Intensive Diabetes Management
Intensive diabetes management is a term to describe treatment therapies which aim to achieve lower average blood glucose results. Tighter blood glucose control is widely believed to reduce the risk of diabetic complications.
Tighter blood glucose control has been shown to reduce the risk of diabetic complications but it may not be appropriate for everyone.
We look here at the benefits of intensive diabetes treatment as well as under which circumstances HbA1c targets may be relaxed.
What is an intensive diabetes treatment therapy?
An intensive diabetes therapy can be regarded as any treatment regime designed to significantly reduce blood sugar control over the long term. How this is achieved may well vary between patients.
For people with type 2 diabetes, this could involve adding a more potent medication, such as a sulfonylurea (eg gliclazide), insulin or a combination of drugs.
For people with type 1 diabetes, it could involve being put on a regime of multiple insulin injections or going onto a diabetes pump - this is known as intensive insulin therapy.
Long term studies have shown that achieving and maintaining a 1% (11 mol/mol) reduction in HbA1c can significantly reduce the risk of developing long term diabetes complications including microvascular complications (retinopathy, nephropathy and neuropathy) and macrovascular complications such as heart disease and stroke.
How safe is intensive diabetes management?
In recent years there has been discussion about the safety of intensive diabetes management within healthcare circles.
Generally studies have found lowering of HbA1c values to be positive, however, some people may be less able to achieve lower HbA1c results without increasing the risk of severe hypoglycemia.
The following groups tend to be at a higher risk of severe hypos:
- People with unstable type 1 diabetes (brittle diabetes)
- People with diminished awareness of hypoglycemia
- Some elderly people
If achieving tighter control results causes increased hypoglycemia or adds a significant burden, particularly in the elderly, it is important to raise these issues with your doctor or consultant.
Intensive diabetes management in the elderly
HbA1c targets for the elderly are the same as those for younger people, that is to achieve an HbA1c of 48 mmo/mol (6.5%) or under, unless there is an increased risk of hypoglycaemia as a result. Patients at greater risk of hypos should instead aim for an HbA1c of 58 mmol/mol or under.
In July 2014, a study carried out by researchers from University College London and the University of Michigan found that in elderly patients with an HbA1c of below 9%, intensive diabetes management only increased life expectancy in cases whereby the treatment was not viewed as a significant burden.
The ACCORD study
The ACCORD study (Action to Control Cardiovascular Risk in Diabetes) is an example of a study in which death rates were noticeably higher in the intensive therapy group.
The ACCORD study ran from 2001 until 2009 and aimed to investigate whether intensive diabetic treatment would reduce risk of cardiovascular disease (heart disease) in people with type 2 diabetes .
Patients selected had an average age of 62 years old (ages varied between 40 and 79) and had pre-existing cardiovascular disease put them at high risk of potentially fatal heart conditions.
In the intensive group, average HbA1c levels were 6.4%, compared with 7.5% in the non-intensive group, however the intensive study was closed early as after about 3 and a half years, the intensive group was shown to have a 20% higher number of deaths than the non-intensive group, and a 35% higher instance of cardiovascular related death.
Whilst the research suggests that intensive diabetes management is likely to be more harmful in older patients with type 2 diabetes and established heart disease, there is controversy over how much the results of the study were influenced by heart deaths as a result of patients taking Avandia.
Avandia (Rosiglitazone) was one of the drugs used to intensively manage blood glucose levels. Shortly after the ACCORD study was halted, the drug was found to be associated with an increased risk of heart disease.
However, the findings of the ACCORD study noted that there was no evidence that any single medication or combination of medications was responsible for increased risk of heart attacks.
What do other studies say?
The ADVANCE (Intensive Blood Glucose Control and Vascular Outcomes in Patients with Type 2 Diabetes) study was relatively similar to the ACCORD study, however, notably the types of drug prescribed in the study were different.
The results of the ADVANCE study showed that those on the intensive therapy arm of the study had a 10% reduction in vascular events.
This 10% reduction occured when compared with the standard therapy and there was a 21% reduction in the development of nephropathy(kidney disease).
The ADVANCE study used sulfonylureas as one of the main prescription drugs within the intensive therapy group and Avandia was rarely prescribed in this group.
This contrasts with the ACCORD study in which the majority of the intensive group were taking Avandia.