Recent publications on Residual Risk

The Action to Control Cardiovascular Risk in Diabetes (ACCORD) Eye study showed significant benefit with fenofibrate on diabetic retinopathy in type 2 diabetes patients treated with simvastatin, reducing disease progression by about one-third over 4 years. The question posed by clinicians was whether this benefit persisted long-term, beyond the clinical trial.
 
As part of the ACCORD Follow-On (ACCORDION) Eye Study (2010–2014), patients were re-evaluated 4 years after the close of the ACCORD trial. The effect of fenofibrate did not persist long-term; progression of diabetic retinopathy was reported for 11.8% of patients allocated fenofibrate versus 10.2% with placebo (adjusted odds ratio 1.13, 95% confidence interval 0.71–1.79, p=0.60). In contrast, the effects of intensive glycaemic control (which did show significant benefit on retinopathy progression in ACCORD-Eye), were even greater than observed during the trial, with 58% reduction in disease progression (5.8% of patients allocated intensive glycemic treatment versus 12.7% with standard treatment showing progression, adjusted odds ratio 0.42, 95% confidence interval 0.28–0.63, p<0.0001). This benefit persisted despite both groups having similar haemoglobin A1c levels. As in the main trial, intensive blood pressure treatment had no benefit (7.5% with intensive blood pressure treatment versus 6.0% on standard treatment showing progression, adjusted odds ratio 1.21, 95% confidence interval 0.61–2.40, p=0.59).
 
As highlighted by the authors, this is the first study to show that previous intensive glycaemic control in patients with type 2 diabetes for at least 10 years and established cardiovascular disease led to a decrease in diabetic retinopathy progression. However, the effects of fenofibrate in reducing diabetic retinopathy progression did not persist beyond the main trial after the drug was discontinuated. This lack of lipid-modification lowering legacy benefit might suggest that previous lipid modification may be less relevant in the long-term for mechanism(s) underlying the pathophysiology of diabetic retinopathy.