Benefits Of Intensive Glycemic Control Research Articles

Poor Glycemic Control Is Associated With More Rapid Kidney Function Decline After the Onset of Diabetic Kidney Disease.

The role of glycemic control and its variability on the rate of kidney function decline after the onset of diabetic kidney disease (DKD) remains unclear. The association between baseline glycated hemoglobin (HbA1c) and rates of estimated glomerular filtration rate (eGFR) loss during follow-up was examined by mixed-effects linear regression in 530 individuals with type 1 diabetes and early-to-moderate DKD from the Preventing Early Renal Loss (PERL) trial and 2378 individuals with type 2 diabetes and established DKD from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. The benefit of intensive vs standard glycemic control in slowing eGFR decline was examined in ACCORD. The associations between continuous glucose monitoring-derived short-term glycemic variability indices and rate of eGFR decline were also evaluated in PERL. A higher baseline HbA1c was associated with a more negative eGFR slope in both PERL and ACCORD (-0.87 and -0.27 mL/min/1.73 m2/year per Hba1c unit increment, P < .0001 and P = .0002, respectively). In both studies, the strength of this association progressively increased with increasing levels of albuminuria (P for interaction <.05). Consistent with this, the benefit of intensive glycemic control on eGFR decline was greater in ACCORD participants with severe rather than moderate albuminuria (+1.13 vs + 0.26 mL/min/1.73 m2/year, P = .01). No independent associations were found in PERL between short-term glycemic variability indices and rate of eGFR decline. In both type 1 and type 2 diabetes, poor glycemic control is associated with a more rapid rate of glomerular filtration rate decline after DKD onset, especially in persons with severe albuminuria.

Treatment of diabetes mellitus has borne much fruit in the prevention of cardiovascular disease.

Cardiovascular (CV) disease is the most alarming complication of diabetes mellitus (DM), and a strategy aiming at cardiovascular event prevention in diabetes mellitus has long been debated. Large landmark clinical trials have shown cardiovascular benefits of intensive glycemic control as a ‘legacy effect’ in newly diagnosed type 2 diabetes mellitus. In contrast, we have learned that excessive intervention aimed at strong glycemic control could cause unexpected cardiovascular death in patients who are resistant to treatments against hyperglycemia. It has also been shown that the comprehensive multifactorial intervention for cardiovascular risk factors that was advocated in the current guideline provided substantial cardiovascular event reduction. The impact of classical antidiabetic agents launched before 1990s on cardiovascular events is controversial. Although there are many clinical or observational studies assessing the impact of those agents on cardiovascular events, the conclusions are inconsistent owing to variable patient backgrounds and concomitant antidiabetic agents among the studies. Moreover, most of them were not large‐scale, randomized, cardiovascular outcome trials. In contrast, GLP‐1RA (glucagon‐like peptide‐1 receptor agonist) and SGLT2 (sodium‐glucose cotransporter 2) inhibitors have demonstrated undeniable cardiovascular benefits in large‐scale, randomized, controlled trials. Whereas GLP‐1RAs decrease atherosclerotic disease, especially stroke, SGLT2 inhibitors mainly prevent heart failure. SGLT2 inhibitors are superior to GLP‐1RAs with respect to hard renal outcomes. Therefore, it can be said that drugs such as GLP‐1RAs and SGLT2 inhibitors that prevent cardiovascular events, in addition to their glucose‐lowering effect, are incredible novel tools that we have gained for use in diabetic treatment.

Pharmacologic Glycemic Management of Type 2 Diabetes in Adults.

Pharmacologic Glycemic Management of Type 2 Diabetes in Adults.

Intensive glycemic control and the risk of end-stage renal disease: an ADVANCE in the management of diabetes?

Posttrial follow-up of participants randomized to intensive versus standard glycemic control in the ADVANCE trial has demonstrated a significant benefit of intensive glycemic control on the risk of end-stage renal disease. In a more detailed analysis, intensive glycemic control appears to be of benefit only before the development of clinically evident kidney disease or in patients with documented early-stage chronic kidney disease.

