The American Diabetes Association (ADA), the American College of Endocrinology (ACE), and the American Association of Clinical Endocrinologists (AACE) all agree that an HbA1c level of less than 6.5% is the ideal goal in patients with Type 2 diabetes. But ADA guidelines allow that up to 7% is “a reasonable goal for many nonpregnant adults” and that even just under 8% is tolerable for patients with “short life expectancy, extensive comorbidities, or other situations where tighter control may be difficult or counterproductive.”
Avoiding pursuit of HbA1c goals that may be “counterproductive” was the topic that Tina Kaur Thethi, MD, MPH spoke on in her recent Pri-Med Southwest 2022 presentation.
Dr. Thethi, an Associate Investigator at the AdventHealth Translational Research Institute and an endocrinologist at the AdventHealth Diabetes Institute in Orlando, Florida, urged looking at “the whole person” when considering how to treat a patient with diabetes, reminding her audience that that includes considering the several circumstances that might support less stringent goals for hbA1c.
Among the questions that Dr. Thethi said she regularly asks herself when considering hbA1c goals for patients were:
- Where and how does the patient live?
- Do they have family support?
- What are their co-morbidities?
The Case of “Ethel.”
By way of illustration, Dr. Thethi presented the case of a theoretical, 74-year-old patient named “Ethel” who has the following medical history:
- T2DM for 20 years
- HTN
- CHG
- CKD stage 2
- AF (sinus rhythm s/p ablation)
- OA
Ethel is taking the following medications:
- Metformin 1000 mg BID
- Sitagliptin 100 mg QD
- Metoprolol 100 mg QD
- Lisinopril 40 mg QD
- Furosemide 40-80 mg QD PRN
- Iron 325 mg QD
- Multivitamin QD
Lab worked revealed that Ethel’s HbA1c is 8.1%, up from 7.3% when last tested, 12 months ago. Additional lab work showed eGFR of 65 mL/min/1.73m2 and Microalbuminuria: 160 mcg/mg.
To this data set, Dr. Thethi added the additional information that “Ethel” is a resident in an assisted living facility and walks with a cane.
8% Can Be Okay.
“When someone has several co-morbidities, as does Ethel, you should be thinking, ‘What is the life span of this patient? How much support does the patient have? Should I have a stringent goal or not?’,” Dr. Thethi said.
“If you can get an hbA1c to be less than 7 without any regular pattern of hypoglycemia or adverse effects, by all means go there. But it’s reasonable to not push it too far,” she said. “Up to 8% is okay under certain adverse conditions.”
In just one example of the potential impact of hbA1c goals that are too stringent on a patient like “Ethel,” Dr. Thethi said that the fact that the patient walks with a cane is a reason to be concerned about hypoglycemia and a potential risk for falls. More significant are the patient’s kidney disease and congestive heart failure.
Glycemic Control vs. Co-morbidities.
“The glycemic control isn’t as important right now as her co-morbid conditions,” Dr. Thethi said.
Considering those co-morbidities, Dr. Thethi noted that an SGLT2 inhibitor could be beneficial for a patient like “Ethel” as that class of drugs has a positive impact in kidney disease and heart failure.
What other drugs might a physician consider for “Ethel”? Dr. Thethi said that Finerenone deserves attention. Approved just last year and sold under the brand name “Kerendia,” the drug is a nonsteroidal mineralocorticoid receptor antagonist for the treatment of chronic kidney disease associated with Type 2 diabetes, but also is proven to reduce the risk of cardiovascular death, non-fatal heart attacks, and hospitalization for heart failure in adults with chronic kidney disease associated with type 2 diabetes.