Paradigm shift in the treatment of diabetes

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Lessons from ADVANCE, VADT (Veterans Affair Diabetes Trial) and ACCORD trial: 2008

It was said that that intensive diabetes control is not required but one patient with diabetes is not equal to another patient.

Intensive diabetes control is absolutely beneficial for subjects who have just diabetes with no complications, who are relatively young, and who have had diabetes for a shorter time, less than 5 years. These healthy diabetics are often ignored as mild diabetes.

Those with significantly more advanced diabetes, who have had myocardial infarctions, stroke, foot amputation, or laser coagulation in the eye need less intensive treatment. One cannot restore the vasculature to its previous state or to the normal condition after it has been damaged by high glucose for 10 or 20 years. What we can do is only to prevent complications, using all the intensive strategies in subjects with intact cardiovascular systems.

What we should do in the changing paradigm of type 2 diabetes treatment? We should focus more on younger people who are newly diagnosed and strive to maintain their A1c level at 6% to 6.5% and not let it go up for years to come. We should be relatively more relaxed with subjects who have long-standing diabetes and multiple complications, who have been treated with insulin 3 or 4 times a day. We should be happy their A1c level is 7% to 7.5%, or even 8% or more. The new treatment algorithm presented at this IDF congress also aimed A1c level of 7%, not 6.5%.