Mechanism of Hypoglycemia-Associated Cardiovascular Diseases

Cardiovascular disease (CVD) is the leading cause of death in patients with diabetes mellitus. However, the benefit of intensive glycemic control in reducing CVD is unclear. In large clinical trials, intensive glycemic control was associated with increased incidence of hypoglycemia and all-cause mortality. Although it is uncertain whether hypoglycemia is a direct cause of CVD, a marker of vulnerability, or both, numerous studies have reported that hypoglycemia is associated with increased cardiovascular events such as cardiac arrhythmia and ischemia. The potential mechanisms of hypoglycemia-associated CVD include sympathoadrenal activation, repolarization abnormality, cardiac autonomic neuropathy, increased thrombogenesis, inflammatory reaction, and endothelial dysfunction. In this article, we review the evidence of an association of hypoglycemia with CVD in patients with diabetes and discuss the possible mechanisms through which hypoglycemia might result in adverse cardiovascular outcomes.

Características diferenciales de la diabetes mellitus tipo 2 en el paciente anciano. Papel de los inhibidores de la dipeptidil peptidasa 4

The prevalence of type 2 diabetes mellitus increases with age, reaching rates around 30% in those over 75 years. The type 2 diabetes mellitus in the elderly has different pathophysiological and clinical characteristics from those of the younger diabetic patient. Some differential aspects in this population are the lower life expectancy and the frequent comorbidity, frailty and associated disability. Avoiding hypoglycemia is a therapeutic priority, given their increased risk of severe hypoglycemia. It is a situation in which the benefits of intensive glycemic control are virtually non-existent, thus prevention of side effects of treatments becomes a priority. Therefore, the goals of glycemic control should be less stringent than in the general population (glycated hemoglobin>7%), and the drugs of choice should be those with a low risk of side effects (especially hypoglycemia) and well tolerated. Dipeptidyl peptidase 4 inhibitors (iDPP4) are particularly useful in this age group, either as a second drug added to metformin monotherapy, or as first line when metformin is contraindicated or not tolerated. In this article the evidence available on the efficacy and tolerance of different pharmacological options available in population over 70 years is reviewed.

New insight into improvement of cardiovascular outcomes with intensive glycemic control in patients with metabolic syndrome and type 2 diabetes mellitus included.

The epidemiology of metabolic syndrome (MetS) is very concerning since this is a widespread chronic disease in adult and elderly population. Different epidemiological studies confirmed strong relationship between type 2 diabetes mellitus (DM2) inclusive MetS and the occurrence of microvascular and macrovascular complications in these patients. Therefore, we are discussing molecular mechanisms and pathways recently introduced and intensively researched. These molecules have been held responsible for direct and indirect correlative trends important in the assessment of potential benefit of intensive glycemic control. Novel substances may improve patient's outcome in recent future regarding cardiovascular complications though their acting mechanisms have not been completely elucidated. We are reviewing whether it would intensive glycemic control be a reasonable approach in patients with MetS when DM2 is included and which recommendations are currently widely applied. The aim was therefore to emphasize current need for further investigations in the field since the utility of intensive glycemic control in all DM/MetS patients as mean for reduction of cardiovascular complications still remains controversial.

Even silent hypoglycemia induces cardiac arrhythmias.

While many studies have shown that intensive glycemic control can prevent the microvascular complications of diabetes, the benefits of intensive glycemic control in preventing macrovascular complications, including heart attacks, strokes, and overall mortality, have been less clear. Intensive glycemic control almost always increases the frequency and severity of hypoglycemic episodes. What remains unclear is whether hypoglycemia directly contributes to, or is merely associated with, the increased mortality noted in recent large trials (e.g., Normoglycaemia in Intensive Care Evaluation and Survival Using Glucose Algorithm Regulation [NICE-SUGAR], Control of Hyperglycaemia in Paediatric intensive care [CHiP], Action to Control Cardiovascular Risk in Diabetes [ACCORD]) (1–3). In the intensive care setting, noniatrogenic hypoglycemia serves as a harbinger of mortality, but it is unlikely to be a direct cause of mortality (4). By contrast, in the outpatient setting, insulin-induced hypoglycemia can be lethal. Among people with diabetes, the mortality rate due to hypoglycemia has been reported to be as high as 10% (5). Indeed, insulin-induced hypoglycemia has been considered responsible for nocturnal deaths in diabetic patients (6), and has been documented to be associated with the “dead-in-bed” syndrome (7). Therefore in the outpatient setting, the microvascular benefits of intensive glycemic control in people with diabetes have to be weighed against the apparent increased mortality associated with iatrogenic hypoglycemia. The mechanism(s) by which hypoglycemia may increase mortality remains unknown. In patients with cardiac disease, hypoglycemia has been associated with ischemic chest pain (8). Hypoglycemia also increases markers of thrombosis and inflammation, potentially increasing the risk of acute thrombotic events or accelerating development of atherosclerosis (9). Although hypoglycemia-associated …

Celebrating 30 years of research accomplishments of the diabetes control and complications trial/epidemiology of diabetes interventions and complications study.

