management was published online recently in Annals of Internal Medicine.