Effect of 1 Year of Near-Normal Blood Glucose Levels on Retinopathy in Insulin-Dependent Diabetics

Lauritzen, Torsten; Larsen, Hans‐Walther; Frost‐Larsen, Kim; Deckert, T.

doi:10.1016/s0140-6736(83)92585-0

Cited by 359 publications

(138 citation statements)

References 21 publications

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“…An improvement in HbA 1c may be attained with slow but progressive decline. In both the VADT [8] and ACCORD [6] trials, HbA 1c declined very quickly, and such a rapid improvement has been associated, in controlled studies, with initial worsening of existing diabetic complications [38,39]. Interestingly, a much smoother reduction in HbA 1c was obtained in the ADVANCE trial [7].…”

Section: Discussionmentioning

confidence: 99%

Megatrials in type 2 diabetes. From excitement to frustration?

Prato

2009

Diabetologia

119

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Whether glycaemic control may result in a reduction of cardiovascular (CV) risk has been a matter of continuous discussion and investigation. Epidemiological analyses have extensively suggested a relationship between glycaemic control and CV events; however, the results of intervention trials have been less conclusive. The UKPDS reported a 16% reduction in the risk of myocardial infarction, but this reduction was not statistically significant. The results of the Kumamoto and PROactive studies could not allow any firm conclusions to be drawn either, because of limited size and the defined primary endpoint, respectively. The results of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) and Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) trials and the Veteran Administration Diabetes Trial (VADT) were published in rapid succession over the second half of 2008 and at the beginning of 2009. A total number of almost 25,000 type 2 diabetic patients were recruited in these three trials, which assessed the effect of intensive glycaemic control vs conventional treatment on well-defined CV endpoints. In spite of the achievement and maintenance of strict glycaemic control (HbA 1c <7.0%), no beneficial effect of intensive therapy was apparent in any of the studies. At the same time these results were presented, the results of an analysis of the 10 year follow-up of the UKPDS also became available and provided a more optimistic view of the potential benefit of achieving good glycaemic control. The relative risk reductions for myocardial infarction and all-cause mortality were significantly lower in the patients who initially received the intensive treatment compared with those in the conventional treatment arm. Moreover, the initial benefit in terms of microvascular complications observed at the end of the intervention trial remained unaltered at follow-up. Once again the debate on the importance of glycaemic control in preventing macrovascular complications remains unsettled. These results, however, require some reconciliation, and the objective of this commentary is to analyse a series of elements, including the changes in the treatment approach to CV risk factors in type 2 diabetes, the effect of glucoselowering agents, and the characteristics of the patients included in the different trials, that should be taken into account when interpreting the results of intervention trials in type 2 diabetes.

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Section: Discussionmentioning

confidence: 99%

Megatrials in type 2 diabetes. From excitement to frustration?

Prato

2009

Diabetologia

119

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“…Values are n (%) a Changes regressed in one patient after the first year b All patients who received laser therapy had early NPDR at baseline Diabetic retinopathy may be adversely affected during pregnancy by major changes in distribution of blood flow, an increase in cardiac output as well as hormonal changes including increased IGF-1 levels [17,18]. In addition, sudden improvement in glycaemic control induces a decrease in retinal blood flow, secondary hypoxia and thus worsening of retinopathy [19,20].…”

Section: Discussionmentioning

confidence: 99%

Influence of pregnancy on long-term progression of retinopathy in patients with type 1 diabetes

Arun

Taylor

2008

Diabetologia

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Aims/hypothesis Pregnancy in type 1 diabetic women is associated with risk of worsening of retinopathy. It has been reported that deterioration continues in the months after delivery, but direct data are lacking. It is also unclear what impact pregnancy has on the long-term progression of retinopathy. Methods We studied 59 women with type 1 diabetes who had retinal photographs before pregnancy and yearly for 5 years post pregnancy. These photographs were graded using the EURODIAB retinopathy grading system. Results The mean duration of diabetes was 14.4±8.2 years and mean age at pregnancy was 29.8±5.5 years. Mean HbA 1c was 8.2±2.0% before pregnancy with tighter control during pregnancy itself. This value was high despite efforts to improve take-up of pre-conception care. Mean HbA 1c was 8.6±1.5 during the follow-up period. At baseline, 43 (72.9%) women were free of retinopathy, 15 had nonproliferative retinopathy and one woman had previously had laser therapy. During pregnancy four women required laser therapy. Over the next 5 years none required laser therapy, although retinopathy worsened in 14 women. Tenyear follow-up data were available on 22 women, one of whom required laser therapy 8 years after pregnancy. Baseline retinopathy status was the only independent risk factor which predicted progression of retinopathy. Conclusions/interpretation Pregnancy is not associated with post-partum worsening of retinopathy.

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“…It has been reported that the cumulative incidence of retinopathy at ten years after the onset of diabetes reaches approximately 20 to 60% (14)(15)(16) (Table 1). In many studies (6)(7)(8)(9)(10)(11) that reported that rapid correction of hyperglycemia led to progression of retinopathy, the subjects were patients who already had retinopathy, and the suggested reasons for this progression were hypoglycemia or abnormality in coagulation (18)(19)(20)(21)(22). The subjects of the current study did not have retinopathy at study entry; our data showed that the rapid reduction of the HbA1c level did not lead to an increased incidence of retinopathy.…”

Section: Discussionmentioning

confidence: 99%