The landmark Diabetes Control and Complications Trial (DCCT) and its follow-up study, the Epidemiology of Diabetes Interventions and Complications (EDIC), have changed the way that type 1 diabetes is treated, and have led to improvements in the health and quality of life of people with the disease. In this Perspective, we look back at the 30 years since the start of DCCT to celebrate the scientific achievements of the DCCT/EDIC study group and patient volunteers—achievements that have had far-reaching benefits for type 1 diabetes and beyond. The insights that continue to emerge from DCCT/EDIC underscore the importance of supporting long-term research on chronic diseases such as type 1 diabetes. We also describe factors that contributed to the success of DCCT/EDIC, its public health implications, and how results continue to inform current-day research directions supported by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of the National Institutes of Health (NIH). A complementary Perspective from the DCCT/EDIC investigators summarizes the methods, and results, and clinical implications of these seminal studies (1). In the late 1970s to the early 1980s, there was considerable debate about whether the potential benefits of intensive glycemic control in reducing the development of diabetes complications outweighed the risks of hypoglycemia (2–4). The studies done before the DCCT were small and short in duration and had enrolled subjects with preexisting retinopathy, thus failing to resolve the controversy about the risks and benefits of intensive treatment or to address primary prevention. Moreover, some studies in individuals with established eye disease showed an early worsening of retinopathy with intensive blood glucose control (5–7). Delineation of the natural history of the preproliferative phases of diabetic retinopathy in conventionally treated type 1 diabetes and validation of retinal photography as an outcome measure provided the …

An Insight into the Recent Diabetes Trials: What is the Best Approach to Prevent Macrovascular and Microvascular Complications?

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.

Targets for Glycemic Control

Targets for Glycemic Control

Intensive Glucose Control in Diabetics with an Acute Myocardial Infarction Does not Improve Mortality and Increases Risk of Hypoglycemia-A Meta-Regression Analysis

Some early trials comparing intensive glucose control in type 2 diabetics with an acute myocardial infarction (MI) reported a decrease in mortality over a short period of follow up leading to a presumption of improved survival with intensive glucose control. Later data refuted this hypothesis. The 2009 ACC/AHA focused update on ST elevation MI gave a weak recommendation for the use of an insulin based regimen to achieve and maintain blood glucose less than 180 mg/dL. We decided to assess the validity of this recommendation.The authors searched the Pub- Med, Cochrane CENTRAL and EMBASE databases for randomized controlled trials from 1965 through 2011.Trials included were direct head-to-head comparisons of an intensive blood glucose control strategy using pharmacological means (insulin in most cases) with a less intensive regimen. The primary outcome assessed was the risk of all -cause mortality in the two groups at the end of follow up. Also assessed was the rate of hypoglycemia. The methodological quality of the studies was assessed. Event rates were compared using a forest plot of relative risk (RR; 95% confidence interval [CI]) using a random effects model (Mantel-Haenszel) assuming inter-study heterogeneity. Statistical analysis was done with Review Manager V5.1 and SYSTAT. Meta-regression was done with duration of therapy as covariate.Three studies (total N = 2113) met the inclusion exclusion criteria. Mortality was not different between the groups (RR 0.94, 95% CI of 0.66-1.34; p=0.73.). Rate of hypoglycemia was significantly higher in the intensive glucose control group (RR 13.40, 95% CI 3.69-48.61; p < 0.01), with a 12% absolute risk increase and a number needed to harm (NNH) of 9 (95% CI 6.8- 9.8)-even without achieving target glycemic control. Neither did intensive control improve CHF, arrhythmias and reinfarction rates. Meta regression revealed that mortality with intensive glycemic control was worse with increased duration of therapy (p=0.001, for trend).This systematic review suggests limited benefit of intensive glycemic control in type 2 diabetics with an MI, with a significant risk of serious hypoglycemia.

