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Action to Control CV Risk in Diabetes (ACCORD) — A New Look at an Old Trial

Was there a common thread in participants who failed to reach target A1c value in ACCORD trial?

While current guidelines recommend a customized patient goal for A1c based on comorbidities, the ACCORD trial has shown that middle-aged and elderly patients with increased cardiovascular risk may benefit by targeting an A1c goal in the 7.0-7.9% range. There are many contributing factors as to why a patient fails to reach their glycemic goal; demographics and clinical characteristics may play a role.

The ability to identify patients who are likely to need additional tools and support to reach their target A1c may increase their chances of success. A recent cohort study analyzed information from the ACCORD trial to identify factors that may have prevented participants from reaching an A1c <8.0%. This study looked at 4,685 of the participants randomly assigned to the standard therapy arm of the ACCORD trial. Standard therapy consisted of: target A1c of 7.0-7.9%, glycemic management visits every 4 months, intensification of therapy when A1c was >8.0%, and therapy with any medication approved by the ACCORD trial formulary, free of charge. The current trial analyzed these participants 12 months after randomization. Baseline demographic, metabolic and clinical profiles were compared between those who achieved an A1c <8.0% to an A1c >8.0% at 12 months. The two-sample t-test and chi-squared test were used to analyze continuous and categorical variables respectively. Logistic regression was employed to analyze the association between participants with A1c <8.0% or >8.0% at 12 months and baseline and follow-up factors. Odds ratios for attaining the goal A1c were derived by using a maximum likelihood estimation.

At 12 months after randomization 1,491 participants had an A1c >8.0% and 3,194 had an A1c <8.0%. Statistically significant findings associated with failure to reach a goal of <8.0% include: insulin use (odds ratio (OR): 0.51, 95% confidence interval (CI): 0.40-0.65; p<0.001), severe hypoglycemia (OR:0.57, CI:0.37-0.89; p=0.014), and black race (OR:0.74, CI:0.61-0.89; p=0.002).

Despite free access to medication and physicians, over 30% of participants failed to reach the target A1c goal of <8.0% at 12 months. This study has identified 3 patient populations that need to be monitored more closely than others. However, more studies need to be conducted to determine why these 3 populations have difficulty reaching their goals, which will help guide clinicians in their choice of therapy.

Practice Pearls:

  • By identifying characteristics of patient populations with trouble reaching their glycemic goals, more support may be allocated early on to avoid treatment failure.
  • 3 populations likely to have trouble reaching glycemic goals are: African Americans, insulin users, and patients who have episodes of severe hypoglycemia.
  • Further studies need to be conducted to find out what why the 3 patient populations in question have trouble attaining their A1c goal.

Researched and prepared by Devon Brooks, Doctor of Pharmacy Candidate from LECOM College of Pharmacy, reviewed by Dave Joffe, BSPharm, CDE

Drake TC, Hsu FC, Hire D, et al. “Factors associated with failure to achieve a glycated haemoglobin target of <8.0% in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial.” Diabetes, Obesity and Metabolism. 18.1 (2016): 92-95. Print.