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Insulin therapy, alone or in combination with OADs, should be considered when more intensive glucose lowering is needed to achieve HbA1C targets (14, 16).
A fourth demonstration was that there was no significant reduction in macrovascular disease but a trend toward fewer myocardial infarctions with more intensive glucose control.
What factors could be responsible for the observation that frequent hypoglycemia reduces the risk of mortality in participants randomly assigned to a more intensive glucose target?
Such management may be more successful if focused on supportive measures and more intensive glucose control, rather than family planning (11).
This observation is not fully understood, but contrasts late follow-ups of the DCCT 9 and UKPDS 10 cohorts, where a CV disease (CVD) benefit emerged in patients originally assigned to more intensive glucose reduction, despite later convergence of HbA1c.
In particular, the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, showing excessive all cause and CV mortality on more intensive glucose lowering therapy, has highlighted the complexity of pros and cons in relation to diabetes treatment [ 3].
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Despite receiving more intensive glucose-lowering therapy, they also have poorer glycaemic control [ 32].
Our AMI analysis showed that more intensive glucose-control strategies did not significantly reduce or increase rates of AMI.
Evolving guidelines have encouraged earlier and more intensive glucose-lowering pharmacotherapy, 11 and this therapy is commonly started by general practitioners outside hospitals in Denmark.
Finally, the link between fluctuations of HbA1c and risk of microvascular complications might relate to the fact that patients with a higher HbA1c-SD are those with a worse CVD risk profile and a more intensive glucose-lowering treatment.
Overall, the effect of more intensive glucose-control strategies on measures of renal status obtained in this comparative effectiveness research analysis is consistent with the results of ACCORD and ADVANCE, supporting the notion that the microvascular results of those studies may apply to a broad group of adults with diabetes.
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