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Intensive Glucose Lowering Does Not Cut CV Risks in Patients with Long-Standing Type 2 Diabetes

Results of a VA trial add to evidence produced by the ACCORD and ADVANCE trials.

In the recent ACCORD and ADVANCE trials, intensive glucose-lowering therapy did not lower risks for cardiovascular (CV) death, nonfatal myocardial infarction, or nonfatal stroke in people with type 2 diabetes and end-organ complications or CV risk factors (JW Jun 6 2008). The results of a similar trial, the Veterans Affairs Diabetes Trial (VADT), are now available.

Investigators randomized 1791 veterans (mean age, 60) with long-standing type 2 diabetes (mean duration, 11.5 years) to receive intensive glucose-lowering therapy or standard therapy. Other CV risk factors were treated uniformly in both groups. After a median follow-up of 5.6 years, the median glycosylated hemoglobin (HbA_1c) level was significantly lower in the intensive-therapy group than in the standard-treatment group (6.9% vs. 8.4%). However, no between-group differences were noted for death from any cause, CV death, or time from randomization to first major CV event. Furthermore, researchers found no differences in microvascular events (e.g., retinopathy, nephropathy, neuropathy). However, hypoglycemic episodes were significantly more common in the intensive-therapy group.

Comment: Intensive glucose-lowering therapy does not lower risks for major CV events or death in patients with long-standing type 2 diabetes. In response to the results of the ACCORD, ADVANCE, and VADT trials, the American Diabetes Association, the American College of Cardiology Foundation, and the American Heart Association issued a joint position statement suggesting that less-stringent glycemic control is appropriate for patients with histories of severe hypoglycemic events, long-standing diabetes, or advanced microvascular and macrovascular complications. However, clinicians should continue to follow guidelines for healthy-lifestyle behaviors, smoking cessation, blood pressure control, and lipid lowering in these patients (J Am Coll Cardiol 2008; 52). Notably, the results of ACCORD, ADVANCE, and VADT might not apply to patients with newly diagnosed type 2 diabetes; evidence suggests such patients benefit from intensive glucose-lowering therapy (JW Oct 14 2008).

— Paul S. Mueller, MD, MPH, FACP

Published in Journal Watch General Medicine December 24, 2008

Citation(s):

Duckworth W et al for the VADT Investigators. Glucose control and vascular complications in veterans with type 2 diabetes. N Engl J Med 2009 Jan 8; 360:129. (http://dx.doi.org/10.1056/NEJMoa0808431)

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