Target Corridor for Older People not Justified

Letters to the Editor regarding the article Shared Decision Making, Diagnostic Evaluation, and Pharmacotherapy in Type 2 Diabetes National Disease Management Guideline by Dr. med. Christina Brockamp, Prof. Dr. med. Rüdiger Landgraf, apl. Prof. Dr. med. habil. Ulrich Alfons Müller, MSc; Prof. Dr. med. Dirk Müller-Wieland, Prof. Dr. rer. soc. Frank Petrak, and Dr. med. Til Uebel in issue 47/2023

We welcome the fact that the item “accepting the treated person’s decision” has been included in the guideline for type 2 diabetes (1). It might be worth considering whether a distinction should be made between “participative decision making” and “shared decision making” (2). For future guideline projects, the latter should be given preference.

The following questions remain: what is the reasoning in favor of pushing an HbA1c target corridor of 6.5–8.5% and 48–69 mmol/mol Hb. which doesn’t differentiate by the affected patient’s age? A quote from the guideline: “The corridor is intended as an orientation aid for doctors and patients to enable individual assessment.”

Is there any independent study—not involving drug manufacturers (meta-analyses should initially be excluded because of their substantial bias)—that has actually confirmed the benefit of blood glucose lowering in older persons in the long term?

Fortunately, the guideline recommends the three-talk model for communication among involved parties (3). This model provides, however, that in the second phase, all options are presented to the affected persons. If a patient is asymptomatic, one option is—at least in older persons, which according to the world health organization includes all people aged 75 or older—sensitive accompaniment, support, and if needed supplementary medication, but without following arbitrarily defined upper thresholds for HbA1c.

Unfortunately the guideline with its provision of a new target corridor and with negative framing (“deliberate rejection […]”) produces pressure—including social pressure—in those affected. Is it not about time that—in terms of the subject “older persons and type 2 diabetes”—we should stop defining target values and producing guilt complexes? Should older people not live the final part of their lives without unnecessary annoyance?

DOI: 10.3238/arztebl.m2024.0019

Dr. med. Armin Mainz

Hausarzt a.D./Facharzt für Innere Medizin

Kassel

Conflict of interest statement

The author declares that no conflict of interest exists.

References

1. Brockamp C, Landgraf R, Müller UA, Müller-Wieland D, Petrak F, Uebel T, on behalf of the National Disease Management Guideline Group: Clinical practice guideline: Shared decision making, diagnostic evaluation, and pharmacotherapy in type 2 diabetes. National Disease Management Guideline. Dtsch Arztebl Int 2023; 120: 804–10

2. der Schmitten J: Autonomie gewähren genügt nicht — Patienten-Selbstbestimmung bedarf aktiver Förderung durch Ärzte. Z Allg Med 2014; 90: 246–50.

3. Elwyn G, Durand MA, Song J, et al.: A three-talk model for shared decision making: multistage consultation process. BMJ 2017; 359: j4891