Nonglycemic Targets in Diabetes

Key points

Hypertension and renal disease targets

Diabetic renal disease commonly involves multiple primary and secondary pathologic processes that lead to a limited variety of clinical manifestations (Box 1). Genetic susceptibility to diabetic nephropathy, suggested by familial clustering of nephropathy,1, 2 is complex because of ill-defined pathophysiology and variable genetic expression.³

Classic diabetic nephropathy, with microalbuminuria progressing to macroalbuminuria and a decreased glomerular filtration rate (GFR), is common and easy to

Blood pressure treatment

The control of hypertension (hyperglycemia aside) is the cornerstone of preventing/delaying the onset and progression of diabetic nephropathy. Treatment of hypertension also has a significant impact on other cardiovascular complications of diabetes. Because medication compliance is a major determinant of treatment effectiveness of hypertension, compliance should be a major determinant of treatment choices. Relevant questions include blood pressure targets and the relative importance of specific

Proteinuria

Microalbuminuria is associated with worse renal and cardiovascular outcomes, with greater degrees of proteinuria increasing the risk. A reduction in the degree of proteinuria by treatment with RASIs is associated with improved outcomes through control of hypertension and other mechanisms.²¹ Although RASI-associated reductions in proteinuria promote their choice as preferred antihypertensives, the highest priority should be given to reaching target blood pressures.

Lipid targets

In 2013, the American College of Cardiology (ACC) and the American Heart Association (AHA) jointly released new, highly controversial guidelines for lipid targets and treatment. Although the ACC/AHA’s review of the evidence shows that high-intensity therapy (lowering low-density lipoprotein [LDL] by ≥50%) or moderate-intensity therapy (≥30%) changes atherosclerotic cardiovascular diseases (ASCVD) outcomes, the new guidelines focus on treatment initialization for patients with a 10-year ASCVD

Mental health targets

In its 2014 Standard of Care, the American Diabetes Association recommends the assessment of patients’ psychological and social situation as an ongoing part of the medical management of diabetes.³² Several mental health conditions can affect the care of patients with diabetes. In addition, some mental health conditions are associated with an increase in diabetes incidence or diabetes-related complications.

The depressive disorders have a prevalence of up to 25% in people with diabetes,32, 33

Weight control targets

The healthy weight target of a body mass index (BMI) less than 25 is well established, but the difficulty of weight loss has been a persistent problem (see the article by Evert and Riddell elsewhere in this issue for further exploration of this topic). Although there is plentiful evidence that exercise is beneficial, the recent Look AHEAD (Action for Health in Diabetes) trial⁴⁶ was stopped early, at 9.6 years, because of futility. The bottom line from this intensive lifestyle intervention trial

Driving targets

Targets for the evaluation of safe driving should include regular (approximately every 2 years) clinical assessments for increased risk.⁵⁵ Although driving is relatively safe for most patients with diabetes, the issue is not without controversy. Commercial drivers with diabetes are legally required to undergo medical evaluation periodically. See the National Institutes of Health’s evaluation site www.diabetesdriving.com. The estimated HR for accidents while driving in those with diabetes is

Summary

In conclusion, targets for patients with diabetes have actually become simpler with the release of new guidelines. The targets discussed in this article are summarized in Box 3. Finally, as clinicians and patients with diabetes struggle with the overwhelming burden of care, clinicians should consider the increasingly codified ethic of minimally disruptive medicine, which considers not just what patients and doctors can do but what patients’ priorities, wishes, and needs are rather than the many