Intensive Glucose Control in Diabetics with an Acute Myocardial Infarction Does not Improve Mortality and Increases Risk of Hypoglycemia-A Meta-Regression Analysis

Objectives: Some early trials comparing intensive glucose control in type 2 diabetics with an acute myocardial infarction (MI) reported a decrease in mortality over a short period of follow up leading to a presumption of improved survival with intensive glucose control. Later data refuted this hypothesis. The 2009 ACC/AHA focused update on ST elevation MI gave a weak recommendation for the use of an insulin based regimen to achieve and maintain blood glucose less than 180 mg/dL. We decided to assess the validity of this recommendation. Methods: The authors searched the Pub- Med, Cochrane CENTRAL and EMBASE databases for randomized controlled trials from 1965 through 2011.Trials included were direct head-to-head comparisons of an intensive blood glucose control strategy using pharmacological means (insulin in most cases) with a less intensive regimen. The primary outcome assessed was the risk of all -cause mortality in the two groups at the end of follow up. Also assessed was the rate of hypoglycemia. The methodological quality of the studies was assessed. Event rates were compared using a forest plot of relative risk (RR; 95% confidence interval [CI]) using a random effects model (Mantel-Haenszel) assuming inter-study heterogeneity. Statistical analysis was done with Review Manager V5.1 and SYSTAT. Meta-regression was done with duration of therapy as covariate. Results: Three studies (total N = 2113) met the inclusion ⁄ exclusion criteria. Mortality was not different between the groups (RR 0.94, 95% CI of 0.66-1.34; p=0.73.). Rate of hypoglycemia was significantly higher in the intensive glucose control group (RR 13.40, 95% CI 3.69-48.61; p<0.01), with a 12% absolute risk increase and a number needed to harm (NNH) of 9 (95% CI 6.8- 9.8)-even without achieving target glycemic control. Neither did intensive control improve CHF, arrhythmias and reinfarction rates. Meta regression revealed that mortality with intensive glycemic control was worse with increased duration of therapy (p=0.001, for trend). Conclusions: This systematic review suggests limited benefit of intensive glycemic control in type 2 diabetics with an MI, with a significant risk of serious hypoglycemia. Keywords: Myocardial infarction, intensive glycemic control, meta-analysis, regression, hypoglycemia, mortality

Intensive Glucose Control in Diabetics with an Acute Myocardial Infarction Does not Improve Mortality and Increases Risk of Hypoglycemia-A Meta-Regression Analysis

Some early trials comparing intensive glucose control in type 2 diabetics with an acute myocardial infarction (MI) reported a decrease in mortality over a short period of follow up leading to a presumption of improved survival with intensive glucose control. Later data refuted this hypothesis. The 2009 ACC/AHA focused update on ST elevation MI gave a weak recommendation for the use of an insulin based regimen to achieve and maintain blood glucose less than 180 mg/dL. We decided to assess the validity of this recommendation. The authors searched the Pub- Med, Cochrane CENTRAL and EMBASE databases for randomized controlled trials from 1965 through 2011.Trials included were direct head-to-head comparisons of an intensive blood glucose control strategy using pharmacological means (insulin in most cases) with a less intensive regimen. The primary outcome assessed was the risk of all -cause mortality in the two groups at the end of follow up. Also assessed was the rate of hypoglycemia. The methodological quality of the studies was assessed. Event rates were compared using a forest plot of relative risk (RR; 95% confidence interval [CI]) using a random effects model (Mantel-Haenszel) assuming inter-study heterogeneity. Statistical analysis was done with Review Manager V5.1 and SYSTAT. Meta-regression was done with duration of therapy as covariate. Three studies (total N = 2113) met the inclusion exclusion criteria. Mortality was not different between the groups (RR 0.94, 95% CI of 0.66-1.34; p=0.73.). Rate of hypoglycemia was significantly higher in the intensive glucose control group (RR 13.40, 95% CI 3.69-48.61; p < 0.01), with a 12% absolute risk increase and a number needed to harm (NNH) of 9 (95% CI 6.8- 9.8)-even without achieving target glycemic control. Neither did intensive control improve CHF, arrhythmias and reinfarction rates. Meta regression revealed that mortality with intensive glycemic control was worse with increased duration of therapy (p=0.001, for trend). This systematic review suggests limited benefit of intensive glycemic control in type 2 diabetics with an MI, with a significant risk of serious hypoglycemia.

In search of the ideal basal insulin: Does the new-generation ultra-long-acting insulin, degludec, provide the answer?

In search of the ideal basal insulin: Does the new-generation ultra-long-acting insulin, degludec, provide the answer?

