Glycemic Goals in Type 2 Diabetes

A computer-generated algorithm based on a survey of leading diabetologists may help clinicians individualize glycemic goals for patients with type 2 diabetes mellitus (T2DM), according to a new study.

Over the past few years, researchers have recognized a need to adjust glycemic targets based on parameters that pertain to individual patient characteristics and comorbidities. “However, the weight and value given to each parameter will clearly vary depending on the experience of the provider, the characteristics of the patient, and the specific clinical situation,” stated the researchers, led by Avivit Cahn, MD, of the Diabetes Research Center, Hadassah Hebrew University Medical Center in Jerusalem, Israel.

Dr. Cahn and colleagues conducted a survey of 244 key worldwide opinion-leading diabetologists to come to a consensus with regard to identifying these parameters and their relative importance. The researchers asked the diabetologists to rank the factors they take into consideration when setting their patients’ glycemic target, according to their relative importance.

Then the diabetologists were presented with six clinical vignettes and were asked to suggest an appropriate glycemic target. The cases ranged from a newly diagnosed patient with no complications to a frail elderly patient with multiple complications and/or comorbidities.

About two-thirds of the diabetologists responded to the survey. They were asked to rank in order of importance 11 parameters affecting a patient’s HbA1c goal based on the American Diabetes Association/ European Association for the Study of Diabetes guidelines. The parameters “life expectancy” and “risk of hypoglycemia from treatment” were considered to be the most important. “Resources” and “disease duration” ranked the lowest.

The researchers used these survey results to formulate an algorithm to estimate the patient’s glycemic target based on computerized, individualized parameters. They assigned points to each factor based on low, medium, or high risk, and then devised formulas for clinicians to use the numbers from a patient’s medical record to generate an HbA1c target between 6.5% and 8.5%.

The basic algorithm includes five objective parameters, including risk of hypoglycemia from treatment, life expectancy, important comorbidities, macrovascular and advanced microvascular complications, and disease duration. The researchers noted that these parameters are easily obtainable from databases already used by clinicians.

The researchers also calculated a second formula that includes three additional subjective parameters, including adherence and motivation, cognitive function, and resources/support system. They noted that adding these parameters can shift the target HbA1c up or down by 0.5%.

To validate the algorithm, the researchers presented three new cases to a new set of 57 leading diabetologists, who suggested glycemic targets that were similar to those calculated by the algorithm.

The researchers admitted that the algorithm needs further study and validation, but believe it will help clinicians individualize care of all T2DM patients. 

In conclusion, the researchers stated: “The resultant suggested algorithm is an additional decision-making tool offered to the clinician to supplement clinical decision making when considering a glycemic target for the individual patient with diabetes.”

Reference: Cahn A, et al. Clinical assessment of individualized glycemic goals in patients with type 2 diabetes: formulation of an algorithm based on a survey among leading worldwide diabetologists. Diabetes Care. 2015 Dec;38(12):2293-2300.