Diabetes debate: Do I need tight glycemic control?
How aggressively should one treat Type 2 diabetes? New norms have sparked a debate.columns Updated: Mar 10, 2018 17:41 IST
A storm is brewing within the global medical community, over new recommendations by the American College of Physicians. The ACP is asking clinicians to treat adults with Type 2 diabetes less aggressively, recommending that they personalise goals for glucose control based on the patient’s preferences, general health and life expectancy, the benefits and harms of drug therapy, the treatment burden, and the costs of care.
The ACP targets a Haemoglobin A1c (HbA1c is a test that represents blood glucose control over the preceding three months) of 7% to 8%, against the current recommendation of below 6.5%. It asks clinicians to deintensify drug therapy in patients with HbA1c levels of less than 6.5%.
The new guidelines also advise clinicians to avoid targeting an HbA1c level in people with a life expectancy of less than 10 years due to advanced age (80 or older), residence in a nursing home, or chronic conditions such as dementia, cancer, end-stage kidney disease, severe chronic obstructive pulmonary disease or congestive heart failure, because in such cases the harms of aggressive treatment outweigh the benefits.
The ACP’s recommendations are drawing flak from other international medical associations. While all existing guidelines stress the need for individualised care, the American Association of Clinical Endocrinologists and American College of Endocrinology (ACE) recommend an HbA1c level of less than 6.5% for non-pregnant adults, while the UK’s National Institute for Health and Care Excellence sets a target of less than 6.5% for people whose blood glucose levels can be managed with diet and lifestyle and a single drug. The US Department of Veterans Affairs sets a target of 6% to 7% for those with a life expectancy between 10 and 15 years.
Hitting out at the ACP’s new norms, the American Diabetes Association in a statement said “individualization of targets is the key factor, and by lumping ’most’ people with type 2 diabetes into a 7-8% target range, ACP’s new guidance may cause potential harm to those who may safely benefit from lower evidence-based targets”. The ACE went a step ahead, calling the ACP recommendations “absolutely wrong and regressive” and a gross neglect of data and an “overabundance of evidence to show that lover HbA1C is better”.
Clinicians in India are in favour of tighter targets for glycemic control because Indians develop Type 2 diabetes at a younger age and the disease is often diagnosed late, sometimes after complications have set in.
India is home to 69.2 million people with diabetes, of whom 47.3% are undiagnosed. About 10.2% of adults have glucose intolerance, a precursor to diabetes if lifestyle changes — nutritious low-sugar and low-carb diet, weight loss, high activity etc — are not made. Diabetes is twice as common in urban areas (11.2%) than rural (5.2%,), with advancing age, obesity, hypertension and family history of diabetes being independent risk factors in both urban and rural areas, according to the Indian Council of Medical Research India Diabetes study reported in The Lancet.
Markedly elevated blood glucose levels initially cause mild symptoms such as thirst (polydipsia), frequent urination (polyuria), weight loss and dehydration. Over time, untreated diabetes leads to vision loss, painful neuropathy (sensory loss), foot ulcers, amputations, silent heart attacks, stroke, and end-stage renal disease.
“It has created quite a buzz, emails are flying thick and fast,” says Dr Nikhil Tandon, head of the department of endocrinology, metabolism and diabetes at the All India Institute of Medical Sciences, New Delhi, referring to the new ACP norms. “I would believe that there is clearly a subset of patients in whom an HbA1c of around 7% would be a reasonable target. But with T2DM starting earlier, in the second and early third decade of life, among Indians, I would be a votary for tighter control in these populations, since we are looking at a longer lifetime exposure to high blood glucose levels.”
All associations are unanimous on 7% and below being the criterion of good control, which has proven benefits for nerve, eye and kidney problems resulting from diabetes over the years, adds Dr Anoop Misra, chairman of the Fortis Centre for Diabetes, Obesity and Cholesterol in New Delhi.
In India, there’s the added danger of blood glucose estimation not being accurate, depending on the quality of the labs where testing is done.
“For people under 40, the target is and must remain less than 6.5% as relaxing the upper limit of blood sugar control may put more people in danger of complications,” says Dr Misra. “It’s only in older people and those with an HbA1c of 6.5% or less that therapy should be de-intensified.”