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Guidelines for Glycemic Control in Type 2 Diabetes
- Leonard Pogach, MD; and
- Clark T. Sawin, MD
- Veterans Affairs New Jersey Health Care System; East Orange, NJ 07019 Boston Veterans Affairs Medical Center; Boston, MA 02130
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
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TO THE EDITOR:
Vijan and colleagues [1] used a Markov decision model to estimate the benefit of glycemic control with respect to the end points of blindness and end-stage renal disease in persons with type 2 diabetes without preexisting microvascular complications. They found that the benefit of glycemic control decreased with increasing age at diabetes onset.
The decrease in absolute risk resulting from decreased duration of diabetes permits risk stratification in determining a patient's target hemoglobin A1c level, an approach used to design the Veterans Health Administration (VHA) Guidelines for Management of Diabetes Mellitus. Developed in collaboration with members of the Executive Committee of the National Diabetes Education Program, the VHA guidelines are available on the Internet (http://www.va.gov/health/diabetes/default.htm) and are to be used in all VHA facilities.
Participants in the guideline development concluded that a synthesis of the evidence, including key controlled trials [2], epidemiologic studies [3], and computer modeling [1, 4] supported the use of life expectancy and clinical microvascular discase as major determinants in setting a target value for glycemic control in an individual patient. Clinicians should still assess other factors, such as psychosocial issues and patient preferences, when negotiating a target with their patients.
The VHA guidelines suggest that patients who are likely to live only a few years might have a target hemoglobin A1c level of about 0.09, whereas younger patients, especially those with microvascular changes, may benefit from a target value of 0.07. Many, perhaps most, patients will have a target of about 0.08.
With risk stratification and flexible individual assessment, the VHA guidelines consider both the likelihood of an absolute reduction in microvascular outcomes and the likelihood of safely achieving a given level of glycemic control in a particular patient. We believe that this approach provides the evidence that practitioners and patients need to make informed choices and strengthens clinicians' role in caring for their patients.
Leonard Pogach, MD
Veterans Affairs New Jersey Health Care System; East Orange, NJ 07019
Clark T. Sawin, MD
Boston Veterans Affairs Medical Center; Boston, MA 02130
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
