Relentless Change Ahead for Type 2 Diabetes Care

Recent news makes it clear. You can be sure that relentless change lies ahead for type 2 diabetes care. The American College of Physicians (ACP, representing 152,000 internists) is fighting with the American Diabetes Association and other experts over the standard of care. And Scandinavian researchers have found that we might do well to split diabetes into five subtypes – not just two. If their observations hold up, they will bring big shifts in diabetes care.

Too Much Focus on A1C?

The heart of the squabble between the ACP and the diabetes establishment is all about tight control of A1C. This measure provides a window into average blood sugar levels over time. A level of 6.5 percent is a typical marker for diabetes. Between 5.7 and 6.4 percent, a person may be on their way to having diabetes.

Right now, the squabble is all how tightly to set treatment goals for a person’s A1C. The new ACP guidance says that physicians should aim for a level between seven and eight percent. That’s higher than guidance from scientific groups focused on diabetes would suggest. ACP President defends his organization’s newer, less stringent guidance:

There are harms associated with overzealous treatment or inappropriate treatment focused on A1C targets. And for that reason, this is not the kind of situation where the college could just sit back and ignore things.

He goes on to suggest that doctors should consider backing off on meds for patients with a lower A1C.

With words like “overzealous” in play, you can be sure that the discussions will get heated. George Grunberger, past president of the AACE, explained the opposing view of endocrinologists:

The moment your glucose goes above normal, it’s incurring damage to the back of the eye, to kidneys and to nerves, especially in your feet. My concern is this will be a message to many practicing physicians saying, “Well, don’t worry about it so much, because it’s OK.”

Expect this controversy to simmer for a while to come.

Precision Medicine for Five Flavors of Diabetes?

Meanwhile, you can be sure that new data pointing to five – not just two – subtypes of diabetes will have important implications for diabetes care. Based on data from more than 15,000 patients in Sweden and Finland, researchers identified three severe and two mild forms of the disease. These insights might eventually make current guideline debates moot. Senior author Leif Groop explains:

Existing treatment guidelines are limited by the fact they respond to poor metabolic control when it has developed, but do not have the means to predict which patients will need intensified treatment. This study moves us towards a more clinically useful diagnosis, and represents an important step towards precision medicine in diabetes.

Continued refinement in diabetes care is no small thing. With ever more patients to manage, we need smarter, more precise strategies.

Click here for more on the fracas ACP has sparked and here for the guidelines that started it. For the research on diabetes subtypes, click here. You’ll find further perspective in a commentary here and from Medscape here.

Madagascar Periwinkle, photograph © Stavros Markopoulos / flickr

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March 8, 2018