Type 2 Diabetes

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Evidence Synopsis: Lifestyle

Smoking

BC Guidelines Encourage patient to stop smoking at each visit, and provide support as needed.
Evidence Smoking in a 55 year old diabetic increases the risk of heart disease and stroke by 6-10% over 10 years. details
Smoking cessation following MI decreased mortality by 36% and recurrent non-fatal MI by 32%. (RRR) details

Exercise

BC Guidelines Discuss and encourage aerobic (2.5 hours per week) and resistance exercise (3 sessions per week).
Evidence Brisk walking 3-5 hours per week by men with diabetes reduced cardiovascular events by 3.6%, and total mortality by 5.3%, over 5 years. details
Brisk walking 4-6 hours per week by diabetic women reduced coronary heart disease (CHD) by 4% over 5 years. details

Evidence Synopsis: Specific Drug Treatments

BP/lipid/glucose/albumin targets are primarily based on epidemiological evidence and expert opinion. There are no trials in which patients have been randomized to different targets, except for hypertension.

HgbA1C

BC Guidelines The target for most patients is an A1C ≤ 7.
Evidence Metformin, in newly diagnosed overweight diabetics (mean age 53 years, 54% women) decreased MI and stroke by 9% and death by 7.1% over 10 years. details
Sulfonylureas and insulin to lower AIC (from 7.9% to 7.0%) in newly diagnosed diabetics reduced an aggregate of 21 diabetes endpoints by 3.1%, mainly the need for retinal photocoagulation by 2.8%, but not visual loss, over 10 years . There was no reduction in the incidence of any macrovascular endpoints over 10 years. details

Hypertension

BC Guidelines Blood pressure control is a priority, aim for BP ≤ 130/80
Evidence Lowering blood pressure (with a solo or combination of thiazide, beta-blocker, CCB, ACE1) from 154/87 to 144/82 mm in newly diagnosed diabetics reduced diabetes related deaths by 5% and stroke by 4% over 8 years. details
Further lowering diastolic BP from 85 to 81 mm reduced major cardiovascular events by 5% and CHD mortality by 3% over 4 years.details

Lipids

BC Guidelines Targets and goals must relate to calculated risk
LDL-C (mmol/L) TC:HDL-C
High Risk
(≥ 20% 10 year risk)		 < 2.5 < 4.0
Moderate Risk
(<20% 10 year risk)		 < 3.5 < 5.0
Evidence Atorvastatin 10mg in diabetics (mean age 62 years, 32% female, diabetic for 8 years, mean A1C 7.9%) reduced a combination of coronary death, non-fatal MI and unstable angina by 2% and stroke by 1% over 4 years. details

Further Vascular Protection

BC Guidelines Promote lifestyle modifications (exercise and stress reduction) and consider low dose ASA and ACE/ARB as clinically indicated.
Evidence ASA (100 mg or 650 mg) in diabetic patients without cardiovascular disease did not reduce cardiovascular events over 4-5 years but did increase bleeding complications by 2%. details
A meta-analysis of 9 trials with about 5000 diabetic patients showed a nonsignificant change for the use of ASA. details
Ramipril in diabetics (68% having had a MI or stroke, mean age 66, 56% HTN) reduced MI and stroke by 5%, CHD by 3% and total mortality by 3% over 5 years. details

Nephropathy

BC Guidelines Treat ACR if persistently above normal threshold (>2 males and >2.8 females) and measure Scr (and eGFR) at least annually.
Evidence In patients with Microalbuminuria: (persistently increased ACR of 2 to 20 in males, 2.8 to 28 in females)
A recent meta-analysis of antihypertensive agents suggests that in patients with diabetes, additional renoprotective actions of ACEI and ARBs beyond lowering blood pressure remains unproven (Lancet 2005;366:2026–33). This is a hotly debated area (Lancet 2006;367:897-902) details
In patients with Macroalbuminuria: (urinary albumin over 300mg/24hrs)
Irbesartan in diabetics with macroalbuminuria (mean age 59, 100% HTN, 30% history of MI) reduced the endpoint of doubling of serum creatinine or ESRD-dialysis, renal transplant or serum creatinine of at least 530 umoles/L or deaths by 6% over 3 years. There was no difference in cardiovascular endpoints (CV death, MI, CHF, stroke, limb amputation). details

Evidence Synopsis: Other Interventions

Hypoglycemia

BC Guidelines Review episodes of hypoglycemia at every visit, aiming to eliminate or minimize it.
Evidence In newly diagnosed diabetics (mean age 53 years, 54% women), rates of major hypoglycemic events per year over 10 years were 0%, 0.6% and 2.3% respectively for metformin, glyburide and insulin. details

Foot Inspection

BC Guidelines Examine the feet at least annually, more frequently for those at high risk, and reinforce the patient’s responsibility for regular self-examination to prevent ulceration, infection, gangrene, and amputation.
Evidence Regular foot inspection and referral to a foot clinic for high-risk features reduced the risk of major amputation compared to usual foot care after 2 years. details

Retinal Exam

BC Guidelines Ensure patients receive a dilated pupil retinal examination at diagnosis, and then every one to two years, or as indicated.
Evidence Early photocoagulation versus deferred coagulation reduces the risk of severe visual loss by 1.1% over 5 years.details

Vaccination

BC Guidelines Annual Influenza vaccination and an initial pneumococcal vaccination (with a repeat if patient is over 65 years and previous vaccination more than 5 years ago) is recommended.
Evidence Influenza vaccination in diabetics preceding an epidemic, reduced the rate of hospitalization for influenza , pneumonia and diabetes-related events by 79% (RRR). details
Pneumococcal vaccines do not appear to reduce pneumonia or pneumonia related deaths in adults, but may be able to reduce invasive pneumococcal disease. details

Self Monitoring

BC Guidelines Reinforce the patient’s responsibility for regular monitoring of blood sugars as appropriate. Ensure patient can use a glucose meter, interpret results and modify treatment as needed. Develop a blood glucose-monitoring schedule with the patient and review records.
Evidence Self-monitoring of blood sugar (approximately 6 times per week) led to a 0.3% greater reduction in A1C than a control group. details