January 21, 2015
Intensive Glucose Conrol After Diagnosis Reduces Type 1 Diabetes Mortality

Pittsburgh—Intensive control of glucose soon after diagnosis lengthens the lives of patients with type 1 diabetes, according to a new study.

The study, published recently in the Journal of the American Medical Association (JAMA), found a 33% reduction in deaths in a long-running trial and follow-up observational study with participants from 27 academic medical centers in the United States and Canada.

The National Institutes of Health–funded study was led by researchers from the University of Pittsburgh Graduate School of Public Health.

“We can now confidently tell doctors and patients that good, early control of blood glucose greatly reduces any risk for early mortality in people with type 1 diabetes, usually diagnosed in children and young adults,” said lead author Trevor Orchard, MD, professor of epidemiology at Pitt. “These results also remove any lingering concern that intensive therapy may lead to increased mortality.”

Although intensive therapy is associated with increased hypoglycemic risk that can be fatal, “The current data suggest net mortality benefit from intensive therapy ... These results provide reassurance that adoption of 6.5 years of intensive therapy in type 1 diabetes does not incur increased risk of overall mortality,” according to the report.

The Diabetes Control and Complications Trial (DCCT) began in 1983, enrolling 1,441 volunteers between ages 13 and 39 with recent-onset type 1 diabetes. Participants were divided into two groups for the 6.5-year intervention: Half were randomly assigned to intensive efforts to keep blood glucose as close to normal levels as possible. Conventional treatment was provided to the other half, with the goal of keeping blood glucose levels from getting so high or low that patients would exhibit symptoms, such as blurred vision or shortness of breath.

When the trial ended in 1993, the intensive care group was found to lower incidence of eye, nerve and kidney disease, and intensive blood glucose control was recommended for all patients with type 1 diabetes. To continue tracking the health of all the participants, who had been trained in intensive blood glucose control, the Epidemiology of Diabetes Control and Complications (EDIC) study was launched.

With vital status ascertained for more than 99% of the participants, researchers report that 7.4% of the patients died during the time period—64 who originally received conventional treatment compared to 43 in the intensive treatment group. Although the overall risk reduction was small, overall mortality risk in the intensive group was lower than that in the conventional group.

The most common causes of death—cardiovascular disease, 22%; cancer, 20%; and acute diabetes complications, 18%—all were more common in the group that originally received routine treatment. For the fourth cause of death, accidents or suicide at 17%, nominally more deaths occurred in patients assigned to the early intensive treatment.

Higher average glucose levels and increased protein in the urine, a marker of diabetic kidney disease, were considered the major risk factors for death.

“These results build on earlier studies that suggested that increased protein in the urine largely accounts for shorter lifespans for people with type 1 diabetes,” Orchard said. “Our findings further emphasize the importance of good, early glucose control, as this reduces the risk for increased protein in the urine in general, as well as for diabetic kidney disease itself.”

In type 2 diabetes treatment, reducing glycemia closer to the nondiabetic range has not consistently reduced mortality, according to background information in the article.

U.S. Pharmacist Social Connect