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Glycemic Control for Patients With Type 2 Diabetes Mellitus: Our Evolving Faith in the Face of Evidence.

Abstract

BACKGROUND

We sought to determine the concordance between the accumulating evidence about the impact of tight versus less tight glycemic control in patients with type 2 diabetes mellitus since the publication of UKPDS (UK Prospective Diabetes Study) in 1998 until 2015 with the views about that evidence published in journal articles and practice guidelines.

METHODS AND RESULTS

We searched in top general medicine and specialty journals for articles referring to glycemic control appearing between 2006 and 2015 and identified the latest practice guidelines. To summarize the evidence, we included all published systematic reviews and meta-analyses of contemporary randomized trials of glycemic control measuring patient-important microvascular and macrovascular outcomes, and completed a meta-analysis of their follow-up extensions. We identified 16 guidelines and 328 statements. The body of evidence produced estimates warranting moderate confidence. This evidence reported no significant impact of tight glycemic control on the risk of dialysis/transplantation/renal death, blindness, or neuropathy. In the past decade, however, most published statements (77%-100%) and guidelines (95%) unequivocally endorsed benefit. There is also no significant effect on all-cause mortality, cardiovascular mortality, or stroke; however, there is a consistent 15% relative-risk reduction of nonfatal myocardial infarction. Between 2006 and 2008, most statements (47%-83%) endorsed the benefit; after 2008 (ACCORD), only a minority (21%-36%) did.

CONCLUSIONS

Discordance exists between the research evidence and academic and clinical policy statements about the value of tight glycemic control to reduce micro- and macrovascular complications. This discordance may distort priorities in the research and practice agendas designed to improve the lives of patients with type 2 diabetes mellitus.

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    ,

    From the Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN (R.R.-G., V.M.M.); Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN (R.R.-G., V.M.M.); and Endocrinology Division, Department of Internal Medicine, University Hospital "Dr. Jose E. Gonzalez", Autonomous University of Nuevo Leon, Monterrey, Mexico (R.R.-G.).

    From the Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN (R.R.-G., V.M.M.); Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN (R.R.-G., V.M.M.); and Endocrinology Division, Department of Internal Medicine, University Hospital "Dr. Jose E. Gonzalez", Autonomous University of Nuevo Leon, Monterrey, Mexico (R.R.-G.). montori.victor@mayo.edu.

    Source

    MeSH

    Biomarkers
    Blood Glucose
    Diabetes Complications
    Diabetes Mellitus, Type 2
    Evidence-Based Medicine
    Glycated Hemoglobin A
    Health Status
    Humans
    Hypoglycemic Agents
    Practice Guidelines as Topic
    Quality of Life
    Risk Assessment
    Risk Factors
    Time Factors
    Treatment Outcome

    Pub Type(s)

    Journal Article
    Meta-Analysis
    Review
    Research Support, N.I.H., Extramural

    Language

    eng

    PubMed ID

    27553599

    Citation

    Rodríguez-Gutiérrez, René, and Victor M. Montori. "Glycemic Control for Patients With Type 2 Diabetes Mellitus: Our Evolving Faith in the Face of Evidence." Circulation. Cardiovascular Quality and Outcomes, vol. 9, no. 5, 2016, pp. 504-12.
    Rodríguez-Gutiérrez R, Montori VM. Glycemic Control for Patients With Type 2 Diabetes Mellitus: Our Evolving Faith in the Face of Evidence. Circ Cardiovasc Qual Outcomes. 2016;9(5):504-12.
    Rodríguez-Gutiérrez, R., & Montori, V. M. (2016). Glycemic Control for Patients With Type 2 Diabetes Mellitus: Our Evolving Faith in the Face of Evidence. Circulation. Cardiovascular Quality and Outcomes, 9(5), pp. 504-12. doi:10.1161/CIRCOUTCOMES.116.002901.
    Rodríguez-Gutiérrez R, Montori VM. Glycemic Control for Patients With Type 2 Diabetes Mellitus: Our Evolving Faith in the Face of Evidence. Circ Cardiovasc Qual Outcomes. 2016;9(5):504-12. PubMed PMID: 27553599.
    * Article titles in AMA citation format should be in sentence-case
    TY - JOUR T1 - Glycemic Control for Patients With Type 2 Diabetes Mellitus: Our Evolving Faith in the Face of Evidence. AU - Rodríguez-Gutiérrez,René, AU - Montori,Victor M, Y1 - 2016/08/23/ PY - 2016/03/31/received PY - 2016/07/01/accepted PY - 2016/8/25/entrez PY - 2016/8/25/pubmed PY - 2017/11/8/medline KW - blindness KW - complications KW - evidence-based medicine KW - myocardial infarction KW - type 2 diabetes mellitus SP - 504 EP - 12 JF - Circulation. Cardiovascular quality and outcomes JO - Circ Cardiovasc Qual Outcomes VL - 9 IS - 5 N2 - BACKGROUND: We sought to determine the concordance between the accumulating evidence about the impact of tight versus less tight glycemic control in patients with type 2 diabetes mellitus since the publication of UKPDS (UK Prospective Diabetes Study) in 1998 until 2015 with the views about that evidence published in journal articles and practice guidelines. METHODS AND RESULTS: We searched in top general medicine and specialty journals for articles referring to glycemic control appearing between 2006 and 2015 and identified the latest practice guidelines. To summarize the evidence, we included all published systematic reviews and meta-analyses of contemporary randomized trials of glycemic control measuring patient-important microvascular and macrovascular outcomes, and completed a meta-analysis of their follow-up extensions. We identified 16 guidelines and 328 statements. The body of evidence produced estimates warranting moderate confidence. This evidence reported no significant impact of tight glycemic control on the risk of dialysis/transplantation/renal death, blindness, or neuropathy. In the past decade, however, most published statements (77%-100%) and guidelines (95%) unequivocally endorsed benefit. There is also no significant effect on all-cause mortality, cardiovascular mortality, or stroke; however, there is a consistent 15% relative-risk reduction of nonfatal myocardial infarction. Between 2006 and 2008, most statements (47%-83%) endorsed the benefit; after 2008 (ACCORD), only a minority (21%-36%) did. CONCLUSIONS: Discordance exists between the research evidence and academic and clinical policy statements about the value of tight glycemic control to reduce micro- and macrovascular complications. This discordance may distort priorities in the research and practice agendas designed to improve the lives of patients with type 2 diabetes mellitus. SN - 1941-7705 UR - https://www.unboundmedicine.com/medline/citation/27553599/full_citation L2 - http://www.ahajournals.org/doi/full/10.1161/CIRCOUTCOMES.116.002901?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub=pubmed DB - PRIME DP - Unbound Medicine ER -