Strategy for Arterial Risk Management in Type 2 (Non-insulin-dependent) Diabetes Mellitus

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DETERMINATION OF ARTERIAL RISK AND APPROPRIATE INTERVENTION

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1. Systematic determination of arterial risk

• The arterial risk factors to be assessed are discussed above and summarized in Table 7.

• Arterial risk should be assessed at diagnosis, referral and at annual review.

• Because of the number of risk factors to be assessed, complete assessment can only be guaranteed when structured records are used as a prompt.

• Results of such an assessment can then be recorded on a form compatible with the European ( DIABCARE ) standard [72] and used to support the development of quality care.

• Risk is cumulative and broad assessment may be made by summing the number of high and medium risk factors. However, this may lead to underestimation of risk when risk factors are multiplicative (e.g. smoking doubles risk).

• At present, it is not possible to build a full quantitative model of arterial risk that could apply to different ages, ethnic groups and gender. The problem of whether factors are additive, multiplicative or subtractive, and associated or dependent, their number and possible variation with respect to environment and culture, may make this an insoluble computational task in the foreseeable future.

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SYSTEMATIC DETERMINATION

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2. Making use of arterial risk assessment

• The results of arterial risk factor assessment should impact on four important areas of diabetes care :

  1. Provision of information for the individual education of people with diabetes on their own health risk.

  2. Highlighting priorities in the choice of interventions to lower arterial risk.

  3. When intervention is not possible (i.e. with factors such as age or history of ischaemic heart disease), arterial risk assessment guides the level at which other risk factors should be treated, the extent and cost of the justifiable intervention, and the targets to be achieved.

  4. Repeated assessment, whether of individual risk factors or complete assessment at annual review, can be used to monitor success in reducing arterial risk.

• Optimal use of arterial risk factor assessment requires the following :

  1. Good communication and rapport between the person with diabetes and other members of their (professional) management team.

  2. Effective patient education programmes.

  3. Involvement of people with diabetes in choosing priorities for management and the appropriate interventions (lifestyle change and/or drug treatment).

  4. Support for lifestyle change, with a trial period initially, and time allowed for the individuals to learn how to adapt such interventions to their own circumstances, before considering drug treatment.

  5. Giving priority to interventions that can be expected to improve more than one risk factor (such as dietary changes and reducing alcohol consumption).

  6. Predicting and managing conflicts in arterial risk factor management (for example smoking and weight control).

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USING THE ASSESSMENT

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3. Implementing change and patient-led planning

• Before drawing up a management plan, priorities need to be set by active and informed involvement of the person with diabetes.

• Discussion of the risk assessment results, and the available options for reducing arterial risk, are both necessary before it is possible to set priorities on which factors to address.

• The patient is particularly likely to want to be involved in any decisions requiring a change in lifestyle; without such involvement, commitment and successful change are unlikely.

• Discerning patients' perception of their disease, and their ability to control it, are important in determining the balance between lifestyle change and drug therapy.

• A patient may make an informed choice not to change lifestyle or accept therapy, but this must be made on the basis of adequate education.

• Once the priorities for addressing arterial risk have been established, a treatment plan can be developed, using both drug and non-drug treatment.

• The patient should generate some of the solutions to the problem of reducing arterial risk where possible; these solutions are more likely to be successful.

• Secondary goals are particularly important for the success of non-drug measures. For goals to be met, they need to make sense to the person concerned, and to fit in with the way that person runs their life.

• Goals should be clearly defined and, when more complex, should comprise a series of simple, measurable, achievable, realistic and short-term steps. A suitable interval should be set to allow the goal to be reached. Follow-up visits to assess progress should then be programmed accordingly.

• At follow-up visits, a full risk profile assessment may be performed, but a simple measurement to assess progress towards goals in one or two factors is generally more useful. Biochemical results should be available at the time of the consultation.

• Positive feedback is needed to reinforce the motivation to continue with a lifestyle intervention programme. It may, therefore, be best to wait until a positive change in risk is likely to have occurred before performing and demonstrating a full risk assessment.

• If progress towards the goals is slow, it may be necessary to re-negotiate them or even to reassess the overall plan.

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CHANGE AND PLANNING

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4. Specific management interventions

• Age, gender and ethnic group are non-modifiable risk factors; they will act to alter the priority and intensity with which other factors are managed.

• Microalbuminuria is modifiable, but the extent to which this might benefit arterial risk (as distinct from progression of diabetic nephropathy) is not known. Currently, its presence should affect the priority and intensity with which the other risk factors are managed.

• Modifiable risk factors therefore include smoking, blood pressure, blood glucose control, serum triglyceride and cholesterol levels, body mass index (body weight) and thrombotic risk.

• Interventions should, in general, always be applied for higher levels of risk in people with a reasonable life-expectancy.

