Letters Section Editor: Robert M. Golub, MD, Senior Editor.
To the Editor: In his Clinical Crossroads article, Dr Abrahamson1 reviewed medications for intensifying glucose control. We were dismayed by his recommendation for intensive glycemic therapy for a 74-year-old woman with no known microvascular disease. Abrahamson implied that the UK Prospective Diabetes Study (UKPDS) clinical trial provided evidence that intensive glycemic control produces cardiovascular benefit in type 2 diabetes; this is not the case. Reviewers of the epidemiological evidence have concluded that for type 2 diabetes (1) there is no experimental evidence suggesting that improved glycemic control produces cardiovascular benefit (the UKPDS clinical trial found no discernable improvements in diabetes-related mortality, cardiovascular events, vision, renal function, pain, symptomatic peripheral neuropathy, amputations, or quality of life over a 10-year period); (2) the UKPDS found significantly lower diabetes-related mortality, stroke, and visual decline from adding 3 to 4 blood pressure medications in pursuit of tight blood pressure control; and (3) in patients who were overweight (>120% of ideal body weight), treatment with metformin monotherapy was associated with reduced diabetes-related mortality and microvascular outcomes, while monotherapy with insulin or sulfonylureas was not, despite similar levels of glycemic control.2- 4 Additionally, and of particular concern for those considering intensifying therapy, combination oral therapy (metformin plus sulfonylurea) was associated with higher diabetes-related mortality.2
Hayward RA, Hofer TP, Vijan S. Intensive Glucose Control in Elderly Adults. JAMA. 2007;297(20):2195-2196. doi:10.1001/jama.297.20.2195-a