What the Revised ADA Guidelines Mean for Primary Care Physicians
Introduction: Numerous agencies provide guidance for management of type 2 diabetes mellitus (T2DM), but probably the most frequently referred to in the United States by primary care clinicians is the annual publication of Clinical Practice Recommendations by the American Diabetes Association (ADA). Many clinicians will welcome the changes found within the 2013 document, since they are both evidence based and patient friendly.
Perhaps the most groundbreaking changes are in regards to goals for glycemic control. The specific language of the goals may be important:
The general A1c goal is NOT <6.5%
“Lowering A1c to below or around 7% has been shown to reduce microvascular complications and, if implemented soon after the diagnosis of diabetes, is associated with long-term reduction in macrovascular disease. Therefore, a reasonable A1c goal for many non-pregnant adults is <7%.” Evidence level: B
An A1c <6.5% is reasonable for SELECTED PATIENTS
“Providers might reasonably suggest more stringent A1c goals (such as <6.5%) for selected individual patients, if this can be achieved without significant hypoglycemia or other adverse effects of treatment. Appropriate patients might include those with short duration of diabetes, long life expectancy, and no significant cardiovascular disease.” Evidence level: C
More relaxed A1c goals (<8%) are appropriate for some patients
“Less stringent A1c goals (such as <8%) may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbid conditions, and those with long-standing diabetes in whom the general goal is difficult to attain despite diabetes self-management education, appropriate glucose monitoring, and effective doses of multiple glucose-lowering agents including insulin.” Evidence level: B
What this fresh new guidance from the ADA provides for us is recognition that there is no one-size-fits-all management regimen for T2DM.1 First, very tight glucose control is often fraught with difficulties such as complexity of medical regimens and risk of hypoglycemia. In the ACCORD trial, hypoglycemia was three times as frequent in the group that strove for tight control (A1c attained = 6.3).2 Second, especially in senior citizens, for whom hypoglycemia may be disproportionately consequential, we now have Clinical Practice Recommendations that allow more relaxed A1c attainment (<8%). This may be particularly welcomed by patients who, for instance, have had to pay the price of substantial weight increase due to well-intended augmentation of treatment with sulfonylureas or insulin, which improved glucose control at the expense of weight gain. Finally, there is a certain commonsense wisdom in the recognition that for patients who already have the primary complications of T2DM on board, one cannot turn back the clock by strict control.
- American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care. 2013;36(Suppl 1):S11-S66.
- Ismail-Beigi F, Craven T, Banerji MA, et al. Effect of intensive treatment of hyperglycaemia on microvascular outcomes in type 2 diabetes: an analysis of the ACCORD randomised trial. Lancet. 2010;376(9739):419-430.