Type 2 diabetes (T2DM) is a complex disease that is not limited to hyperglycaemia. Antidiabetic treatments should be aimed at preventing late onset complications and avoiding both hypo-and hyperglycaemic events. Unfortunately, recently discovered antidiabetic drugs only modestly impacted on disease clinical outcomes. These results might be affected by the selection of hyperglycaemia as the main therapeutic target for antidiabetic treatments. Historically, international guidelines are particularly focused on glucose control [1]. However, the relationship between the control of glycemia and risk of diabetic complications is not completely understood: a modest glucose control (HbA1c <7Á5%-58 mmol/mol) was shown to prevent microvascular disease, while CV complications were partially related to glucose (HbA1c <6Á5%-48 mmol/mol) [2]. This is in apparent contrast to the epidemiological observation that high HbA1c values are associated with increased rate of cardiovascular death. Despite scant evidence, many guidelines dictate HbA1c <7% (53 mmol/mol) as a therapeutic goal in patients with T2DM, suggesting that a higher glucose control could be appropriate in special subpopulations (tailored therapy). In our opinion, these recommendations might be misleading, as a very strict control is exclusively suggested to grant significant clinical advantages. Importantly, it is relevant to acknowledge that intensive correction of hyperglycaemia could be a very demanding task, with severe complications and even potential burden for patients [3]. Several 'frail' patients with T2DM might benefit of a less strict glycemic control, this avoiding adverse complications related to treatment.Differently from T2DM, the strict control of hyperglycaemia in patients with T1DM could beneficially impact on disease outcomes and complications. The discovery of insulin changed the clinical course T1DM from a short surviving to a 'new' disease. In T1DM, microvascular and neuropathic morbidities (retinopathy, kidney failure and lower limb amputation) were more frequent in patients with greater glycosuria, suggesting a causative pathophysiological role of hyperglycaemia in diabetic complications.A prospective trial, the Diabetes Control and Complications Trial (DCCT), was then designed to test this hypothesis in patients with T1DM comparing the usual care to a more intensive insulin treatment with the target of a lower HbA1c [4]. As expected and despite an increased risk of hypoglycaemia, patients treated by an intensive antidiabetic approach (HbA1c 7Á4%-57 mmol/mol vs. 9Á1%-76 mmol/mol) developed less microvascular complications. The DCCT protocol of basal/ bolus insulin therapy became soon the standard of T1DM therapy. The concept 'lower is better, with minimal risk of hypoglycaemia' for glucose control is today widely recommended for patients with T1DM.As both micro-and macrovascular diseases also affect T2DM, the intensive glucose control was tested in T2DM-related clinical outcomes. The United Kingdom Prospective Diabetes Study (UKPDS) was designe...
Background: Despite a general consensus about the importance of diagnosis and treatment of gestational diabetes mellitus (GDM), there is no agreement on screening criteria. The aim is to compare the performance of universal versus risk factor-based screening for GDM. Materials and Methods: The authors reviewed the medical records of 894 pregnant women, who were screened throughout 75 two-hour 75-gram oral glucose tolerance test (OGTT) between 24 and 28 weeks of gestation, from May 2012 to May 2014 at a single University Hospital. Each patient was evaluated for the presence of risk factors for GDM (age ≥ 35 years old, BMI ≥ 25 kg/m², previous fetal macrosomia, a family history of type 2 diabetes mellitus, and high risk ethnicity). Results: Out of the 894 pregnant women, 150 (16.8%) were diagnosed with GDM according to the universal screening. Two hundred five women (22.9%) were at low risk for GDM, while 689 presented at least one or more risk factors. Using a risk factors based screening, 205 low-risk women would have skipped OGTT, but 19 of them (12.7% of women affected by GDM) received the diagnosis of GDM throughout OGTT. Nevertheless, risk factors showed a high strength as predictors of GDM diagnosis, with the exception of age ≥ 35 years. The comparison of maternal fetal outcomes between GDM women with or without risk factors presented no statistically significant differences. Conclusions: In the present authors' experience, the implementation of a risk factors based screening may lead to a reduction in the detection rate of GDM women.
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