No Go on Tight Diabetes Control

January 5th, 2009 | Sources: MedPageToday, NEJM

Putting the clamps on blood glucose did not prevent eye, nerve or kidney complications in a large cohort of patients with type 2 diabetes, according to a study in the New England Journal of Medicine

William Duckworth and colleagues at the Phoenix VA randomized 1,791 veterans with an average  baseline glycated hemoglobin of 9.4% to intensive or standard therapy and followed them for 6 years.

Patients had diabetes for an average of 11.5 years prior to randomization. Nearly 40% had sustained a cardiovascular event and 60% had developed microvascular complications prior to randomization.

The same oral drugs were used in both groups but they were used more aggressively in the intensive therapy group. Insulin was added when glycated hemoglobin exceeded 6% and 9% for the intensive and standard groups, respectively.

Median glycated hemoglobin levels during the study were 8.4% and 6.9% for those in the standard and intensive therapy groups, so there’s no question diabetes control was tighter in the latter group.

However, the need for photocoagulation during the study was 15.7% and 15.5% for those in standard and intensive therapy, respectively.

Similarly 4.0% and 5.7% of those in standard and intensive therapy groups experienced progression to proliferative eye disease (not a misprint). A doubling of serum creatinine was seen in 8.8% of patients in both groups.

Neuropathy developed in 43.8% and 43.5% of those in standard and intensive therapy respectively, so across the board there were no real differences.

Cardiovascular outcomes and all-cause mortality also did not differ, but hypoglycemic episodes were 4 times more frequent in those receiving intensive treatment. 

The cardiovascular results confirmed findings from other studies but left open the possibility that a longer follow-up period might reveal benefits for those receiving intensive treatment. 

Helena Rodbard, M.D., a former president of the American Association of Clinical Endocrinologists, concluded for MedpageToday that “the upshot of it is, if we catch the patients early on, they are going to benefit from intensive treatment.” 

But “if we wait too long, intensive treatment can be deleterious,” she warned.


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