HbA1c targets

[rmz80]

I noticed on this forum’s newsfeed the following advice for adults with type 2 diabetes.

The American College of Physicians (ACP) has informed doctors to advise people to aim for HbA1c levels between 7-8% (53-64 mmol/mol), rather than the traditional advice of 6.5-7% (48-53 mmol/mol).

It then goes on to say;

In the UK, the National Institute for Health and Excellence recommends that most people with type 2 diabetes aim for an HbA1c of 6.5% (48 mmol/mol), but doctors may suggest different targets depending on personal circumstances.

I’ve seen this advice before and couldn’t work out why the target should be so high rather than a value in the low 30’s.

With the introduction of meter’s such as the FreeStyle Libre which will record any BG lows I would have thought you should aim for a HbA1c target in the low 30’s if you have such a meter. Then back off if hypo’s become an issue.

What are other people thoughts on this?

 

[phdiabetic]

7-8% is definitely not ideal! Obviously in individual circumstances it may be the best you can get (for example, hypo unawareness, or someone with dementia who doesn't understand what to do, etc) but for the general population it is far too high. Doctors should evaluate each patient and decide on individual target ranges based on their situation.

Also, why "between"!! What's wrong with being less than 7? I know a lot of doctors don't like it if you're less than 6, but less than 7 seems slightly over-cautious. Especially since T2's are unlikely to have any hypos in the first place (the main objection to T1's having "low" HbA1c).

 

[Deleted Account]

Lower targets would be great if achievable within tight budgets.
However, we need the tools to achieve this. Few people can afford to self fund CGMs or Libres and they are only available to very very very few people on the NHS.
And then people need to be educated to use the data from these devices.

 

[kokhongw]

What is dangerous is sudden low blood glucose...

Consistent low blood glucose due to diet with adequate levels of ketones/ketosis is neuro-protective.

In this context, the proposed guidelines are gear for those who have difficulties matching their meals to their medication. So they are recommended to eat to their medication. Eat more to stay safe...

 

[SockFiddler]

I haven't read it, so can't comment on why the recommendation changed, but here's an article (from a good source) that explains the 7 - 8% more fully:

https://www.sciencedaily.com/releases/2018/03/180305174312.htm

Edit: Have now had a glance and saw this paragraph:

If patients with type 2 diabetes achieve an A1C of less than 6.5 percent, ACP recommends that clinicians consider de-intensifying drug therapy by reducing the dosage of current treatment, removing a medication if the patient is currently taking more than one drug, or discontinuing drug treatment.

"Results from studies included in all the guidelines demonstrate that health outcomes are not improved by treating to A1C levels below 6.5 percent," Dr. Ende said. "However, reducing drug interventions for patients with A1C levels persistently below 6.5 percent will reduce unnecessary medication harms, burdens, and costs without negatively impacting the risk of death, heart attacks, strokes, kidney failure, amputations, visual impairment, or painful neuropathy."

Sorta says it all: we get below a certain level and the drugs get dangerous. And I guess there's no suggestion of working in partnership with our GP..?

 

[Rachox]

I think these targets are ridiculously high ,our good friends at Phlaunt.com suggest otherwise!
http://www.phlaunt.com/diabetes/14045678.php

 

[rmz80]

I guess it’s a case of grouping everyone with t2 into one big melting pot of standard advice.

I still think advances in meter technology and peoples greater access to information on the internet mean these targets are more at home in a museum of medicine.

 

[Boo1979]

This would indicate that the different targets seem to relate to the safety / intensity of the treatment needed to attain them with the use high medication doses being potentially less safe than allowing higher hba1c
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2258341/

 

[ringi]

In the UK the target is higher when people are on more drugs, the USA it says to aim lower then the target when using only diet and metformin.

 

[bamba]

I haven't read it, so can't comment on why the recommendation changed, but here's an article (from a good source) that explains the 7 - 8% more fully:

https://www.sciencedaily.com/releases/2018/03/180305174312.htm

Edit: Have now had a glance and saw this paragraph:



Sorta says it all: we get below a certain level and the drugs get dangerous. And I guess there's no suggestion of working in partnership with our GP..?

I think it depends on what you consider "Treatment".

Also the advice is aimed medical practioners. They have control over prescibing drugs.
Aiming to push down to lower glucose levels with Glicazide brings the dangers of hypoglycemia into scope.

Controlling diet is in the hands of the patient -(unless you are in hospital - and even then the catering services seem to not be integrated with treatment plans).

This is a lifestyle change which only the patient can pursue successfully (or not as the case may be).

