In 2009, New England Journal of Medicine Published results of the Veterans Affairs Diabetes Trial (VADT). gave the study found that intensive glucose (blood sugar) control in older men with long-standing type 2 diabetes didn't significantly reduce their risk of major cardiovascular (CV) events, including heart attack, stroke, and including death resulting from CV, compared with standard blood sugar control.
The researchers reported recently 15-year follow-up results From the VADT they found that there was no “legacy effect” from intensive blood sugar control: the intensive blood sugar control group didn't enjoy CV advantages 15 years after the beginning of the study.
Veterans Affairs Diabetes Trial
The VADT study originally enrolled greater than 1,700 veterans who had long-standing type 2 diabetes, who were at high risk for heart disease, and had poor blood sugar control after they entered the study. was At enrollment, study participants had been diagnosed with diabetes for a median of 12 years. Their average A1c level, a measure of average blood sugar levels over the past two to 3 months, was 9.4%.
Participants were randomly assigned to either intensive glucose-lowering therapy or usual care for about 5.6 years. At study completion, there was a major difference in blood sugar control: the mean A1c within the intensive treatment group was 6.9%, while the mean A1c in the standard care group was 8.4%.
Despite low A1c levels, no acute treatment profit was shown on CV outcomes, including nonfatal heart attack, nonfatal stroke, recent or worsening heart failure, diabetes-related tissue damage, and amputation. , or including death resulting from CV.
Intensive blood sugar control has no long-term cardiovascular profit.
A follow-up observational study was then conducted to evaluate whether there have been any lasting effects of the intensive treatment after the interventions were accomplished through the 5.6-year study period. gave 10-year VADT follow-up showed some good thing about intensive treatment with regard to CV events. At that point, despite a spot of several years after the completion of the study, participants within the intensive treatment group still had lower A1c levels than those in the standard care group.
However, in a newly published 15-year follow-up, the advantages of intensive control on any CV outcomes were lost. By this time, A1c levels were around 8% in each groups.
This trend may suggest that to realize CV advantages, blood sugar control must be maintained and that tight short-term control, without sustained blood sugar control, may not have long-lasting effects.
New evidence supports existing evidence.
The recent VADT findings add to existing evidence from previous large studies which have failed to point out lasting advantages of intensive blood sugar control during observational follow-up. However, one study showed some helpful legacy effect. The United Kingdom Prospective Diabetes Study (UKPDS) evaluated intensive care compared with usual care in adults with newly diagnosed type 2 diabetes. When the UKPDS cohort was evaluated 10 years after completion of the study, participants within the intensive treatment arm showed heart problems advantages compared with standard care.
Taken together, the evidence suggests that older adults with an extended duration of diabetes and/or multiple coexisting conditions may not profit from intensive blood sugar control. On the opposite hand, intensive treatment could also be helpful in younger patients, with shorter duration of diabetes and fewer coexisting medical conditions.
Individualize treatment and control other cardiovascular risk aspects.
Personalizing goals and treatment regimens that the patient can safely maintain over the long run stands out as the best strategy for reducing the chance of heart problems. As I discussed in a previous blog post, treatment of older adults must consider the potential risks of intensive treatment. For example, severe blood sugar control can overshoot and result in hypoglycemia, a potentially dangerous condition wherein blood sugar drops too low. Hypoglycemic episodes are particularly harmful in older adults and will negate the potential advantages or tight control of diabetes. In older adults, slightly than aiming for tight control, we aim for the perfect control that might be achieved without increasing the chance of hypoglycemia.
To reduce the chance of CV, the authors Editorial who was with him. NEJM The study suggests prioritizing interventions that address other CV risk aspects. This includes stopping smoking, and controlling blood pressure and levels of cholesterol with medication if needed. Newer classes of diabetes medications, corresponding to sodium glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists, have CV advantages and a reduced risk of hypoglycemia, and may additionally be considered. Is.