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Glucose-lowering trials in type 2 diabetes

Changes in levels of haemoglobin A 1c during the first 6 years after diagnosis of clinical type 2 diabetes Clinical implications Niels de Fine Olivarius Volkert Siersma Lars J. Hansen Thomas Drivsholm Mogens Hørder. Glucose-lowering trials in type 2 diabetes. Lesson to be learned.

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Glucose-lowering trials in type 2 diabetes

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  1. Changes in levels of haemoglobin A1c during the first 6 years after diagnosis of clinical type 2 diabetes Clinical implications Niels de Fine Olivarius Volkert Siersma Lars J. Hansen Thomas Drivsholm Mogens Hørder

  2. Glucose-loweringtrialsin type 2 diabetes

  3. Lesson to belearned • Treatmentregimensaiming at normalizingbloodglucose for all patients maybedetrimental, • at least in middle-aged and olderadultswith diabetes of long duration.

  4. Againstgeneralizedthought Average figures used to describe changes in HbA1c may conceal a clinically important diversity in the way the blood glucose level deteriorates or even improves, especially immediately after diabetes diagnosis.

  5. Objective To assess the variability in levels of glycosylated haemoglobin (HbA1c) during the first six years after diagnosis of clinical type 2 diabetes in relation to possible predictors.

  6. Flow chart

  7. All measurements of HbA1c Upper limit of reference range

  8. HbA1c for 50 randomlyselected patients

  9. Modelling the courseof HbA1c Level of HbA1c one year after diabetes diagnosis Haemoglobin A1c (%) Slope of the HbA1c-curve Years since diabetes diagnosis

  10. Predictors of level and slope of HbA1c Multivariate linear regression models

  11. Predictors of level and slope of HbA1c Multivariate linear regression models

  12. Predictors of level and slope of HbA1c SLOPE LEVEL Multivariate linear regression models

  13. Changes in HbA1caccording to HbA1c at diagnosis HbA1c > 10% Haemoglobin A1c (%) HbA1c ≤ 10% Years since diabetes diagnosis

  14. Changes in HbA1c according to age Age ≤ 65 y. Haemoglobin A1c (%) Age > 65 y. Years since diabetes diagnosis

  15. Changes in HbA1c (I)From generalisation to individualisation HbA1c > 10 at diagnosis Haemoglobin A1c (%) Years since diabetes diagnosis Patients are grouped according to quartiles of the slope of HbA1c after 1-year follow-up

  16. Changes in HbA1c (II)From generalisation to individualisation HbA1c ≤ 10 at diagnosis Haemoglobin A1c (%) Years since diabetes diagnosis Patients are grouped according to quartiles of the slope of HbA1c after 1-year follow-up

  17. Conclusion 1 ACCORD – ADVANCE – VADT – UKPDS – UGDP Lowering glucose levels for all patients with T2DM has limited benefit and can lead to significant harm

  18. Conclusion 2 Diabetes Care in General Practice Individualization: A more appropriate strategy to reduce the level and variability of HbA1c could be to monitor changes in HbA1c more closely and intensify treatment of those patients who actually experience the beginning of an apparently inexorable deterioration of their glycaemic control

  19. Changes in HbA1c (I)From generalisation to individualisation HbA1c > 10 at diagnosis Haemoglobin A1c (%) Years since diabetes diagnosis Patients are grouped according to quartiles of the slope of HbA1c after 1-year follow-up

  20. DCGP vs. UKPDS UKPDS DCGP Fasting plasma glucose (mmol/l) conventional treatment comparison group (=conventional treatment) structured care intensive treatment Years since diabetes diagnosis

  21. DCGP vs. UKPDS UKPDS DCGP 45% Fasting plasma glucose (mmol/l) 70% 90% 32% 29% 40% 55% % treated with diet alone 7% 13% 17% Years since diabetes diagnosis

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