Optimal Hemoglobin A_1c Targets: Guidance from the ACP

 The core recommendation is not new, but the ACP commendably focuses on individualizing goals for glycemic control.

The American College of Physicians’ Clinical Efficacy Assessment Subcommittee reviewed the strengths and weaknesses of guidelines from nine generalist and specialist organizations, using a standard appraisal instrument, to develop recommendations regarding glycemic control goals for patients with type 2 diabetes. On the basis of the guideline review, they recommend the following standards for patient care:

• The goal for glycemic control should be as low as feasible without undue risk for adverse events or unacceptable patient burden; a hemoglobin A_1c value of <7% was deemed a reasonable goal for many patients.
• The goal should be individualized based on risk for microvascular complications versus complications of tight control, comorbidity, life expectancy, and patient preferences.

The recommendations emphasize physician-patient discussions to determine goals and recognize that the <7% goal is not appropriate for all patients (e.g., older, frail patients).

Comment: Although the advice to aim for a hemoglobin A_1c value of <7% is not new, these recommendations are useful in their emphasis on individualizing the goal for glycemic control. A remaining challenge is to clarify, from additional research, the actual benefits and harms of various levels of control for people with a range of comorbidity and life expectancy, so that recommendations can be truly individualized. In addition, the recent controversy over rosiglitazone reminds us that clinical outcomes may depend not only on the target A_1c, but also on the specific drug class used to achieve the target.

— Richard Saitz, MD, MPH, FACP, FASAM

Published in Journal Watch General Medicine October 9, 2007

Citation(s):

Qaseem A et al. Glycemic control and type 2 diabetes mellitus: The optimal hemoglobin A_1c targets. A guidance statement from the American College of Physicians. Ann Intern Med 2007 Sep 18; 147:417.