In his article, Dr Havas1 recommends to ignore hyperglycemia in patients with type 2 diabetes mellitus until it becomes symptomatic, and even then he allows the use of metformin only, in addition to diet and exercise. I strongly disagree with his recommendations. I would like to ask Dr Havas if he would prescribe any medicine if a patient has a fasting blood glucose level between 250 and 300 mg/dL (to convert to millimoles per liter, multiply by 0.0555) while following a regimen of diet, exercise, and metformin therapy but is asymptomatic? Roughly what percentage of his patients with diabetes adhere to weight loss and exercise? For how long has he put his strategy into practice, and what kind of results is he seeing on the complications of diabetes in his patients? I find the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial interesting. To me, the message is clear: if you focus on reducing blood glucose level by any means without paying attention to treating insulin resistance, the root cause of type 2 diabetes, you will have disappointing results in the prevention of coronary artery disease (CAD) events because insulin resistance plays a major role in the pathogenesis of CAD. In the ACCORD trial, physicians were allowed to use any combination of drugs. When a thiazolidinedione agent was used, it was mostly rosiglitazone. Compared with rosiglitazone, pioglitazone has been shown to be not only safe2 but also beneficial for CAD.3,4 Dr Havas seems to ignore these excellent studies on pioglitazone. He recommends a strategy that is the opposite extreme of that used in the ACCORD trial, and to me it appears just as harmful, if not more. The results of the ACCORD trial have not changed my practice pattern at all. For a long time, I have been treating type 2 diabetes by treating insulin resistance. I use a 5-component strategy that consists of diet, exercise, stress management, vitamins, and medications, mainly the insulin sensitizers metformin and pioglitazone. I occasionally use sulfonylurea agents, meglitinides, exenatide, or sitagliptin, and only as an add-on to the insulin sensitizers. I almost never use insulin. With this strategy, I achieve an HbA1c level of less than 6.5% in the majority of my patients with type 2 diabetes. I rarely encounter hypoglycemia. Severe hypoglycemia due to insulin and sulfonylurea agents is one of the plausible explanations for the unexpected increase in cardiovascular disease events in the ACCORD study. In contrast to the ACCORD findings, I see a notable decrease in cardiovascular disease events. Other complications of type 2 diabetes are also remarkably decreased. Correspondence: Dr Zaidi, Department of Internal Medicine, Jamila Diabetes and Endocrine Medical Center, 1429 E Thousand Oaks Blvd, Ste 105, Thousand Oaks, CA 91362 (firstname.lastname@example.org). References 1. Havas S The ACCORD trial and control of blood glucose level in type 2 diabetes mellitus: time to challenge conventional wisdom. Arch Intern Med 2009;169 (2) 150- 154PubMedGoogle ScholarCrossref 2. Lincoff AMWolski KNicholls SJNissen SE Pioglitazone and risk of cardiovascular events in patients with type 2 diabetes mellitus: a meta-analysis of randomized trials. JAMA 2007;298 (10) 1180- 1188PubMedGoogle ScholarCrossref 3. Dormandy JACharbonnel BEckland DJ et al. PROactive investigators, Secondary prevention of macrovascular events in patients with type 2 diabetes in the PROactive Study (PROspective pioglitAzone Clinical Trial In macroVascular Events): a randomised controlled trial. Lancet 2005;366 (9493) 1279- 1289PubMedGoogle ScholarCrossref 4. Nissen SENicholls SJWolski L et al. PERISCOPE Investigators, Comparison of pioglitazone vs glimepiride on progression of coronary atherosclerosis in patients with type 2 diabetes. JAMA 2008;299 (13) 1561- 1573PubMedGoogle ScholarCrossref
Archives of Internal Medicine – American Medical Association
Published: Jul 13, 2009
Keywords: diabetes mellitus, type 2
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