Intended for healthcare professionals

Clinical Review State of the Art Review

Benefits and harms of intensive glycemic control in patients with type 2 diabetes

BMJ 2019; 367 doi: https://doi.org/10.1136/bmj.l5887 (Published 05 November 2019) Cite this as: BMJ 2019;367:l5887
  1. René Rodriguez-Gutierrez, professor of medicine1 2 3,
  2. José Gerardo Gonzalez-Gonzalez, professor of medicine1 3,
  3. Jorge A Zuñiga-Hernandez, assistant professor of medicine1 3,
  4. Rozalina G McCoy, associate professor of medicine4 5
  1. 1Plataforma INVEST Medicina UANL – KER Unit (KER Unit México), Subdireccion de Investigacion, Universidad Autónoma de Nuevo León, Monterrey, 64460, Mexico
  2. 2Knowledge and Evaluation Research Unit in Endocrinology, Mayo Clinic, Rochester, MN 55905, USA
  3. 3Endocrinology Division, Department of Internal Medicine, University Hospital “Dr José E González,” Universidad Autonoma de Nuevo Leon, Monterrey, 64460, Mexico
  4. 4Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
  5. 5Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN 55905, USA
  1. Correspondence to: R Rodríguez-Gutiérrez rodriguezgutierrez.rene{at}mayo.edu

ABSTRACT

Diabetes is a major and costly health concern worldwide, with high morbidity, disability, mortality, and impaired quality of life. The vast majority of people living with diabetes have type 2 diabetes. Historically, the main strategy to reduce complications of type 2 diabetes has been intensive glycemic control. However, the body of evidence shows no meaningful benefit of intensive (compared with moderate) glycemic control for microvascular and macrovascular outcomes important to patients, with the exception of reduced rates of non-fatal myocardial infarction. Intensive glycemic control does, however, increase the risk of severe hypoglycemia and incurs additional burden by way of polypharmacy, side effects, and cost. Additionally, data from cardiovascular outcomes trials showed that cardiovascular, kidney, and mortality outcomes may be improved with use of specific classes of glucose lowering drugs largely independently of their glycemic effects. Therefore, delivering evidence based, patient centered care to people with type 2 diabetes requires a paradigm shift and departure from the predominantly glucocentric view of diabetes management. Instead of prioritizing intensive glycemic control, the focus needs to be on ensuring access to adequate diabetes care, aligning glycemic targets to patients’ goals and situations, minimizing short term and long term complications, reducing the burden of treatment, and improving quality of life.

Footnotes

  • Series explanation: State of the Art Reviews are commissioned on the basis of their relevance to academics and specialists in the US and internationally. For this reason they are written predominantly by US authors

  • Contributors: RRG, JGGG, RGM, and JAZH reviewed and provided valuable information, insight, and edition to the manuscript. All authors have agreed on the final version of the manuscript. RRG is the guarantor.

  • Funding: RGM is supported by the Mayo Clinic Robert D and Patricia E Kern Center for the Science of Health Care Delivery and by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health under award number K23DK114497. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

  • Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following interests: none.

  • Provenance and peer review: Commissioned; externally peer reviewed.

  • Patient involvement: Mrs J is a patient in the Diabetes Clinic of the Endocrinology Division at the University Hospital “Dr José E Gonzalez” of the Universidad Autonoma de Nuevo Leon. On being invited to participate in this review, Mrs J provided informed consent to share her personal experience as a person living with type 2 diabetes, which framed our discussion of person centered care.

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