Have I gotten it wrong or has the evidence changed?

OVERALL – statins appear to reduce mortality, and coronary and cerebrovascular events
DIABETICS – no statistically significant reduction in events has been shown, but confident intervals clearly overlap with the OVERALL group so we can’t rule out that the benefit could be similar – but we just don’t know based on the available data.

OVERALL
Mortality 0.88 (0.81-0.96)
Coronary 0.70 (0.61-0.81)
Cerebrovascular 0.81 (0.71-0.93)
DIABETICS
Mortality 0.95 (0.84-1.07)
Coronary 0.88 (0.69-1.13)
Cerebrovascular 0.88 (0.60-1.28)

I think our PRIMARY intervention should be to get people with increased HbA1c (notice I didn’t say diabetes) to increase activity and eat less/healthier food – typically that leads to weight loss but these interventions are easier said than done. However, in my opinion, this intervention should apply to every “patient” in general and we should avoid drugs as much as possible. Thanks for your comment.

Prior meta-analysis showed ARR=2.6% in major CV outcomes among diabetics without prior CVD for primary prevention. [1] However, somehow without clear explanation, they managed to exclude negative trials-4D, ASPEN, and CORONA. [2] Just this week, BMJ released the article on this matter again with better sub-group analysis. Their finding is diabetic patients do not get any benefit from statin drugs for primary prevention. [3]

Does that mean diabetic patients rarely get benefit from statin treatment and may get benefit from glucose lowering, and 0.4% of ARR at most from aspirin and mainly from BP reduction (SBP<140 mmHg)? Isn’t it the high time to look at weight gain rather than glucose or HbA1c for follow up of DM2 ?

[1] Lancet (2008) 371:117-25
http://therapeuticseducation.org/?attachment_id=458
[2] Lancet (2008) 371:94-95
[3] BMJ 2009;338:b2376
http://www.bmj.com/cgi/content/abstract/338/jun30_1/b2376

As noted in UKPDS, ACCORD, VADT, ADVANCE trials, intensive Blood sugar control provides almost no benefit in macrovascular outcomes. Besides, including all small sized trials, there is not good evidence that lowering glycemia will be beneficial in DM2. [1] UK NICE recommends against screening for DM2 which is also in accordance with USPSTF. The only possible benefit is to reduce the microvascular complications of DM2 which is practically retinopathy or proteinuria. Less retinopathy doesn’t lead to less of cataract surgery or blindness in UKPDS and as discussed in your prior podcasts, proteinuria is a just one of the “possible” surrogate markers for major CV outcomes since decreasing the proteinuria did not save pts from less ESRD or Dialysis. Then, to me there doesn’t seem to be any indication for oral hypoglycemic agents or insulin as there is no point of bringing down the blood sugar to the acceptable range. This idea was echoed by Dr. Nortin Hadler, author of ‘Worried sick’ who wrote the thought-provoking article on abcnews.com that he has never prescribed oral hypoglycemic agents for the past 40 years. [2]

Only exception that I can find in DM2 for benefit in major CV outcomes is replenishing insulin when endogenous insulin is too low, which can be detected by C-peptide level. [3]

I am more than happy to listen to your opinion on this whole thing (insulin, oral hypoglycemic agents.

[1] The effect of interventions to prevent cardiovascular disease in patients with type 2 diabetes. Am J Med 2001;111:633-42
[2] If There’s No Benefit, Why Tolerate Any Risk? http://abcnews.go.com/Health/Story?id=3232247&page=2
[3] Effect of interactions between C peptide levels and insulin treatment on clinical outcomes among patients with type 2 diabetes mellitus. CMAJ 2009; 180:919-26