The prestigious American College of Physicians (ACP) has challenged the American Diabetes Association (ADA) when it comes to how to treat type 2 diabetes. It’s the internists against the endocrinologists. The result of this conflict is likely to be confusion for patients.

What’s All the Fuss About?

The ACP is the largest medical specialty group in the U.S. It is comprised of over 150,000 internists, internal medicine subspecialists, residents, fellows and medical students. The organization issued new guidelines about how to treat type 2 diabetes (Annals of Internal Medicine, March 6, 2018). The bottom line is that the experts for the ACP are encouraging their colleagues to treat type 2 diabetes less aggressively than before.

The president of the ACP, Dr. Jack Ende, summarized the evidence-based guidance statement this way:

“ACP’s analysis of the evidence behind existing guidelines found that treatment with drugs to targets of 7 percent or less compared to targets of about 8 percent did not reduce deaths or macrovascular complications such as heart attack or stroke but did result in substantial harms. The evidence shows that for most people with type 2 diabetes, achieving an A1C between 7 percent and 8 percent will best balance long-term benefits with harms such as low blood sugar, medication burden, and costs.”

Heresy Among Specialists:

You might not think the difference between a goal of 7 to 8 percent vs. a goal of less than 7 percent would be such a big deal. Au contraire. This represents a huge fight between specialists. The ADA recommends getting AIC levels below 7 percent (Diabetes Care, Jan. 2018). The experts for the ADA go on to suggest that:

“Providers might reasonably suggest more stringent A1C goals (such as less than 6.5 percent) for selected patients…”

The difference between 6.5 to 7 percent and 7 to 8 percent may not seem like much to you. But it is the difference between aggressive blood sugar control and a more relaxed approach to the way doctors treat type 2 diabetes.

What is A1C?

Doctors abbreviate Hemoglobin A1c to HbA1c. Then they shorten it even more to A1C. This blood test, also referred to as glycosylated or glycated hemoglobin, is a measure of average blood sugar control over three months. Many health professionals prefer this metric to daily blood sugar readings. That’s because it gives them a rough idea how their patients are controlling blood glucose over a longer period of time.

Why Are Endocrinologists So Upset?

It’s all about the more aggressive vs. less aggressive way to treat type 2 diabetes. Intensive control of blood sugar has been a goal of the ADA for years. Many endocrinologists believe that this approach will lead to fewer complications of diabetes. We can imagine that there are patients for whom this approach would be desirable. But an aggressive approach to treat type 2 diabetes can have unexpected consequences for some people.

The feud between the internists and the endocrinologists centers around interpretation of research results. One of the biggest and best trials of the effects of intensive treatment (AIC levels of less than 6 percent) compared to standard therapy (targets of 7.0 to 7.9 percent) produced controversial results. The ACCORD trial upset the apple cart (New England Journal of Medicine, June 12, 2008).

The group of who were randomized to treat their type 2 diabetes aggressively had a:

“22% increase in all-cause mortality, a 35% increase in cardiovascular related death, and a 3-fold increase in risk for severe hypoglycemia. More intensive treatment also resulted in increased weight gain of more than 10 kg (27.8% vs. 14.1%) and increased fluid retention.”

You can learn more about the ACCORD trial in this article:

New Research Poses Diabetes Dilemma

The Risks of Hypoglycemia:

When patients don’t treat type 2 diabetes adequately they become vulnerable to many serious complications including eye damage, peripheral neuropathy and cardiovascular disease. Overly aggressive treatment, though, can put them at risk for dangerously low blood sugar (hypoglycemia).

Historically, this is usually considered a risk for people with type 1 diabetes who have to take insulin. A new perspective published in the Journal of Clinical Endocrinology & Metabolism (March. 5, 2018) suggests that it can also be a problem for people with type 2 diabetes.

Symptoms of Hypoglycemia:

When blood sugar levels drop too low, the patient may become shaky, spacey and experience sweating, headache and blurred vision. If allowed to continue, hypoglycemia can lead to fainting, seizures or coma. This can become an emergency, requiring hospitalization. Worst case, hypoglycemia can lead to death.

The authors call for personalized patient management strategies that will help all people with diabetes avoid the dangers of hypoglycemia. That is also the recommendation from the experts at the American College of Physicians. These internists are concerned about the complications of hypoglycemia. They too call for a personalized approach to treat type 2 diabetes.

What Should Patients Do When Doctors Fight?

We have written an article about this very question. Click on the link below to get The People’s Pharmacy perspective.

The Balancing Act:

We have always loved the revised story of Goldilocks and the Three Bears. That’s because it is a wonderful tale about moderation. Goldilocks rejected the first bowl of porridge because it was too hot. She rejected the second bowl because it was too cold. When she tasted the last bowl she said:

“Ahhh, this porridge is just right”

We think the way to treat type 2 diabetes requires a careful balance so the outcome is just right…or as close as we can get to that goal. That means aiming to prevent the serious consequences of diabetes while simultaneously avoiding adverse drug reactions and dangerously low blood sugar levels. Exercise and thoughtful eating can help.

We have also written a Guide to Managing Diabetes that provides some practical tips. Here is a link.

Share your own story about how you successfully treat type 2 diabetes below in the comment section. If you have ever experienced side effects from diabetes drugs we would like to know about them. What about hypoglycemia? Has that ever been a problem. Share your story so others can benefit.

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