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Diabetes Distilled: The glycaemic management paradox

Pam Brown
This large US database study showed that older people and those with more diabetes-related comorbidities had tighter glycaemic control and were more likely to be treated with insulin or sulfonylureas, while younger and healthier people had less stringent control and were less likely to receive these drugs, even at high HbA1c levels in which they would be recommended. This demonstrates an ongoing paradox whereby those least likely to gain benefit from tight control and most likely to sustain hypoglycaemia were most likely to have low HbA1c levels and be treated with insulin. The reverse was also true: those most likely to benefit and less likely to be harmed by tight control were less likely to achieve it.

Individualisation of glycaemic goals is accepted good practice and should include consideration of age, life expectancy, comorbidities, likelihood of benefit and drug-specific risk of hypoglycaemia. Early tight control is known to slow the progression of microvascular complications, while relaxation of targets in those at high risk of hypoglycaemia and those with multimorbidity can improve safety. 

This database study of nearly 200 000 people with type 2 diabetes in the US looked at glycaemic data and treatment with insulin and sulfonylureas during 2016. The mean age of the cohort was 66.2 years, 62% were age 65 or older, and 91.5% had at least one comorbidity (mean, 2.1 comorbidities).

The mean HbA1c was 61 mmol/mol (7.7%) in those aged 18–44 years, compared with 52 mmol/mol (6.9%) in those aged 75 and older. Only 46% of the younger age group achieved an HbA1c ≤52 mmol/mol, compared with 63% of those aged ≥75 years. The younger group was four times more likely to have an HbA1c of ≥75 mmol/mol (9.0%) than the older group.

In the 18–44-years age group, only 50% of those with an HbA1c ≥86 mmol/mol (10.0%) were treated with insulin, compared with 61% of those aged ≥65 years, despite insulin being recommended by the American Diabetes Association at this glycaemic level.

These data were the HbA1c levels achieved rather than targets necessarily pursued by the treating teams. No matter how well we believe we are implementing guidelines and managing our patients, a review of our own practice may identify similar missed opportunities both for de-intensification amongst older people – particularly those with comorbidities – and for greater intensification and increased effort to overcome clinical inertia when managing younger, healthier people with type 2 diabetes.
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