In type 2 diabetes, intensive glucose control for 5.6 years did not differ from usual care for major CV events at 14 years
These long-term follow-up data show no legacy effect from intensive glucose control on cardiovascular (CV) events, differing from the results of the United Kingdom Prospective Diabetes Study, an ACP Journal Club commentary noted.
The Veterans Affairs Diabetes Trial Follow-up (VADT-F) found that the cardiovascular (CV) benefit of having been treated with intensive glucose control for about five years was not sustained after 15 years. The initial trial randomized 1,791 patients with an HbA1c level of 7.5% or above to either intensive glucose control (target of a normal HbA1c level and median level at least 1.5% lower than the usual care group) or usual care (target HbA1c level of 8% to 9%). Ten years after the intervention began, CV events were significantly lower in the intensive group, but in the latest results, they were not.
The study was published on June 6 by the New England Journal of Medicine. The following commentary by Gaetano Santulli, MD, was published in the ACP Journal Club section of the Sept. 17 Annals of Internal Medicine.
Whether the benefits of intensive blood glucose control extend beyond a finite period of intensive management (the so-called legacy effect) continues to be debated. Although a glycemic legacy effect was found in UKPDS (United Kingdom Prospective Diabetes Study), the VADT-F study found no such effect for long-term rates of major CV events in patients with advanced type 2 diabetes. The 2 postintervention studies differed in diabetes stage at the time of intervention (new onset in UKPDS, advanced in VADT), which might partly explain the dissimilar outcomes and suggest a crucial role for tight glycemic control in the early phases of the disease.
What is the main take-home message for physicians? The findings of these studies support the importance of maintaining glycemic control over time and suggest that we should promote intensive dietary and lifestyle approaches, which hold promise for long-term remission. We also need to consider the availability of effective cardioprotective strategies, including statins, angiotensin-converting enzyme inhibitors, and antiplatelet agents, none of which were standard practice at the time of UKPDS. Moreover, glucagon-like peptide-1 receptor agonists and sodium–glucose cotransporter 2 inhibitors have recently been shown to improve CV outcomes independently of glycemic control. Evidence for CV benefit in type 2 diabetes continues to evolve; hence, we should never lower our guard!