Type 2 diabetes

“De-intensify”: the pendulum swings against HbA1c targets

New US guidelines recommend less intensive glycaemic control for patients with type 2 diabetes on the grounds that intensive control may cause substantial harm with little or no benefit on clinical outcomes.

The new guidance released by the American College of Physicians recommends that the target for HbA1c levels should be between 7% and 8% for most people, in contrast to the current Australian Diabetes Society target of below 7%.

After reviewing the evidence from landmark studies such as ACCORD, ADVANCE and the UKPDS trials, the ACP concluded that the balance of benefits and harms lay with less intensive glycaemic control for most patients.

“Collectively, these trials showed that treating to targets of 7% or less compared with targets around 8% did not reduce death or macrovascular events over about 5 to 10 years of treatment but did result in substantial harms, including but not limited to hypoglycaemia,” they said.

The ACP noted that most of the trials used to inform guideline recommendations for intensive HbA1c targets only showed benefits on surrogate outcomes and the benefits took many years to become apparent.

The College therefore recommended that intensive control would be more of a priority for patients with a longer life expectancy, and they would still have to weigh up the benefits against the higher burden of treatment, risks of hypoglycaemia and the costs of medications.

For most patients with type 2 diabetes, the intensive targets could be relaxed with a view to de-escalating treatment and reducing treatment burden, they suggested.

“If a patient achieves an HbA1c level less than 6.5%, the clinician should deintensify treatment by reducing the dosage, removing a medication if the patient is receiving more than one, or discontinuing pharmacologic treatment,” the ACP said

And for older or sick patients with a  life expectancy of less than 10 years, the focus of treatment should be on minimising symptoms rather than meeting HbA1c targets, the guidelines advised.

HBA1c targets would cause more harm than benefit in people older than 80 years and those who have serious health conditions such as dementia, cancer, kidney disease, COPD or heart failure, the statement said.

Less stringent HbA1c targets would also allow patients to reduce their risk from diabetes using lifestyle and diet measures rather than drugs, the guideline authors noted.

“Smoking cessation, adequate blood pressure control, and lipid management are also indicated in patients with type 2 diabetes and, for many patients, may take priority over achieving glycemic control, especially for preventing macrovascular complications,” they said.

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