Public Release: 

ACP recommends less intensive blood sugar control for type 2 diabetes

Embargoed news from Annals of Internal Medicine

American College of Physicians

1. ACP recommends less intensive blood sugar control targets for most patients with type 2 diabetes

Note: HD video soundbites of ACP's president discussing the recommendations are available to download at https://www.dssimon.com/MM/ACP-diabetes-A1C/.

Abstract: http://annals.org/aim/article/doi/10.7326/M17-0939

URLs go live when the embargo lifts

The American College of Physicians (ACP) recommends less intensive blood sugar control targets for patients with type 2 diabetes. Patients should be treated to achieve an A1C between 7 percent and 8 percent rather than 6.5 percent to 7 percent. ACP's evidence-based guidance statement is published in Annals of Internal Medicine.

An A1C test measures a person's average blood sugar level over the past two or three months. An A1C of 6.5 percent indicates diabetes. Guidelines that recommended lower treatment targets suggest that more intensive blood sugar control would reduce microvascular complications over many years of treatment. However, the evidence for reduction is inconsistent and reductions were seen only in surrogate microvascular complications such as the presence of excess proteins in the urine.

ACP recommends that clinicians should personalize goals for blood sugar control in patients with type 2 diabetes based on a discussion of benefits and harms of drug therapy, patients' preferences, patients' general health and life expectancy, treatment burden, and costs of care. If patients with type 2 diabetes achieve an A1C of less than 6.5 percent, ACP recommends that clinicians consider de-intensifying drug therapy by reducing the dosage of current treatment, removing a medication if the patient is currently taking more than one drug, or discontinuing drug treatment altogether.

ACP also recommends that clinicians should treat patients with type 2 diabetes to minimize symptoms related to high blood sugar rather than targeting an A1C level in patients with a life expectancy less than 10 years due to advanced age (80 years or older) or chronic conditions (such as dementia, cancer, end stage kidney disease, severe COPD or congestive heart failure, and patients residing in nursing homes), as the harms of A1C targeted treatment outweigh the benefits in this patient population.

Although ACP's guidance statement focuses on drug therapy to control blood sugar, a lower treatment target is appropriate if achievable with diet and lifestyle modifications.

Media contact: For an embargoed PDF or to interview an ACP spokesperson, please contact Steve Majewski at smajewsi@acponline.org or 215-351-2514.

2. HCV-infected kidney donors could save lives

Prophylactic HCV treatment in non-infected kidney recipients could significantly expand organ donor pool

Abstract: http://annals.org/aim/article/doi/10.7326/M17-2871

URLs go live when the embargo lifts

Pre- and post-transplant treatment with direct-acting antiviral medications is safe and prevents chronic hepatitis C virus (HCV) infection in an HCV-negative patient receiving a kidney from a HCV-positive donor. Employing this strategy could significantly expand organ options and reduce mortality for kidney transplant candidates without HCV infection. Findings from a small open-label nonrandomized trial are published in Annals of Internal Medicine.

More than 420,000 persons in the United States require hemodialysis for end-stage kidney disease and these patients face a high mortality rate. Kidneys from deceased donors with HCV infection have been underused concerns about the impact of HCV on recipient outcomes. However, the introduction of direct-acting antiviral agents with high cure rates, even in kidney transplant recipients, has changed the landscape of kidney donation. As such, currently discarded kidneys from HCV-infected donors may be a neglected public health resource.

Researchers from Johns Hopkins School of Medicine studied 10 HCV-negative recipients of 10 HCV-positive donor kidneys to determine the tolerability and feasibility of using HCV treatment as prophylaxis before and after transplant. The transplant kidneys came from deceased donors aged 13 to 50 years with confirmed HCV infection. All recipients received a dose of grazoprevir, 100 mg, and elbasvir, 50 mg, immediately before transplant and continued receiving this combination for 12 weeks after transplant. Recipients who received organs from donors with HCV genotype 2 or 3 infection had sofosbuvir, 400 mg, added to their regimen. Among the 10 organ recipients, no treatment-related adverse events occurred, and HCV RNA was not detected in any recipient 12 weeks after treatment.

The researchers believe that this strategy should be studied further in carefully monitored clinical trials. If confirmed in larger studies, this approach should markedly expand the organ donor pool for persons with end-stage kidney failure.

Media contacts: For an embargoed PDF, please contact Angela Collom. To interview the lead author, Christine M. Durand, MD, please contact Chanapa Tantibanchachai at chanapa@jhmi.edu or 410-502-9433.

3. Vaccination may need to wait in infants born to mothers taking adalimumab for inflammatory bowel disease

Abstract: http://annals.org/aim/article/doi/10.7326/L17-0629

URLs go live when the embargo lifts

Clinicians should be aware that prolonged persistence of adalimumab is a possibility in some infants born to mothers being treated for active inflammatory bowel disease during gestation. As such, live vaccinations should be delayed until no sign of the agent is detectable. A brief case report is published in Annals of Internal Medicine.

Some pregnant women with inflammatory bowel disease benefit from treatment with a monoclonal antibody directed against tumor necrosis factor-a, such as infliximab or adalimumab. However, concerns have been raised about possible effects on the fetus or newborn. For example, after bacille Calmette-Guerin vaccination, a 4.5 month-old infant born to a mother receiving infliximab died of bacille Calmette-Guerin infection.

Researchers from University Hospital of Saint-Etienne report the case of a 34-year-old woman who took adalimumab for Crohn's disease during her pregnancy. Once her Crohn's disease was under control, the mother continued to take a maintenance dose until her baby was born at 39 weeks. While the birth was uneventful, the infant has had persistent serum presence of adalimumab up to its last test at 19 months. The persistence of this agent remains unexplained, but the researchers caution that clinicians should be aware of this possibility and delay vaccines in children born to mothers treated for inflammatory bowel disease with infliximab or adalimumab.

Media contacts: For an embargoed PDF, please contact Angela Collom. The lead author, Xavier Roblin, can be contacted via email at xavier.roblin@chu-st-etienne.fr.

Also new in this issue:

Technology and Transparency: Empowering Patients and Clinicians to Improve Health Care Value

Suzanne Delbanco, PhD; Tom Delbanco, MD

Ideas and Opinions

Abstract: http://annals.org/aim/article/doi/10.7326/M17-3269

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