Tailoring Treatment for Type 2

Type 2 diabetes patients may need individual blood sugar target goals

/ Author:  / Reviewed by: Joseph V. Madia, MD

People with diabetes face the risk of a variety of health problems, especially heart-related problems. In fact, heart disease is the main cause of death among diabetes patients. So, how do patients avoid these risks?

The answer is not exactly straight forward. While blood sugar management is the mainstay of diabetes treatment, there is much debate about how intensely patients should control their blood sugar levels. It may be that treatment goals should be different for each individual patient.

In many cases, it is recommended that patients practice intensive blood sugar control, which is usually defined as a target HbA1c (long-term measure of blood sugar) of 6.0 to 6.5 percent. The American Diabetes Association and the European Association for the Study of Diabetes recommend that most patients should keep their HbA1c levels at seven percent or less.

According to the American Association of Clinical Endocrinologists and the American College of Endocrinology, patients should set a target goal of 6.5 percent or less.

Patients with poorly managed diabetes are at risk for a number of microvascular and macrovascular complications, or complications that affect both tiny and large blood vessels in the body. These complications include eye disease, kidney disease, nerve damage, narrowed arteries, and foot amputation.

Through the careful management of blood sugar levels, diabetes patients can avoid many of these complications. However, it has been hard to tell how intensely patients should control their blood sugar. Does intensive blood sugar control reduce the risk of heart disease and other complications, or does it create more problems for some patients?

A couple studies from the 1990s indicate that intensive blood sugar control with sulfonylureas (a type of anti-diabetic medication) or insulin (a natural hormone that manages blood sugar) can lower the risk of microvascular complications.

However, patients from those same studies were commonly affected by hypoglycemic episodes, or dangerously low blood sugar levels. From the results of those studies, it also did not look as though intensive blood sugar control reduced the risk of macrovascular disease, more commonly known as cardiovascular disease.

More recently, researchers have reexamined the issue of intensive blood sugar control. In three different studies, they compared the effects of traditional treatment versus intensive blood sugar control. The results showed that intensive blood sugar control may not lower the risk of cardiovascular disease by a significant amount.

On top of that, intensive treatment appeared to raise the risk of severe hypoglycemic episodes, which can potentially lead to death. These studies also revealed that intensive blood sugar control might be most helpful to those who have had diabetes for a shorter period of time, those with a lower HbA1c at the beginning of the study, and patients without cardiovascular disease.

Based on those three studies, the American Diabetes Association and the American College of Cardiology Foundation recommended that doctors continue using the target HbA1c of seven percent or less. They suggested that a less intense target may be better for older patients who have had diabetes for a long time and have a history of hypoglycemia or atherosclerosis (narrowed arteries).

Even though hypoglycemia is more common among type 1 diabetes patients than among type 2 patients, severe hypoglycemic episodes are about as common among type 2 patients treated with insulin as they are among type 1 patients, according to a 2003 study in the journal Diabetes Care.

At the moment, tight blood sugar control is recommended by both sets of guidelines mentioned above. Be that as it may, studies from the last two decades indicate that tight control may be linked to a greater risk of hypoglycemia, which can affect patients' physical and mental health.

Both sets of guidelines also recognize that there are choices when it comes to blood sugar targets and drugs used by diabetes patients. When it comes down to it, patients and their doctors have to figure out what method is best to keep their blood sugar at healthy levels while also avoiding the risks associated with overly aggressive blood sugar management. Each diabetes patient may need his or her own individual treatment goals. It is up to doctors to make sure their patients - especially their older patients - do not fall victim to the complications of diabetes and diabetes treatments. 

Review Date: 
December 9, 2011
Michael J. Fowler, "Microvascular and Macrovascular Complications of Diabetes." Clinical Diabetes. April 2008. David M. Nathan, et al. "Medical Management of Hyperglycemia in Type 2 Diabetes: a Consensus Algorithm for the Initiation and Adjustment of Therapy." Clinical Diabetes. December 21, 2009. Helena W. Rodbard, et al. "Statement of an American Association of Clinical Endocrinologists/American College of Endocrinology Consensus Panel on Type 2 Diabetes Mellitus: an algorithm for glycemic control." Endocrine Practice. September/October 2009. UKPDS Group. "Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes." Lancet. August 14, 1999. The Diabetes Control and Complications Trial Research Group. "The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus." New England Journal of Medicine. 1993. Jay S. Skyler, et al. "Intensive Glycemic Control and the Prevention of Cardiovascular Events: Implications of the ACCORD, ADVANCE, and VA Diabetes Trials." Diabetes Care. January 2009. The Action to Control Cardiovascular Risk in Diabetes Study Group. "Effects of Intensive Glucose Lowering in Type 2 Diabetes." New England Journal of Medicine. June 12, 2008. William Duckworth, et al. "Glucose Control and Vascular Complications in Veterans with Type 2 Diabetes." New England Journal of Medicine. January 8, 2009. The ADVANCE Collaborative Group. "Intensive Blood Glucose Control and Vascular Outcomes in Patients with Type 2 Diabetes." New England Journal of Medicine. June 12, 2008. Denise E. Bonds, et al. "The association between symptomatic, severe hypoglycaemia and mortality in type 2 diabetes: retrospective epidemiological analysis of the ACCORD study." BMJ. 2010. Graham P. Leese, et al. "Frequency of Severe Hypoglycemia Requiring Emergency Treatment in Type 1 and Type 2 Diabetes." Diabetes Care. April 2003.