The New England Journal of Medicine has published two papers this week that compared intensive treatment of blood glucose in diabetes with usual care.
The first, the ACCORD study, involved 10,251 patients with type two diabetes. Average age was 62 and diabetes had been present for an average of 10 years. Participants were randomly assigned to treatment with any number of glucose lowering therapies, including insulin, to achieve a target HbA1c of 6% or less.
The study was stopped early, after 3.5 years of follow up, when it became clear that all-cause mortality (5% versus 4%) and cardiovascular mortality (2.6% versus 1.8%) was higher in the intensive group of the study.
In the ADVANCE study, 11,140 participants (mean age 66, diabetes for 8 years) were randomly assigned to intensive treatment with modified release gliclazide to achieve a target HbA1c of 6.5% or less. After 5 years follow up, HbA1c was 6.5% in the intensive group and 7.3% in the control group.
The study found no differences in all cause mortality, cardiovascular mortality or major cardiovascular events. A statistically significant difference was detected in microvascular outcomes (hazard ratio 0.86, 95% CI 0.77 - 0.97, P=0.01) mainly driven by a reduction in nephropathy. This difference was also reflected in the composite primary outcome of combined major macrovascular and microvascular events.
An accompanying editorial illustrates the similarities and differences between these two studies and attempts to place the results in the context of the existing evidence. The authors point out that diabetes care should be comprehensive and include smoking cessation, dietary and exercise advice, blood pressure control, cardiovascular risk reduction (using aspirin, statins and possibly metformin) and finally, attainment of current glycaemic targets.
Action: Clinicians should ensure that diabetes care does not concentrate solely around glycaemic control. In fact, intensive glycaemic control should only be considered after other interventions aimed at smoking cessation, blood pressure and cardiovascular risk have been optimised.
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