A recent study by the Joslin Clinic’s highly regarded Drs. Katie Weinger (director of the Joslin Clinic’s Center for Excellence in Diabetes Education) and Medha Munshi (director of the Joslin Geriatric Diabetes Program) of the Joslin Clinic, published online in the Journal of Diabetes and Its Complications last month found that “flexible” A1c goals did not decrease hypoglycemia in older patients with type 2 diabetes. The study reports that A1c did not predict hypoglycemia in geriatric patients with type 2 diabetes regardless of treatment intensity or regimen. This is great in our view since we have heard recommendations of late to just “relax” guidelines and in the absence of solid evidence, we don’t think that is a great idea. Patients are already far from the A1c guidelines of 7%, and we think giving GPs another reason to miss guidelines is, well, misguided – even though it is of course the right advice for many HCPs – which is bigger, the downside or the upside, is a good question.
The Joslin researchers used CGMs to monitor 65 patients with type 2 diabetes (mean age = 76 years) with different A1c baselines: 26% had an A1c <7%; 42% between 7.1% and 8%; 21% between 8.1% and 9%; and 11% with >9%. Notably, across the four groups, neither the number of hypoglycemic events nor time spent in hypoglycemia differed significantly. In addition, even after de-intensification of insulin regimens from multiple insulin injections per day to once-a-day basal insulin, time spent in hypoglycemia did not differ based on A1c levels, although overall time in hypoglcyemia decreased significantly (p<0.0001). One implications of this are that patients need much more help with prandial insulin dosing – good to see so much help with dosing coming! Also notably, in fact, the authors note that the group of subjects with A1c between 7% and 8% – the current recommendation for older adults – spent just as much time in hypoglycemia as those with A1c <7% or >9%. Patients within this A1c range did spend numerically more time in nocturnal hypoglycemia than other groups, but the difference was not statistically significant.
Some clinicians have recommended “loosening” A1c goals up to even 9% for older adults as a hypoglycemia avoidance strategy – Yale’s Dr. Kasia Lipska in particular has written and spoken extensively in favor of this. While the sample size in this study is relatively small, it provides evidence that simply increasing A1c goals for older adults does not necessarily protect against hypoglycemia and may even pose risks associated with poor glycemic control. The authors conclude that CGM – rather than higher A1c goals – should be standard-of-care in terms of managing hypoglycemia in older adults. We agree wholeheartedly, and also believe that greater access to and uptake of non-insulin type 2 diabetes agents (GLP-1 agonists, SGLT-2 inhibitors, GLP-1/basal/combos) or next-generation insulins (Tresiba, Toujeo) can substantially reduce hypoglycemia in these patients as well.
-- by Hae-Lin Cho, Helen Gao, and Kelly Close