Physician-authored summaries and commentary on the most important medical research, provided by the NEJM Group, a division of the Massachusetts Medical Society.
© Massachusetts Medical SocietyMarch 2025
Patients with slightly elevated haemoglobin A1c generally were not at higher risk.
Clinical guidelines recommend against tight glycaemic control for most older adults with type 2 diabetes (Diabetes Care 2025; 48 [Suppl 1]: S266-S282). One concern with less-intensive treatment is infection; poor control (i.e. glycosylated haemoglobin [HbA1c] above 75mmol/mol [9%]) increases infection risk. Researchers performed a retrospective study in 103,000 older patients (age, 65 years and older) to examine whether an intermediate HbA1c target (i.e. 53 to 75 mmol/mol [7 to 9%]) is associated with excess infections (respiratory; genitourinary; skin, soft tissue and bone; and sepsis). Patients were stratified by baseline glycaemic control: HbA1c of 64 to 75 mmol/mol (8 to 9%), 53 to 64 mmol/mol (7 to 8%) or ‘intensive control’ (42 to 53 mmol/mol [6 to 7%]).
A total of 3.6% of patients were hospitalised with infections during 12 months of follow up. After adjustment for confounders, overall hospitalisation rates for the intensive-control reference group were not significantly different from either of the relaxed-control groups. Only one subcategory of infection showed higher risk: bone, skin and soft tissue infection (adjusted relative risk, 1.33 for the 64 to 75 mmol/mol (8 to 9%) group compared with intensive control); however, excess risk was only a few cases per 1000 person-years.
Comment: Clinicians must weigh carefully the need to avert symptoms and complications of hyperglycaemia against harms of treatment (especially hypoglycaemia) in older adults with type 2 diabetes. These results are reassuring: a more relaxed glycaemic target between 53 and 75 mmol/mol (7% and 9%) does not appear to substantially increase overall risk for serious infection. The 53 to 64 mmol/mol (7 to 8%) target might be slightly safer with respect to skin, soft tissue and bone infections, but as always, treatment decisions should be individualised.
Sarah E. Post, MD, Lecturer in Medicine, Harvard Medical School; Internal Medicine Physician, Atrius Health, Boston, USA.
Lipska KJ, et al. Risk of infection in older adults with type 2 diabetes with relaxed glycemic control. Diabetes Care 2024; 47: 2258-2265.
This summary is taken from the following Journal Watch titles: General Medicine, Ambulatory Medicine, Hospital Medicine.