The Real Lessons from ACCORD

By Richard Jackson, MD
Director of Medical Affairs
Healthcare Services, and Strategic Initiatives
Joslin Diabetes Center

We keep hearing about the recently published ACCORD study, and how tight blood glucose control might not be that important — or even risky.  What should your typical Type 2 patient really be taking away from these studies?

Although the reported results from the ACCORD study may have been unexpected, the overall messages are fairly clear, and they are good news.  For those of you with pressing time commitments who wish to cut to the quick, there are two main takeaway messages:

*  First, the incidence of heart disease in patients with Type 2 diabetes continues to decrease.

* Second, if you are older, with longer duration of diabetes, with multiple risk factors for heart disease, and have a high A1C, you should not be using multiple glucose lowering therapies to achieve an A1C of lower than 7.0.

To elaborate: The main message demonstrated by the ACCORD study is that the incidence of cardiovascular events in people with Type 2 diabetes is steadily decreasing, and decreasing faster than the experts have expected.  This isn’t the message that appeared in the media, nor was it the focus of the expert discussions at the American Diabetes Association meeting in June.  However, this message has the most impact for people with Type 2 diabetes.

The ACCORD study addressed the question of whether aggressively pushing for an A1C target of under 6.0 would reduce serious heart disease and deaths from heart disease, when compared to a control group treated to the currently accepted A1C target of 7.0 or less.   The primary result was unexpected; the study was stopped early because the people in the more intensively treated group had significantly more deaths, including deaths from heart disease.  This result received the most press, but I find it the second most important message, and here’s why: The differences in deaths was relatively small, 14 deaths/1,000 patient years in the intensive group vs. 11 deaths/1,000 in the standard treatment group.  This difference was statistically significant, however, so the study was halted by the safety monitoring group that oversees every big clinical study.

However, the most impressive number of all was not directly quoted in the paper.  When planning a study such as this, calculating the ‘expected event rate’ is one of the most important steps.  In the ACCORD study, this step involved estimating, as accurately as possible, using the best data available at the time, the expected incidence of heart attacks and deaths from heart attacks in this particular high-risk patient population. This was necessary so that researchers could plan how many people with diabetes they would need to follow, and for how long, to determine whether there was an advantage to tighter control.  Experienced biostatisticians, using the best data available, calculated the expected event rate to be 55 deaths/1,000 patient years.  AMAZING! Both the intensive treatment (14/1,000 patient years) and the standard treatment group (11/1,000 patient years) had a much lower incidence of severe heart events than predicted.

Another recently published study looking at the benefits of lower blood pressure and LDL cholesterol targets in people with Type 2 diabetes, used this language in their summary (excuse their ueber-academic style):

“As the effectiveness of therapy improves and new treatment strategies are widely applied, it is becoming more difficult to conduct a trial in which adequate numbers of clinical end points are achievable in a reasonable length of time for individuals without CVD (cardiovascular disease) at baseline.”

The translation: “Pesky patients with diabetes are living too long, and no one is getting heart disease!  How can we do our research?!”  These studies also serve as a reminder for Type 2 diabetics that glucose control is not the single most important factor in avoiding cardiovascular complications.  Blood pressure control is probably the most important, followed by keeping your LDL cholesterol on target, and then by glucose control.

btw, although they were not included in this study, it is certainly reasonable to carry these same messages from the ACCORD study over to people with Type 1 diabetes.

So plan your future carefully, as you are probably going to live a long time!

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Today’s post is a re-post from DiabetesMine, one of our favorite diabetes blogs. We liked what Dr. Jackson said so much that we asked Amy Tenderich, who blogs at DiabetesMine,  to let us share it with you.

This entry was posted in Diabetes Day2Day and tagged , , , , . Bookmark the permalink.

3 Responses to The Real Lessons from ACCORD

  1. Doris J. Dickson says:

    Sorry, doc. As a 34 year veteran of juvenile onset diabetes (who has no major complications), I beg to differ and I will NEVER knowingly go back to an A1C anywhere close to 7.0.

    I may have no major complications as defined by the gods that be but I had plenty of more subtle “features” as I call them when my A1Cs were in the prescribed low to mid 6′s.

    Since adjusting my target blood sugar to 85 (in other words, normalized) and my A1C is consistently 4.7-5.1 (still trying for consistently mid 4′s), my “features” have decreased and many have gone bye-bye entirely.

    I do this without passing out, without seizures, without requiring assistance. I do this by NOT eating whatever is in sight and injecting large doses. I use small doses (similar to Dr. Bernstein’s Theory of Small Numbers) of insulin (10-15 times per day) – but I do not use a pump. I don’t eat carbs if I’m >110. I wait. I test 12-15 times a day. I project manage. I analyze. I adjust. I am diligent and not whiney.

    My point – there is a difference between a 7 and 5. It is not always dangerous if done correctly and the body will talk to you.

    I no longer have a highly acidic stomach or a spastic colon. I no longer have a big pink blop on my ankle. I have far fewer blood sugar swings and far fewer anger issues (we’ll call it serotonin is more in balance).

    I do not take cholesterol meds and won’t – you’re not messing with my liver or my glucose store. I do take lisinopril because I DO believe keeping BP down is important. I also have an underactive thyroid and take levoxyl – but I target a TSH of 2.5 or lower there too – direct correlation between a pile of symptoms and that target including high LDL.

    Oh – my triglycerides are in the 50 ball park and my HDL is in the 75 ball park – consistently.

    So, I firmly do believe in cause and effect of blood sugar (and thyroid levels) you should see how those triglycerides drop with a small A1C drop and NO side-effect ridden meds.

    And please medical people – stop calling those of use who do it well “anecdotes” (and the other charming phrases we are referred to). Is it not possible we do know our butt from our elbows? Is it not possible WE are the Subject Matter Experts? I realize we’re rare but we should not be dismissed so easily.

  2. greg says:

    I think this story is great. I wish my a1c was this good,ive had diabetes for over 20 years. Its so hard for me to keep it in control. I think if i had health insurance it would be alot better. I like to know what can i do to try and keep this under control when i cant afford 875 per month for insurance. Its been so hard on me.If anyone has any answers i would welcome you to please write back to me. God bless

    • Living with diabetes is not easy without access to medical care. I would strongly suggest that you find a way to access any free medical care that you can find.

      In addition, there are a number of resources online that can help. One is the Joslin Diabetes Forums. The Forums are moderated by staff from the clinic at Joslin Diabetes Center; contributors to the forums include a number of very helpful individuals who have much to offer in the way of advice and tips on how to live with diabetes. You can find the forums at http://forums.joslin.org/

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