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- December 1, 2008 |
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"Lowering blood glucose - Walking the tightrope between good and evil"Prof. Richard O'Brien (biography)
English - 2008-05-17 - 44 minutes
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Summary :
Glucose control in type 1 and type 2 diabetic patients has been shown to reduce microvascular complications, as seen in the DCCT and UKPDS trials, however there is some controversy about the relationship between intensive glycaemic control and cardiovascular (CV) risk.
There is clinical trial data suggesting that intensive glucose control in type 2 patients is not effective in lowering CVD risk. In the context of such findings it is of interest to consider the somewhat “flat” relationship between A1c and CV risk making it difficult to show short-term benefits, or potential adverse effects of insulin or of oral hypoglycaemic agents.
Among the oral hypoglycaemic agents it has long been suggested that sulfonylureas carry an increased risk of cardiovascular events, and non-UKPDS studies of metformin versus comparators even show a non-significant but 3-fold increased risk of mortality and CHD with metformin, according to a Cochrane Review (2005), however caution must be used in interpreting these short-term findings. Recently the glitazones came under scrutiny following the meta-analysis published by Nissen and Wolski in the NEJM, in which the authors noted the analysis had important limitations. This was followed by an interim analysis of the prospective RECORD trial which was designed to look at cardiovascular outcomes, and at the time showed no evidence of any increase in death from either cardiovascular causes or all causes with rosiglitazone, but an increased risk of heart failure (1).
According to the Avandia (rosiglitazone) product information, the drug is not recommended in patients with known ischaemic heart disease, particularly in those taking nitrates, and has been shown in pooled short-term clinical studies to be associated with an increased risk of myocardial ischaemia (angina, infarction), particularly in those who needed several antidiabetic drugs or nitrates. On the basis of the available information says Prof. O'Brien, it would be prudent that this recommendation apply both to rosiglitazone and pioglitazone.
The news however is not all bad. Prof. O'Brien shows evidence from the DCCT/EDIC study suggesting that early tight glucose control leads to reduced macrovascular disease many years later, and he talks about why rosiglitazone is ideal for achieving good control early in diabetes in patients without cardiac disease.
Copyright © 2008 E-MedHosting.com Inc.
Learning objectives :
After viewing this presentation the participant will be able to discuss:
Lowering blood glucose in the context of:
- Microvascular effects
- Macrovascular effects
- Possible harm
- Mechanisms for possible harm
- Glitazones, glucose control and CVD
Bibliographic references :
1. Philip D. Home, D.M., D.Phil., Stuart J. Pocock, Ph.D., Henning Beck-Nielsen, D.M.S.C., Ramón Gomis, M.D., Ph.D., Markolf Hanefeld, M.D., Ph.D., Nigel P. Jones, M.A., Michel Komajda, M.D., John J.V. McMurray, M.D., for the RECORD Study Group Rosiglitazone Evaluated for Cardiovascular Outcomes — An Interim Analysis NEJM 2007. Volume 357:28-38.
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