The goal of “treating to a target” is not a new concept in clinical medicine. Indeed, in many specialties, goal-directed treating to target is already the standard. For example, the goal of reducing low-density lipoprotein is widely accepted and followed by cardiologists and primary care physicians (PCPs), as determined by the number of coronary artery disease risk factors present in each patient. The Joint National Commission (JNC) 7 blood pressure guidelines have also been widely adopted by the medical community. Physicians have come to accept that blood pressure must not exceed 140/90 mmHg in “normal” patients, and that blood pressures less than 130/80 mmHg must be targeted in patients with diabetes or chronic kidney disease. Finally, endocrinologists and PCPs alike recognize the importance of achieving a hemoglobin A1C level as close to 6.0 mg/dl as possible, and use this value as an indicator of the success of their therapeutic strategy in achieving “tight” control of the patient’s diabetes in the outpatient setting.
At the same time, recent studies of patients with diabetes have shown that pushing for hemoglobin A1C levels less than 6.5 mg/dl in the elderly population may also lead to increased morbidity and mortality. The lesson from these studies is that “treating to target” is beneficial not just to avoid undertreating, but to avoid overtreating as well. It is difficult, however, to define the boundaries of overtreating and undertreating without first setting a target.
