New insights from ADVANCE.
OBJECTIVE
ADVANCE (Action in Diabetes and Vascular Disease - PreterAx and DiamicroN MR Controlled Evaluation) is a large-scale clinical trial designed to investigate the benefits of blood pressure lowering and intensive glucose control in patients with type 2 diabetes mellitus.


METHODS
ADVANCE is a 2 x 2 factorial randomized trial evaluating the benefits of the low-dose fixed combination of perindopril and indapamide versus placebo to lower blood pressure and of an intensive gliclazide-MR-based regimen, targeting glycosylated haemoglobin (HbA1c) levels of 6.5% or less versus standard therapy to lower blood glucose. The two primary outcomes, taken separately and jointly, are a composite macrovascular endpoint and a composite microvascular endpoint.


RESULTS
A total of 11 140 participants were randomized between July 2001 and March 2003 from among 12 878 individuals with type 2 diabetes recruited from 215 centres in 20 countries, who entered a 6-week run-in phase. The average (SD) baseline blood pressure of 145(22)/81 (11) mmHg fell by 8/3 mmHg during the run-in phase during which participants received one tablet of open-labelled perindopril 2 mg-indapamide 0.625 mg. Only 3.6% of the 12 878 patients who entered the run-in phase withdrew because of suspected intolerance to perindopril-indapamide. With over 4 years of follow-up on average so far, over 80% of participants are still adhering to randomized therapy. Follow-up of the blood pressure arm will be completed during 2007.


CONCLUSIONS
The safety and efficacy of perindopril-indapamide in lowering blood pressure and of a gliclazide-MR-based regimen in lowering blood glucose have been established with the completion of a 6-week run-in phase and of more than 4 years of post-randomization follow-up. It is anticipated that ADVANCE will provide many new insights including: whether blood pressure lowering with perindopril-indapamide reduces the risk of both macrovascular and microvascular events irrespective of baseline blood pressure; whether more intensive blood pressure lowering with a gliclazide-MR-based regimen targeting on HbA1c levels of 6.5% or less reduces these two outcomes compared with standard guidelines therapy; and finally whether the separate benefits of these two treatment regimens are additive.
Chalmers
John
J
The George Institute for International Health, University of Sydney and The Royal Prince Alfred Hospital, Sydney, NSW, Australia. jchalmers@george.org.au
Kengne
Andre-Pascal
AP
Joshi
Rohina
R
Perkovic
Vlado
V
Patel
Anushka
A
D000959:Antihypertensive Agents / Q000627:therapeutic use*; D001786:Blood Glucose / Q000187:drug effects; D001794:Blood Pressure / Q000187:drug effects; D048909:Diabetes Complications / Q000188:drug therapy* / Q000503:physiopathology; D003924:Diabetes Mellitus, Type 2 / Q000188:drug therapy* / Q000503:physiopathology; D004305:Dose-Response Relationship, Drug; D004338:Drug Combinations; D004359:Drug Therapy, Combination; D005907:Gliclazide / Q000627:therapeutic use*; D006801:Humans; D006973:Hypertension / Q000188:drug therapy* / Q000209:etiology / Q000503:physiopathology; D007004:Hypoglycemic Agents / Q000627:therapeutic use*; D007190:Indapamide / Q000627:therapeutic use; D038622:Internationality; D008875:Middle Aged; D015337:Multicenter Studies as Topic; D020913:Perindopril / Q000627:therapeutic use; D016032:Randomized Controlled Trials as Topic
D000959:Antihypertensive Agents; D001786:Blood Glucose; D004338:Drug Combinations; D007004:Hypoglycemic Agents; D007190:Indapamide; D005907:Gliclazide; D020913:Perindopril