Just recently announced was the discontinuation of a large, NIH run study in diabetics. The ACCORD study was designed to look at whether getting the sugar to as close to normal as possible would prevent heart attacks and deaths. In fact, patients in the intense treatment group did worse than patients with standard care, leading to 54 excess deaths, which is why the study was stopped early. This study has already been mentioned on some of the main media outlets (MSNBC, NY Times, and the Washington Post) and will likely make its way to the morning TV news.
Bottom Line: Trying to get the sugar too low in these patients may have been harmful. However, most physicians don't even try to come close to getting the sugar this low. If you are diabetic, keeping your sugar under control is still extremely important. Also, it was made clear that Avandia was not a factor in these deaths.
For those who want to know more: We have known for some time that there is more to diabetes treatment than just the sugar. People with Type 2 diabetes don't die for high sugar, but rather suffer from the complications caused by diabetes- heart attack, stroke, kidney failure, blindness. One of the largest diabetes trials done in Europe (UKPDS) showed us that by treating diabetes more agressively, these complications were reduced. Recommendations to keep the hemoglobin A1c (measure of overall sugar control) under 7.0% was based on this study. However, though heart attacks were reduced in the UKPDS, this difference was only 95% certain (most scientist say you need more that 95% certainty to prove something). Thus, when it comes to heart attacks, there is something more than the sugar. The ACCORD study tried to get patients to a hemoglobin A1c under 6.0% (or normal) believing that more agressive care would benefit patients. Surprisingly, there were more deaths. The full report has not yet been released, but in order to get patients this close to normal, insulin was likely neededin many cases. Insulin can drop the sugar too low and has also been associated with an increase in cardiac risk. Interestingly, guidelines from the ADA suggest preferably using insulin to get patients under control, rather than use other (newer) agents because they are more expensive and don't work as well as insulin. (Perhaps this may not be the best approach).
Also released today, was a study in the New England Journal of Medicine that had absolutely no press. This was another agressive management study, but rather than try to get the sugar as low as possible, this study tried not lonly to get patients to an A1c below 6.5% ( a more reasonable target), but also their cholesterol less than 175, and blood pressure less than 130/80. Patients were treated for over seven years and then followed for more that 5 years after treatment. After 13 years, patients in the intensive treatment group had the total death rate cut in half, with over 40% lower rates of cardiac death and heart attacks, and almost half as many patients treated for eye complications. In order to achieve these goals, the patients in the intense group needed more medicine, including insulin, but likely not as much as those in the ACCORD study.
The implication of these two studies are that:
1) Diabetics should try to keep the sugar under control for as long as possible, at an A1c less than 6.5%
2) Going below 6.5% is probably not necessary, and going below 6.0% may be harmful.
3) Diabetics must also control blood pressure and cholesterol. (All diabetics should take a statin medication, even if their cholesterol is normal!)