ACCORD: microvascular outcomes
http://general-medicine.jwatch.org/cgi/content/full/2010/1230/3?q=topic_diabetes
老年糖尿病患者，嚴格血糖控制，對ESRD, retinopathy沒有用，neuropathy有一點點用
血脂控制(加上fenofibrate)也沒有滿意的答案
唯一一個明確的答案是BP control SBP 130mmHg 即可
ACCORD: Microvascular Outcomes
In older diabetic patients, clinical microvascular endpoints were unaffected by tight glycemic control.
In the landmark ACCORD trial, older patients with longstanding type 2 diabetes were randomized to various intensities of glycemic control, blood pressure (BP) control, and lipid management. The first round of published results dealt with so-called "macrovascular outcomes" — myocardial infarction, stroke, and cardiovascular death (JW Gen Med Jun 6 2008, JW Cardiol Mar 14 2010, and JW Cardiol Mar 14 2010; also JW Gen Med Dec 30 2010). In 2010, data on microvascular outcomes were published.
In the glycemic-control arm of the study, patients were randomized to intensive or standard treatment, which resulted in mean glycosylated hemoglobin (HbA1c) levels of 6.4% and 7.5%, respectively. The primary composite microvascular endpoint included both renal and retinal outcomes — development of end-stage renal disease, rise in serum creatinine level to >3.3 mg/dL, or need for retinal photocoagulation or vitrectomy. During nearly 4 years of follow-up, researchers found no difference in the frequency of this microvascular endpoint in the two groups. Intensive treatment did, however, appear to slow progression of some measures of neuropathy (JW Gen Med Jul 13 2010).
For a subgroup of 2800 patients, retinopathy outcomes were tracked in more detail. Intensive glycemic control lowered the incidence of progressive retinopathy (according to changes in serial retinal photographs), but not the incidence of moderate vision loss. The same pattern was seen for patients who received fenofibrate plus simvastatin (vs. simvastatin alone) — less progression of retinopathy on photographs, but no difference in incidence of vision loss. However, intensive BP control lowered neither the incidence of progressive retinopathy nor vision loss (JW Gen Med Jul 13 2010).
If you are looking for nice black-and-white conclusions from ACCORD, you will be disappointed. Two interventions, tight glycemic control and addition of fenofibrate to simvastatin, led to a better outcome for a surrogate microvascular endpoint (progression of retinopathy on photographs) but not for a hard clinical endpoint (moderate vision loss). Moreover, in previously published results from ACCORD, neither tight glycemic control nor fenofibrate prevented cardiovascular death or stroke, and tight glycemic control was associated with higher all-cause mortality and excess hypoglycemia.
Putting all of the ACCORD microvascular and macrovascular information together, intensive glycemic control and fenofibrate therapy have not been proven to confer net clinical benefit in older diabetic patients; whether longer duration of treatment could tip the balance of benefits and harms favorably is unknown. The one unambiguous finding from ACCORD is that intensive control of systolic BP (target, <120 mm Hg) was no better than standard control (<140 mm Hg) for any outcome.
— Allan S. Brett, MD
Published in Journal Watch General Medicine December 30, 2010
老年糖尿病患者，嚴格血糖控制，對ESRD, retinopathy沒有用，neuropathy有一點點用
血脂控制(加上fenofibrate)也沒有滿意的答案
唯一一個明確的答案是BP control SBP 130mmHg 即可
ACCORD: Microvascular Outcomes
In older diabetic patients, clinical microvascular endpoints were unaffected by tight glycemic control.
In the landmark ACCORD trial, older patients with longstanding type 2 diabetes were randomized to various intensities of glycemic control, blood pressure (BP) control, and lipid management. The first round of published results dealt with so-called "macrovascular outcomes" — myocardial infarction, stroke, and cardiovascular death (JW Gen Med Jun 6 2008, JW Cardiol Mar 14 2010, and JW Cardiol Mar 14 2010; also JW Gen Med Dec 30 2010). In 2010, data on microvascular outcomes were published.
In the glycemic-control arm of the study, patients were randomized to intensive or standard treatment, which resulted in mean glycosylated hemoglobin (HbA1c) levels of 6.4% and 7.5%, respectively. The primary composite microvascular endpoint included both renal and retinal outcomes — development of end-stage renal disease, rise in serum creatinine level to >3.3 mg/dL, or need for retinal photocoagulation or vitrectomy. During nearly 4 years of follow-up, researchers found no difference in the frequency of this microvascular endpoint in the two groups. Intensive treatment did, however, appear to slow progression of some measures of neuropathy (JW Gen Med Jul 13 2010).
For a subgroup of 2800 patients, retinopathy outcomes were tracked in more detail. Intensive glycemic control lowered the incidence of progressive retinopathy (according to changes in serial retinal photographs), but not the incidence of moderate vision loss. The same pattern was seen for patients who received fenofibrate plus simvastatin (vs. simvastatin alone) — less progression of retinopathy on photographs, but no difference in incidence of vision loss. However, intensive BP control lowered neither the incidence of progressive retinopathy nor vision loss (JW Gen Med Jul 13 2010).
If you are looking for nice black-and-white conclusions from ACCORD, you will be disappointed. Two interventions, tight glycemic control and addition of fenofibrate to simvastatin, led to a better outcome for a surrogate microvascular endpoint (progression of retinopathy on photographs) but not for a hard clinical endpoint (moderate vision loss). Moreover, in previously published results from ACCORD, neither tight glycemic control nor fenofibrate prevented cardiovascular death or stroke, and tight glycemic control was associated with higher all-cause mortality and excess hypoglycemia.
Putting all of the ACCORD microvascular and macrovascular information together, intensive glycemic control and fenofibrate therapy have not been proven to confer net clinical benefit in older diabetic patients; whether longer duration of treatment could tip the balance of benefits and harms favorably is unknown. The one unambiguous finding from ACCORD is that intensive control of systolic BP (target, <120 mm Hg) was no better than standard control (<140 mm Hg) for any outcome.
— Allan S. Brett, MD
Published in Journal Watch General Medicine December 30, 2010
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