In April 2012, the American Diabetes Association (ADA) updated its guidelines for evaluating and treating type 2 diabetes mellitus (T2DM). In particular, the ADA acknowledges the value of an individualized, patient-centered approach that is less formulaic than its earlier guidelines. In this article, we highlight these and other recently published developments in the context of a case study. To help ensure follow-through on these newest recommendations, we also frame our review with the mnemonic, “ABCD IS diabetes.”
CASE JR is a 57-year-old man being seen for a regular follow-up appointment. His medical history includes T2DM, hypertension, and obesity. He is taking metformin 1000 mg twice daily, lisinopril 40 mg each morning, and amlodipine 10 mg each morning. He is current on his influenza and pneumococcal vaccinations. He does not smoke cigarettes. His physical exam and lab results reveal the following:
- blood pressure (BP), 132/70 mm Hg
- body mass index (BMI), 33 kg/m2
- glycosylated hemoglobin (A1C), 7.6%
- lipid profile: Total cholesterol, 185 mg/dL; high-density lipoprotein (HDL), 40 mg/dL; triglycerides (TG), 145 mg/dL; low-density lipoprotein (LDL), 90 mg/dL
Applying the “ABCD IS diabetes” mnemonic leads us through the following assessments.
Antiplatelets
In the past, guidelines have recommended that most patients with diabetes be placed on aspirin therapy. However, 2 trials published in 2008 failed to demonstrate significant reduction in cardiovascular disease (CVD) end points with aspirin use, raising questions about its effectiveness for primary CVD prevention in patients with diabetes.1,2 In 2010, the ADA, American Heart Association, and American College of Cardiology Foundation modified their recommendations for primary prevention,3 which remain unchanged in the 2012 ADA guidelines.4
Antiplatelet agents continue to play a role in primary prevention of CVD for patients with T2DM, but only after appropriate risk stratification.4 Consider low-dose aspirin therapy (75-162 mg/d) for patients with diabetes who have a 10-year Framingham risk >10%.4 (To calculate a patient’s 10-year risk, go to http://hp2010.nhlbihin.net/atpiii/calculator.asp.)
Many patients with T2DM seen in the primary care setting will reach this risk level and qualify for aspirin—in particular, men older than 50 years and women older than 60 with a family history of CVD, hypertension, smoking, dyslipidemia, or albuminuria.4 Aspirin therapy is not recommended for primary prevention in adults with diabetes at low risk for CVD (10-year Framingham risk <5%)—eg, men <50 and women <60 years without additional CVD risk factors.4 For patients with a 10-year Framingham risk between 5% and 10%, a decision to treat rests with the physician.
CASE Should JR be started on aspirin therapy for primary prevention of CVD? Initiating low-dose aspirin is recommended, assuming no contraindications, because his 10-year Framingham risk assessment is 11%.
“ABCD IS diabetes” at-a-glance practice recommendations4,16,28
A (antiplatelets): Consider low-dose aspirin therapy (75-162 mg/d) for diabetes patients with a 10-year Framingham risk >10%.
B (blood pressure): Individualize a patient’s goal for systolic blood pressure, aiming higher or lower than the customary systolic target of <130 mm Hg, as appropriate.
C (cholesterol): Recommend lifestyle changes and prescribe a statin, as needed, to achieve LDL goals in T2DM patients.
D (drug management): Use a patient-centered approach to achieve an individualized A1C goal. Metformin is the initial medication of choice. Select additional drug classes to balance adverse effects, cost, and effectiveness.
I (immunizations): Ensure that each T2DM patient receives influenza and pneumococcal vaccines, and the hepatitis B vaccine if <60 years.
S (surveillance): Confirm at each visit that annual surveillance testing for nephropathy, retinopathy, and peripheral neuropathy has been completed.
Blood pressure
The benefits of lowering BP in diabetes to <140 mm Hg systolic and <80 mm Hg diastolic have been established in randomized control trials.5-8 However, the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial demonstrated that, in patients with T2DM, intensive BP lowering to <120 mm Hg systolic yielded no significant differences in fatal and nonfatal cardiovascular events compared with BP maintained between 130 and 140 mm Hg.9 Moreover, aggressive BP lowering may be associated with serious adverse events.10 The 2012 ADA guidelines state that a systolic BP goal of <130 mm Hg is appropriate for most patients; however, higher or lower BP targets may be individualized.4
Recommendations for adding a second antihypertensive agent and timing medication administration. For T2DM patients with hypertension, the 2012 guidelines recommend that you treat initially with either an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB), if tolerated.4 When adding a second agent, the Avoiding Cardiovascular Events through COMbination therapy in Patients LIving with Systolic Hypertension (ACCOMPLISH) trial demonstrated reduced morbidity and mortality in patients receiving benazepril and amlodipine compared with those receiving benazepril and hydrochlorothiazide.11 As a result, amlodipine has joined diuretics as a preferred second oral antihypertensive agent after an ACEI or ARB.