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ADA revises guidelines: Type 1 diabetes HbA1c target should be 7.5% across all age groups
SAN FRANCISCO — In an effort to “harmonize” recommendations for patients with type 1 diabetes across the age groups, the American Diabetes Association has released a position statement for treatment in which they recommend all patients with type 1 diabetes aim for an HbA1c of less than 7.5%.
“Our goal here is to present a position statement that looks specifically at the needs of people with type 1 diabetes across the age spectrum,” Anne Peters, MD, FACP, professor at the Keck School of Medicine, University of Southern California, said during a press conference at the American Diabetes Association’s 74th Scientific Sessions. “We now know that we have many, many people who are older with type 1 diabetes ... who are frankly living long enough to now be dealing with the same issues that our elderly population faces. So we want this to really address those needs across the lifespan and address both the pediatric population as well as this much larger, older population.”
Reexamining target levels
Peters and her co-authors described the new guidelines as filling a need in the medical community as type 1 diabetes is often grouped with type 2 diabetes in adults or considered only a pediatric disease where a fear of hypoglycemia previously mandated staged glycemic targets.
Lori Laffel, MD, chief of the pediatric, adolescent and young adult section at Joslin Diabetes Center and associate professor of pediatrics at Harvard Medical School said those previous guidelines (<8.5% for children <6 years; <8.0% for ages 6-12 years; <7.5% for ages 13-19 years) were based on the Diabetes Control and Complications Trial (DCCT).
“Fast forward, now we are 21 years past the DCCT with advanced therapies and new ways to think about approaches to glycemic control in the pediatric population,” Laffel said. “Those targets were based on experience with severe hypoglycemia in a distant era. In addition, we have new information that allows us to reexamine rates of hypoglycemia in the current intensive insulin era and recognize that rates of hypoglycemia are not increased in the youngest vulnerable, and they are not increased with lower HbA1c levels. Furthermore, we recognize that there is increasing data recognizing the potential acute adverse effects on the central nervous system from hyperglycemia in young patients.”
Sue Kirkman
Sue Kirkman, MD, professor of medicine in the division of endocrinology and metabolism at the University of North Carolina, expressed her frustration at the notion that type 1 diabetes is a pediatric disease despite the fact that many cases are not diagnosed until after the age of 18 years, and even those diagnosed young live into adulthood and “very old age.”
“It has driven me crazy for a long time,” she said. “We need to remember that the vast majority of people with type 1 diabetes are adults.”
Simple, consistent message
Jane Chiang, MD, senior vice president of medical and community affairs for the American Diabetes Association, said the association debated if these guidelines were a change that should be made since practitioners were comfortable with the previous levels.
“We felt it was very important to harmonize with other organizations nationally and internationally to make sure we have simple and consistent messages for glycemic targets for those with type 1 diabetes,” she said. “We want all of you to know that the American Diabetes Association is very committed to patients with type 1 diabetes. ... We really want to separate out the two different types of diabetes.”
Chiang reiterated that these are merely guidelines and physicians must continue to take their individual patient’s needs into consideration.
“ADA guidelines are guidelines. ... They recommend that this is what the evidence supports. However, how you do that is really up to the physicians and one thing we really try to avoid in our guidelines is to be prescriptive,” Chiang said. “We realize that we’re very committed to the type 1 diabetes community, but there’s more that we can do. This is just the beginning. We’re hoping to continue this conversation.”
Additional recommendations
Chiang and Kirkman also brought to the attention of the audience that there are additional recommendations on subjects such as exercise and cardiovascular disease as they apply to type 1 diabetes as this compilation of research was not previously available. Peters suggested this would assist in providers working with reimbursement considerations while Laffel pointed to the empirically supported recommendation for increased daily testing.
“We are so pleased to be able to have offered a unified target for the pediatric population and even more pleased to have a single set of guidelines that will cross the lifespan of our patients with type 1 diabetes,” Laffel said. “Now as we’re caring for our pediatric patients with type 1 diabetes, we can be assured that as we pass them onward toward adult providers, as they leave our pediatric practices, ... that we will all be singing to the same song because we will have a single set of guidelines.”
For More Information: Type 1 Diabetes Through the Life Span: A Position Statement of the American Diabetes Association. Presented at: American Diabetes Association’s 74th Scientific Sessions; June 13-17, 2014; San Francisco.