Intensive Diabetes Management

Intensive diabetes management aims to achieve lower blood sugars

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.

We look here at why some controversy has arisen over lower HbA1c targets.

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 very 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.

How safe is intensive diabetes management?

In recent years there has been discussion about the safety of intensive diabetes management within the media and within healthcare circles.

Generally studies have found lowering of HbA1c values to be positive, however, some question marks have arisen about whether certain therapies may carry more danger.

The ACCORD study, discussed in further detail below, is an example of a study in which death rates were noticeably higher in the intensive therapy group.

No explicit reason was given for why and, within the medical profession, this has lead practitioners and consultants to question whether HbA1c targets under 7% should be achieved.

However, a number of commentators have since questioned the involvement of the now banned drug Avandia in the study and contest that a lower HbA1c, in itself, should not be isolated as the reason for the higher death rate.

Experts advice on blood glucose control

The advice to patients is to maintain good control of diabetes. Lower HbA1c values have been shown to reduce the risk of long term complications and, where hypoglycemia can be avoided, an HbA1c value below 7% represents good health management.

The ACCORD study

The ACCORD (Action to Control Cardiovascular Risk in Diabetes) 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 ^[12].

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.

Why were there more deaths amongst the intensive therapy group in the ACCORD study?

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.

However, not everyone is convinced and a number of commentators have questioned certain drugs, such as Avandia, as being a potential cause of the deaths. Avandia was later banned, in 2010, for being associated with an increased risk of cardiovascular disease.

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. ^[13]

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.