New Diabetes Guidelines Offer More Leeway for Primary-Care Physicians, Patients

By Annette M. Boyle

SAN DIEGO — What is an appropriate blood glucose level for patients with diabetes?

It depends, according to the latest position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD).

While it may complicate therapeutic decision-making for primary-care providers, the groups’ new recommendations replace the formulaic treatment guidelines of previous versions with a much more personalized approach to management of hyperglycemia in patients with type 2 diabetes mellitus (T2DM).

“The latest guidelines are much more vague in terms of, Step 1: Do this. Step 2: Do that,” said Candis Morello, PharmD, CDE, FCSHP, director, Diabetes Intense Medical Management Clinic, Veterans Affairs San Diego Healthcare System and associate professor of clinical pharmacy, University of California San Diego, Skaggs School of Pharmacy and Pharmaceutical Sciences.

“The recommendations now are based more on the individual: Does the patient have kidney problems? Obesity or vision issues? What about costs?” she said.

The position statement encourages clinicians to give particular weight to factors such as age, disease duration, history of hypoglycemia, comorbidities, life expectancy and patient attitudes when setting goals for HbA1C levels and selecting treatment options.

One of the biggest changes involves establishing target blood-glucose levels for patients. The glycemic goal recommended by the ADA in its 2009 statement was a glycated hemoglobin (HbA1c) level of less than 7%, with a note that “this goal is not appropriate or practical for some patients.”

The new statement goes further, delineating groups for which the 7% goal may not be desirable and recommending more appropriate target ranges.

Depiction of the elements of decision making used to determine appropriate efforts to achieve glycemic targets. Greater concerns about a particular domain are represented by increasing height of the ramp. Thus, characteristics/predicaments toward the
left justify more stringent efforts to lower HbA1c, whereas those toward the right are compatible with less stringent efforts. Where possible, such decisions should be made in conjunction with the patient, reflecting his or her preferences, needs, and values.
This “scale” is not designed to be applied rigidly but to be used as a broad construct to help guide clinical decisions. Source: Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hyperglycemia in type 2 diabetes: A patient-centered approach.
Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2012; Published ahead of print April 19, 2012.

Everyone is Different

“Finally, the guidelines match the way we’ve treated patients for decades in the VA, especially in diabetes clinics,” Morello told U.S. Medicine. “I love the fact that they point out that every single person with diabetes is different, and we can’t treat them all the same.”

More stringent HbA1c targets of 6.0-6.5%, for instance, may be desirable for newly diagnosed, younger patients without significant cardiovascular disease. Maintaining a low A1c in young patients can delay the onset of complications or keep them from ever occurring, Morello said.

“Most of my patients at the VA clinic are older — an average age of 65 to 70 — and they tend to be at higher risk for falls, hypoglycemia and cardiovascular disease. For them, the new guidelines say that HbA1c levels of 7.5%-8.0% or slightly higher may make more sense,” she noted.

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