Abstract:
Background - The effects of intensive glucose control on cardiovascular events in patients with long-standing type 2 diabetes mellitus remain uncertain.
Methods - We randomly assigned 1791 military veterans (mean age, 60.4 years) who had a suboptimal response to therapy for type 2 diabetes to receive either intensive or standard glucose control. Other cardiovascular risk factors were treated uniformly. The mean number of years since the diagnosis of diabetes was 11.5, and 40% of the patients had already had a cardiovascular event. The goal in the intensive-therapy group was an absolute reduction of 1.5 percentage points in the glycated hemoglobin level, as compared with the standard-therapy group. The primary outcome was the time from randomization to the first occurrence of a major cardiovascular event, a composite of myocardial infarction, stroke, death from cardiovascular causes, congestive heart failure, surgery for vascular disease, inoperable coronary disease, and amputation for ischemic gangrene.
Results - The median follow-up was 5.6 years. Median glycated hemoglobin levels were 8.4% in the standard-therapy group and 6.9% in the intensive-therapy group. The primary outcome occurred in 264 patients in the standard-therapy group and 235 patients in the intensive-therapy group (hazard ratio in the intensive-therapy group, 0.88; 95% confidence interval [CI], 0.74 to 1.05; P=0.14). There was no significant difference between the two groups in any component of the primary outcome or in the rate of death from any cause (hazard ratio, 1.07; 95% CI, 0.81 to 1.42; P=0.62). No differences between the two groups were observed for microvascular complications. The rates of adverse events, predominantly hypoglycemia, were 17.6% in the standard-therapy group and 24.1% in the intensive-therapy group.
Conclusions - Intensive glucose control in patients with poorly controlled type 2 diabetes had no significant effect on the rates of major cardiovascular events, death, or microvascular complications, with the exception of progression of albuminuria (P = 0.01).
My Opinion:
This article mainly speaks on the relationship between vascular complications and intensive glucose control. Maximal and standard doses of an oral agent or insulin therapy. The reason veterans were selected in my opinion is because, after strict rigorous regime and diet plans, most of them tend to loosen up once they return to the comfort of their homes. In order to preoccupy themselves, they would socialize more with family and friends and catch up on what they have missed out on while they were in training or for some, while at the battlefield. Most of the time, this socializing lead to lots of "good" food. Food becomes a "go to drug" for these ex-soldiers to de-stress themselves.
Some veterans would not be able to give up their disciplined lifestyle. Others however may succumb to the temptations around them and it is with them that metabolic diseases such as diabetes develops. This can be applied to veterans in an Asian setting and the older generation in our communities face a similar problem as well. Most old people cannot hold their tiring jobs after a certain age and become home bound with a very sedentary lifestyle. Lack of activity and high intake of carbohydrates and fats can lead to type 2 diabetes.
Intensive glucose control may sound like the best way to solve this problem but according to this article it proved to have no significant effect on reducing mainly vascular complications. However, if started at an early stage this could prove effective. For this to happen, people should be educated on detecting early signs and symptoms of diabetes. Early intervention must be made available for such patients. Hospitals and clinics should be equipped to be able to administer to these patients from developing a more serious case of type 2 diabetes mellitus.
If prevention fails, we can still hope that early intensive intervention when detected can save the day.
References:
http://www.nejm.org/doi/full/10.1056/NEJMoa0808431#t=article
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