Tour of a Government Lab Research
It is time to pack your bags because you are headed on a “virtual” journey to a governmental research institution. You will be selecting a leading governmental research institution (you can see a list of top 25 leading governmental organizations below). The institution’s main website will be the focus of your tour. After you have spent time fully exploring the website, you will write a 3-page paper (exclusive of title page or bibliography) that addresses the following elements: an introduction with a thesis statement, a brief history of the institution and its significance, an analysis of any primary sources that exist on the website (or in a physical archives associated with the institution), and a discussion of any issues that the institution is facing today. Also, address the rationale for government sponsored scientific research, and make an argument for where scientific innovation is strongest: governmental, private, commercial, or educational institutions.
Included in your analysis will be at least 3 peer reviewed or scholarly sources that help you assess the significance of the institution and its history.
Here are some approved government institutions that are considered the top 25 in the world. Ask your instructor for approval of one not on the list:
Alternative Energies and Atomic Energy Commission, France, Website: www.cea.fr
Chinese Academy of Sciences, China, Website: english.cas.cn
Commonwealth Scientific & Industrial Research Organisation, Australia, Website: www.csiro.au
Fraunhofer Society, Germany, Website: www.fraunhofer.de
French Institute of Health & Medical Research, France, Website: english.inserm.fr
German Cancer Research Center, Germany, Website: www.dkfz.de
German Research Center For Environmental Health Munich, Germany, Website: www.helmholtz-muenchen.de
Health & Human Services Laboratories, USA, Website: www.hhs.gov
Japan Science & Technology Agency, Japan, Website: www.jst.go.jp
Jlich Research Center, Germany, Website: www.fz-juelich.de
Korea Institute of Science & Technology, South Korea, Website: eng.kist.re.kr
Lawrence Livermore National Laboratory, USA, Website: www.llnl.gov
Los Alamos National Laboratory, USA, Website: www.lanl.gov
Max Planck Society, Germany, Website: www.mpg.de
Medical Research Council, United Kingdom, Website: www.mrc.ac.uk
National Aeronautics & Space Administration, USA, Website: www.nasa.gov
National Center for Scientific Research, France, Website: www.cnrs.fr
National Institute for Materials Science, Japan, Website: www.nims.go.jp
National Institute of Advanced Industrial Science & Technology, Japan, Website: www.aist.go.jp
National Research Council Canada, Canada, Website: www.nrc-cnrc.gc.ca
Pasteur Institute International Network, France, Website: www.pasteur.fr
RIKEN, Japan, Website: www.riken.jp
Spanish National Research Council, Spain, Website: www.csic.es
United States Navy, USA, Website: www.navy.mil
US Department of Veterans Affairs, USA, Website: www.va.gov Running head: THIS IS THE TITLE OF YOUR INSTITUTIONAL TOUR PAPER 2
This is the Title of Your Institutional Tour Paper
Your Name
American Public University System
I. Introduction Paragraph
a. Identify your selected institution
b. Overview of your paper.
c. Thesis statement. Click here for help on writing a thesis statement. http://writingcenter.unc.edu/handouts/thesis-statements/
d. This should be a half page in length.
II. Subsection 1: History
a. History of your institution.
b. This should be a half page in length.
III. Subsection 2: Primary Sources at Website
a. Analyze primary sources at the site. For example, if you were working on NASA there are thousands of primary sources at its website. Here is a 1959 staff report on Astronautics and Space Exploration: https://www.hq.nasa.gov/office/pao/History/conghand/spcover.htm
b. This should be a half page in length.
IV. Subsection 3: Current Issues that the Institution is Experiencing Today
a. Discuss the key current issues.
b. Use three scholarly secondary sources to support your discussion. These sources need to be found in the APUS library.
c. Click here for how you find peer reviewed or scholarly sources: https://apus.libanswers.com/faq/2244
d. This should be a half page in length.
V. Subsection 4: Discuss Government Funded Scientific Research
a. Address the rationale for government sponsored scientific research.
b. Make an argument for where scientific innovation is strongest: governmental, private, commercial, or educational institutions.
c. This should be a half page in length.
