Comment expliquer la controverse à propos de l'efficacité/sécurité cardiovasculaire dans les essais cliniques concernant le diabète de type 2 ?

There is a controversy for the studies ofefficacy, the studies which have evaluated the cardiovascular benefit of a blood glucose reduction (whatever were the antidiabetic agents used, generally in combination, to get HbA 1c to target). After the results of VADT at 10years, these studies converge to a cardiovascular benefit ofreducing blood glucose, even though this trend remains largely opened to debate. However the excess mortality risk observed in the ACCORD intensive arm remains a controversial issue. On the other hand, for the so-called cardiovascular safety studies, which compare a given antidiabetic agent to placebo, without blood glucose difference, orminor, between both arms, there is not really a controversy. All these studies showed a cardiovascular safety of the drug which was evaluated and one of them (EMPA-REG OUTCOME for empagliflozine) even demonstrated a reduction in cardiovascular mortality, probably due to a pleiotropic effect, i.e. not related to the blood glucose lowering effect of empagliflozin. It is a pity not having such safety studies for sulfonylureas for which there is a concern on their cardiovascular safety, precisely because specific studies are lacking. Expecting a pleiotropic benefit of an antidiabetic medication is relevant but the main clinical question is: does lowering blood glucose with a given medication results in a cardiovascular benefit?