23rd March 2009
An editorial in the BMJ concludes that there should be a re-evaluation of recommendations about what constitutes high quality care for older people with type 2 diabetes. This stems from recent findings which suggest that tighter glycaemic control in these people does not provide substantial benefit and may increase the risk of adverse outcomes.
Health professionals and people with type 2 diabetes should prioritise lifestyle interventions (losing weight, healthy diet, stopping smoking if relevant), blood pressure control as well as taking a statin, aspirin if cardiovascular disease is present, and metformin. They should follow NICE guidance and agree individual targets for blood glucose. Interventions to control blood glucose intensively appear to add little and attempts to achieve very tight control of blood glucose may do more harm than good.
What is this about?
The BMJ editorial points out that during the past year, three important studies (ACCORD, ADVANCE and VADT) have provided evidence that tighter glycaemic control (to <7% glycated haemoglobin) in older adults with type 2 diabetes does not provide substantial benefit and may increase the risk of adverse outcomes. These studies and their implications have been discussed in several previous NPCi blogs:
- Once again, intensive glucose control does not benefit people with established type 2 diabetes if other cardiovascular risk factors are addressed
- Putting blood glucose control in type 2 diabetes into perspective
- Increased death rate found in intensive blood glucose-lowering arm of trial in type 2 diabetes – study arm halted
From April 2009, the glycated haemoglobin (HbA1c) target in one of the diabetes indicators in the quality and outcomes framework (QoF) is changing from a target of 7.5% or less to a target of 7% or less. The editorial argues that by encouraging tighter glycaemic control in all patients with type 2 diabetes, regardless of disease duration and the drugs used to achieve control, the new QoF target encourages an outdated strategy and one that may not provide a net benefit to patients. It suggests the new target should be withdrawn before it wastes resources and possibly harms patients.
More information on the management of type 2 diabetes can be found on the type 2 diabetes section of NPC, which is soon to be updated with new materials.