Summary of the ACE Consensus conference on guidelines for glycemic control
Two decades ago, chances are most people did not know their cholesterol level. Today, nearly everyone is all too familiar with the terms LDL and HDL, even if they can only identify them as "bad cholesterol" and "good cholesterol." Now the American College of Endocrinology (ACE) has embarked on a mission to make the glycosylated hemoglobin (HbA1c) test a household word for patients with diabetes.
An international panel convened by ACE and the American Association of Clinical Endocrinologists (AACE) has issued the ACE Consensus Conference on Guidelines for Glycemic Control. "Currently, diabetes guidelines in the United States are not consistent with worldwide standards," said Rhoda Cobin, M.D., president of AACE. "We need more aggressive, complete, and cohesive standards," she said.
"There are data that suggest we are making the diagnosis [of diabetes] between six and a half and 10 years too late," declared Jaime Davidson, M.D. He is clinical associate professor of internal medicine at the University of Texas, Southwestern Medical School and conference cochair. Recent information from the Centers for Disease Control & Prevention showed a 71% increase in the prevalence of diabetes in adults age 30 to 39 years. This led the panel to agree that current guidelines for diabetes screening be reduced from 45 years of age to 30 for high-risk groups (see box below).
Claresa Levetan, M.D., director of diabetes education at the Medstar Clinical Research Center in Washington, D.C., and conference cochair, noted that diabetes is primarily asymptomatic and is most often diagnosed incidentally after one of the disease's complications appears. According to Davidson, 80% of the cost of diabetes can be blamed on the complications it causes.
The panel has also recommended that HbA1c be universally adopted as the primary assessment of glycemic control and that it bear the simple, standard name "A1C." The HbA1c test yields a person's average blood glucose level over the previous two to three months. "The HbA1c can be viewed as the summation of both preprandial and postprandial glycemia," observed Davidson.
The findings from the Diabetes Control and Complications Trial (DCCT) and the United Kingdom Prospective Diabetes Study (UKPDS) demonstrated that any reduction in elevated HbA1c levels was associated with a significant decrease in the risk of microvascular complications of diabetes. "In the epidemiologic data from the UKPDS, elevated risk for microvascular and macrovascular complications was shown to begin at 6.5% HbA1c and above," said Davidson. The panel has therefore lowered the target for diabetes control to < 6.5%.
Levetan referred to a CDC survey conducted throughout the country that revealed that almost 75% of diabetes patients had never heard of the term HbA1c. She explained that it is critical for patients to know their HbA1c level and their goals. They must also be made aware that lowering their level by even 1% can decrease the risk of diabetes-related morbidities and mortalities by 25%. HbA1c assessments should be performed at least twice yearly in patients who are on target and quarterly or more frequently in patients who are above target and/or undergoing a change in therapy, according to the guidelines.
The panel also addressed the issues of fasting, preprandial glucose targets, and postprandial targets. Davidson remarked that increased risk of retinopathy is clearly associated with fasting plasma glucose > 110 mg/dl. Therefore, the panel recommends a fasting blood level target < 110 mg/dl. Davidson also advised patients and healthcare providers to become familiar with what their individual blood glucose meter measures, because values obtained through self-monitoring may or may not reflect plasma glucose.
Significant attention has recently been placed on postprandial glucose levels. Postprandial hyperglycemia is one of the earliest abnormalities noted in diabetes. While there is a relatively small body of evidence from which to draw conclusions regarding postprandial control, the panel recommends a targeted two-hour postmeal glucose of < 140 mg/dl.
"Addressing the postprandial levels is significant not only because it will reduce tissue damage for patients but also because it alerts them to a problem previously unaddressed in blood sugar monitoring," said Cobin.
The American Diabetes Association along with CDC and the National Institutes of Health are reviewing recent findings on diabetes and evaluating the need to update their clinical practice recommendations.
Source: ACE Consensus Conference on Guidelines for Glycemic Control
Tammy Chernin. New diabetes guidelines call for more aggressive screening. Drug Topics 2001;18:20.