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Prof. Jaakko Tuomilehto,
Dr. Michael Lehrke (Aachen, Germany) pointed out the high risk of cardiovascular diseases (CVD) in type 2 diabetic (T2D) patients, and that the risk increases with increasing glycaemia, measured by HbA1c. The main question is: to what extent this excess risk can be reduced by treatments lowering glycaemia. Recent trials have pointed out that intensive glucose lowering treatment may lead to hypoglycaemic events and these can be dangerous causing vascular events and even deaths. A recent meta-analysis of controlled trials indicated a 10% and 15% reduction in all MIs and in non-fatal MI, respectively. NNT to prevent one MI with glucose lowering treatment is 140 patients/5years. For cholesterol lowering it is 44 and blood pressure lowering 34. It seems that there is no benefit to lower HbA1c below 7.5%, actually mortality starts to increase at lower levels. On the other hand, in non-diabetic people “ideal” HbA1c is around 5.3%, and in T2D the greatest benefits are seen in those whose baseline HbA1c is <7.5%. Also, patients who are free of CVD benefit more from glucose lowering than those with CVD . With comorbidities, life expectance is dramatically reduced. Therefore, it is important to apply individualized glucose lowering therapy, and combine it with multifactorial risk reduction strategy. Reducing excess body weight as early as possible is very important; antidiabetic drug therapy often represents an attempt to compensate the failure of restriction of excess energy intake. With modern new antidiabetic drugs, treatment can be rather expensive, too.
ESC/EAS guidelines for treatment of dyslipidaemia in diabetes have just been published (Eur Heart J 2011;32:1769): LDL goal in high-risk T2D patient is <1.8 mmol/L, all T2D <2.5 mmol/L and T1D >30% reduction. Statin therapy is the basis, fibrates do not improve the prognosis. Aspirin should be used with care, paying attention to the risk of bleeding, and not used on every T2D patient.
Controversial issues in diabetes management
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