To the Editor: Drs Giugliano and Esposito1 suggested that lowering risk factor levels is not always better. Clinical inertia may benefit patients, such as failing to intensify antihypertensive therapy in patients with a history of orthostasis. However, we question the extent of their assertions and believe that clinical inertia remains an important problem worth solving.
Although the authors cited research to support their contentions, several key points were not addressed. Treatment of most chronic diseases continues to be inadequate. In the management of diabetes, for example, more than 1 in 5 individuals with diabetes in the United States have a glycated hemoglobin (HbA1c) level more than 8.0%.2 Although the reasons for this are multifaceted, physicians often intensify therapy far less than recommended.3 The authors did not discuss evidence of benefit of intensive therapy. With regard to diabetes, both the UK Prospective Diabetes Study and the Diabetes Control and Complications Trial showed a significant risk reduction in microvascular end points.4 The authors also seemed to discount evidence from follow-up of these trials that showed benefit for macrovascular end points as well.4 Although cost and ethical issues have in many instances limited the duration of randomized trials to a few years, the real clinical horizon is often 30 or 40 years, so the number needed to treat to attain benefit may often be much lower than that within the trial period.