Posts Tagged ‘aggressive vs less aggressive approach in diabetes’

Action to  control cardiovascular risks in diabetes (ACCORD ) : The accord long-term follow-up results are just out  in NEJM  March 2011   http://www.nejm.org/doi/full/10.1056/NEJMoa1001286

The ACCORD study which created a huge buzz in 2008 when it was prematurely terminated  for fear of  bad outcome ,  with aggressive blood sugar lowering (Hb A1 c <6 %)  .The  negative  trend was confirmed in the aggressive* group even after switching to non aggressive group  at further 1.7 years follow-up  till late 2009.

*Intensive /Aggressive is used interchangeably in this article .

Why should aggressive glucose lowering be harmful ?

This  question is  struggling to get  a  logical answer for over 5 decades. To answer this question,  it  need to realised  our  fundamental understanding of  diabetes  itself  is  flawed ,   as  we have equated it with high blood sugar.

                                                    A  persistent state of  high blood sugar   can never be  used  as a  synonym for diabetes melites.  There is much . . . much  more , to it  !    Patients ,  lay persons and pharma industry  may  think  like  that   but  it is unfortunate many  physicians  have the same thinking   pattern .  The fault lies there .

Diabetes is a systemic metabolic disorder  apparently due to lack of insulin( or relative excess of it ! as in insulin resistance ) in which hyperglycemia is one of  grossly visible abnormality.

It is estimated there can be at least 100 invisible or less visible  biochemical abnormality in every diabetic individual.In fact , DM has more profound effect on lipid metabolism  than carbohydrate metabolism. Almost every microproteins   in our body  gets glycated . That  can be either be  reversible or irreversible .We know how difficult it to reverse diabetic nephropathy or retinopathy

If we realise the above reality there is absolutely no surprise why lowering blood sugar alone  does not reverse diabetic complications !

The second major issue is the modalities we  use  to target the  blood sugar 

Right from the days of early sulphonyl ureas  and biguanides ( of  Tolbutmide and Phenphormin etc ) one thing was very clear (or unclear  ! ) vigorous control of blood sugar has always been a doubtful intervention in controlling  diabetic complications .

                                                If  high blood sugar causes  excess mortality,   why  bringing it to  normal levels  does not reduce long-term mortality convincingly  ?

Is the Madness  lie in the methods ?

It seems so.  ACCORD study has strong reasons to suggest the  worse outcome in aggressive management is due to multiple , drugs used in a random fashion.

Then there  is always this  question  . . .How good is HB A1c  to assess the adequacy of DM control.  ? Biochemically this molecule still has lots of issues regarding its reproducibility.

Individuals who control blood sugar  by  natural means and by minimal drugs seem to do well. Early diabetics and  pre diabetics  should be our targets.

One should also remember the drugs we have today to control DM  have yet to prove the long-term safety records (Say for a span of 30-40 years)

Modern medicine  usually does not bother about the future  . . . it simply shrugs of the issue  with a caution statement . . . that the ” Drugs  you take  are well-tested and  thought to be  safe and useful with the current level of research !”

What is aggression in DM management ?

No one has defined it so far. But the any of the following may fit in with the  definition

  • Any DM patients prescribed more than  two drugs and Insulin
  • Premature start of Insulin
  • Lack of diet and exercise management  and  trying to substitute them with  incremental drugs and insulin 
  • Finally ,any patient who is always tensed up about his HBA1C and switches his physician  frequently  end up in  early complication   than the ones who follow simple non pharmacological approach.


How good is the idea  ,   to define aggressive thrapy  with reference to HBA1  levels ?

ACCORD defines aggressive approach  with HBA1C   as less than 6 %  and   Non aggressive as  7-8%  ( or  is it 6-7 %)

Not withstanding the limitations of HBA1C , there can be many patients who will require multiple drugs and insulin to maintain the HBA1C  even  at  7-8 %

How do yo label  them ?  Aggression by  number of  drug used   . . .  but still  considered  Non aggresive control  by HBA1c  criteria .

If ACCORD study fixes the indiscriminate use of drugs as a cause for bad outcome ,  then the very definition of aggressive approach need to be changed !

 Final message

ACCORD says it all . Never be aggressive on diabetic patients. The aggression we show with drugs can be more dangerous than the deadly diabetes itself.

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