All are true about bronchial carcinoids except:
1- arises from Kulchitsky cells one type of the neuroendocrine cells APUD.
2- Serum chromogranin A mild elevated.
3- Causes carinoid syndrome in less than 5%.
4- Causes acromegaly due to releasing GHRH.
5- Can cause Cushing second to the release of ectopic ACTH.
6- Silver stain is the gold standard to identify the tumors histologically.
7- CT lung will identify most of the tumors. MR with gado will show enhancement of T2 if CT can not distinguish them from vessels. Octreotide scan will show metastasis however these are rare and the scan picks up other tumors and granuloma.
8- In bronchoscopy the tumor have characteristic appearance.
9- Central carcionids are diagnosed by biopsy through bronchoscopy.
10- peripheral carcinoids are diagnosed by CT-guided transthoracic needle aspiration.
11- Treatment of choice is surgical excision with mediastinal lymph node resection.
12- Liver is the most common site of metastasis that are better image by MRI, resection would prolong survival.
13- In patient with more advanced disease the treatment of choice is somatostatin analogue.
All are correct except silver stain it used to be the common stain used in the past now the confirmatory immunohistochemical stain in diagnosing Carcinoids are NSE, synaptophysin and chromogranin. The tumors are commonly locally malignant and slowly growing with 10 years survival is over 80% atypical carinoids however tends to have worse prognosis. MRI of the liver will identify metastasis to the liver. Though carcinoids rarely metastasis less than 5%. The liver is the main site of their metastasis.
Saturday, April 11, 2009
Friday, April 10, 2009
Glucagonoma
All of the following are true about glucagnoma except:
1- The tumore arises from the alpha cells of the pancreas.
2- The tumor most often arise from the tail of the pancrease.
3- Necrolytic migratory erythema rash is specific to glucagonoma.
4- Glucagon level > 1000pg/ml is diagnostic.
5- CT abdomen with contrast is intial study for localization.
6- Endoscopic US of pancreas will help both the localization and obtaining biopsy of the tumor.
7- It is among endocrine tumors that is uniquely associated with venous thromboembolism.
All are true except 3, this rash can occur in other conditions, however it is commonly the clue to this rare diagnosis. Weight loss and diabetes mellitus are common as well. Neuropsychiatric symptoms are common. The diagnosis is usally established late after the tumor have metastasized. The diagnosis is usually made after the skin rash occured and glucagon level is commonly quite elevated > 500 the normal is 100 level can be at high normal in few patients. CT is usually the test ordered to localize the tumor and potential metastasis which are commonly to the liver. Octreotoide scan will also show the tumor and metastasis however rarely needed since the CT will visualize the tumor in most cases. The second study is usually through endoscopic US that can identify tumors and as well allow needle biopsy of the tumors in the pancreas. In the early cases with no metastasis surgical removal of the tumor is done. In hepatic predominant disease from metastasis resection of hepatic metastasis or hepatic artery embolization may be effective in slowing the disease. Octretoide is quite effective in controlling the symptoms however regress of tumor is not clearly shown. Alpha interferon and chemotherapy are other options. Disease is monitored regularly with serum glucagon and CT. It is not uncoomon to have 5 year survival of 50% in metastatic slowly progressing disease.
1- The tumore arises from the alpha cells of the pancreas.
2- The tumor most often arise from the tail of the pancrease.
3- Necrolytic migratory erythema rash is specific to glucagonoma.
4- Glucagon level > 1000pg/ml is diagnostic.
5- CT abdomen with contrast is intial study for localization.
6- Endoscopic US of pancreas will help both the localization and obtaining biopsy of the tumor.
7- It is among endocrine tumors that is uniquely associated with venous thromboembolism.
