Glycemic and blood pressure targets What should glycaemic and blood pressure targets be?

‘This week we have seen the death of Rosiglitazone’, said Dr Neil Munro (Esher, UK) after European regulators recommended withdrawal of the drug due to increased concerns about cardiovascular safety. The management of Type II diabetes remains a challenge for primary care physicians. A range of drugs with different mechanisms of action are available to clinicians but what targets of glycaemic control should we be aiming towards? The UKPDS trial showed a beneficial effect of improving blood pressure control in reducing microvascular complications but this was not seen for macrovascular complications during the study. However, a ‘legacy effect’ was seen after the initial phase of the trial completed with reduced rates of myocardial infarction and death in the group with more intensive blood glucose control. So is a ‘the lower the better’ approach justifiable in clinical practice and is it safe? The ACCORD study has recently cast doubt on the safety of a very intensive approach to blood glucose lowering. Patients who were treated to a target HbA1c of 6% had a significantly increased mortality compared to those with less tight blood glucose control and the trial was stopped early. Observational data of the relationship between HbA1c and survival suggests an optimal HbA1c of 7-7.5%.

Multifactorial intervention in diabetes has been shown to be effective in patients with type II diabetes. In the STENO-2 study, patients were randomised to receive an intensified multifactorial intervention or standard therapy. The intensified multifactorial intervention included tight glucose control and use of aspirin, lipid lowering agents and renin-angiotensin system blockers. There was a significant reduction in cardiovascular mortality and microvascular complications in the group which was intensively treated. The ADDITION study is also investigating the role of intensified multifactorial intervention in patients with type II diabetes detected by screening.

Blood pressure control in addition to adequate glycaemic control is also important to reduce diabetic complications but the optimal blood pressure target is not known. Is ‘the lower the better’ justifiable? The INVEST study included patients over 50 years of age with diabetes and coronary heart disease and randomised patients to a target systolic blood pressure of less than 130mmHg, 130-140mmHg (usual care) or >140mmHg. There was an increased mortality seen in the group treated to a target of less than 130 systolic during the extended follow-up period compared with the usual care group suggesting a target of 130-140mmHg may be optimal in patients with diabetes and coronary heart disease.
 

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