Type 2 diabetes: Which interventions best reduce absolute risks of adverse events?

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Original Research

Type 2 diabetes: Which interventions best reduce absolute risks of adverse events?

J Fam Pract. 2009 June;58(6):E1-E10

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References

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Results

TABLE 1 lists 10-year ARs for adverse events for the base case and the ARRs for each intervention. Macrovascular complications were projected to occur at much higher rates than microvascular complications. The 10-year AR estimates for MI and CVA for the model case were 22.3% and 14.4%, respectively, whereas those for ESRD, blindness, and amputation were less than 1%. The risk of MI was greater than the risk of all other complications combined.

BASE CASE

Aspirin, exercise clearly worthwhile

For the base case, aspirin was the most effective way to reduce the risk of MI (ARR=6.8%). Moderate exercise reduced the risk of MI by only 2.7%, but it reduced the risk of CVA by 6.8%, more than any other intervention. Combining aspirin and moderate exercise reduced the risk of MI by 8.9% and CVA by 7.8% (data not shown).

FAST TRACK

In a simulated black male 65 years of age, aspirin and exercise reduced risk of MI even more effectively than in the base case.

Reducing HbA1c from 10% to 6.5% reduced MI risk by 6.4%; reducing systolic BP from 140 to 120 mm Hg reduced MI risk by 5%. Reducing the LDL level from 120 to 70 mg/dl reduced risk of MI by 3.5%, but it had little effect on risk of CVA.

Glycemic control and exercise were the only interventions that had any meaningful effect on risk of foot ulceration. Weight reduction and use of an ACE inhibitor did not affect outcomes. The maximum possible risk reduction for MI using all available interventions was 15.2% (10-year risk reduced from 22.3% to 7.1%), and for stroke was 11.1% (risk reduced from 14.4% to 3.3%).

CASE VARIATION—WHITE WOMAN

Exercise reduces MI risk even further

The 10-year AR estimates for the female case ( TABLE 2 ) were similar to those of the base case, with a slightly lower risk for foot ulceration. Treatment effects were also similar, except that exercise more effectively reduced MI risk (ARR=10% vs 2.7%). Aspirin was slightly less effective for reducing MI risk (ARR 5.9% vs 6.8%), but similarly effective for reducing stroke risk. Weight loss alone and use of an ACE inhibitor had no effect on any outcome.

TABLE 2
Absolute risk reduction predicted by Archimedes risk engine
65-year-old white female, sedentary, nonsmoker with a 5-year history of diabetes mellitus; BMI 27 kg/m²; BP 140/90 mm Hg; HbA1c 10%; LDL 120 mg/dL; HDL 45 mg/dL

	MI	CVA	ESRD	BLINDNESS	FOOT ULCERATION	FOOT AMPUTATION
10-year AR before interventions	21.7%	14.3%	0%	0.8%	3.7%	0.5%
INTERVENTIONS*			RISK (ARR)
Aspirin, 81 mg/d	15.8% (5.9%)	11.1% (3.2%)	0% (0%)	0.5% (0.3%)	3.6% (0.1%)	0.5% (0%)
Moderate aerobic exercise	11.7% (10.0%)	7.8% (6.5%)	0% (0%)	0.8% (0%)	3.4% (0.3%)	1.0% (-0.5%)
Reduce HbA1c to 7.0%	17.3% (4.4%)	9.5% (4.8%)	0% (0%)	0.8% (0%)	0.7% (3.0%)	0.5% (0%)
Reduce HbA1c to 6.5%	16.2% (5.5%)	7.7% (6.6%)	0% (0%)	0.8% (0%)	0.7% (3.0%)	0.5% (0%)
Reduce SBP to 130 mm Hg	18.9% (2.8%)	9.1% (5.2%)	0% (0%)	0.8% (0%)	3.7% (0%)	0.5% (0%)
Reduce SBP to 120 mm Hg	15.9% (5.8%)	7.3% (7.0%)	0% (0%)	0.8% (0%)	3.6% (0.1%)	0.5% (0%)
Reduce LDL to 100 mg/dL	20.3% (1.4%)	14.2% (0.1%)	0% (0%)	0.6% (0.2%)	3.6% (0.1%)	0.5% (0%)
Reduce LDL to 70 mg/dL	19.4% (2.3%)	14.1% (0.2%)	0% (0%)	0.8% (0%)	3.7% (0%)	0.5% (0%)
β-Blocker	19.7% (2.0%)	12.0% (2.3%)	0% (0%)	0.5% (0.3%)	3.4% (0.3%)	0.5% (0%)
All of the above	1.4% (20.3%)	1.5% (12.8%)	0% (0%)	0.2% (0.6%)	0.6% (3.1%)	0.5% (0%)
AR, absolute risk, ARR, absolute risk reduction; BMI, body mass index; BP, blood pressure; CVA, cerebrovascular accident; ESRD, end-stage renal disease; HbA1c, glycosylated hemoglobin; HDL, high-density lipoprotein; LDL, low-density lipoprotein; MI, myocardial infarction; SBP, systolic blood pressure.
*Weight loss alone and use of an ACE inhibitor had no effect on any outcome.