All are true except 3, this rash can occur in other conditions, however it is commonly the clue to this rare diagnosis. Weight loss and diabetes mellitus are common as well. Neuropsychiatric symptoms are common. The diagnosis is usally established late after the tumor have metastasized. The diagnosis is usually made after the skin rash occured and glucagon level is commonly quite elevated > 500 the normal is 100 level can be at high normal in few patients. CT is usually the test ordered to localize the tumor and potential metastasis which are commonly to the liver. Octreotoide scan will also show the tumor and metastasis however rarely needed since the CT will visualize the tumor in most cases. The second study is usually through endoscopic US that can identify tumors and as well allow needle biopsy of the tumors in the pancreas. In the early cases with no metastasis surgical removal of the tumor is done. In hepatic predominant disease from metastasis resection of hepatic metastasis or hepatic artery embolization may be effective in slowing the disease. Octretoide is quite effective in controlling the symptoms however regress of tumor is not clearly shown. Alpha interferon and chemotherapy are other options. Disease is monitored regularly with serum glucagon and CT. It is not uncoomon to have 5 year survival of 50% in metastatic slowly progressing disease.
Glucocorticoid-Remediable Aldosteronism
In Glucocorticoid-Remediable Aldosteronism (GRA) all are true except:
1- It is an autosomal dominant condition.
2- Patients commonly present before age of 21 years old with hypertension.
3- Family history may be obtained of GRA, brain aneurysms or intracranial hemorrhage.
4- It is due to increase production of ACTH-sensitive aldosterone in the zona fasciulata.
5- Aldosterone:renin ratio and hypokalemia are not as significant as in primary hyperaldosteronism.
6- It is primarily diagnosed with dexamthazone suppression test and the presence of elevated 18 hydroxycortisol and 18 oxocortisol.
7- It is well treatable with glucocorticoid or aldosterone receptor antagonist.
All are true except 6 the primary diagnosis now is with demonstration of the chimeric gene. It should be considered in patients with early hypertension, family history or early strokes <40>
1- It is an autosomal dominant condition.
2- Patients commonly present before age of 21 years old with hypertension.
3- Family history may be obtained of GRA, brain aneurysms or intracranial hemorrhage.
4- It is due to increase production of ACTH-sensitive aldosterone in the zona fasciulata.
5- Aldosterone:renin ratio and hypokalemia are not as significant as in primary hyperaldosteronism.
6- It is primarily diagnosed with dexamthazone suppression test and the presence of elevated 18 hydroxycortisol and 18 oxocortisol.
7- It is well treatable with glucocorticoid or aldosterone receptor antagonist.
All are true except 6 the primary diagnosis now is with demonstration of the chimeric gene. It should be considered in patients with early hypertension, family history or early strokes <40>
Craniopharyngioma
All are true about Craniopharyngioma except:
1- Arises from remnants of Rhathke pouch.
2- A cystic calcified lesion in CT is very suggestive of the tumor.
3- Is malignant with metastasis in 20%.
4- Primary treatment is surgery.
5- Edema along optic tract is common finding in MRI.
6- Both anterior and posterior pituitary can be affected.
All are true except 3 it is a benign tumor but has high recurrence rate that it is dealt with as locally malignant tumor. Histologically it can be cystic epithelia, epithelial islands with degenerative cysts or epithelial humps like the enamel of developing teeth. It rarely metastasizes. Surgery is commonly incomplete and is followed by radiation. Attempt of total or subtotal excision using microsurgery decreases recurrence but has high operative mortality and morbidity rates. Cyst aspiration or intracystic radiation or chemotherapy may be used for recreant cysts. Patients commonly present in childhood with delay growth and in adult age with sexual dysfunction of amenorrhea in females and erectile dysfunction in males. hypothyroidism, adrenal insufficiency increase prolactin and central DI can also occur. Headaches and change in vision due to pressure in the optic chiasma can also occur.
1- Arises from remnants of Rhathke pouch.
2- A cystic calcified lesion in CT is very suggestive of the tumor.
3- Is malignant with metastasis in 20%.
4- Primary treatment is surgery.
5- Edema along optic tract is common finding in MRI.
6- Both anterior and posterior pituitary can be affected.