Management of Hyperglycemia in Type 2 Diabetes: A Patient-Centered Approach: Position Statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

Glycemic management in type 2 diabetes mellitus has become increasingly complex and, to some extent, controversial, with a widening array of pharmacological agents now available,1–5 mounting concerns about their potential adverse effects and new uncertainties regarding the benefits of intensive glycemic control on macrovascular complications.6–9 Many clinicians are therefore perplexed as to the optimal strategies for their patients. As a consequence, the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) convened a joint task force to examine the evidence and develop recommendations for antihyperglycemic therapy in nonpregnant adults with type 2 diabetes. Several guideline documents have been developed by members of these two organizations10 and by other societies and federations.2,11–15 However, an update was deemed necessary because of contemporary information on the benefits/risks of glycemic control, recent evidence concerning efficacy and safety of several new drug classes,16,17 the withdrawal/restriction of others, and increasing calls for a move toward more patient-centered care.18,19 This statement has been written incorporating the best available evidence and, where solid support does not exist, using the experience and insight of the writing group, incorporating an extensive review by additional experts (acknowledged below). The document refers to glycemic control; yet this clearly needs to be pursued within a multifactorial risk reduction framework. This stems from the fact that patients with type 2 diabetes are at increased risk of cardiovascular morbidity and mortality; the aggressive management of cardiovascular risk factors (blood pressure and lipid therapy, antiplatelet treatment, and smoking cessation) is likely to have even greater benefits. View this table: Table 1. Properties of Currently Available Glucose-Lowering Agents That May Guide Treatment Choice in Individual Patients With Type 2 Diabetes Mellitus These recommendations should be considered within the context …

Is there a U‐shaped curve of A1c versus mortality?

In a report 2 years ago based on the UK General Practice Research Database, Currie et al.1 obtained information on 27 965 diabetic people receiving oral agents in combination and on 20 005 diabetic people who initially received oral agents and subsequently received insulin. Over a 5-year follow-up period, the lowest mortality was for those with a mean A1c of 7.5%. Either higher or, worrisomely, lower A1c levels were associated with lower survival. This was particularly true in the insulin-treated group, for whom mortality nearly doubled at either A1c 10.5% or A1c 6.0% compared with A1c 7.5%.1 Two recently published epidemiologic studies of diabetic patients with renal insufficiency show similar patterns. Shurraw et al.2 identified 23 296 diabetic patients with a glomerular filtration rate (GFR) lower than 60 mL/min per 1.73 m2, finding worse survival among those with A1c either >8% or <6.5%, although progression to end-stage renal disease (ESRD) only worsened at A1c >9%. In the second study performed on 54 757 diabetic patients receiving maintenance hemodialysis, Ricks et al.3 found that at A1c ≥10%, 3-year mortality was 19% greater than at A1c 7%–7.9%; however, mortality increased even more (by 35%) at A1c ≤5%. What is the biological implication of a “U-shaped curve”? Efforts to understand the relationship between obesity and illness have been stymied by such relationships, although the divergence between smokers and non-smokers in relationships between body mass index (BMI) and mortality (with smokers showing higher mortality at lower BMI, and non-smokers exhibiting higher mortality at high BMI)4 has led to the hypothesis that the effects of lower weight are an effect of ill health.5 Some studies excluding cigarette and alcohol users and those with diagnosed illnesses still suggest higher mortality at both lower and higher body weight levels.6 Similar reports of U-shaped curves exist for blood pressure,7 alcohol use,8 fasting insulin,9 and the duration of sleep.10 The question for A1c is then whether the U-shaped curves suggest that type 2 diabetic patients are optimal at a moderately elevated level of A1c, with a causal relationship between low (i.e. normal for non-diabetic people) A1c and adverse outcome, or whether this apparent effect is due to confounding factors that lead to both lower A1c and worse outcome. Conceptually, it is difficult to understand how normal glucose levels for non-diabetic people would (directly) lead to adverse outcome among those with diabetes. However, it is important to realize that the relationship between glycemia and outcome may be less consistent as more advanced disease develops. Thus, in the study of Shurraw et al.2 the relationship between A1c and likelihood of progression to ESRD was significant only for a GFR >40 mL/min per 1.73 m2 and was progressively stronger at higher baseline GFR levels. Similarly, in the Veteran’s Administration Diabetes Trial there appeared to be benefit of intensive glycemic control in those diabetic patients with baseline coronary calcium scores below, but not above, 100.11 It may be that certain advanced levels of diabetic complications do not benefit from improved glycemia, with intensive control only leading to a greater likelihood of harm from hypoglycemia. The notion that improved glycemia mediates adverse outcome then inherently conflates a biochemical measure of glycemic control with the measures taken to achieve lower glycemia. New approaches to improving glycemia may well allow benefit without adverse effects.12 Furthermore, although the relationship between A1c and glycemia is significant, in the study of Ricks et al.3 just over one-third of the variance in glucose was explained by the A1c level, and low glucose was much weaker in its association with mortality than was low A1c.3 It may be that A1c is not sufficiently precise to truly measure overall glycemic exposure.13 This may particularly be the case with renal insufficiency or with anemia, among the situations in which A1c can be particularly misleading,14 but it is important to realize that approximately 20% of diabetic people have A1c levels differing by >1% from that which would be predicted from their mean glucose.15 Do the “U-shaped curve” phenomena then imply that normalization of glycemia for type 2 diabetes is misguided? The jury is still out, but it seems that we should continue to optimize glycemic control for those diabetic patients with relatively early disease for whom the progression of complications can be halted while making sure that we avoid any adverse effects of treatment, particularly those associated with hypoglycemia.

