The latest results from the ACCORD
trial, discussed
on page 5, are consistent with other landmark studies
that confirmed short term pain for long term gain.
In 1993, the DCC Trial's discovery
that patients with type I diabetes developed less microvascular
complications with lower glucose set our A1c target
at <7%. We suspected similar benefits in type II
diabetes, and the UKPDS trial proved that, by showing
a 1% A1c reduction decreased the risk of any microvascular
endpoint by 25% and diabetes-related death by 10%.
Subsequent studies sent us on a
spiral of ever tightening glycemic targets. Achievement
of lower targets, however, comes at a price. In the
UKPDS, reduction of diabetes-related death took 10 years
to become apparent; in the STENO-II trial, the intensive
control group had higher mortality for the first four
years. ACCORD has shown that an A1c of 6.4% is too low
and the cardiovascular mortality risks outweigh the
benefits in the short term. Ironically, the intensive
group in ACCORD showed a 10% decrease in non-fatal MI,
which shows that there are benefits as well as risks
to intensive glucose lowering.
At the end of the day, the question
is: Does aggressively lowering A1c below the currently
recommended target of decrease complications of diabetes?
The answer is no. While there may be some benefits,
there are also increased risks. Other studies, like
ADVANCE, have not shown signals of increased risk, but
until we have the results of these trials we must stick
to the clinical practice guidelines of the CDA which
recommends getting A1c below 7%.
If intensive glycemic control doesn't
kill you, it will make you stronger. — J Robin
Conway, MD, Canadian Centre for Research on Diabetes,
Smiths Falls, ON
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