The 2018 update of the American College of Physicians glycaemic management recommendations: An invitation to continued inertia?

Abstract

The management of type 2 diabetes has become increasingly controversial. Tight control has been advocated for years; however, there was a recent revision published by the American College of Physicians in which limitations were made to liberalize glycaemic goals for most diabetics, targeting a level between 7% and 8%. In recent years, the evolution of diabetes care has been such that more potent drugs, with low risk of hypoglycaemia when used in the absence of insulin or secretagogues, have made their way into the market place. Use of such agents has made it easier to achieve greater glycaemic control reasonably safely. Unfortunately, it appears that there has been a significant amount of inertia over the past decade, which continues to persist. Relaxing the glycaemic control targets, as recommended by the American College of Physicians, may only help to propagate this inertia.

Use of Linagliptin for the Management of Medicine Department Inpatients with Type 2 Diabetes in Real-World Clinical Practice (Lina-Real-World Study)

“…Patients with moderate degrees of hyperglycaemia, patients without previous insulin therapy and elderly or frail patients at high risk of hypoglycaemia may be treated with a combination of DPP4i and basal insulin according to a recent therapeutic algorithm [ 23 ]. Treatment with intensive insulin regimens is part of our routine clinical practice for all hospitalized patients with T2D but an important proportion of these patients could be highly exposed to suffer hypoglycaemia [ 11 , 24 , 25 , 26 ], which would significantly impact in our clinical practice [ 27 , 28 , 29 ]. For this reason, we should develop protocols with differentiated treatment regimens according to glycaemic control before hospitalization.…”

Comorbid Diabetes and Severe Mental Illness: Outcomes in an Integrated Health Care Delivery System

“…1). Specifically, young adults [18][19][20][21][22][23][24][25][26][27][28][29] had over twice the risk of having poor control compared to older adults (aRR 2.15, 95% CI 1.65-2.79, p < 0.001), Hispanics were 18% more likely to have poor control compared to whites (aRR 1.18, 95% CI 1.01-1.39, p value 0.041), and people without any primary care visits were over twice as likely to have poor control when compared to those who frequently utilized primary care services (aRR 2.72, 95% CI 2.23-3.33, p < 0.001).…”

“…We then used Poisson models 20 with robust standard errors to estimate the associations of SMI with diabetes control and care outcomes, adjusting for smoking status, age, gender, race, urban area type, BMI, primary care utilization, and medical facility. Since glycemic control are often personalized based on co-morbidity and some suggest a cutoff of < 8%, 21 we also conducted a sensitivity analysis in which the threshold for A1c control was defined as A1c < 8%. In addition, we used a Poisson model to examine whether age, gender, race/ethnicity, comorbid substance use, BMI, or primary care utilization-all variables that could impact glycemic control-were independently associated with poor control among people with SMI.…”