Faramarz Ismail-Beigi, MD, PhD; Etie Moghissi, MD; Margaret Tiktin, NP; Irl B. Hirsch, MD; Silvio E. Inzucchi, MD; Saul Genuth, MD
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-2380.
Requests for Single Reprints: Faramarz Ismail-Beigi, MD, PhD, Department of Medicine, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44122-4951; e-mail, email@example.com.
Current Author Addresses: Drs. Ismail-Beigi and Genuth and Ms. Tiktin: Department of Medicine, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44122-4951.
Dr. Moghissi: 4644 Lincoln Boulevard, Suite 409, Marina Del Rey, CA 90292.
Dr. Hirsch: University of Washington Medical Center, 1959 Northeast Pacific Street, Seattle, WA 98915-6176.
Dr. Inzucchi: Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520.
Author Contributions: Conception and design: F. Ismail-Beigi, E. Moghissi, M. Tiktin, S.E. Inzucchi.
Analysis and interpretation of the data: F. Ismail-Beigi, E. Moghissi, I.B. Hirsch, S.E. Inzucchi, S. Genuth.
Drafting of the article: F. Ismail-Beigi, E. Moghissi, M. Tiktin, I.B. Hirsch, S. Genuth.
Critical revision of the article for important intellectual content: F. Ismail-Beigi, E. Moghissi, M. Tiktin, I.B. Hirsch, S.E. Inzucchi, S. Genuth.
Final approval of the article: F. Ismail-Beigi, E. Moghissi, M. Tiktin, I.B. Hirsch, S.E. Inzucchi, S. Genuth.
Collection and assembly of data: F. Ismail-Beigi, E. Moghissi.
Ismail-Beigi F., Moghissi E., Tiktin M., Hirsch I., Inzucchi S., Genuth S.; Individualizing Glycemic Targets in Type 2 Diabetes Mellitus: Implications of Recent Clinical Trials. Ann Intern Med. 2011;154:554-559. doi: 10.7326/0003-4819-154-8-201104190-00007
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Published: Ann Intern Med. 2011;154(8):554-559.
One of the first steps in the management of patients with type 2 diabetes mellitus is setting glycemic goals. Professional organizations advise setting specific hemoglobin A1c (HbA1c) targets for patients, and individualization of these goals has more recently been emphasized. However, the operational meaning of glycemic goals, and specific methods for individualizing them, have not been well-described. Choosing a specific HbA1c target range for a given patient requires taking several factors into consideration, including an assessment of the patient's risk for hyperglycemia-related complications versus the risks of therapy, all in the context of the overall clinical setting. Comorbid conditions, psychological status, capacity for self-care, economic considerations, and family and social support systems also play a key role in the intensity of therapy. The individualization of HbA1c targets has gained more traction after recent clinical trials in older patients with established type 2 diabetes mellitus failed to show a benefit from intensive glucose-lowering therapy on cardiovascular disease (CVD) outcomes. The limited available evidence suggests that near-normal glycemic targets should be the standard for younger patients with relatively recent onset of type 2 diabetes mellitus and little or no micro- or macrovascular complications, with the aim of preventing complications over the many years of life. However, somewhat higher targets should be considered for older patients with long-standing type 2 diabetes mellitus and evidence of CVD (or multiple CVD risk factors). This review explores these issues further and proposes a framework for considering an appropriate and safe HbA1c target range for each patient.
David C. Aron
Cleveland VA Medical Center
April 25, 2011
Response to Ismail-Beigi
Absent or mildb
> 10 years of life expectancy
5-10 years of life expectancy
< 5 years of life
David Aron, MD, MS, Associate Chief of Staff/Education, Cleveland VA Medical Center Cleveland, OH firstname.lastname@example.org;
Paul R. Conlin, MD Chief, Medical Service Boston VA Medical Center Boston, MA PCONLIN@PARTNERS.ORG
Curtis Hobbs, MD Director, Diabetes Care Center Madigan Healthcare System Tacoma WA 98431 email@example.com
Robert A. Vigersky, MD Director, Diabetes Institute Walter Reed Health Care System ROBERT.VIGERSKY@US.ARMY.MIL
Leonard Pogach, MD, MBA VA National Program Director for Diabetes New Jersey VA Healthcare System Leonard.firstname.lastname@example.org
The authors are members of the VA-DoD Diabetes Guideline Working Group. The authors report no actual or potential conflicts of interest with regard to this letter. The opinions expressed herein are those of the authors and do not necessarilyreflect those of the U.S. Government, or any of its agencies.
1. Ismail-Beigi F, Moghissi E, Tiktin M, Hirsch IB, Inzucchi SE, Genuth S. Individualizing Glycemic Targets in Type 2 Diabetes Mellitus: Implications of Recent Clinical Trials Ann Intern Med. 2011;154:554-559.
2. Pogach LM, Brietzke SA, Cowan CL Jr., Walder DJ, Sawin CT; VA/DoD Diabetes Guideline Development Group. Development of evidence-based guidelines for diabetes: The Department of Veterans Affairs/Department of Defense guideÂ¬lines initiative. Diabetes Care. 2004;27(suppl 2):B82-B89.
3. US Department of Veterans Affairs Office of Quality and Performance; US Army Medical Command Quality Management Division. VA/DoD clinical practice guideline for the management of diabetes mellitus. http://www.healthquality.va.gov/diabetes /DM2010_SUM-v4.pdf [DoD: https://www.QMO. amedd.army.mil]. Updated August 2010. Accessed March 8, 2011.
4. Pogach L, Conlin PR, Hobbs C, Vigersky RA, Aron D for the VA-DoD Diabetes Guideline Working GroupVA-DoD Update of Diabetes Guidelines: What Clinicians Need to Know About Absolute Risk of Benefits and Harms and A1c Laboratory Accuracy. Federal Practitioner 2011; April: 39-44
5. Little RR, Rohlfing CL, Sacks DB; National Glycohemoglobin Standardization Program (NGSP) Steering Committee. Status of hemogloÂ¬bin A1c measurement and goals for improvement: From chaos to order for improving diabetes care. Clin Chem. 2011;57(2):205-214.
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Cardiology, Endocrine and Metabolism, Diabetes, Coronary Risk Factors, Prevention/Screening.
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