Thursday, October 15, 2009


The European Association for the Study of Diabetes ( EASD ) at their Annual Scientific meeting in Vienna this October debated the HbA1c target for good control of diabetes. The scientific committee organised a debate to a packed audience of the "Lower HbA1c is better ". They took note of the criteria set by the ESAD and ADA ( American Diabetes Association ) of HbA1c level of <7%, as opposed to the American Association of Clinical Endocrinologist ( AACE ) and the Iternational Diabetes Federation ( IDF ) which set the level of <6.5%. Is the EASD/ADA being too conservative or is the AACE/IDF being too aggressive. Where does the evidence point too? I had infact talked about this in a posting about a year ago. This is an update.
Unfortunately, a latest review of the literature is still confusing. The landmark UKPDS study ( we have relied on this for a longtime ) seem to point to the fact the lower is better. However, more recent studies using never agents seemed to point to the fact the sometimes lower can cause harm, as in the ACCORD ( Action to control CVS risk in diabetes ), where lower HbA1c levels seemed to be associated with higher mortality. This fact in fact cause the study to be prematurely terminated. Other studies with the same objective, including the VADT ( Veteran Affairs Diabetes Trial ), the ADVANCE ( Action in Diabetes and vascular disease ) seemed also not to be decisive. Some studies seem to suggest that there was an improvement in urine albuminuria ( ADVANCE ) with lower HbA1c without an improvement in mortality.
Basically, we are all still very confusing.
I have been keeping a lookout for any progress, but I do take a few important message from the lack of concensus. I take it there the reasons for lowering mortality is not just from lowering HbA1c alone. It may have to be taken together with lowering hypertension to target and also the serum cholesterol, afterall diabetics die from vascular disease and serum cholesterol and hypertension may impact on the outcome. I also take note that diabetologist is beginning to note that gluco-centrism alone is not complete. Glucose level control must be seen in the light of outcomes. Therapy of diabetics must be patient-centric.
All in all, looking at all the data, I still follow the principle that in the elderly diabetics, fair control ( dont be so aggressive ) is reasonable. In this group, hypoglycemia from aggressive gluco-centrism may be bad for the patient. In the adults with established end-organ damage a conservative control, as proposed by the EASD/ADA may be reasonable. However in the younger adults or in adults with no evidence of target end-organ damage ( those with just diabetes mellitus ), then aggressive control ( in my opinion ) is justified. I will push fo HbA1c of <6.5% or even <6% especially in those who are obese and who are educated and compliant.
Looks like the issue of "lower HbA1c is better " cannot be answered in one word. We will more then ever here, to individualised patient care. The act of medicine is still very important.

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