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Type 2 Diabetes Glucose Management Goals
#1
Optimal management of type 2 diabetes requires treatment of the “ABCs” of diabetes: A1C, blood pressure, and cholesterol (ie, dyslipidemia). This web page provides the rationale and targets for glucose management; AACE guidelines for blood pressure and lipid control are summarized in Management of Common Comorbidities of Diabetes.


Glucose Targets

Glucose goals should be established on an individual basis for each patient, based on consideration of both clinical characteristics and the patient's psychosocioeconomic circumstances.1 Accordingly, AACE recommends individualized glucose targets (Table 1) that take into account the following factors:
  • Life expectancy


  • Duration of diabetes


  • Presence or absence of microvascular and macrovascular complications


  • Comorbid conditions including CVD risk factors


  • Risk for development of or consequences from severe hypoglycemia


  • Patient's social, psychological, and economic status


Table 1. AACE-Recommended Glycemic Targets for Nonpregnant Adults



.pdf   Table 8.pdf (Size: 165.39 KB / Downloads: 0)


The American Diabetes Association (ADA) also recommends individualizing glycemic targets (Table 2) based on patient-specific characteristics3:
  • Patient attitude and expected treatment efforts


  • Risks potentially associated with hypoglycemia as well as other adverse events


  • Disease duration


  • Life expectancy


  • Important comorbidities


  • Established vascular complications


  • Resources and support system
Table 2. ADA-Recommended Glycemic Targets for Nonpregnant Adults




.pdf   Table 9.pdf (Size: 170.06 KB / Downloads: 0)



Evidence and Rationale for Recommended Glucose Targets


The AACE and ADA recommendations are based on findings from 4 major clinical trials in type 2 diabetes mellitus (T2DM) and 1 trial in type 1 diabetes mellitus (T1DM), as listed in Table 3.


Table 3. Major Diabetes Trials




.pdf   Table 10.pdf (Size: 106.12 KB / Downloads: 0)



The main message from these trials is that improved glycemic control is associated with significant reductions in the risk of microvascular complications in all types of patients and with reduced long-term risk of macrovascular disease in younger patients with a short duration of diabetes (either newly diagnosed T2DM or T1DM diagnosed within 5 years of study entry) whose glycemia was intensively controlled soon after diagnosis.5,6,8-10,12,13 In older patients with a longer duration of T2DM and/or multiple cardiovascular risk factors, intensive glucose control did not significantly reduce the risk of macrovascular disease or mortality.7,10,11 However, it may not be surprising that it has been difficult to demonstrate improved CVD outcomes with modest improvements in glycemia in subjects who have had intensive treatment of blood pressure and dyslipidemia.14
Glucose control aimed at normal (or near-normal) glycemia may be considered for adults with recent onset of T2DM and no clinically significant CVD, with the aim of preventing the development of microvascular and macrovascular complications over a lifetime, if it can be achieved without substantial hypoglycemia or other unacceptable adverse consequences. Although it is uncertain that the clinical course of established CVD is improved by strict glycemic control in the average patient with type 2 diabetes, the progression of microvascular complications is clearly reduced. A less stringent goal (A1C 7% to 8%) may be considered for individuals with history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbid conditions, or long-standing diabetes in which the general goal has been difficult to attain despite intensive efforts, including diabetes self-management education, intensive lifestyle recommendations, and optimal use of available antihyperglycemic medications.


Microvascular Complications


Reducing hyperglycemia is the primary means of preventing the microvascular complications of diabetes, although treating elevated blood pressure (when present) is also vital for microvascular risk reduction.2 Hyperglycemia damages tissues via at least 4 mechanisms:
  • Increased polyol pathway flux


  • Increased advanced glycation end-product (AGE) formation


  • Activation of protein kinase C (PKC) isoforms


  • Increased hexosamine pathway flux
Each of these pathogenic mechanisms results from overproduction of reactive oxygen species (ROS) at a cellular level. In brief, excess glucose increases the amount of electrons that pass through mitochondria in endothelial cells, which in turn increases production of superoxide (a major ROS). The resulting oxidative stress contributes to the development of both microvascular and macrovascular complications of diabetes.


