Intensive Diabetes Treatment and Cardiovascular Disease in Patients with Type 1 DiabetesN Eng J Med 353;25: 2643 – 2653

DCCT: Diabetes Control and Complications Trial

EDIC: Epidemiology of Diabetes Interventions and Complications Study

Taz Babiker

Population

Patients with type 1 diabetes

Aged between 13 – 40 at randomisation

Excluded Cardiovascular disease

BP > 140/90

Fasting cholesterol > 3 SD above age and sex-specific means

Mean 17 years follow up

Intervention

≥ 3 daily injections with insulin, OR

Insulin pump

4 self-monitored glucose measurements/24hrs

Target glucose 3.9 – 6.7 mmol/l

Target HbA1c < 6.05%

At the end of DCCT, conventionally treated group offered intensive treatment

Differences between 2 groups less over 11 yrs of EDIC

Comparison

Conventional therapy = No glucose goals beyond those needed to prevent

symptoms of hyperglycaemia and hypoglycaemia

1-2 daily injections of insulin

At the end of DCCT – 7.4% vs 9.1% (p<0.01) Conventional group offered intensive treatment

HbA1c differences narrowed over 11 years of EDIC

Outcome

Primary outcome = time to first cardiovascular event Non-fatal MI/stroke

Death due to CVD

Subclinical MI

Angina

Need for angioplasty/CABD

Effect of HbA1c during EDIC was not assessed

Medications

No medication history during DCCT but use of ACE inhibitors discouraged and statins not available – microalbuminuria associated with 2.5 x increased risk of CVD

Year 11 of EDIC – significant difference in use of beta-blockers: conventional 7% vs intensive 3% (p<0.05)

Discussion

Should we intensively treat early then relax? i.e. “metabolic memory”

What role do beta blockers play in diabetes and cardiovascular disease risk

Low numbers of events

Some CV events subjective

High number of silent MIs