Current data reinforce HbA1c goal less than 7%

American Association of Diabetes Educators 36th Annual Meeting

John B. Buse, MD, PhD, discussed how to interpret the recent Action to Control Cardiovascular Risk in Diabetes (ACCORD) findings in the context of other major cardiovascular disease trials at the American Association of Diabetes Educators 36th Annual Meeting.

Buse presented a review of data from ACCORD as well as the Action in Diabetes and Vascular Disease (ADVANCE) trial, Veterans Affairs Diabetes Trial (VADT), United Kingdom Prospective Diabetes Study (UKPDS) and Diabetes Control and Complications Trial (DCCT). The five trials reveal similar findings about the risks and benefits of glycemic intervention on diabetes care, according to Buse, professor of medicine and chief of endocrinology at University of North Carolina School of Medicine.

“In light of multiple clinical trials reported over the last two years, lowering HbA1c to a goal of <7% is still a reasonable strategy for the vast majority of patients with diabetes and substantial life expectancy,” Buse told Endocrine Today.

As previously reported in Endocrine Today, lower HbA1c levels were associated with lower mortality in patients assigned to both intensive and standard glucose control in the ACCORD trial. Researchers reported a statistically significant 66% higher relative risk for mortality with each 1% increase in HbA1c level (HR=1.66; P=.0001). Further, patients who rapidly lowered their HbA1c levels during the first year of treatment had a lower risk for death — excess mortality in the intensive control group occurred among those who were unsuccessful in reaching a target goal at or near 6%.

“Lower targets are supportable in recently diagnosed diabetes and particularly in younger patients without advanced complications,” Buse said. “Less stringent targets may be reasonable in those with limited life expectancy or those who fail to reach an HbA1c target of <7% despite treatment based on American Diabetes Association/American Association of Diabetes Educators standards with comprehensive patient-centered management, including lifestyle intervention and multiple antihyperglycemic agents and insulin in appropriate doses.”

Taken together, the findings from the five major trials also indicate that CVD benefits from glucose lowering are relatively modest overall and take a long time to emerge. Further, patients with known CVD are at high risk for complications from intensive glucose management strategies, and patients with shorter duration of disease, better glycemic control and no prior CVD may derive greater CVD benefits from intensification therapy.

Additionally, the data document the overall safety and efficacy of metformin, sulfonylureas, glitazones and insulin. However, the outcome of trials that involve novel agents such as glucagon-like peptide 1-based therapies have not been completed, “leaving a sense of great promise and unknown risk,” Buse said. “More consistent management of blood pressure and cholesterol to recommended targets should be a major focus of diabetes treatment and education.” – by Jennifer Southall

For more information:

Buse JB. ACCORD in the context of other CVD trials: translation to practice. Presented at: The American Association of Diabetes Educators 36th Annual Meeting; August 5-8, 2009; Atlanta.