Diabetes mellitus

updated by Martijn Scherrenberg, 17 August 2021

The ESC Prevention Guidelines (Piepoli MF 2016) [1] call on page 2355 for lifestyle management as a first line intervention for the prevention and treatment of diabetes mellitus type 2 (DMT2). Furthermore, ESC disseminated in 2019 the Guidelines on Diabetes, Pre-Diabetes and Cardiovascular Diseases developed in collaboration with the EASD [2].

In brief:

• Hyperglycaemia is a symptom of multiple causes, and therefore requires a multifactorial approach and thus comprehensive lifestyle changes, especially in DMT2
• Moderate to vigorous aerobic physical activity and resistance training are 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 l, targeting a near-normal HbA1c (<7.0% or <53 mmol/mol, 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 or GLP-1 RAs are recommended 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 tables (Cosentino F, European Heart Journal 2019 [2]):

Table 1: Recommendations for lifestyle modifications in patients with diabetes and pre-diabetes

CV = cardiovascular; CVD = cardiovascular disease; DM = diabetes mellitus; IGT = impaired glucose tolerance; T2DM = type 2 diabetes mellitus.

a Class of recommendation.

b Level of evidence.

c A commonly stated goal for obese patients with DM is to lose ∼5% of baseline weight.

d It is recommended that all individuals reduce the amount of sedentary time by breaking up periods of sedentary activity with moderate-to-vigorous physical activity in bouts of ≥10 min (broadly equivalent to 1000 steps).

Table 2: Recommendations for the management of blood pressure in patients with diabetes and pre-diabetes

ABPM = ambulatory blood pressure monitoring; ACEI = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor blocker; BP = blood pressure; DBP = diastolic blood pressure; DM = diabetes mellitus; GLP1-RA = glucagon-like peptide-1 receptor agonist; IFG = impaired fasting glycaemia; IGT = impaired glucose tolerance; LV = left ventricular; RAAS = renin–angiotensin–aldosterone system; SBP = systolic blood pressure; SGLT2 = sodium-glucose co-transporter 2.

a Class of recommendation.

b Level of evidence.

Table 3: Recommendations for the management of dyslipidaemia with lipid-lowering drugs

CV = cardiovascular; DM = diabetes mellitus; EAS = European Atherosclerosis Society; ESC = European Society of Cardiology; HDL-C = high-density lipoprotein cholesterol; LDL-C = low-density lipoprotein cholesterol; PCSK9 = proprotein convertase subtilisin/kexin type 9; T1DM = type 1 diabetes mellitus; T2DM = type 2 diabetes mellitus.

a Class of recommendation.

b Level of evidence.

c See Table 7 (of ref. 2).

d See the ESC/EAS Guidelines for the management of dyslipidaemias (Eur Heart J 2016;37:2999–3058) for non-HDL-C and apolipoprotein B targets.

Table 4: Recommendations for glucose-lowering treatment for patients with diabetes

ACS = acute coronary syndromes; CV = cardiovascular; CVD = cardiovascular disease; DM = diabetes mellitus; DPP4 = dipeptidyl peptidase-4; GLP1-RA = glucagon-like peptide-1 receptor agonist; HF = heart failure; SGLT2 = sodium-glucose co-transporter 2; T2DM = type 2 diabetes mellitus.

a Class of recommendation.

b Level of evidence.

c See Table 7 (of ref. 2).

Table 5: Recommendations for patient-centred care of patients with diabetes

DM = diabetes mellitus.

a Class of recommendation.

b Level of evidence.