Top POEMs of 2018: Practice Guidelines

Top 20 POEMs of 2018

Relaxed Hemoglobin A1c Goals for T2DM from the American College of Physicians

Clinical question
How tight should glycemic control be for adults with type 2 diabetes?

Bottom line
The American College of Physicians suggests aiming for a hemoglobin A1c level between 7% and 8% for most adults with type 2 diabetes, but they add a caveat that the patient should be the one who makes that decision. The authors weakly recommend backing off treatment for patients with an A1c level of less than 6.5% (cue Moro reflex for those in the lower-is-better camp) and suggest forgoing A1c goals and treating to minimize symptoms in patients 80 years or older and those with a life expectancy of fewer than 10 years (cue spit take from same audience). (LOE = 5)

Reference
Qaseem A, Wilt TJ, Kansagara D, et al, for the Clinical Guidelines Committee of the American College of Physicians. Hemoglobin A1c targets for glycemic control with pharmacologic therapy for nonpregnant adults with type 2 diabetes mellitus: a guidance statement update from the American College of Physicians. Ann Intern Med 2018;168(8):569-576.

Study design: Practice guideline

Funding source: Self-funded or unfunded

Setting: Various (guideline)

Synopsis
These authors followed good practices for developing guidelines. They focused on the benefits and harms of treatment and based their recommendations on outcomes from studies of outpatient adults with type 2 diabetes. They obtained the research after a systematic review of the available literature, graded the evidence, and included both a methodologist and a patient representative unencumbered by relationships with pharma. Voting members did not have financial conflicts of interest. As with recent changes to recommendations from the American Diabetes Association, they suggest basing glycemic goals on patient wishes, not hard-and-fast targets, following a discussion of benefits and harms. For most patients, an A1c level between 7% and 8% is suitable. In a direct smackdown to recommendations from US endocrinologist societies (Endocr Pract 2018;24(1):91-120), they suggest backing off treatment if a patient's A1c level is below 6.5%, to avoid hypoglycemic symptoms. With a nod toward other preventions aimed at baseline risk, they suggest tossing glycemic targets and treating to minimize symptoms related to hyperglycemia in patients 80 years or older or with other chronic diseases and/or a life expectancy of fewer than 10 years.

Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA

ACC/AHA Guidelines Take More Aggressive, Less Evidence-Based Approach to Hypertension Management

Clinical question
What changes to hypertension management are proposed by the 2017 guideline from the American College of Cardiology and the American Heart Association?

Bottom line
This guideline from the American College of Cardiology and the American Heart Association (ACC/AHA) labels all patients with a blood pressure greater than 130/80 as hypertensive, and methodologically takes a step back from the 2014 Joint National Committee 8 guidelines by focusing more on observational studies and disease-oriented outcomes to support their recommendations, and by extending the Systolic Blood Pressure Intervention Trial (SPRINT) findings to patients with diabetes, lower cardiovascular risk, and chronic kidney disease. The United States is in the midst of a "society war," pitting primary care professional societies against subspecialty societies regarding the definition of hypertension, when to begin treatment, and blood pressure treatment goals. In fact, this guideline was explicitly not endorsed by the American Academy of Family Physicians (AAFP). This conflict illustrates the problem with practice guidelines: Who is on the committee, how they assess the studies, and the types of outcomes they consider can result in different recommendations. If you choose to use a blood pressure target of 130/80 mmHg for your patients with diabetes, chronic kidney disease, or a greater than 10% 10-year risk of a cardiovascular event, it is critical that you measure blood pressure the same way that it was measured in the SPRINT trial (have the patient sit in a quiet room for 5 minutes before testing, then use the average of 3 mechanically measured blood pressures). (LOE = 5)

Reference
Whelton PK, Carey RM, Aronow AS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. J Am Coll Cardiol 2017; doi: 10.1016/j.jacc.2017.11.006 [Epub ahead of print].

Study design: Practice guideline

Funding source: Foundation

Setting: Various (guideline)

Synopsis
The most recent US national hypertension guideline was originally developed by National Heart, Lung, and Blood Institute, and when it was proposed that its home move to the AHA/ACC, the members of the panel objected and published their "guideline formerly known as JNC 8" separately from either organization. That guideline endorsed a blood pressure target of 140/90 for most adults, with 150/90 acceptable for those older than 60 years. Similar targets have been endorsed by the AAFP and the American College of Physicians (ACP). The AHA/ACC have now released a new guideline in conjunction with a number of specialty societies, but notably without participation from the societies of physicians who take care of most hypertensive patients in the United States: the AAFP and ACP. The change that has received the most coverage is a target blood pressure of 130/80 for everyone, with drug therapy recommended for persons with known cardiovascular disease, diabetes, chronic kidney disease, or who have a 10-year risk of a cardiovascular event greater than 10%. This revised blood pressure target is based largely on the results of the recent, and controversial, SPRINT trial. This trial enrolled hypertensive patients without diabetes who had at least a 15% 10-year risk of cardiovascular event. However, evidence of similar benefit for patients with diabetes or those at lower risk is lacking or was not found in other trials. The guideline authors state that this new target would only lead to a relatively small increase in the percentage of persons requiring drug therapy compared with current goals, but it is not hard to imagine that it will become the new de facto standard for all patients, regardless of risk. The guideline recommends use of the pooled cohort equations to estimate risk, which are also used to guide decisions about statin and aspirin use. However, there is evidence that these equations somewhat overestimate risk, which could also lead to overtreatment. The SPRINT trial also measured blood pressure very differently than do most offices: patients sat alone in a quiet room for 5 minutes, and then the average of 3 measurements was used as the final reading. Sound like your office? A SPRINT blood pressure of 130/80 is probably closer to a typical office blood pressure of 140/90 or higher, again potentially leading to overtreatment. The actual absolute benefit of achieving a target of 120/80 instead of 140/90 (measured the SPRINT way) was modest, with an absolute reduction of 0.54% per year in cardiovascular events and 0.37% per year in all-cause mortality. And, of course, there were harms associated with a more aggressive blood pressure target, including higher risks of a greater than 30% reduction in glomerular filtration rate (0.86% per year), more episodes of hypotension, and the need to take one additional medication. The current guidelines extends the 130/80 target to patients with chronic kidney disease and diabetes, as well, despite inconsistent evidence of benefit from other trials such as ACCORD and HOPE-3 of more intensive blood pressure targets in these patients (see POEM 120502. There is a clear bias toward avoiding undertreatment, rather than avoiding the harms of overtreatment. The guideline also recommends chlorthalidone 12.5 mg to 25 mg over hydrochlorothiazide 25 mg to 50 mg as the diuretic of choice. These doses are higher than those currently used by many patients, and are based on the doses used in trials like ALLHAT; however, they also carry a higher risk of hypokalemia. Consistent with the US Preventive Services Task Force, the guidelines recommend out-of-office blood pressure measurements to guide care. An important question is whether physicians will actually use the pooled cohort equations, or whether they will take the simpler approach of just using a target of 130/80 for all adults, resulting in overtreatment.

Mark H. Ebell, MD, MS
Professor
University of Gerogia
Athens, GA

POEMs are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, please see http://www.essentialevidenceplus.com(www.essentialevidenceplus.com).