ACP Sets Eased Blood Sugar Control Levels in New T2D Guidelines

David W. Lam, MD

The American College of Physicians (ACP) has released new guidelines recommending less intensive blood sugar control (A1C) targets for patients with type 2 diabetes (T2D).

According to the new guidelines, patients should be treated to achieve A1C levels between 7% and 8% — a lenient change from the previous 6.5% to 7% standard of the previous guidelines.

Although the A1C test indicates diabetes in a patient at 6.5% blood sugar level, evidence for a reduction in microvascular complications due to tighter treatment target levels is lacking, according to the ACP. The only proven reductions to come from earlier treatment due to stricter guideline levels are in surrogate microvascular complications, such as excess proteins in patients’ urine.

The ACP maintained that clinicians should personalize patients goals for blood sugar control in T2D. Patient treatment personalization should be based on general health, life expectancy, treatment burden, and costs of care.

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 that the guideline changes come in an era of increasing diabetes rates, in an aging population that is in need of consideration to more clinical scenarios.

“The treatment recommendations in this clinical guideline are not drastically different from the recommendations by other professional organizations and therefore I would not expect a drastic change in clinical practice,” Lam said.

Where significant change is notable in the guidelines is in its standard of A1C levels by which to de-escalate therapy, Lam said. He reiterated the importance of physicians considering the potential impact of the subsequent increase in A1C may have on a patient’s quality of life and overall health perception.

He added another statement — that recommends against the use of a specific A1C target in older patients ((80-plus years) with limited life expectancy (10 years), multiple comorbid conditions, and a focus on symptoms of hyperglycemia — as another crucial change. Other guidelines promote a relaxation of A1C goals in this patient group.

“While many providers likely already adjust their A1C goals in this subset of patients, this guideline may further change the care in this group of patients,” 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.”

The ACP maintained that lower treatment target is still appropriate if it is achievable with patient changes to diet and lifestyle.

Even more changes to the guidelines in the years to come are feasible. Lam said new therapies and advancement of diabetes-related technology, which would reduce hypoglycemia risks and allow for better control, would bring along more change.

The implementation of such resources would even more so better these new guideline practices.

“Empowering providers with tools that can quickly assess disease burden and quality of life, in any clinical setting, and be adding more transparency in the cost of medications to patients would be essential to integrate these aspects into clinical decision making,” Lam said.

The new guidelines were published Monday evening in the Annals of Internal Medicine.

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