Focus Shifts for Long-Term Diabetes
For Advanced Diabetes, Intense Blood Sugar Control May Be Wrong Goal
Jan. 8, 2009 -- People with longstanding diabetes should focus on lowering blood pressure and cholesterol rather than intensive blood sugar control, diabetes experts now say.
It's still extremely important for people in the earlier stages of diabetes to do as much as they can to keep their blood sugar as close as possible to normal levels. There's little doubt that this cuts the risk of the microvascular (kidney, eye, and nerve) and macrovascular (heart attack and stroke) complications that plague people with diabetes.
But three recent studies -- including one by William Duckworth, MD, and colleagues in the current issue of the New England Journal of Medicine -- suggest that people with advanced diabetes have more important things to worry about than making heroic efforts to get their blood sugar down to near-normal levels.
"Blood pressure and blood lipid control are more important than very intensive glucose control," Duckworth, director of diabetes research for Phoenix Veterans Affairs, tells WebMD. "That is not to say glucose control is not important: I said very intensive glucose control."
Not long ago, nobody would have agreed. Tight glucose control -- the tighter the better -- was the mantra for all diabetes patients. In fact, it took some time (and the invention of new blood sugar-lowering drugs) for researchers to put this mantra to the test.
Now, Duckworth's study is the third major study to find that although patients with advanced diabetes must keep their blood sugar from going wild, intensive blood sugar control offers little extra benefit.
How Low Should Blood Sugar Go?
What does intensive blood sugar control mean? Diabetes doctors and patients usually focus on A1c (glycated hemoglobin level or HbA1c), a measure of blood sugar control over time. The ADA says people with diabetes should try to get their A1c levels below 7%. Those who can't do this with one oral diabetes medication should make more "intensive" efforts by using multiple medications and/or insulin.
There are risks. More drugs mean more side effects -- and with some diabetes drugs, a very unwanted side effect is weight gain. Much more important is the risk of a sudden crash in blood sugar: hypoglycemia. A severe hypoglycemic event means an altered mental state, unconsciousness, or even death. And there's evidence that a severe hypoglycemic event increases a person's risk of heart attack or stroke.
In a new guideline issued this month, The American Diabetes Association, the American College of Cardiology, and the American Heart Association still recommend intensive glucose control for most adults with diabetes.
But the guideline also notes that in advanced diabetes, where heart disease may already be well developed, blood sugar control has "minimal or no role." Jay S. Skyler, MD, associate director for academic programs at the University of Miami's Diabetes Research Institute, is lead author of the guideline.