Setting HbA1c targets for patients with type 2 diabetes

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tactics for high-risk patients with type 2 diabetes practical lessons from ACCORD and ... Email: [email protected] · [email protected]

Journal of Diabetology, June 2015; 2:3

Letter to the Editor :

Setting HbA1c targets for patients with type 2 diabetes *S .M .S I slam 1 , 2 , L .B . R aw al 3

Observations Therapeutic strategies to optimize glycaemic control are an important part of clinical decision for management of patients with type 2 diabetes (T2DM). Several guidelines provide a target value of HbA1c for all T2DM patients. However, a "one-size-fits-all" goal might not be the best strategy for all T2DM patients. The UK Prospective Diabetes Study (UKPDS) and other landmark studies provide evidence that intensive glycemic control effectively slowed the onset and progression of diabetic complications and mortality rates (1). However, the ACCORD (Action to Control Cardiovascular Risk in Diabetes) trial demonstrated in 65 years old patients with pre-existing cardiovascular diseases (CVD) that lowering HbA1c to less than 6 percent resulted in higher mortality rates and no reduction in CVD outcomes (2). The ADVANCE (Action in Diabetes and Vascular Disease) and VADT (Veterans Affairs Diabetes Trial) studies show no increases in mortality and no reduction in CVD outcomes from intensive control (3). On the other hand, lower HbA1c levels can cause damage to vascular endothelium and elevated levels over years might cause increased morbidity and mortality. Thus, both low and high mean HbA1c values are associated with increased mortality and CVD events with higher risks for patients whose blood glucose levels remain high despite intensive treatment. Diabetes is a complicated condition affected by several factors than only glycaemic control, such as diet, lifestyle factors, blood pressure, dyslipidaemia, co morbidity, age and duration of disease. The optimum HbA1c level depends on these factors. Intensive therapy might benefit young diabetes patients with no CVD but for middle-aged to elderly patients with macrovascular complications, the target would necessarily be translated to upper levels (from 7% to 8% HbA1c), which would result in a lesser aggressive therapeutic pattern and hence lower drug related adverse effects. An HbA1c target should be negotiated individually, but a

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level close to 7% seems to be an acceptable compromise for majority of the patients with T2DM based on clinical estimates and ongoing professional support (2). Acknowledgements We would like to express our gratitude and thanks to Dr. Med. PD Andreas Lechner, Diabetes Center, Diabetes Research Group, Medizinische Klinik und Poliklinik IV, LudwigMaximilians-Universität (LMU), Munich, Germany for his support. References Turner R, Holman R, Cull C, Stratton I, Matthews D, Frighi V, et al,. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). lancet 1998, 352(9131):837-853. Riddle MC, Karl DM. Individualizing targets and tactics for high-risk patients with type 2 diabetes practical lessons from ACCORD and other cardiovascular trials. Diabetes Care 2012, 35(10):2100-2107. Peterson K. Should the target A1C level be less than 7 percent? Yes: This should be the target for most patients. American family physician 2012, 86(12):1-2. Center for Control of Chronic Diseases (CCCD), icddr,b, Dhaka, Bangladesh 1

Center for International Health (CIH), LudwigMaximilians-Universität (LMU), Munich, Germany 2

Center for Equity and Health Systems (CEHS), icddr,b, Dhaka, Bangladesh. 3

*Corresponding author: (Current Details)

Sheikh Mohammed Shariful Islam Center for Control of Chronic Diseases, International Center for Diarrhoeal Diseases Research, Bangladesh, Dhaka- Bangladesh. Email: [email protected] [email protected]

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