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Diabetes is an extremely burdensome and costly chronic disease. It affects an estimated 4–6% of the world’s population, and its prevalence continues to rise.1 2 Diabetes is a major cause of blindness, end stage renal disease, and cardiovascular complications, all of which are preventable.3 4 Clinical practice guidelines for the management of diabetes emphasise the importance of optimal glycaemic control. Specifically, some clinical practice guidelines have suggested targeting a glycated haemoglobin (Hb) A1c concentration ⩽7%, or ⩽6% for those able to safely achieve it.5
ACCORD, ADVANCE, AND UKPDS 10-YEAR FOLLOW-UP
With the recent publication of 3 notable trials, a great deal of debate and confusion has been created about the cardiovascular effects of lowering glucose to near-normal concentrations in people with type 2 diabetes. The Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, the Action in Diabetes and Vascular Disease: Preterax and Damicron Modified Release Controlled Evaluation (ADVANCE) trial, and the 10-year follow-up of the UK Prospective Diabetes Study (UKPDS) provide complementary information about cardiovascular risk reduction with glucose lowering that can be used to help patients to develop evidence-based goals of therapy individualised to their own circumstances.
ACCORD, ADVANCE, and the 10-year follow-up of the UKPDS all reported the effects of intensive glucose lowering on vascular outcomes.6–8 All 3 studies were randomised controlled trials, with an intensive glucose-lowering group and a “standard” control group with less stringent glycaemic targets. The trials differed in many respects (table 1) that may help to reconcile the differences in results (table 2).
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Participants and duration of follow-up
There were important differences in the types of participants recruited and the duration of follow-up. ACCORD enrolled >10 000 patients starting in 2001 and followed them for a median of 3.4 years, at which point the intervention was discontinued (17 mo before the planned completion date) because of unexplained …
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