VI. Conclusion
a. Rephrase your central thesis statement.
b. For help on writing a conclusion visit: https://writingcenter.unc.edu/tips-and-tools/conclusions/
c. This should be a half page in length.
VII. Bibliography
a. This should appear on the next page.
b. YOU MUST DIVIDE YOUR BIBLIORGPAHY INTO PRIMARY AND SECONDARY SOURCES.
c.
d. For a sample APA paper see: https://owl.purdue.edu/owl/research_and_citation/apa_style/apa_formatting_and_style_guide/apa_sample_paper.html Synopsis of the 2017 U.S. Department of Veterans Affairs/
U.S. Department of Defense Clinical Practice Guideline:
Management of Type 2 Diabetes Mellitus
Paul R. Conlin, MD; Jeffrey Colburn, MD; David Aron, MD, MS; Rose Mary Pries, DrPH; Mark P. Tschanz, DO; and
Leonard Pogach, MD, MBA
Description: In April 2017, the U.S. Department of Veterans Af-
fairs (VA) and the U.S. Department of Defense (DoD) approved a
joint clinical practice guideline for the management of type 2
diabetes mellitus.
Methods: The VA/DoD Evidence-Based Practice Work Group
convened a joint VA/DoD guideline development effort that in-
cluded a multidisciplinary panel of practicing clinician stakehold-
ers and conformed to the Institute of Medicine’s tenets for
trustworthy clinical practice guidelines. The guideline panel de-
veloped key questions in collaboration with the ECRI Institute,
which systematically searched and evaluated the literature
through June 2016, developed an algorithm, and rated recom-
mendations by using the GRADE (Grading of Recommendations
Assessment, Development and Evaluation) system.
Recommendations: This synopsis summarizes key features of
the guideline in 7 areas: patient-centered care and shared
decision making, glycemic biomarkers, hemoglobin A1c target
ranges, individualized treatment plans, outpatient pharmaco-
logic treatment, glucose targets for critically ill patients, and
treatment of hospitalized patients.
Ann Intern Med. 2017;167:655-663. doi:10.7326/M17-1362 Annals.org
For author affiliations, see end of text.
This article was published at Annals.org on 24 October 2017.
Diabetes is the leading cause of major complica-tions, such as end-stage renal disease and lower
extremity amputations, and is a significant contributor
to ischemic heart disease, stroke, peripheral vascular
disease, and vision loss (1). There has been increasing
acceptance of the importance of individualizing glyce-
mic management and assessment of risk for adverse
events, especially hypoglycemia (2 6). This is of great
importance for all patients, especially older adults
(aged 65 years) with comorbid conditions. In 2013,
12.0 million older adults in the United States had diabe-
tes, comprising 40% of the 30.2 million persons with the
disease (7). Older adults account for an estimated 60% to
70% of the U.S. Department of Veterans Affairs (VA) and
U.S. Department of Defense (DoD) diabetic population
(largely retirees) (VA/DoD. Unpublished data). These
considerations make safe and effective diabetes manage-
ment a policy priority for health care providers (physi-
cians, nurses, dietitians, and pharmacists) and policymak-
ers in both the VA and the DoD.
The 2017 VA/DoD Clinical Practice Guideline
(CPG) for the Management of Type 2 Diabetes Mellitus
in Primary Care offers health care providers an
evidence-based framework to evaluate, treat, and man-
age persons with type 2 diabetes mellitus in the context
of their individual needs and preferences (8). The current
article is a summary of key CPG recommendations, which
was developed with multiple stakeholders to ensure rep-
resentation by a broad spectrum of clinicians. It provides
practice recommendations for the care of patients with
diabetes, with an emphasis on shared decision making.
GUIDELINE DEVELOPMENT AND REVIEW
PROCESS
These recommendations were developed using
methods established by the VA/DoD Evidence-Based
Practice Work Group (EBPWG) (9), which are aligned
with standards for trustworthy guidelines (10). The
EBPWG and the U.S. Army Medical Command selected
guideline panel cochairs (1 each from the VA and the
DoD). The cochairs then selected a multidisciplinary
panel of practicing clinician stakeholders, including pri-
mary care physicians (family and internal medicine), en-
docrinologists, medical nutritionists, pharmacists, dia-
betes educators, and nurse practitioners. At the start of
the CPG development process and at other key points
throughout, all members were required to submit dis-
closure statements for potential conflicts of interest in
the previous 24 months. Verbal affirmations of no con-
flicts were used during meetings throughout the devel-
opment process. The project team was also subject
to random Web-based surveillance (for example,
ProPublica).
