New evidence supports diabetes guidance
Overview: Diabetes mellitus is the most common endocrine disease affecting more than one million people in the UK. Type 2 diabetes is defined by high blood glucose and is characterised by an increased risk of problems including coronary, cerebrovascular, ophthalmological and renal disease. In addition to encouraging a healthy lifestyle and modifying levels of blood pressure and lipids, Good care for people with diabetes involves lowering blood glucose in order to reduce the risk of complications. In addition management of blood pressure and lipids can help control associated risk factors.
Current treatment: To help control risk factors associated with type 2 diabetes, for management of blood lipids NICE recommends initiating therapy with generic simvastatin (up to 40 mg daily) or a statin of similar efficacy and cost unless the cardiovascular risk from non-hyperglycaemia related factors is low and to only consider prescribing a fibrate as well if triglyceride levels remain high.
New evidence: The ACCORD study (N Eng J Med 362: 1563 – 1574) looked at risk-factor control in type 2 diabetes. The study group investigated whether combination therapy with a statin plus a fibrate, as compared with statin monotherapy, would reduce the risk of cardiovascular disease in patients with type 2 diabetes mellitus who were at high risk for cardiovascular disease.
More than 5,500 patients who were being treated with open-label simvastatin for type 2 diabetes were randomly assigned to receive either masked fenofibrate or placebo.The study found no significant difference in outcomes between patients receiving simvastatin 40mg daily plus fenofibrate, and those receiving simvastatin 40mg daily plus placebo. It therefore suggests that the addition of fenofibrate causes neither a great risk nor a benefit.
The ACCORD group also looked at the effects of intensive blood-pressure control in type 2 diabetes and found no significant difference in outcomes between patients targeting 140 mmHg systolic blood pressure and those receiving more intensive therapy – with a target level of 120 mmHg. It therefore suggests that the recommended target level should not be lowered.Both outcomes support current NICE guidance.
More than 5,500 patients who were being treated with open-label simvastatin for type 2 diabetes were randomly assigned to receive either masked fenofibrate or placebo.The study found no significant difference in outcomes between patients receiving simvastatin 40mg daily plus fenofibrate, and those receiving simvastatin 40mg daily plus placebo. It therefore suggests that the addition of fenofibrate causes neither a great risk nor a benefit.
The ACCORD group also looked at the effects of intensive blood-pressure control in type 2 diabetes and found no significant difference in outcomes between patients targeting 140 mmHg systolic blood pressure and those receiving more intensive therapy – with a target level of 120 mmHg. It therefore suggests that the recommended target level should not be lowered.Both outcomes support current NICE guidance.
Commentary: This new data from the ACCORD study supports current NICE guidance on blood pressure and lipid management in people with type 2 diabetes (NICE CG 66/87 ) .NICE Guidance is to aim for a systolic blood pressure at or less than 140 mmHg in most people and to aim for a level of at or below 130mmHg only in those who have kidney, eye or cerebrovascular damage.
It also supports current NICE guidance on lipid therapy in type 2 diabetes where fibrates are not recommended to be used routinely. NICE suggests that they are only used in people who have a significantly raised triglyceride level despite maximal tolerated dose of effective statin.
This data from ACCORD can also be said to be compatible with current QOF diabetes clinical indicators for blood pressure and lipids". – Dr Roger Gadsby is the clinical lead for NHS Evidence – diabetes For more evidence on diabetes visit NHS Evidence – diabetes
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