Joint Statement from ACC, ADA and AHA Revises Recommendations for Glycemic Targets for Some Patients
December 17, 2008
Some people with diabetes may require less stringent glycemic control than previously recommended, but most should stick with the target goal of less than 7 percent long advised for reducing the risk of diabetes-related complications, according to a position statement issued jointly today by the American College of Cardiology, American Diabetes Association and American Heart Association and published online in the journals of each organization, the Journal of the American College of Cardiology, Diabetes Care and Circulation: Journal of the American Heart Association.
The national health associations conducted a careful re-examination of glycemic control guidelines in light of three recent clinical trials in people with longstanding type 2 diabetes and high cardiovascular risk that suggested no significant benefit and/or risks related to intensive glycemic control and heart disease prevention. One trial – the ACCORD study – was halted early because of an increased death rate in the intensive control group, while two others, the ADVANCE and VADT studies, found no apparent increase in deaths, but no significant cardiovascular benefit. Previous observational studies had found an association between higher levels of A1C (a measure of blood glucose level over the prior 2-3 months) and cardiovascular events. Long-term follow-up of the DCCT and UKPDS cohorts found cardiovascular benefit for people with type 1 and type 2 diabetes who underwent intensive glycemic control soon after the diagnosis of diabetes.
“Given the confusion created by these conflicting results, we thought it imperative to review our recommendations for all people with diabetes,” said Dr. Jay Skyler, who headed the writing group. “What we conclude is that for most people with diabetes, there’s no need to change treatment goals in light of these findings and many reasons to continue to strive for good glycemic control. But for some people with type 2 diabetes, depending upon their history and current medical condition, it may be wise to make adjustments.” The recommendations are consistent with prior suggestions that glycemic goals should be individualized depending on the medical history of the patient.
Maintaining A1C levels at or below 7 percent should remain the goal for most people with diabetes, because numerous studies provide evidence that achieving this goal substantially reduces the risk of microvascular complications, such as eye, kidney and nerve disease. The long-term follow-up of the DCCT and UKPDS participants, as well as subgroup analyses from the three recent studies, also suggest a cardiovascular benefit for people without known cardiovascular disease and who have had diabetes for a relatively short period of time.
“The lack of significant reduction in CVD events with intensive glycemic control should not lead clinicians to abandon the general target of A1C levels of less than 7 percent, and thereby discount the benefit of good control on what are serious and debilitating microvascular complications,” the joint statement concluded.
However, for those who have a “history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbid conditions, and those with longstanding diabetes in whom the general goal is difficult to attain despite diabetes self-management education, appropriate glucose monitoring, and effective doses of multiple glucose lowering agents including insulin,” less stringent A1C goals should be considered, according to the statement. Specific goals for people with these conditions should be determined by an individual’s health care team.
The statement also reiterates evidence-based strategies for preventing cardiovascular disease apart from glycemic control. Both the ADA’s Standards of Medical Care and the AHA’s prevention guidelines call for reducing cardiovascular risk factors through blood pressure control, lipid-lowering with statin therapy, aspirin therapy, and lifestyle modifications such as weight loss, proper nutrition and increased physical activity.
About the American College of Cardiology:
The American College of Cardiology is leading the way to optimal cardiovascular care and disease prevention. The College is a 36,000-member nonprofit medical society and bestows the credential Fellow of the American College of Cardiology upon physicians who meet its stringent qualifications. The College is a leader in the formulation of health policy, standards and guidelines, and is a staunch supporter of cardiovascular research. The ACC provides professional education and operates national registries for the measurement and improvement of quality care.
About the American Diabetes Association:
The American Diabetes Association is leading the fight against the deadly consequences of diabetes and fighting for those affected by diabetes. The Association funds research to prevent, cure and manage diabetes; delivers services to hundreds of communities; provides objective and credible information; and gives voice to those denied their rights because of diabetes. Founded in 1940, our mission is to prevent and cure diabetes and to improve the lives of all people affected by diabetes. For more information please call the American Diabetes Association at 1-800-DIABETES (1-800-342-2383) or visit www.diabetes.org. Information from both these sources is available in English and Spanish.
About the American Heart Association:
Founded in 1924, the American Heart Association is the nation’s oldest and largest voluntary health organization dedicated to building healthier lives, free of heart disease and stroke. To help prevent, treat and defeat these diseases — America’s No. 1 and No. 3 killers — the American Heart Association funds cutting-edge research, conducts lifesaving public and professional educational programs, and advocates to protect public health. To learn more or join AHA in helping all Americans, call 1-800-AHA-USA1 or visit americanheart.org.
About the American Diabetes Association
More than 30 million Americans have diabetes, and every 21 seconds another person is diagnosed with diabetes. The American Diabetes Association (Association) is the global authority on diabetes and since 1940 has been committed to its mission to prevent and cure diabetes and to improve the lives of all people affected by diabetes. To tackle this global public health crisis, the Association drives discovery in research to treat, manage and prevent all types of diabetes, as well as to search for cures; raises voice to the urgency of the diabetes epidemic; and provides support and advocacy for people living with diabetes, those at risk of developing diabetes and the health care professionals who serve them. For more information, please call the American Diabetes Association at 1-800-DIABETESS (1-800-342-2383) or visit diabetes.org. Information from both of these sources is available in English and Spanish. Find us on Facebook (American Diabetes Association), Twitter (@AmDiabetesAssn) and Instagram (@AmDiabetesAssn)