Target Hemoglobin A1c < 6-6.5% May be Harmful in Patients with Type 2 Diabetes
(level 2 [mid-level] evidence)
Three major trials tested the idea that more aggressive glycemic control (compared to standard target HbA1c < 7%) would provide better clinical outcomes in patients with type 2 diabetes. The Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial with 10,251 patients aged 40-82 years was terminated early due to increased mortality in the group with target HbA1c < 6% (p = 0.04, NNH 100) (N Engl J Med 2008 Jun 12;358(24);2545). The Action in Diabetes and Vascular Disease: PreteraAx and DiamicroN MR Controlled Evaluation (ADVANCE) trial with 11,140 patients > 55 years old found target HbA1c < 6.5% using gliclazide as initial therapy resulted in increased hospitalization rates with “benefit” possibly limited to reduction in development in macroalbuminuria (N Engl J Med 2008 Jun 12;358(24):2560). The Veterans Affairs Diabetes Trial (VADT) with 1,791 patients (mean age 60.4 years) found intensive glucose control (with insulin if needed to reach HbA1c < 6%) did not reduce vascular complications but increased weight and hypoglycemia (N Engl J Med 2009 Jan 8;360(2):129). For more information, see the Glycemic goals in patients with type 2 diabetes topic in DynaMed.
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For Knee Osteoarthritis
Therapeutic Exercise is Effective (level 1 [likely reliable] evidence) but not Arthroscopic Surgery (level 2 [mid-level] evidence)
Therapeutic exercise of the knee, in particular strength training, reduces pain and improves physical function in patients with knee osteoarthritis, based on 2 systematic reviews (Cochrane Database Syst Rev 2008 Oct 8;(4):CD004376, Arthritis Rheum 2008 Oct 15;59(10):1488). For moderate to severe secondary or idiopathic knee osteoarthritis, the addition of arthroscopic surgery appears no more effective than optimized physical and medical therapy alone, based on an unblinded randomized trial of 188 patients ≥ 18 years old (N Engl J Med 2008 Sep 11;359(11):1097). For more information, see the Degenerative joint disease of the knee topic in DynaMed.
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Presenting Spirometry Results as “Lung Age” Increases Rate of Smoking Cessation at 12 Months
(level 1 [likely reliable] evidence)
Informing a patient of his or her spirometric lung age immediately upon testing increases the smoking cessation rate at 12 months (NNT 14), based on a randomized trial of 561 smokers > 35 years old who were randomized to receive spirometric lung function assessment results in terms of “lung age” (age of average healthy person performing similarly on spirometry) immediately vs. raw figure for FEV1 sent by mail. All participants were advised to quit and were offered a referral to local NHS smoking cessation services (BMJ 2008 Mar 15;336(7644):598 full-text). For more information, see the Tobacco use disorder topic in DynaMed.
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