Tuesday, March 6, 2018

Idiotic Guidelines

A group called the American College of Physicians (ACP) has released new guidelines for the treatment of type 2 diabetes in nonpregnant adults. These guidelines are insane.

They want patients with hemoglobin A1c levels under 6.5% to reduce their treatments so their A1c levels rise to 7% to 8% (8% is an average blood glucose [BG] level of about 183). This is despite the fact that numerous studies have shown that mortality rates are increased with higher BG levels, even in people who are not considered diabetic.

Here is a good illustration of this. Scroll down to the graphs.

Why are they recommending this idiotic approach? Jack Ende, president of the ACP, told Medscape, "For most people with type 2 diabetes, achieving an HbA1c between 7% and 8% will best balance long-term benefits with harms such as low blood sugar, medication burden, and costs.”

Well, I don't know about Dr. Ende, but me, I'd rather incur higher costs and have a medication burden than expire or have my legs cut off.

As for the possible low blood sugar, seriously low BG levels aren't common among people with type 2 diabetes, but physicians worry about them. According to Dr. Richard Bernstein, he has been told something like this by many physicians. "I like to keep the BG levels a little high, because if my patient dies from hypoglycemia, I can be sued. But if the patient goes blind or has legs amputated because of high BG levels, people will say, 'Well, that's what happens when you have diabetes."

In other words, some doctors care more about themselves than they do about their patients.

The authors of this paper write, "Metformin is not associated with hypoglycemia and is generally well-tolerated and low cost, but it is associated with other known adverse effects and results in use of additional medication with little to no benefit at HbA1c levels below 7%." They don't specify what the adverse effects are, but common ones are gastrointestinal like nausea and diarrhea. I'd rather have a little diarrhea than drop dead from heart disease.

What is the ACP anyway? It turns out it's an organization if internists, not endocrinologists. And two other organizations, the American Diabetes Association and the American Association of Clinical Endocrinologists, disagree with the ACP. Medscape has outlined the controversy, but you may have to register with Medscape to read it.

Most organizations recommend individualizing A1c goals according to the patient's characteristics. Both groups support less stringent goals in people with limited life expectancy or who are incapacitated and unable to manage medications well and hence apt to make mistakes and have serious hypoglycemia. But to recommend such goals to everyone is idiotic.

And of course the authors don't suggest that for most people, a low-carb diet can have as much effect on A1c as multiple medications without the risks of the medications. 

What I find scary about this article is that it can be used for CME (continuing medical education) credit, which implies it's generally accepted knowledge. Let's hope that more groups with experience treating patients with type 2 diabetes will protest against the ACPs guidelines.


  1. Protest how? I will certainly mention it to my own GP the next time I see her (because to her, sadly, all of this type of advice resonates equally). But what kind of protest did you have in mind?

  2. Robin, I was thinking of articles or letters to the editor in major medical journals, the ones that publicize the ACP's position.