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Diabetes mellitus

Facts on glycaemic control in a nutshell

Discover general recommendations on the management of diabetes mellitus.

ESC and European Association for the Study of Diabetes scientific statements (Ryden L 2013) as well as the most recent ESC Prevention Guideline (Piepoli MF 2016) call on page 2355 for lifestyle management as a first line intervention for the prevention and treatment of diabetes mellitus type 2 (DMT2).

In brief:

  • hyperglycaemia is a symptom of multiple causes, and therefore requires a multifactorial approach and thus comprehensive lifestyle changes, especially in DMT2
  • physical activity is key to increasing caloric expenditure, combatting insulin resistance, reducing hospitalizations and improving the prognosis
  • physical activity supported by sustainable dietary changes improves weight control and, more importantly, induce weight loss
  • strict glycaemic control reduces the risk of microvascular and macrovascular complications; so does a systolic blood pressure ≤140 mmHg, whereas ≤ 130 mmHg even further lessens the risks for stroke, retinopathy and albuminuria and should therefore be the target if tolerated  
  • if tight glycaemic and/or blood pressure control are/is not tolerated, temporarily consider relaxed targets in the elderly, frail and / or those with long-term DM and /or cardiovascular disease; however, reconsider stricter targets after timely reassessment
  • statins are recommended in all DMT2 patients >40 years and selected younger patients at high risk
  • in DMT2 with co-existing cardiovascular disease, a sodium-glucose co-transporter-2 (SGLT2) inhibitor should be considered early since it improves prognosis without major adverse effects
  • improved risk factor management reduces cardiovascular mortality in DMT2 – more needs to be done to reach all patients in need, which includes initiation of prevention and/or rehabilitation programmes in the patient’s vicinity
  • risk factor management is a Class I Level A indication often superior to medical treatment.
  • it is unacceptable that the majority of patients do not have access to supporting programmes of proven efficacy.

Imagine a medical treatment with similar proven efficacy that is withheld! Patients and doctors together should urge politicians and health insurance companies to have a sufficient number of programmes implemented. The costs should be covered by the insurance companies, like any other medical therapy of comparable class and level of proven efficacy.

Further “Recommendations on the management of diabetes” are given in the following table (Piepoli MF, Eur Heart 2016):

Recommendations Classa Levelb Refc
Lifestyle changes including smoking cessation, low fat diet, high fibre diet, aerobic physical activity, and strength training are recommended I A 387
Reduction in energy intake is recommended to patients to help achieve lower weight or prevent weight gain. I 387
A target HbA Ic for the reduction in risk of CVD and microvascular complications in DM of <7.0% (<53 mmol/mol) is recommended for the majority of non-pregnant adults with either type I or type 2 DM I A 388, 389
For patients with a long duration of DM, the elderly, frail, or those with existing CVD, a relaxing of the HbA Ic targets (ie. less stringent) should be considered. IIa B 389
 A target HbA Ic of <=6.5% (<=48mmol/mol) should be considered at diagnosisor early in the course 2 DM in patients, who are not frail and do not have CVD. IIa 389
When screening for DM in individuals with or without CVD, assessment of HbA Ic (which can be done non-fasting) or fasting blood glucose should be considered. An oral glucose tolerance test can be offered when there is still doubt. IIa A 390
Metformin is recommended as first-line therapy, if tolerated and not contra-indicated, following evaluation of renal function. I B 391
Avoidance of hypoglycaemia and excessive weight gain should be considered and individual approaches (with respect to both tratment targets and drug choices) should be considered in patients with advances disease. IIa B 389, 392, 393
In patients with type 2 DM and CVD, the use of an SGLT2 inhibitor should be considered early in the course of the disease to reduce CV and total mortality. IIa B 394
Lipid lowering agents (principally statins) are recommended to reduce CV risk in all patients with type 2 or type I DM above the age of 40 years. I A 371, 372
Lipid lowering agents (principally statins) may be considered also in individuals below 40 years of age if at significantly elevated risk, based on the presence of micro-vascular complications or of multiple CV risk factors. IIb A 371, 372
In DM patients at very high-risk (see table 5), a LDL-C target <1.8mmol/L (<70mg/dL), or a reduction of at least 50% if the baseline LDL-C is between 1.8 and 3.5mmol/L (70 and 135mg/dL), is recommendedd.
In DM patients with high-risk (see table 5), LDL-C target <2.6mmol/L (<100mg/dL) or a reduction of at least 50% if the baseline LDL-C is between 2.6 and 5.1 mmol/L (100 and 200mg/dL) is recommendedd.
B 395
BP targets in type 2 DM are generally recommended to be <140/85 mmHg, but a lower target of <130/80 mmHg is recommended in selected patients (e.g. younger patients at elevated risk for specific complications) for additional gains on stroke, retinopathy and albuminuria risk. Renin-angiotensin-aldosterone system blocker is recommended in the treatment of hypertension in DM, particularly in the presence of proteinuria or micro-albuminuria. Recommended BP target in patients with type I DM is <130/80 mmHg. I B 396, 397
The use of drugs that increase HDL-C to prevent CVD in type 2 DM is not recommended. III A 386
Antiplatelet therapy (e.g. with aspirin) is not recommended for people with DM who do not have CVD. III A 398

BP: blood pressure; CV: cardiovascular; DM: diabetes melitus; HbAc: glycated haemoglobin; HDL-C: high-density lipoprotein cholesterol; LDL-c: low-density lipoprotein cholesterol; SGLT2: Sodium-glucose co-transporter-2.

aClass of recommendation.

bLevel of evidence

cReference(s) supporting recommendations.

dNon-HDL-C is a reasonable and practical alternative target because it does not require fasting. Non HDL-C secondary targets of 

Access the European Guidelines on CVD Prevention in Clinical Practice.


Piepoli MF et al. 2016 European Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J 2016;37:2315–2381.

Ryden L et al. ESC guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD: the Task Force on diabetes, pre-diabetes, and cardiovascular diseases of the European Society of Cardiology (ESC) and developed in collaboration with the European Association for the Study of Diabetes (EASD). Eur Heart J 2013;34:3035–3087.

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.

The ESC Prevention of Cardiovascular Disease programme is supported by AMGEN, AstraZeneca, Ferrer, and Sanofi and Regeneron in the form of educational grants.