High ‘Tight’ is Tight Enough for Control of Type 2 Diabetes

Two recent papers touch on the important subject of drug treatment of type 2 diabetes.[1] [2] The first paper deals with the risks of ‘tight’ control, and the second examines the effect of ‘tight control’ on the microvascular complications of diabetes. So what is meant by ‘control’ vs. ‘tight control’. ‘Control’ brings HbA1c levels into the range 7-8%, while ‘tight control’ brings it under 7%. Both papers cast doubt on the value of ‘tight control’ vs. just ‘control’ achieved by pharmacological means. The first paper points out that ‘tight’ pharmacological control is associated with an increased risk of sudden death when compared to ‘control’.[1] This is thought to result from an increased incidence and severity of severe hypoglycaemic episodes when insulin doses are ramped up to achieve ‘tight’ control. The second paper, based on a review of RCT evidence,[2] finds that microvascular disease (causing blindness, renal failure, leg ulcers) is not measurably reduced by ‘tight control’ vs. ‘control’. So there we have it – ‘tight’ pharmacological control introduces the hazard of sudden death for no countervailing benefit in long-term outcomes. To put this another way, going from ‘control’ to ‘tight control’ increases the risk of sudden death for little, if any, compensatory advantage.

If there are limits to what can be achieved by ramping up pharmacological treatment, then what about dieting to the point that diabetes goes into remission? The evidence suggest that three-quarters of people with type 2 diabetes will achieve remission if they lose at least 15kg of weight. Bariatric surgery is highly effective in resulting in sustained weight loss.[3] Up to 10% of people can achieve a 15kg drop in weight by dieting alone, but about one-third of them revert each year. Nevertheless, it is worth trying hard to achieve weight loss because societal and personal gains are immense. And we have argued before for an inexpensive model to increase access to bariatric surgery.[4] [5]

Thank you to Ewan Hamnett for drawing my attention to this paper.

— Richard Lilford, CLAHRC WM Director

References:

  1. McCombie L, Leslie W, Taylor R, Kennon B, Sattar N, Lean MEJ. Beating type 2 diabetes into remission. BMJ. 2017; 358: j4030.
  2. Rodriguez-Gutierrez R & Montori VM. Glycemic Control for Patients with Type 2 Diabetes: Our Evolving Faith in the Face of Evidence. Circ Cardiovasc Qual Outcomes. 2016; 9(5): 504-12.
  3. Schaeur PR, Bhatt DL, Kirwan JP, et al. Bariatric Surgery versus Intensive Medical Therapy for Diabetes – 5-Year OutcomesNew Engl J Med. 2017; 376: 641-51.
  4. Lilford RJ. Bariatric Surgery – Improve Five-Year Outcomes. NIHR CLAHRC West Midlands News Blog. 23 June, 2017.
  5. Lilford RJ. Is It Safe for One Surgeon to Oversee Two Operations Concurrently? NIHR CLAHRC West Midlands News Blog. 27 October, 2017.
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