Intensive diabetes control below QOF targets 'is not evidence-based'

Aiming for glycaemic control below QOF targets in type-2 diabetes will not reduce patient mortality and may increase severe hypoglycaemia, a major meta-analysis suggests.

Researchers analysed trials targeting a range of HbA1c levels from below 6 per cent to below 7.5 per cent (59mmol/mol, the lower QOF target).

They concluded that there was no evidence that intensive glucose control reduces cardiovascular mortality, non-fatal MI, microvascular complications, or retinopathy.

Leicester GP Professor Kamlesh Khunti, professor of primary care diabetes at the University of Leicester, said the data supported other studies showing the need to avoid blanket targets for patients.

‘We should individualise HbA1c target, as per NICE guidelines,’ he said. ‘We should be aiming for a lower target early on and then going for a less tight target later in a patient’s disease journey, for instance after 10 years.’

He added: ‘QOF targets unfortunately do not allow individualisation of therapy.’

Researchers analysed data from 14 clinical trials involving 28,614 patients. They found that intensive control did not affect the risks of all-cause or cardiovascular mortality, but risk of severe hypoglycaemia was increased by 30 per cent.

County Down GP Dr Colin Kenny, former chairman of the Primary Care Diabetes Society, said: 'GPs reading this study will be pleased to see that the target strategy, led by QOF, of trying to lower HbA1c to 7.5 per cent is safe and can be effective.’

Coventry GP Dr Roger Gadsby, associate clinical professor at Warwick Medical School, said data from three large studies in the meta-analysis ‘overwhelmed’ data showing benefits of reducing HbA1c to 7 per cent.

‘RCT and observational data suggests that the goal of glycaemic lowering therapy is to maintain HBA1c at or below 7.5 per cent and that the ideal is between 7 and 7.4 per cent.’

Dr Iain Frame, director of research at Diabetes UK, said the study had a number of limitations.

'Each of the trials featured unique characteristics and differed in many significant ways, such as patients’ age and risk of cardiovascular disease, blood glucose targets and the methods used to assess these,' he said.

'Such variations reduce the strength of the conclusions that can be drawn, so further trials are needed to determine the clinical relevance of these findings for specific groups of people with Type 2 diabetes.'

He added: 'Blood glucose targets should always be agreed by the person with diabetes and their healthcare team according to individual needs and not according to a blanket set of rules or targets.'

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