New perspectives in type 2 diabetes, cardiovascular risk, and treatment goals

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An article published in the May 2010 issue of Postgraduate Medicine highlights the seriousness of cardiovascular disease (CVD) in patients with type 2 diabetes. Cardiovascular disease is the cause of death in > 65% of patients with diabetes, and when complicated by the presence of obesity, the lifetime risk of developing CVD increases to 90%. The inherent problem is that many of the antihyperglycemic medications used to combat high glycated hemoglobin are associated with weight gain and/or hypoglycemia, which negatively affect CVD.

The article reviews the results of three large-scale type 2 diabetes cardiovascular outcome trials—the Action to Control Cardiovascular Risk in Diabetes trial, the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation trial, and the Veterans Affairs Diabetes Trial— of the effect of glucose control on reducing the risk of microvascular and macrovascular complications associated with type 2 diabetes. The author, Carol H. Wysham, MD, explains how clinicians can select appropriate treatment strategies for their patients, not only to control glucose levels but to prevent further CVD complications, including dyslipidemia, hypertension, hypoglycemia, and weight gain. Analysis of the aforementioned trials showed that benefits of intensive therapy in patients with long-duration type 2 diabetes, and a significant percentage of patients with prior cardiovascular events, were difficult to prove.

A number of clinical trials have demonstrated improvement in CVD risk factors with weight loss in patients with type 2 diabetes. However, intensive long-term intervention with lifestyle modification and behavioral and pharmacologic treatment is needed to achieve and maintain weight loss, which has shown to be too challenging and/or too exhausting for patients.

The author explains that pathophysiology, including the role of hormones besides insulin, coupled with an increased awareness of emerging treatment options, can lead to improved outcomes for CVD risk. Clinicians should also recognize that incretin therapies effectively lower glucose levels without increasing weight. With the absence of a superior antihyperglycemic therapy, patients’ personal health factors should be examined as well as their type 2 diabetes background, to meet a customized management plan that will successfully lower their chance of developing CVD while maintaining target blood glucose levels.

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