Preventing Diabetes Complications: Non-glucose Interventions

Abstract

Evidence from a cohort of randomised trials in the past decade has challenged the accepted framework for the prevention and management of Type 2 diabetes (T2D) complications, in particular the requirement for consistently rigorous glycaemic control, and even very low blood pressure. The results of several recent studies compel a broader approach to T2D with an individualised emphasis on risk factors that will reduce meaningful outcomes, especially cardiovascular disease (CVD), disability from limb loss and end-stage renal disease. The Steno-2 trial is our main clinical guide, which confirms that relatively cheap and practical interventions can generate significant cardiovascular benefits. Clinicians must be particularly vigilant for the definite adverse consequences of over-vigorous control of glycaemia and blood pressure, while acknowledging that strenuous LDL-cholesterol reduction is the most cost-effective and safest individual therapy currently available in the majority of people with T2D, where the greatest risk is premature macrovascular disease. New guidelines should incorporate this compelling new evidence. The only contexts in which the now-habitual term ‘aggressive control’ can be justified in relation to risk factor reduction in diabetes are smoking cessation (where we have been notably and regrettably unsuccessful) and LDL reduction.