Holistic approach needed when managing type 2 diabetes
Having type 2 diabetes more than doubles a person’s risk of dying from cardiovascular (CV) causes. Tight control of blood glucose helps prevent CV events in the long term in people who are newly diagnosed with type 2 diabetes. However studies show that lowering blood pressure and LDL cholesterol has a more immediate effect in reducing cardiovascular risk in the short term (3-5 years).
The latest therapeutic program from NPS MedicineWise — Type 2 diabetes: priorities and targets — encourages GPs to take a holistic approach when caring for their patients with type 2 diabetes and to address blood pressure and lipids as a priority.
NPS MedicineWise clinical adviser Dr Philippa Binns says that when a diagnosis of type 2 diabetes is made, early assessment and identification of the patient’s CV risk is crucial.
“Treating high blood pressure and cholesterol substantially reduces absolute risk — compared with focussing on blood glucose control alone — and gives the patient a chance of achieving better outcomes,” says Dr Binns.
“The most benefit of lipid-lowering and antihypertensive treatments is seen in people with high absolute CV risk or with established CV disease. But for people with low to moderate CV risk these same benefits are not as pronounced, so a trial of lifestyle changes can be recommended in this group before prescribing drug therapies.
“For all patients, however, targets for blood pressure and cholesterol need to be individualised and used as guides rather than goals that must be achieved at all costs — remembering that drug-related risks can increase as therapy is intensified.”
Whether or not a person with diabetes has established CV disease will also help determine whether treatment with aspirin is appropriate. The latest National Vascular Disease Prevention Alliance guidelines1 no longer recommend the routine use of aspirin in people without known cardiovascular disease. This has been informed by recent studies that show aspirin benefits people with established CV disease, but for those without CV disease — including those with diabetes — the risk of adverse events outweighs the benefits of treatment.
Given that blood glucose control is still important to prevent microvascular complications, Dr Binns also says that HbA1c targets should be individualised based on duration of type 2 diabetes and other patient factors such as the risk of hypoglycaemia — especially for older patients.
“Someone recently diagnosed with type 2 diabetes will benefit from tight blood glucose control and near normal levels of HbA1c.
“But for a person with advanced diabetes who is likely to be on multiple glucose-lowering medicines, treating to low HbA1c levels can increase their risk of hypoglycaemia and even death, so their target HbA1c levels may not need to be so tightly controlled.”
As well as discussing CV risk management the latest NPS News — Cardiovascular disease risk in type 2 diabetes — details the advantages and disadvantages of available glucose-lowering medicines, including the lack of long-term outcomes for some of the newer glucose lowering therapies.
“As with many progressive chronic conditions a careful balance is required to manage all the medicines and lifestyle changes for people with type 2 diabetes. As the disease progresses patients can end up being overburdened by medicines and it can be difficult for them to manage,” says Dr Binns.
“By consistently keeping patients at the centre of management decisions and helping them understand why certain medicines and lifestyle changes are essential for them, there is a higher chance they will adhere to their treatment regimen.”
To access the latest NPS News, a case study on cardiovascular disease risk in type 2 diabetes, and other relevant resources for health professionals, visit www.nps.org.au/healthprofessionals
For more information about diabetes for health professionals and for patients, visit the online diabetes information hub on the NPS MedicineWise website at www.nps.org.au/conditions/diabetes.
Independent, evidence-based and not-for-profit, NPS MedicineWise enables better decisions about medicines and medical tests. We are funded by the Australian Government Department of Health and Ageing.