Today, I want to talk about what is new in research in type 2 diabetes and heart disease. For the last several years, we have been learning about whether or not controlling blood glucose levels to very specific targets can prevent the progression of heart disease in people with known heart disease or at high risk of heart disease. We have heard about the ADVANCE, ACCORD and the VADT trials. Unfortunately none of these were able to show that aggressively treating diabetes could make a difference in heart disease outcomes. Most recently the American Diabetes Association meeting was held in Philadelphia. This is considered the most prestigious meeting of researchers in diabetes. The big news from this year’s conference was the “ORIGIN” trial.
Why is the ORIGIN trial so interesting to people living with diabetes? This is a long-term study (over 8 years) in people with pre-diabetes or very early diabetes and known heart disease. The question that was studied was whether starting insulin glargine (Lantus®) very early in the treatment of their diabetes and targeting a fasting blood glucose level target of 5.3 mmol/L, would prevent the progression of their heart disease. This was compared to standard care. The trial also studied the effect of fish oil tablets in the prevention of heart disease. This was compared to placebo tablets (dummy pills).
What did we learn? We learned that using insulin was not harmful and there was not a significant increase in weight and in addition, the risk of hypoglycemia (low blood sugar) was well tolerated by the participants. But unfortunately in this very long study, we also learned that lowering glucose to the levels targeted did not prevent progression of heart disease any better than standard care. So no benefit and no harm. The same was found for the fish oil part of the study.
However, there was one very important finding from this study. For the last few years, we have been receiving confusing information about whether or not using insulin glargine (Lantus®) increased the risk of certain kinds of cancer. This study was able to clearly show that there was a 0% increased risk of cancer compared to standard therapy in over 12,000 patients worldwide. This is important to people living with diabetes and the healthcare professionals who treat them! This was only the first report from this study and we will continue to learn more in the future.
There is some good news though; many years ago two very important trials were conducted in both type 1 and type 2 diabetes to determine if good blood sugar control could prevent the complication of diabetes. These studies helped us to set the target of ≤ 7.0% for A1C to prevent the “microvascular” (eye, kidney and nerve) complications of diabetes. Neither trial showed that it prevented “macrovascular” (heart and stroke) complications. The participants in both these trials have been followed for over 10 years since those trials ended. There was no change to their treatment – just occasional checks as to how they were doing from time to time. We now clearly have learned from both of these groups that early in the disease, managing glucose levels to target WILL prevent macrovascular complications (heart disease) in the long term.
In the next few years to come, we will learn the results from other very large clinical trials in type 2 diabetes. These studies are trying to understand if any particular medication to treat diabetes has an increased risk (keeping our patient safe) or additional benefit (keeping our patient healthy) of heart disease. Stay tuned!