Some diabetes guidelines set low glycemic control goals for patients with type 2 diabetes mellitus (such as a hemoglobin A1c level as low as 6.5% to 7.0%) to avoid or delay complications. Our review and critique of recent large randomized trials in patients with type 2 diabetes suggest that tight glycemic control burdens patients with complex treatment programs, hypoglycemia, weight gain, and costs and offers uncertain benefits in return. We believe clinicians should prioritize supporting well-being and healthy lifestyles, preventive care, and cardiovascular risk reduction in these patients. Glycemic control efforts should individualize hemoglobin A1c targets so that those targets and the actions necessary to achieve them reflect patients' personal and clinical context and their informed values and preferences.
In its negative view of tight glycemic control in DM 2 this review, in my opinion, does not make enough of a distinction between microvascular and macrovascular outcomes.
One remarkable outcome of all the DM 2 trials abstracted in the review was weight gain. That’s the price you pay for intensive glycemic control with insulin and insulin secretogogues and it’s precisely the outcome you do not want if you’re trying to reduce macrovascular disease. That helps explain why macrovascular disease is an elusive target and why macrovascular complications were increased in the ACCORD study. As I said here, I will offer a theory on diabetes treatment and macrovascular disease in a future post.