Management of hyperglycemia in type 2 diabetes: a patient-centered approach: position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD).

Glycemic management in type 2 diabetes mellitus has become increasingly complex and, to some extent, controversial, with a widening array of pharmacological agents now available (1–5), mounting concerns about their potential adverse effects and new uncertainties regarding the benefits of intensive glycemic control on macrovascular complications (6–9). Many clinicians are therefore perplexed as to the optimal strategies for their patients. As a consequence, the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) convened a joint task force to examine the evidence and develop recommendations for antihyperglycemic therapy in nonpregnant adults with type 2 diabetes. Several guideline documents have been developed by members of these two organizations (10) and by other societies and federations (2,11–15). However, an update was deemed necessary because of contemporary information on the benefits/risks of glycemic control, recent evidence concerning efficacy and safety of several new drug classes (16,17), the withdrawal/restriction of others, and increasing calls for a move toward more patient-centered care (18,19). This statement has been written incorporating the best available evidence and, where solid support does not exist, using the experience and insight of the writing group, incorporating an extensive review by additional experts (acknowledged below). The document refers to glycemic control; yet this clearly needs to be pursued within a multifactorial risk reduction framework. This stems from the fact that patients with type 2 diabetes are at increased risk of cardiovascular morbidity and mortality; the aggressive management of cardiovascular …

Classification of Older Adults Who Have Diabetes by Comorbid Conditions, United States, 2005–2006

IntroductionOlder adults who have diabetes vary widely in terms of comorbid conditions; these conditions help determine the risks and benefits of intensive glycemic control. Not all people benefit from intensive glycemic control. The objective of this study was to classify by comorbid conditions older American adults who have diabetes to identify those who are less likely to benefit from intensive glycemic control.MethodsWe used latent class analysis to identify subgroups of a nationally representative sample of community-dwelling older adults (aged 57–85 y) who have diabetes (n = 750). The subgroups were classified according to 14 comorbid conditions prevalent in the older population. Using the Akaike Information Criterion, the Bayesian Information Criterion (BIC), the sample-size adjusted BIC, and the χ2 goodness-of-fit statistic, we assessed model fit.ResultsWe found 3 distinct subgroups. Class 1 (63% of the sample) had the lowest probabilities for most conditions. Class 2 (29% of the sample) had the highest probabilities of cancer, incontinence, and kidney disease. Class 3 (9% of the sample) had the highest probabilities (>90%) of congestive heart failure and myocardial infarction. Class 1 had only 0, 1, or 2 comorbid conditions, and both class 2 and class 3 had 6 or more comorbid conditions. The 5-year death rates for class 2 (17%) and class 3 (33%) were higher than the rate for class 1 (9%).ConclusionOlder adults who have diabetes, cardiovascular disease, and 6 or more comorbid conditions may represent a subgroup of older adults who are less likely to benefit from intensive glycemic control.

Evolving Consensus on Managing Patients with Type 2 Diabetes

In 2012, the American Diabetes Association (ADA) and the European Association for the Study of Diabetes collaborated to issue an important position statement. They now acknowledge “new uncertainties regarding the benefits of intensive glycemic control” and recommend a patient-centered approach with individualized targets — that is, more-stringent control for motivated patients with new-onset diabetes and long life expectancies and less-stringent control for less-motivated patients with longstanding diabetes, limited life expectancies, and high risk for hypoglycemia. Consistent with flexibility in setting treatment goals, the authors also note that using “the percentage of diabetic patients who are achieving …