Less-Stringent HbA_1c Goal May Be Appropriate

The VADT (Veterans Affairs Diabetes Trial) randomized nearly 1,800 patients with an average baseline HbA_1c level of 9.4% to either a standard regimen or an intensive regimen with a target HbA_1c level of 1.5% less than what would be achieved in the standard-treatment arm.

After 3 months, this goal was reached, with an average achieved HbA_1c level of 6.9% in the intensive-regimen group and an average level of 8.4% in the standard-treatment patients. After an average of 5.6 years, there was no significant difference in the primary outcome (the rate of major cardiovascular events, including MI, stroke, heart failure, surgery for vascular disease, cardiovascular death, or other cardiovascular events).

The two groups also showed no significant differences in the rate of cardiovascular death or the rate of all-cause death. And there were no significant differences in the rates of microvascular complications between the two groups (N. Engl. J. Med. 2009;360:129–39).

The results from these three studies led to a statement from an expert panel organized by the American Diabetes Association, the American College of Cardiology, and the American Heart Association (Diabetes Care 2009;32:187–92). In part, the statement said: “Less stringent A_1c goals than the general goal of less than 7% may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, or extensive comorbid conditions or [for] those with long-standing diabetes in whom the general goal is difficult to attain.”