Diabetic Kidney Disease


Diabetic kidney disease (DKD; or diabetic nephropathy) is the leading cause of kidney failure in the United States and affects approximately 40% of patients with diabetes.16,17 In addition, patients with both diabetes and kidney disease have a 2- to 3-fold higher risk of cardiovascular complications and death relative to patients who have diabetes but normal kidney function.18,19

DKD results from an interplay between hyperglycemia, increased levels of angiotensin II, and increased blood pressure in genetically susceptible individuals (family history of nephropathy is critical). These factors collectively increase oxidative stress, proinflammatory cytokines, and mechanical injury from hemodynamic stress.20-22 Key features of the resulting damage include:
  • Accumulation of matrix in the mesangial area, which reduces the capillary surface area available for filtration


  • Nephron dropout due to tubulointerstitial fibrosis


  • Dysfunction of the glomerular endothelium


  • Thickening of the glomerular basement membrane (GBM)


  • Podocyte injury
These changes occur more or less in concert with each other. Collectively, they lead to a progressive breakdown in the glomerular filtration barrier, which increases the permeability of renal tissues to proteins. Increasing proteinuria further exacerbates the damage caused by hyperglycemia, angiotensin II, and hypertension, progressively worsening renal function.21

From a clinical perspective, DKD is characterized by an initial period of hyperfiltration, which in a subgroup of genetically susceptible individuals is followed by a declining glomerular filtration rate (GFR) and proteinuria that increases to a varying degree.23,24 Starting at diagnosis of T2DM, annual assessment of serum creatinine to estimate GFR and a spot urine albumin:creatinine ratio should be performed to identify, stage, and monitor disease progression.2,24,25

Recently, the National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (KDOQI) endorsed the effort by Kidney Disease: Improving Global Outcomes (KDIGO) to update the classification system for kidney disease severity (Table 4). While the thresholds for both estimated GFR and albuminuria remain unchanged in the new classification, 3 albuminuria stages have been added to enhance the GFR stages. Stage 3 CKD has also been subdivided at an estimated GFR of 45 mL/min per 1.73 m2, and there is a new emphasis on clinical diagnosis in addition to GFR and albuminuria stages.25 It is also important to remember that patients may have developed chronic kidney disease (CKD) prior to onset of T2DM—nearly 18% of patients with prediabetes have CKD.


Table 4. KDIGO Chronic Kidney Disease Classification—Composite Ranking for Relative Risks




.pdf   Table 11.pdf (Size: 221.33 KB / Downloads: 0)


Neither a spot urine albumin level without simultaneous measurement of urine creatinine, nor measurement of serum creatinine alone, should be used for screening. By themselves, spot urine albumin tests are suboptimal and fraught with errors because albumin excretion can be increased by exercise, febrile illness, urinary tract infection, hematuria, severe hypertension, heart failure, and even high-grade hyperglycemia. Therefore, it is prudent to confirm albuminuria status with repeated testing before establishing a firm basis for therapeutic intervention for diabetic nephropathy. Ideally, 3 (minimum of 2) separate spot urines should be collected to evaluate the albumin to creatinine ratio over several days, with the result determined by the mean value. Serum creatinine alone is also an inaccurate measure of kidney function and should only be used with a GFR-estimating equation such as the Modification of Diet in Renal Disease (MDRD) equation. Many laboratories now routinely report the estimated GFR, and the National Institutes of Health also has GFR calculators.2
Prevention of the development or progression of diabetic nephropathy includes optimal control of plasma glucose (A1C <7%) and blood pressure (<130/80 mm Hg), inhibition of the renin-angiotensin-aldosterone system (RAAS), and modification of other risk factors such as smoking and hyperlipidemia. Antihypertensive drugs that block RAAS—namely angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs)—provide nephroprotective benefits beyond their blood pressure–lowering effects. When therapy with one of these agents is initiated, renal function and serum potassium levels must be closely monitored.2 Nondihydropyridine calcium channel blockers (CCBs; eg, diltiazem or verapamil) will help further reduce albuminuria.26 ACE inhibitors or ARBs should not be combined with aliskiren, an orally active direct renin inhibitor. Such combinations are contraindicated due to an increased risk of renal impairment, hypotension, and hyperkalemia in patients with diabetes.27

In general, patients with stage 1-2 DKD should consume no more than the recommended daily allowance of protein (0.8 g/kg per day), and further protein restriction (0.6-0.8 g/kg per day) may be beneficial in slowing GFR decline in patients with more severe DKD (stages 3-4).2,24

