New guidelines for metabolic targets in diabetes: clinician’s opinion does matter

Evidence-based medicine replaced eminence-based medicine as a way to manage unavoidable clinical uncertainty. Moving away from “one-size-fits-all” medicine, personalized medicine seemed to have the potential of tailoring therapies to subsets of patients. Despite the rapid progress in drug development for diabetes, it is still challenging to achieve good glycemic control in a substantial population. Different diabetes management algorithms have been proposed: most agree with a HbA1c target of <7.0 % for the majority of people with diabetes, except the American Association of Clinical Endocrinologists (AACE) that claims for a lower HbA1c target (<6.5 %). The recently released American guidelines on the treatment of blood cholesterol recommends moderate-intensity statin therapy for primary prevention for persons aged 40–75 years with type 1 or 2 diabetes and LDL-cholesterol levels between 70 and 189 mg/dl. The Eighth Joint National Committee recommends pharmacologic treatment in the population aged 18 years or older with diabetes, with a goal systolic blood pressure of lower than 140 mmHg and a goal diastolic blood pressure lower than 90 mmHg. There are differences and similarities among these recent guidelines for people with diabetes, with the main differences related to the level of the evidence. There are recommendations based on expert opinions (insufficient evidence or existing evidence unclear or conflicting) in almost all guidelines. The ultimate decision about care of a particular patient is left to clinicians, as the way to manage unavoidable guideline uncertainty: clinician’s opinion does matter.