All are true except 3 it is a benign tumor but has high recurrence rate that it is dealt with as locally malignant tumor. Histologically it can be cystic epithelia, epithelial islands with degenerative cysts or epithelial humps like the enamel of developing teeth. It rarely metastasizes. Surgery is commonly incomplete and is followed by radiation. Attempt of total or subtotal excision using microsurgery decreases recurrence but has high operative mortality and morbidity rates. Cyst aspiration or intracystic radiation or chemotherapy may be used for recreant cysts. Patients commonly present in childhood with delay growth and in adult age with sexual dysfunction of amenorrhea in females and erectile dysfunction in males. hypothyroidism, adrenal insufficiency increase prolactin and central DI can also occur. Headaches and change in vision due to pressure in the optic chiasma can also occur.
Tuesday, March 10, 2009
Resolving the Coronary Artery Disease Epidemic through Plant-Based Nutrition
By: Caldwell B. Esselstyn, Jr., MD
From the Cleveland Clinic Foundation, Cleveland, Ohio
Taking the Offensive
Figure 4--Coronary angiograms of right coronary artery before (left) and showing 30% improvement (right) following approximately 60 months of a plant-based diet and cholesterol-lowering medication.As I have reported earlier,28,29 a plant-based diet in conjunction with cholesterol-reducing medication eliminated progression of coronary artery disease over a 12-year period in patients with triple-vessel disease. Most of the 18 patients had experienced an earlier failed intervention of bypass surgery or angioplasty. All patients who maintained the diet achieved the cholesterol goal of less than 150 mg/dL and had no recurrent coronary events during the 12 years. At 5 years, angiography was repeated in most cases. By analysis of the stenosis percentage none had progression of disease, and 70% had selective regression.28 These data are compelling when one considers that the same group had experienced more than 49 coronary events during the 8 years before this study.28
The recent case of a colleague is particularly telling. During September and October of 1996, a 44-year-old surgical colleague experienced occasional chest discomfort, yet neither electrocardiogram, stress echocardiography, or thallium scanning found evidence of disease. While eating the typical American diet, he had a total cholesterol of 156 mg/dL and an LDL of 97 mg/dL. He was lean, non-diabetic, and normotensive, did not smoke, and had no family history of coronary disease. His lipoprotein (a) and homocysteine levels were normal. On November 18, 1996, after his surgical duties, he became acutely ill with pain in the left arm, jaw, and chest. Immediate coronary catheterization found all vessels to be normal except for the left anterior descending artery, the distal third of which was diseased. Enzymes confirmed a myocardial infarction. However, no intervention was deemed appropriate.
This patient was aware of my ongoing study and was curious for more information. He and his wife consulted me for an in-depth review of the plant-based diet and techniques of this arrest and reversal study. He became the personification of commitment to the plant-based diet. Over the next 32 months, without cholesterol-lowering drugs, he maintained a mean total cholesterol of 89 mg/dL and an LDL of 38 mg/dL. The repeat angiogram 32 months after his infarction showed that the disease was completely reversed. (Fig.1)
Even though many people might find a plant-based diet initially difficult to follow, every patient with the diagnosis of coronary artery disease should at the least be offered the option of this potentially curative arrest and reversal approach. As this young surgeon's case illustrates, our plant-based diet approach can achieve total disease arrest and selective regression even in advanced cases. This approach is particularly compelling because patients can take control over the disease that was destroying them. If traditional interventional cardiology is a rear-guard action, our arrest and reversal therapy can be likened to a military offensive against atherosclerosis.
Limitations of this study are its modest number of participants and lack of comparable controls. Nevertheless, its size permitted the caregiver an opportunity for frequent patient encounters. These interactions enabled 75% of participants to achieve profound lipid reduction, dietary goals, and relief of symptoms which continued to improve throughout the study's 12-year duration. Patients essentially served as their own controls often achieving profound angiographic reversal of disease as reviewed in the angiographic core laboratory. Fig. 1-4
In addition, Dr. Dean Ornish has reported both 1- and 5-year data that support a plant-based approach to control coronary artery disease.16
Above is a portion copied from the author article.
