Few medical practitioners would dispute the importance of HbA1c tests for people with type 2 diabetes. But physician groups sparred publicly this spring over how doctors should respond to HbA1c test results.
One group – the American College of Physicians – came out in favor of relaxing blood sugar targets; others, led by the American Diabetes Association, loudly and publicly disagreed.
Diabetes mellitus is a leading cause of death in the United States and is associated with microvascular and macrovascular complications, according to the American College of Physicians. More than 29 million people, or 9.3 percent of the U.S. population, have type 2 diabetes.
The hemoglobin A1c (HbA1c) – also called glycosylated or glycated hemoglobin level – approximates average blood glucose control over about three months. Markedly elevated glucose levels can result in subacute symptoms, such as polyuria (frequent urination), polydipsia (excessive thirst), weight loss, and dehydration, points out the ACP. Over time, people with diabetes may suffer vision loss, painful neuropathy or sensory loss, foot ulcers, amputations, myocardial infarctions, strokes, and end-stage renal disease.
Lowering blood glucose may decrease risk for complications, but lowering strategies come with harms, patient burden and costs, says the ACP in its clinical guidelines, published March 6 in the Annals of Internal Medicine. Those harms include hypoglycemia.
Accordingly, the American College of Physicians recommends that clinicians aim to achieve an HbA1c level between 7 percent and 8 percent in most patients with type 2 diabetes (while conceding that clinicians should personalize goals for glycemic control depending on each patient’s circumstances). Furthermore, the organization recommends that clinicians ease up on pharmacologic therapy in patients with type 2 diabetes who achieve HbA1c levels less than 6.5 percent.
A different point of view
Wrong, said the American Diabetes Association, the American Association of Clinical Endocrinologists, the American Association of Diabetes Educators and the Endocrine Society, in a statement issued March 9.
“While there is agreement on individualization of treatment based on patient-specific factors, with the aim of protecting those at highest risk, the ACP’s recommendation of blood glucose targets for A1C from 7 to 8 percent could prevent many patients from receiving the full benefits of long-term glucose control,” wrote the associations.
“We are also concerned the broad range suggested by ACP’s guidance is too large to apply to most patients withtype 2 diabetes, and has the potential to do more harm than good for many patients for whom lower blood glucosetargets may be more appropriate, particularly given the increased risk of seriouscomplications such as cardiovascular disease, retinopathy, amputation and kidney disease, which are the result of higher blood glucose (A1C) levels.
“While ACP’s guidance is only one additional percentage point, this may equate to a difference of nearly 30 points when blood glucose is measured in mg/dl. 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.”
A believer in tighter controls
James Anderson, M.D.
“Whether one believes that there are two types of diabetes, or five types (as Scandinavian researchers postulate), all human diabetes occurs in people (not patients or diabetics),” says James H. (Andy) Anderson, Jr., M.D., FFPM, FACE, medical director, PTS Diagnostics, which makes the A1CNow system.
“People are individuals. Each individual is unique in their medical history, current health conditions, lifestyle, socio-economic status, and quality of life desires. Each person requires an individualized treatment and monitoring plan.
“As healthcare professionals know, successful treatment of diabetes is dependent upon the knowledge and motivation of the person with diabetes. The degree of control recommended by the healthcare professional is determined by the multiple factors listed above. Increased knowledge leads to greater motivation.
“I personally am a strong believer in tighter HbA1c control where it can be accomplished safely, and with the informed agreement of the person with diabetes. It is unfortunate that many reimbursement entities and quality care systems limit HbA1c measurements to twice a year. Point-of-care testing (with immediate healthcare professional feedback) and A1c self-testing on a more frequent basis can add knowledge and increase motivation in people with diabetes.
“As treatment goals are relaxed, some individuals may feel less need to continue with treatment (pharmacologic and lifestyle) goals that are safely and effectively controlling their diabetes and promoting their health,” says Anderson. “This is unfortunate. However, regardless of the treatment and A1c goals with which the person with diabetes and their healthcare professional have agreed, regular point-of-care and self-testing of HbA1c remain a critical contributor to improved diabetes control and better health.”