Intended for healthcare professionals

Rapid response to:

Clinical Review State of the Art Review

Benefits and harms of intensive glycemic control in patients with type 2 diabetes

BMJ 2019; 367 doi: https://doi.org/10.1136/bmj.l5887 (Published 05 November 2019) Cite this as: BMJ 2019;367:l5887

Rapid Response:

Not needing intensive glycaemic control does not mean letting blood glucose go unchecked

Dear Editors

This article provides a timely discussion on the issue of intensive glycaemic control (GC) in patients with Type 2 Diabetes Mellitus (T2DM).

I would like to draw readers' attention to the authors’ definition of “intensive glycemic control as a treatment strategy used to target HbA1c 6.5-7.0% (48-53 mmol/mol) or below, irrespective of the number and type of drugs used, and conventional glycemic control as targeting HbA1c above 7.0% (53 mmol/mol) but below 8.0-8.5 (64-69 mmol/mol).”

They concluded that “moderate glycemic targets, with HbA1c levels between 7% and 8% (53-63 mmol/mol), are adequate for most people with type 2 diabetes if this is achieved without symptomatic hypoglycemia or hyperglycemia and unless lower targets are easily achievable without treatment burden or adverse effects.”

The reason for my rapid response is to point out a disturbing trend of patients reporting being told by their GPs that they don’t need tight control of their blood glucose and it’s ok to have double digit blood glucose level (mmol/L), invariably their HbA1c is 9 or higher. I suspect that some doctors may have misinterpreted recent call to avoid hypoglycaemic episodes when pursuing intensive GC, as equivalent to tolerating poor GC and allowing GC to be less monitored. The idea of conventional (moderate) GC seemed to have been thrown out together with the bath water.

This kind of misconception not only puts patients with T2DM at risk of diabetic complications, it also particularly makes the discussion (with these patients) of adequate GC more difficult when it appears to be in direct conflict with what their GPs told them. This issue is particularly relevant when considering management of poorly controlled wound infections when the patient’s HBA1c is 11 for example, or when I have to advise patients with poor GC I cannot proceed with elective joint replacement due to unacceptably high peroperative risk.

I need to emphasise this misconception does not belong solely to primary care providers; many JMOs and even specialists mistake the message of not requiring intensive GC in T2DM conditions to meant that it’s ok not to watch blood glucose closely at all.

There are many instances I have found when diabetic nurse specialists, JMOs and even physicians tolerate blood glucose constantly above 12 for up to 20 for days before making an adequate attempt to address GC. Many do not even consider blood glucose control as a factor in the management of sepsis and wound infection, beyond just “getting the right antibiotics for the bug”.

It is time for the correct message to be broadcast to undo the mismanagement arising from the message “it’s ok not to do intensive GC”.

Competing interests: No competing interests

07 November 2019
Shyan Goh
Orthopaedic Surgeon
Sydney, Australia