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Cardio Diabetes Medicine 2017 425

Glycemic Control- How Tight It Should Be?

Dr. R. M. Anjana,
MD, Dip. Diab (UK), Ph.D, FICP, FACP, FRCP (Glasg,Edin, Lond)

&
Dr. Janani Karthik, M.B.B.S.,
Dr. Mohan’s Diabetes Specialities Centre, 6B,
Conran Smith Road, Gopalapuram, Chennai.

INTRODUCTION 2 diabetes who is controlled on lifestyle measures
With the prevalence of type 2 diabetes now reach- alone or on a small dose of metformin. An HbA1c val-
ing pandemic proportions, there is a concomitant in- ue corresponding to the threshold of microvascular
crease in diabetic complications. Until 1993, the rela- complication risk is a valid therapeutic target in such
tionship between blood glucose control and diabetic individuals, since they will be able to achieve such
complications was arguable. With the publication of targets without significant hypoglycemia.
results of large randomised controlled trials such as
the Diabetes Control and Complications trial(DCCT) CURRENT RECOMMENDATIONS
and United Kingdom Prospective Diabetes Study
(UKPDS), there is no longer any doubt that tight gly- FOR GLYCEMIC TARGETS
cemic control reduces the risk of development and Although most clinicians have set different glycemic
progression of long term complications of diabetes. targets for their patients with type 1 and type 2 diabe-
tes for more than three to four decades , these facts
The EDIC( Epidemiology of Diabetes Intervention and have only recently been reflected in the American
Complications) trial, the 10-year posttrial monitoring Diabetes Association (ADA),European Association
of the DCCT, showed a 40% reduction in cardiovascu- for the Study of Diabetes (EASD),and International
lar events and an almost 60% reduction in myocardial Diabetes Federation (IDF) guidelines.
infarction, stroke and cardiovascular death in those
patients whose sugars were initially intensively con- Current recommendations for glycemic targets in type
trolled compared to those who were less intensively 2 diabetes in non-pregnant adults
controlled.
Individualization of glycemic targets is based upon ADA/ AACE/ACE IDF CDA NICE
the age of the patient, duration of diabetes, life ex- EASD
pectancy, type of diabetes, type of therapy, presence Fasting 70–130 <110 <115 72– Not men-
of complications, propensity for hypoglycemia, hypo- glucose mg/dL mg/dL mg/ 126 tioned
glycemia awareness, availability of family support, dL mg/dL
patient motivation, and patient education. 2-h PP <180 <140 <160 90– Not men-
glucose mg/dL mg/dL mg/ 180 tioned
FIXING TIGHT GLYCEMIC TARGETS dL mg/dL
For fixing glycemic targets, theoretically, there are at HbA1c <7 % ≤6.5 % <7 % <7 % 6.5–7.0%
least two approaches: the HbA1c or blood glucose
can be rendered completely normal or alternatively TREATING EARLY GIVES THE BEST
lowered to the extent that it minimizes complica-
tions without producing distressing incidence of hy- BENEFITS
poglycemia. Reduction of HbA1c to the normal level Three trials have looked at whether glycemic control
is difficult to achieve in most patients with diabetes to near-normoglycemia (i.e. control tighter than that
without significant hypoglycemia. The only exception achieved in the DCCT or UKPDS) reduces cardio-
to this would be a person with newly diagnosed type vascular disease in type 2 diabetes. These are the

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