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Multi-Pronged Intervention for Type 2 Diabetes

This study reveals an important opportunity to improve type 2 diabetes care.

As type 2 diabetes becomes more prevalent, we must identify effective strategies for modifying cardiovascular risk factors such as hyperglycemia, hypertension, and dyslipidemia. In this open, parallel trial from Denmark, researchers randomized 160 patients with type 2 diabetes and microalbuminuria to either intensive therapy or guideline-directed conventional therapy.

Intensive therapy involved the behavioral goals of low-fat diet, light-to-moderate exercise for 30 minutes at least 3-5 times/week, and participation in smoking-cessation courses, as well as ACE-inhibitor therapy, aspirin therapy, and vitamin-mineral supplementation. An oral hypoglycemic agent was started when a patient could not maintain a glycosylated hemoglobin value <6.5%. Hypertension and dyslipidemia were treated in stepwise fashion.

During a mean follow-up of 7.8 years, incidence of the primary composite endpoint (cardiovascular death, nonfatal MI, nonfatal stroke, revascularization, ischemia-related amputation, or vascular surgery for peripheral arterial disease) was significantly lower in the intensive-therapy group than in the conventional-therapy group (24% vs. 44%; adjusted hazard ratio, 0.47; 95% CI, 0.22-0.74). Nephropathy, retinopathy, and autonomic neuropathy were significantly less common with intensive than with conventional therapy. The intensive-therapy group also showed better achievement of blood-pressure, lipid, and diet goals by study's end. The 2 groups had similar incidences of hypoglycemic episodes.

Comment: In patients with type 2 diabetes and microalbuminuria, an intensive intervention was associated with significantly better outcomes than was conventional therapy over 8 years, revealing a remarkable opportunity to improve care. The authors estimate that only 5 patients must be treated for this length of time to avoid 1 adverse cardiovascular event. This study was small, but its findings have face validity. The challenge will be translating these sensible strategies to real-world practice.

— Harlan M. Krumholz, MD, SM

Published in Journal Watch Cardiology March 14, 2003

Citation(s):

Gæde P et al. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med 2003 Jan 30; 348:383-93.

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• Medline abstract (Free)

Solomon CG. Reducing cardiovascular risk in type 2 diabetes. N Engl J Med 2003 Jan 30; 348:457-9.

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• Medline abstract (Free)