RESPUESTA DE LA AACE A LOS RESULTADOS DEL VA DIABETES TRIAL

AACE Diabetes Scientific Advisory Committee Response to VADT Trial Data
Dear AACE Members:
The recent publication of the VA Diabetes Trial has raised questions about glycemic targets in certain populations. In the study, subjects had an average duration of diabetes of 11.5 years and multiple cardiovascular risk factors. The intensively treated group lowered A1c from 9.4% to 6.9 % compared with 8.4% in the conventional therapy group. All subjects were intensively treated to reduce LDL-cholesterol and blood pressure, to use anti-platelet therapies, and to stop tobacco use.. The cardiovascular event rate was much lower than anticipated, likely because of aggressive use of non-glycemic therapies, so that the study became underpowered for observing a difference in outcome based on glycemic control. Intensive glycemic control was associated with a 3-4-fold increase in hypoglycemia and with weight gain, but only with a modest reduction in cardiovascular events, nephropathy, and retinopathy.
The American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE) continue to advocate good glycemic control for diabetic patients, recognizing that treatment targets and strategies have to be individualized by clinicians for their patients. Aggressive glycemic control may not be warranted, for example, in later stages of type 2 diabetes, or in patients with higher risk of hypoglycemia or cardiovascular disease. AACE/ACE Diabetes Guidelines (link) continue to stress comprehensive management of the diabetic patient, including lipid and blood pressure control, anti-platelet agents, and smoking cessation.
As always, risks and benefits of therapies must be weighed by clinicians. AACE/ACE will continue to monitor and report on developments as they occur.

DIABETES Y COPLICACIONES VASCULARES (VETERANS)

Por fin se publica el VADT y la conclusión principal es la que conocíamos desde el ADA de San Francisco y apoya los resultados del ACCORD. En pacientes con alto riesgo cardiovascular y mal control previo, el tratamiento intensivo de la hiperglucemia y la reducción de la HbA1c hasta 6,9 % no se asoció a ninguna mejoría en los endopoints macro ni microvasculares, mientras que aumentaron las hipoglucemias.

Estos resultados pueden hacernos cambiar la práctica clínica o al menos ver las cosas de otra forma.