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Invited Commentary
May 28, 2012

Prioritizing Treatments in Type 2 Diabetes Mellitus: Comment on “Role of Intensive Glucose Control in Development of Renal End Points in Type 2 Diabetes Mellitus”

Author Affiliations

Author Affiliations: HealthPartners Research Foundation, Minneapolis, Minnesota.

Arch Intern Med. 2012;172(10):770-772. doi:10.1001/archinternmed.2012.1775

The analyses presented by Coca et al1 demonstrate the lack of evidence that intensive glycemic control reduces the kinds of advanced complications of major concern to patients, such as renal failure. In this Invited Commentary, we will discuss this article's results in the larger context of preventing complications of type 2 diabetes mellitus (T2DM).

Current T2DM guidelines2 suggest that hemoglobin A1c (HbA1c) goals should be personalized in the range of less than 6.5% to less than 8% based on individual patient factors, such as age, comorbidity, complications, hypoglycemia risk, and other factors. The recommendation for the lower HbA1c goal carries an evidence grade C, and for a very good reason—there is little evidence that an HbA1c goal less than 6.5% (or <7%) is beneficial to patients with T2DM. Let us consider the evidence from randomized trials in T2DM. The UKPDS did not test any specific HbA1c goal. Rather, that study provided strong evidence of the long-term microvascular and macrovascular benefits of early treatment with metformin, a sulfonylurea, or insulin soon after diagnosis.3 It is clear that using these drugs has benefit and that they may often lower HbA1c to well below 7%, but the UKPDS did not demonstrate the benefit of sustained multidrug therapy to maintain HbA1c less than 7%.