1. Should we reconsider our therapeutic goals in 2011 ? » Pr. Bernard CHARBONNEL - Nantes « Should we reconsider our therapeutic goals in 2011 ? » Pr. Bernard CHARBONNEL - Nantes SFD Congress-Geneva Reported by Dr Ramona Abi Gerges

2. Publications : 1.N Engl J Med 2011;364:818-28 2.N Engl J Med 2003;348:383-93 3.N Engl J Med 2011;364:829-41 4.The Lancet 2010, vol.375,issue 9713, Pages 481 - 489 5.Diabetes Care 2010,April 28 vol. 33 no. 5 983-990 6.Diabetologia 2010, 53:2079–2085 7.Diabetologia 2009,52:2288–2298 8.BMJ 2010; 340:b5444 9.BMJ 2000; 321:405-12 10.Annals of Internal Medicine 2009, Vol.151 Nbr 6-396

3. No epidemiologic argument in favor of poor glycemic control Paradoxical results in ACCORD showed that mortality increases when HBA1C 8% UKPDS: reduction in micro-vascular, microalbuminuria complications when HBA1C<8%

4. Reasons for increased mortality Rapid decrease in HBA1c ? Severe hypoglycemia ? Uncontrolled hyperglycemia itself? Drug interactions, polymedications?

6. VADTADVANCEACCORD Baseline HBA1c9,4%7,2%8,1% ∆HBA1C-2,5-0,9-1,7 Insulin used89%40%77% Duration of diabetes11,5 y8 y10 y Severe Hypoglycemia intensive v/s standard 21,2% v/s 9,92,7% v/s 1,516,2 % v/s 5,1 cardiovascular mortality /y 2,1 v/s 1,74,5 v/s 5,22,6 v/s 1,8 All cause of Mortality8,9 v/s 9,65,0 v/s 4,0

14. Epidemiologic Relationships Between A1C and All- Cause Mortality During a Median 3.4-Year Follow- up of Glycemic Treatment in the ACCORD Trial Diabetes Care doi: 10.2337/dc09-1278

18. Conclusion 1.Hba1c is a marker of risk of complication 2.Hypoglycemia is a marker of risk of mortality rather than reason 3.The objective of the treatment is not to bring down HBA1C but to prevent complications micro and macro-vascular, irreversible once installed

19. Conclusion 1.Hba1c est un marqueur de risque de complication 2.Hypoglycémie est un marqueur de risque de mortalité plutôt que la cause 3.L’objectif du traitement n’est pas de faire baisser le chiffre HBA1C mais de prévenir les complications micro- et macro-vasculaires irréversibles une fois installés

20. Conclusion 1.The target HbA1c varies between 6,5 % and 8 % according to the patients 2.The individualization of the therapeutic way remains the best daily approach in our clinical practice ? ? 3.« Earlier ? Probably» « More extremely ? Probably not »

21. Conclusion 1.La cible HbA1c varie entre 6,5 % et 8% selon les patients 2.L’individualisation du chemin thérapeutique reste la meilleure conduite quotidienne à tenir dans notre pratique clinique ? ? 3.« Faut-il traiter plus tôt ? Probablement » « Plus fort ? Probablement pas »

23. Thank you