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Glycemic Control in Type 2 Diabetes:
How Tight is Too Tight?
Frederick L. Brancati, MD, MHS
Professor of Medicine & Epidemiology
Director, Division of General Internal Medicine
Visit Hopkins GIM at www.hopkinsmedicine.org/gim
NCH Healthcare System, Naples, FL
21 January 2010
Objectives
• Identify controversy in diabetes care
• Establish framework for decision-making
• Compare/contrast results from recent trials
Why Treat A1c to 7% Target ?
• Hyperglycemia predicts micro &
macrovascular disease epidemiologically
• The link with micro & macrovascular
disease is biologically plausible
• Hyperglycemia poses non-vascular risks
– Infection, Hypovolemia, Urinary Frequency
• Improved glycemic control reduces risk of
microvascular disease
Why Treat A1c to 7% Target ?
• Improved glycemic control reduces CVD in
– Type 1 diabetes (DCCT)
– Recently diagnosed type 2 diabetes (UKPDS)
• Black box warnings require context
– Lactic acidosis with metformin is very rare
– CHF with TZDs is relatively mild/reversible
– Black box MI warning for rosiglitazone only
Cumulative Risk of Infectious Disease
Death by Diabetes Status in US Adults,
NHANESII Mortality Study
AG Bertoni et al. Diabetes
Care 2001 24:1044-9.
Age, Sex, RaceAdjusted
Relative Hazard
of CHD by
HbA1c in 1321
Adults without
Diabetes (A) and
1626 Adults with
Diabetes (B)
Selvin, E. et al. Arch Intern
Med 2005;165:1910-1916.
Cumulative Incidence of First Episode of Falling in 139
Elderly Nursing Home Residents by Diabetes Status
In multivariate analysis, only
diabetes (adjusted hazard ratio
4.03; 95% confidence interval,
1.96–8.28) and gait and
balance (adjusted hazard ratio
5.26; 95% confidence interval,
1.26–22.02) were significantly
and independently associated
with an increased risk of falls.
MS Maurer et al.
J Gerontol A Biol Sci
Med Sci (2005)
60:1157–62