The VA/DoD contracted with The Lewin Group, a
third party with expertise in clinical practice guideline
development, to facilitate meetings. The guideline
panel, in collaboration with the ECRI Institute, devel-
oped 9 key questions using the PICOTS (population,
intervention, comparator, outcomes, timing of out-
comes measurement, and setting) format. A systematic
search of the peer-reviewed literature from January
2009 through March 2016 was conducted to find
evidence relevant to the key questions that focused on
randomized trials, systematic reviews, and meta-
analyses of fair or better quality. One key question was
See also:
Editorial comment . . . . . . . . . . . . . . . . . . . . . . . . . 677
Web-Only
CME/MOC activity
Supplement
Annals of Internal Medicine CLINICAL GUIDELINE
Annals.org Annals of Internal Medicine Vol. 167 No. 9 7 November 2017 655
http://www.annals.org
http://www.annals.org
http://www.annals.org
updated through 14 June 2016. The search methods
and results are detailed in the full guideline (8). The
guideline panel rated recommendations by using the
GRADE (Grading of Recommendations Assessment,
Development and Evaluation) method (11).
The guideline panel focused on developing new
and updated recommendations using the evidence re-
view for the key questions. The panel also considered,
without a complete review of the relevant evidence, the
current applicability of recommendations that were in-
cluded in the 2010 CPG.
As part of the development process, a patient fo-
cus group was also convened to better understand the
perspectives of patients receiving diabetes treatment in
the VA and the DoD. Five patients were included, con-
sistent with the requirements of the federal Paperwork
Reduction Act. All patients had type 2 diabetes and
were veterans receiving care in the VA. The focus
group explored knowledge of treatment options, views
on the delivery of care, patients’ needs and prefer-
ences, and the effect of diabetes on their lives. Impor-
tant concepts that emerged from the focus group were
shared with the panel and informed guideline develop-
ment. It was acknowledged that this convenience sam-
ple may not be representative of all VA and DoD pa-
tients receiving treatment for type 2 diabetes.
The draft guideline was sent to more than 15 ex-
pert reviewers inside and outside the federal sector.
Comments were reviewed and, where appropriate,
were incorporated into the final guideline based on
panel consensus. The VA/DoD EBPWG approved the
final document on 3 April 2017 and released it on 17
April 2017. Recommendations are presented in the Ta-
ble, and an algorithm for establishing a personalized
glycemic goal and treatment plan is presented in the
Figure. Key recommendations are reviewed in this
article.
RECOMMENDATIONS
Provide Patient-Centered Care and Incorporate
Shared Decision Making
The CPG strongly encourages clinicians to incorpo-
rate shared decision making and partner with their pa-
tients. Shared decision making is the process by which
the patient and family, in conjunction with the care pro-
vider, reach an agreement about a plan of care and
Table. Summary of Recommendations From the 2017
VA/DoD CPG on the Management of Type 2 Diabetes
Mellitus
General approach to type 2 diabetes care
Shared decision making to enhance patient knowledge and
satisfaction is recommended.
All patients with diabetes should be offered ongoing, individualized
diabetes self-management education via various methods tailored to
their preferences, learning needs, and abilities and based on
available resources.
Offer 1 type of bidirectional telehealth intervention (typically health
communication via computer, telephone, or other electronic means)
involving licensed independent practitioners to patients selected by
their primary care provider as an adjunct to usual patient care.
Glycemic control targets and monitoring
Set an HbA1c target range based on absolute reduction of risk for
significant microvascular complications, life expectancy, patient
preferences, and social determinants of health using shared decision
making.
Develop an individualized glycemic management plan based on the
provider’s appraisal of the riskbenefit ratio and patient preferences.
Assess patient characteristics, such as race, ethnicity, chronic kidney
disease, and nonglycemic factors (e.g., laboratory methods and
assay variability), when interpreting results of HbA1c, fructosamine,
and other glycemic biomarker testing.