From the Cleveland Clinic Foundation, Cleveland, Ohio
Taking the Offensive
Figure 4--Coronary angiograms of right coronary artery before (left) and showing 30% improvement (right) following approximately 60 months of a plant-based diet and cholesterol-lowering medication.As I have reported earlier,28,29 a plant-based diet in conjunction with cholesterol-reducing medication eliminated progression of coronary artery disease over a 12-year period in patients with triple-vessel disease. Most of the 18 patients had experienced an earlier failed intervention of bypass surgery or angioplasty. All patients who maintained the diet achieved the cholesterol goal of less than 150 mg/dL and had no recurrent coronary events during the 12 years. At 5 years, angiography was repeated in most cases. By analysis of the stenosis percentage none had progression of disease, and 70% had selective regression.28 These data are compelling when one considers that the same group had experienced more than 49 coronary events during the 8 years before this study.28
The recent case of a colleague is particularly telling. During September and October of 1996, a 44-year-old surgical colleague experienced occasional chest discomfort, yet neither electrocardiogram, stress echocardiography, or thallium scanning found evidence of disease. While eating the typical American diet, he had a total cholesterol of 156 mg/dL and an LDL of 97 mg/dL. He was lean, non-diabetic, and normotensive, did not smoke, and had no family history of coronary disease. His lipoprotein (a) and homocysteine levels were normal. On November 18, 1996, after his surgical duties, he became acutely ill with pain in the left arm, jaw, and chest. Immediate coronary catheterization found all vessels to be normal except for the left anterior descending artery, the distal third of which was diseased. Enzymes confirmed a myocardial infarction. However, no intervention was deemed appropriate.
This patient was aware of my ongoing study and was curious for more information. He and his wife consulted me for an in-depth review of the plant-based diet and techniques of this arrest and reversal study. He became the personification of commitment to the plant-based diet. Over the next 32 months, without cholesterol-lowering drugs, he maintained a mean total cholesterol of 89 mg/dL and an LDL of 38 mg/dL. The repeat angiogram 32 months after his infarction showed that the disease was completely reversed. (Fig.1)
Even though many people might find a plant-based diet initially difficult to follow, every patient with the diagnosis of coronary artery disease should at the least be offered the option of this potentially curative arrest and reversal approach. As this young surgeon's case illustrates, our plant-based diet approach can achieve total disease arrest and selective regression even in advanced cases. This approach is particularly compelling because patients can take control over the disease that was destroying them. If traditional interventional cardiology is a rear-guard action, our arrest and reversal therapy can be likened to a military offensive against atherosclerosis.
Limitations of this study are its modest number of participants and lack of comparable controls. Nevertheless, its size permitted the caregiver an opportunity for frequent patient encounters. These interactions enabled 75% of participants to achieve profound lipid reduction, dietary goals, and relief of symptoms which continued to improve throughout the study's 12-year duration. Patients essentially served as their own controls often achieving profound angiographic reversal of disease as reviewed in the angiographic core laboratory. Fig. 1-4
In addition, Dr. Dean Ornish has reported both 1- and 5-year data that support a plant-based approach to control coronary artery disease.16
Above is a portion copied from the author article.
Friday, February 20, 2009
Out-of-Control Blood Sugar May Affect Memory
From: Your Total Health News.
February 19 (HealthDay News) -- A rise in blood sugar levels causes poorer brain function in people with type 2 diabetes, according to a study that included nearly 3,000 people aged 55 and older at 52 sites in Canada and the United States.
The participants, who were part of a larger study on cardiovascular risk in diabetes, underwent cognitive tests designed to measure several aspects of memory function. The researchers found that a 1 percent increase in A1C levels (average blood glucose levels over a period of two to three months) was associated with slightly lower scores on tests of psychomotor speed, global cognitive function, memory and multi-tasking.
However, no link was found between tests scores and daily blood glucose levels, which are measured by a fasting plasma glucose test.
The findings appear in the February issue of Diabetes Care.
"One of the little-known complications of type 2 diabetes is memory decline leading to dementia, particularly Alzheimer's disease," principal investigator Dr. Jeff Williamson, of Wake Forest University Baptist Medical Center, said in a news release from the university.
"This study adds to the growing evidence that poorer blood glucose control is strongly associated with poorer memory function and that these associations can be detected well before a person develops severe memory loss," he said.
