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Facts and Fiction about Type 2 Diabetes

Facts and Fiction about Type 2 Diabetes. Michael L. Parchman, MD Department of Family & Community Medicine September 2004. Complications from Type 2 Diabetes. Microvascular Retinopathy Neuropathy Nephropathy Autonomic: gastroparesis, blood pressure Macrovascular MI CVA

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Facts and Fiction about Type 2 Diabetes

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  1. Facts and Fiction about Type 2 Diabetes Michael L. Parchman, MD Department of Family & Community Medicine September 2004

  2. Complications from Type 2 Diabetes • Microvascular • Retinopathy • Neuropathy • Nephropathy • Autonomic: gastroparesis, blood pressure • Macrovascular • MI • CVA • Claudication/PVD

  3. Preventing Complications from Type 2 Diabetes • Glucose • Blood Pressure • Lipids • What is the Evidence?

  4. UKPDS • 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 end-points. • Added a secondary arm to study the effect of blood pressure and lipid control.

  5. Glucose: Fact or Fiction? • Tight control of blood glucose improves mortality. • FACT: Tight control of blood glucose did not prevent premature mortality

  6. 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.”

  7. Glucose: Fact or Fiction? • Tight control of blood glucose prevents the onset of microvascular and macrovascular complications. • 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.

  8. BP: Fact or Fiction • Tight blood pressure control prevents macrovascular but not microvascular complications • 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

  9. 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.

  10. Systolic BP and Incidence Rate of Any DM Complication

  11. How Do We Get This Low? • UKPDS: Over 60% of patients in “tight” BP control group requires 3 or more drugs2 (“tight” = mean BP 144/82)

  12. 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

  13. How Low Can We Go? Grundy et al. Circulation 2004;110:227. July 13, 2004

  14. 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

  15. 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

  16. 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

  17. The “5-minute” Diabetes Visit • Pressure • Lipids • Aspirin • Glucose • Urine protein • Eyes • Feet

  18. P: Blood Pressure ADA Target: BP < 130/80

  19. 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

  20. 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 36%

  21. G: Glucose Testing • If < 7.0: A1c testing twice each year, at least 3 months apart • If > 7.0; every 3 months

  22. ADA Target: A1c < 7.0%

  23. U: Urine Protein Annual screening urine micro-albumin Detection of nephropathy Begin ACEI to slow progression of nepthropathy

  24. E: Eyes • Annual dilated eye exam or at frequency recommended by eye specialist after initial exam

  25. Screening for Retinopathy:Vijan S, et al JAMA 2000;238:889-896 Risk of Blindness, %

  26. F: Feet • Visual inspection at every visit • Comprehensive exam once each year with monofilament, tuning fork, palpation and visual examination

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