Concern over intensive treatment for patients with Type 2 diabetes

ScienceDaily (July 26, 2011) — Doctors should be cautious about prescribing intensive glucose lowering treatment for patients with type 2 diabetes as a way of reducing heart complications, concludes a new study published online in the British Medical Journal.See Also:Health & MedicineDiabetesPersonalized MedicineHeart DiseaseCholesterolWounds and HealingToday's HealthcareReferenceDiabetes mellitus type 2Blood sugarDiabetic dietGlycemic index

French researchers found that intensive glucose lowering treatment, which is widely used for people with type 2 diabetes to reduce their heightened risk of cardiovascular disease, showed no benefit on all-cause or cardiovascular mortality.

Globally, there were an estimated 150 million adults with diabetes in 2000 and this is expected to rise to 366 million by 2030. People with type 2 diabetes are twice as likely to have cardiovascular disease than non-diabetics and are also more at risk of microvascular complications (damage to small blood vessels).

Glycaemic lowering therapies are commonly used to treat people with type 2 diabetes to prevent long term cardiovascular complications and renal and visual impairment, but previous studies have not shown clear and universal benefits of the treatment.

So a team, led by Catherine Cornu at the Louis Pradel Hospital in Bron, France, reviewed studies that looked at microvascular complications and cardiovascular events related to the intensity of glycaemic control and the quality of trials.

They analysed 13 studies involving 34,533 patients of whom 18,315 were given intensive glucose lowering treatment and 16,218 given standard treatment.

They found that intensive glucose treatment did not significantly affect all-cause mortality or cardiovascular death.

There was, however, a 15% reduction in the risk of non-fatal heart attacks, following intensive treatment and a 10% reduction in microalbuminuria -- an indication of kidney problems and heart disease -- but a more than two-fold increase in the risk of severe hypoglycaemia (dangerously low blood glucose levels).

The researchers calculated that over a five-year treatment period, 117 to 150 patients would need to be treated to avoid one heart attack, 32 to 142 to avoid one case of microalbuminuria, and 15 to 52 to avoid one severe hypoglycaemic event.

They conclude: "Intensive glucose lowering treatment of type 2 diabetes should be considered with caution and therapeutic escalation should be limited."

In an accompanying editorial, UK experts state that clinicians should consider the absolute risks and benefits of more intensive therapy carefully on an individual patient basis to determine the most sensible treatment strategy.

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New data-based strategies and treatment models can improve diabetes care for older African-Americans

ScienceDaily (July 25, 2011) — Better data are needed to evaluate access to care by minority groups at increased risk for diabetes, such as older African Americans, and to assess the benefits of new community-based treatment strategies, including greater use of health information technology and access to multilevel diabetes education teams, according to a report in Population Health Management, a peer-reviewed journal published by Mary Ann Liebert, Inc.See Also:Health & MedicineDiabetesHealth PolicyDiseases and ConditionsMental Health ResearchToday's HealthcareElder CareReferenceAthletic trainingDiabetes mellitus type 2Palliative careDiabetic diet

Older adults of racial or ethnic minority descent tend to have a higher incidence of diabetes than whites, and these populations often have less access to quality health care. Karen Fitzner, PhD, American Association of Diabetes Educators (Chicago, IL), David Dietz, MSW, MHSA, U.S. Department of Health and Human Services (Rockville, MD), and Ernest Moy, MD, MPH, Agency for Healthcare Research and Quality (Rockville, MD) identify the gaps in care for underserved older adults and describe how better use of health information technology and multilevel diabetes education teams can help fill those gaps and improve health outcomes for older African Americans with diabetes.

The authors focus on treatment models that incorporate advances in information technology such as telehealth and geo-mapping for improved data sharing, Diabetes Self-Management Education and Training (DSME/T) programs, national collaboratives, and a multilevel diabetes education team approach that relies on less-skilled team members such as community health workers, supervised and supported by a multidisciplinary team of professional health care providers to facilitate community-based diabetes care, education, and prevention.