Prompt referral to a nephrologist is indicated when the diagnosis of diabetic nephropathy is in doubt (eg, patients with nonclassic presentation, suspected IgA nephropathy, rapidly worsening nephropathy, or active urinary sediment). Patients with advanced or severe kidney disease (estimated GFR <30 mL/min/1.73 m2) also should be cared for in consultation with a nephrologist to delay the progression of nephropathy for as long as possible, unless the T2DM caregiver is adept at delivering optimal management of risk factors for worsening nephropathy, such as hyperglycemia, hypertension, and dyslipidemia.2 Evidence suggests that referral of patients with stage 4 CKD to a nephrologist is cost-effective and delays the time to dialysis treatment.28 Patients with stage 5 CKD require renal replacement therapy. Mortality while receiving such therapy is higher in patients with diabetes than in patients without diabetes, largely because of CVD complications.29 Renal transplantation is the preferred replacement therapy for T2DM patients who have end-stage kidney disease because long-term outcomes are superior to those achieved with dialysis.


Retinopathy


Diabetic retinopathy is the leading cause of blindness in adults in the United States.16 About 30% of patients with newly diagnosed T2DM may have some evidence of diabetic retinopathy, and the prevalence increases with duration and severity of disease—among insulin users with T2DM, approximately two-thirds may have retinopathy.


There are 4 main types of diabetic retinopathy lesions, which increase in severity:
  • Background or nonproliferative retinopathy


  • Macular edema


  • Preproliferative retinopathy


  • Proliferative retinopathy
The rates of more severe retinopathy increase with the duration of T2DM. In the Wisconsin Epidemiologic Study of Diabetic Retinopathy (WESDR) study, macular edema was found in 3% of patients within 5 years of diagnosis, but in 28% after 20 years duration.16,30,31 Therefore, the goal is to detect clinically significant retinopathy before vision is threatened, and both AACE and the ADA recommend referral to an experienced ophthalmologist for an annual dilated eye examination starting at diagnosis of T2DM.2,4 Patients with active lesions may be followed up more frequently, while those who have had repeatedly normal eye findings can be seen less frequently. The complete ophthalmologic examination can also detect other common conditions such as cataracts, glaucoma, and macular degeneration.


Neuropathy


Diabetic neuropathy encompasses multiple disorders involving proximal, distal, somatic, and autonomic nerves (Table 5). The majority, and possibly all, T2DM patients have at least mild nerve damage, which may present as acute and self-limiting or a chronic, indolent condition.2,16 In addition to those with T2DM, patients with metabolic syndrome and prediabetes are at risk for various neuropathies, which develop as a result of oxidative stress and inflammation.2,36 Optimal control of glucose, lipids, and blood pressure are essential to the management of all forms of diabetic neuropathy.


Table 5. Diabetic Neuropathies: Key Characteristics and Management Recommendations



[Image: pdf.png]   Table 12.pdf (Size: 102.6 KB / Downloads: 0) 

Each type of neuropathy is diagnosed according to specific criteria and tests too numerous to list here. More detail can be found in the 2011 AACE Medical Guidelines for Clinical Practice for Developing a Diabetes Mellitus Comprehensive Care Plan as well as other reviews.2,37


Macrovascular Complications



Hyperglycemia increases CVD both directly and by indirect effects on other cardiovascular risk factors.2 Diabetes is considered a cardiovascular risk equivalent, because the risk of a cardiovascular event is roughly the same for patients with diabetes but without a history of CVD as for patients without diabetes but with a prior event.38,39Nevertheless, the beneficial effects of intensive glycemic control in reducing vascular complications may be considered to be inversely related to the extent of vascular disease at the time it is initiated.14 Evidence from the DCCT and UKPDS follow-up studies suggests that intensive glucose control in younger, healthier patients without cardiovascular disease significantly reduces the risk of developing macrovascular complications later in life; this is known as the legacy effect or metabolic memory.6,13 However, as mentioned, in older patients with T2DM and existing CVD or extensive risk factors, intensive glucose control has not provided a significant benefit, and patients with long-standing, very difficult-to-control glycemia may be at even greater risk from intensive therapy.7,10,11,40For these reasons, glucose control goals must be set individually, as described above, and macrovascular risk reduction should focus on treatment of other cardiovascular risk factors:

  • Hypertension control


  • Dyslipidemia control


  • Autonomic cardiac neuropathy diagnosis and management


  • Kidney disease diagnosis and management


  • Smoking cessation


  • Aspirin therapy



Reference:

http://outpatient.aace.com/type-2-diabetes/management
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