Previous research has shown that people with diabetes are 1.5 times more likely than those without diabetes to experience cognitive decline and develop dementia.
Williamson said that "people with type 2 diabetes and their health-care providers need to be careful in situations where there is education and teaching about diabetes care, as patients may need a little more time to absorb and process information."
And he urged people with diabetes to "be open to having a family member periodically making sure they are keeping track of managing their diabetes through monitoring, diet, exercise and medication."
Wake Forest University Baptist Medical Center, news release, Feb. 11, 2009
February 19 (HealthDay News) -- A rise in blood sugar levels causes poorer brain function in people with type 2 diabetes, according to a study that included nearly 3,000 people aged 55 and older at 52 sites in Canada and the United States.
The participants, who were part of a larger study on cardiovascular risk in diabetes, underwent cognitive tests designed to measure several aspects of memory function. The researchers found that a 1 percent increase in A1C levels (average blood glucose levels over a period of two to three months) was associated with slightly lower scores on tests of psychomotor speed, global cognitive function, memory and multi-tasking.
However, no link was found between tests scores and daily blood glucose levels, which are measured by a fasting plasma glucose test.
The findings appear in the February issue of Diabetes Care.
"One of the little-known complications of type 2 diabetes is memory decline leading to dementia, particularly Alzheimer's disease," principal investigator Dr. Jeff Williamson, of Wake Forest University Baptist Medical Center, said in a news release from the university.
"This study adds to the growing evidence that poorer blood glucose control is strongly associated with poorer memory function and that these associations can be detected well before a person develops severe memory loss," he said.
Previous research has shown that people with diabetes are 1.5 times more likely than those without diabetes to experience cognitive decline and develop dementia.
Williamson said that "people with type 2 diabetes and their health-care providers need to be careful in situations where there is education and teaching about diabetes care, as patients may need a little more time to absorb and process information."
And he urged people with diabetes to "be open to having a family member periodically making sure they are keeping track of managing their diabetes through monitoring, diet, exercise and medication."
Wake Forest University Baptist Medical Center, news release, Feb. 11, 2009
Glycemic Goals Clarified: HbA1c Of 7% Still Ceiling: Three groups issue position statement.
From: Clinical Endocrinology News
MIRIAM E. TUCKER (Senior Writer)
A target hemoglobin A1c of less than 7% should remain the general goal for nonpregnant adults with diabetes, despite the recent results from three large randomized trials showing that intensive glucose lowering did not reduce the risks of cardiovascular disease in people with longstanding type 2 diabetes.
But glycemic targets that are either more or less stringent than that standard may be prudent for certain individuals with diabetes, according to a joint position statement issued by the American College of Cardiology, American Diabetes Association, and American Heart Association and published online in their respective journals: the Journal of the American College of Cardiology, Diabetes Care, and Circulation.
“The ADA/AHA/ACC position statement is very well thought out and very well articulated. The authors should be commended for their concise analysis of the available data,” Dr. J. Michael Gonzalez-Campoy, medical director and CEO, Minnesota Center for Obesity, Metabolism, and Endocrinology, said in an interview.
The three organizations conducted a careful reexamination of glycemic control guidelines in light of the findings from the Action to Control Cardiovascular Risk in Diabetes (ACCORD), the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE), and the Veterans Affairs Diabetes Trial (VADT). All showed no significant reduction in cardiovascular outcomes with intensive glucose control, but the ACCORD caused particular concern—and was halted early—because it showed a 22% increase in mortality among subjects randomized to a strategy of very intensive glycemic control with a target HbA1c of less than 6% (N. Engl. J. Med. 2008;358:2545–9).
Still, “The evidence obtained from ACCORD, ADVANCE, and VADT does not suggest the need for major changes in glycemic control targets, but rather additional clarification of the language that has consistently stressed individualization,” Dr. Jay S. Skyler and his associates wrote (Diabetes Care 2009;32:187–92).