• Moderate levels of risk should also be reduced where possible, provided :

  1. there is reasonable life-expectancy

  2. one, or more, non-modifiable risk factor is present, or

  3. one, or more, high-risk modifiable risk factor is present, but is not itself amenable to management in that individual.

• An exception is hyperglycaemia, for which intervention is usually indicated at moderate risk levels because of microvascular rather than major vessel disease.

• In general, lifestyle modifications should be given a reasonable trial, with appropriate counselling and educational support, before drug therapy is introduced.

• Specific lifestyle interventions to consider for specific risk factors are :

  • For raised blood pressure :
    modification of dietary salt intake, appropriate calorie intake, control of excess alcohol intake.

  • For high body mass index and/or abdominal adiposity :
    appropriate calorie intake, increased physical activity.

  • For blood glucose levels above target :
    appropriate calorie intake, control of excess free sugar intake, increased physical activity.

  • For serum triglyceride levels above target :
    appropriate calorie intake, control of free sugar intake, reduced saturated fat intake, high intake of foods containing antioxidants (fresh fruit and vegetables), control of excess alcohol intake, increased physical activity.

  • For serum total (or LDL) cholesterol levels above target :
    appropriate calorie intake, reduced saturated fat intake.

  • For smoking :
    reduction/cessation programme, nicotine substitution products, behavioural modification programme, alternative therapy (e.g. hypnosis, acupuncture).

• Permanent lifestyle change is a major burden to some people, but may become learnt and habitual (and welcomed) by others. Those in the first category will need continued counselling and educational support if they are to achieve their chosen goals.

• Some lifestyle changes are easiest to make at times of key life events and thus advantage should be taken of any opportunities that arise.

  • At diagnosis :
    motivation can be high for dietary change and cessation of smoking, if this offers the prospect of avoiding drug intervention.

  • Following MI or 'minor' stroke :
    motivation may be particularly high to tackle arterial risk factors by dietary change or stopping smoking.

• Where conflicts occur in lifestyle management, sympathy will be needed. A degree of tolerance may be advisable towards small increases in weight (in addition to appropriate dietary advice) when stopping smoking, for example.

• Aspirin is indicated for all people with cardiovascular disease, and may be beneficial in people with Type 2 diabetes and other arterial risk factors (unless specifically contraindicated).

• The success of other drug interventions is limited by :

  • Professional and patient beliefs that taking a preparation constitutes 'treatment' and that, therefore, no further action or modification is necessary.

  • Poor understanding of the purpose of drug therapy, due to inadequate education, with resulting failure to take the preparation prescribed regularly.

  • Limited efficacy of many drugs, such as some fibrates, in the management of raised triglyceride levels, and most anti-hypertensive agents when blood pressure is well above target levels [73].

  • Drug side-effects causing non-compliance or the need to reduce the dosage/failure to reach target dose.

  • Continued progression of the underlying disease with age, in particular of deficient islet B-cell insulin secretion, and of rising systolic blood pressure.

• These problems can be limited and ameliorated by addressing them when therapeutic targets are not met.

• Conflict may arise if the management of one arterial risk factor worsens another. For example, patients with raised blood pressure not responding to lifestyle intervention should be given a trial of management with anti-hypertensive agents which do not worsen glucose tolerance or the lipid profile (avoid thiazides and beta-adrenergic-blockers).

• Specific symptomatic and prophylactic management of established vascular disease, such as in people with ischaemic heart disease, is generally not affected by diabetes. The relatively greater impact of cardiac failure may, however, suggest the need for more aggressive management. Greater care is needed with ACE-inhibitors or beta-blockers in people prone to peripheral vascular disease.

• Where a trial of therapy produces no measurable benefit, that therapy should be stopped, and the possible reasons for failure examined before starting another.

• Where the response to a drug is good, but inadequate (that is, a large improvement is needed), multiple therapy may be needed in addition to lifestyle intervention to reach target levels. Synergisms (e.g. ACE inhibitor and loop diuretics) and adverse interactions (e.g. fibrates and statins) need to be considered.

• Where a medium-term clinical outcome is improved by a drug that may worsen arterial risk factors (in particular, beta-adrenergic blockers in the management of angina and post-myocardial infarction), then these drugs should be used in people with diabetes, unless alternatives are available (as in the management of hypertension).

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SPECIFIC INTERVENTIONS

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CONCLUSIONS

• Care for people with Type 2 diabetes needs more focus on preventing cardiovascular disease.

• A management plan should be agreed with the individual, based on assessment of their risk factor profile.

• Successful cardiovascular risk reduction requires interventions that address agreed targets, and repeated review of the patient's progress and risk factor profile.

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CONCLUSIONS

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ACKNOWLEDGEMENTS

ACKNOWEDLGEMENTS

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