1、LETTERIntensified glucose lowering in type 2 diabetes: dont throwthe baby out with the bathwaterJ. H. DeVriesReceived: 10 October 2010 /Accepted: 9 November 2010 /Published online: 3 December 2010# The Author(s) 2010. This article is published with open access at SKeywords Cardiovascular disease.Gly
2、caemic control.Guidelines.Risk factors.Risk reduction.Type 2 diabetesAbbreviationsACCORD Action to Control Cardiovascular Risk inDiabetesADVANCE Action in Diabetes and Vascular Disease:Preterax and Diamicron Modified ReleaseControlled EvaluationNNT Number needed to treatUKPDS UK Prospective Diabetes
3、 StudyVADT Veterans Affairs Diabetes TrialTo the Editor: In their Editorial, Yudkin, Richter and Galeargue that Hyperglycaemia is a substantially weaker riskfactor for CVD than cholesterol or blood pressure, andglucose-lowering interventions are correspondingly lesseffective 1. They come to this con
4、clusion on the basis ofnumber needed to treat (NNT) derived from epidemiolog-ical studies, the UK Prospective Diabetes Study 2andthree recent megatrials (Action to Control CardiovascularRisk in Diabetes ACCORD 3, Action in Diabetes andVascular Disease: Preterax and Diamicron Modified Re-lease Contro
5、lled Evaluation ADVANCE 4 and VeteransAffairs Diabetes Trial VADT 5), which were subsequent-ly meta-analysed. Of course, the results of any meta-analysisare dependent on the validity of the individual trialsanalysed. The external validity of ACCORD and VADT isseverely compromised with the recent dec
6、ision of theEuropean Medicines Agency to retract the market author-isation of rosiglitazone. In VADT, all patients in theintensively treated group were started on rosiglitazone bytrial design. In ACCORD, 91.2% of patients were onrosiglitazone in the intensively treated group. It seemsimpossible to d
7、raw any conclusion on possible cardiovas-cular benefits of glucose lowering if such glucose loweringwas attained using a drug which has now been concluded toincrease the risk of myocardial infarction by its very nature.So we are left with UKPDS and ADVANCE as the relevantstudies. The key differentia
8、tors between these two studiesare duration of disease at enrolment and the treatmenttargets in the intensively and conventionally treated groups.In UKPDS, patients were randomised soon after thediagnosis of type 2 diabetes was made, and ADVANCEenrolled patients with a diabetes duration of 8 years. U
9、singthe UKPDS follow-up data 6, Yudkin et al. calculated theNNT for 10 years to prevent one myocardial infarction orstroke to be 29.4 1. This number relates to the sulfonyl-ureainsulin group. In the metformin group, thecorresponding NNT is 14. Moreover, the 10 year NNT toprevent one death was 29 in
10、the sulfonylureainsulin and 14in the metformin group. I think most diabetologists wouldagree that patients with newly diagnosed diabetes areentitled to treatment aiming to achieve an HbA1cvalue of7.0% for at least 10 years. There is no reason to believethat the UKPDS results would have been differen
11、t if the trialhad been of longer duration, so it seems reasonable to keepthis as the HbA1ctarget. After the first 10 years of diabetes,ADVANCE becomes a relevant study. This study showedonly minimal beneficial effects of intensive treatment ofglucose as compared with conventional treatment, but itsh
12、ould be noted that mean HbA1cin the conventionallyJ. H. DeVries (*)Academic Medical Center, Internal Medicine,P.O. Box 22660, Amsterdam 1100 DD, the Netherlandse-mail: j.h.devriesamc.uva.nlDiabetologia (2011) 54:705706DOI 10.1007/s00125-010-1991-6treated group was maintained at 7.3% throughout the t
13、rial.There is no trial evidence to indicatethatHbA1clevels abovethis are safe. Therefore, treatment guidelines will probablycontinue to advise a target HbA1cof 7.0% for people withdiabetes, with the possibility of a slightly higher target of7.3% after a diabetes duration of 810 years. Of course,cons
14、iderations relating to hypoglycaemia, weight gain,diminished life-expectancy or adherence may well justifyhigher targets in selected individuals.Duality of interest The author declares that there is no duality ofinterest associated with this manuscript.Open Access This article is distributed under t
15、he terms of theCreative Commons Attribution Noncommercial License whichpermits any noncommercial use, distribution, and reproduction inany medium, provided the original author(s) and source arecredited.References1. Yudkin JS, Richter B, Gale EA (2010) Intensified glucose loweringin type 2 diabetes:
16、time for a reappraisal. Diabetologia 53:207920852. UK Prospective Diabetes Study (UKPDS) Group (1998) Intensiveblood-glucose control with sulphonylureas or insulin comparedwith conventional treatment and risk of complications in patientswith type 2 diabetes (UKPDS 33). Lancet 352:8378533. The Action
17、 to Control Cardiovascular Risk in Diabetes StudyGroup (2008) Effects of intensive glucose lowering in type 2diabetes. N Engl J Med 358:254525594. The ADVANCE Collaborative Group (2008) Intensive bloodglucose control and vascular outcomes in patients with type 2diabetes. N Engl J Med 358:256025725.
18、Duckworth W, Abraira C, VADT Investigators et al (2009) Glucosecontrol and vascular complications in veterans with type 2 diabetes.N Engl J Med 360:1291396. Holman RR, Paul SK, Bethel MA, Matthews DR, Neil HA (2008)10-year follow-up of intensive glucose control in type 2 diabetes.N Engl J Med 359:15771589706 Diabetologia (2011) 54:705706
