Early intensive glycaemic control in type 2 diabetes provides near-lifelong protection, study finds

Treating type 2 diabetes mellitus (T2DM) with early intensive glycaemic control, using metformin, sulfonylurea or insulin, reduced the risk of death and myocardial infarction (MI) for up to 24 years, study results have shown.

A follow-up study, published in The Lancet on 17 May 2024, monitored clinical outcomes of 1,489 participants from a previous diabetes study in the UK, using NHS data that were routinely collected between October 2007 and September 2021.

The original study — the UK Prospective Diabetes Study (UKPDS), published in 1998 — included 5,102 newly diagnosed T2DM patients, who were enrolled between 1977 and 1991, and found major clinical benefit of intensive glycaemic control compared to conventional control (primarily diet) during the 20-year trial period. Following this, 3,277 participants were monitored for a further 10 years until 2007.

An extended follow-up of these participants was then carried out by linking them to their routinely collected NHS data for a further 14 years.

In the follow-up trial, the mean age of the remaining participants at baseline was 50.2 years, with 41.3% of participants being female. The mean age of those still alive by September 2021 was 79.9 years.

At the end of the additional 14-year follow-up period (24 years after the original study ended) researchers found that, compared with conventional therapy, early intensive glycaemic control with metformin reduced the overall relative risk of death from any cause by 20% (P=0.010) and MI by 31% (P=0.003) — absolute risk reductions of 4.9% and 6.2%, respectively. No significant risk reduction for microvascular disease was observed.

In those treated with sulfonylurea or insulin, the researchers observed an overall relative risk reduction of 10% for death from any cause (P=0·015), 17% for MI (P=0·002), and 26% (P<0·0001) for microvascular disease — absolute risk reductions of 2.7%, 3.3% and 3.5%, respectively.

The authors also reported that no significant risk reductions for stroke or peripheral vascular disease were observed in either intensive glycaemic control groups, during or after the trial.

Commenting on the study, Helen O’Neil, medicines optimisation lead for diabetes for North East and North Cumbria Integrated Care Board, said: “The study highlights the benefits of tight glycaemic control early on in diagnosis, with significant reductions in risk of death and myocardial infarction throughout life.

“Whether this is dependent on the medications taken to achieve this or in fact just as a result of early tight glycaemic control is not clear,” she added.

“How we achieve tight glycaemic control now has also evolved, T2DM is now far more closely linked to obesity, and this is highlighted in the national rolling out of the NHS Type 2 Diabetes Path to Remission Programme, which has shown, by rapid weight reduction, diabetes control can also improve rapidly.

“Overall, the take-home message to clinicians should be to ensure tight glycaemic control is achieved rapidly following diagnosis, whether this be via medications or diet interventions,” she added.

In May 2024, NHS England and charity Diabetes UK announced the expansion of the NHS Type 2 Diabetes Path to Remission Programme to the whole of England, increasing the availability of the low-calorie ‘Soups and Shakes’ diet, to a further 10,000 people in 2024.

The liquid diet of just over 800 calories per day was trialled in 2,000 patients for three months in 2018, following positive results from a study funded by Diabetes UK, which found that 46% of patients on the diet achieved remission of their T2DM after one year.

In 2022, NHS England tendered for a £20m contract to operate the service from June 2023, stating that more than 2,000 people had taken part in the pilot scheme, losing an average of 13kg in 3 months.

Commenting on the follow-up study, Faye Riley, research communications manager at Diabetes UK, said: “The UKPDS, backed by Diabetes UK, found that keeping blood glucose levels in target range is the cornerstone of T2DM management, influencing care worldwide.

“Now, the latest results underscore the importance of early diagnosis and immediate action in T2DM, to get blood glucose to target range as quickly as possible to give long-lasting protection against diabetes complications and ensure more people live longer, healthier lives,” she added.