The ACCORD (Action to Control Cardiovascular Risk in Diabetes) Eye Follow-On Study (ACCORDION Eye; summarised alongside) investigated two effects. The first was whether, as in the DCCT (Diabetes Control and Complications Trial) in patients with type 1 diabetes, there was a “metabolic memory” or legacy effect from intensive glycaemic control on the progression of retinopathy in patients with type 2 diabetes. The second was whether there was also a legacy effect from fenofibrate treatment of dyslipidaemia, which in the FIELD (Fenofibrate Intervention and Event Lowering in Diabetes) study demonstrated a reduced retinopathy progression and need for laser treatment, particularly in patients with pre-existing retinopathy. The ACCORD Eye Study confirmed the beneficial effect of intensive glycaemic control and of combined simvastatin and fenofibrate therapy on progression of retinopathy, as noted in the FIELD study.
The ACCORDION Eye Study demonstrated that intensive glycaemic control did indeed confer enduring protection from progression of retinopathy. This effect suggests that, even relatively late in the course of diabetes (the average duration at baseline was 9.9 years), improved glycaemic control can have a beneficial effect.
The ACCORD Eye and FIELD studies showed that fenofibrate reduced the progression of retinopathy, need for laser treatment and need for vitrectomy, particularly in patients with pre-existing retinopathy. However, the ACCORDION Eye study did not demonstrate a “legacy” effect. This suggests that patients need to continue on long-term treatment with fenofibrate.
Unfortunately, fenofibrate did not demonstrate an effect on cardiovascular events in the ACCORD and FIELD studies, and some concerns have been raised regarding its safety. It is, therefore, not routinely prescribed for the management of dyslipidaemia by either general practitioners or diabetologists.
Historically, ophthalmologists have not intervened in the medical management of diabetes, although medical retina specialists are becoming more confident in the assessment of risk factors for development and progression of diabetic retinopathy, and in referring their patients for improved diabetes care. There exists a niche specialty in the UK – medical ophthalmology. Medical ophthalmologists are qualified in both medicine and ophthalmology. They are able to directly intervene in the medical management of diabetes, but there are relatively few posts, mainly in centres of excellence.
Good collaborative management of patients with diabetes between ophthalmologists, diabetologists and general practitioners in the UK is patchy, despite the evidence from a paper on reduction of blindness in Sweden that clearly attributed success to a combination of good ascertainment of diabetes, effective screening for diabetic retinopathy and collaboration between ophthalmologists, diabetes physicians and primary care providers (Olafsdottir et al, 2007). The same lead author has demonstrated in another paper (summarised on the following page) that early detection of type 2 diabetes combined with screening for diabetic retinopathy reduced the prevalence and severity of retinopathy. This highlighted the need for ophthalmologists and general practitioners to work together.
In conclusion, the ACCORDION Eye Study suggests that the role of fenofibrate for the treatment of diabetic retinopathy, regardless of its lack of effect on cardiovascular events, needs to be considered by providers of diabetes care across the UK.
To read the article summaries, please download the PDF
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