Tuesday, June 02, 2009

Another evidence synthesis and perspective on treatment of DM 2

The conclusions of this Annals piece must sound heretical to the one-size-fits-all EBM Nazis (italics mine):

Some diabetes guidelines set low glycemic control goals for patients with type 2 diabetes mellitus (such as a hemoglobin A1c level as low as 6.5% to 7.0%) to avoid or delay complications. Our review and critique of recent large randomized trials in patients with type 2 diabetes suggest that tight glycemic control burdens patients with complex treatment programs, hypoglycemia, weight gain, and costs and offers uncertain benefits in return. We believe clinicians should prioritize supporting well-being and healthy lifestyles, preventive care, and cardiovascular risk reduction in these patients. Glycemic control efforts should individualize hemoglobin A1c targets so that those targets and the actions necessary to achieve them reflect patients' personal and clinical context and their informed values and preferences.

In its negative view of tight glycemic control in DM 2 this review, in my opinion, does not make enough of a distinction between microvascular and macrovascular outcomes.

One remarkable outcome of all the DM 2 trials abstracted in the review was weight gain. That’s the price you pay for intensive glycemic control with insulin and insulin secretogogues and it’s precisely the outcome you do not want if you’re trying to reduce macrovascular disease. That helps explain why macrovascular disease is an elusive target and why macrovascular complications were increased in the ACCORD study. As I said here, I will offer a theory on diabetes treatment and macrovascular disease in a future post.


Anonymous said...

The microvascular outcomes you are so confident in are not very impressive.

UKPDS and ADVANCE showed clinically insignificant differences in outcomes with tight vs. "typical" control.

"retinopathy" with no visual differences (ukpds), and "nephropathy" (advance) that didn't matter for any patients. These are meaningless surrogate differences that don't matter for patients.

Interestingly, the retinopathy benefit, however inconsequential, wasn't seen in ADVANCE, and the nephropathy "benefit" wasn't as clear in UKPDS.

R. W. Donnell said...

In UKPDS the nephropathy outcome was a rise in creatinine if I remember correctly.

I suppose what "matters" is in the perception of the patient but for me a creatinine rise would matter as would a number of other asymptomatic endpoints, but that's just me.

I'm all for honoring patients' preferences. I believe the best approach would be to select the glycemic goal for the individual patient based on that patient's values about what outcomes are, or are not, worth the trouble to achieve particular HgbA1C goals.