Good Glycemic Control the Goal, Despite ACCORD, ADVANCE, and VADT

The benefits of intensive glycemic control on microvascular and neuropathic complications remain clear and well established in both type 1 and type 2 diabetes.

The benefits of intensive glycemic control on microvascular and neuropathic complications remain clear and well established in both type 1 and type 2 diabetes, but the evidence that tight control may also reduce cardiovascular disease risk remains limited.

However, that does not mean that clinicians and patients should stop trying to achieve good glycemic control, David M. Kendall, MD, chief scientific and medical officer of the American Diabetes Association, said at the American Association of Clinical Endocrinologists 19th Annual Meeting and Clinical Congress.

“Despite the results of ACCORD, ADVANCE, and VADT, the ADA, American Heart Association and American College of Cardiology continue to maintain that — for microvascular disease prevention, the A1C goal for non-pregnant adults in general should remain below 7%,” Kendall said. “And, since I am speaking to an audience of endocrinologists, I will say below 6.5% -- and that’s still below 7%.”

These organizations further maintain that individualized targets, both lower and higher, may be appropriate for some individuals.

Many clinicians and patients have been confused by these trials, said Kendall, who was also one of the investigators in the ACCORD trial.

“Their confusion is not so much as to the benefits of good glucose control as it relates to the prevention of classic complications of diabetes — microvascular disease – this has not been questioned or contradicted,” he noted. “What has been called into question or suggested is that more intensive glucose control – to even lower blood glucose targets –do not appear to lower the risk of cardiovascular disease.”

But, he added, “Cardiologists are clearly correct in saying that many patients with diabetes develop and die of heart disease, and in so doing, we certainly have learned that reasonable control of blood pressure and LDL cholesterol and judicious use of aspirin are of benefit, so that’s not in question.What I think has been inferred is that good glucose control should then also lower the risk of heart disease, but none of these studies confirmed that. However, simply because glucose lowering doesn’t reduce the risk of heart disease doesn’t mean we should abandon glucose lowering which is known for its established benefits.

In the ACCORD trial, patients who were older and who had long-standing diabetes in fact did not do as poorly as younger patients with more labile disease and other co-morbidities, Kendall noted. “The inference that every older patient with heart disease who has high glucose should not strive for better control was not borne out in ACCORD. Many of these older patients can likely be treated reasonably aggressively, and with acceptable safety. But in those patients in whom reasonable attempts at glucose lowering have not been successful, further aggressive therapy may be less rational and carry some risk. Lowering glucose will likely have substantial benefit in patients whose glucose can be lowered safely and easily.”