CASE VARIATION—BLACK MAN

Greater benefit from aspirin

For the black male ( TABLE 3 ), risk of foot ulceration was substantially less than with the base case (ARR=0.7% vs 5.2%). Both aspirin and exercise were more effective for reducing risk of MI (ARRs=9.4% and 7.0% vs 6.8% and 2.7%). Tight control of BP (120) and LDL (70) were also somewhat more effective (ARRs=6.9% and 5.7% vs 5.0% and 3.5%). Weight loss and use of an ACE inhibitor did not affect outcomes.

TABLE 3
Absolute risk reduction predicted by Archimedes risk engine
65-year-old black male, sedentary, non-smoker with a 5-year history of diabetes mellitus; BMI 27 kg/m²; BP 140/90 mm Hg; HbA1c 10%; L DL 120 mg/dL; HDL 45 mg/dL

	MI	CVA	ESRD	BLINDNESS	FOOT ULCERATION	FOOT AMPUTATION
10-year risks before interventions	24.9%	14.1%	0%	0.8%	0.7%	0.7%
INTERVENTIONS*	RISK (ARR)	RISK (ARR)	RISK (ARR)	RISK (ARR)	RISK (ARR)	RISK (ARR)
Aspirin, 81 mg/d	15.5% (9.4%)	11.7% (2.4%)	0% (0%)	0.8% (0%)	0.7% (0%)	0.7% (0%)
Moderate aerobic exercise	17.9% (7.0%)	9.2% (4.9%)	0% (0%)	0.7% (0.1%)	1.2% (-0.5%)	0.7% (0%)
Reduce HbA1c to 7.0%	19.8% (5.1%)	11.1% (3.0%)	0% (0%)	0.5% (0.3%)	0% (0.7%)	0% (0.7%)
Reduce HbA1c to 6.5%	19.0% (5.9%)	10.4% (3.7%)	0% (0%)	0.5% (0.3%)	0% (0.7%)	0% (0.7%)
Reduce SBP to 130 mm Hg	21.0% (3.9%)	12.0% (2.1%)	0% (0%)	0.6% (0.2%)	0.7% (0%)	0.5% (0.2%)
Reduce SBP to 120 mm Hg	18.0% (6.9%)	10.6% (3.5%)	0% (0%)	0.6% (0.2%)	0.7% (0%)	0.5% (0.2%)
Reduce LDL to 100 mg/dL	22.5% (2.4%)	14.0% (0.1%)	0% (0%)	0.6% (0.2%)	0.6% (0.1%)	0.6% (0.1%)
Reduce LDL to 70 mg/dL	19.2% (5.7%)	13.8% (0.3%)	0% (0%)	0.4% (0.4%)	0.5% (0.2%)	0.5% (0.2%)
β-Blocker	20.9% (4.0%)	13.1% (1.0%)	0% (0%)	0.6% (0.2%)	0.5% (0.2%)	0.7% (0%)
All of the above	3.6% (21.3%)	4.1% (10.0%)	0% (0%)	0.4% (0.4%)	0% (0.7%)	0% (0.7%)
AR, absolute risk; ARR, absolute risk reduction; BMI, body mass index; BP, blood pressure; CVA, cerebrovascular accident; ESRD, end-stage renal disease; HbA1c, glycosylated hemoglobin; HDL, high-density lipoprotein; LDL, low-density lipoprotein; MI, myocardial infarction; SBP, systolic blood pressure.
*Weight loss alone and use of an ACE inhibitor had no effect on any outcome.