Réflexions pour de nouvelles recommandations de traitement médicamenteux du diabète de type 2 après post-UKPDS, ACCORD, VADT, ADVANCE

The year 2008 has been full of events and learning experience for the glycemic objectives in type 2 diabetic patients regarding their cardiovascular risk. The analysis of studies published in 2008 (ACCORD, STENO 2 post-trial, ADVANCE, VADT, UKPDS post-trial), brings lessons for the clinical practice: a glycemic memory but an absence of blood pressure legacy and the major role of a strict control of each cardiovascular risk factor. For determining HbA1c objectives, former HbA1c level, age of the patient, duration of diabetes, presence of cardiovascular risk factors and undesirable effects as major hypoglycaemic attacks must be taking into account. The “early” management of type 2 diabetic patients needs a good glycemic control (HbA1c <7%). In older and more fragile patients a fast and too strict glycemic control should be deleterious, i.e. hypoglycaemia and a less stringent glycemic control must be, by contrast, combined with a strict control of the other cardiovascular risk factors. The new treatments, gliptins and GLP-1 analogs offer new potential strategies, without undesirable effects as body weight gain, fluid retention and hypoglycaemia. However their, long term, real efficacy and costs require to be validated before to be largely introduced in the new guidelines. Their place remains not yet precisely determined.