« Should we reconsider our therapeutic goals in 2011 ? » Pr. Bernard CHARBONNEL - Nantes

SFD Congress-Geneva

Reported by

Dr Ramona Abi Gerges

Publications :1. N Engl J Med 2011;364:818-282. N Engl J Med 2003;348:383-933. N Engl J Med 2011;364:829-414. The Lancet 2010, vol.375,issue 9713, Pages 481 -

4895. Diabetes Care 2010,April 28 vol. 33 no. 5 983-9906. Diabetologia 2010, 53:2079–20857. Diabetologia 2009,52:2288–22988. BMJ 2010; 340:b5444 9. BMJ 2000; 321:405-1210.Annals of Internal Medicine 2009, Vol.151 • Nbr

6-396

• No epidemiologic argument in favor of poor glycemic control

• Paradoxical results in ACCORD showed that mortality increases when

HBA1C<6% and >8%

• UKPDS: reduction in micro-vascular , microalbuminuria complications when HBA1C<8%

• Reasons for increased mortality

• Rapid decrease in HBA1c ?• Severe hypoglycemia ?• Uncontrolled hyperglycemia

itself?• Drug interactions,

polymedications?

VADT ADVANCE

ACCORD

Baseline HBA1c 9,4% 7,2% 8,1%

∆HBA1C -2,5 -0,9 -1,7

Insulin used 89% 40% 77%

Duration of diabetes

11,5 y 8 y 10 y

Severe Hypoglycemia intensive v/s standard

21,2% v/s 9,9

2,7% v/s 1,5 16,2 % v/s 5,1

cardiovascular mortality /y

2,1 v/s 1,7 4,5 v/s 5,2 2,6 v/s 1,8

All cause of Mortality

8,9 v/s 9,6 5,0 v/s 4,0

 Epidemiologic Relationships Between A1C and All-Cause Mortality During a Median 3.4-Year Follow-up of Glycemic Treatment in the ACCORD Trial

Diabetes Care doi: 10.2337/dc09-1278

Conclusion

1. Hba1c is a marker of risk of complication

2. Hypoglycemia is a marker of risk of mortality rather than reason

3. The objective of the treatment is not to bring down HBA1C but to prevent complications micro and macro-vascular, irreversible once installed

Conclusion 1. The target HbA1c varies between 6,5 % and 8 %

according to the patients

2. The individualization of the therapeutic way remains

the best daily approach in our clinical practice

3. « Earlier ? Probably»

« More extremely ? Probably not

»

Thank you