Eyeworld

EW RETINA 116 by Liz Hillman EyeWorld Staff Writer give it attention and [come up with] ways to bridge the gap between the internal medicine physicians and ophthalmologists," Dr. Chew said. As for advising diabetic patients to aggressively control glycemia, Dr. Chew said patients in the study were kept at an A1C between 6 and 6.5. However, the American Diabetes As- sociation recommends that patients aim to achieve an A1C level <7%. "That means more insulin, mul- tiple drugs. Diet is important as well as exercise," she said. This intensive therapy might not be for everyone. The intensive therapy portion of the ACCORD study was stopped at 3.5 years, short of its intended 5.6-year study period, due to an increased risk of death in patients in this group. Dr. Chew said they are not sure why this happened. As such, she said patients should discuss this therapy with their doctor before starting it. She also noted that other comorbidi- ties, intense blood pressure issues, or heart problems might make it harder to stay within this range. "I think people need to talk to their doctor to see how safe it is for them. For someone who is prone to hypoglycemia, it's not good to push them as hard because of some of the side effects. I think it's very individ- ualized," Dr. Chew said. According to the NIH, diabetic retinopathy cases in the U.S. are ex- pected to double between 2010 and 2050 from 7.7 million people to 14.6 million. 3 EW References 1. Chew EY, et al. Persistent effects of intensive glycemic control on retinopathy in type 2 diabetes in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) Follow-on Study. Diabetes Care. 2016;39: 1089–1100. 2. Chew EY, et al. Rationale, design, and meth- ods of the Action to Control Cardiovascular Risk in Diabetes Eye Study (ACCORD EYE). Am J Cardiol. 2007;99:103i–111i. 3. National Institutes of Health National Eye Institute. Diabetic Retinopathy Defined. Accessed July 14, 2016. nei.nih.gov/eyedata/ diabetic Editors' note: Dr. Chew has no finan- cial interests related to her comments. Contact information Chew: echew@nei.nih.gov though glycated hemoglobin levels were similar 8 years after random- ization and about 4 years after the cessation of the clinical trial," the study authors wrote. "This is the first study in people with type 2 diabetes of about 10 years' duration and es- tablished cardiovascular disease […] that demonstrated this effect." What causes this legacy effect, also called metabolic memory, re- mains a mystery. "Is it inflammation? Is it some other mechanism? We really don't know. There is a lot of speculation but no one knows for sure," Dr. Chew said. Fenofibrate, which is given to lower triglyceride levels, was also found to reduce diabetic retinopa- thy progression during the initial study period, but it was not found to have a legacy effect. Interestingly, fenofibrate was previously found to be beneficial for reducing progres- sion of diabetic retinopathy in the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study. "We found [fenofibrate] re- duced about a third of progression, and those were mostly people who already had retinopathy in the orig- inal ACCORD Eye Study," Dr. Chew said, calling this reduction "signifi- cant" and "clinically meaningful." Given that it was not found in the ACCORD study to reduce cardio- vascular disease, Dr. Chew thinks it will be a hard sell for an internist to prescribe it to prevent retinopathy progression. "The internist is saying, 'If it doesn't do anything for the heart, I'm not going to prescribe it.' The ophthalmologists are left holding the bag, and we don't normally prescribe drugs that have systemic effects. I think there needs to be a resolution for how that can be done," Dr. Chew said. As such, Dr. Chew described a new study she is involved with that is looking at ophthalmologists starting to prescribe fenofibrate to decrease diabetic retinopathy pro- gression and how that would relate to internal medicine and primary care doctors. "We also want to prove to the medical community that this is not a subgroup analysis in the ACCORD study and the FIELD study, but we may again see that this is a treat- ment effect, and that will hopefully "I think people may not be totally aware of how they can help themselves to preserve their vision, but we also know people fear vision loss greatly," said Emily Chew, MD, NEI Division of Epidemiology and Clinical Applications, and lead author of the study report. While the persistent beneficial effect of intensive glycemic control had been seen in prior research in persons with type 2 diabetes, Dr. Chew said their study involved patients who were sicker and had a longer duration of diabetes with results showing they still had a per- sistent effect from this therapy. "It bodes well that at any stage you should consider this type of intensive glycemic therapy," Dr. Chew said. The initial ACCORD Eye Study clinical trial was conducted to assess the effect of intensive glycemic control, intensive blood pressure control, and fenofibrate to address cholesterol control. This study demonstrated that both intensive glycemic control and fenofibrate reduced retinopathy progression. The ACCORDION study examined diabetic retinopathy progression in 1,310 participants 8 years after randomization in the initial study and 3 to 5 years after clinical trial therapies ended. "Our results showed that in- tensive glycemic control conferred enduring protection from progres- sion of diabetic retinopathy even Effect was seen several years after therapy was stopped I t's no secret that patients with diabetes are more at risk for developing glaucoma, cata- racts, and diabetic retinopathy, among other conditions. But a new study adding to the body of re- search on preventive measures that can be taken to curb vision-threaten- ing diseases suggests intensive con- trol of blood sugar can cut retinop- athy progression in half for patients with type 2 diabetes. The Action to Control Cardio- vascular Risk in Diabetes Follow-on (ACCORDION) Eye Study, funded by the National Institutes of Health's National Eye Institute (NEI), found that patients with well-established diabetes who were part of an in- tensive glycemic control group for 3.5 years saw an average 6.4% A1C blood glucose level compared to 7.7% in patients with standard gly- cemic control. 1 Eight years after the initial ACCORD Eye Study, 2 those in the intensive therapy group had maintained similar A1C levels with discontinuing the intensive therapy several years before. While diabetic retinopathy had advanced in 12.7% of standard therapy group patients, it had only advanced in 5.8% of patients in the intensive therapy group. Intensive blood sugar control reduces diabetic retinopathy risk Dr. Chew examines a patient's eyes. Source: National Eye Institute September 2016

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