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Intensive glycemic control and the prevention of cardiovascular events - implications of the ACCORD, ADVANCE, and VA diabetes trials
Diabetes is defined by its association with hyperglycemia-specific microvascular complications; however, it also imparts a two- to fourfold risk of cardiovascular disease. Although microvascular complications can lead to significant morbidity and premature mortality, by far the greatest cause of death in people with diabetes is CVD.
Because of ongoing uncertainty regarding whether intensive glycemic control can reduce the increased risk of CVD in people with type 2 diabetes, several large long-term trials were launched in the past decade to compare the effects of intensive versus standard glycemic control on CVD outcomes in relatively high-risk participants with established type 2 diabetes. In 2008, two of these trials, ADVANCE and VADT, were completed and showed no significant reduction in cardiovascular outcomes with intensive glycemic control. A third trial, ACCORD, terminated its glycemic control study early due to the finding of increased mortality in participants randomized to a strategy of very intensive glycemic control with a target A1C of <6%. The findings of these three major trials led the ADA, with representatives of the American Heart Association (AHA) and the American College of Cardiology (ACC), to reexamine the recommendations for glycemic targets in patients with diabetes, the majority of whom have type 2 diabetes.
Acromegaly: An Endocrine Society Clinical Practice Guideline
This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe both the strength of recommendations and the quality of evidence. The Task Force reviewed primary evidence and commissioned two additional systematic reviews.
Using an evidence-based approach, this acromegaly guideline addresses important clinical issues regarding the evaluation and management of acromegaly, including the appropriate biochemical assessment, a therapeutic algorithm, including use of medical monotherapy or combination therapy, and management during pregnancy.
AACE medical guidelines for developing a diabetes mellitus comprehensive care plan
This CPG will complement and extend existing CPGs available in the literature, as well as previously pub- lished American Association of Clinical Endocrinologists DM CPGs. When a routine consultation is made for DM management, these new guidelines advocate that a comprehensive approach is taken and suggest that the clinician should move beyond a simple focus on glycemic control. This comprehensive approach is based on the evi- dence that although glycemic control parameters (hemoglobin A1c, postprandial glucose excursions, fasting plasma glucose, glycemic variability) have an impact on cardiovascular disease risk, mortality, and quality of life, other factors also affect clinical out- comes in persons with DM.These are clinical practice guidelines for developing a diabetes mellitus comprehensive care plan. The mandate for this CPG is to provide a practical guide for comprehensive care that incorporates an integrated consideration of microvascular and macrovascular risk rather than an isolated approach focusing merely on glycemic control.
Interdisciplinary European Guidelines on Metabolic and Bariatric Surgery
In 2012, an outstanding expert panel derived from IFSO-EC (International Federation for the Surgery of Obesity – European Chapter) and EASO (European Association for the Study of Obesity), composed by key representatives of both Societies including past and present pres- idents together with EASO’s OMTF (Obesity Management Task Force) chair, agreed to devote the joint Medico-Surgical Workshop of both institutions to the topic of metabolic surgery as a pre-satellite of the 2013 European Congress on Obesity (ECO) to be held in Liverpool given the extraordinarily advancement made specifically in this field during the past years. It was further agreed to revise and update the 2008 Interdisciplinary European Guidelines on Sur- gery of Severe Obesity produced in cooperation of both Societies by focusing in particular on the evidence gathered in relation to the effects on diabetes during this lustrum and the sub- sequent changes that have taken place in patient eligibility criteria. The expert panel compo- sition allowed the coverage of key disciplines in the comprehensive management of obesity and obesity-associated diseases, aimed specifically at updating the clinical guidelines to re- flect current knowledge, expertise and evidence-based data on metabolic and bariatric surgery.
Management of Obesity in Adults: European Clinical Practice Guidelines
The development of consensus guidelines for obesity is complex. It involves recommending both treatment interventions and interventions related to screening and prevention. With so many publications and claims, and with the awareness that success for the individual is short-lived, many find it difficult to know what action is appropriate in the management of obesity. Furthermore, the significant variation in existing service provision both within countries as well as across the regions of Europe makes a standardised approach, even if evidence-based, difficult to implement. In formulating these guidelines, we have attempted to use an evidence-based approach while allowing flexibility for the practicing clinician in domains where evidence is currently lacking and ensuring that in treatment there is recognition of clinical judgment and of regional diversity as well as the necessity of an agreed approach by the individual and family. We conclude that i) physicians have a responsibility to recognise obesity as a disease and help obese patients with appropriate prevention and treatment, ii) treatment should be based on good clinical care and evidence-based interventions and iii) obesity treatment should focus on realistic goals and lifelong management.