ADDITION-Europe: Diabetes screening, early intensive intervention improved CV outcomes

ADA 71st Scientific Sessions

SAN DIEGO — In patients who had their type 2 diabetes detected by screening in general practice, intensive multifactorial treatment led to small but significant improvements in risk factors when compared with usual care, including small reductions in mortality and cardiovascular events, researchers found in a new study.

Patients with longstanding diabetes will likely draw CV benefits from intensive multifactorial therapy, although how such treatment affects patients with diabetes found through screening is unclear. To answer this question, researchers conducted the multicenter Anglo-Danish-Dutch Study of Intensive Treatment In People with Screen Detected Diabetes in Primary Care (ADDITION-Europe).

Routine vs. intensive multifactorial therapy

Between 2001 and 2006, patients were screened for type 2 diabetes at 343 general practices in Denmark, the Netherlands and the United States. The researchers then randomly assigned the centers to provide routine care or intensive multifactorial therapy to the 3,057 patients (mean age, 60 years) who were diagnosed with diabetes via screening.

“Practices in routine care were asked to follow national guidelines, whereas family physicians assigned to provide intensive care were urged to give intensive lifestyle advice, such as changing diet or physical activity level, and drug treatments for blood glucose, lipids and blood pressure,” Torsten Lauritzen, MD, chairman of the ADDITION-Europe steering committee and professor at the University of Arhus in Denmark, said at a press conference said.

After a mean follow-up of 5 years, the intensive therapy group had CV outcomes that were only slightly better than the routine care group, results showed. The incidence of first CV event was 7.2% in the intensive therapy arm and 8.5% in the routine care arm. The incidence of all-cause mortality was 6.2% in the intensive treatment group and 6.7% in the routine care group. The slight discrepancies between the two treatment groups linked the intensive therapy to a nonsignificant 17% reduction in incidence of CV events.

Likewise, improvements in CV risk factors were comparable. The decline in BP, from 150 mm Hg at baseline to 138 mm Hg at follow-up, in the routine care arm was on par with the decrease observed in the intensive therapy arm (149 mm Hg to 135 mm Hg). Similarly, cholesterol levels dropped from 5.6 mmol/L to 4.4 mmol/L in the routine care group and from 5.5 mmol/L to 4.2 mmol/L in the intensive treatment group.

“Family physicians in the routine care group did a much better job than we expected,” Lauritzen said in a press release. “Even in that group, there was a clinically significant reduction in BP and cholesterol levels, and small reductions in blood glucose levels and weight were maintained over 5 years.”

Remaining questions

Lauritzen explained that the study results provide a basis for offering routine screening for type 2 diabetes. “This study adds to the evidence that early detection and treatment is beneficial and may be useful in terms of encouraging high risk screening in the general population,” he said.

In an accompanying editorial, David Preiss, MRCP, of the British Heart Foundation, and Naveed Sattar, MBChB, MRCP, of the University of Glasgow, remained cautious.

While they noted that the data indicate the benefits of early diagnosis and treatment of diabetes, they said this study cannot answer “whether screen detection of diabetes is clinically beneficial against the background of current clinical diagnosis and practice.

“The key questions now are whether a sizeable reduction in the lead time between diabetes onset and clinical diagnosis can be achieved by implementation of simpler diagnostic criteria and, if so, to what extent this development might further reduce CV and mortality risks in patients with diabetes,” Preiss and Sattar wrote in The Lancet editorial. – by Melissa Foster

For more information:

• Lauritzen T. Joint ADA/The Lancet Symposium. Presented at: American Diabetes Association’s 71st Scientific Sessions; June 24-28, 2011; San Diego, Calif.
• Griffin SJ. Lancet. 2011;doi:10.1016/S0140-6736(11)60698-3.
• Preiss D. Lancet. 2011;doi:10.1016/S0140-6736(11)60819-2.

Disclosure: ADDITION-Europe received funding from several institutions, public health councils as well as Novo Nordisk, Astra, Pfizer, GlaxoSmithKline, Servier, HemoCue and Merck. Drs. Preiss and Sattar report no relevant financial disclosures.

You might look at this trial and say that it is a little disappointing that the researchers did not see a significant difference between the intensive care and the routine care groups, but there are a couple of things to consider. First, only 5 years of follow-up were done. I do not know that you would really expect to see a very significant difference in the sort of hard CV outcomes with only 5 years, especially when treating people with very early diabetes. It will be interesting to see how the long-term follow-up works out. Second, the kind-of-surprising thing is how well the routine care patients were treated. It is almost like there were not huge differences between the care. Overall, [the study] does suggest that screening, finding people early and treating them early does seem to have some benefits.

- Sue Kirkman, MD
Senior Vice President, Medical Affairs and Community Information
American Diabetes Association

Disclosure: Dr. Kirkman reports no relevant financial disclosures.

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