Doctors cannot actually control a patient's choices - they can pontificate as much as they like, but actually paying attention is down to us - so they may have to play safe on the medication guidelines.

If your diet control takes you out of the scope of medication - they don't see you as needing treatment anyway.

 

[SockFiddler]

Yes to all, but my point is that GPs (and US family practitioners) are easily capable - whether through DNs or otherwise - of working in partnership with patients and then being responsive to their results: if a patient is proactive, works on what they eat, regularly tests, gets that HbA down, then GPs should be able to adjust their input accordingly instead of simply having a drugs or no drugs response to diabetes.

"To drug or not to drug" as a response is much too binary, and many of us are in this boat at all because of other binary pieces of advice: Lose weight; "healthy" diets; lots of exercise. The common view is that people who don't do that get T2D, but we have plenty of people on the forum who were doing this and ended up with T2D anyway.

Our lives are complicated, sprawling, demanding, evolving. We here are willing to fit actively managing our diabetes in with all of that other stuff. My point was that in the 8 minutes I spend with my GP, they make a more sophisticated choice than "Drug or not to drug" and that choice is based upon my life, and not their defensive guidelines.

 

[rmz80]

Perhaps if GP’s had a risk assessment score for t2 they could assess a t2 patient as ok to aim for a lower HbA1c target.
This could be similar to the screening questionnaire for cardiovascular (CVD) health risk.

 

[phdiabetic]

Lower targets would be great if achievable within tight budgets.
However, we need the tools to achieve this. Few people can afford to self fund CGMs or Libres and they are only available to very very very few people on the NHS.
And then people need to be educated to use the data from these devices.

Even without cgms it is absolutely possible for everyone to achieve at least <7% (or better!) HbA1c as long as they have test strips. Especially T2s who are not going to get low - the main point of cgms is to alert you to dropping/low blood sugar so you have the chance to fix things before they get too bad, but if you're not going to go low in the first place there is no need for that.

 

[Boo1979]

Even without cgms it is absolutely possible for everyone to achieve at least <7% (or better!) HbA1c as long as they have test strips. Especially T2s who are not going to get low - the main point of cgms is to alert you to dropping/low blood sugar so you have the chance to fix things before they get too bad, but if you're not going to go low in the first place there is no need for that.

Depending on what meds they are on, T2’s can go low. My record hypo was a 2.1 mmol
T2s on sulfonylureas or insulin can all get hypos because of the mechanism of action of those medications

 

[JohnEGreen]

I have had a low of 2.4 mmol without benefit of BG lowering meds and that was about a week or two ago. A freak occurrence maybe but has taught me to be careful.

 

[phdiabetic]

Depending on what meds they are on, T2’s can go low. My record hypo was a 2.1 mmol
T2s on sulfonylureas or insulin can all get hypos because of the mechanism of action of those medications

I have had a low of 2.4 mmol without benefit of BG lowering meds and that was about a week or two ago. A freak occurrence maybe but has taught me to be careful.

Wow you guys had some scary lows! I've never even been below 2.6. I knew it is possible for T2s to get low with meds but how did it happen to you John?? (Maybe a bad strip? Did you feel funny?)

 

[ringi]

Even without cgms it is absolutely possible for everyone to achieve at least <7% (or better!) HbA1c as long as they have test strips. Especially T2s who are not going to get low - the main point of cgms is to alert you to dropping/low blood sugar so you have the chance to fix things before they get too bad, but if you're not going to go low in the first place there is no need for that.

But the level of inslin needed, often 400 units a day, does more harm then a a1c that is a little higher. And they do not agree with LC.

 

[phdiabetic]

But the level of inslin needed, often 400 units a day, does more harm then a a1c that is a little higher. And they do not agree with LC.

I'm not sure I understand what you are saying...who is taking the 400 units? And level of insulin needed for what?

 

[ringi]

I'm not sure I understand what you are saying...who is taking the 400 units? And level of insulin needed for what?

That level is common in Type2 in the USA, using more and more insilin to chase the A1c target, while eating ever increasing carbs to remove the risk of hypos.

 

[Brunneria]

Wow you guys had some scary lows! I've never even been below 2.6. I knew it is possible for T2s to get low with meds but how did it happen to you John?? (Maybe a bad strip? Did you feel funny?)

Yeah, non medicated T2s - and even non diabetics - can get pretty low, but it isn't a common event. Most T2s don't experience hypos without meds pushing bgs down.
My lowest recorded (caught on Libre, which is notoriously inaccurate when at the top and bottom of range) was 1.6.
That was caused by reactive hypoglycaemia (no meds).
And yes, I felt DREADFUL.