Glycemic Control Guidelines for Patients with Diabetes

We have noted before that one problem with evidence-based medicine is that the evidence keeps changing, even for diseases with a high level of prevalence.  Diabetes is one of the most common chronic conditions and has a rapidly growing incidence.  Aggressive guidelines for blood sugar have been adopted by a number of bodies.  This time the research suggests that tight glycemic control may be very beneficial.  A study from Sweden published in the New England Journal of Medicine of a large population of Type 1 diabetics over an extended follow-up period looked at the relationship between glycemic control and outcomes.  The primary outcomes were all-cause death and cardiovascular-related death.  Compared to matched controls, the patients with Type 1 diabetes had a higher risk of death, almost twice as high.  The excess deaths are almost entirely due to the result of diabetes itself and to cardiovascular issues.  But Type 1 patients with lower glycated hemoglobin levels had a lower risk of death than those patients who appeared to have poorly control blood sugar levels.  For these individuals the risk could be as much as 8 to 10 times greater.

We are big fans of using science to guide the practice of medicine.  But policymakers need to be realistic on the state of the science–it is not always well-established.  So caution is warranted in adopting guidelines and certainly in penalizing or incenting certain practice standards.  But this research supports the notion of careful monitoring and maintaining of glycemic control for Type 1 diabetics, in contrast to some earlier research that found that for Type 2 patients, to tight a control might lead to more adverse events.