[Intensive blood glucose-lowering therapy: to which extent?]

The excess mortality in the group of intensively treated patients in the 'Action to control cardiovascular risk in diabetes' (ACCORD) study casts doubts on the safety ofglycated haemoglobin (HbA(1C)) levels below 7%. However, comparison of the ACCORD study with the 'Action in diabetes and vascular disease: preterax and diamicron-MR controlled evaluation' (ADVANCE) trial, which showed no excess mortality, indicates that not a low HbA(1C) level per se, but the method by which it was achieved, was responsible for the adverse outcome. Although no specific cause was identified, the excessive use of rosiglitazone, and the combination of up to 5 glucose-lowering drugs, most strikingly distinguishes the ACCORD study from other studies. Thus, the data from ACCORD added to previously voiced concerns about the safety of rosiglitazone and polypharmacy. Several large studies have failed to prove that improved glycaemic control reduces macrovascular events. However, the beneficial effects on microvascular events are undisputed. Thus, the benefits of HbA(1C) levels below 7% should be weighed against the risks of 'modern' polypharmacy.