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Test measuring blood glucose control may help predict risk of CVD events in patients with diabetes

ScienceDaily (July 25, 2011) — Measuring hemoglobin A 1c (HbA 1c ) levels in patients with diabetes is associated with improvement in models for predicting risk for cardiovascular disease (CVD), according to a report published Online First on July 25 by Archives of Internal Medicine, one of the JAMA/Archives journals.See Also:Health & MedicineDiabetesCholesterolWounds and HealingAsthmaMultiple Sclerosis ResearchDiseases and ConditionsReferenceDiabetic dietBlood sugarDiabetes mellitus type 2Hyperglycemia

According to background information in the article, diabetes has been recognized as a risk factor for CVD. But recent research indicates that the level of risk may vary among patients with diabetes. "Simulated cost-benefit analyses have suggested that this variability in CVD risk could provide an opportunity for tailored preventive therapy in diabetic patients," write the authors. They sought to investigate the predictive value of HbA 1c levels; this test reflects the average blood glucose level over the previous two to three months, and generally indicates how well the diabetes is being managed.

Nina P. Paynter, Ph.D., from Brigham and Women's Hospital, Boston, and colleagues, used data from participants of the Women's Health Study and the Physician's Health Study II. To generate the model, they included data from 24,674 women, of whom 685 had diabetes at baseline, and 11,280 men, of whom 563 had diabetes at baseline. Questionnaires provided participants' health history, and baseline blood samples were evaluated for cholesterol, C-reactive protein and HbA 1c levels. The researchers followed up participants for incident (new cases) CVD; women were followed up for a median (midpoint) of 10.2 years and men for a median of 11.8 years.

During follow-up, 125 cardiovascular events occurred in the 685 women with diabetes and 170 events occurred in the 563 men with diabetes (compared with 666 and 1,382 events, respectively, in participants without diabetes). In both sexes, including HbA 1c into risk modeling for CVD improved prediction of CVD compared to classification of all diabetic participants as high risk (10-year risk at least 20 percent). This association was especially pronounced in women. The risk modeling demonstrated that 71.9 percent of female diabetic participants had less than a 20 percent risk of CVD over 10 years, whereas only 24.5 percent of male diabetic participants had a predicted 10-year CVD risk of less than 20 percent. In models that included a term for HbA 1c , there was substantial improvement in CVD risk prediction for women, and more modest improvement in risk prediction for men. Using a yes/no term for diabetes instead of HbA 1c also improved prediction over classification as high risk in both men and women. In women, however, HbA 1c further improved prediction over the yes/no term.

"We found that in these large population-based cohorts of both men and women, presence of diabetes alone did not confer a 10-year risk of CVD higher than 20 percent, and measurement of HbA 1c level in diabetic subjects improved risk prediction compared with classification as cardiovascular risk equivalent," note the researchers. They propose that the difference in risk between the sexes may be partly attributed to the increase in CVD risk with age and the delayed risk in women. The authors call for further research to replicate their results, but conclude, "Our findings suggest that the improvement in CVD risk prediction, and possibly calibration, obtained with adding HbA 1c levels is highest in lower-risk populations."

This work was carried out with support from F. Hoffmann-La Roche Ltd; and grants from the National Heart Lung and Blood Institute, the National Cancer Institute and the Donald W. Reynolds Foundation, Las Vegas.

Commentary: Cardiovascular Risk Stratification, Hemoglobin A 1c , and the Tempo of Translation

An accompanying commentary by Mark J. Pletcher, M.D., M.P.H., from the University of California, San Francisco, notes that the Adult Treatment Panel III (ATP III) guidelines and other cardiovascular disease (CVD) prevention guidelines will be updated soon.

"One specific guideline refinement up for consideration this year is the approach to CVD risk stratification in patients with diabetes," writes Pletcher. He states that under current ATP III guidelines, diabetes is considered a "CHD