HbA1c targets and hypoglycaemia
Mention the term hypoglycaemia (hypo) to many health care professionals and what comes to mind? Perhaps something to record on the relevant template or an inconvenience that requires minimal medication adjustment. However, this can be a gross underestimate given that, from the patient point of view, hypos are often feared requiring them to make significant changes to daily activity in order to avoid them. This is not without significant reason – hypos can result in significant problems such as falls, accidents or even death (the dead in bed syndrome). Hypo frequency and severity are influenced by a variety of conditions including diet and exercise but as the plethora of hypoglycaemic agents increase in number, treatment choice is clearly a major issue in determining their frequency.
This week’s publication of JAMA reinforces this by providing evidence that than 20% of patients with type 2 diabetes received intensive treatment that may be unnecessary. Among patients with high clinical complexity, intensive treatment nearly doubles the risk of severe hypoglycaemia (defined as hypoglycaemia requiring third party assistance).
One of the benefits of the recent NICE guidance for Type 2 diabetes is the frequent mention of individualising treatment options, specifically taking hypoglycaemia into account. This is reflected in differing targets for HbA1c – 6.5% in most patients but 7.0% if the patient is taking a drug associated with hypoglycaemia such as a sulphonylurea. However, despite this guidance, many patients targets are set inappropriately low, perhaps generated by the desire to reach the relevant QoF target instead of focusing care to the patient. For example, it may be preferable to set a target A1c of <6.5% for a young person with retinopathy but between 8.5-9.5% for an elderly patient living alone where hypoglycaemia may have major consequences. The frequent conflict between individual patient care and funding related targets seems set to continue.
Dr. Mark Freeman