For years, I’ve kept a firm rein on my A1C numbers – I’ve prided myself on my 5.7 to 6.1 results. So when the American College of Physicians recently put out a guidance report that raised the target A1C reading from 7 to 8, I was skeptical, curious, and most of all, surprised.
According to the ACP guidance, patients in my A1C range might consider de-intensifying treatment, perhaps reducing, or even eliminating, medication.
It seemed the world had turned upside down.
I wasn’t the only one unsettled by the report – the big diabetes groups were quick to challenge the recommendations.
The American Diabetes Association (ADA), the American Association of Clinical Endocrinologists (AACE), the American Association of Diabetes Educators( AADE) and the Endocrine Society issued their objections, emphasizing that to avoid microvascular complications, it was best to keep numbers in the below 7 or 6.5 range.
Curious about the findings, I put on my journalist hat and reached out directly to two of the main representatives on either side of the discussion – Dr. Jack Ende, president of the ACP and Dr. Jonathan Leffert, president of the AACE. I wanted to know what they felt about the standards, and more importantly, what we, as patients, should take away from them. Among their points:
- They agreed that diabetes care should be personalized to the patient.
- They differed on A1C targets. While Leffert felt that diabetic complications were less likely to occur with numbers below 7, Ende saw fewer benefits from keeping numbers that low.
- They also differed on risk/benefit analysis. The ACP felt that lower numbers presented a greater risk to patients (think hypoglycemia), while the AACE believes that the benefits of keeping sugars low outweigh these risks. But be sure to check in with your doctor if you’re having frequent lows.
- They agreed that costs could and should play a part in individualized care. Both doctors agreed that if medication costs to keep A1C’s very low were prohibitive, this was a topic that should be discussed with the patient.
Since I had the experts on the phone, I took the opportunity ask what they thought my own next move should be. Despite their dispute over the guidance standards, they both served up the same advice when it came to my own diabetes care: stay the course. If I wasn’t hypoglycemic (I’m not) and didn’t have adverse effects of my medication (I didn’t), they both said I was fine where I was. If I wanted at some point to change my meds or reduce them, that was between my doctor and me.
Overall, I think the most important thing to remember is that guidance standards are tools, not rules. I think if you’re doing well, you should keep doing what you’re doing, and if you’re not, you should talk to your doctor about the guidance standards and get his or her take on them.
Leffert did note that with the myriad of issues around diabetes in the U.S. and the rising numbers of people with type 2 diabetes and prediabetes, it may not be the best course to be complacent with an A1C of 7 to 8 percent and think “everything is okay.” Basically, if it’s possible to do better, we should try to do better.