Amir Qaseem, MD, PhD, MHA; Timothy J. Wilt, MD, MPH; Devan Kansagara, MD, MCR; Carrie Horwitch, MD, MPH; Michael J. Barry, MD; Mary Ann Forciea, MD; for the Clinical Guidelines Committee of the American College of Physicians *
Note: Guidance statements are “guides” only and may not apply to all patients and all clinical situations. Thus, they are not intended to override clinicians' judgment. All ACP guidance statements are considered automatically withdrawn or invalid 5 years after publication, or once an update has been issued.
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Acknowledgment: The CGC thanks members of the ACP Guidelines Public Panel for their review and comments on the paper from a nonclinician public perspective: Cynthia Appley, Jane Eleey, Ray Haeme, James Pantelas, Missy Carson Smith, Janice Tufte, and Lelis Vernon.
Financial Support: Financial support for the development of this guidance statement comes exclusively from the ACP operating budget.
Disclosures: Dr. Barry reports grants and personal fees from Healthwise, a nonprofit, outside the submitted work. Authors not named here have disclosed no conflicts of interest. Authors followed the policy regarding conflicts of interest described at www.annals.org/article.aspx?articleid=745942. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M17-0939. All financial and intellectual disclosures of interest were declared, and potential conflicts were discussed and managed. Dr. Vijan was recused from voting on the recommendations for an active direct financial conflict. Dr. Manaker was recused from voting on the recommendations for an active indirect financial conflict. A record of disclosures of interest and management of conflicts of interest is kept for each CGC meeting and conference call and can be viewed at www.acponline.org/clinical_information/guidelines/guidelines/conflicts_cgc.htm.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.
Requests for Single Reprints: Amir Qaseem, MD, PhD, MHA, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, email@example.com.
Current Author Addresses: Dr. Qaseem: 190 N. Independence Mall West, Philadelphia, PA 19106.
Dr. Wilt: VA Medical Center 111-0, Minneapolis, MN 55417.
Dr. Barry: 50 Staniford Street, 9th Floor, Boston, MA 02114.
Dr. Horwitch: 1100 Ninth Avenue C8-GIM, Seattle, WA 98101.
Dr. Kansagara: 3710 SW US Veterans Hospital Road, Portland, OR 97239.
Dr. Forciea: 3615 Chestnut Street, Philadelphia, PA 19104.
Author Contributions: Conception and design: A. Qaseem, T.J. Wilt, D. Kansagara, M.J. Barry, M.A. Forciea.
Analysis and interpretation of the data: A. Qaseem, T.J. Wilt, D. Kansagara, C. Horwitch, M.J. Barry, M.A. Forciea.
Drafting of the article: A. Qaseem, T.J. Wilt, D. Kansagara, C. Horwitch, M.A. Forciea.
Critical revision of the article for important intellectual content: A. Qaseem, T.J. Wilt, D. Kansagara, M.J. Barry, M.A. Forciea.
Final approval of the article: A. Qaseem, T.J. Wilt, D. Kansagara, C. Horwitch, M.J. Barry, M.A. Forciea.
Statistical expertise: A. Qaseem, T.J. Wilt.
Obtaining of funding: A. Qaseem.
Administrative, technical, or logistic support: A. Qaseem.
Collection and assembly of data: A. Qaseem, T.J. Wilt, D. Kansagara, M.J. Barry.
The American College of Physicians developed this guidance statement to guide clinicians in selecting targets for pharmacologic treatment of type 2 diabetes.
The National Guideline Clearinghouse and the Guidelines International Network library were searched (May 2017) for national guidelines, published in English, that addressed hemoglobin A1c (HbA1c) targets for treating type 2 diabetes in nonpregnant outpatient adults. The authors identified guidelines from the National Institute for Health and Care Excellence and the Institute for Clinical Systems Improvement. In addition, 4 commonly used guidelines were reviewed, from the American Association of Clinical Endocrinologists and American College of Endocrinology, the American Diabetes Association, the Scottish Intercollegiate Guidelines Network, and the U.S. Department of Veterans Affairs and Department of Defense. The AGREE II (Appraisal of Guidelines for Research and Evaluation II) instrument was used to evaluate the guidelines.
Clinicians should personalize goals for glycemic control in patients with type 2 diabetes on the basis of a discussion of benefits and harms of pharmacotherapy, patients' preferences, patients' general health and life expectancy, treatment burden, and costs of care.
Clinicians should aim to achieve an HbA1c level between 7% and 8% in most patients with type 2 diabetes.
Clinicians should consider deintensifying pharmacologic therapy in patients with type 2 diabetes who achieve HbA1c levels less than 6.5%.
Clinicians should treat patients with type 2 diabetes to minimize symptoms related to hyperglycemia and avoid targeting an HbA1c level in patients with a life expectancy less than 10 years due to advanced age (80 years or older), residence in a nursing home, or chronic conditions (such as dementia, cancer, end-stage kidney disease, or severe chronic obstructive pulmonary disease or congestive heart failure) because the harms outweigh the benefits in this population.
Qaseem A, Wilt TJ, Kansagara D, et al, for the Clinical Guidelines Committee of the American College of Physicians. Hemoglobin A1c Targets for Glycemic Control With Pharmacologic Therapy for Nonpregnant Adults With Type 2 Diabetes Mellitus: A Guidance Statement Update From the American College of Physicians. Ann Intern Med. 2018;168:569–576. [Epub ahead of print 6 March 2018]. doi: https://doi.org/10.7326/M17-0939
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Published: Ann Intern Med. 2018;168(8):569-576.
Published at www.annals.org on 6 March 2018
Cardiology, Coronary Risk Factors, Diabetes, Endocrine and Metabolism, Guidelines.
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