Diabetes Organizations Rebuke ACP's Type 2 Guidelines

MARCH 12, 2018
Kevin Kunzmann
Grazia Aleppo, MDGrazia Aleppo, MD
Following the American College of Physician’s (ACP) announced change to their blood sugar control guidelines for patients with type 2 diabetes (T2D) last week, criticism from their peers came swiftly and wholly.

A joint statement from the Endocrine Society, the American Diabetes Association (ADA), the American Association of Clinical Endocrinologists (AACE), and the American Association of Diabetes Educators (AADE) expressed strong disagreement with the ACP’s new guidelines, which raised goal A1C levels to between 7% and 8% for patients with T2D.

The change, an increase from the commonly advocated and practiced levels between 6.5% and 7%, came from lacking evidence that stricter treatment target levels equated to reductions in microvascular complications. Though diabetes is indicated in patients reporting blood sugar levels of at least 6.5%, the ACP now advises physicians provide personalized treatment and differing perception in an era of increasing diabetes rates.

 However, the dissenting endocrinology organizations have responded that lenient A1C target treatment levels could prevent patients from receiving thorough benefits from long-term glucose control.

“While ACP’s guidance is only 1 additional percentage point, this may equate to a difference of nearly 30 points when blood glucose is measured in mg/dl,” the organizations wrote in a statement. “This difference in the lower and higher A1Cs in the range ACP suggests also has been shown to have clear differences in microvascular complications from large, multicenter randomized trials of patients newly diagnosed with type 2 diabetes.”

The organizations also expressed concern for the broad range advised by the ACP, noting that it is too large to apply to most patients with T2D, and could cause more harm than benefit for patients that would be better served by lower A1C target levels.

David W. Lam, MD, Assistant Professor of Medicine in the Division of Endocrinology, Diabetes and Bone Diseases at the Icahn School of Medicine at Mount Sinai, told MD Magazine at the time of the published guidelines that the new recommendations are not drastically different from current clinical guidelines.

The most significant changes Lam noted from the new guidelines are in its standard of A1C levels by which to de-escalate therapy, and the recommendation against specific A1C targets in patients 80 years or older with limited life expectancy, multiple comorbid conditions, and a focus on symptoms of hyperglycemia.

Though providers often already adjust A1C goals for this patient group, the ACP guidelines could lead to change of treatment for this group, Lam said.

“It also has the potential to modify quality metrics that are currently monitored and reported whether in the actual outcome measures or in the patient group in which these metrics are applied to,” Lam said.

While the joint organizations agree on the ACP’s call for individualized therapy, their chief concern comes from their “lumping together most diabetes patients,” Clinical Affairs Core Committee Chair Grazia Aleppo, MD, told MD Magazine.

Aleppo noted the ACP guidelines do not give consideration to promising clinical data from intensive blood glucose control trials, nor the efficacy of sodium-glucose cotransporter 2 (SGLT2) inhibitors or glucagon-like peptide-1 (GLP-1) receptor agonists. The latter 2 therapies’ clinical efficacy in reducing the morbidity and mortality of high-risk patients with T2D is counterintuitive to the lax guidelines, Aleppo said.

“In the primary care setting — or even the endocrinologist setting — not every patient with T2D has the advanced form of the disease,” Aleppo said. “Why not keep these people in the best A1C condition possible?”

The joint organizations reiterated that the A1C level adjustment from just 1 percentage point in treating patients with T2D is enough to affect patients’ daily lives.

“It’s just that the devil is in the details,” Aleppo said.

The ACP guidelines can be read here.

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