Glycemic control targets reviewed after results from ACCORD, ADVANCE, VADT

American Diabetes Association's 56th Annual Postgraduate Course

Data from ACCORD, ADVANCE, and VADT do not suggest the need for major changes in glycemic control targets, according to information presented at the American Diabetes Association’s 56th Annual Postgraduate Course.

Clarification of the language stressing individualization is necessary, according to John B. Buse, MD, PhD, professor of medicine at the University of North Carolina School of Medicine, in Chapel Hill. Buse presented data from the various trials, which was also published in Diabetes Care and reported in the February 10 issue of Endocrine Today.

For macrovascular disease, the general goal of HbA1c ≤7% is also reasonable until more evidence becomes available. Data from trials investigating intensive glycemic control have not demonstrated a significant decrease in cardiovascular disease outcomes. However, long-term follow-up results from the DCCT and UKPDS studies have shown that reaching HbA1c goals of ≤7% in the years immediately after a patient was diagnosed with diabetes was linked to reduction of macrovascular disease risk, according to Buse.

In general, for microvascular disease, the HbA1c goal for nonpregnant adults should be ≤7%; lowering HbA1c to this target has been shown to reduce microvascular and neuropathic complications of type 1 and type 2 diabetes, according to Buse.

Results of the studies also showed that there was a small but incremental benefit in microvascular outcomes with HbA1c values closer to normal in subgroup analyses of the DCCT and UKPDS and microvascular evidence from ADVANCE, according to Buse. For selected patients, including those with short diabetes duration and no significant CVD, lowering HbA1c goals below the general goal of ≤7% may be appropriate if it can be achieved without significant hypoglycemia or other adverse effects.

Certain patients may benefit from less strict HbA1c goals, according to Buse. These patients include those with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications or extensive comorbid conditions, or patients with longstanding diabetes in whom the goal is difficult to attain despite self-management education, proper glucose monitoring and effective doses of glucose lowering agents including insulin.

Evidence-based recommendations, as defined in the ADA Standards of Medical Care in Diabetes and the AHA/ADA guidelines for primary CVD prevention, should be followed for blood pressure treatment, including lipid-lowering with statins, aspirin prophylaxis, smoking cessation and healthy lifestyle behaviors, to reduce CV risk in patients with diabetes, Buse noted.

“We need to change the way we think about diabetes care,” he said. “The payoff is to do the best we can in controlling glucose, blood pressure and lipids. Sometimes we may fall short of the target, but we should put in a good faith effort with multipharmacologic agents, broad-based lifestyle recommendations and assistance to control diabetes complications.” – by Christen Haigh

The bottom line is that glycemic control prevents cardiac problems but is not helpful with established heart disease. The risks associated with hypoglycemia, which induces an inflammatory state and suppresses baroreceptor activity, prolonged QT interval and cardiac arrythmias in the patient with diabetes and established cardiovascular problems, cannot be overemphasized.

– David S. H. Bell, MD

Endocrine Today Editorial Board member

For more information:

Buse JB. A1C after the ACCORD/ADVANCE/VADT trials: How long should we go? Presented at: ADA 56th Annual Advanced Postgraduate Course; Feb. 6-8, 2009; New York.

Diabetes Care. 2009;32:187-192.