Title:An Insight into the Recent Diabetes Trials: What is the Best Approach to Prevent Macrovascular and Microvascular Complications?
VOLUME: 9 ISSUE: 5
Author(s):Manige Konig, Elizabeth Mary Lamos, Stephanie Aleskow Stein and Stephen N. Davis
Affiliation:University of Maryland Medical Center, 22 South Greene St. N3W42, Baltimore, Maryland 21201.
Keywords:ACCORD, ADVANCE, BARI 2D, diabetes trials, intensive glycemic control, macrovascular disease, ORIGIN,
VADT.
Abstract:Type 2 diabetes mellitus (T2DM) accounts for 90%–95% of all diabetes cases. The overarching goal in caring
for patients with T2DM is to prevent microvascular and macrovascular complications with glycemic control. Several studies
such as UKPDS, DCCT, and EDIC have been performed to evaluate the effects of glucose control on tissue complications
in patients with diabetes. In recent diabetes trials including ACCORD, ADVANCE, VADT, BARI 2D, and ORIGIN,
intensive glucose control did not prevent macrovascular complications in older patients with long-standing diabetes with
either cardiovascular disease or risk factors for cardiovascular disease. In fact, intensive therapy was associated with increased
mortality in the ACCORD trial. Although no clear macrovascular benefit was seen in these trials, analyses of earlier
studies in younger patients with type 1 and type 2 diabetes have suggested a significant benefit of intensive glycemic
control in patients with a shorter duration of diabetes and less vasculopathy. In the UKPDS, the incidence of microvascular
disease, particularly retinopathy, was reduced significantly with intensive glucose control, but in the more recent trials (ACCORD,
ADVANCE, VADT, ORIGIN) the benefit was relatively modest and limited to reduced proteinuria. Perhaps the
most important message from the above trials is to optimize control of cardiovascular risk factors. Although the goal
HbA1c to prevent microvascular and macrovascular complications, per the American Diabetes Association, is less than 7%,
hypoglycemia should be avoided as it can increase the risk for severe cardiovascular events.
