Annals for Educators - 17 April 2018

Darren B. Taichman

doi:10.7326/AFED201804170

Clinical Practice Points

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

Guidelines recommend different hemoglobin A_1c targets in patients with type 2 diabetes. The American College of Physicians (ACP) reviewed available recommendations to guide clinicians in selecting targets for pharmacologic treatment of type 2 diabetes in nonpregnant adult outpatients.

Use this guidance statement to:

Start a teaching session with a multiple-choice question. We've provided one below!
Ask your learners what risks and benefits of treatment they discuss with their patients with type 2 diabetes. What glycemic goals do they recommend, and why?
Do your learners adjust glycemic goals according to their patients' characteristics? Which characteristics do they consider, and what adjustments do they make?
The ACP recommends that clinicians aim to achieve a hemoglobin A_1c level between 7% and 8% in most patients with type 2 diabetes. Some published guidelines discussed by the ACP recommend a lower target. Why does the ACP recommend less stringent glycemic goals? What do we know about the risks and benefits of tighter glycemic control?
Will this paper alter your learners' practices? Will it alter yours?

Medicine and Society

Addressing Social Determinants to Improve Patient Care and Promote Health Equity: An American College of Physicians Position Paper

The social conditions in which people live can profoundly affect their ability to stay healthy, their ability to access care, and their risks for illness and premature death. In this position paper, the American College of Physicians evaluates social determinants of health and makes recommendations to address them.

Use this paper to:

Ask your learners to define “social determinants of health.”
How many can they name?
Which social issues most commonly affect the care of your learners' patients? What services are available to help individual patients navigate these social issues? Which ones are beyond the reach of these services?
Where do the boundaries around what is within our sphere of responsibility as physicians end? At the hospital doors? Can we fix everything? Is there a point at which we are allowed to say, “Not my problem”?
Do your learners believe that the recommendations in this position paper will help address the negative effects of social determinants on health? Use the accompanying editorial to frame your discussion.

Annals Graphic Medicine - An Apple a Day

This short, compelling video graphically illustrates the enormity of the problem of food insecurity.

Use this video to:

Ask your learners what food insecurity is.
Do your learners know whether their patients have to worry about getting enough to eat?
How might such insecurity affect a patient's health and the care of chronic conditions? How might it affect the care of a patient with diabetes, or a patient with heart failure?
Do your learners ask patients about this issue? Would it be insulting to ask? How could they ask in a sensitive way? What would your learners do if they learned that their patient had difficulty getting enough to eat? Invite a social worker to join your discussion. What options are available to help?
Ask a patient on your team's service whether he or she worries about getting enough to eat outside the hospital. If so, would he or she be comfortable talking about this with your entire team present? How do concerns about food influence the patient's health care?

Humanism and Professionalism

On Being a Doctor: Heart Size

Dr. Quagliarello describes self-doubt while considering whether the behavior he models when others are watching matches his own thoughts and actions when no one else is around.

Use this essay to:

Listen to an audio recording, read by Dr. Virginia Hood.
Ask your learners whether they share Dr. Quagliarello's disquietude.
Do your learners agree with the connection the essay seems to make between our actions at the bedside with patients and our interactions with strangers who appear to be homeless and/or beg for money?

MKSAP 17 Question

A 52-year-old woman presents for follow-up evaluation after being diagnosed with type 2 diabetes mellitus 6 weeks ago. Her initial hemoglobin A1c level was 8.0%. Management at this time is with lifestyle modifications. She has worked closely with a diabetes educator and a nutritionist since her diagnosis. She has lost 3.2 kg (7 lb) by making changes to her diet and activity level. Review of her blood glucose log for the past 2 weeks shows preprandial blood glucose values in the 150 to 160 mg/dL (8.3-8.9 mmol/L) range and several 2-hour postprandial blood glucose values of 190 to 200 mg/dL (10.5-11.1 mmol/L). Her only other medical problem is hypertension for which she takes lisinopril.

On physical examination, blood pressure is 125/70 mm Hg and pulse rate is 74/min. BMI is 28. There is no evidence of diabetic retinopathy. She has normal monofilament and vibratory sensation in her extremities.

Except for her blood glucose parameters, basic laboratory studies obtained at the time of her initial diagnosis were normal.

In addition to continuing lifestyle modifications, which of the following is the most appropriate management for this patient's diabetes?

A. Initiate dapagliflozin

B. Initiate glipizide

C. Initiate metformin

D. Initiate sitagliptin

Correct Answer

C. Initiate metformin

Educational Objective

Manage early type 2 diabetes mellitus.

Critique

The most appropriate management for this patient is to initiate metformin. The patient is early in her diabetes disease course without evidence of microvascular disease. For otherwise healthy adults meeting these criteria, the American Diabetes Association recommends a hemoglobin A1c level of less than 7.0%, preprandial glucose values of 70 to 130 mg/dL (3.9-7.2 mmol/L), and 1- to 2-hour postprandial glucose values of less than 180 mg/dL (10 mmol/L). Because the patient has not met these goals, a pharmacologic agent should be added at this time. Lifestyle recommendations consisting of increased physical activity, dietary modifications, and weight loss (if BMI is elevated) are the initial first step in treating diabetes. When lifestyle modifications fail to meet glycemic goals within 6 weeks, metformin is the recommended first-line therapy to be started in conjunction with continued lifestyle modifications. If glycemic goals are not met after 3 months of lifestyle modifications and metformin use, additional agents should be added to the regimen every 3 months until glucose goals are met. The American College of Physicians recommends a hemoglobin A1c level between 7% and 8% in most patients with type 2 diabetes. The rationale for these targets is based on evidence that collectively shows treating to targets of <7% compared with targets around 8% did not reduce death or macrovascular events over about 5 to 10 years of treatment but did result in substantial harms. More stringent targets may be appropriate for patients who have a long life expectancy (>15 years) and are interested in more intensive glycemic control with pharmacologic therapy despite the risk for harms, including but not limited to hypoglycemia, patient burden, and pharmacologic costs.

Dapagliflozin, a sodium-glucose transporter-2 (SGLT-2) inhibitor, increases excretion of glucose through the kidney. It is a second-line agent that should be used after lifestyle modifications and metformin fail to reach glycemic goals.

The sulfonylurea glipizide stimulates insulin secretion from the pancreatic beta cells. This agent could improve the patient's postprandial hyperglycemia, but it may also induce weight gain in a patient actively working on weight loss. Glipizide is a second-line agent that should be used after lifestyle modifications and metformin fail to reach glycemic goals.

Sitagliptin, a dipeptidyl peptidase-4 (DPP-4) inhibitor, improves glycemic control by slowing gastric emptying and suppressing glucagon secretion. It is also considered a second-line agent that might be considered if lifestyle modifications and metformin fail to reach glycemic goals.

Key Point

For most patients with type 2 diabetes mellitus, lifestyle modifications and metformin therapy are the most appropriate initial treatments.

Bibliography

American Diabetes Association. (7) Approaches to glycemic treatment. In: Standards of Medical Care in Diabetes-2015. Diabetes Care. 2015 Jan;38 Suppl 1:S41-8.

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Clinical Practice Points

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

Medicine and Society