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Whittington Health NHSUCL

What have important trials taught us about diabetes?

There is so much research into type 2 diabetes that it can be very difficult to keep on top of the evidence. Many papers come out on a weekly basis.

Below are some of the important papers to have come out over the last few decades, it is by no means an exhaustive list.

See also Important papers for health professionals.

The ADVANCE trial (ongoing): blood pressure medicines improve outcomes

The ADVANCE trial confirms that lowering blood pressure improves survival in diabetes. It also tentatively suggests that even people with normal blood pressure may benefit.

An ongoing randomised control trial involving over 11,000 patients across 20 countries.

Its aims are to assess whether tighter control of blood pressure than is usually recommended is beneficial in diabetes. It also asks the question whether people with normal blood pressure and diabetes may also benefit from blood pressure medicines.

One of the strengths of this trial is its size and its focus on older patients.

ADVANCE stands for: Action in Diabetes and Vascular disease: preterAx and diamicroN-MR Controlled Evaluation study

The ACCORD trial (2001-2009): intensive treatment may not be better

The ACCORD study failed to show that intensive treatment of blood pressure, blood glucose and lipids is better than standard treatment.

A randomised control trial involving 10,251 people with type 2 diabetes over 77 sites across the United States and Canada.

The study aimed to find out how best to reduce the risk of major cardiovascular problems, such as heart attack and stroke in people with diabetes.

It did this by looking specifically at intensive lowering of blood glucose levels, intensive lowering of blood pressure and treatment of multiple blood lipids with two drugs rather than one.

The study is unusual in that it focused on particularly high risk individuals who had had diabetes for at least 10 years.

Unfortunately, it showed no benefit with intensive therapy and perhaps even an increased risk with intensive therapy. However, this may not apply to lower risk individuals and more research is needed to look into this.

Summary of the findings of the ACCORD trial published in the New England Journal of Medicine in 2008

ACCORD stands for: Action to Control Cardiovascular Risk in Diabetes

The UKPDS trial (1977-1997): treating diabetes is worth it

The UKPDS trial was one of the first trials to show that treating type 2 diabetes really is worthwhile.

A randomised control trial set up in 1977. The original trial ran for 20 years.

Its aims were to establish whether reducing blood glucose levels and maintaining good blood pressure control actually protects people with type 2 diabetes from having complications.

Over 5,000 patients were enrolled across 23 UK sites.

The initial trial showed that improving blood glucose levels reduced the microvascular complication rate. This means that people with lower blood glucose levels had a lower risk of eye and kidney problems, for example.

Reducing blood pressure levels helped reduce the risk of microvascular but also macrovascular complications such as stroke.

UKPDS stands for: the UK Prospective Diabetes Study

Peer support can improve glycaemic control

Peer support through coaching brings real benefits in glycemic control to low income patients.

A recent article in the journal Annals of Family Medicine suggested that patients can benefit greatly from the support of their peers. The results show that conversations with fellow patients can help people achieve improved glycaemic control.

The study recruited patients to train as peer coaches. Following 36 hours of training over an eight week period, 24 patients (with average HbA1c of 6.88%) enrolled as peer coaches. They then took part in a clinical trial, which aimed to test the effects of 1-to-1 peer coaching on levels of HbA1c in a sample of 148 low income patients with an HbA1c of 8% or more. This group was compared with a similar group (151 patients) receiving usual care.

Ths study took place in San Francisco, USA.

The coaching was mainly by telephone, with an average of five contacts per patient in the coaching group, and each coach working with around seven patients.

After six months results showed an average change of -1.07% in HbA1c in the patients receiving peer coaching. This compared with a much smaller improvement of 0.3% in the usual care group.

The authors assert that peer coaching significantly improved glycaemic control.

Questions around how such an intervention would transfer to a British healthcare context may be unclear, but the results do strongly suggest the benefits to be had from diabetes patients supporting each other in achieving their self-management goals.