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Dr K K Aggarwal

All diabetics must get an eye check up done

By Dr K K Aggarwal
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The vast majority of diabetic patients who develop diabetic retinopathy (eye involvement) have no symptoms until the very late stages (by which time it may be too late for effective treatment). Because the rate of progression may be rapid, therapy can be beneficial for both symptom amelioration as well as reduction in the rate of disease progression, it is important to screen patients with diabetes regularly for the development of retinal disease. The eyes carry important early clues to heart disease, signaling damage to tiny blood vessels long before symptoms start to show elsewhere. Diabetic people with retinopathy are more likely to die of heart disease over the next 12 years than those without it. As per a study from the University of Sydney and the University of Melbourne in Australia and the National University of Singapore, people with retinopathy are nearly twice as likely to die of heart disease as people without it. People with these changes in the eyes may be getting a first warning that damage is occurring in their arteries, and work to lower cholesterol and blood pressure. Patients with retinopathy have a greater risk of incident cardiovascular disease (CVD) events, including heart attack, stroke, revascularization, and CVD death, compared with those without retinopathy.

Diabetes Update

By Dr K K Aggarwal
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• Morbidity from diabetes involves both macrovascular (atherosclerosis) and microvascular disease (retinopathy, nephropathy and neuropathy).

• Smoking cessation is essential for patients who smoke.

• Cardiovascular morbidity can also be significantly reduced with aggressive management of hypertension, cholesterol (goal LDL less than 80 mg/dL and use of aspirin (8o mg/day) in patients with or at high risk for cardiovascular disease.

• Glycemic control can minimize risks for retinopathy, nephropathy and neuropathy in both type 1 and type 2 diabetes, and has been shown to decrease the risk for cardiovascular disease for type 1 diabetes.

• A1c goal is <7% for most patients.

• More stringent control (A1c <6%) may be indicated for individual patients with type 1 diabetes and during pregnancy.

• A higher target A1c (i.e., <8%) may be preferable for some type 2 patients with comorbidities or with an anticipated lifespan, owing to advanced age or other factors, that is too brief to benefit from the effects of intensive therapy on long–term complications.

• The appropriate target for A1c in fit elderly patients who have a life expectancy of over 10 years should be similar to those developed for younger adults (<7.0%).

• The risk of hypoglycemia, which may lead to impaired cognition and function, is substantially increased in the elderly. Thus, avoidance of hypoglycemia is an important consideration in establishing goals and choosing therapeutic agents in elderly adults.

• In the absence of specific contraindications, start with metformin as initial therapy for all patients with diabetes including the elderly. Start with metformin at the time of diabetes diagnosis, along with consultation for lifestyle intervention. Titrate metformin to its maximally effective dose (usually 2000–2500 mg/day in divided doses) over 1 to 2 months, as tolerated. Metformin should not be administered when conditions predisposing to lactic acidosis are present.

• In patients with contraindications and/or intolerance to metformin, a short–acting sulfonylurea (e.g., glipizide) is an alternative option.

• In patients who are intolerant of or are not candidates for metformin or sulfonylureas, repaglinide is a reasonable alternative, particularly in a patient with chronic kidney disease (CKD) at risk for hypoglycemia. • Start lifestyle intervention first, at the time of diagnosis. The weight gain that accompanies a sulfonylurea will presumably be less if lifestyle efforts are underway. However, if lifestyle intervention has not produced a significant reduction in symptoms of hyperglycemia or in glucose values after one or two weeks, then the sulfonylurea should be added.

• DPP4–inhibitors can be given as monotherapy in elderly patients who are intolerant of or have contraindications to metformin, sulfonylureas, or repaglinide. They are weak agents and only lower A1c by 0.6%. They are given when the A1c level is relatively close to the goal level. DPP–4 inhibitors have no risk of hypoglycemia and are weight-neutral, when used as monotherapy. Sitagliptin or saxagliptin are the choices but more expensive and less potent in lowering glycemia than repaglinide.

• Insulin can also be considered a first–line therapy for all patients with type 2 diabetes, particularly patients presenting with A1c >10%, fasting plasma glucose >250 mg/dL, random glucose consistently >300 mg/dL, or ketonuria.

• Another alternative is a thiazolidinedione, which may be considered in patients with lower initial A1c values or if there are specific contraindications to sulfonylureas.

• Patients who are initially thought to have type 2 diabetes may actually have type 1 diabetes, and therefore require insulin as initial therapy. In patients in whom it is difficult to distinguish type 1 from type 2 diabetes, initial treatment with insulin is required.

• Further adjustments of therapy, which should usually be made no less frequently than every three months, are based upon the A1c result (and the results of home glucose monitoring).

• If inadequate control is achieved (A1c remains >7.0%), another medication should be added within 2 to 3 months of initiation of the lifestyle intervention and metformin.