AMERICAN COLLEGE OF PHYSICIANS NEW BOLD GUIDELINES FOR TYPE 2 DIABETES IN NON PREGNANT ADULT PATIENTS. NEW THINKING IN MEDICINE.

American College of Physicians has come up with their guidelines of management of Type 2 Diabetes in non pregnant adults.
These are the latest 2018 guidelines.
These guidelines will become a paradigm shift not only in management of Diabetes but also in the way guidelines are written.
I am impressed that American college of Physicians ( ACP) has come out with guidance written in a way which encompasses the essence how guidelines should be written.
These guidelines have been called “controversial”. In my opinion they make the most sense of any Diabetes guidelines so far.
Here are some of the highlights of these guidelines.

Guidance Statement 1:
Clinicians should personalize goals for glycemic control in patients with type 2 diabetes on the basis of a discussion of benefits and harms of pharmacotherapy, patients' preferences, patients' general health and life expectancy, treatment burden, and costs of care.

The number of Americans who cannot afford their medications is staggering.
Number of Americans who don’t fill their prescriptions because of cost is 1 in 7.

In Medicine today we are practicing ideas that should have left us a long time ago. Studying two large populations against set goals and looking for outcomes has been helpful. It ignores the fact that personalized medicine should be the essence of treating individuals. One size does not fit all. No guideline has ever talked about treatment burden and cost of care until now. Medically these patients are labeled “non compliant” when they can’t afford their medicines. They are anything but non compliant. They are not the fringe of society. These are everyday Americans and unfortunately lots of them. Last week I diagnosed a patient with emphysema and prescribed an inhaler. With insurance the cost was 47 dollars. Without insurance the cost would be more than 300 dollars. Luckily the patient had good insurance and would have to pay 47 dollars only. Later that day patient called and said that they cannot afford the inhaler. It was heartbreaking. The burden of disease is bad but the burden of treatment was even worse. With modifications in how the patient is using the inhaler, they are breathing better. Yet the treatment is not “approved” to be used in the fashion it is being used by the patient. It is not non compliance. Patient is compliant to the best of their abilities. I love the fact that the a guideline is taking these burdens into account.

Guidance Statement 4:
Clinicians should treat patients with type 2 diabetes to minimize symptoms related to hyperglycemia and avoid targeting an HbA1c level in patients with a life expectancy less than 10 years due to advanced age (80 years or older), residence in a nursing home, or chronic conditions (such as dementia, cancer, end-stage kidney disease, or severe chronic obstructive pulmonary disease or congestive heart failure) because the harms outweigh the benefits in this population

As you get older you generally end up on a lot of medications with a lot of side effects and interactions. Medications cause appetite changes, fatigue, insomnia just to name a simple few things that effect the quality of life. The focus should shift greatly to quality of life and patient happiness and feelings of well being rather than a wild goose chase of parameters that worsen quality of life. Again, the introduction of such ideas in a guideline is impressive and heartwarming. My dad is a diabetic. This is personal to me. He craves sweets. It brings a smile to my face to see him happy sneaking sweets when he thinks no one is looking. He is happy and I am happy. I hope to have the great guy around forever but I am not too certain if I will get my wish. I don’t wish to see him exist miserably while trying to get the numbers right on paper. When he tried he had low blood sugar episode and crashed his car. I love you dad. Have an ice cream and be happy. You are 86. live long and prosper. 🖖

The other 2 important aspects of the guidelines are mentioned below.

Guidance Statement 2:
Clinicians should aim to achieve an HbA1c level between 7% and 8% in most patients with type 2 diabetes.

Guidance Statement 3:
Clinicians should consider deintensifying pharmacologic therapy in patients with type 2 diabetes who achieve HbA1c levels less than 6.5%.

Other guidelines pushed Hemoglobin A1C which is a measure of average blood glucose over the past 3 months to below 6.5. The authors clearly explain their rationale and risks versus benefits of choosing lower vs higher goals. I have linked the article above so all concerned can see the validity of arguments presented.

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