Individualize the target range for HbA1c, taking into account individual
preferences, presence or absence of microvascular complications,
and presence or severity of comorbid conditions.
A target HbA1c range of 6.0%7.0% (if it can be safely achieved) is
recommended for patients with a life expectancy greater than 1015
y and no or mild microvascular complications.
In patients with type 2 diabetes, an HbA1c target range of 7.0%8.5% is
appropriate (if it can be safely achieved) for most persons with
established microvascular or macrovascular disease, comorbid
conditions, or life expectancy of 510 y.
A target HbA1c range of 8.0%9.0% is recommended for patients with
type 2 diabetes with a life expectancy <5 y; significant comorbid
conditions; advanced complications; or difficulties with
self-management attributable to mental status, disability, or other
factors (such as food insecurity or insufficient social support).
Providers should be aware that HbA1c variability is a risk factor for
microvascular and macrovascular outcomes.
Nonpharmacologic treatments
Offer therapeutic lifestyle counseling that includes nutrition, physical
activity, cessation of smoking and excessive use of alcohol, and
weight control to patients with diabetes (see VA/DoD CPGs for
obesity, substance use disorders, and tobacco use cessation).
A Mediterranean diet is recommended if it aligns with patients' values
and preferences.
A nutrition intervention strategy to reduce the percentage of energy
from carbohydrates to 14%45% per day and/or foods with a lower
glycemic index are recommended in patients with type 2 diabetes
who do not choose a Mediterranean diet.
Inpatient care
Targeting blood glucose levels to <6.1 mmol/L (<110 mg/dL) for all
hospitalized patients with type 2 diabetes receiving insulin is not
recommended.
Adjust insulin to maintain a blood glucose level between 6.1 and 10.0
mmol/L (110 and 180 mg/dL) only for patients with type 2 diabetes
who are critically ill or have acute myocardial infarction in ICU
settings.
Use of a split-mixed insulin regimen for all hospitalized patients with
type 2 diabetes is not recommended.
A regimen that includes basal insulin and short-acting mealtime or
basal insulin and correction insulin is recommended for noncritically
ill hospitalized patients with type 2 diabetes.
Provide medication education and diabetes survival skills to patients
before hospital discharge.
Table 1Continued
Consideration for combination pharmacologic therapy
Metformin should be given as the first-line agent unless it is
contraindicated.
When initial therapy no longer provides adequate glycemic control,
addition of a second-line agent from another class rather than
substitution (which should be reserved for intolerance of or adverse
effects from a drug) is usually necessary.
When selecting an agent, consider efficacy, contraindications, drug inter-
actions, comorbidities, and potential adverse effects. Discuss with
patients the various treatment options, and arrive at a shared treatment
plan.
CPG = clinical practice guideline; DoD = U.S. Department of Defense;
HbA1c = hemoglobin A1c; ICU = intensive care unit; VA = U.S. Depart-
ment of Veterans Affairs.
CLINICAL GUIDELINE Synopsis of the VA/DoD Guideline on Management of Type 2 Diabetes Mellitus
656 Annals of Internal Medicine Vol. 167 No. 9 7 November 2017 Annals.org
http://www.annals.org
Figure. Algorithmic approach to evaluating glycemic control risk factors, setting a personalized glycemic control target range,
providing self-management (including lifestyle and nutrition) education, and initiating or reevaluating medication therapy.
Patient with type 2
diabetes mellitus Comorbidities and Other Considerations
lschemic vascular disease
Advanced diabetic complications
Diminished life expectancy
Cognitive impairment or dementia
Cardiovascular disease
Mental health/substance use conditions
Substance use disorders
Any chronic kidney disease
Motor disorders
Acute episodes of care
Cancer and transplant
Transitions of care, especially initiation of insulin
or change in insulin requirements, e.g.,
new insulin regimen at discharge
Does the patient have severe or
sustained hyperglycemia or
hypoglycemia needing urgent/
emergency care?
Assess patient's social determinants of health
(e.g., loss of partner, food sufficiency, economic
status change)
Provide all patients with understandable health
information/education
Does the patient understand and
feel confident about ability to
self-manage? Consider teach-
back method
Is the patient
receiving medication?
