No one likes being treated like a number. But for people with diabetes, sometimes it seems that your latest A1C number has way too much control on your life, your mood, and how your doctor prescribes treatment. But we don’t all fit into the same size pants; perhaps we don’t need to all shoot for the same A1C.
According to new guidelines put out by the American College of Physicians (ACP), a shift from “treating the numbers” to treating the patient, and his or her individual needs, may be just the thing to improve both long-term outcomes and immediate quality of life for those with type 2 diabetes.
After first diagnosis, doctors usually prescribe lifestyle changes if medication is not yet needed. But if lifestyle changes aren’t able to get a patient into a target range, then medication is added, and eventually insulin if necessary. Medication can help patients hit their target A1C, but the ACP examined the cost of hitting those numbers, and if the harms of medication always outweighed the benefits.
The physicians examined the results of several studies in order to evaluate how current guidelines were working. They acknowledged that serious negative outcomes are caused by high blood sugar, but they also acknowledged that aggressive use of medication comes with increased side effects, burden to the patient, and a financial cost.
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The authors found, again and again, that groups treated with more intensive therapy (more medications taken sooner) did achieve lower A1C, but that they also experienced more hypoglycemic events (low blood sugar) and hospitalizations related to those events. The authors said, “Studies have not consistently shown that intensive glycemic control to HbA1c levels below 7% reduces clinical microvascular events, such as loss or impairment of vision… or reduces macrovascular events and death.”
That’s a serious statement. Some of the studies they reviewed found that “very intensive control” actually resulted in an increased risk for death for patients while still not reducing risk for events like stroke or heart failure. Intensive treatment also often caused weight gain, which is of course exactly what those with type 2 want to avoid.
Blood sugar alone is not the whole story of someone’s health. The authors found consistent evidence that as the intensity of diabetes medications increases, so do side effects and risks. There’s a point when the benefits no longer outweigh the costs.
The authors proposed 4 new common-sense guidelines that aim to refocus doctors on treating the patient instead of the patients numbers. Doctors should design a treatment plan based on a patient’s general health, life expectancy, and the potential burden of taking medication. Here are the guidelines the ACP suggest:
1. Take a look at the whole picture
Doctors and recently diagnosed type 2 patients should have an open conversation about the benefits and drawbacks of different levels of pharmaceutical intervention. Sounds obvious, but sometimes obvious things need to be said! The study authors noticed that there is a delicate balance between the harm and benefit of intense control, more so than previously thought. If a person is at a high risk for other conditions, they may want less pharmaceutical intervention.