Glycemic Targets for Elderly Diabetic Patients Need Reappraisal

Abstract

Over the past several decades, a key assumption in diabetes management has been that intensive glycemic control reduces diabetic vascular complications, and implicitly leads to improved long-term patient outcomes. The Diabetes Control and Complications Trial (DCCT) has clearly shown that tight glycemic control reduces the risk of retinopathy and renal disease in type 1 diabetic patients, 1 The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993; 329: 977-986 Crossref PubMed Scopus (22513) Google Scholar and thus confirmed the earlier conclusions of J. Pirart, based on observational data. 2 Pirart J. [Diabetes mellitus and its degenerative complications: A prospective study of 4,400 patients observed between 1947 and 1973 (author’s translation)]. Diabetes Metab. 1977; 3: 97-107 Google Scholar The value of tight glycemic control was also demonstrated in type 2 diabetes by the UK Prospective Diabetes Study (UKPDS), although the benefits were relatively modest. 3 UK Prospective Diabetes Study Group Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). The Lancet. 1998; 352: 837-853 Abstract Full Text Full Text PDF PubMed Scopus (12094) Google Scholar Indeed, an 8-year intervention lowering HbA1c by approximately 1% in newly diagnosed diabetic patients resulted in a lower incidence of microvascular complications but not of myocardial infarction and stroke. Nonetheless, current treatment recommendations from the American Diabetes Association (ADA) set an HbA1c target of lower than 7.0% for most adults with type 2 diabetes. They acknowledge that “less stringent HbA1c goals (…) may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, or extensive comorbid conditions and those with longstanding diabetes in whom the general goal is difficult to attain.” 4 American Diabetes Association. Executive Summary: Standards of Medical Care in Diabetes—2010. Diabetes Care. 2010; 33: S4-S10 Crossref PubMed Google Scholar These restrictions reflect the unease many clinicians often feel with the implementation of tight glycemic control in elderly patients with comorbidities, but still implicitly define a HbA1c lower than 7.0% as the optimal target, with some acceptable exceptions. In the present editorial we will argue that a higher HbA1c target (7.0%–8.0%) should be recommended for most elderly patients, and that lower values should raise a suspicion of malnutrition.