Discusss diet and exercise
Initiate medication
therapy with metformin or
other agents if indicated,
considering adverse effects,
contraindications, and
patient preferences
Are there adverse effects
or other barriers/concerns
with medication?
Are there problems with
patient medication
adherence?
Is the patient within
glycemic target range?
Adjust medication therapy as
indicated; consider adverse
effects, contraindications
and patient preferences;
discuss setting new targets
Adjust and/or change
medication
Reassess status and
goals at next
scheduled visit
Provide appropriate
intervention (e.g.,
motivational
interviewing) to address
patient medication
adherence; discuss with
patient and family as
appropriate
Refer patient to diabetes self-
management education and/or medical
nutrition therapy and ensure appropriate
intervention to address patient adherence
to lifestyle changes. Consider teach-back
method
Using shared decision making, determine a personalized glycemic control target and
behavioral goals by:
Determining recommended glycemic control target using risk stratification criteria
Discussing or evaluating the glycemic control target according to patient factors
Setting a glycemic control target range after discussion with patient
Setting behavioral goals
Coordinating care between primary care and specialty care as needed
Consider referral to the
emergency department
or an endocrinologist as
appropriate
Assess patient and glycemic control, taking into
consideration the patient's:
Age
Reproductive status
Comorbidities (see sidebar)
Stability
Medication adverse effects and contraindications
1
2
3
5
6
7
8 9 10 11
15
12
13
14
16
17
18
No
Yes Yes
Yes
Yes
No
No
NoNo
Yes
4
Yes
No
Synopsis of the VA/DoD Guideline on Management of Type 2 Diabetes Mellitus CLINICAL GUIDELINE
Annals.org Annals of Internal Medicine Vol. 167 No. 9 7 November 2017 657
http://www.annals.org
treatment. Key principles include readiness of the pa-
tient and family, tools with understandable information
about the benefits and harms of all options, and strat-
egies to identify and incorporate patient preferences.
Patients cannot effectively participate in care and
shared decision making unless they understand diabe-
tes and how they can be involved in planning and car-
rying out the jointly developed care plan.
Shared decision making reinforces a trusted thera-
peutic relationship and increases patient satisfaction
and treatment buy-in with regard to the methods
used to reach a particular goal or treatment plan (12
14). It should be used not only for patients with stable
glycemic control but also to assist those who are not
able or willing to make lifestyle changes and decisions
that affect their diabetes at any time during the course
of treatment. At a minimum, shared decision making
should be included at the time of diagnosis, during dif-
ficulties with management, and at times of transition or
development of complications (14).
Benefits include greater knowledge of medications
(13) and understanding of risks (14). In addition,
patient-centered care and shared decision making to-
gether may decrease patient anxiety, increase trust in
clinicians (15), and improve treatment adherence (16).
Family involvement should be considered if appropri-
ate, especially in older adults (17). Patient information
should be culturally appropriate; understandable and
actionable by people with limited literacy skills; and ac-
cessible to those with physical, sensory, or learning
needs (18).
As part of the patient-centered care approach to
diabetes management, clinicians should explore with
the patient the outcomes of previous opportunities for
shared decision making, their ability to self-manage,
prior efforts to change health behaviors, past treatment
experiences (including reasons for discontinuing treat-
ment), and relevant clinical outcomes. In actively shar-
ing decisions, they should involve the patient in priori-
tizing problems to be addressed and setting specific
goals regardless of the setting or level of care.
Assess Patient Characteristics and Nonglycemic
Factors When Interpreting Results of
Hemoglobin A1c, Fructosamine, and Other
Glycemic Biomarker Testing
Many factors affect measurement of hemoglobin
A1c (HbA1c) besides the level of glycemia (19). Because
HbA1c level depends on the duration of erythrocyte ex-
posure to glucose, conditions that alter erythrocyte life
span affect the measured level of HbA1c (20, 21). Iron
deficiency anemia, which prolongs erythrocyte life span
and exposes the cell to glucose for a longer period, is
associated with falsely elevated HbA1c levels (22). In
contrast, conditions that shorten erythrocyte life span
(such as hemolytic anemia) may result in falsely low
HbA1c levels. Various other conditions, such as chronic
kidney disease, may alter HbA1c measurement. Hemo-
globin variants can result in falsely elevated or falsely
lowered HbA1c levels, depending on the assay used
(2325). In addition, oral hypoglycemic agents (met-
formin or sulfonylureas) may alter the relationship be-
tween blood glucose and HbA1c levels, although the
clinical significance is unclear (26).