Those clarifications include:
▸ To prevent microvascular and neuropathic complications in people with both type 1 and type 2 diabetes, the HbA1c goal for nonpregnant adults in general remains less than 7%. This recommendation is based on robust data from long-term studies including the Diabetes Control and Complications Trial (DCCT) and the United Kingdom Prospective Diabetes Study (UKPDS).
The American Association of Clinical Endocrinologists (AACE), which was not part of the group issuing the statement, recommends aiming for an HbA1c level of 6.5% or less.
▸ The general HbA1c goal of less than 7% also “appears reasonable” for prevention of macrovascular disease among those with recent onset of diabetes, based on long-term follow-up of the DCCT and UKPDS cohorts.
▸ For selected individual patients, even lower HbA1c goals than the general goal of less than 7% might be reasonable, provided that this target can be achieved without significant hypoglycemia or other adverse effects of treatment. Such individuals might include those with short duration of diabetes, long life expectancy, and no significant cardiovascular disease. This recommendation was based on subgroup analyses of the DCCT, UKPDS, and the microvascular evidence from the ADVANCE trial.
▸ Conversely, less stringent HbA1c goals may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, or extensive comorbid conditions or those with longstanding diabetes in whom the general goal is difficult to attain despite diabetes self-management and education, appropriate glucose monitoring, and effective doses of multiple glucose-lowering agents, including insulin.
▸ For primary and secondary cardiovascular risk reduction in patients with diabetes, providers should continue to follow the evidence-based recommendations for blood pressure treatment, lipid-lowering with statins, aspirin prophylaxis, smoking cessation, and healthy lifestyle behaviors delineated in the ADA Standards of Medical Care in Diabetes (Diabetes Care 2008;31[suppl 1]:s12–54) and the AHA/ADA guidelines for primary CVD prevention (Circulation 2007;115?:114–26).
Dr. Gonzalez-Campoy, who serves on the AACE board of directors, agreed with the recommendations. “The ACCORD, ADVANCE, and VADT emphasize the need to individualize care. … The recent publications that show no benefit in cardiovascular outcomes with attempts at normalizing glycemic control were all done on people with [longstanding] type 2 diabetes. Therefore, these findings are not applicable to people with type 1 diabetes, nor do they apply to people with new-onset diabetes mellitus.”
“People with type 2 diabetes who may achieve normal A1c values with lifestyle changes alone, or with weight management, should not increase their A1c values,” Dr. Gonzalez-Campoy added.
Indeed, a substudy of VADT presented at the ADA's annual meeting in June suggested that individuals earlier in their history of type 2 diabetes had the most benefit of improved glycemic control, noted Dr. Daniel Einhorn, head of the Sharp Diabetes Treatment and Research Center, San Diego.
“The key is not to throw out the baby with the bathwater. The VADT and ACCORD suggest that some populations may not benefit from tight glycemic control and there may be risks associated with tight control in these same populations, i.e with cardiovascular disease and/or increased risk of hypoglycemia. This does not detract from the wealth of information that good glycemic control confers benefit on microvascular disease and, given a long enough window, cardiovascular disease,” said Dr. Einhorn, also on the AACE board of directors.
Dr. Einhorn is a consultant to Takeda, Eli Lilly, Amylin Pharmaceuticals, and Merck.
MIRIAM E. TUCKER (Senior Writer)
A target hemoglobin A1c of less than 7% should remain the general goal for nonpregnant adults with diabetes, despite the recent results from three large randomized trials showing that intensive glucose lowering did not reduce the risks of cardiovascular disease in people with longstanding type 2 diabetes.
But glycemic targets that are either more or less stringent than that standard may be prudent for certain individuals with diabetes, according to a joint position statement issued by the American College of Cardiology, American Diabetes Association, and American Heart Association and published online in their respective journals: the Journal of the American College of Cardiology, Diabetes Care, and Circulation.
“The ADA/AHA/ACC position statement is very well thought out and very well articulated. The authors should be commended for their concise analysis of the available data,” Dr. J. Michael Gonzalez-Campoy, medical director and CEO, Minnesota Center for Obesity, Metabolism, and Endocrinology, said in an interview.
