ADA Officials 'Concerned' Over ACP's Diabetes Recommendations

A recent recommendation from the American College of Physicians (ACP) that "lumps" most people with type 2 diabetes into a 7% to 8% hemoglobin A1C target range, could potentially cause increased complication rates for those who may safely benefit from lower evidence-based targets, according to a response statement from the American Diabetes Association.

"Multiple clinical trials confirm increased additional risk of complications among patients who are above an A1C of 7%,” ADA's Chief Scientific, Medical and Mission Officer William T. Cefalu, MD said in the statement. While ADA officials noted that there are aspects of the guidance they agree with, association members are concerned by the missing consideration of the positive impact of several newer medication classes (SGLT2 inhibitors and GLP-1 receptor agonists) that are associated with low risk for hypoglycemia, have favorable effects on weight and improved cardiovascular disease outcomes.

The ADA recommends deintensification or simplification of complex regimens to reduce the risk of hypoglycemia in older adults, if this can be achieved within the individualized A1C target. The key is to individualize the A1C target based on patient factors—and any deintensification should be based on these factors, such as the presence of severe hypoglycemia, and not on a number. ACP’s guidance for deintensification is contrary to the collective evidence, which confirms lower A1Cs reduce complications with no lower limit on benefit and should be pursued and maintained as long as there is minimal risk of hypoglycemia, according to the ADA statement.

With regards to an emphasis on minimizing symptoms of high blood glucose rather than target A1C levels in certain very old or very sick patients, ACP’s guidelines are consistent with ADA’s end-of-life recommendations. However, in their statement the ADA disagrees that this applies broadly to anyone over age 80, anyone living in a nursing home, or anyone with chronic conditions and who has a limited life expectancy.

“ADA urges health care providers to continue to develop personalized care plans that can yield optimal short and long-term results for each individual with diabetes—improved quality of life and health outcomes. And every person with diabetes should have the opportunity to reduce and minimize their risk of the serious complications of diabetes, which can be achieved by lower A1C targets and with management strategies that provide acceptable clinical benefit given the known risks. We stand by the recommendations in our Standards of Care and the detailed evaluations of the landmark clinical trials from which they were derived,” concluded Dr. Cefalu.

Reference

American Diabetes Association® Deeply Concerned About New Guidance from American College of Physicians Regarding Blood Glucose Targets for People with Type 2 Diabetes [news release]. Arlington, VA. ADA press office. March 8, 2018. http://www.diabetes.org/newsroom/press-releases/2018/ada-acp-guidance-response.html. Accessed March 9, 2018.