In the last year I’ve written about a major change in our understanding of diabetes treatment. The goals of treatment used to be to get blood glucose as close to normal non-diabetic levels as possible. That usually meant increasing medication doses or adding additional medications until the glycated hemoglobin was down to normal. (Glycated hemoglobin, or hemoglobin A1c, is a blood test that measures an average of blood glucose over the previous 3 months.) Targeting normal glycated hemoglobins frequently meant complex medication regimens, occasional low blood sugars and the side effects caused by the medications. But we were willing to accept this because we thought that getting the glycated hemoglobin down to normal prevented strokes, heart attacks, and other complications of diabetes.
Then the ACCORD and ADVANCE studies turned that thinking on its head. They were both large randomized trials that looked at the effects of strict glucose control on outcomes in diabetes. Rather than confirm the benefits we assumed, they showed that diabetics who were treated to get their glucose down to the normal range did no better (and in one trial did worse) than diabetics who were treated with more lax glucose control. Suddenly the goal for the glucose and the glycated hemoglobin was no longer clear. How low should we go?
A perspective article just released in the Annals of Internal Medicine attempts to review the issue and make recommendations. The review reminds us of what we definitely know about tight blood-sugar control in diabetes: it causes more frequent hypoglycemia, more weight gain, and frequently requires a more complex and more expensive medication regimen. But the benefits are now uncertain. The article suggests that we instead focus on the interventions that have proven benefit in diabetes: smoking cessation, blood pressure control, cholesterol control, dietary modification and exercise.
The authors suggest for the glucose goals:
“Glycemic control efforts should individualize hemoglobin A1c targets so that those targets and the actions necessary to achieve them reflect patients’ personal and clinical context and their informed values and preferences.”
Which sounds to me like a nice way of saying “We’re not really sure what we’re doing any more, so try to prescribe medicines that the patient can afford and won’t cause harm, and focus on the sugars a little less.”
Annals of Internal Medicine article: Glycemic Control in Type 2 Diabetes: Time for an Evidence-Based About-Face?
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