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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.
Estão estas inovações terapêuticas ao dispor dos diabéticos portugueses? A resposta é sim e não. Segundo o Observatório da Diabetes 2015 a prevalência da diabetes é de 13,1% da população portuguesa (20-70 anos) dos quais 5,7% não sabem que são diabéticos. A diabetes tipo 1 é o tipo menos frequente de diabetes mas atinge pessoas em idades mais frágeis (crianças e adolescentes), e obriga à administração diária de várias injecções de insulina para toda a vida. A diabetes tipo 2 é mais comum em pessoas adultas e obesas e o tratamento inicial é emagrecer e antidiabéticos orais.
Pituitary Incidentaloma: An Endocrine Society Clinical Practice Guideline
We recommend that patients with a pituitary incidentaloma undergo a complete history and physical examination, laboratory evaluations screening for hormone hypersecretion and for hypopituitarism, and a visual field examination if the lesion abuts the optic nerves or chiasm. We recommend that patients with incidentalomas not meeting criteria for surgical removal be followed with clinical assessments, neuroimaging (magnetic resonance imaging at 6 months for macroincidentalomas, 1 yr for a microincidentaloma, and thereafter progressively less frequently if unchanged in size), visual field examinations for incidentalomas that abut or compress the optic nerve and chiasm (6 months and yearly), and endocrine testing for macroincidentalomas (6 months and yearly) after the initial evaluations. We recommend that patients with a pituitary incidentaloma be referred for surgery if they have a visual field deficit; signs of compression by the tumor leading to other visual abnormalities, such as ophthalmoplegia, or neurological compromise due to compression by the lesion; a lesion abutting the optic nerves or chiasm; pituitary apoplexy with visual disturbance; or if the incidentaloma is a hypersecreting tumor other than a prolactinoma.
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.
Diagnosis and Treatment of Hyperprolactinemia: 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.
Practice guidelines are presented for diagnosis and treatment of patients with elevated prolactin levels. These include evidence-based approaches to assessing the cause of hyperprolactinemia, treating drug-induced hyperprolactinemia, and managing prolactinomas in nonpregnant and pregnant subjects. Indications and side effects of therapeutic agents for treating prolactinomas are also presented.
Evaluation and Treatment of Adult Growth Hormone Deficiency: An Endocrine Society Clinical Practice Guideline
The objective is to provide guidelines for the evaluation and treatment of adults with GH deficiency (GHD).
GHD can persist from childhood or be newly acquired. Confirmation through stimulation testing is usually required unless there is a proven genetic/structural lesion persistent from childhood. GH therapy offers benefits in body composition, exercise capacity, skeletal integrity, and quality of life measures and is most likely to benefit those patients who have more severe GHD. The risks of GH treatment are low. GH dosing regimens should be individualized. The final decision to treat adults with GHD requires thoughtful clinical judgment with a careful evaluation of the benefits and risks specific to the individual.