Facts and Fiction about Type 2 Diabetes

Facts and Fiction about Type 2
Michael L. Parchman, MD
Department of Family & Community
September 2004
Complications from Type 2
 Retinopathy
 Neuropathy
 Nephropathy
 Autonomic: gastroparesis, blood pressure
 MI
 Claudication/PVD
Preventing Complications from
Type 2 Diabetes
Blood Pressure
What is the Evidence?
The only large study of patients with Type 2 DM
of new onset
20 year study conducted in 23 centers in the U.K.
More than 5,000 patients enrolled
Primary Aim: determine the effect of intensive
control of glucose on 21 predetermined endpoints.
Added a secondary arm to study the effect of
blood pressure and lipid control.
Glucose: Fact or Fiction?
Tight control of blood glucose improves
 FACT: Tight control of blood glucose did
not prevent premature mortality
Glucose: Fact or Fiction?
All patients with type 2 diabetes benefit from
treatment with metformin.
FACT: In overweight patients, metformin
decreased mortality related to diabetes or other
cause (13.5 v. 20.6 events per 1000 pt yrs, NNT
per year=141) AND diabetes related complications
(29.8 v. 43.3 events/1000 pt yrs)
“Overweight patients with type 2 DM seem to
benefit not so much from the overall control of
glucose but rather from taking metformin.”
Glucose: Fact or Fiction?
Tight control of blood glucose prevents the onset
of microvascular and macrovascular
FACT: Changes in HbA1c produced by intensive
drug treatment did not correlate with
microvascular or macrovascular outcomes.
FACT: In overweight patients, treatment with
insulin or sulfonylureas had no effect on
individual or aggregate microvascular or
macrovascular outcomes.
BP: Fact or Fiction
Tight blood pressure control prevents
macrovascular but not microvascular
FACT: Tight control of blood pressure decreased
likelihood of ALL 21 different endpoints,
microvascular, macrovascular and mortality.
Control of BP had greater effect on complications
than glucose control (24% v. 12% decreased risk
in diabetes related complications
BP: Fact or Fiction
Diastolic blood pressure is a more important risk
factor for MI and stroke than systolic
FACT: Systolic BP is a more important risk factor
for MI and stroke than diasolic.
FACT: Each 10mm Hg reduction in systolic BP
associated with 12% reduction in risk for ANY
complication of diabetes
FACT: No lower threshold for any complication
below which risk no longer decreased.
Systolic BP and Incidence Rate
of Any DM Complication
How Do We Get This Low?
UKPDS: Over 60% of
patients in “tight” BP
control group requires
3 or more drugs2
(“tight” = mean BP
Lipids: Fact or Fiction
Patients with type 2 diabetes and no history
of CVD should have an LDL level of <130
 FACT: Heart Protection Study*
 T2DM over age 40
 Total Cholesterol over 135
 LDL reduction of 30% associated with
25% reduction in first major coronary
event, regardless of baseline LDL level
How Low Can We Go?
Grundy et al. Circulation 2004;110:227. July 13, 2004
Adult Treatment Panel III
Guidelines as of July 13, 2004
Diabetes AND CHD
LDL goal of less than 70 mg/dl
Diabetes Without CHD
LDL goal of less than 100 mg/dl
Grundy et al. Circulation
2004;110:227. July 13, 2004
Heart Protection Study*
“…statin therapy should now be
considered routinely for all diabetic
patients at sufficiently high risk for such
major vascular events, irrespective of their
initial cholesterol concentrations.”
*Lancet 2003;361:2005-2016
Evidence: Know your “A,B,Cs”
“A”: A1c
 less than 7.0
“B”: Blood Pressure
 less than 130/80
“C”: Cholesterol:
 LDL less than 100 mg/dl;
 OR 30% reduction in LDL with a statin if over
age 40 & total cholesterol>135 mg/dl
The “5-minute” Diabetes Visit
Urine protein
P: Blood Pressure
ADA Target: BP < 130/80
L: Lipid Control
LDL < 100
TG < 150
HDL > 40 men;
>50 women
If over 40, and total
Cholesterol >135:
 Use statin to reduce
LDL by 30%
regardless of baseline
LDL level
A: Aspirin, 75-162 mg/day
Recommended for all patients with T2DM
US Physician’s Health Study
 a reduction in myocardial infarction from
10.1% (placebo) to 4.0% (aspirin),
Early Treatment Diabetic Retinopathy Study
 For those on ASA: relative risk 0.72 for
myocardial infarction in the first 5 years
Hypertension Optimal Treatment (HOT) Trial
 Aspirin significantly reduced cardiovascular
events by 15% and myocardial infarction by
G: Glucose Testing
If < 7.0: A1c testing twice each year, at least
3 months apart
 If > 7.0; every 3 months
ADA Target: A1c < 7.0%
U: Urine Protein
Annual screening urine micro-albumin
Detection of nephropathy
Begin ACEI to slow progression of
E: Eyes
Annual dilated eye
exam or at frequency
recommended by eye
specialist after initial
Screening for Retinopathy:
Vijan S, et al JAMA 2000;238:889-896
Risk Group
Risk of Any
Risk of Blindness, %
No Screening Annual
High (age 45y;
A1c 11%
Moderate (age
65 y; A1c 9%
Low (age 75y;
Ac1 7%
F: Feet
Visual inspection at every visit
 Comprehensive exam once each year with
monofilament, tuning fork, palpation and
visual examination

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