Glucose lowering and cardiovascular disease: what do we know and what should we do?

For the reduction of microvascular complications in type 2 diabetes, glycemic control has been shown to be an important and effective intervention. However, considering the findings from several recent, large, randomized controlled trials, the utility of very tight glycemic control in all those with type 2 diabetes, for the reduction of cardiovascular disease remains controversial. The decision to aim for very tight glycemic control must be individualized and the potential benefit of reduced risk of nephropathy must be weighed against the increased risk for hypoglycemia. The results of the 10-year post-trial monitoring of the United Kingdom Prospective Diabetes Study (UKPDS) demonstrated macrovascular benefits of glycemic control in newly diagnosed type 2 diabetes but lengthy follow-up was required to demonstrate the effect. This raises the possibility that benefits of glucose lowering to reduce cardiovascular risk is more evident in those with a shorter duration of diabetes and requires many years to manifest. For the time being, there remains good evidence for targeting A1c <7% for microvascular protection but attempts to lower A1c beyond this must be considered on an individual basis.