Transcript of learning module Preventing complications in patients with type 2 diabetes (Dur: 09' 40") Contributor: Vinod Patel Available online at: http://learning.bmj.com/ Duration: 0:09:40 Vinod: Diabetes and its management consumes around 10% of the entire NHS budget and a lot of this is around the complications of diabetes. For example, end stage renal failure is the commonest cause of patients needing dialysis programmes in this country. Diabetic retinopathy is the commonest cause of blindness under the age of 65. Strokes and heart disease is increased at least twoto fourfold in patients with diabetes. However, there s very good news. With good care planning, patient education, and a multi-factoral approach we can actually reduce all the complications of diabetes by well over 50%. Diabetic nephropathy is now the commonest single reason for patients going onto end stage renal replacement programmes. We can prevent this by early aggressive management of the hypertension, especially by using agents such as ACE inhibitors and the angiotensin II receptor antagonists.
Diabetic neuropathy we often don t think about neuropathy, however we know that it has a devastating effect on a patient s quality of life. By this we mean erectile dysfunction and also painful peripheral neuropathy. Once again, if these conditions are picked up early enough, maybe we can prevent them by management of risk factors, particularly smoking, and there are also very good treatments now available for these individual complications. Diabetic retinopathy is now the commonest cause of blindness under the age of 65 in the UK population. If we can pick the early types of diabetic retinopathy sufficiently early on in their natural history then we can intervene and stop them going on to sight threatening retinopathy. This includes management of clinical risk factors such as hypertension and poor glycaemic control. If patients are sufficiently advanced in their retinopathy then laser treatment will be needed. Patients with type 2 diabetes have at least two- to fourfold increase in the risk of heart disease, that is ischaemic heart disease, leading to heart attacks and angina. But they also have an increased risk of stroke. Once again, the way to manage these complications is to treat the risk factors early on, and with macrovascular disease, it s going to be the hypertension and the dyslipidaemia particularly. With respect to dementia, I think we re realising that a lot of our patients with dementia actually have type 2 diabetes. Type 2 diabetes would increase your risk of dementia because of its association with multiple strokes. What are the risk factors for the multiple strokes? They will be poor blood pressure control and the poor control of an abnormal lipid profile. So once again we have to be aggressive and treat these risk factors to reduce strokes and to reduce dementia. 2
The overall approach to all these complications should be focused on a multi-professional approach where we re looking at all the risk factors as a bundle. If you treat them all, then the evidence suggests that you can reduce all of them significantly. One of the best studies that we have in this regard is a Steno-2 study that came out in Denmark. What they showed was that if you aim towards a blood pressure of around 130 systolic, a total cholesterol of 4 or under and good glycaemic control, together with the appropriate use of agents such as ACE inhibitors, statins, and aspirin, then you can reduce all the complications of diabetes by at least 50%. Statins, for example, in large randomised controlled trials have been shown to reduce cardiovascular risk by at least 25% and cardiovascular events by around the same amount as well. And we can use agents that are generic such as simvastatin 40, to achieve this in the vast majority of cases. ACE inhibitors and some angiotensin II receptor antagonists are now also generic and they have been shown to reduce risk of stroke by a third, and even risk of kidney disease by around 25% as well. The use of aspirin in patients with type 2 diabetes has become a bit more controversial recently. In terms of secondary prevention for ischaemic heart disease or stroke, it is obviously the treatment of choice if the patient can tolerate it. However, for primary prevention, the most recent metaanalysis shows that we should probably only focus on a patient who has a cardiovascular risk of more than 10% over the next 10 years. In people at a lower risk of 5% or under, we should probably not use aspirin because the disbenefits are going to be much higher than the actual benefits in this group of patients. If we wanted to summarise an overall approach to reducing complications in patients with diabetes, they would have to focus on two or three main areas. The most important area is patient 3
education and care planning. You need to have an engaged patient who knows their future risks and how to prevent them. The more we educate our patients, they are more likely to engage with their targets for management and also to be concordant with the treatment that we are recommending. So if the patient understands, they can look after themselves. It s very important to remember that because the patient with diabetes only sees healthcare professionals for three hours in a whole year. The other 8700 or so hours, they are on their own. So we must focus on care planning. There are lots of care plans out there but in essence, they summarise what the healthcare team is trying to achieve and hopes that the patient will engage in planning their own care. This is so that the patient can focus on the risk factors that they really want to concentrate on. They may be risk factors that they are having difficulty achieving, but we may need to leave them aside for the time being and then concentrate on the ones that we can do something about. In terms of care planning, what we often forget is how well the patients are actually doing. Because nobody will be scoring 0 as it were on all their risk factors. A lot of people will be desperately trying to look after themselves with their diet, incorporating physical activity into their everyday life, and a lot of people are now giving up smoking as well. So people must be congratulated on what they are doing well, but we must give a clear steer on their main risk factors that can affect their future life and particularly increased risk of complications. What I often try to do is concentrate on what the patient is actually doing well, so I ll use models such as this here, where we ll say to the patient, Look, you re now in the green zone, your chances of 4
having heart attacks and strokes has gone down considerably, look how small these columns are in comparison to where you were six months ago, when your risk was much higher, when your blood pressure was higher, and your diabetes control was poorer. This is based on the UKPDS risk model for diabetes complications. So the key messages when it comes to caring for patients with type 2 diabetes have to be based on patient education and care planning, and the approach must be individualised to the patient. In terms of strategies to reduce future complications, we must look out for the early warning signs of complications. These will be picked up in various settings, for example, the optician might say Have you got diabetes? when they come to get their new glasses. But we must also screen for early complications such as microalbuminuria, make sure patients have retinal screening, and make sure that they have their feet examined on a regular basis. Thereafter we have to optimise the pharmacological management, and this will be based around evidence based treatments, such as the statins, the ACE inhibitors, and the aspirins if appropriate for that patient. The final bit is to make sure that your patient is engaged with the healthcare system so they know how to navigate through it and they know how to ask for help if they need it. BMJ Learning 2012 5