The three organizations conducted a careful reexamination of glycemic control guidelines in light of the findings from the Action to Control Cardiovascular Risk in Diabetes (ACCORD), the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE), and the Veterans Affairs Diabetes Trial (VADT). All showed no significant reduction in cardiovascular outcomes with intensive glucose control, but the ACCORD caused particular concern—and was halted early—because it showed a 22% increase in mortality among subjects randomized to a strategy of very intensive glycemic control with a target HbA1c of less than 6% (N. Engl. J. Med. 2008;358:2545–9).
Still, “The evidence obtained from ACCORD, ADVANCE, and VADT does not suggest the need for major changes in glycemic control targets, but rather additional clarification of the language that has consistently stressed individualization,” Dr. Jay S. Skyler and his associates wrote (Diabetes Care 2009;32:187–92).
Those clarifications include:
▸ To prevent microvascular and neuropathic complications in people with both type 1 and type 2 diabetes, the HbA1c goal for nonpregnant adults in general remains less than 7%. This recommendation is based on robust data from long-term studies including the Diabetes Control and Complications Trial (DCCT) and the United Kingdom Prospective Diabetes Study (UKPDS).
The American Association of Clinical Endocrinologists (AACE), which was not part of the group issuing the statement, recommends aiming for an HbA1c level of 6.5% or less.
▸ The general HbA1c goal of less than 7% also “appears reasonable” for prevention of macrovascular disease among those with recent onset of diabetes, based on long-term follow-up of the DCCT and UKPDS cohorts.
▸ For selected individual patients, even lower HbA1c goals than the general goal of less than 7% might be reasonable, provided that this target can be achieved without significant hypoglycemia or other adverse effects of treatment. Such individuals might include those with short duration of diabetes, long life expectancy, and no significant cardiovascular disease. This recommendation was based on subgroup analyses of the DCCT, UKPDS, and the microvascular evidence from the ADVANCE trial.
▸ Conversely, less stringent HbA1c goals may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, or extensive comorbid conditions or those with longstanding diabetes in whom the general goal is difficult to attain despite diabetes self-management and education, appropriate glucose monitoring, and effective doses of multiple glucose-lowering agents, including insulin.
▸ For primary and secondary cardiovascular risk reduction in patients with diabetes, providers should continue to follow the evidence-based recommendations for blood pressure treatment, lipid-lowering with statins, aspirin prophylaxis, smoking cessation, and healthy lifestyle behaviors delineated in the ADA Standards of Medical Care in Diabetes (Diabetes Care 2008;31[suppl 1]:s12–54) and the AHA/ADA guidelines for primary CVD prevention (Circulation 2007;115?:114–26).
Dr. Gonzalez-Campoy, who serves on the AACE board of directors, agreed with the recommendations. “The ACCORD, ADVANCE, and VADT emphasize the need to individualize care. … The recent publications that show no benefit in cardiovascular outcomes with attempts at normalizing glycemic control were all done on people with [longstanding] type 2 diabetes. Therefore, these findings are not applicable to people with type 1 diabetes, nor do they apply to people with new-onset diabetes mellitus.”
“People with type 2 diabetes who may achieve normal A1c values with lifestyle changes alone, or with weight management, should not increase their A1c values,” Dr. Gonzalez-Campoy added.
Indeed, a substudy of VADT presented at the ADA's annual meeting in June suggested that individuals earlier in their history of type 2 diabetes had the most benefit of improved glycemic control, noted Dr. Daniel Einhorn, head of the Sharp Diabetes Treatment and Research Center, San Diego.
“The key is not to throw out the baby with the bathwater. The VADT and ACCORD suggest that some populations may not benefit from tight glycemic control and there may be risks associated with tight control in these same populations, i.e with cardiovascular disease and/or increased risk of hypoglycemia. This does not detract from the wealth of information that good glycemic control confers benefit on microvascular disease and, given a long enough window, cardiovascular disease,” said Dr. Einhorn, also on the AACE board of directors.
Dr. Einhorn is a consultant to Takeda, Eli Lilly, Amylin Pharmaceuticals, and Merck.
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