Diese Präsentation wurde erfolgreich gemeldet.
Die SlideShare-Präsentation wird heruntergeladen. ×
Anzeige
Anzeige
Anzeige
Anzeige
Anzeige
Anzeige
Anzeige
Anzeige
Anzeige
Anzeige
Anzeige
Anzeige
Nächste SlideShare
DCCT
DCCT
Wird geladen in …3
×

Hier ansehen

1 von 16 Anzeige
Anzeige

Weitere Verwandte Inhalte

Diashows für Sie (20)

Ähnlich wie ACCORD (20)

Anzeige

Aktuellste (20)

Anzeige

ACCORD

  1. 1. ACCORD The ACCORD Study Group. “Effects of intensive glucose lowering in Type 2 Diabetes” New England Journal of Medicine. 2008. 358(24):2545-59. SUMMARIZED BY MARIA MORKOS
  2. 2. Action to Control Cardiovascular Risk in Diabetes (ACCORD) Summarized by: Maria Morkos, MD; Laxmi Suthar, MD
  3. 3. BACKGROUND  Research has shown that in T2DM patients, a relationship exists between A1c levels and CV events  No previous study has investigated if intensive therapy to target normal A1c levels would decrease CV events in T2DM patients who had CV disease/risk factors
  4. 4. CLINICAL QUESTION Would a therapeutic strategy targeting normal A1c levels (below 6% vs targeting A1c levels of 7.0-7.9%) reduce the rate of cardiovascular events in T2DM persons with established cardiovascular disease and/or additional cardiovascular risk factors?
  5. 5. DESIGN  Analysis: chi square tests and two-sample t-tests  77 clinical centers across the US and Canada  N = 10,251  Group 1: received intensive therapy targeting an A1c of less than 6.0%  Group 2: received standard therapy targeting an A1c of 7.0 to 7.9%  Follow-up was 3.5 years (intensive therapy was discontinued after higher mortality was found in the intensive therapy group)  Primary outcomes:  first occurrence of nonfatal MI or stroke  or death from CV causes (MI, HF, stroke, CV cause of death after non-cardiovascular surgery)  Secondary outcome: death from any cause
  6. 6. POPULATION Inclusion Criteria  T2DM and A1c of 7.5% or higher  ages 40-79 yo  CV disease or between 55-79 yo and had anatomical evidence of significant atherosclerosis, albuminuria, LVH, or at least 2 additional risk factors for CV disease (dyslipidemia, HTN, currently smoking, obesity) Exclusion Criteria  Frequent or recent serious hypoglycemic events  Unwillingness to do home glucose monitoring or inject insulin  BMI > 45  Serum Cr of > 1.5  Or other serious illness
  7. 7. INTERVENTIONS  Group 1  received intensive therapy targeting A1c of less than 6.0%  attended monthly visits for the first 4 months then q2 months after that, with at least one interim phone call  Group 2 (Placebo Control)  received standard therapy targeting A1c of 7.0 to 7.9%  glycemic management visits q4 months  All patients received study formulary meds as well as glucose monitoring supplies  Any marketed anti-hyperglycemic therapy that was not provided by formulary could also be prescribed but was not provided by study investigators  Also received instructional materials and behavioral counseling regarding diabetes  Therapeutic regimens were individualized at investigators’ and patients’ discretion based on study-group assignment and response to therapy
  8. 8. INTERVENTIONS (CONT’D)  Glucose lower drugs included: metformin, secretagogues, thiazolidinediones, an alpha glucosidase inhibitor, incretin, insulin  In addition…  4733 patients were randomly assigned to lower their BP by receiving either intensive therapy (SBP target <120) or standard therapy (SBP target <140)  5518 patients were randomly assigned, while on simvastatin, to either fenofibrate or placebo  At time of study publication, BP and lipid trials were still continuing
  9. 9. RESULTS  At 1 year and after, throughout the follow-up period,  median A1c for intensive therapy group was 6.4%  median A1c for standard therapy group was 7.5%  The intensive therapy group had significantly higher rates of:  hypoglycemia (requiring assistance)  weight gain (>10 kg)  and fluid retention  The intensive therapy group had a lower rate of nonfatal MI BUT higher rate of death from CV causes; no significant difference in rates of nonfatal stroke  Rate of death from any cause was HIGHER in the intensive therapy group
  10. 10. CRITICISMS/LIMITATIONS  Did not study the components of the intervention strategies used  Did not address an optimal rate to lower glucose levels  Glucose lowering strategies were adjusted for each patient in an open fashion based on their glycemic response to a drug/drug combination and the development of clinical sx such as hypoglycemia  No clear explanation for higher mortality found in intensive therapy group  ?Application to T2DM patients with A1c lower than 7.5% or T2DM patients w/o CV history or risk factors  Benefits from intensive glucose lowering therapy may need more than 3.5 years to emerge
  11. 11. BOTTOM LINE Therapeutic targeting of A1c levels below 6.0% INCREASED the rate of death from any cause after a mean of 3.5 years, as compared with a strategy targeting levels of 7.0-7.9% In patients with a median A1c 8.1% and previous CV events/multiple CV risk factors
  12. 12. DISCUSSION QUESTIONS  What are two important inclusion criteria for the diabetic population this trial targeted?  What were the target A1c levels of the two different therapy groups?  What was the outcome discovered after ~3 years of the trial?
  13. 13. DISCUSSION ANSWERS  What are two important facts about the patient population this trial targeted?  ANSWER: Had A1c greater than 7.5% and had to have either a CV event in past or several CV risk factors  What were the target A1c levels of the two different therapy groups?  ANSWER: intensive therapy group target was A1c < 6.0%; standard therapy group target was A1c 7.0-7.9%  What was the outcome discovered after ~3 years of the trial?  ANSWER: intensive therapy to target lower A1c levels (<6.0%) increased mortality and did not significantly reduce major cardiovascular events
  14. 14. BOARD-LIKE QUESTION 43 yo M is evaluated during a follow-up visit for management of T1DM. Pt has had multiple complications including ESRD, gastroparesis, frequent hypoglycemia with hypoglycemic unawareness, painful neuropathy, and proliferative retinopathy. He uses an insulin pump and checks fingerstick glucoses several times during the day, which range from 65 to 250. Most recent A1c is 7.5% (Adapted from MKSAP 17) QUESTION Which of the following is the most appropriate next step in the management of this patient? A. Alter insulin pump settings to attain an A1c of less than 7.0% B. Alter insulin pump settings to decrease the insulin doses C. Discontinue the insulin pump, start subQ insulin injections D. Start gabapentin for treatment of painful peripheral neuropathy
  15. 15. BOARD-LIKE QUESTION Educational Objective: Liberalize glycemic targets in a patient with multiple diabetic complications and advanced microvascular disease Key Point: - Frequent hypoglycemia/hypoglycemic unawareness increases the risk of morbidity and mortality - A less stringent A1c goal (such as 8%, per the ADA) is appropriate for persons with DM with a decreased life expectancy, history of severe hypoglycemia, multiple comorbidities, or advanced micro/macrovascular disease QUESTION Which of the following is the most appropriate next step in the management of this patient? A. Alter insulin pump settings to attain an A1c of less than 7.0% B. Alter insulin pump settings to decrease the insulin doses C. Discontinue the insulin pump, start subQ insulin injections D. Start gabapentin for treatment of painful peripheral neuropathy
  16. 16. REFERENCES  Effects of intensive glucose lowering in Type 2 Diabetes (2008). New England Journal of Medicine, 358:2545.-2559. doi 10.1056/NEJMoa0802743

×