Joslin Diabetes Center has serious concerns regarding portions of a newly released set of guidance statements for clinicians in assessing appropriate A1C targets for non-pregnant adults with type 2 diabetes.

Physicians at Joslin disagree with the second statement declared in the set of guidelines published by the American College of Physicians (ACP) in the Annals of Internal Medicine, stating that “Clinicians should aim to achieve an HbA1c level between 7% and 8% in most patients with type 2 diabetes.”

“While we agree with the ACP statement that glucose control should be personalized, its recommendation that the A1C target should be between 7% and 8% for most patients with type 2 diabetes is a gross oversimplification of existing data on A1C and diabetes-related outcomes, and therefore represents misleading advice. No one size fits all,” said Dr. Om Ganda, chair of the Clinical Oversight Committee.

The authors reviewed earlier studies concluding that targeting A1C to below 7% had little to no benefit in reducing the progression of microvascular or macrovascular events. “This statement paints a misleading picture of equal risk of complications in all patients with diabetes, ignores what medications the patients used, and assumes 'treat-to-target' is the focus of diabetes care,” said Dr. Samar Hafida, a staff endocrinologist on Joslin’s Clinical Oversight Committee.

“The big concern is that many patients will be left at A1C slightly above 8% and not be given treatments that we know can reduce morbidity and mortality,” said Dr. Robert Gabbay, Joslin’s chief medical officer. “Targets need to be individualized to optimally reduce the risk of diabetes complications. The ACP statement is even more concerning for younger individuals with type 2 diabetes who have a longer lifetime exposure to high glucoses. For these individuals, we need to lower targets, where safe, to reduce their risks.”

Joslin experts recommend utilizing known methods to not only prevent diabetes, but to treat patients newly diagnosed with type 2 diabetes safely and effectively by targeting an A1C of well under 7% to prevent complications. Moreover, it is important to remember that A1C is one of many markers of optimal glycemic control; reviewing the day-to-day fluctuations of glucose should also be taken into consideration in each individual.

Others with advanced disease and multiple comorbidities, cognitive difficulties, and advanced age, should have their A1C targets weighed against the potential harm of medications used. Joslin’s recommendations for optimal care are fully outlined in our Joslin Clinical Guidelines.

Joslin joins the American Diabetes Association, the American Association of Clinical Endocrinologists, the American Association of Diabetes Educators, and the Endocrine Society, all of which have expressed similar concerns in a joint press release.