74th Scientific Sessions of the American Diabetes Association (ADA):
New ADA Position Statement: Lower Target A1C for Type 1 Diabetes
During the American Diabetes Association (ADA) 74th Scientific Sessions, held at the Moscone Center in San Francisco, June 13-17, 2014, David Maahs, MD, a pediatric endocrinologist at the Barbara David Center for Childhood Diabetes, Children’s Hospital Colorado, and the University of Colorado Denver, moderated a panel discussion about the ADA’s position statement on its recommendation to lower its target blood glucose levels for children with Type 1 Diabetes (T1D).
- Anne Peters, MD, FACP, Professor, Keck School of Medicine, University of Southern California, Los Angeles, CA
- Lori Laffel, MD, Chief, Pediatric, Adolescent and Young Adult Section, Joslin Diabetes Center and Associate Professor of Pediatrics, Harvard Medical School, Boston, MA
- Sue Kirkman, MD, Professor of Medicine, Division of Endocrinology and Metabolism, University of North Carolina, Chapel Hill, SC
- Jane L. Chiang, MD, Senior Vice President, Medical and Community Affairs, American Diabetes Association, Alexandria, VA
Identify Type 1 Diabetes Treatment Needs
“This process didn’t actually begin with wanting to change a pediatric target,” rather “the interest was to create a separate position statement for the treatment of type 1 diabetes, because type 1 and type 2 diabetes are not the same disease,” stated Dr. Peters. The ADA’s position statement evolved from the creation of the Type 1 Diabetes Sourcebook, which was written by the panel members and many other authors.
Dr. Peters explained the goal of the position statement is to cover the needs of people of all ages with T1D. She pointed out that “we don’t even know how many people have T1D” because many patients receive treatment through a primary care provider. Dr. Peters broadly estimated the number to be “on the order of one to two million who are adults who are living long enough to now be dealing with the same issues that our elderly population faces.” Therefore, the issues related to T1D affects a wide range of age groups—birth to geriatric.
Targeting A1C 2005 Forward
“When we distilled the book down to the position statement, we realized we had yet another opportunity to help improve the health and outcomes of our pediatric patients as well as our adult patients with type 1 diabetes, and that stems from the opportunity to reexamine the glycemic control target levels that were previously recommended by the American Diabetes Association,” Dr. Laffel explained. She further explained, “those previous target were grounded in the best science and experience we had when we first wrote the statement in 2005.” The 2005 position statement was in part created by data from the Diabetes Control and Complications Trial (DCCT, 1993) that included a decade’s worth of legacy information.
Previous A1C targets were based on experience with severe hypoglycemia from a long time ago. New information allowed the ADA to reexamine the rates of hypoglycemia in an era of intensive insulin use. It was discovered that the rate of hypoglycemia has not increased in the younger and most vulnerable patients.
- Under age 6: Target A1C <8.5%
- Ages 6-12: Target A1C <8.0%
- Ages 13-19: Target A1C <7.5%
Dr. Laffel pointed out that there is “increasing data recognizing the potential acute adverse effects upon the central nervous system of hyperglycemia in patients. Therefore, it seemed timely for us to reexamine the age-specific A1C targets.” This examination allowed the panel members and authors to look across different guidelines, such as those from other countries in respect to pediatric care and glycemic targets.
Summary of A1C recommendations (nonpregnant) for people with diabetes1
- <18 years: <7.5%1
- Adults: <7.0%1
- Healthy adults with no comorbidities: <7.5%1
- Complex/intermediate health: <8.0%1
- Very complex/poor health: <8.5%1
Type 1 Diabetes Spans a Lifetime
“I think it’s really great that there is this emphasis that type 1 diabetes spans the entire age spectrum, and that we don’t forget that once people turn 18 or 21 … they don’t get mixed in with the type 2 population,” Dr. Kirkman related. Simply considering the number of people on Medicare with type 1 diabetes demonstrates that this disease requires transitional care as the patient ages.
Dr. Chiang highlighted that the ADA is very committed to patients with type 1 diabetes; and type 1 and type 2 are two different types of diabetes. “The complications are the same at the end, but there aren’t very clear evidence-based recommendations about what patients with type 1 diabetes need,” stated Dr. Chiang. More work needs to be done (eg, cardiovascular, microvascular outcomes), and this is just the beginning.
- Chiang JL, Kirkman MS, Laffel LMB, Peters AL. Type 1 diabetes through the life span: a position statement of the American Diabetes Association. Diabetes Care. 2014;37:2034-2054.