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The Latest Example of the Over-hyped Value of Guidelines

By June 6, 2019Commentary

Some medical experts are convinced that they know the absolute best way to care for certain conditions and they have become quite good at getting their ideas embedded into guidelines, which in some cases are used to reward or punish physicians.  Unfortunately for these experts the research often fails to support their rigid approaches.  Such is the case with intensive glucose control for patients with Type 2 diabetes, as reflected in research published in the current New England Journal of Medicine.  One rationale for intensive control has been that it would lower cardiovascular disease risks.   (NEJM Article)   Diabetes patients have been whipsawed for several years as recommendations for how intensively blood sugar levels should be controlled have changed.  A similar pattern has been seen in regard to treatment of hypertension.  The current article is a 15 year follow-up to a trial of several thousand patients at high-risk for cardiovascular disease assigned to either intensive control or usual care.  The treatment period of intensive glucose control was about 6 years.  The primary outcome was occurrence of a major cardiovascular event, such as a heart attack or development of congestive heart failure.  Blood glucose levels were significantly lower in the intensive treatment group during the trial but the levels began to equalize in the follow-up period.  The intensive control group also experienced more weight gain during the trial and follow-up period.  While the risk of major cardiovascular events was slightly lower in the intensive control group at the end of the follow-up period, that decrease did not reach statistical significance.  There was no evidence of shorter time to death or of better quality of life for the intensive control patients.  Rates of hospitalization were similar across both groups.  One interpretation is that intensive glucose control may have some benefit when it is being used, but has no carryover effect if a patient returns to standard care.  But intensive control has its own risks, such as the weight gain that was observed and hypoglycemia.  And treatments to prevent cardiovascular disease, such as statins, have become more widespread and may be a more effective method of reducing that risk for diabetes patients.  In any event, great caution should always be taken before assuming that medical experts have the definitive answer to what the best treatment must be.

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