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April 07, 2008
ADVANCE ACCORD
This editorial evaluates the differences in conclusions between ACCORD (which showed that the group with the lower risk of death from heart attacks was the group that had the less-intensive glycemic-lowering target) and ADVANCE [Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation] (which preliminary results without release of mortality data indicates the opposite).
What is most interesting to me about this analysis is that Dr. Hellman identifies two factors that might explain the differences between the studies. Both are patient characteristics: the ability to detect one's own low blood sugar, and the decreased mental acuity or cognitive function of advanced diabetics.
This is a novelty: a recognition that real patients with real and multiple problems don't fit our neat study categories. Sure, maybe it is true that intensive therapy for diabetics save lives, if the study is done under controlled other-worldly conditions. But in real patients with difficult lives, intensive therapy kills.
Dr. Hellman calls for individualizing therapy. This is certainly important. Knowing the patient, loving the patient and caring for the patient are essential. And then, the A1c isn't so important.
| By Robert Maddox | 06:05 PM