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Glycemic Control in Type 2 Diabetes: Time for an Evidence-Based About-Face?

Victor M. Montori, MD, MSc; and Mercè Fernández-Balsells, MD
[+] Article and Author Information

From the Mayo Clinic, Rochester, Minnesota, and Hospital Universitari de Girona Doctor J. Trueta, Girona, Spain.


Grant Support: The American Diabetes Association awarded Dr. Montori a Clinician Investigator grant in 2004. Novo Nordisk, a maker of insulin, subvented the American Diabetes Association granting program but did not have direct contact with the investigators and did not play any role in the awarding of the grant to the research team. Dr. Fernández-Balsells has received grant support from the Instituto de Salud Carlos III, Ministerio de Sanidad y Consumo (BA08/90035), Government of Spain.

Potential Financial Conflicts of Interest:Grants received: V.M. Montori (American Diabetes Association), M. Fernández-Balsells (Instituto de Salud Carlos III, Ministerio de Sanidad y Consumo, Government of Spain). Dr. Montori's research group does not take funding from pharmaceutical or medical device corporations.

Requests for Single Reprints: Victor M. Montori, MD, MSc, Knowledge and Encounter Research Unit, Mayo Clinic, Plummer 3-35, 200 First Street SW, Rochester, MN 55905; e-mail, kerunit@mayo.edu.

Current Author Addresses: Dr. Montori: Knowledge and Encounter Research Unit, Mayo CTSA, Plummer 3-35, 200 First Street SW, Rochester, MN 55905.

Dr. Fernández-Balsells: Servei d'Endocrinologia, Hospital Universitari de Girona Doctor J. Trueta, Carretera de França s/n, 17007 Girona, Spain.


Ann Intern Med. 2009;150(11):803-808. doi:10.7326/0003-4819-150-11-200906020-00008
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Some diabetes guidelines set low glycemic control goals for patients with type 2 diabetes mellitus (such as a hemoglobin A1c level as low as 6.5% to 7.0%) to avoid or delay complications. Our review and critique of recent large randomized trials in patients with type 2 diabetes suggest that tight glycemic control burdens patients with complex treatment programs, hypoglycemia, weight gain, and costs and offers uncertain benefits in return. We believe clinicians should prioritize supporting well-being and healthy lifestyles, preventive care, and cardiovascular risk reduction in these patients. Glycemic control efforts should individualize hemoglobin A1c targets so that those targets and the actions necessary to achieve them reflect patients' personal and clinical context and their informed values and preferences.

Figures

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Figure.
Forest plots of trials measuring the effect of intensive glycemic control on macrovascular complications (A), microvascular complications (B), and weight gain and severe hypoglycemia (C).

For all plots, no difference between intensive and less intensive glycemic control is denoted by the vertical continuous line. UKPDS(a) refers to the main UKPDS trial, which included 2729 patients in the intervention group and 1138 patients in the conventional group. We subdivided the main UKPDS trial in overweight patients with diabetes into 2 comparisons: UKPDS(b), which included 342 overweight patients in the intervention group with metformin and 411 in the conventional group, and UKPDS(c), which included all 1293 overweight patients in the intervention group (metformin, glibenclamide, and insulin) and 411 in the conventional group. When possible, we presented the results using data from UKPDS(c). We calculated the number of cardiovascular deaths in UKPDS(a) by subtracting all noncardiovascular deaths from all reported deaths. When trials used different outcome definitions, the asterisk and dagger identify which trial reported which outcome definition or combination of outcomes (when both symbols accompany the trial name). ACCORD = Action to Control Cardiovascular Risk in Diabetes; ADVANCE = Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation; CGC = conventional glycemic control; IGC = intensive glycemic control; RR = relative risk; UKPDS = United Kingdom Prospective Diabetes Study; VADT = Veterans Affairs Diabetes Trial.

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