There are also racial/ethnic differences in HbA1c
levels for a given level of glycemia. A previous study
found that African Americans with prediabetes (27) had
HbA1c values that were 0.4% higher than among white
persons; those who were within 3 years of diagnosis
(28) also had higher HbA1c values than white persons
for any measure of glycemia. This difference cannot be
explained by measured differences in glycemia, clinical
factors known to affect HbA1c measurement, or so-
ciodemographic factors (27, 28). Therefore, it is recom-
mended that a new diagnosis of diabetes be based on
a confirmatory fasting blood glucose level of at least
7.0 mmol/L (126 mg/dL) if the initial HbA1c value is
6.5% to 6.9%.
How and where the HbA1c level is measured can
also affect results because of intralaboratory variation
(variation in test accuracy and precision) and interlabo-
ratory variation (variation related to use of different test
methods). A single HbA1c measurement, even from a
high-quality laboratory, has a margin of error such that
the true value is within a range defined by the coeffi-
cient of variation. Sequential HbA1c values that are
within 0.5% do not statistically differ from one another
unless the assay coefficient of variation is less than 3%,
and ideally less than 2% (29). Treatment decisions
based solely on a single HbA1c measurement without
consideration of other clinical data, such as glucose
monitoring results, may lead to unnecessary initiation
or intensification of therapy. Comparing HbA1c tests
performed in different clinical laboratories introduces
another source of error, as does use of point-of-care
HbA1c testing, which is not subject to systematic quality
oversight. Assessing the effect of these patient charac-
teristics and nonglycemic factors that affect HbA1c lev-
els allows for better individualization of management.
For these reasons, the VA/DoD does not recommend
the use of estimated average glucose level, which is
derived from HbA1c values using a formula.
Set HbA1c Target Ranges Based on Absolute
Reduction in Risk for Significant Microvascular
Complications, Life Expectancy, and Patient
Preferences
An individualized approach to treatment goals is
recommended, based on the patient's absolute risk
for microvascular complications balanced against
comorbidities, estimated life expectancy, presence or
absence of existing complications, the risk and incon-
venience associated with polypharmacy, risk for hypo-
glycemia and other adverse events, effects on concom-
itant conditions (such as weight), and overall treatment
burden.
The shared decision-making process might be af-
fected by the framing of trial results. Clinicians should
therefore consider a patient's values and preferences
when discussing the magnitude of clinically important
outcomes and harms from trials (11). The VA/DoD CPG
recommends that clinicians discuss absolute risk reduc-
CLINICAL GUIDELINE Synopsis of the VA/DoD Guideline on Management of Type 2 Diabetes Mellitus
658 Annals of Internal Medicine Vol. 167 No. 9 7 November 2017 Annals.org
http://www.annals.org
tion rather than relative risk reduction when conveying
to patients their estimated likelihood of achieving
a reduction in clinically significant complications or po-
tential risks of therapy. The VA/DoD CPG summarizes
the available evidence from major clinical trials as well
as meta-analyses to inform strength of recommenda-
tions (30 44) that apply to patients with both recent-
onset and longer-duration diabetes with established
complications.
Develop Individualized Treatment Plans Based
on Complications, Comorbidities, Life
Expectancy, and Patient Preferences
The CPG proposes HbA1c target ranges (rather
than an all-or-nothing target value) based on the pres-
ence or absence of microvascular complications, co-
morbidities, and life expectancy. This is rooted in the
substantial body of evidence showing a direct relation-
ship between glucose control and microvascular com-
plications (for example, retinopathy, neuropathy, and
nephropathy). The overarching goal of these recom-
mendations is to develop individualized treatment
plans and HbA1c target ranges that are tailored to a
patient's unique characteristics and goals of care.
