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Surprise over new diabetes advice

Sections of diabetes specialists in India have expressed surprise over guidelines published on Tuesday by the American College of Physicians that they say appear to challenge standard dogma for sugar control practiced for more than two decades.

By G.S. Mudur
  • Published 7.03.18
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A person's blood sugar level being measured. Stock image/ Shutterstock

New Delhi: Sections of diabetes specialists in India have expressed surprise over guidelines published on Tuesday by the American College of Physicians that they say appear to challenge standard dogma for sugar control practiced for more than two decades.

The specialists are questioning a guidance statement that recommends doctors should aim to achieve HbA1C levels between 7 per cent and 8 per cent in most patients with type-2 diabetes. The HbA1C level, determined through a blood test, indicates the average blood sugar over the past eight to 12 weeks.

"This is a bolt from the blue - it has huge implications, it challenges all that we've practiced and taught for nearly three decades," said Anoop Misra, a senior diabetes consultant and the chairman of the Fortis Centre for Diabetes Obesity and Cholesterol.

"Many of us are going to find it hard to accept this guidance."

Diabetes experts across the world have all these years been trying to get patients to maintain HbA1C levels at least below 7, and preferably below 6.5. Misra said the guidance statement suggesting that it is okay to have HbA1C up to 8 per cent would translate into 20 to 30 point increases in fasting or post-meal blood sugar levels.

The ACP's guidelines, published on Tuesday in the journal Annals of Internal Medicine, also recommend that doctors should "personalise goals" for sugar control on the basis of discussions of benefits and harm of pharmacotherapy, patients' preferences, general health, life expectancy, treatment burden and costs of care.

The guidance also says doctors should consider "deintensifying pharmacologic therapy" - in other words, lower drug treatment - in patients with type-2 diabetes who achieve HbA1C levels less than 6.5 per cent.

Persistently high blood sugar levels among diabetes patients raise the risk of complications - from eye disease to kidney damage and cardiovascular disorders, heart attacks or stroke.

Misra and others believe the ACP's new guidelines appear influenced by the results of clinical trials that have suggested that too much of tight control on sugar through pharmacological therapy may increase the risk of cardiovascular disease and deaths in some patients.

They argue that pharmacotherapy needs to be tailored to patients' individual conditions and needs.

"We should all be aiming for individualised therapy," said Satinath Mukhopadhyay, professor of endocrinology at the Institute of Postgraduate Medical Education and Research, Calcutta.

"For young patients with an active lifestyle and no underlying risks, we're likely to continue recommending that they try keep their HbA1C levels below 6.5 if that is safely achievable, but we could relax this for patients who already have underlying cardiovascular disorders or for patients above 80 years of age in whom 7.5 to 8 could be a desirable target."

Senior endocrinologists are particularly vexed by the guidance urging doctors to aim for HbA1C between 7 and 8 per cent.

"This will be controversial - the right target would be to try maintain HbA1C at 7, although the reality is that even with good therapy, it is difficult for patients to achieve such levels, and most patients worldwide remain in the zone between 7.5 to 8.5," said Ambrish Mithal, chairman of endocrinlogy at the Medanta hospital in Gurgaon.

"However, if we set 8 as an acceptable target, we might end up with being satisfied with 8 and make no attempt to lower HbA1C further, to the detriment of patients."

Some doctors argue that the ACP guidelines may also have emerged from studies that seem to suggest that the benefits that accrue from maintaining HbA1C below 7 per cent are not significantly different from the benefits that accrue from keeping HbA1C below 8 per cent.

"The ACP guidelines appear to be designed mainly for primary and secondary care physicians, who might find it challenging to individualise treatments," said Mukhopadhyay.