b'New Focus in the Fight to ReduceCV Risks in Type 2 DiabetesIs the Answer Specific Drugs, Not Tight Glycemic Control?By Brenda L. MooneyAt one point, intensive glycemic control was seen as a magic[ActiontoControlCardiovascular bullet to keep Type 2 diabetes patients from developingRisk in Diabetes], ADVANCE [Action inDiabetesandVascularDisease: cardiovascular disease. That approach faded, however,PreteraxandDiamicronModified when VA research cautioned that any benefits of intensiveReleaseControlledEvaluation],and ourownVADT[VeteransAffairs therapy must be weighed against adverse effects such asDiabetes Trial]) showed that improved hypoglycemia and weight gain. Now, the focus has shifted toglucose control over a median of 3 to 6 years provided modest and nonsignifi-better medication selection, with guidelines suggesting that,cant reductions in the incidence of car-for Type 2 diabetes patients who have cardiovascular diseasediovascular events and did not reduce cardiovascular diseaserelated mortal-or are at high risk for it, therapy including an SGLT-2 inhibitority or total mortality.or GLP-1 RA should be considered as optimal treatment.Whilethe10-yearfollow-upofthe VADT showed an emerging benefit for CVD reduction from the original inten-sive glucose-lowering, the longer-term follow-up indicated no significant drop, PHOENIXThe VAs battle to protectit looks like as if the focus is less onon average, in heart attacks or stroke.veterans with Type 2 diabetes from car- glycemic control and more on specificIn15-yearfindingsfromVADT, diovascular disease morbidity and mor- agents that appear to improve cardio- researchers found that nearly six years tality has gone on for decades. vascularoutcomes,especiallygluca- of aggressive lowering of blood sugar Its landmark VA Diabetes Trial, whichgon-likepeptide1(GLP-1)receptorlevels resulted in a non-significant 12% began in 2000, was a randomized trialagonistsandsodium-glucosecotrans- declineincardiovasculareventsa ofintensiveglycemiccontrolinvet- porter 2 (SGLT2) inhibitors. composite of heart attack, stroke, car-erans with advanced Type 2 diabetes.The issue is especially critical at thediovasculardeath,congestiveheart The 1,791 participants from 20 VAMCsVA,wherenearlyone-fourthofthefailureandamputationfromgan-were at relatively high risk for cardio- patients have diabetes, primarily Typegrenewhen compared with standard vascular disease, including heart attack2. Those veterans also are estimated totherapy. In addition, no differences in and stroke, with many of them alreadyhave two to four times the risk of heartall-cause death were documented, and having been diagnosed with cardiovas- disease. along-termtrendforreducedrenal cular disease. A15-yearVADTfollow-uppub- events was insignificant. 1VAresearcherssoughttodeterminelishedlastyearintheNewEnglandThispointsouthowdifficultit whetherintensiveglycemiccontrolJournalofMedicinenotedthattri- sometimesistomaintaintightgly-would reduce those risks and found thealsinvolvingpatientswithadvancedcemiccontrol,NicholasEmanuele, long-term effects to be limited. Now,Type2diabetes(suchasACCORDMD, of the Edward Hines Jr. VAMC Continued on Page 30 u2020 COMPENDIUM OF FEDERAL MEDICINE 25'