Yale’s Dr. Kasia Lipska publishes JAMA Patient Page on the risks of tight A1c targets for older patients – July 25, 2016

Dr. Kasia Lipska (Yale University, New Haven, CT) published a JAMA Patient Page in JAMA’s last issue, reiterating the view that tight A1c targets (<7.5%) may do more harm than good in elderly patients with diabetes. The article is framed an educational resource for older adults with diabetes, with guiding questions for patients to ask their healthcare providers. At the top of the list – “at my age, will tight glucose control (A1c <7.5%) decrease my risk of diabetes complications?” Dr. Lipska argues that this benefit does not outweigh the risks for older patients with diabetes, who may not experience a significant reduction in macrovascular events for at least 10 years. She underscores the increased risk of hypoglycemia that often accompanies a target A1c <7.5% and discusses why this risk is enhanced for older people: (i) kidney function becomes less efficient with age, which may cause accumulation of insulin in the body; (ii) older patients are often taking multiple medications, some of which may interact in unexpected ways with diabetes drugs; (iii) multiple-drug regimens increase the chance for error in insulin dosing; (iv) and older patients experience fewer warning symptoms of mild hypoglycemia, which puts them at greater risk for a severe hypoglycemia episode with limited time to intervene.

Dr. Lipska has been vocal on this topic in the past, authoring a review paper published in JAMA earlier this year recommending an A1c target between 7.5-9% for individuals >65 years-old, an earlier JAMA Internal Medicine study of the use of sulfonylureas and insulin to achieve stringent target A1c <7%, and a New York Times op-ed advocating for less stringent A1c targets in older people. While we share Dr. Lipska’s concerns about the risks of hypoglycemia in older patients and agree that an A1c goal of <7% or even <7.5% may not be the right choice for everyone, in our view, it’s important to individualize diabetes care and take a patient’s perspective, lifestyle, and preferences into account along with their age – to say nothing of suggesting therapy that is not associated with hypoglcyemia. To this end, an older patient may not require tight A1c control for personally-defined optimal outcomes and as long as it is reasonably low, we feel fine with this. On the other hand, we feel that raising an older patient’s target A1c is forcing compromise when we should be offering the best of both worlds – that is, coupling a lower A1c target with interventions that reduce the risk of hypoglycemia. There is untapped potential for CGMs to help control hypoglycemia risk in this patient population; we also hope for better patient training on hypoglycemia moving forward so that all are able to achieve closer-to-normal blood sugar without fearing severe lows.

-- by Payal Marathe, Helen Gao, and Kelly Close