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JAMA Essay Warns Higher A1C Target Could Have Unintended Consequences on Younger Adults

Mary Caffrey
The guidance from the American College of Physicians continues to drive debate on how to care for adults with diabetes.
The uproar sparked this spring when a leading physicians’ group eased up on targets for controlling blood sugar in people with diabetes has reached the pages of JAMA, and it’s clear the debate won’t end any time soon.

Elizabeth L. Tung, MD, MS; Andrew M. Davis, MD, MPH; and Neda Laiteerapong, MD, MS, wrote in JAMA that the shift in guidance from the American College of Physicians (ACP), who represent the nation’s internists, could have “unintended consequences,” that cause long-term harm to younger adults, despite the purported call to tailor glycated hemoglobin (A1C) targets to the individual.

The authors say the ACP’s call for most adults with type 2 diabetes (T2D) to target an A1C between 7% and 8% “appears to take a population-based approach,” one that recognizes many with T2D are older with other comorbidities. By contrast, other leading professional groups that specialize in diabetes care, such as the American Diabetes Association and the American Association of Clinical Endocrinologists, as well as Joslin Diabetes Center, take an individual approach in keeping their targets of 7% or lower, citing evidence that less glycemic control causes long-term harm.

Robert A. Gabbay, MD, PhD, FACP, chief medical officer at Joslin and the editor in chief for Evidence-Based Diabetes Management™, wrote in March that it was unclear what message ACP hoped to send with the revised guideline. “To me, the greatest surprise in the ACP recommendations is the lack of concern for our younger patients with T2D. Data from CDC show T2D incidence is occurring at younger ages, but with today’s treatments, these patients should have decades of life ahead of them,” he wrote.

The JAMA authors express similar concerns. While they say that the ACP guidance “adds to an important conversation about balancing the benefits and harms of intensive therapy,” there are potential “unintended consequences” if clinicians apply looser standards not only to older patients with other health problems, but also to young patients who face harsh long-term consequences if they fail to maintain strict control.

“A serious concern is that clinicians may apply ACP recommendations to this group, which could lead to systematic undertreatment and worse outcomes for younger adults,” they wrote. “Moreover, clinicians have little current guidance on maintaining [A1C] levels within a narrow range or safely deintensifying diabetes medications as patients age and develop comorbidities … More relaxed targets may also reduce the impetus to identify and treat adults with currently undiagnosed type 2 diabetes that is relatively early in its course.”

The authors share Gabbay’s observation that there are other benefits of newer classes of medication—both sodium glucose co-transporter-2 inhibitors and some glucagon-like peptide-1 receptor agonists have been shown to have cardioprotective effects.

“A broader risk-benefit calculation based on clinical factors … as well as patient preferences regarding various risks and therapies may better determine personalized goals in the future,” the JAMA authors write.

Reference

Tung EL, Davis AM, Laiteerapong N. Glycemic control in nonpregnant adults with type 2 diabetes. JAMA. 2018;319(23):2430-2431.

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