Higher HbA1c levels carry greater risk for complica-
tions, and decreasing levels prospectively reduces risk
(30, 31, 33, 34). The relationship between HbA1c and
risk for microvascular complications is continuous and
accelerates when levels exceed 9% (35). There is no
apparent HbA1c threshold above which benefits are not
accrued by decreasing levels, but the absolute risk re-
duction is less at lower levels (31). Thus, a decrease in
HbA1c level may have minimal clinical impact on com-
plications in patients with limited life expectancy. Con-
versely, there are no data on the appropriate lower
limit for achieved HbA1c level, although strong data ex-
ist on the risks for hypoglycemia as HbA1c is targeted to
near-normal levels for patients receiving insulin (36).
Lower levels of HbA1c (closer to 6%) may be reasonable
in younger patients treated with metformin alone.
Microvascular complications develop over an ex-
tended period. Thus, persons with long life expectancy
and no or mild microvascular complications (such as
early background retinopathy, microalbuminuria, or
mild neuropathy) may benefit from a lower HbA1c level
(6.0% to 7.0%) (Supplement, available at Annals.org).
For patients with comorbidities or complications
that shorten life expectancy (<10 years), higher HbA1c
target ranges are appropriate. Systematic reviews com-
paring intensive and conventional glucose control
showed no statistically significant differences in all-
cause mortality or death from cardiovascular disease
but did show statistically significant risk reduction for
microvascular complications, such as nephropathy, ret-
inopathy, and lower extremity amputation (36 38).
These trials provided no firm evidence that decreasing
HbA1c levels to less than 8.5% reduces risk for death
from cardiovascular disease (39). Depending on the
presence and degree of microvascular complications,
HbA1c target ranges of 7.0% to 8.0% or 7.5% to 8.5%
are appropriate for most patients (Supplement).
The presence of major comorbidities that decrease
life expectancy (<5 years) or advanced microvascular
complications (such as severe nonproliferative or pro-
liferative retinopathy, renal insufficiency [stage 3b or
greater chronic kidney disease], insensate extremities,
or autonomic neuropathy) may justify a higher HbA1c
target range. Such patients are less likely to benefit
from intensive glucose control and more likely to have
risks from treatment.
Intensive glucose control may cause frank harms,
such as increased risk for death from cardiovascular
events (40) and severe hypoglycemia (that is, hypogly-
cemia requiring help from another person). Risk factors
for hypoglycemia include use of specific drugs (insulin
and sulfonylureas), advanced age (>75 years), cognitive
impairment, and chronic kidney disease (including
causes unrelated to diabetic nephropathy) (41 43). Ad-
ditional risk factors include lack of appropriate glucose
monitoring, inadequate diabetes education, lack of
family and social support systems, and food insuffi-
ciency. There are racial differences between estimated
average glucose level and HbA1c values in patients with
established type 2 diabetes based on 7-point glucose
testing (44). Thus, self-monitoring results and HbA1c
test results may be discordant. The presence of any of
these factors should prompt a discussion about higher
HbA1c target ranges.
Assessing the effect of these patient characteristics
and nonglycemic factors that affect HbA1c levels allows
for better individualization of management. Thus, we
recommend that treatment goals involve target ranges
for HbA1c rather than levels above or below a specific
value for most persons with diabetes. This approach is
consistent with clinical and laboratory science and
avoids unnecessary intensification of therapy due to
fluctuations within the range. This recommendation al-
lows for individualized treatment plans and is consis-
tent with patient values.
Pharmaceutical Agents Should Be Selected on
the Basis of Efficacy, Contraindications, Drug
Interactions, Comorbidities, and Potential
Adverse Effects and Patients Should Be Engaged
With the Various Treatment Options and Should
Arrive at a Shared Treatment Plan With Their
Clinician
When individualized glycemic goals are not
achieved with nonpharmacologic therapy, such as diet
and increased physical activity, adjunctive therapy with
medications is indicated. The magnitude of the reduc-
tion in HbA1c level necessary to achieve goals should
be considered when choosing medications, along with
hypoglycemia risk, weight gain, administrative burden,
and cost.
Although evidence for pha
