New VA Initiative Battles Excesses of ‘Tight Glucose Control’ Trend

Effort Seeks to Reduce Hypoglycemia in Older Veterans

By Brenda L. Mooney

WASHINGTON – At the beginning of the 21st century, tight glucose control for patients with type 2 diabetes was all the rage.

Now, 15 years later, that one-size-fits-all approach has been rethought to such an extent that the VA now is launching an initiative to manage rampant hypoglycemia occurring in older veterans, largely brought on by overtreatment of high blood sugar. Instead, personalized healthcare goals and more patient self-management will be urged.

diabetes treatment

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That is a significant change from what appeared to be a breakthrough in preventing complications resulting from type 2 diabetes.

Published in 1998, the landmark United Kingdom Prospective Diabetes Study, involving nearly 4,000 patients with newly diagnosed type 2 diabetes, had suggested that long-term complications of type 2 diabetes could be prevented through intensive blood glucose management.1

While the possibility of pushing blood sugars too low was noted in passing, most of the hype focused on double-digit decreases in diabetes complications with use of sulphonylureas or insulin. The practice of tight glucose control was widely adopted at the VA, where more than a million patients are being treated for diabetes, and elsewhere.

That all began to turn around, however. In 2009, a VA study published in the New England Journal of Medicine, found that intensive glucose control in patients with poorly controlled type 2 diabetes had no significant effect on the rates of major cardiovascular events, death, or microvascular complications, with the exception of progression of albuminuria. In that study, rates of adverse events, predominantly hypoglycemia, were 17.6% in the standard-therapy group and 24.1% in the intensive-therapy group.2

Other studies linked hypoglycemia in the elderly with dementia and cardiovascular issues.

Fast forward to the present, and the VA is launching the national Hypoglycemic Safety Initiative (HSI) to encourage veterans with diabetes to seek support to lower the risk of hypoglycemia.

“The Hypoglycemic Safety Initiative is designed to enable veterans and their families, partners and caregivers to create a personal plan for blood sugar management based upon the veteran’s unique health goals,” said Carolyn Clancy, MD, interim Under Secretary for Health. “Our objective is to change how diabetes is managed in VA and the United States and to help patients improve their personal well-being, not just manage their numbers.”

Clancy added that hypoglycemia “has only recently been prioritized as a national public health issue, but federal agencies are taking a leadership role in addressing the problem. We are proud to note the collaboration of VA with the Department of Health and Human Services in aggressively addressing this problem.”

Intensive Treatment in Half of Patients

A year ago, a study conducted by VA’s New Jersey Health Care System reported that  patients with risk factors for serious hypoglycemia represent a large subset of veterans receiving agents to lower blood sugar. As late as 2009, when the data was collected, about one-half of the patients had evidence of intensive treatment.3

Rates of overtreatment were found to be 10.1% for HbA1c less than 6.0%, 25.2% for less than 6.5%, and 44.3% for less than 7.0%.

In the article published in JAMA Internal Medicine, study authors called for a patient safety indicator derived from administrative data to identify high-risk patients for whom reevaluation of glycemic management may be appropriate.

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Comments (5)

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  1. Judith Hill ARNP says:

    I refer to the AGS (Annals of Long-Term Care, December, 2014). AGS recommends appropriate glycemic control be determined ny the patient’s goals, health status, and life expectancy. Reasonable HbA1c targets should be between 7 and 7.5% in healthy adults with a long life expectancy; 7.5% to 8.0 % in adults with moderate comorbidit7y and life expectancy below 10 years and 8-9% in older adults with many comorbidities and shorter life expectancy.

    • Tammy Pritchard says:

      Thank you very much for the quick reply!
      So, I assume that this is patient stratification proposed to be used under the new HSI VA initiative.

      • Mark McConnell, MD says:

        Great question. Yes, the HSI is consistent with the 2010 VA/DoD Diabetes Guideline (which we think is consistent with best available evidence). And that guideline articulates the “7-8-9” approach described above. Of importance is a shared decision about goals with patients and/or caregivers.

  2. Tammy Pritchard says:

    How is the Overtreatment rate defined here? Any HbA1c between 6-7% or is it a certain number of hypoglycemic episodes within a given time frame?

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