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Evolution in the American Diabetes Association Standards of Care

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Glycemic treatment goals have been discussed twice annually for at least the past 3 years that I have served on the Professional Practice Committee of the American Diabetes Association (ADA). These were first established over a decade ago without the benefit of any of the landmark outcomes studies that are available for review today. The overall recommendations have been subsequently well supported by the Stockholm Diabetes Intervention Study,1 the Diabetes Control and Complications Trial,2 the Kumamoto study,3 and, most recently, the U.K. Prospective Diabetes Study (UKPDS).4,5 In each of these trials, a more intensively treated group achieved an average hemoglobin A_1c (A1C) of 7%, and there was an associated reduction in microvascular endpoints and trend toward improvement in macrovascular endpoints. In each, the more stringently controlled group had a higher incidence of hypoglycemia, greater weight gain, and increased costs, although the net benefit with respect to endpoint reduction was felt to adequately compensate for these adverse effects.

However, the trend towards reduction in cardiovascular events in these trials is in part counterbalanced by the Veterans Administration Cooperative Study,6 a feasibility study of modest size and short duration, in which there was a nonstatistically significant increase in cardiovascular events in the intensive treatment group. Furthermore, interpretation of the UKPDS results is complicated by the fact that there was a statistically significant reduction in cardiovascular disease (CVD) events in the obese group treated with metformin (Glucophage), but a lesser effect in those treated with insulin and sulfonylurea despite their having a modestly greater reduction in A1C. Thus, it remains uncertain whether more intensive glycemic control is associated with cardiovascular benefit. At least three large-scale multicenter trials are underway to examine the effect of glycemic control on CVD events, and they will hopefully provide a definitive . . . [Full Text of this Article]

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