SPECIAL FEATURE GLP-1 TEST YOUR KNOWLEDGE ANSWER, PART 3

Correct Answer: b

The AACE/ACE Consensus Statement recommends targeting an A1c of £ 6.5%.² The International Diabetes Federation recommends the same goal.⁷ The ADA/EASD Guidelines, however, recommend targeting an A1c of less than 7.0%.¹ Finally, the Veterans Affairs/Department of Defense (VA/DoD) guidelines make recommendations for A1c based on patient specific factors, such as age, complications, and life-expectancy. The VA/DoD would recommend a target of less than 7.0%, for example, for a patient with minimal to no complications and a life expectancy of more than 15 years.⁸ 

Studies show that microvascular and macrovascular complications are reduced with reduced blood glucose levels. An analysis of the United Kingdom Prospective Diabetes Study (UKPDS), for example, found a 37% reduction in the risk for microvascular complications (P < 0.0001), and a 21% reduction in the risk of any diabetes-related endpoint, including death (P < 0.0001) to be associated with a 1% decrease in A1c levels.⁹ 

The exact level that should be targeted is not black-and-white. Trials that have attempted to compare intensive glycemic control to more standard control have been somewhat conflicting. The Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial actually found that intesnsive glycemic control (A1c < 6.0% vs < 7.9%) was associated with increased risk for all-cause mortality (P < 0.04).¹⁰ The Action in Diabetes and Vascular Disease Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) trial, however, showed a reduced incidence of major macrovascular and microvascular complications in the intensive glycemic control arms without increasing mortality.The ADVANCE trial did find increased rates of hypoglycemia in the intensive group.¹¹

Diabetes guidelines are therefore consistent in recommending that the A1c goal be tailored for each patient according to factors such as existing complications, history of hypoglycemic episodes, and life expectancy.

References

1. Nathan DM, Buse JB, Davidson MB, et al. American Diabetes Association, European Association for the Study of Diabetes (ASA/EASD). Medical management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy: a consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2009; 32: 193-203.
2. Rodbard HW, Jellinger PS, Davidson JA, et al. Statement by an American Association of Clinical Endocrinologists/American College of Endocrinology consensus panel on type 2 diabetes mellitus: an algorithm for glycemic control. Endocr Pract. 2009; 15:540-59.
3. Buse JB, et al. Efficacy and safety of exenatide once weekly versus liraglutide in subjects with type 2 diabetes (DURATION-6): a randomised, open-label study. EASD 2011; Abstract 75.
4. Verspohl EJ. Novel therapeutics for type 2 diabetes: Incretin hormone mimetics (glucagon-like peptide-1 receptor agonists) and dipeptidyl peptidase-4 inhibitors. Pharmacology & Therapeutics 2009; 124(1): 113-38.
5. Klonoff DC, Buse JB, Nielsen LL, et al. Exenatide effects on diabetes, obesity, cardiovascular risk factors and hepatic biomarkers in patients with type 2 diabetes treated for at least 3 years. Curr Med Res Opin 2008;24:275–286.
6. Hansen KB, Vilsboll T, Knop FK. Incretin mimetics: a novel therapeutic option for patients with type 2 diabetes – a review. Diabetes Metab Syndr Obes 2010; 3: 155-63.
7. IDF Clinical Guidelines Task Force. Global guideline for Type 2 diabetes. Brussels: International Diabetes Federation, 2005.
8. Management of Diabetes Mellitus Update Working Group. (2010). VA/DoD Clinical Practice Guideline for the Management of Diabetes Mellitus. Version 4.0. Washington, DC: Veterans Health Administration and Department of Defense.
9. Stratton IM, Adler AI, Neil HA, et al. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ 2000; 321: 405-12.
10. The Action to Control Cardiovascular Risk in Diabetes (ACCORD) Study Group: Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med. 2008; 358: 2545-59.
11. The Action in Diabetes and Vascular Disease Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) Collaborative Group: Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med. 2008; 358: 2560-72.
     

Copyright © 2012 Diabetes In Control, Inc.

Need a review of your diabetes knowledge? Check out all of our questions on our Test Your Knowledge pages including previous SPECIAL FEATURE GLP-1 Questions.