Clinical Question: Does intensive glucose control in patients with type 2 diabetes improve outcomes more than usual control?

Bottom Line: This study confirms the initial findings of the ACCORD study: In middle-aged or older patients with cardiovascular risk factors, the best target for glycated hemoglobin is between 7.0% and 7.9%. (Level of Evidence: 1b)

Reference: The ACCORD study group. Long-term effects of intensive glucose lowering on cardiovascular outcomes. N Engl J Med 2011;364(9):818-828.

Study Design: Randomized controlled trial (double-blinded)

Funding Source: Government

Allocation: Concealed

Setting: Outpatient (any)

Synopsis: The ACCORD study randomized persons aged 40 to 79 years with type 2 diabetes mellitus and known cardiovascular disease or cardiovascular risk factors to either intensive glucose control (glycated hemoglobin target < 6.0%) or usual control (7.0% to 7.9%). The study was stopped after 3.7 years when a significant increase in all-cause mortality was detected in the intensive therapy group. At that time, the median glycated hemoglobin levels were 6.4% and 7.5% in the intensive and usual treatment groups, respectively. At that time, the target for patients in the intensive therapy group was relaxed to a target glycated hemoglobin between 7.0% and 7.9%; follow-up continued for an additional 17 months. This report describes the results at the end of the entire 5 year follow-up period. At that time, the median glycated hemoglobin levels were 7.2% and 7.6%. Essentially, there was little difference between the outcomes of the original study and those at 5 years. Although nonfatal myocardial infarctions were still less common after 5 years (hazard ratio [HR] = 0.82; 95% CI, 0.7 - 0.96), cardiovascular and all-cause deaths (HR = 1.19; 1.03 - 1.38) were more common.